gunshot
Michell
J.
peripheral
of
wounds
nerves..
F.R.C.P.,
Clarke, M.D.,
Lieut.-Col., R.A.M.C.(T), Professor of Medicine, University of Bristol.
Injuries
of
Projectiles
of
peripheral
nerves
high velocity
with
successful treatment is of the prevention of
permanent
It may be said make nerve
positive injuries
in wounds due
to
great frequency, and their highest importance in the
disabilities of the most serious kind..
at once that
statements and the
occur
are
we
as to
not
yet
in
a
position
to
what the ultimate results of
operations
undertaken for their relief
will be. The
spiral,
nerves
most
frequently
affected
are
the musculo-
median and ulnar in the arm, the sciatic, and
especially
branch, in the
external
popliteal
Injuries
to the brachial
leg. plexus are also common. A nerve may be (i) completely divided?when this is so there is rarely a clean cut through it, but more often destruction
or
obliteration of it for
to several inches ;
a
considerable distance, from
one
(2) partially divided, or (3) injured by by callus, by fragments of bone, compression by a lodged bullet, or portions of clothing, or by a traumatic aneurysm, by bruising or concussion. It is important to remember that perineural scars and adhesions, though conspicuous at operation, may not be responsible for blocking the passage of impulses, but that this may be due to concomitant intra-neural hemorrhage, fibrosis (neuroma), or molecular changes of concussion. Trotter and Davis have shown the intolerance of the ordinarily isolated or
in scar-tissue,
62
J. MICHELL CLARKE
LIEUT.-COL.
nerve-tissue to the contact of connective tissue, and that the active
of
out-growth
fibrils of
nerve
a
response to the contact of non-nervous forms
part
a
tough,
fibrous
their further extension ; nerve
capsule
nerve
tissue, which
around them, and
is
on
a
its
prevents
this may lead to irritation of the
and
hyper-sensitiveness. experiences of the knowledge as to the course
The extensive exact
divided
individual
nerve
The location of the on
the
give
nerves
more
of the
bundles to different muscles, information
which is much needed for
data, and
should
war
in the
more exact
to
injury
course
of the
plastic
a nerve
surgery.
rests on
anatomical
aided
by X-rays
projectile,
the presence of foreign bodies. In multiple wounds the diagnosis of the one causing the lesion is made from as to
The extent of
anatomical considerations. nerve
is estimated
damage
to the
of motor and sensory
by investigation wasting, pains
muscular
and hyperesthesia, paralysis, and electrical reactions, and all of these trophic lesions, symptoms which are present should be compared, and the
diagnosis based upon the full results. There is no short cut to diagnosis. Many consider that sensory changes give more important
information both
lesion than motor
paralysis
as
or
to extent and progress of the electrical reactions.
It has been claimed that in the
area
of loss
sensation, and
incomplete division of a nerve to protopathic is greater than to epicritic that the borders of the respective areas
approach and recede not yet established. It
is
certain
from
or
that the
cross
but this is
each other ;
distinction
between
complete
physiological blocking of it by involvement in scar tissue cannot always be made, for full sensory and motor loss with R.D. may be present in
anatomical division of
a nerve
and
the latter. Pains and
hyperesthesia
mean
partial injury
of
a
nerve ;
GUNSHOT WOUNDS OF PERIPHERAL
"when these gradually disappear and give place to and tactile anaesthesia
"tissue,
of the
compression probably taking place.
callus, etc., is
63
NERVES.
analgesia scar
by
nerve
Hysterical anaesthesia of the sleeve, glove or stocking type may be present as a complication of peripheral nerveinjuries, generally in partial ones. In gunshot wounds, however, especially of plexuses, the symptoms are often very and the sensory loss may not at first correspond the known anatomical distribution of the nerves,
complicated, with
and may resemble hysterical anaesthesia, but after a few weeks Partially clears up leaving a residual loss in recognised areas
nerve-supply. The
severe
forms of trophic disturbance, such
intractable ulcers, usually nerve,
the milder forms in
A lesion
complete 111
for
partial
complete
the sciatic, where
a
whole
a
?* as
or not at
Their any
most
wound of the
nerve
to
electrical power, is
limited
on
important
excitable fibres
high or
the
internal
and leave the other
in the
nerve at
electrical reactions
give
no
information
the seat of
peripheral
to the
reactions.
are
When all have
injury.
as to extent
Its
of
injury
now
This
fact, that voluntary give such
to nerve.
largely
great advantages
sufficient information, is
No. 133.
injury.
returns before the muscles
response does not go pari passu with the chief reason why electrical reactions
reliable, gives
as
function is to decide whether there
The Lewis Jones Condenser is
XXXV.
as
external
power usually Faradism or the condenser.
information
electrical
on
Electrical reactions
going
keen lost, voluntary respond
a
all affected.
nerves.
to what is
and
nerve
Much discussion has taken place
damaged
deep
lesions.
gluteal region may completely divide the Popliteal fibres, most often the former,
little
as
division of
may, however, be of its bundles of fibres ; this is not infrequent for
partial one
in
occur
used for are
painless,
taking
that it is and
saves
64
LIEUT.-COL.
time.
On the other
MICHELL CLARKE
J.
hand,
it has been
shown
that the
discharges vary with the resistance and other and that the patient's resistance is not constant, as
condenser
factors, practical
purposes it was at first assumed that it would be, and therefore caution is necessary in estimating the for
progress of a lesion by condenser reactions, for which it has been especially advocated. Further, the ready diffusion of the current renders its
advantages defects, and
although
gained from general use.
be for
(1)
secondary
greatly outweigh
think that
methods,
Operations
it
its
more
information is
seems
likely
on cases
in this
to come
country
will
Before
operation can be done,. soundly healed; (2) there must be a after the injury before exact diagnosis is suture.
the wound must be
sufficient interval
possible, partly nerve
of
some
the older
As to treatment.
The
difficult for small muscles.
of the condenser, however,
to be
into
use
because characteristic
take time to
develope,
wounds of
and
partly
signs
of division of
because in most
a
cases
the extent of
paralysis is at first more extensive than remains permanently. Especially in wounds of a plexus, the immediate loss of sensation and motion may affect the whole limb, and after a time partially clear up, leaving a residual paralysis. Whilst waiting, preliminary treatment must be carried out. This consists in wrapping the limb up warmly to protect it from cold and injury; in placing it on a suitable splint to keep the paralysed muscles relaxed?a point of the greatest importance ; daily gentle massage and movements, during which the paralysed muscles must be kept relaxed ; and electrical treatment by the passage of a constant current,, condenser discharge, rhythmically interrupted by a or metronome, and just strong enough to cause a contraction gunshot
nerves
of the muscle. It is desirable before
operation
to
give
a
prophylactic
65
GUNSHOT WOUNDS OF PERIPHERAL NERVES.
dose of
antitoxin,
tetanus
operation undertaken
Operation
some
is advisable
as
tetanus may
months after the
(and,
ceteris
develop after original injury.
paribus,
the earlier
performed the better the results) (i) in complete division of nerve ;
in
(2)
incomplete
lesions
a
where the condition is
(a)
paralysis after three to four months, (b) where improvement has begun but stopped abruptly, with signs of compression of the nerve by scartissue, callus, etc., (c) where there is great pain, not relieved
stationary
after
with
be
definite residue of
weeks'
some
always
a
careful treatment, the
explored (pieces
of bone,
should
nerve
foreign bodies,
or
shreds
?f
clothing may be found in the nerve) ; and (3) in cases of old standing with intractable trophic lesions, for even if no paralysis results, the trophic lesions quickly heal. In the majority of cases there is little difficulty in deciding whether operation is necessary or rjot. Even slight return ?f voluntary power negatives operation. In doubtful cases nothing is lost and often much gained by an exploratory ?peration, though occasionally the nerve may be found to be apparently normal in cases where the paralysis was complete. This is especially true of the musculo-spiral nerve. In plexus lesions where several trunks have been divided, often at different levels with much perineural scar-tissue, good
to the
accurate identification of trunks and end to end suture is most difficult, and if found to leave
things
Trotter
advises
every
impossible,
probably
early operation
nerve
in cauda
where there is the least
case
it is
alone than to do indiscriminate
better
crossing.
lesions in
equina suspicion of an
element
of pressure.
The post-operative treatment, and that of
division
of
nerves
is the
same as
given
cases
above in
of
partial
preliminary
treatment, and should be continued daily until there is a return ?f
voluntary impulses,
the lower
extremity
which may take weeks or years. In a walking instrument must also be
66
J. MICHELL CLARKE
LIEUT.-COL.
for
provided little
dropped
feet.
electrical treatment
nerve
time,
After end to end suture of should not be
and then with
begun
for
a
some
care.
great especially in the early stages, care must be fatigue of the muscles by electrical treatment;
In all cases, taken to avoid
the balance of evidence is that contractions due to electrical stimulation have
no
may be severe
beneficial in the
stage of'regeneration, but effect on muscular wasting. In later stages there irreparable paralysis and joint or bone lesions so are
as to
neutralise the effect of recovery of paralysed cases operations for tendon transplantation
muscles ; for such or
arthrodesis may be advisable. As to results. Cases of nerve concussion should
within four to six weeks ;
partial
division of
a nerve
recover
should
complete recovery in several months (? two to six). As to cases of complete division with secondary suture, it
go to
time to
speak as to the results. Meanwhile, some statements of recent experiences seem to show a much earlier return of sensation and motion than was before held possible. The greater the distance from the periphery the site of the lesion the longer is the period before recovery. is not
yet
Findings, by Short, M.S., F.R.C.S.
Operative Procedures
and
Capt. Rendle
2.
may appear to be normal (vide supra). division of the nerve, with a bulbous
mass
of the upper segment, succeeded by a of scar-tissue of variable thickness, and adherent to the
1.
The
nerve
Complete swelling at the end surrounding
tissues. The treatment
adopted is to free the segment through the swelling, so as to expose
two ends of the nerve, cut off the upper
upper end of or above the bulbous visible nerve-bundles with no excess of interstitial fibrous
tissue, and suture with catgut.
Many English
surgeons wrap
67
GUNSHOT WOUNDS OF PERIPHERAL NERVES.
the
junction in Cargile membrane ; others sometimes use a segment of saphena vein, but often nothing is used. It frequently happens that the ends cannot be brought
together
because of
bridged by
gap of
a
two or three
plies
one
to two inches.
This is
of internal cutaneous
from the upper arm, but some surgeons and others employ nerve-anastomosis.
use
nerve
catgut strands,
There may be a bulbous swelling on the nerve, to the track of the bullet, and it may be doubtful
3.
adherent
whether the nerve-fibres pass through it or are interrupted. In such a case we stimulate the nerve electrically above and below the bulb.
sized
(not
nerve
contract, the
saphena
If, in the
scar
of
a
small
sciatic), any muscles is freed and wrapped in
If there is
vein.
case
the
no
response,
we
or
medium-
supplied by it a segment of excise the
scar
and suture.
large nerve, such as the sciatic, may show symptoms partial division, and at operation part of the nerve shows a scar. The best procedure is to take out a quadrilateral, including the scar, and, by splitting the nerve-trunk up and down, to bring the two ends together, leaving the intact A
4.
?f
a
portion of the The
5.
bullet the
cause
time,
it is
undisturbed.
may be intact, but pressed upon by a shattered bone. The treatment is to remove
nerve
by
or
nerve
although this relieves pain at the during the process of healing, and
of pressure, but
apt
to return
prove very intractable.
REFERENCES.
Nerve Injuries and their Treatment, Purves Stewart & Evans, London, 1916. discussion on Gunshot Wounds of the Peripheral Nerves," Medical Society's Trans., 1916, xxxix. 27.
Core,
"
Dissociation of
Cutaneous Sensations in
Nerves," Lancet, 19x6, i. 716. Stopford, Peripheral Nerve Injuries," ibid., 1916, "
Injuries ii.
718.
to
Peripheral
68
LIEUT.-COL.
JAMES
SWAIN
"
Cause and Nature of Changes which occur in Muscles after Nerve Section," ibid., 1916, ii. p. 6.
Langley,
Langley, ibid., 1916, ii. p. 161. Hernaman Johnson, ibid., 1916, ii. p. 120. Hernaman Johnson, Condenser Reactions," Proc. Roy. Soc. Med., 1916, Surgical Section, p. 1. Warrington and Nelson, Musculo-Spiral Nerve Injuries," Liverpool Med. Chir. Journ., 1916, lxix. p. 61. Bernard Roth, Gunshot Wounds of Peripheral Nerves," Journ. R.A.M.C., 1915, i. p. 267. Treatment of Nerve Injuries of Warfare," Clin. Journ., 1916, Piatt, Aug. 9th., p. 285. Electrical Reaction of Muscles before and after Nerve Injury," Adrian, "
"
"
"
"
Brain, 1916, vol. xxxix., pt. i., p. 1. " Roberts, Degeneration of Muscle following Nerve Injury," Brain, 1916, vol. xxxix., pt. iii., p. 297.
" Electrical Testing," Proc. Roy. Soc. Med., 1914., Elect. Cumberbatch, Therap. Section, p. 38.
Purser, Roy. Acad. Med. Ireland, Section Surgery, 1916. Tubby, Nerve Concussion due to Bullet and Shell Wounds," Journ., 1915, i. p. 57. "
Brit. Med.
Michell
J.
peripheral
of
wounds
nerves..
F.R.C.P.,
Clarke, M.D.,
Lieut.-Col., R.A.M.C.(T), Professor of Medicine, University of Bristol.
Injuries
of
Projectiles
of
peripheral
nerves
high velocity
with
successful treatment is of the prevention of
permanent
It may be said make nerve
positive injuries
in wounds due
to
great frequency, and their highest importance in the
disabilities of the most serious kind..
at once that
statements and the
occur
are
we
as to
not
yet
in
a
position
to
what the ultimate results of
operations
undertaken for their relief
will be. The
spiral,
nerves
most
frequently
affected
are
the musculo-
median and ulnar in the arm, the sciatic, and
especially
branch, in the
external
popliteal
Injuries
to the brachial
leg. plexus are also common. A nerve may be (i) completely divided?when this is so there is rarely a clean cut through it, but more often destruction
or
obliteration of it for
to several inches ;
a
considerable distance, from
one
(2) partially divided, or (3) injured by by callus, by fragments of bone, compression by a lodged bullet, or portions of clothing, or by a traumatic aneurysm, by bruising or concussion. It is important to remember that perineural scars and adhesions, though conspicuous at operation, may not be responsible for blocking the passage of impulses, but that this may be due to concomitant intra-neural hemorrhage, fibrosis (neuroma), or molecular changes of concussion. Trotter and Davis have shown the intolerance of the ordinarily isolated or
in scar-tissue,
62
J. MICHELL CLARKE
LIEUT.-COL.
nerve-tissue to the contact of connective tissue, and that the active
of
out-growth
fibrils of
nerve
a
response to the contact of non-nervous forms
part
a
tough,
fibrous
their further extension ; nerve
capsule
nerve
tissue, which
around them, and
is
on
a
its
prevents
this may lead to irritation of the
and
hyper-sensitiveness. experiences of the knowledge as to the course
The extensive exact
divided
individual
nerve
The location of the on
the
give
nerves
more
of the
bundles to different muscles, information
which is much needed for
data, and
should
war
in the
more exact
to
injury
course
of the
plastic
a nerve
surgery.
rests on
anatomical
aided
by X-rays
projectile,
the presence of foreign bodies. In multiple wounds the diagnosis of the one causing the lesion is made from as to
The extent of
anatomical considerations. nerve
is estimated
damage
to the
of motor and sensory
by investigation wasting, pains
muscular
and hyperesthesia, paralysis, and electrical reactions, and all of these trophic lesions, symptoms which are present should be compared, and the
diagnosis based upon the full results. There is no short cut to diagnosis. Many consider that sensory changes give more important
information both
lesion than motor
paralysis
as
or
to extent and progress of the electrical reactions.
It has been claimed that in the
area
of loss
sensation, and
incomplete division of a nerve to protopathic is greater than to epicritic that the borders of the respective areas
approach and recede not yet established. It
is
certain
from
or
that the
cross
but this is
each other ;
distinction
between
complete
physiological blocking of it by involvement in scar tissue cannot always be made, for full sensory and motor loss with R.D. may be present in
anatomical division of
a nerve
and
the latter. Pains and
hyperesthesia
mean
partial injury
of
a
nerve ;
GUNSHOT WOUNDS OF PERIPHERAL
"when these gradually disappear and give place to and tactile anaesthesia
"tissue,
of the
compression probably taking place.
callus, etc., is
63
NERVES.
analgesia scar
by
nerve
Hysterical anaesthesia of the sleeve, glove or stocking type may be present as a complication of peripheral nerveinjuries, generally in partial ones. In gunshot wounds, however, especially of plexuses, the symptoms are often very and the sensory loss may not at first correspond the known anatomical distribution of the nerves,
complicated, with
and may resemble hysterical anaesthesia, but after a few weeks Partially clears up leaving a residual loss in recognised areas
nerve-supply. The
severe
forms of trophic disturbance, such
intractable ulcers, usually nerve,
the milder forms in
A lesion
complete 111
for
partial
complete
the sciatic, where
a
whole
a
?* as
or not at
Their any
most
wound of the
nerve
to
electrical power, is
limited
on
important
excitable fibres
high or
the
internal
and leave the other
in the
nerve at
electrical reactions
give
no
information
the seat of
peripheral
to the
reactions.
are
When all have
injury.
as to extent
Its
of
injury
now
This
fact, that voluntary give such
to nerve.
largely
great advantages
sufficient information, is
No. 133.
injury.
returns before the muscles
response does not go pari passu with the chief reason why electrical reactions
reliable, gives
as
function is to decide whether there
The Lewis Jones Condenser is
XXXV.
as
external
power usually Faradism or the condenser.
information
electrical
on
Electrical reactions
going
keen lost, voluntary respond
a
all affected.
nerves.
to what is
and
nerve
Much discussion has taken place
damaged
deep
lesions.
gluteal region may completely divide the Popliteal fibres, most often the former,
little
as
division of
may, however, be of its bundles of fibres ; this is not infrequent for
partial one
in
occur
used for are
painless,
taking
that it is and
saves
64
LIEUT.-COL.
time.
On the other
MICHELL CLARKE
J.
hand,
it has been
shown
that the
discharges vary with the resistance and other and that the patient's resistance is not constant, as
condenser
factors, practical
purposes it was at first assumed that it would be, and therefore caution is necessary in estimating the for
progress of a lesion by condenser reactions, for which it has been especially advocated. Further, the ready diffusion of the current renders its
advantages defects, and
although
gained from general use.
be for
(1)
secondary
greatly outweigh
think that
methods,
Operations
it
its
more
information is
seems
likely
on cases
in this
to come
country
will
Before
operation can be done,. soundly healed; (2) there must be a after the injury before exact diagnosis is suture.
the wound must be
sufficient interval
possible, partly nerve
of
some
the older
As to treatment.
The
difficult for small muscles.
of the condenser, however,
to be
into
use
because characteristic
take time to
develope,
wounds of
and
partly
signs
of division of
because in most
a
cases
the extent of
paralysis is at first more extensive than remains permanently. Especially in wounds of a plexus, the immediate loss of sensation and motion may affect the whole limb, and after a time partially clear up, leaving a residual paralysis. Whilst waiting, preliminary treatment must be carried out. This consists in wrapping the limb up warmly to protect it from cold and injury; in placing it on a suitable splint to keep the paralysed muscles relaxed?a point of the greatest importance ; daily gentle massage and movements, during which the paralysed muscles must be kept relaxed ; and electrical treatment by the passage of a constant current,, condenser discharge, rhythmically interrupted by a or metronome, and just strong enough to cause a contraction gunshot
nerves
of the muscle. It is desirable before
operation
to
give
a
prophylactic
65
GUNSHOT WOUNDS OF PERIPHERAL NERVES.
dose of
antitoxin,
tetanus
operation undertaken
Operation
some
is advisable
as
tetanus may
months after the
(and,
ceteris
develop after original injury.
paribus,
the earlier
performed the better the results) (i) in complete division of nerve ;
in
(2)
incomplete
lesions
a
where the condition is
(a)
paralysis after three to four months, (b) where improvement has begun but stopped abruptly, with signs of compression of the nerve by scartissue, callus, etc., (c) where there is great pain, not relieved
stationary
after
with
be
definite residue of
weeks'
some
always
a
careful treatment, the
explored (pieces
of bone,
should
nerve
foreign bodies,
or
shreds
?f
clothing may be found in the nerve) ; and (3) in cases of old standing with intractable trophic lesions, for even if no paralysis results, the trophic lesions quickly heal. In the majority of cases there is little difficulty in deciding whether operation is necessary or rjot. Even slight return ?f voluntary power negatives operation. In doubtful cases nothing is lost and often much gained by an exploratory ?peration, though occasionally the nerve may be found to be apparently normal in cases where the paralysis was complete. This is especially true of the musculo-spiral nerve. In plexus lesions where several trunks have been divided, often at different levels with much perineural scar-tissue, good
to the
accurate identification of trunks and end to end suture is most difficult, and if found to leave
things
Trotter
advises
every
impossible,
probably
early operation
nerve
in cauda
where there is the least
case
it is
alone than to do indiscriminate
better
crossing.
lesions in
equina suspicion of an
element
of pressure.
The post-operative treatment, and that of
division
of
nerves
is the
same as
given
cases
above in
of
partial
preliminary
treatment, and should be continued daily until there is a return ?f
voluntary impulses,
the lower
extremity
which may take weeks or years. In a walking instrument must also be
66
J. MICHELL CLARKE
LIEUT.-COL.
for
provided little
dropped
feet.
electrical treatment
nerve
time,
After end to end suture of should not be
and then with
begun
for
a
some
care.
great especially in the early stages, care must be fatigue of the muscles by electrical treatment;
In all cases, taken to avoid
the balance of evidence is that contractions due to electrical stimulation have
no
may be severe
beneficial in the
stage of'regeneration, but effect on muscular wasting. In later stages there irreparable paralysis and joint or bone lesions so are
as to
neutralise the effect of recovery of paralysed cases operations for tendon transplantation
muscles ; for such or
arthrodesis may be advisable. As to results. Cases of nerve concussion should
within four to six weeks ;
partial
division of
a nerve
recover
should
complete recovery in several months (? two to six). As to cases of complete division with secondary suture, it
go to
time to
speak as to the results. Meanwhile, some statements of recent experiences seem to show a much earlier return of sensation and motion than was before held possible. The greater the distance from the periphery the site of the lesion the longer is the period before recovery. is not
yet
Findings, by Short, M.S., F.R.C.S.
Operative Procedures
and
Capt. Rendle
2.
may appear to be normal (vide supra). division of the nerve, with a bulbous
mass
of the upper segment, succeeded by a of scar-tissue of variable thickness, and adherent to the
1.
The
nerve
Complete swelling at the end surrounding
tissues. The treatment
adopted is to free the segment through the swelling, so as to expose
two ends of the nerve, cut off the upper
upper end of or above the bulbous visible nerve-bundles with no excess of interstitial fibrous
tissue, and suture with catgut.
Many English
surgeons wrap
67
GUNSHOT WOUNDS OF PERIPHERAL NERVES.
the
junction in Cargile membrane ; others sometimes use a segment of saphena vein, but often nothing is used. It frequently happens that the ends cannot be brought
together
because of
bridged by
gap of
a
two or three
plies
one
to two inches.
This is
of internal cutaneous
from the upper arm, but some surgeons and others employ nerve-anastomosis.
use
nerve
catgut strands,
There may be a bulbous swelling on the nerve, to the track of the bullet, and it may be doubtful
3.
adherent
whether the nerve-fibres pass through it or are interrupted. In such a case we stimulate the nerve electrically above and below the bulb.
sized
(not
nerve
contract, the
saphena
If, in the
scar
of
a
small
sciatic), any muscles is freed and wrapped in
If there is
vein.
case
the
no
response,
we
or
medium-
supplied by it a segment of excise the
scar
and suture.
large nerve, such as the sciatic, may show symptoms partial division, and at operation part of the nerve shows a scar. The best procedure is to take out a quadrilateral, including the scar, and, by splitting the nerve-trunk up and down, to bring the two ends together, leaving the intact A
4.
?f
a
portion of the The
5.
bullet the
cause
time,
it is
undisturbed.
may be intact, but pressed upon by a shattered bone. The treatment is to remove
nerve
by
or
nerve
although this relieves pain at the during the process of healing, and
of pressure, but
apt
to return
prove very intractable.
REFERENCES.
Nerve Injuries and their Treatment, Purves Stewart & Evans, London, 1916. discussion on Gunshot Wounds of the Peripheral Nerves," Medical Society's Trans., 1916, xxxix. 27.
Core,
"
Dissociation of
Cutaneous Sensations in
Nerves," Lancet, 19x6, i. 716. Stopford, Peripheral Nerve Injuries," ibid., 1916, "
Injuries ii.
718.
to
Peripheral
68
LIEUT.-COL.
JAMES
SWAIN
"
Cause and Nature of Changes which occur in Muscles after Nerve Section," ibid., 1916, ii. p. 6.
Langley,
Langley, ibid., 1916, ii. p. 161. Hernaman Johnson, ibid., 1916, ii. p. 120. Hernaman Johnson, Condenser Reactions," Proc. Roy. Soc. Med., 1916, Surgical Section, p. 1. Warrington and Nelson, Musculo-Spiral Nerve Injuries," Liverpool Med. Chir. Journ., 1916, lxix. p. 61. Bernard Roth, Gunshot Wounds of Peripheral Nerves," Journ. R.A.M.C., 1915, i. p. 267. Treatment of Nerve Injuries of Warfare," Clin. Journ., 1916, Piatt, Aug. 9th., p. 285. Electrical Reaction of Muscles before and after Nerve Injury," Adrian, "
"
"
"
"
Brain, 1916, vol. xxxix., pt. i., p. 1. " Roberts, Degeneration of Muscle following Nerve Injury," Brain, 1916, vol. xxxix., pt. iii., p. 297.
" Electrical Testing," Proc. Roy. Soc. Med., 1914., Elect. Cumberbatch, Therap. Section, p. 38.
Purser, Roy. Acad. Med. Ireland, Section Surgery, 1916. Tubby, Nerve Concussion due to Bullet and Shell Wounds," Journ., 1915, i. p. 57. "
Brit. Med.
