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RE-PRINTED FROM THE "CANADA MEDICAL & SURGICAL JOURNAL - 
 
 JANUARY, 1887. 
 
 3 
 
 .' t 
 
 SECONDARY SUTURE OF THE ULNAR NERVE 
 WITH RAPID RESTORATION OF SENSATION. ' 
 
 By Francis J. Shepherd, M.D.. 
 Surgeon to the Montreal General Hospital. 
 
 Suture of nerves after division, though done by Arnemann in 
 1826 and Flourens in 1828, has never been performed exten- 
 sively till within the last few years. Primary suture of the 
 divided ends of nerves is a proceeding which commends itself to 
 every surgeon, but secondary suture has not been so popular, 
 and up to :]. end of 1885 only some half-dozen cases had been 
 reported in America. In these cases where the wound has long 
 closed, the divided ends of the nerve undergo degeneration, and 
 are generally imbedded in cicatricial tissue. The proximal end 
 is generally bulbous and the distal much atrophied ; both ends 
 are often so degenerated that no nerve structure can be found 
 in them. The divided ends are sometimes separated by a Ion*' 
 interval, the upper portion of the nerve retracting, and it is often 
 very difficult to bring them together. It was formerly thought 
 that to get union it was necessary to cut the terminal portions 
 of the nerve till healthy nerve tissue was reached ; this pro- 
 ceeding, of course, increased the distance between the divided 
 ends and the difficulty of bringing them together. It is, how- 
 ever, now conclusively proved that a mere joining of the fresh- 
 ened ends is all that is needed for purposes of union. Where 
 the divided ends of the nerve cannot be brought into contact, 
 strands of catgut, or fresh nerve tissue from amputated limbs, 
 have been introduced into the interval between the ends of the 
 nerves, and perfect restoration of function has followed. The 
 sooner the operation of secondary suture is performed after the 
 perfect healing of the original wound the better, but good results 
 have been obtained months and years after the division of the 
 
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 nerve. Mr. Jessop sutured the ulnar nerve with partial success 
 nine years after its division. 
 
 Many cases of apparent failure turn out well. Mr. Holmes 
 QLancet, June, 1883) reports a case where the function of the 
 nerve was not completely restored for more than a year after 
 operation. Sensation generally returns before motion, but occa- 
 sionally the opposite is the rule. In some cases, where sen- 
 sation was good in the course of a week, motion was not restored 
 for six months. It has been asserted by those who oppose the 
 suture of nerves months after the closure of the wound that the 
 nerves will recover their functions if left to themselves. That 
 they do so in some cases, says Mr. Holmes, is certain, and he 
 gives cases to prove it, but he remarks that such a favorable 
 issue is highly dubious, especially when the distance between 
 the divided ends is great and the proximal end terminates in a 
 bulbous enlargement. 
 
 With regard to the method of suturing the nerves, experi- 
 ments have been made on animals by Rawa, Falkenheim and 
 others. Rawa, in his cases, made the nerve ends overlap, and 
 held them together by an encircling ligature ; physiological union 
 took place at end of six to twenty months. Falkenheim united 
 nerves by the direct and indirect method ; in the former the 
 suture is passed through the trunk of the nerve, and in the latter 
 the sheaths only of the divided nerves are united. The indirect 
 was found by him to be preferable. It is now the opinion of 
 surgeons that it matters little how the divided ends are held so 
 long as the raw surfaces are firmly secured in close apposition. 
 Horse-hair, fine catgut and silk have been used as sutures, and 
 the ends of the nerves have been cut in various ways — oblique, 
 transverse, etc. It is important that after operation the newly 
 united nerve should be subject to as little tension as possible, 
 and that the union of the wound should be by first intention, for 
 if suppuration takes place the nerve may again become imbedded 
 in cicatricial tissue. The following case of suture of the ulnar 
 nerve is interesting because of the rapidity with which sensation 
 returned : — 
 
 John D., aged 50, in the beginning of April, 1885, whilst 
 working at Lake Nepissing, was cut with an axe over the left 
 
8 
 
 elbow, between the olecranon process and the internal condyle. 
 The wound healed rapidly, but he found that afterwards he could 
 not use his arm, and that there was considerable pain in the 
 elbow. He entered the Montreal General Hospital for treatment 
 June 23rd, 1885, some ten weeks after the injury, and then 
 presented the following conditions : Left arm was semiflexed and 
 fixed ; on attempting to straighten it the man complained of 
 great pain in the elbow and resisted the movement ; the muscles 
 on the ulnar side of arm and hand were wasted, and the little 
 finger and ring finger bent and useless ; no sensation in the little 
 and ring fingers and other parts supplied by ulnar, and, in fact, 
 arm was useless and painful ; could not separate his fingers. 
 On examining the elbow, a scar two inches long was seen stretch- 
 ing across the space between the olecranon and internal condyle. 
 This cicatrix was excessively tender on pressure. The diagnosis 
 of division of the ulnar nerve was easily made, and next day 
 (June 24th) an operation was performed for the purpose of 
 uniting the divided ends. An incision was made in the line of 
 the ulnar nerve and across the scar, and the nerve reached. The 
 upper end, which was bulbous, was easily discovered and dis- 
 sected out from the cicatricial tissue in which it was imbedded ; 
 half an inch lower down was found the other end, much atrophied, 
 and also imbedded in scar tissue. After dissecting out the 
 divided ends, they were freshened and l)rought together with a 
 continuous suture of fine catgut^ the wound sewed up and dressed 
 with iodoform and dry dressing, a small drain inserted at the 
 lower end, and the arm was put up in the extended position in 
 an anterior splint. Next day when patient was seen he had a 
 tingling feeling in the little and ring fingers, and general and 
 tactile sensibility was good. The wound was first dressed on 
 the sixth day and the tube was removed ; union by first inten- 
 tion, except where drainage tube had been. It was firmly 
 healed on July 8th, and gentle movement was commenced in 
 the arm. The sensation was good, but motion was deficient. 
 As his wound was healed he was allowed to go home, with a 
 promise that he would write and let me know how he progressed. 
 He was told that it would probably be some months before he 
 recovered the use of his arm. 
 
 tii 
 
') 
 
 Not hearing from him, my house surgeon, Dr. Eberta, wrote 
 in January, 1886, and received a reply from Nepissmg saymg 
 he was fast recovering the use of his arm, and that he had gone 
 back to his work ; and the only complaint he had was a slight 
 burning pain in his little finger. Since then I have endeavored 
 to hear from him, but cannot find out his whereabouts, he havmg 
 left Nepissing some months ago. 
 
 The rapid restoration of sensibility in this case is the interest- 
 ing feature. Surmay (Archives GSn. de MSdecine, Oct. '85,) 
 reports a case where general and tactile sensibility were restored 
 in twenty-four hours after resection of three-quarters of an inch 
 of the median nerve, and the complete restoration of the other 
 functions occurred after six months. 
 
 Note.— In May, 1884, Dr. Roddick of Montreal sutured the 
 sciatic nerve in a young man seventeen months after its division. 
 The immediate result of the operation was the healing of two 
 troublesome ulcers on the foot. Sensation did not return for 
 some time, and motion is not yet completely restored, b'tt he is 
 still improving, and can now walk about without a stick. The 
 interest in this case lies in the rapid restoration of the nerves of 
 nutrition, whilst those of sensation and motion more slowly re- 
 sumed their functions. 
 
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