Fulminating Septicaemia associated with Purpura and Adrenal Haemorrhage (Waterhouse-Friderichsen Syndrome)

Abstract

Short nerve gaps, however, are not a problem of human surgery, and in addition do not test out the utmost limitations of the homeograft. We considered it necessary to determine the fate of grafts at least three inches long in order that the results might have more direct application to the surgery of man.We therefore carried out a series of experiments in monkeys, the results of which are being recorded in detail elsewhere. Briefly, in eight monkeys three inches of the external popliteal division of the sciatic nerve in the upper part of the thigh was removed and the gap bridged by a similar length of external popliteal nerve from the thigh of another monkey.The extent of regeneration through the grafts was determined at different periods after operation by noting the results of electrical stimulation of the nerves and by histological study of the graft and the nerve distal to the graft, as in our previous work in 1936. We found, much as we had expected, that the graft excited a connectivetissue reaction, but that fibres were able to grow through it to the distal end of the nerve, and that about 250 days after operation motor response was obtained in the extensors of the foot. At 500 days there was a very satisfactory motor response, and histological study showed large numbers of fibres in the external popliteal nerve as low down as the ankle. Endoneural scar at the suture lines was more severe than when autogenous grafts were used, and we believe it would be advantageous to employ the technique described by Davis and Cleveland (1934) and excise the distal suture line at a time when it was estimated that nerve fibres had reached this level, and so give the nerve fibres a better chance of reaching the distal end of the nerve.Commentary Our experiments showed without equivocation that a three-inch gap in a main limb nerve of a monkey can be bridged with a homeograft. A nerve graft does not solve the problem of the incomplete recovery that follows nerve suture as a result of axon crossing. It probably intensifies it compared with simple nerve suture, but it is the only way to get even a partial result when a length of nerve has been lost. We believe that where a nerve gap exists in a limb nerve of man a homeograft from a fresh cadaver should be employed, since the results in monkeys are so encouraging and there is no other satisfactory method of treatment. The greatest accuracy in suturing, followed by careful recording of the result, will give us an answer to whether the homeograft can solve the problem of the limb-nerve gap in man.