Family Health Care Nursing: Theory,

Practice, and Research 6th Edition

Visit to download the full and correct content document:
https://ebookmass.com/product/family-health-care-nursing-theory-practice-and-resear
ch-6th-edition/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Family Therapy: History, Theory, and Practice 6th

Edition, (Ebook PDF)

https://ebookmass.com/product/family-therapy-history-theory-and-
practice-6th-edition-ebook-pdf/

Health Behavior: Theory, Research, and Practice

(Jossey-Bass Public Health)

https://ebookmass.com/product/health-behavior-theory-research-
and-practice-jossey-bass-public-health/

Family therapy : History, Theory, and Practice 6th,

Edition Samuel T. Gladding

https://ebookmass.com/product/family-therapy-history-theory-and-
practice-6th-edition-samuel-t-gladding/

Health Psychology: Theory, Research and Practice 5th

Edition, (Ebook PDF)

https://ebookmass.com/product/health-psychology-theory-research-
and-practice-5th-edition-ebook-pdf/
Mental Health Nursing: Applying Theory to Practice. 1st
Edition Gylo Hercelinskyj

https://ebookmass.com/product/mental-health-nursing-applying-
theory-to-practice-1st-edition-gylo-hercelinskyj/

Health Care Ethics (6th Edition ) 6th Edition

https://ebookmass.com/product/health-care-ethics-6th-edition-6th-
edition/

eTextbook 978-1451187908 Maternal and Child Health

Nursing: Care of the Childbearing and Childrearing
Family

https://ebookmass.com/product/etextbook-978-1451187908-maternal-
and-child-health-nursing-care-of-the-childbearing-and-
childrearing-family/

Maternal Child Nursing Care 6th Edition

https://ebookmass.com/product/maternal-child-nursing-care-6th-
edition/

Patient and Public Involvement in Health and Social

Care Research: An Introduction to Theory and Practice
1st ed. Edition Jurgen Grotz

https://ebookmass.com/product/patient-and-public-involvement-in-
health-and-social-care-research-an-introduction-to-theory-and-
practice-1st-ed-edition-jurgen-grotz/
 SIXTH EDITION

•
Care urstng

Joanna Rowe Kaakinen

Deborah Padgett Coehlo
Rose Steele
Melissa Robinson
00_Rowe_FM.indd 6 12/22/17 12:59 PM
 Pre f a c e

OVERVIEW OF THE course in family nursing. An alternative approach

for the use of this text is for students to purchase the
SIXTH EDITION book at the beginning of their program of study so

A
that specific chapters can be assigned for specialty
sk anyone about a time they were affected
courses throughout the curriculum. The sixth edition
by something that happened to one of their
complements a concept-based curriculum design.
  family members and you will be overwhelmed
For example, Chapter 16, Family Mental Health
with the intensity of the emotions and the exhaustive
Nursing, could be assigned when students take
details. Every person is influenced significantly by his
their mental health nursing course, and Chapter
or her family and the structure, function, and processes
13, Family Child Health Nursing, could be studied
within the family. Even people who do not interact
during a pediatric course or in conjunction with a
with their families have been shaped by their families.
life-span–concept curriculum for chronic illness
The importance and connection between individuals
and acute care courses. Thus, this textbook could
and their families have been studied expansively in
be integrated throughout the undergraduate or
a variety of disciplines, including nursing.
graduate nursing curriculum.
The importance of working in partnerships
Families in North America are very similar relative
with families in the health care system is evident.
to needs and health care outcomes. Though it is true
Yet many health care providers view dealing with
that the United States and Canada have different
patients’ families as an extra burden that is too
health care systems, many of the stressors and chal-
demanding. Some nurses are baffled when a family
lenges for families overlap. All of the chapters in this
acts or reacts in certain ways that are foreign to their
edition include information, statistics, programs, and
own professional and personal family experiences.
interventions that address the individual needs of
Some nurses avoid the tensions and anxiety that
families and family nurses for both Canada and the
exist in families during a crisis situation. But it is in
United States. Where nursing practice and policy
just such situations that families most need nurses’
differ, specific content is included that addresses
understanding, knowledge, and guidance.
these policies and interventions.
The purpose of this book is to provide nursing
students, as well as practicing nurses, with the un-
derstanding, knowledge, and guidance to practice
family nursing. Since the last edition there have been ADDITIONS AND DELETIONS
many changes in families, family health, and policy
that affect the health of families. Every chapter in This edition contains one new chapter, Chapter 7,
this edition reflects those changes with updated, Nursing Care of LGBTQ Families. Since the
current, evidence-based information. last edition gay marriage has been legalized in all
states. All chapters have been changed and updated
significantly so that they reflect the present state of
USE OF THIS BOOK “family,” current evidence-based practice, research,
and interventions. Chapter 4, Family Policy, is
Family Health Care Nursing: Theory, Practice, and significantly updated and focused more on helping
Research, Sixth Edition, is organized so that it can students understand the importance of policy in
be used on its own and in its entirety to structure a providing access to health care.
vii

00_Rowe_FM.indd 7 12/22/17 12:59 PM

 viii Preface
STRUCTURE OF THIS BOOK
Each chapter begins with the critical concepts to be
addressed within that chapter. The purpose of placing
the critical concepts at the beginning of the chapter is
to focus the reader’s thinking and learning and offer
a preview and outline of what is to come. Another
organizing framework for the book is presented in
Chapter 2, Theoretical Foundations for the Nursing
of Families. This chapter covers the importance of
using theory to guide the nursing of families and
presents five theoretical perspectives, with a case study
demonstrating how to apply these five theoretical
approaches in practice. These three family nursing
theories, Family Systems Theory, Developmental
and Family Life Cycle Theory, and Bioecological
Theory, are threaded throughout the book and are
applied in many of the chapter case studies. Most
of the chapters include two case studies; all of the
case studies contain family genograms and ecomaps.
The main body of the book is divided into three
units: Unit 1: Foundations in Family Health Care
Nursing, which includes Chapters 1 to 5; Unit 2:
Families Across the Health Continuum, which includes
Chapters 6 to 11; and Unit 3: Nursing Care of Families
in Clinical Areas, which includes Chapters 12 to 17.
AVAILABLE ON DAVISPLUS
The Family Health Care Nursing Active Classroom
Instructors’ Guide is an online faculty guide that pro-
vides assistance to faculty teaching family nursing or
the nursing care of families in a variety of settings.
Instructors will also find PowerPoint presentations
and test bank questions for each chapter.
The References, Suggested Readings, and Web
resources are available for students and instructors.
In addition, a bonus chapter, Relational Nursing
and Family Nursing in Canada, and Appendix A,
The Friedman Family Assessment Model, are on
DavisPlus.
UNIT 1: FOUNDATIONS IN
FAMILY HEALTH CARE NURSING
Chapter 1: Family Health Care Nursing: An
­Introduction provides foundational materials ­essential
to understanding families and family nursing. The
00_Rowe_FM.indd 8
first half of the chapter discusses dimensions of family
nursing and defines family, family health, and healthy
families. The chapter follows with an explanation of
family health care nursing and the nature of interven-
tions in the nursing care of families, along with the four
approaches to family nursing (context, client, system,
and component of society). The chapter then presents
the concepts or variables that influence family nursing,
family nursing roles, and obstacles to family nursing
practice. The second half of the chapter elaborates on
theoretical ideas involved with understanding family
structure, family functions, and family processes.
Chapter 2: Theoretical Foundations for the
Nursing of Families lays the theoretical groundwork
needed to practice family nursing. The introduction
builds a case for why nurses need to understand the
interactive relationships among theory, practice, and
research. It also makes the point that no single the-
ory adequately describes the complex relationships
of family structure, function, and processes. The
chapter then continues by delineating and explaining
relevant theories, concepts, propositions, hypotheses,
and conceptual models. Selected for this textbook,
and explained in this chapter, are three theoretical/
conceptual models specific to family nursing: Family
Systems Theory, Developmental and Family Life
Cycle Theory, and Bioecological Theory. Using a
family case study, the chapter explores how each of
the three theories could be used to assess and plan
interventions for a family. This approach enables
learners to see how different interventions are derived
from different theoretical perspectives.
Chapter 3: Family Demography: Continuity
and Change in North American Families provides
nurses with a basic contextual orientation to the
demographics of families and health. This chapter
examines changes and variations in North American
families in order to understand what these changes
portend for family health care nursing. The subject
matter of the chapter is structured to provide family
nurses with background on changes in the North
American family so that they can understand their
patient populations. The chapter briefly touches on
the implications of these demographic patterns on
practicing family nursing.
Chapter 4: Family Policy: The Intersection of
Family Policies, Health Disparities, and Health
Care Policies explores the many factors and poli-
cies that influence the health outcomes for families.
Threaded throughout the chapter is the role of the
nurse providing care within a framework of family
12/22/17 12:59 PM

nursing and multiple sociopolitical contexts. Specif-
ically, key theoretical models guide family policies
that continue to be challenged by health disparities
resulting from negative social ­stigmatizations,
­restricted access to health care resources, and a
complex political system of cultural beliefs that
contribute to continued negative health outcomes.
Health disparities are explored in the context of health
determinants, family policy, and the nurse’s role in
advocating for family policies that enhance, rather
than discriminate against, positive health care and
resulting health outcomes. This chapter also discusses
the unique factors that affect health policy and family
health across Westernized countries. A case study has
been added that demonstrates the role of nurses in
advocating for family policies. At the completion of
this chapter, the nurse will have developed a broad
understanding of family policy and how it can con-
tribute to or mitigate health disparities and health
outcomes. Armed with this knowledge, nurses can
assist families to adopt health promotion and disease
prevention strategies and can advocate for families
in their organizations, communities, and nations
for policies that minimize disparities and maximize
access to resources. This, in turn, will contribute
to improved health of families and their members.
Chapter 5: Family Nursing Assessment and
Intervention presents a systematic approach to
­develop a plan of action for the family with the family,
to address its most pressing needs. This chapter is
built on the traditional nursing process model to
create a dynamic systematic family nursing assessment
approach. Assessment strategies include selecting
assessment instruments, determining the need for
interpreters, assessing for health literacy, and learning
how to diagram family genograms and ecomaps.
The chapter also explores ways to involve families
in shared decision making and explores analysis, a
critical step in the family nursing process that helps
focus the nurse and the family on identification of
the family’s primary concern(s). The chapter uses a
family case study as an exemplar to demonstrate the
family nursing assessment and intervention.
UNIT 2: FAMILIES ACROSS
THE HEALTH CONTINUUM
Chapter 6: Family Health Promotion fosters
the health of the family as a unit and encourages
families to value and incorporate health promotion
00_Rowe_FM.indd 9
Preface ix
into their lifestyles. The purpose of this chapter is to
introduce the concepts of family health and family
health promotion. The chapter presents models
to represent these concepts, including the Family
Health Model, the Family Resilience Framework,
the McMaster Model of Family Functioning, the
Family Health Promotion Model, the Developmen-
tal Model of Health and Nursing, and the Model
of the Health-Promoting Family. The chapter also
examines internal and external factors through a lens
of the bioecological systems theory that influences
family health promotion, family nursing intervention
strategies for health promotion, and two family case
studies demonstrating how different theoretical
­approaches can be used for assessing and intervening
in the family for health promotion.
Chapter 7: Nursing Care of LGBTQ Fami-
lies is a new chapter for this edition. Families with
LGBTQ members are working to achieve the same
socially prescribed functions of all families to rear
responsible and independent children, provide
emotional and instrumental support to one another,
and provide family member health care across the
life span. Nurses care for families with members
with unique gender identities, sexual orientations,
and family structures in a variety of settings and
circumstances with increasing visibility and fre-
quency. The purpose of this chapter is to provide
nurses with an evidence-based foundation and to
facilitate the delivery of culturally competent fam-
ily nursing care, thus decreasing health risks and
disparities among this most vulnerable population.
In this chapter, historical, political, sociocultural,
religious, and economic contexts are explored that
influence the meaning of gender, gender identi-
ties, and gender expressions. Language and social
ideas about gender are ever evolving; therefore,
a glossary of terms and pronouns is presented to
assist nurses in using correct terminology to create
safe and ­respectful dialogue from the position of
learner when caring for LGBTQ individuals and
their families. The chapter presents LGBTQ family
structures and family processes that are unique to
LGBTQ families, which are explored across the life
span. Health challenges and disparities in LGBTQ
families also are presented using a life-span approach.
A case study demonstrates evidence-based family
nursing practice.
Chapter 8: Genomics and Family Nursing
Across the Life Span describes nursing responsi-
bilities for families of persons who have, or are at
12/22/17 12:59 PM
 x Preface
risk for having, genetic conditions. The ability to
apply an understanding of genetics in the care of
families is a priority for nurses and for all health
care providers. As a result of genomic research and
the rapidly changing body of knowledge ­regarding
genetic influences on health and illness, more
­emphasis has been placed on involving all health
care providers in this field, including family n
­ ursing.
Genetic ­conditions are life-long, so families living
with genetic conditions need ongoing care and
support. These responsibilities are described for
families working with individuals and families across
the life span. The goal of the chapter is to describe
the relevance of genetic information within ­families
when there is a question about genetic aspects of
health or disease for members of the family. The
chapter begins with a brief introduction to ­genomics
and genetics, and then goes on to explain how
families react to finding out they are at risk for
genetic conditions and decide how and with whom
to disclose genetic information. The critical aspect
of confidentiality is then discussed. The chapter
outlines the components of conducting a genetic
assessment and history and offers interventions that
include education and resources. Several specific case
examples and a detailed case study illustrate nurses
working with families that have a member(s) with
a genetic condition.
Chapter 9: Families Living With Chronic
Illness describes ways for nurses to think about the
impact of chronic illness on families and to consider
strategies for helping families manage chronic
illness. The chapter begins with the importance of
integrating ethnoculture in family health care and
the impact of chronic illness on family life. Four
theoretical approaches are introduced for assisting
nurses to think about the best way to assist the family
living with chronic illness. The rest of the chapter
captures a variety of possible nursing actions to assist
these families. Two case studies are presented in this
chapter: one family who has a family member living
with type 1 diabetes and another family helping an
older parent and grandparent managing Parkinson’s
disease. Although every family and illness experience
is completely individual, many of the trials that these
two families demonstrate are universal to other
families supporting members living with different
chronic illnesses.
Chapter 10: Families in Palliative and End-of-Life
Care details the key components to consider in
providing palliative and end-of-life care, as well as
00_Rowe_FM.indd 10
families’ most important concerns and needs when a
family member experiences a life-threatening illness
or is dying. It also presents some concrete strategies
to assist nurses in providing optimal palliative and
end-of-life care to all family members. More spe-
cifically, the chapter begins with a brief definition
of palliative and end-of-life care, including its focus
on improving quality of life for patients and their
families. The chapter then outlines principles of
palliative care and ways to apply these principles
across all settings, regardless of whether death results
from chronic illness or a sudden or traumatic event.
Three evidence-based, palliative care and end-of-life
case studies conclude the chapter.
Chapter 11: Trauma and Family Nursing
helps nurses develop knowledge about trauma
and family nurses’ key role in the field of trauma.
It emphasizes the importance of prevention, early
treatment, encouraging family resilience, and helping
the family to make meaning out of negative events.
This chapter also stresses an understanding of sec-
ondary trauma or the negative effects of witnessing
the trauma of others. This discussion is particularly
salient for family nurses, because they are some of
the most likely health care providers to encounter
traumatized victims in their everyday practice. Two
case studies explicate family nursing when working
with families who are experiencing the effects of
traumatic life events.
UNIT 3: NURSING CARE OF
FAMILIES IN CLINICAL AREAS
Chapter 12: Family Nursing With Childbearing
Families focuses on family relationships and the
health of all family members in childbearing fam-
ilies. Therefore, nurses involved with childbearing
families use family concepts and theories as part
of developing the plan of nursing care. A review
of literature provides current evidence about the
processes families experience when deciding on
and adapting to childbearing, including theory
and clinical application of nursing care for fami-
lies planning pregnancy, experiencing pregnancy,
adopting and fostering children, struggling with
infertility, and coping with illness during the early
postpartum period. This chapter starts by presenting
theoretical perspectives that guide nursing practice
with childbearing families. It continues with an
exploration of family nursing with childbearing
12/22/17 12:59 PM

families before conception through the postpar-
tum period. The chapter covers specific issues that
childbearing families may experience, including
postpartum depression, attachment concerns, and
postpartum illness. Nursing interventions are inte-
grated throughout this chapter to demonstrate how
family nurses can help childbearing families prevent
complications, increase coping strategies, and adapt
to their expanded family structure, development,
and function. The chapter concludes with two case
studies that explore family adaptations to stressors
and changing roles related to childbearing.
Chapter 13: Family Child Health Nursing
builds on the major task of families to nurture
children to become healthy, responsible, creative
adults who can develop meaningful relationships
across the life span. Families experience the stress
of normative transitions with the addition of each
child and situational transitions when children are
ill. Knowledge of the family life cycle, child devel-
opment, and illness trajectory provides a foundation
for offering anticipatory guidance and coaching at
stressful times. Family life influences the promotion
of health and the experience of illness in children,
and is influenced by children’s health and illness. This
chapter provides a brief history of family-centered care
of children and then presents foundational concepts
that will guide nursing practice with families with
children. The chapter goes on to describe nursing
care of well children and families with an empha-
sis on health promotion, nursing care of children
and families in acute care settings, nursing care of
children with chronic illness and their families, and
nursing care of children and their families during
end of life. Case studies illustrate the application of
family-centered care across settings.
Chapter 14: Family Nursing in Acute Care
Adult Settings discusses how the hospitalization of
an adult family member for an acute illness, injury,
or exacerbation of a chronic illness is stressful for
patients and their families. The ill adult enters the
hospital, usually in a physiological crisis, and the
family most often accompanies the ill or injured
family member into the hospital; both the patient
and the family are usually in an emotional crisis.
Families with members who are acutely or critically
ill are seen in adult medical-surgical units, intensive
care or cardiac care units, or emergency depart-
ments. The purpose of this chapter is to describe
family nursing in acute care settings, including
families in the CCUs and medical-surgical units.
00_Rowe_FM.indd 11
Preface xi
The chapter begins with a review of literature that
captures the major stressors families face during
hospitalization of an adult family member: the
transfer from one unit to another, being discharged
home, participation in cardiopulmonary resusci-
tation (CPR), withdrawing life support therapy,
and organ donation. This chapter concludes with
a family case study that (1) highlights the issues
families experience and adapt to when an adult
member is ill; and (2) applies the Family Systems
Theory in order to demonstrate one theoretical
approach for working with families.
Chapter 15: Family Health in Mid- and Later
Life examines families using a variety of different
theoretical approaches, including Family Systems
Theories, Developmental and Family Life Cycle
Theory, and a Bioecological Model. The chapter
presents evidence-based practice on working with
adults in mid- and later life, including a review of
living choices for older adults with chronic illness,
and the importance of peer relationships and
intergenerational relationships to quality of life.
This chapter includes extensive information about
family caregiving for and by older adults, including
spouses, adult children, and grandparents. Two case
studies conclude the chapter. One family case study
illustrates the integrated generational challenges
facing older adults today. The second case study
addresses care of an older adult family member
who never married and has no children. This case
presents options for caregiving and the complexity
of living healthy.
Chapter 16: Family Mental Health Nursing
begins with a brief demographic overview of the
pervasiveness of mental health conditions (MHCs)
in both Canada and the United States. The remain-
der of the chapter focuses on the impact a specific
MHC can have on the individual with the MHC,
individual family members, and the family as a
unit. Although the chapter does not go into specific
diagnostic criteria for various conditions, it does
offer nursing interventions to assist families. One
case study explores the impact and treatment of
substance abuse. The second presents how a family
nurse can work with a family to improve the health
of all family members when one family member lives
with paranoid schizophrenia.
Chapter 17: Families and Community and
Public Health Nursing offers a description of
community health nursing in promoting the health
of families in communities. It begins with a definition
12/22/17 12:59 PM
 xii Preface
of community health nursing and follows with a
discussion of concepts and principles that guide
the work of these nurses, the roles they enact in
working with families and communities, and the
various settings in which they work. This discussion
00_Rowe_FM.indd 12
is organized around a visual representation of
community health nursing. The chapter ends with
a discussion of current trends in community and
public health nursing. A case study is presented on
working with a homeless family.
12/22/17 12:59 PM

Annette Bailey, PhD, RN
Associate Professor
Ryerson University
Toronto, Ontario, Canada
Mary E. Bartlett, DNP, APRN,
FNP-BC, AAHIVs
Assistant Professor
Linfield-Good Samaritan School of Nursing
Linfield College
Portland, Oregon
Henny Breen, PhD, RN, CNE, COI
Associate Professor of Nursing
Linfield-Good Samaritan School of Nursing
Linfield College
Portland, Oregon
Juliana C. Cartwright, PhD, RN
Associate Professor
School of Nursing
Oregon Health & Science University
Portland, Oregon
Lynne M. Casper, PhD
Professor of Sociology
University of Southern California
Los Angeles, California
Deborah Padgett Coehlo, PhD, C-PNP,
PMHS, CFLE
Developmental and Behavioral Specialist
Juniper Pediatrics
Faculty Member
Oregon State University Cascades
Bend, Oregon
Alli Coritz, PhD Candidate
PhD Candidate, Sociology
University of Southern California
Los Angeles, California
00_Rowe_FM.indd 13
C o n t ri b u t o r s
Dawn Doutrich, PhD, RN
Associate Professor Emeritus
College of Nursing
Washington State University
Vancouver, Washington
Linda L. Eddy, PhD, RN, ARNP
Associate Dean and Associate Professor
College of Nursing
Washington State University
Vancouver, Washington
Louise Fleming, PhD, RN
Assistant Professor
School of Nursing
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Tammy L. Henderson, PhD, CFLE
Professor and Department Chair
Family and Consumer Sciences
Lamar University
Beaumont, Texas
Joanna Rowe Kaakinen, PhD, RN
Professor and Interim Dean
Linfield-Good Samaritan School of Nursing
Linfield College
Portland, Oregon
YeounSoo Kim-Godwin, PhD, MPH,
CNE, RN
Professor
School of Nursing
University of North Carolina Wilmington
Wilmington, North Carolina
Kimberly E. Kintz, DNP, ANP-BC, RN
Associate Professor
Linfield-Good Samaritan School of Nursing
Linfield College
Portland, Oregon
xiii
12/22/17 12:59 PM
 xiv Contributors

Chuck Lester, MPH Candidate Rose Steele, PhD, RN

Grant Coordinator Professor
Oklahoma State University School of Nursing, Faculty of Health
Stillwater, Oklahoma York University
Toronto, Ontario, Canada
Judith A. MacDonnell, BScN, RN,
MEd, PhD Aaron Tabacco, PhD, RN
Associate Professor Director of Pre-Licensure Program
School of Nursing, Faculty of Health Linfield-Good Samaritan School of Nursing
York University Linfield College
Toronto, Ontario, Canada Portland, Oregon

Joyce M. O’Mahony, RN, PhD Marcia Van Riper, PhD, RN, FAAN
Assistant Professor Professor
School of Nursing Chair of Family Health Division
Thompson Rivers University University of North Carolina at Chapel Hill
Kamloops, British Columbia, Canada Chapel Hill, North Carolina

Carole A. Robinson, PhD, RN Linda Veltri, PhD, RN

Associate Professor
Professor
RN to BSN Program Director
School of Nursing
Northwest Christian University
University of British Columbia Okanagan
Eugene, Oregon
Kelowna, British Columbia, Canada
Jacqueline F. Webb, DNP, FNP-BC, RN
Melissa Robinson, PhD, RN Associate Professor
Associate Professor of Nursing
Linfield-Good Samaritan School of Nursing
Linfield-Good Samaritan School of Nursing
Linfield College
Linfield College
Portland, Oregon
Portland, Oregon
Diana L. White, PhD
Laura S. Rodgers, PhD, PMHNP-BC Senior Research Associate
Professor Institute on Aging
Linfield-Good Samaritan School of Nursing Portland State University
Linfield College Affiliate Faculty
Portland, Oregon School of Nursing
Maria Elena Ruiz, PhD, RN, FNP-BC Oregon Health and Science University
Associate Adjunct Professor Portland, Oregon
School of Nursing Kimberley A. Widger, PhD, RN,
Coordinator, International Scholarly Activities CHPCN(C)
Mexico-Cuba Programs Assistant Professor
Affiliate Faculty: Chicano Studies Research Center; Lawrence S. Bloomberg School of Nursing
Latin America Institute University of Toronto
University of California Los Angeles Toronto, Ontario, Canada
Los Angeles, California
Karline Wilson-Mitchell, DNP, MSN,
Paul S. Smith, PhD, RN, CCRN, CNE CNM, RN, RM
Assistant Professor Associate Professor
Linfield-Good Samaritan School of Nursing Midwifery Education Program
Linfield College Ryerson University
Portland, Oregon Toronto, Ontario, Canada

00_Rowe_FM.indd 14 12/22/17 12:59 PM

 Revi ew e r s

Christine Aramburu Alegria, PhD, Brenda G. Kucirka, PhD,

APRN, FNP-BC PMHCNS-BC, CNE
Associate Professor Assistant Professor
Orvis School of Nursing Widener University
University of Nevada, Reno Chester, Pennsylvania
Reno, Nevada
Victoria Kyarsgaard, DNP, RNC,
Jennifer Casperson, MSN, RN, CPN, PHN, CNE
CHSE Associate Professor
Nursing Instructor Crown College
Everett Community College St. Bonifacius, Minnesota
Everett, Washington
Joan Clites, EdD, RN Krista Lussier, RN, BScN, MSN
Associate Professor of Nursing Senior Lecturer
California University of Pennsylvania Thompson Rivers University
California, Pennsylvania Kamloops, British Columbia
Canada
Patricia E. Freed, MSN, EdD, CNE
Associate Professor, Faculty Nicole McCain, MSN, RN, CNE, CNL
School of Nursing Assistant Professor
Saint Louis University Jefferson College of Health Sciences
St. Louis, Missouri Roanoke, Virginia
Mary Ann Glendon, PhD, RN
ACE and RN to BSN Program Coordinator Kim Pickett, MS, APRN, BC-ADM,
Professor of Nursing CDE/PhD(c)
Nurse Practitioner
Southern Connecticut State University
Center for Family Medicine Residency Program
New Haven, Connecticut
Spartanburg Regional Healthcare System
Sue K. Goebel, RN, MS, WHNP, SANE Spartanburg, South Carolina
Associate Professor of Nursing
Colorado Mesa University Judith Quaranta, PhD, RN, CPN,
Grand Junction, Colorado AE-C, FNAP
Beverley Jones, RN, MScN, MPA Assistant Professor
Professor BScN Collaborative Program Decker School of Nursing
St. Clair College Binghamton University
Windsor, Ontario Binghamton, New York
Canada Theresa Turick-Gibson, EdD(c), MA,
Jean M. Klein, PhD, PMHCNS, BC PNP-BC, RN-BC
Associate Professor Emerita Professor
Widener University Hartwick College
Chester, Pennsylvania Oneonta, New York
xv

00_Rowe_FM.indd 15 12/22/17 12:59 PM

 xvi Reviewers

Susan S. VanBeuge, DNP, APRN, Kelli D. Whittington, PhD, RN, CNE

FNP-BC, CNE, FAANP Chair, Division of Nursing
Associate Professor in Residence Assistant Professor
University of Nevada, Las Vegas McKendree University
Las Vegas, Nevada Lebanon, Illinois

00_Rowe_FM.indd 16 12/22/17 12:59 PM

 Contents

U N I T 1 Foundations in Family Health Care Nursing 1

chapter 1 Family Health Care Nursing 3

An Introduction
Joanna Rowe Kaakinen, PhD, RN
chapter 2 Theoretical Foundations for the Nursing of Families 27
Joanna Rowe Kaakinen, PhD, RN
chapter 3 Family Demography 53
Continuity and Change in North American Families
Lynne M. Casper, PhD
Alli Coritz, PhD Candidate

chapter 4 Family Policy 83

The Intersection of Family Policies, Health Disparities,
and Health Care Policies
Deborah Padgett Coehlo, PhD, C-PNP, PMHS, CFLE
Tammy L. Henderson, PhD, CFLE
Chuck Lester, MPH Candidate

chapter 5 Family Nursing Assessment and Intervention 113

Joanna Rowe Kaakinen, PhD, RN

U N I T 2 Families Across the Health Continuum 147

chapter 6 Family Health Promotion 149

YeounSoo Kim-Godwin, PhD, MPH, CNE, RN
Melissa Robinson, PhD, RN
chapter 7 Nursing Care of LGBTQ Families 181
Judith A. MacDonnell, BScN, RN, MEd, PhD
Mary E. Bartlett, DNP, APRN, FNP-BC, AAHIVs
Aaron Tabacco, PhD, RN
chapter 8 Genomics and Family Nursing Across the Life Span 211
Marcia Van Riper, PhD, RN, FAAN
Louise Fleming, PhD, RN

xvii

00_Rowe_FM.indd 17 12/22/17 12:59 PM

 xviii Contents

chapter 9 Families Living With Chronic Illness 231

Jacqueline F. Webb, DNP, FNP-BC, RN
Maria Elena Ruiz, PhD, RN, FNP-BC
Kimberly E. Kintz, DNP, ANP-BC, RN
chapter 10 Families in Palliative and End-of-Life Care 279
Carole A. Robinson, PhD, RN
Rose Steele, PhD, RN
Kimberley A. Widger, PhD, RN, CHPCN(C)
Melissa Robinson, PhD, RN
chapter 11 Trauma and Family Nursing 323
Deborah Padgett Coehlo, PhD, C-PNP, PMHS, CFLE
Henny Breen, PhD, RN, CNE, COI

U N I T 3 Nursing Care of Families in Clinical Areas 355

chapter 12 Family Nursing With Childbearing Families 357

Linda Veltri, PhD, RN
Karline Wilson-Mitchell, DNP, MSN, CNM, RN, RM
Joyce M. O’Mahony, RN, PhD
chapter 13 Family Child Health Nursing 389
Deborah Padgett Coehlo, PhD, C-PNP, PMHS, CFLE
chapter 14 Family Nursing in Acute Care Adult Settings 429
Paul S. Smith, PhD, RN, CCRN, CNE
Melissa Robinson, PhD, RN
chapter 15 Family Health in Mid- and Later Life 457
Diana L. White, PhD
Juliana C. Cartwright, PhD, RN
chapter 16 Family Mental Health Nursing 497
Laura S. Rodgers, PhD, PMHNP-BC
chapter 17 Families and Community and Public Health Nursing 533
Linda L. Eddy, PhD, RN, ARNP
Annette Bailey, PhD, RN
Dawn Doutrich, PhD, RN

Index 557

00_Rowe_FM.indd 18 12/22/17 12:59 PM

 Foundations
1
U N I T

in Family
Health Care
Nursing

01_Rowe_Ch01.indd 1 30/11/17 4:48 pm

01_Rowe_Ch01.indd 2 30/11/17 4:48 pm
 C h a p t er
1
Family Health Care Nursing
An Introduction
Joanna Rowe Kaakinen, PhD, RN

Critical Concepts

■■ Family health care nursing is an art and a science that has evolved as a way of thinking about and working with
families.
■■ The term family is defined in many ways, but the most salient definition is, The family is who the members say it is.
■■ Health and illness are family events.
■■ Health and illness affect all members of families.
■■ Families influence the process and outcome of health care.
■■ Understanding families enables nurses to assess the family health status, ascertain the effects of the family on
individual family member’s health status, predict the influence of alterations in the health status of the family system,
and work with members as they plan and implement action plans customized for improved health for each individual
family member and the family as a whole.
■■ Knowledge about each family’s structure, function, and process informs the nurse in how to optimize nursing care in
families and provide individualized nursing care, tailored to the uniqueness of every family system.

Family health care nursing is an art and a science,
a philosophy and a way of interacting with families
about health care. It has evolved since the early
1980s as a way of thinking about, and working
with, families when a member experiences a health
problem. This philosophy and practice incorporates
the following assumptions:
■■ Health and illness affect all members of
families.
■■ Health and illness are family events.
■■ Families influence the process and outcome
of health care.
All health care practices, attitudes, beliefs, behaviors,
and decisions are made within the context of larger
family and societal systems.
Families vary in structure, function, and processes.
The structure, functions, and processes of the family
influence and are influenced by each individual family
member’s health status and the overall health status
of the whole family. Families even vary within given
cultures because every family has its own unique
culture. People who come from the same family of
origin create different families over time. Nurses need
to be knowledgeable about the theories of families

01_Rowe_Ch01.indd 3 30/11/17 4:48 pm

 4 Foundations in Family Health Care Nursing
© iStock.com/YinYang
as well as the structure, function, and processes of
families to assist them in achieving or maintaining
a state of health.
When families are considered the unit of care—as
opposed to individuals—nurses have much broader
perspectives for approaching health care needs of
both individual family members and the family unit
as a whole (Kaakinen & Hanson, 2015). Under-
standing families enables nurses to assess the family
health status, ascertain the effects of the family on
individual family members’ health status, predict
the influence of alterations in the health status of
the family system, and work with members as they
plan and implement action plans customized for
improved health for each individual family member
and the family as a whole.
Recent advances in health care, such as changing
health care policies and health care economics,
ever-changing technology, shorter hospital stays,
and health care moving from the hospital to the
community/family home, are prompting changes
from an individual person paradigm to the nursing
care of families as a whole. This paradigm shift is
affecting the development of family theory, prac-
tice, research, social policy, and education, and it
is critical for nurses to be knowledgeable about
and at the forefront of this shift. The centrality
of family-centered care in health care delivery is
emphasized by the American Nurses Association
(2015) in its publication, described in the American
Nurses Association Guide to Nursing’s Social Policy
Statement (Fowler, 2015). In addition, ANA’s Nursing:
Scope and Standards of Practice mandates that nurses
provide family care (ANA, 2015). The National
Strategy for Quality Improvement in Health Care is
the first policy to set national goals to improve the
quality of health care (Department of Health and
01_Rowe_Ch01.indd 4
Human Services [DHHS], 2015). It sets standards
and regulations to measure the quality of health
care and its impacts on public health. The National
Quality Strategy (DHHS, 2015), the Nursing Alliance
for Quality Care (NAQC, 2013), and the Agency
for Health care Research and Quality (2015) place a
priority on ensuring that each person and the family
as a whole are engaged as partners in their health
care. “Nurses have an ethical and moral obligation
to involve families in their health care practices”
(Wright & Leahey, 2013, p. 1).
The overall goal of this book is to enhance nurses’
knowledge and skills in the theory, practice, research,
and social policy surrounding nursing care of families.
This chapter provides a broad overview of family
health care nursing. It begins with an exploration
of the definitions of family and family health care
nursing, as well as the concept of healthy families.
Next are described four approaches to working with
families: family as context, family as client, family
as system, and family as a component of society.
The chapter presents the varied, but ever-changing,
family structures and explores family functions
relative to reproduction, socialization, affective
function, economic issues, and health care. Finally,
the chapter discusses family processes, so that nurses
know how their practice makes a difference when
families experience stress because of the illness of
individual family members.
THE FAMILY AND FAMILY
HEALTH
Three foundational components of family nurs-
ing are (1) determining how family is defined,
(2) ­understanding the concepts of family health,
and (3) knowing the current evidence about the
elements of a healthy family.
What Is the Family?
Family life is a universal human experience and
no two individuals have the exact same expe-
rience within a family (Galvin, Braithwaite, &
Bylund, 2015). However, there is no universally
agreed-upon definition of family. Now more than
ever, the traditional definition of family is being
challenged and is shifting. Canada enacted the Civil
Marriage Act in 2005, becoming the fourth country
to legalize same-sex marriage (Hogg, 2006). Spain
had legalized same-sex marriage less than a month
30/11/17 4:48 pm

earlier. In June 2015, the United States became
the 21st country to legalize same-sex marriage
nationwide (Pew Research Center, 2015). Family is
a word that conjures up different images for each
individual and group, and the word has evolved
in its meaning over time. Definitions differ by
discipline; for example:
■■ Legal: relationships through blood ties, adop-
tion, guardianship, or marriage
■■ Biological: genetic biological networks among
and between people
■■ Sociological: groups of people living together
with or without legal or biological ties
■■ Psychological: groups with strong emotional
ties
Historically, early family social science theorists
(Burgess & Locke, 1953, pp. 7–8) adopted the fol-
lowing traditional definition in their writing:
The family is a group of persons united by ties of
marriage, blood, or adoption, constituting a single
household; interacting and communicating with
each other in their respective social roles of husband
and wife, mother and father, son and daughter,
brother and sister; and creating and maintaining a
common culture.
The U.S. Census Bureau basically has held the
same definition of family since 1930 (Pemberton,
2015). It defines family as two or more people
living together who are related by birth, marriage,
or adoption. This traditional definition continues to
be the basis for the implementation of many social
programs and policies. Yet, this definition excludes
many diverse groups who consider themselves to be
families and who perform family functions, such as
economic, reproductive, and affective functions, as
well as child socialization. Depending on the social
norms, all the following examples could be viewed
as “family”: married or remarried couples with
biological or adoptive children, cohabitating same-
sex couples (gay and lesbian families), single-parent
families with children, kinship care families such as
two sisters living together, or grandparents raising
grandchildren without the parents.
The definition of family adopted by this text-
book and that applies from the previous edition
(Kaakinen & Hanson, 2015) is as follows: Family
refers to two or more individuals who depend on one
another for emotional, physical, and economic support.
The members of the family are self-defined. Nurses
who work with families should ask clients who they
01_Rowe_Ch01.indd 5
Family Health Care Nursing: An Introduction 5
© iStock.com/Juanmonino
consider to be members of their family and should
include those persons in health care planning with
the patient’s permission.
What Is Family Health?
The World Health Organization (WHO, 2016) notes
that there are more than 400 million people in the
world who lack essential health care. In response
to this growing need, the WHO developed the
Framework on Integrated People-Centered Health
Services. This framework states that care should be
coordinated around the needs of the people; respect
their preferences; and be safe, effective, timely, af-
fordable, and of acceptable quality. It is important to
note that this framework is not about patient-centered
care, which focuses on the individual, but is about
people-centered care that expands the care to indi-
viduals, families, communities, and society. The term
family health is often used interchangeably with the
terms family functioning, healthy families, or familial
health. To some, family health is the composite of
individual family members’ physical health, because
it is impossible to make a single statement about the
family’s physical health as a single entity.
The definition of family health adopted in this
textbook and that applies from the previous edition
(Kaakinen & Hanson, 2015) is as follows: Family
health is a dynamic, changing state of well-being, which
includes the biological, psychological, spiritual, sociological,
and cultural factors of individual members and the whole
family system. This definition and approach combines
all aspects of life for individual members, as well as
for the whole family. An individual’s health (on the
wellness-to-illness continuum) affects the entire
family’s functioning; in turn, the family’s ability to
function affects each individual member’s health.
30/11/17 4:48 pm
 6 Foundations in Family Health Care Nursing
Assessment of family health involves simultaneous
data collection on individual family members and the
whole family system (Kaakinen & Hanson, 2015).
What Is a Well-Functioning Family?
Although it is possible to define family health, it is
more difficult to describe characteristics of a family
that is well-functioning. Characteristics used to de-
scribe functional versus dysfunctional families have
varied throughout time in the literature. Krysan,
Moore, and Zill (1990) described “healthy families”
as “successful families” in a report prepared by the
U.S. DHHS. Otto (1963) was the first scholar to
develop psychosocial criteria for assessing family
strengths, and emphasized the need to focus on
positive family attributes instead of the patholog-
ical approach that accentuated family problems
and weaknesses. Pratt (1976) introduced the idea
of the “energized family” as one whose structure
encourages and supports individuals to develop
their capacities for full functioning and independent
action, thus contributing to family health. Curran
(1985) investigated not only family stressors but
also traits of healthy families, incorporating moral
and task focus into traditional family functioning.
These traits are listed in Box 1-1.
Olson and Gorall (2005) conducted a longitudinal
study on families in which they merged the concepts
of marital and family dynamics in the Circumplex
Model of Marital and Family Systems. They found
that the ability of the family to demonstrate flexibility
Box 1-1
Traits of a Healthy Family
■■ Communicates and listens
■■ Fosters table time and conversation
■■ Affirms and supports each member
■■ Teaches respect for others
■■ Develops a sense of trust
■■ Has a sense of play and humor
■■ Has a balance of interaction among members
■■ Shares leisure time
■■ Exhibits a sense of shared responsibility
■■ Teaches a sense of right and wrong
■■ Abounds in rituals and traditions
■■ Shares a religious core
■■ Respects the privacy of each member
■■ Values service to others
■■ Admits to problems and seeks help
01_Rowe_Ch01.indd 6
is related to its ability to alter family leadership
roles, relationships, and rules, including control,
discipline, and role sharing. Functional, healthy
families have the ability to change these factors
in response to situations. Dysfunctional families,
or unhealthy families, have less ability to adapt
and flex in response to changes. See Figures 1-1
and 1-2, which depict the differences in functional
and dysfunctional families in the Circumplex Model.
Balanced families will function more adequately
across the family life cycle and tend to be healthier
families. The family communication skills enable
balance and help families to adjust and adapt to
situations. Couples and families modify their levels
of flexibility and cohesion to adapt to stressors, thus
promoting family health.
Building on the work of Olson and Gorall (2005),
Metegevic, Todorovic, and Javanovic (2014) conducted
a study that explored patterns of family function
related to parenting style. Their work supports the
idea that balanced cohesion and balanced flexibility
are the dominant patterns of family functioning.
Well-functioning families have tremendous diversity
in the ways they cope with predictable and unpre-
dictable stressors and changes (Bush, Price, Price, &
McKenry, 2015).
FAMILY HEALTH CARE NURSING
The specialty area of family health care nursing
has been evolving since the early 1980s. Some
question how family health care nursing is distinct
from other specialties that involve families, such as
maternal-child health nursing, community health
nursing, and mental health nursing. The definition
and framework for family health care nursing adopted
by this textbook and that applies from the previous
edition (Kaakinen & Hanson, 2015) is as follows:
The process of providing for the health care needs
of families that are within the scope of nursing
practice. This nursing care can be aimed toward the
family as context, the family as a whole, the family
as a system, or the family as a component of society.
At the same time, it cuts across the individual,
family, and community for the purpose of promoting,
maintaining, and restoring the health of families.
This framework illustrates the intersecting concepts
of the individual, the family, nursing, and society
(Figure 1-3).
30/11/17 4:48 pm
Another random document with
no related content on Scribd:
mistake in the formation of a diagnosis. There are, nevertheless,
some pathological conditions, such as hemorrhages in the medulla
oblongata or thrombosis and embolism of the arteries supplying the
latter with blood, which may give rise to the same or very similar
phenomena, and thus render a correct diagnosis difficult. In such
cases it must be remembered that the cause of true labio-glosso-
laryngeal paralysis, depending upon degeneration and atrophy of the
nervous nuclei along the floor of the fourth ventricle, is very gradual,
while the symptoms produced by the causes before mentioned
generally make their appearance in a more acute and sudden
manner. The latter also, if not remaining stationary for some time,
have rather a tendency to improvement, wanting, therefore, the
progressive character of the former.

Tumors at the base of the brain also, by pressing upon the roots of
the cerebral nerves or upon the medulla oblongata itself, may
produce similar symptoms, which, on account of their comparatively
slow and gradual development, may prove more difficult to
distinguish from those characterizing genuine, progressive labio-
glosso-laryngeal paralysis. Errors of diagnosis, however, may here
be avoided by taking into consideration the special symptoms which
generally accompany the presence of tumors of the brain, such as
vertigo, headache, vomiting or even hemiplegia, and local paralysis.
The sensory nerves also may become affected by the pressure of
the tumor upon them. Thus, pressure upon the trifacial nerve may
give rise to neuralgic pains, feelings of tingling and numbness, or
even anæsthesia; while pressure upon the optic nerves or their
tracts, or upon the olfactory and lingual nerves, will be followed by
derangements of vision, smell, and taste. The symptoms produced
by the pressure of a tumor at the base of the brain, moreover, are
not strictly progressive, but may for some time appear, and
disappear again before becoming permanent.

Facial diplegia, in which the expression of the face somewhat

resembles that of a patient affected with labio-glosso-laryngeal
paralysis, is distinguished from the latter disease by the paralysis
affecting both divisions of the facial nerve, while the tongue remains
free and deglutition is undisturbed.

There are still other affections of the cerebro-spinal axis, such as

paralysis of the insane, disseminated sclerosis, etc., which in their
course present some or perhaps all of the symptoms characterizing
labio-glosso-laryngeal paralysis; these may be distinguished from
the latter disease by taking their own special symptoms into
consideration.

TREATMENT.—Although almost all cases of progressive labio-glosso-

laryngeal paralysis terminate fatally, some cases have been reported
by several observers in which a temporary improvement in the
symptoms of the disease, or even a total cure, had been obtained by
treatment. Of course such favorable results can only be obtained in
the initial or earlier stages of the disease. Thus, Kussmaul
recommends in the initial stage, when pains in the head and neck
are present, wet cupping of the nape of the neck in strong persons,
also the use of the shower-bath, while nitrate of silver may be given
internally. The application of galvanism in an alternate direction he
also recommends—first, through the neck, and later on through the
whole spinal column—and at the same time currents in an
alternating direction from the neck and hypoglossus nerve to the
tongue. Dowse reported a case of bulbar paralysis which he cured
by the application of the constant current upon the paralyzed parts,
subcutaneous injections of atropine and strychnine, with the internal
administration of cod-liver oil, quinine, and phosphorus. He attaches
great importance to the careful feeding of the patient through a tube
passed through the nose, and to the strict application of the galvanic
current; for excessive salivation he recommends atropine. Erb
recommends to regulate the diet and the habits of life of the patient
in such a manner as to avoid every irritation of the nervous system;
furthermore, to generally stimulate the nutrition in order to produce a
tonic effect upon the nervous system. For this purpose he principally
relies upon a cautious hydropathic treatment, to be continued for a
long time and with great regularity. The greatest importance,
however, he attaches to electricity, considering the best method of
galvanism as follows: “Galvanize with stabile application transversely
through the mastoid processes and longitudinally through the skull,
the so-called galvanism of the cervical sympathetic (anode on the
nuchus, and cathode at the angle of the lower jaw), and then induce
movements of deglutition (twelve to twenty at each sitting); besides
this, apply, according to circumstances, direct galvanic or faradic
currents to the tongue, lips, and palate.” The electric treatment must
be continued for some time, with from four to seven sittings a week.
Of the medicines taken internally, Erb recommends nitrate of silver,
iodide of potassium, iodide of iron, chloride of gold and sodium,
ergotin, belladonna, and preparation of iron and quinine.

DISEASES OF THE PERIPHERAL NERVES.

BY FRANCIS T. MILES, M.D.

The nervous system of the higher animals is the apparatus by which

stimuli coming from the external world or originating in the interior of
their own bodies are perceived (its sensitive functions), or cause
muscular contraction (its motor functions), or, lastly, cause molecular
changes in tissues (its trophic functions).
Besides this power which the nervous system possesses of
receiving impressions originating outside of itself and actively
replying to them, it appears also to possess the power of originating
within itself changes the result of which are sensations, movements,
and trophic alterations. In other words, it can act automatically.

The apparatus for the performance of these various functions

consists of the end-organs, the nervous centres, and the nerves.

The end-organs are peripheral mechanisms for the reception of

impressions. The structure and mode of action of some of them, as
the eye and the ear, are pretty well understood, while others, as
those connected with the sense of touch, temperature, etc., are but
imperfectly known. It is probable that there are also peripheral
mechanisms which facilitate the delivery of the impulses coming
from the nerve-centres to the organs, tissues, muscles, glands, etc.

The nervous centres are made up of nerve-cells variously connected

with each other. They are immediately concerned in receiving
impressions conveyed to them by the nerves and transforming them
into sensations, or transmitting them to other organs, causing reflex
actions, or in originating sensations and impulses.

The nerves are organs which, connected at one extremity with the
end-organs and at the other with the nervous centres, convey
peripheral impressions to the centres, and impulses and influences
from the centres to the various organs of the body.

As it is with diseases of the peripheral nerves that we are now

concerned, let us begin by looking more closely into their structure
and functions.

The nerves appear to the naked eye as white strands of variable

size, which a close inspection shows to be made up of threads or
fibrils (best seen when the cut end of a nerve is examined) bound
together by fine connective tissue and scantily supplied with blood-
vessels. A microscopic examination shows that each of the fibrils
visible to the naked eye is made up of a great number of fibres.
These are the medullated nerve-fibres, and they extend unbroken
between the nerve-centres, with the cells of which they are
connected, to the various organs and tissues, with which they also
enter into organic union.

If we examine the structure of a medullated nerve-fibre, we find it to

consist of a central thread called the central axis or axis-cylinder, in
which close microscopic investigation shows a longitudinal striation,
indicating that it is made up of fibrillæ. Surrounding the central axis
like a sheath is the white substance of Schwann, composed of an
oleo-albuminous substance, myeline, to which the nerves owe their
white appearance. According to some observers, the white
substance of Schwann is pervaded by a meshwork of fibres.
Surrounding the white substance of Schwann is the sheath of
Schwann, a structureless membrane having at intervals upon its
inner surface nuclei, around which is a small amount of protoplasm.

At intervals along the course of the nerve-fibres are seen

constrictions which involve the sheath and white substance of
Schwann, but which do not affect the central axis, which passes
unbroken the points of constriction. These are the nodes of Ranvier.
Each space on the fibre beneath the nodes of Ranvier contains one
of the nuclei of the sheath of Schwann, and probably, together with
the white substance of Schwann, represents a cellular element.
Diseased conditions sometimes respect the limits of these cellular
elements.

The central axis is the true conducting part of the nerve-fibre, and it
is probable that each of the fibrillæ of which it is composed has a
separate peripheral termination and possesses the power of isolated
conduction. The white substance of Schwann and the sheath of
Schwann protect the central axis and seem to be connected with its
nutrition.

The fibres in a nerve are bound together by loose connective tissue,

the endoneurium, into the primitive bundles, which are again united
by the perineurium, a membrane of laminated connective tissue, into
more definite funiculi seen by the naked eye, the secondary bundles.
The secondary bundles are tied together by connective tissue, in
which are found fat-cells and in which run the fine blood-vessels
supplying the nerves. This connective tissue has been named the
epineurium, and its condensed outer layers constitute the sheath of
the nerve. It is important to observe that the connective tissue of the
nerves is permeated by lymphatics which penetrate to the nerve-
fibres, so that these are brought in contact with, and as it were,
bathed in, the lymph.

Each nerve-fibre runs an isolated course from end to end, without

anastomosing with other fibres, and near its peripheral termination it
usually divides into two or more branches.

The fibres of the peripheral nerves depend for their integrity and
nutrition upon their connection with central organs. The large
multipolar cells of the anterior horns of gray matter of the spinal cord
preside over the nutrition of the motor fibres; the ganglia on the
posterior roots of the spinal nerves over the nutrition of the sensitive
fibres.

If a nerve be severed from its connection with these centres of

nutrition, it in a short while undergoes degenerative changes which
result in complete destruction of its fibres.

The nerve-fibres when in a state of functional activity conduct

impressions along their length to the end-organs or to the nerve-
centres with which they are in connection. This property of the fibres
we call their conductivity. Each fibre conducts impressions in an
isolated manner, not communicating them to other fibres with which
it may be in contact. The rapidity of this conduction in human nerve-
fibres is estimated at 33.9 meters (about 38 yds.) per second. This
rate may be diminished by cold or by the anelectrotonic condition
which is induced in the nerve by the passage through it of an electric
current.

The nerve-fibres are irritable; that is, the application to them of

stimuli excites their functional activity, and the impression made by
the stimulus is transmitted to their extremities.1
 1 The nerve-fibres in man do not appear to attain their full irritability until the fifth or
tenth month after birth (Soltman).

The natural or physiological stimuli of the nerves act upon their

extremities. Either they act through the peripheral mechanisms,
giving rise to impressions which are conducted centripetally to the
cells of the nerve-centres and there cause sensations or reflex
actions, or they act upon the nerve-centres, giving rise to impulses
which are conducted centrifugally and cause the various phenomena
of contraction of muscles, inhibition of contraction, secretion, etc.
Besides the physiological, there are other stimuli which excite the
functional activity of nerve-fibres when applied at any point along
their course.

Mechanical stimuli, blows, concussions, pressure, traction, etc.,

excite the nerves, causing sensations when applied to sensitive
nerves, or contraction of muscles when applied to motor nerves.
When mechanical stimuli are pushed farther, the irritability of the
nerves may be destroyed. The gradual application of mechanical
stimuli may destroy the irritability of nerve-fibres without any
exhibition of excitation, as in paralysis from pressure. In nerve-
stretching it is probable that many of the results depend upon the
mechanical stimulation of the nerve-fibres by the traction. With a
certain amount of force used the irritability of the nerve may be
increased; carried farther, both the irritability and the conductivity
may be diminished, and finally destroyed. As the centripetal fibres
are soonest affected in the stretching, we can see how this
proceeding is most beneficial in neuralgias, where a potent factor, if
not the cause of the disease, is an abnormal excitability of the nerve-
fibres. It is to be observed, nevertheless, that in cases of continued
pressure upon mixed nerves the motor fibres are the first to suffer
loss of their conductivity.

Sudden alterations of temperature act as stimuli to nerves. Heat

increases their irritability, but its prolonged application diminishes it.
Cold in general diminishes the nervous irritability, and may be carried
to the point of completely destroying it temporarily.2
 2 But at a certain age in freezing the ulnar nerve Mitchell found its irritability notably
increased.

Many substances of widely-different chemical constitution, as acids,

alkalies, salts, alcohol, chloroform, strychnine, etc., act as stimuli
when applied directly to the nerves, apparently by causing in them
rapid molecular changes. Also may be enumerated as chemical
stimuli to the nerves substances found naturally in the body, as bile,
bile salts, urea. The rapid withdrawal of water from nerve-tissue first
increases, and then diminishes, its irritability. The imbibition of water
decreases nervous irritability.

An electric current of less duration than the 0.0015 of a second does

not stimulate the nerve-fibres. It would appear that more time is
required for the electric current to excite in nerve-tissue the state of
electrotonus which is necessary to the exhibition of its functional
activity. The electric current stimulates a nerve most powerfully at the
moments of entrance into and exit from the nerve, and the more
abruptly this takes place the greater the stimulation. Thus the weak
interrupted currents of the faradic or induced electricity owe their
powerfully stimulating effects to the abruptness of their generation
and entrance into and exit from the nerves. At the moment of the
entrance of the electric current into the nerve—that is, upon closing
the circuit—the stimulating effect is at the negative pole or cathode;
when the current is broken—i.e. leaves the nerve—the stimulating
effect is at the positive pole or anode. A current of electricity very
gradually introduced into or withdrawn from a nerve does not
stimulate it. But if while a current is passing through a nerve its
density or strength be increased or diminished with some degree of
rapidity, the nerve is stimulated, and the degree of stimulation is in
proportion to the suddenness and amount of change in the density or
strength of the current. Although with moderate currents the
stimulation of the nerve takes place only upon their entrance and
exit, or upon variations of their density, nevertheless, with a very
strong current the stimulation continues during the passage of the
current through the nerve. This is shown by the pain elicited in
sensitive nerves, and the tetanic contraction of the muscles to which
motor nerves are distributed.

An important factor in electrical stimulation is the direction of the

current through the nerve. A current passed through a nerve at right
angles with its length does not stimulate it. Currents passing through
a nerve stimulate in proportion to the obliquity of their direction, the
most stimulating being those passing along the length of the nerve.
Motor nerves are more readily stimulated by the electric current the
nearer it is applied to their central connection. Experiments on the
lower animals would seem to indicate that the motor fibres in a
nerve-trunk do not all show the same degree of irritability when
stimulated by the electric current.

The irritability of the nerve-fibres may be modified or destroyed in

various ways. Separation of nerves from their nutritive centres
causes at first an increase of their irritability, which is succeeded by a
diminution and total loss, these effects taking place more rapidly in
the portions nearer the nerve-centres. It is important to observe that
an increase of irritability preceding its diminution is generally
observed in connection with the impaired nutrition of nerves, and is
the first phase of their exhaustion.

Prolonged and excessive activity or disuse of nerves causes

diminution of their irritability, which may go to the extent that neither
rest in the one case nor stimulation in the other can restore it. If a
galvanic current is passed through a nerve in its length, the irritability
of the fibres is increased in the region of catelectrotonus—viz. in the
part near the cathode—and diminished in the region of
anelectrotonus—viz. in the part near the anode. Certain substances,
as veratria, first increase and then destroy the irritability of the
nerves; others, as woorara, rapidly destroy it.

The fibres of the peripheral nerves are divided into two classes: first,
those which conduct impressions or stimuli to the nerve-centres, the
afferent or centripetal fibres; and, secondly, those which conduct
impulses from the centres to peripheral organs, the efferent or
centrifugal fibres. Belonging to the first class are (1) sensitive fibres,
whose stimulation sets up changes in the nerve-centres which give
rise to a sensation; (2) excito-motor fibres, whose stimulation sets up
in the nerve-centres changes by which impulses are sent along
certain of the centrifugal fibres to peripheral end-organs, causing
muscular contraction, secretion, etc. Belonging to the second class
are (1) motor fibres, through which impulses are sent from the nerve-
centres to muscles, causing their contraction; (2) secretory fibres,
through which impulses from nerve-centres stimulate glands to
secretion; (3) trophic fibres, through which are conveyed influences
from the centres, affecting the nutritive changes in the tissues; (4)
inhibitory fibres, through which central influences diminish or arrest
muscular contraction or glandular activity. No microscopic or other
examination reveals any distinction between these various fibres.

Every nerve-fibre has the power of conducting both centripetally and

centrifugally, but the organs with which they are connected at their
extremities permit the exhibition of their conductivity only in one
direction. Thus, if a nerve-fibre in connection with a muscle at one
end and a motor nerve-cell at the other be stimulated, although the
stimulus is conducted to both ends of the fibre, the effect of the
stimulus can only be exhibited at the end in connection with the
muscle, causing the muscle to contract. Or if a fibre in connection
with a peripheral organ of touch be stimulated, we can only
recognize the effects of such stimulation by changes in the nerve-
cells at its central end which give rise to a sensation.

When we consider the extensive distribution and exposed position of

the peripheral nerves, their liability to mechanical injury and to the
vicissitudes of heat and cold, we cannot but anticipate that they will
be the frequent seat of lesions and morbid disturbances. It may be
that not a few of their diseased conditions have escaped observation
from a too exclusive looking to the central nervous system as the
starting-point of morbid nervous symptoms. This occurs the more
readily as many of the symptoms of disease of the peripheral nerves,
as paralysis of muscles, anæsthesia, hyperæsthesia, etc., may
equally result from morbid conditions of the brain or spinal cord, and
not unfrequently the peripheral and central systems are conjointly
affected in a way which leaves it doubtful in which the disease began
or whether both systems were simultaneously affected.

The elucidation of such cases involves some of the most difficult

problems in diagnosis, and requires not only a thorough
acquaintance with the normal functions of the peripheral nerves, but
also the knowledge of how those functions are modified and
distorted in disease.

The symptoms arising from injuries and diseases of the peripheral

nerves are referable to a loss, exaggeration, or perversion of their
functions, and we often see several of these results combined in a
single disease or as the result of an injury.

The fibres may lose their conductivity or have it impaired, causing

feebleness or loss of motion (paralysis), or diminution or loss of
sensation (anæsthesia). Or there may be induced a condition of
over-excitability, giving rise to spasm of muscles and sensations of
pain upon the slightest excitation, not only from external agents, but
from the subtler stimulation of molecular changes within themselves
(hyperæsthesia). Or diseased conditions may induce a state of
irritation of the nerve-fibres, which shows itself in apparently
spontaneous muscular contraction or in sensations abnormal in their
character, and not corresponding to those ordinarily elicited by the
particular excitation applied, as formication or tingling from simple
contact, etc. (paræsthesiæ), or in morbid alterations of nutrition in
the tissues to which the fibres are distributed (trophic changes).

If we could recognize the causes of all these varied symptoms and

discover the histological changes invariably connected with them, it
would enable us to separate and classify the diseases of the
peripheral nerves, and give us a sound basis for accurate
observation and rational therapeutics. But, although the progress of
investigation is continually toward the discovery of an anatomical
lesion for every functional aberration, we are still so far from a
complete pathological anatomy of the peripheral nerves that of many
of their diseases we know nothing but their clinical history. We are
therefore compelled in treating of the diseases of the peripheral
nerves to hold still to their classification into anatomical and
functional, as being most useful and convenient, remembering,
however, that the two classes merge into each other, so that a rigid
line cannot be drawn between them, and that such a classification
can only be considered as provisional, and for the purpose of more
clearly presenting symptoms which we group together, not as
entities, but as pictures of diseased conditions which may thus be
more readily observed and studied.

It is well to begin the study of the diseases of the peripheral nerves

by a consideration of nerve-injuries, because in such cases we are
enabled to connect the symptoms which present themselves with
known anatomical alterations, and thus obtain important data for the
elucidation of those cases of disease in which, although their
symptomatology is similar, their pathological anatomy is imperfectly
or not at all known.

Injuries of the Peripheral Nerves.

If the continuity of the fibres of a mixed nerve be destroyed at some

point in its course by cutting, bruising, pressure, traction, the
application of cold, the invasion of neighboring disease, etc., there
will be an immediate loss of the functions dependent on the nerve in
the parts to which it is distributed. The muscles which are supplied
by its motor fibres are paralyzed; they no longer respond by
contraction to the impulse of the will. No reflex movements can be
excited in them either from the skin or the tendons. They lose their
tonicity, which they derive from the spinal cord, and are relaxed, soft,
and flabby. As the interrupted sensory fibres can no longer convey
impressions to the brain, we might naturally look for an anæsthesia,
a paralysis of sensation, in the parts to which they are distributed, as
complete as is the loss of function in the muscles. Such, however, is
not the fact. Long ago cases were observed in which, although
sensitive nerves were divided, the region of their distribution retained
more or less sensation, or seemed to recover it so quickly that an
explanation was sought in a supposed rapid reunion of the cut fibres.
Recent investigations, moreover, show that in a large number of
cases where there is complete interruption of continuity in a mixed
nerve the region to which its sensitive fibres are distributed retains,
or rapidly regains, a certain amount of sensation, and that absolute
anæsthesia is confined to a comparatively small area, while around
this area there is a zone in which the sensations of pain, touch, and
heat are retained, though in a degree far below the normal condition;
in short, that there is not an accurate correspondence between the
area of anæsthesia consequent upon cutting a sensitive nerve and
the recognized anatomical distribution of its fibres. We find the
explanation of this partly in the abnormal distribution of nerves, but
principally in the fact of the frequent anastomoses of sensitive
nerves, especially toward their peripheral distribution, thus securing
for the parts to which the cut nerve is distributed a limited supply of
sensitive fibres from neighboring nerves which have joined the trunk
below the point of section. This seems proved not only by direct
anatomical investigation, but also from the fact that the peripheral
portion of the divided nerve may be sensitive upon pressure, and
that the microscope shows normal fibres in it after a time has
elapsed sufficiently long to allow all the divided fibres to degenerate,
in accordance with the Wallerian law. Some of the sensation
apparently retained in parts the sensitive nerve of which has been
divided may be due to the excitation of the nerves in the adjacent
uninjured parts, caused by the vibration or jar propagated to them by
the mechanical means used to test sensation, as tapping, rubbing,
stroking, etc.3 It is to be observed that this retained sensation after
the division of nerves exists in different degrees in different regions
of the body; thus it is greatest in the hands, least in the face.
3 Létiévant, Traité des Sections nerveuses.

As the vaso-motor and trophic nerve-fibres run in the trunks of the

cerebro-spinal nerves, destructive lesions of these trunks cut off the
influence of the centres with which those fibres are connected, and
hence they are followed by changes in the circulation, calorification,
and nutrition of the parts to which they are distributed. Thus, the loss
of the vaso-motor influence is at first shown in the dilation of the
vessels and the unvarying warmth and4 congestion of the part.5 This
gives way in time to coldness, due to sluggish circulation and
diminished nutritive activity. Marked trophic changes occur in the
paralyzed muscles. They atrophy, their fibres becoming smaller and
losing the striations, while the interstitial areolar tissues proliferates,
and finally contracts cicatricially. The skin is sometimes affected in its
nutrition, becoming rough and scaly. Other trophic changes of the
skin resembling those produced by irritation of a nerve are very
rarely seen, and they may probably be referred to irritation of fibres
with which the part is supplied from neighboring trunks.
4 A remarkable exception is seen, however, in the effect of gradual pressure
experimentally applied to nerve-trunks until there is complete interruption of sensation
and motion, in which case the temperature invariably falls.

5 In a case of gunshot wound that came under the writer's care in 1862, the leg and
foot, which were paralyzed from lesion of the popliteal nerve, remained warm and
natural in color during repeated malarial chills, which caused coldness and pallor of
the rest of the body.

Anatomical Changes in the Divided Nerve and Muscles.—The

peripheral portion of a divided nerve separated from its nutritive
centres degenerates and loses its characteristic appearance, looking
to the naked eye like a grayish cord, and being shrunken to one-
fourth of its natural size. The changes which take place in the
degeneration of the nerve-fibres, and which proceed from the point
of lesion toward the periphery, are, first, an alteration of the white
substance of Schwann, which breaks into fragments, these melting
into drops of myeline, and finally becoming reduced to a granular
mass. The central axis at a later period likewise breaks up, and is
lost in the granular contents of the sheath of Schwann. Meanwhile,
absorption of the débris of the fibres goes on, until, finally, there
remains but the empty and collapsed sheath of Schwann with its
nuclei, the whole presenting a fibrous appearance. When this has
taken place the degenerated motor nerve-fibres can no longer be
excited, and no stimulation applied to them can cause the muscles to
contract. At the same time, the muscles atrophy and undergo
degenerative changes in their tissue. The fibres become smaller and
their transverse striæ indistinct, with the appearance of fatty
degeneration, and finally there is proliferation of the interstitial
cellular tissue. They do not, however, lose their contractility, and
upon a mechanical stimulus being applied directly to them they
contract in a degree that is even exaggerated, but with a slowness
that is abnormal. If, now, we apply the stimulus of electricity to the
muscles themselves, we encounter phenomena of the greatest
interest and importance. The application of the faradic current,
however strong, elicits no contraction; there is loss of faradic
excitability. But if the galvanic current be applied the muscles
contract, and that, too, in reply to a current too weak to excite
healthy muscles to action; there is increased galvanic excitability.
The kind of contraction thus induced is peculiar, differing from that
ordinarily seen in muscles. Instead of its being short, and
immediately followed by relaxation, as when we make or break the
galvanic current in healthy muscles, it is sluggish, long-drawn out,
and almost peristaltic in appearance. This is characteristic of
degenerated muscles, and is the degenerative reaction. But there is
also a change in the manner in which the degenerated muscles reply
to the two poles of the galvanic current. Instead of the strongest
contraction being elicited, as in the normal condition, by the
application of the negative pole to the muscle (C. C. C., cathode
closing contraction), an equally strong or stronger is obtained by the
application of the positive pole (A. C. C., anode closing contraction),
while the contraction normally caused on opening the circuit by
removal of the positive pole (A. O. C., anode opening contraction)
becomes weaker and weaker, until it is at last exceeded by the
contraction upon opening the current by the removal of the negative
pole (C. O. C., cathode opening contractions). In short, the formula
for the reply of the healthy muscles to galvanic excitation is reversed;
there is a qualitative galvanic change in the paralyzed and
degenerated muscles.

If no regeneration of the nerve takes place, the reaction of the

muscles to the galvanic current is finally lost, and they exhibit those
rigid contractions which probably result from a sclerotic condition of
the intramuscular areolar tissue.

After complete destruction of the fibres of a nerve at some point of its

course, even when a considerable length of it is involved, and after
the consequent degeneration of the peripheral portion has taken
place, we have, with lapse of time, restoration of its function,
consequent upon its regeneration and the re-establishment of its
continuity. The histological changes by which the degenerated fibres
are restored and the divided ends reunited have not been made out
with such certainty as to preclude difference of opinion as to the
details. But the process in general seems to be a proliferation of the
nuclei in the sheath of Schwann, with increase of the protoplasm
which surrounds them, filling the sheath of Schwann with the
material from which the new fibre originates. In this mass within the
sheath is formed first the central axis of the new fibre, which is later
surrounded by the white substance of Schwann. With the
regeneration of the nerve-fibres the functions of the nerve return, but
in the order of sensation first, and afterward the power of transmitting
the volitional impulse to the muscles. Even after regeneration has so
far advanced that the muscles may be made to contract by an
exercise of the will, the newly-formed fibres fail to respond to other
stimuli; thus, the faradic current applied to the nerve does not cause
the muscles to contract; the stimulation is not transmitted along the
imperfectly restored fibres.

It may be here remarked that after regeneration has restored the

functions of a divided nerve the muscles to which it is distributed
may still exhibit for a time the degenerative reaction in consequence
of unrepaired changes in themselves. In the end we may look for
complete restoration in both nerve and muscles.

The time required for the regeneration and reunion of a divided

nerve depends somewhat upon the manner in which the destruction
has been caused. Thus, a nerve which has been divided by a clean
cut, and where the cut ends remain in apposition or close proximity,
unites much more readily than one in which bruising, tearing, or
pressure has destroyed an appreciable length of its fibres or the
divided ends have been thrust apart.

In complete division of a nerve we must not look for regeneration

and restoration of its functions, even in favorable circumstances,
before the lapse of several months, although cases have been
recorded where the process has been much more rapid.

Injuries of mixed nerves, with incomplete destruction of the fibres,

give rise to many and varied symptoms, some of which are the direct
result of the injury—many others of subsequent changes of an
inflammatory character (neuritis) in the nerves or in the parts to
which they are distributed. Pain is one of the most prominent
symptoms immediately resulting from nerve-injury, although as a rule
it soon subsides. There is sometimes merely numbness or tingling,
or there may be no disturbance of sensation at the moment of injury.
Rarely is spasm of muscles an immediate effect. Generally, motion is
at first very much impaired, but if the injury is not grave enough to
cause a lasting paralysis, the muscles may rapidly regain their
activity. In observing the effects of injuries of mixed nerves one
remarkable fact strikes us: it is the very much greater liability of the
motor fibres to suffer loss or impairment of function. Thus, it is
common to see sensation but little or only transiently affected by
injuries which cause marked paralysis of muscles. So in the progress
of recovery the sensory disturbances usually disappear long before
restoration of the motor function; indeed, sensation may be entirely
restored while the muscular paralysis remains permanent. Direct
experimental lesions of the mixed nerve-trunks of animals give the
same result.6 For this immunity of the sensitive nerve-fibres no
explanation can be given other than an assumed difference in their
inherent endowments.
6 Luderitz, Zeitschrift für klin. Med., 1881.

According to the amount of damage the nerve has sustained will

there remain after the immediate effects of the injury have passed off
more or less of the symptoms already described as due to loss of
conductivity in the fibres—viz. paralysis of motion, and anæsthesia.
Sometimes the impairment of conductivity in the sensitive fibres
shows itself by an appreciable time required for the reception of
impressions transmitted through them, giving rise to the remarkable
phenomenon of delayed sensation. Degeneration of the nerve
peripherally from the point of lesion, and consequently of the
muscles, will likewise take place in a greater or less degree,
according to the amount of the injury and the subsequent morbid
changes, and give rise to the degenerative reaction which has been
already described. We will not, however, always encounter the
degenerative reaction in the typical form which presents itself after
the complete division of nerves. Many variations from it have been
observed; as, for instance, Erb's middle form of degenerative
reaction, in which the nerve does not lose the power of replying to
the faradic or galvanic current, but the muscles show both the loss of
the faradic with increased galvanic excitability, with also the
qualitative change in regard to the poles of the galvanic current.
Such irregularities may be explained by the supposition of an
unequal condition of degeneration in the nerve and the muscles. A
rare modification has been recorded which has once come under the
writer's observation, in which the muscles reply with the sluggish
contraction characteristic of the degenerative reaction to the
application of the faradic current.

A highly important class of symptoms arise later in injuries of nerves,

due not so much to a loss as to an exaggeration or perversion of
their functions: they are the result of molecular changes in the
nerves, giving rise to the condition called irritation. Irritation of motor
nerves shows itself in muscular spasm, or contractions of a tonic or
clonic character, or in tremor. If the sensitive fibres are irritated by an
injury or the subsequent changes in the nerve resulting from it, we
may have hyperæsthesia of the skin, in which, although the sense of
touch may be blunted, the common sensation is exaggerated, it may
be, to such a degree that the slightest contact with the affected part
gives rise to pain or to an indescribable sensation of uneasiness
almost emotional in its character—something of the nature of the
sensation of the teeth being on edge. There may be hyperæsthesia
of the muscles, shown by a sensitiveness upon deep pressure, in
which the skin has no part. Pain, spontaneous in its character, is a
very constant result of nerve-irritation, whether caused by gross
mechanical interference or by the subtler processes of inflammation
in the nerve-tissue. It is generally felt in the distribution of the
branches of the nerve peripheral to the point of lesion, although it is
occasionally located at the seat of the injury. Neuralgias are a
common result of the irritation of nerves from injuries.

Causalgia, a burning pain, differing from neuralgia, and sometimes

of extreme severity, is very frequent after injuries of nerves,
especially in parts where the skin has undergone certain trophic
changes (glossy skin). A number of abnormal sensations
(paræsthesiæ) result from the irritation of sensitive fibres, and are
common after nerve injuries. Among these we may mention a
sensation of heat (not the burning pain of causalgia) in the region of
the distribution of the nerve, which does not coincide with the actual
temperature of the part; it occurs not unfrequently after injury to a
nerve-trunk, and may be of value in diagnosis.

The effect of irritative lesions of mixed nerves upon nutrition is very

marked, and sometimes gives rise to grave complications and
disastrous results. Any or all of the tissues of the part to which the
injured nerve is distributed may be the seat of morbid nutritive
changes.

In the skin we may have herpetic or eczematous eruptions or

ulcerations. It may become atrophied, thin, shining, and, as it were,
stretched tightly over the parts it covers, its low nutrition showing
itself in the readiness with which it ulcerates from trifling injuries. This
condition, called glossy skin, usually appears about the hands or
feet, and is very frequently associated with causalgia. The hair may
drop off, or, as has been occasionally seen, be increased in amount
and coarsened, and the nails become thickened, crumpled, and
distorted.

The subcutaneous cellulo-adipose tissue sometimes becomes

œdematous, sometimes atrophies, and rarely has been known to
become hypertrophied. The bones and joints, finally, may, under the
influence of nerve-irritation, undergo nutritive changes, terminating in
various deformities.

With regard to the trophic changes, as well as to the pain and

paræsthesiæ resulting from nerve-injury, we must bear in mind that
they may be attributed not only to the direct irritation of trophic and
sensitive fibres in the injured nerve, but also, in part, to influences
reflected from abnormally excited nutritive centres in the spinal cord,
and to the spread of the sensitive irritation conveyed to the brain by
the injured fibres to neighboring sensitive centres, thus multiplying
and exaggerating the effect, causing, as it were, sensitive echoes
and reverberations. Indeed, the variety of the symptoms resulting
from apparently similar nerve lesions would seem to point to the
introduction of other factors in their causation than the simple injuries
of the nerve-fibres themselves.

DIAGNOSIS OF NERVE INJURIES.—Although in the great majority of

cases the circumstances attending nerve injuries render their
diagnosis a matter of little difficulty, it is yet important to keep in mind
those symptoms which distinguish them from lesions or diseases of
the brain and spinal cord, inasmuch as in cases of multiple lesion,
injuries to the spinal column, or where the history of the case is
imperfect, it may be difficult to determine to which part of the nervous
system, peripheral or central, some of the gravest resulting troubles
are due. Paralysis, spasm, anæsthesia, atrophy, etc. may be of
central or spinal as well as peripheral origin, and an intelligent
prognosis and rational treatment alike demand that we should
distinguish between them. Moreover, many diseased conditions of
the peripheral nerves of whose pathology we are ignorant, and in
which localizing symptoms—i.e. those indicating the exact point at
which the nerve is implicated—are wanting, can only be
distinguished as peripheral affections by the occurrence of
symptoms which we recognize as identical with those arising from
injuries of nerves, in which definite histological changes are known to
occur. Indeed, cases of disease of the nervous system are not
infrequent in which a careful study of their symptomatology leads to
a difference of opinion in the minds of the best observers as to