Surgical Experiences in South Africa, 1899-1900 Part 35

(125) _Brachial nerves._--Wounded at Magersfontein. _Entry_ and _exit_, in the upper third of the arm internal to the humerus.

Complete median paralysis, anaesthesia in the ulnar area, and in the radial supply to the dorsum of the middle and ring fingers.

Could flex, extend, and adduct and abduct the wrist; some power of flexion in index finger, in others none. The flexion of the wrist was dependent on the ulnar supply to the muscles of the forearm. No wasting of the interossei, skin normal except for a large trophic blister on the dorsum of the hand. Little improvement had taken place in this patient at the end of a year.

(126) _Brachial nerves._--Wounded at Magersfontein. The wound traversed the lower part of the upper third of the arm, fracturing the humerus. Immediate complete loss of power in the arm was experienced, together with loss of all sensation. Three weeks later the humerus was united; the fracture was evidently the result of pa.s.sing contact, and not of direct impact. The paralysis was still complete in the distribution of the median, ulnar, and musculo-spiral nerves. There was considerable wasting of the hand and forearm, and a good deal of thickening in the lower third of the arm.

Four months after the original injury, the nerves were explored by Mr. Eve, who kindly gives me the following information. All the nerves and vessels of the arm were united into one firm bundle by cicatricial tissue. When dissected clear, the median nerve was found to be thickened and enlarged for about 1-1/2 inch of its length; the ulnar was not completely freed, but was found to be continuous and indurated; the musculo-spiral was also intact, but at its entrance into the humeral groove a ma.s.s of callus was felt. A sclerosed and thickened portion of the median nerve 3-1/2 inches in length was resected, also 1 inch of sclerosed ulnar nerve, and both were sutured. The musculo-spiral nerve was left for future exploration. A small traumatic aneurism was found on the brachial artery, and the vessel was ligatured above it.

Ten months later no improvement in the median or ulnar nerves.

Electrical reaction present in musculo-spiral group of muscles.

(127) _Musculo-spiral._--Transverse wound through arm posterior to humerus. Slight suppuration. Triceps weakened only, complete paralysis of radial extensors and posterior interosseous group.

Radial sensation lowered only.

(128) _Musculo-spiral._--_Entry_, 2 inches above and 1/2 an inch behind the external humeral condyle; _exit_, at the inner edge of the biceps, 1/2 an inch lower in the arm than the entry. It is doubtful whether the paralysis was noted at first, but a few days later complete posterior interosseous paralysis and lowered radial sensation were remarked. No change except a deepening of the anaesthesia, and the development of formication on manipulation of the wound occurred, and at the end of three weeks the nerve was exposed (Mr. Watson), and it was found that a notch had been cut in its outer border, which had opened out into a V shape. The margins of this notch were refreshed and the gap closed. Ten days later radial sensation was fairly good, but the motor symptoms remained unchanged. Nine months later steady but very slow improvement was reported.

(129) _Ulnar and musculo-cutaneous nerves._--_Entry_, back of forearm; the bullet pa.s.sed between the bones and was retained at the posterior aspect of the arm. Three weeks later the hand was glossy and stiff, the fingers extended and adducted, the thumb was held stiffly in the palm with no power of extension.

The forearm was held semip.r.o.ne, and the elbow flexed by a rigid biceps. Six months later the same position was maintained, but the contracture disappeared under an anaesthetic.

(130) _Median and posterior interosseous._--_Entry_, over the external margin of the radius at the centre of the forearm; _exit_, at the inner margin of the olecranon 1-1/2 inch below the tip. Lowered cutaneous sensation in median distribution, and loss of median flexion of wrist and fingers. Complete wrist-drop. The triceps supinator longus and extensor carpi radialis longior were perfect. Twelve days later the wrist could be raised into a direct line with forearm, but there was no change in the median symptoms. A week after this the anaesthetic median area became hyperaesthetic both as to skin and on deep pressure over the muscles.

(131) _Sacral plexus. Great sciatic nerve._--Wounded at Modder River. _Entry_, in left loin; _exit_, at lower margin of b.u.t.tock. The wound was followed immediately by complete peroneal paralysis, both motor and sensory. Fourteen days later hyperaesthesia developed in the area of distribution of the internal popliteal nerve, the superficial pain being greatest in the sole; the muscles of the calf were also very tender on manipulation. The pain increased, and at the end of twenty-four days the patient's sufferings were so great that Mr. Thornton cut down upon and exposed the nerve. It was found embedded in firm cicatricial tissue close to the sciatic notch; this compressed the nerve to such a degree that a waist was apparent upon it.

The nerve was freed and resumed its normal outline. For a few days the patient was much relieved, but the neuralgia then returned in greater intensity than ever. Morphia was injected hypodermically, and other hypnotics employed, but with little effect, the patient developing the hysterical condition so common in the subjects of severe sciatica. Some five weeks later a sudden improvement took place, the morphia was decreased, and the patient became sufficiently well to return to England, but there was still deep tenderness in the calf, and well-marked hyperaesthesia of the sole.

A year later the patient had been discharged from the Service, but was earning his living in a shop. He walked fairly well, but still with foot-drop, and complained of tenderness in the sole. I am indebted to Dr. Turney for the following report on the condition of the muscles.

Calf muscles practically normal. In the anterior tibial and peroneal groups the faradic irritability is much diminished, that in the peroneus longus being the lowest of all.

Contraction can be induced in the extensor longus hallucis, extensor longus digitorum, and peroneus brevis; but reaction is doubtful in the case of the tibialis anticus and peroneus longus.

With the galvanic current contraction is sluggish, and the irritability diminished. No serious changes are present except in the peroneus longus. ACC > KCC at 10 M. A.

(132) _Great sciatic._--_Entry_, at outer aspect of the thigh, just above the centre; _exit_, at the junction of the inner and posterior aspects of thigh, about 2 inches lower. The wound was produced by a ricochet bullet, and beyond the perforation of the sciatic nerve the femur was fractured obliquely (see plate XVI.). Hyperaesthesia of the sole was noted early, and when I saw the patient three months later, there was wasting of the muscles of the leg, and foot-drop, although he walked with a stick.

These symptoms persisted, and on his return to England an exploration was made by Sir Thomas Smith, and the two fragments of mantle seen in the skiagram were removed from the substance of the sciatic nerve. Eight months after the injury, the patient still walked with foot-drop; there was modified sensation in the musculo-cutaneous area, and a feeling as if the bones of the foot were uncovered when he walked. The circ.u.mference of the affected leg was more than 1 inch less than that of the sound one. Steady but slow improvement was taking place.

(133) _Great sciatic_.--In a third patient with a b.u.t.tock track, the symptoms were identical with those observed in case 131. In this an exploration showed that the nerve had been perforated. Although the symptoms were never so severe as in No. 131, yet recovery was very much slower and less complete, the muscular weakness remained more marked, and the skin exhibited more evidence of trophic lesion. Some contracture of the knee and rigid foot-drop took place, and at the end of twelve months the patient walked poorly with a stick.

Improvement is, however, continuing.

(134) _Great sciatic_.--Wounded at Ladysmith. _Entry_, immediately below left b.u.t.tock fold; _exit_, at anterior aspect of thigh, 3-1/2 inches below Poupart's ligament. The left leg was paralysed, and patient was sent down to the Base, where he remained two months. The wound closed by primary union, the paralysis improved, and the man rejoined his regiment. After he had been in camp four days, his leg gave way, and he returned to hospital, where he contracted enteric fever. Later, he was sent home, and eight months after the reception of the injury his condition was as follows:

Left lower limb somewhat wasted, a diminution of 1 inch in the circ.u.mference of the leg and 1/2 an inch in the thigh being found. The patient walks with foot-drop, and the flexor muscles of the knee are weak. On examination the peroneal muscles reacted but sluggishly to faradic irritation. There is complete anaesthesia of the foot to above the ankle, and up to the knee tactile sensation and appreciation of pain were dulled. The left plantar reflex was absent, the right slight, the left patellar reflex was abnormally brisk. There was neither ankle nor patellar clonus, and the other reflexes were present and normal. The gait was spastic, and the patient was more troubled by a contraction of the calf muscles, which prevented his putting the heel to the ground, than by the foot-drop.

Beyond these local phenomena there was marked tremor of the upper extremities on any exertion, and slight lateral nystagmus. The patient was not sure that this had not been present ever since he recovered from the enteric fever, but it was sufficiently marked to give rise to the suspicion of the development of disseminated sclerosis.

The patient was a hard-headed, sensible man. He remained in the hospital under the care of Dr. Turney, to whom I am indebted for notes of the case, forty-six days. During this period he was treated by faradic electricity, and, with some checks, notably the development of pa.s.sive effusion into the left knee-joint, and a fugitive attack of redness over the dorsum of the foot, both suggesting trophic changes, steadily improved.

The anaesthesia became limited to the outer half of the leg, at the end of one month was limited to the dorsum of the foot only, and at the end of six weeks entirely disappeared.

Meanwhile the tendency to drawing up of the heel by the calf muscles became less, and the gait improved. The man left the hospital at the end of two months, very satisfied with his condition, although the tremor of the hands was still present in a lessened degree.

(135) _External popliteal._--Wounded at Magersfontein, 250-300 yards. _Entry_, at the outer side of the thigh, 5 inches above the lower extremity of the external condyle; _exit_, at the inner margin of the adductors, at a level 4 inches higher in the thigh. The track crossed behind the femur. Complete peroneal motor paralysis and anaesthesia, except in the hinder part of the region supplied by the mixed external saphenous.

Slight hyperaesthesia of the sole. Improving at the end of three weeks, but paralysis still nearly complete.

(136) _External popliteal._--Wounded at Magersfontein. _Entry_, 5 inches below the highest part of the right iliac crest, on outer aspect of hip; _exit_, at the posterior margin of the gracilis, 2 inches from the perineum. Complete peroneal paralysis followed, which rapidly improved, and on the twenty-second day was nearly well.

(137) _Internal popliteal. Secondary anaesthesia_.--_Sh.e.l.l_ wounds of the right popliteal s.p.a.ce. Wounded at Belmont.

Anaesthesia of the outer side of the calf, the leg and sole of foot. No motor paralysis. As cicatrisation progressed, the anaesthesia became more marked and was complete over the whole of the external saphenous area.

(138) _Internal popliteal._--Wounded at Paardeberg. 400-500 yards. _Entry_, about the centre of the outer half of the patella; _exit_, at the centre of the calf, about 2 inches from the popliteal crease. Five days after the injury severe burning pain developed in the sole. A fortnight later the pain was much less severe, but varied in degree with the heat of the weather, being worse when cool. At this date, however, rubbing became comforting.

(139) _External popliteal._---Wounded at Magersfontein.

_Entry_, 1 inch above the upper end of the internal margin of the patella; _exit_, at the margin of leg, just below the outer tuberosity of the tibia. Complete peroneal paralysis followed the injury. A month later the nerve was bared and found slightly thickened. An improvement in cutaneous sensation followed quickly, and a much slower improvement in the motor power commenced.

(140) _External popliteal nerve._--Wounded at Beacon Hill. A _bayonet_ entered over upper quarter of fibula, and pa.s.sed between the bones of leg into the calf. An aneurismal varix of the calf vessels developed, also incomplete peroneal paralysis.

The scar was raised from the nerve (Major Simpson, R.A.M.C.) six weeks later, and at the end of a fortnight the power and sensation were both much improved and the patient returned to England.

(141) _External popliteal._--Wounded at Modder River. _Entry_, 1/2 an inch above the internal border of the patella; _exit_, 1-1/2 inch from the head of the fibula and over that bone. The wound was followed by peroneal paralysis. Six weeks later sensation was still diminished in the anterior tibial and musculo-cutaneous nerve areas, and marked foot-drop, little improved, persisted. The patient came to England, and at the end of twelve months is reported as very little improved.

(142) _Anterior tibial._--_Entry_, 1 inch in front and below the external malleolus; _exit_, at the centre of the sole, just anterior to the bases of the metatarsal bones. Wasting and paralysis of extensor brevis digitorum.

(143) _Small sciatic and small saphenous._--Wounded at Magersfontein. 200 yards. Two wounds: (i) _Entry_, below the centre of the twelfth rib on the left side; _exit_, immediately to the left of the b.u.t.tock furrow at upper part, (ii) _Entry_, in the right loin, midway between the last rib and iliac crest; _exit_, just within the centre of the left b.u.t.tock; the two wounds crossed diagonally. Hyperaesthesia in area of distribution of small saphenous and small sciatic nerves, which rapidly improved.

(144) _Lumbar plexus._--Boer, wounded at Magersfontein.

_Entry_, eleventh inters.p.a.ce, posterior axillary line; _exit_, tenth inters.p.a.ce, right mid-axillary line. Impaired sensation in area of distribution of external cutaneous and crural branch of genito-crural nerves. At the end of a fortnight anaesthesia was less apparent, but a feeling of numbness persisted, which soon disappeared.

_Prognosis and treatment._--In considering the prognosis in cases of nerve injury, several of the points already raised as to the nature of the lesion are of importance. Short of actual section, it may be broadly stated that no lesion is too serious to render ultimate recovery impossible.

In cases in which the injury has been produced by a bullet fired at a short range, or in which contact with the nerve has been close, the return of functional activity is very slow. In such instances the condition probably resembles that in which a divided nerve has been sutured, with the additional disadvantage that a considerable portion of the nerve, both above and below the point actually struck, has been destroyed as far as the conduction of nervous impulses is concerned.

This may reasonably be concluded in the light of the evidence offered by the injuries of the spinal cord, in which several segments usually suffered if the velocity of the bullet was great, and also if the fact is remembered that, when thickening takes place, a considerable length of the nerve is usually implicated.

Recovery is notably slow in the case of certain nerves, _e.g._ musculo-spiral and peroneal, even when the injury has not been of extreme severity. Again, these same nerves are apparently more seriously affected by moderate degrees of damage than are others.

As favourable prognostic elements we may bear in mind: low velocity on the part of the travelling bullet, and with this a lesser degree of contiguity of the track to the nerve. The early return of sensation is a favourable sign, and in this relation the development of hyperaesthesia, whether preceded by anaesthesia or no, points to the maintenance of continuity of, and a moderate degree of damage to, the nerve. The early return of sensation, even if modified in acuteness, was always a very hopeful sign; also the production of formication in the area of distribution of the nerve on manipulation of the injured spot. As in the case of nerve injuries of every nature, the disposition and temperament of the patient exerted considerable influence on the course of the cases.

Complete section of the nerves in these bullet wounds only obtained special importance in two ways: first, in that a considerable portion of the trunk might be shot away in oblique tracks, and, secondly, in that very severe contusion might affect the nerve for a considerable distance beyond the point actually implicated. In point of fact, complete section when treated by suture was often more rapidly recovered from than an injury in which only a portion of the width of a trunk was divided. This was no doubt to be explained on the theory that the contiguous portion of the nerve suffered less when tension and resistance were lessened by complete severance of the cord.

_The treatment_ of slight nerve contusion was simple; rest alone was necessary, and in the course of hours or days paralysis was recovered from. The symptoms were most troublesome in patients of a neurotic temperament, or those who had suffered from severe systemic shock.

In severe concussions and contusions the first care had to be devoted to the discrimination of the lesion from that of division. A period of rest then needed to be followed by one of ma.s.sage and movement, to maintain the nutrition of the muscles. In a considerable portion of the cases a stage of neuritis had to be expected. In all cases, either of severe concussion, contusion, or complete section, accompanied by the fracture of a bone, especial care was necessary that the bandaging and fixation of the limb were not sufficiently tight to add the dangers of muscular ischaemia to those of the nerve injury already present.

Neuritis, whether dependent on local injury, implication in the scar, pressure from callus, or of the ascending variety, needed the same treatment: rest, preservation of the limb from cold or damp, and the local application of anodynes, as belladonna, or hot laudanum fomentations. In some cases a general anodyne, as morphia, was preferable; then always to be used with caution, as the patients soon craved inordinately for it, and were unwilling to give it up. Later, local blisters in the line of the nerve trunk, careful ma.s.sage and exercise when muscular and cutaneous tenderness had subsided, the application of the continuous current to the nerves, and perhaps faradisation of the muscles, were all useful.

Splints were often temporarily required to resist contracture, or the a.s.sumption of false positions; in either case they needed to be frequently removed, and movement &c. made, in order to avoid any chance of troublesome stiffness.

_Operative treatment._--Early interference was only warranted by positive knowledge that some source of irritation or pressure could be removed; thus a bone spicule, or a bullet, or part of one, particularly portions of mantles.

In case of contusion the expiration of three months is the earliest date at which any operation should be taken into consideration, and interference is only then advisable if there is good prospect of freeing the nerve from compressing adhesions. The two strongest indications for operation are (1) signs pointing to the secondary implication of the nerve in a cicatrix, especially when these are of such a nature as to indicate local tension, fixation, or pressure; (2) the possibility of the irritation being the result of the presence of some foreign body, such as a bone spicule, or portions of a bullet mantle; in such cases the X rays will often give useful help.

With regard to the early exploration of cases of traumatic neuralgia, it may be pointed out that when this was undertaken the results were as a rule very temporary. In many cases in which the measure was resorted to, either no macroscopic evidence of injury to the nerve was discovered, or a bulbous thickening was met with of such extent as to make excision inadvisable, even if it were considered otherwise the most suitable treatment.