Alexis Thomson and Alexander Miles - Manual of Surgery

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Tinel's sign is present before voluntary movement, muscular tone, or the
normal electrical reactions reappear.

In cases of complete nerve paralysis that have not been operated upon,
the tingling test is helpful in determining whether or not regeneration
is taking place. Its detection may prevent an unnecessary operation
being performed.

Primary suture should not be attempted so long as the wound shows signs
of infection, as it is almost certain to end in failure. The ends should
be sutured, however, as soon as the wound is aseptic or has healed.

#Secondary Suture.#--The term secondary suture is applied to the
operation of stitching the ends of the divided nerve after the wound has
healed.

_Results of Secondary Suture._--When secondary suture has been performed
under favourable conditions, the prognosis is good, but a longer time is
required for restoration of function than after primary suture. Purves
Stewart says protopathic sensation is sometimes observed much earlier
than in primary suture, because partial regeneration of axis cylinders
in the peripheral segment has already taken place. Sensation is
recovered first, but it seldom returns before three or four months.
There then follows an improvement or disappearance of any trophic
disturbances that may be present. Recovery of motion may be deferred for
long periods--rather because of the changes in the muscles than from
want of conductivity in the nerve--and if the muscles have undergone
complete degeneration, it may never take place at all. While waiting for
recovery, every effort should be made to maintain the nutrition of the
damaged nerve, and of the parts which it supplies.

When suture is found to be impossible, recourse must be had to other
methods, known as nerve bridging and nerve implantation.

#Incomplete Division of a Mixed Nerve.#--The effects of partial division
of a mixed nerve vary according to the destination of the nerve bundles
that have been interrupted. Within their area of distribution the
paralysis is as complete as if the whole trunk had been cut across. The
uninjured nerve-bundles continue to transmit impulses with the result
that there is a _dissociated paralysis_ within the distribution of the
affected nerve, some muscles continuing to act and to respond normally
to electric stimulation, while others behave as if the whole nerve-trunk
had been severed.

In addition to vasomotor and trophic changes, there is often severe pain
of a burning kind (_causalgia_ or _thermalgia_) which comes on about a
fortnight after the injury and causes intense and continuous suffering
which may last for months. Paroxysms of pain may be excited by the
slightest touch or by heat, and the patient usually learns for himself
that the constant application of cold wet cloths allays the pain. The
thermalgic area sweats profusely.

Operative treatment is indicated where there is no sign of improvement
within three months, when recovery is arrested before complete
restoration of function is attained, or when thermalgic pain is
excessive.

#Subcutaneous Injuries of Nerves.#--Several varieties of subcutaneous
injuries of nerves are met with. One of the best known is the
compression paralysis of the nerves of the upper arm which results from
sleeping with the arm resting on the back of a chair or the edge of a
table--the so-called "drunkard's palsy"; and from the pressure of a
crutch in the axilla--"crutch paralysis." In some of these injuries,
notably "drunkard's palsy," the disability appears to be due not to
damage of the nerve, but to overstretching of the extensors of the wrist
and fingers (Jones). A similar form of paralysis is sometimes met with
from the pressure of a tourniquet, from tight bandages or splints, from
the pressure exerted by a dislocated bone or by excessive callus, and
from hyper-extension of the arm during anaesthesia.

In all these forms there is impaired sensation, rarely amounting to
anaesthesia, marked muscular wasting, and diminution or loss of voluntary
motor power, while--and this is a point of great importance--the normal
electrical reactions are preserved. There may also develop trophic
changes such as blisters, superficial ulcers, and clubbing of the tips
of the fingers. The prognosis is usually favourable, as recovery is the
rule within from one to three months. If, however, neuritis supervenes,
the electrical reactions are altered, the muscles degenerate, and
recovery may be retarded or may fail to take place.

Injuries which act abruptly or instantaneously are illustrated in the
crushing of a nerve by the sudden displacement of a sharp-edged fragment
of bone, as may occur in comminuted fractures of the humerus. The
symptoms include perversion or loss of sensation, motor paralysis, and
atrophy of muscles, which show the reaction of degeneration from the
eighth day onwards. The presence of the reaction of degeneration
influences both the prognosis and the treatment, for it implies a lesion
which is probably incapable of spontaneous recovery, and which can only
be remedied by operation.

The _treatment_ varies with the cause and nature of the lesion. When,
for example, a displaced bone or a mass of callus is pressing upon the
nerve, steps must be taken to relieve the pressure, by operation if
necessary. When there is reason to believe that the nerve is severely
crushed or torn across, it should be exposed by incision, and, after
removal of the damaged ends, should be united by sutures. When it is
impossible to make a definite diagnosis as to the state of the nerve, it
is better to expose it by operation, and thus learn the exact state of
affairs without delay; in the event of the nerve being torn, the ends
should be united by sutures.

#Dislocation of Nerves.#--This injury, which resembles the dislocation
of tendons from their grooves, is seldom met with except in the ulnar
nerve at the elbow, and is described with injuries of that nerve.

DISEASES OF NERVES

#Traumatic Neuritis.#--This consists in an overgrowth of the
connective-tissue framework of a nerve, which causes irritation and
pressure upon the nerve fibres, sometimes resulting in their
degeneration. It may originate in connection with a wound in the
vicinity of a nerve, as, for example, when the brachial nerves are
involved in scar tissue subsequent to an operation for clearing out the
axilla for cancer; or in contusion and compression of a nerve--for
example, by the pressure of the head of the humerus in a dislocation of
the shoulder. Some weeks or months after the injury, the patient
complains of increasing hyperaesthesia and of neuralgic pains in the
course of the nerve. The nerve is very sensitive to pressure, and, if
superficial, may be felt to be swollen. The associated muscles are
wasted and weak, and are subject to twitchings. There are also trophic
disturbances. It is rare to have complete sensory and motor paralysis.
The disease is commonest in the nerves of the upper extremity, and the
hand may become crippled and useless.

_Treatment._--Any constitutional condition which predisposes to
neuritis, such as gout, diabetes, or syphilis, must receive appropriate
treatment. The symptoms may be relieved by rest and by soothing
applications, such as belladonna, ichthyol, or menthol, by the use of
hot-air and electric baths, and in obstinate cases by blistering or by
the application of Corrigan's button. When such treatment fails the
nerve may be stretched, or, in the case of a purely sensory trunk, a
portion may be excised. Local causes, such as involvement of the nerve
in a scar or in adhesions, may afford indications for operative
treatment.

#Multiple Peripheral Neuritis.#--Although this disease mainly comes
under the cognizance of the physician, it may be attended with phenomena
which call for surgical interference. In this country it is commonly due
to alcoholism, but it may result from diabetes or from chronic poisoning
with lead or arsenic, or from bacterial infections and intoxications
such as occur in diphtheria, gonorrhoea, syphilis, leprosy, typhoid,
influenza, beri-beri, and many other diseases.

It is, as a rule, widely distributed throughout the peripheral nerves,
but the distribution frequently varies with the cause--the alcoholic
form, for example, mainly affecting the legs, the diphtheritic form the
soft palate and pharynx, and that associated with lead poisoning the
forearms. The essential lesion is a degeneration of the conducting
fibres of the affected nerves, and the prominent symptoms are the result
of this. In alcoholic neuritis there is great tenderness of the muscles.
When the legs are affected the patient may be unable to walk, and the
toes may droop and the heel be drawn up, resulting in one variety of pes
equino-varus. Pressure sores and perforating ulcer of the foot are the
most important trophic phenomena.

Apart from the medical _treatment_, measures must be taken to prevent
deformity, especially when the legs are affected. The bedclothes are
supported by a cage, and the foot maintained at right angles to the leg
by sand-bags or splints. When the disease is subsiding, the nutrition of
the damaged nerves and muscles should be maintained by massage, baths,
passive movements, and the use of the galvanic current. When deformity
has been allowed to take place, operative measures may be required for
its correction.

NEUROMA[5]

[5] We have followed the classification adopted by Alexis Thomson in his
work _On Neuroma, and Neuro-fibromatosis_ (Edinburgh: 1900).

Neuroma is a clinical term applied to all tumours, irrespective of their
structure, which have their seat in nerves.

A tumour composed of newly formed nerve tissue is spoken of as a #true
neuroma#; when ganglionic cells are present in addition to nerve fibres,
the name _ganglionic neuroma_ is applied. These tumours are rare, and
are chiefly met with in the main cords or abdominal plexuses of the
sympathetic system of children or young adults. They are quite
insensitive, and their removal is only called for if they cause pain or
show signs of malignancy.

A #false neuroma# is an overgrowth of the sheath of a nerve. This
overgrowth may result in the formation of a circumscribed tumour, or may
take the form of a diffuse fibromatosis.

_The circumscribed or solitary tumour_ grows from the sheath of a nerve
which is otherwise healthy, and it may be innocent or malignant.

_The innocent_ form is usually fibrous or myxomatous, and is definitely
encapsulated. It may become cystic as a result of haemorrhage or of
myxomatous degeneration. It grows very slowly, is usually elliptical in
shape, and the solid form is rarely larger than a hazel-nut. The nerve
fibres may be spread out all round the tumour, or may run only on one
side of it. When subcutaneous and related to the smaller unnamed
cutaneous nerves, it is known as a _painful subcutaneous nodule_ or
_tubercle_. It is chiefly met with about the ankle, and most often in
women. It is remarkably sensitive, even gentle handling causing intense
pain, which usually radiates to the periphery of the nerve affected.
When related to a deeper, named nerve-trunk, it is known as a
_trunk-neuroma_. It is usually less sensitive than the "subcutaneous
nodule," and rarely gives rise to motor symptoms unless it involves the
nerve roots where they pass through bony canals.

A trunk-neuroma is recognised clinically by its position in the line of
a nerve, by the fact that it is movable in the transverse axis of the
nerve but not in its long axis, and by being unduly painful and
sensitive.

[Illustration: FIG. 85.--Amputation Stump of Upper Arm, showing bulbous
thickening of the ends of the nerves, embedded in scar tissue at the
apex of the stamp.]

_Treatment._--If the tumour causes suffering it should be removed,
preferably by shelling it out from the investing nerve sheath or
capsule. In the subcutaneous nodule the nerve is rarely recognisable,
and is usually sacrificed. When removal of the tumour is incomplete, a
tube of radium should be inserted into the cavity, to prevent recurrence
of the tumour in a malignant form.

_The malignant neuroma_ is a sarcoma growing from the sheath of a nerve.
It has the same characters and clinical features as the innocent
variety, only it grows more rapidly, and by destroying the nerve fibres
causes motor symptoms--jerkings followed by paralysis. The sarcoma tends
to spread along the lymph spaces in the long axis of the nerve, as well
as to implicate the surrounding tissues, and it is liable to give rise
to secondary growths. The malignant neuroma is met with chiefly in the
sciatic and other large nerves of the limbs.

The _treatment_ is conducted on the same lines as sarcoma in other
situations; the insertion of a tube of radium after removal of the
tumour diminishes the tendency to recurrence; a portion of the
nerve-trunk being sacrificed, means must be taken to bridge the gap. In
inoperable cases it may be possible to relieve pain by excising a
portion of the nerve above the tumour, or, when this is impracticable,
by resecting the posterior nerve roots and their ganglia within the
vertebral canal.

The so-called _amputation neuroma_ has already been referred to (p. 344).

_Diffuse or Generalised Neuro-Fibromatosis--Recklinghausen's
Disease._--These terms are now used to include what were formerly known
as "multiple neuromata," as well as certain other overgrowths related to
nerves. The essential lesion is an overgrowth of the endoneural
connective tissue throughout the nerves of both the cerebro-spinal and
sympathetic systems. The nerves are diffusely and unequally thickened,
so that small twigs may become enlarged to the size of the median, while
at irregular intervals along their course the connective-tissue
overgrowth is exaggerated so as to form tumour-like swellings similar to
the trunk-neuroma already described. The tumours, which vary greatly in
size and number--as many as a thousand have been counted in one
case--are enclosed in a capsule derived from the perineurium. The
fibromatosis may also affect the cranial nerves, the ganglia on the
posterior nerve roots, the nerves within the vertebral canal, and the
sympathetic nerves and ganglia, as well as the continuations of the
motor nerves within the muscles. The nerve fibres, although mechanically
displaced and dissociated by the overgrown endoneurium, undergo no
structural change except when compressed in passing through a bony
canal.

The disease probably originates before birth, although it may not make
its appearance till adolescence or even till adult life. It is sometimes
met with in several members of one family. It is recognised clinically
by the presence of multiple tumours in the course of the nerves, and
sometimes by palpable enlargement of the superficial nerve-trunks
(Fig. 86). The tumours resemble the solitary trunk-neuroma, are usually
quite insensitive, and many of them are unknown to the patient. As a
result of injury or other exciting cause, however, one or other tumour
may increase in size and become extremely sensitive; the pain is then
agonising; it is increased by handling, and interferes with sleep. In
these conditions, a malignant transformation of the fibroma into sarcoma
is to be suspected. Motor disturbances are exceptional, unless in the
case of tumours within the vertebral canal, which press on the spinal
medulla and cause paraplegia.

[Illustration: FIG. 86.--Diffuse enlargement of Nerves in generalised
Neuro-fibromatosis.

(After R. W. Smith.)]

Neuro-fibromatosis is frequently accompanied by _pigmentation of the
skin_ in the form of brown spots or patches scattered over the trunk.

The disease is often stationary for long periods. In progressive cases
the patient becomes exhausted, and usually dies of some intercurrent
affection, particularly phthisis. The treatment is restricted to
relieving symptoms and complications; removal of one of the tumours is
to be strongly deprecated.

In a considerable proportion of cases one of the multiple tumours takes
on the characters of a malignant growth ("secondary malignant neuroma,"
Garre). This malignant transformation may follow upon injury, or on an
unsuccessful attempt to remove the tumour. The features are those of a
rapidly growing sarcoma involving a nerve-trunk, with agonising pain
and muscular cramps, followed by paralysis from destruction of the
nerve fibres. The removal of the tumour is usually followed by
recurrence, so that high amputation is the only treatment to be
recommended. Metastasis to internal organs is exceptional.

[Illustration: FIG. 87.--Plexiform Neuroma of small Sciatic Nerve, from
a girl aet. 16.

(Mr. Annandale's case.)]

There are other types of neuro-fibromatosis which require brief mention.

_The plexiform neuroma_ (Fig. 87) is a fibromatosis confined to the
distribution of one or more contiguous nerves or of a plexus of nerves,
and it may occur either by itself or along with multiple tumours of the
nerve-trunks and with pigmentation of the skin. The clinical features
are those of an ill-defined swelling composed of a number of tortuous,
convoluted cords, lying in a loose areolar tissue and freely movable on
one another. It is rarely the seat of pain or tenderness. It most often
appears in the early years of life, sometimes in relation to a pigmented
or hairy mole. It is of slow growth, may remain stationary for long
periods, and has little or no tendency to become malignant. It is
usually subcutaneous, and is frequently situated on the head or neck in
the distribution of the trigeminal or superficial cervical nerves. There
is no necessity for its removal, but this may be indicated because of
disfigurement, especially on the face or scalp or because its bulk
interferes with function. When involving the ophthalmic division of the
trigeminus, for example, it may cause enlargement of the upper lid and
proptosis, with danger to the function of the globe. The results of
excision are usually satisfactory, even if the removal is not complete.

[Illustration: FIG. 88.--Multiple Neuro-fibromas of Skin (Molluscum
fibrosum, or Recklinghausen's disease).]

_The cutaneous neuro-fibroma_ or _molluscum fibrosum_ has been shown by
Recklinghausen to be a soft fibroma related to the terminal filaments of
one of the cutaneous nerves (Fig. 88). The disease appears in the form
of multiple, soft, projecting tumours, scattered all over the body,
except the palms of the hands and soles of the feet. The tumours are of
all sizes, some being no larger than a pin's head, whilst many are as
big as a filbert and a few even larger. Many are sessile and others are
distinctly pedunculated, but all are covered with skin. They are mobile,
soft to the touch, and of the consistence of firm fat. In exceptional
cases one of the skin tumours may attain an enormous size and cause a
hideous deformity, hanging down by its own weight in lobulated or folded
masses (pachy-dermatocele). The treatment consists in removing the
larger swellings. In some cases molluscum fibrosum is associated with
pigmentation of the skin and with multiple tumours of the nerve-trunks.
The small multiple tumours rarely call for interference.

[Illustration: FIG. 89.--Elephantiasis Neuromatosa in a woman aet. 28]

_Elephantiasis neuromatosa_ is the name applied by Virchow to a
condition in which a limb is swollen and misshapen as a result of the
extension of a neuro-fibromatosis to the skin and subcutaneous cellular
tissue of the extremity as a whole (Fig. 89). It usually begins in early
life without apparent cause, and it may be associated with multiple
tumours of the nerve-trunks. The inconvenience caused by the bulk and
weight of the limb may justify its removal.

SURGERY OF THE INDIVIDUAL NERVES[6]

[6] We desire here to acknowledge our indebtedness to Mr. James
Sherren's work on _Injuries of Nerves and their Treatment_.

#The Brachial Plexus.#--Lesions of the brachial plexus may be divided
into those above the clavicle and those below that bone.

In the #supra-clavicular injuries#, the violence applied to the head or
shoulder causes over-stretching of the anterior branches (primary
divisions) of the cervical nerves, the fifth, or the fifth and sixth
being those most liable to suffer. Sometimes the traction is exerted
upon the plexus from below, as when a man in falling from a height
endeavours to save himself by clutching at some projection, and the
lesion then mainly affects the first dorsal nerve. There is tearing of
the nerve sheaths, with haemorrhage, but in severe cases partial or
complete severance of nerve fibres may occur and these give way at
different levels. During the healing process an excess of fibrous tissue
is formed, which may interfere with regeneration.

_Post-anaesthetic paralysis_ occurs in patients in whom, during the
course of an operation, the arm is abducted and rotated laterally or
extended above the head, causing over-stretching of the plexus,
especially of the fifth, or fifth and sixth, anterior branches.

A _cervical rib_ may damage the plexus by direct pressure, the part
usually affected being the medial cord, which is made up of fibres from
the eighth cervical and first dorsal nerves.

When a lesion of the plexus complicates a _fracture of the clavicle_,
the nerve injury is due, not to pressure on or laceration of the nerves
by fragments of bone, but to the violence causing the fracture, and this
is usually applied to the point of the shoulder.

Penetrating _wounds_, apart from those met with in military practice,
are rare.

In the #infra-clavicular injuries#, the lesion most often results from
the pressure of the dislocated head of the humerus; occasionally from
attempts made to reduce the dislocation by the heel-in-the-axilla
method, or from fracture of the upper end of the humerus or of the neck
of the scapula. The whole plexus may suffer, but more frequently the
medial cord is alone implicated.

_Clinical Features._--Three types of lesion result from indirect
violence: the whole plexus; the upper-arm type; and the lower-arm type.

_When the whole plexus is involved_, sensibility is lost over the entire
forearm and hand and over the lateral surface of the arm in its distal
two-thirds. All the muscles of the arm, forearm, and hand are paralysed,
and, as a rule, also the pectorals and spinati, but the rhomboids and
serratus anterior escape. There is paralysis of the sympathetic fibres
to the eye and orbit, with narrowing of the palpebral fissure, recession
of the globe, and the pupil is slow to dilate when shaded from the
light.

The _upper-arm type_--Erb-Duchenne paralysis--is that most frequently
met with, and it is due to a lesion of the fifth anterior branch, or, it
may be, also of the sixth. The position of the upper limb is typical:
the arm and forearm hang close to the side, with the forearm extended
and pronated; the deltoid, spinati, biceps, brachialis, and supinators
are paralysed, and in some cases the radial extensors of the wrist and
the pronator teres are also affected. The patient is unable to supinate
the forearm or to abduct the arm, and in most cases to flex the forearm.
He may, however, regain some power of flexing the forearm when it is
fully pronated, the extensors of the wrist becoming feeble flexors of
the elbow. There is, as a rule, no loss of sensibility, but complaint
may be made of tickling and of pins-and-needles over the lateral aspect
of the arm. The abnormal position of the limb may persist although the
muscles regain the power of voluntary movement, and as the condition
frequently follows a fall on the shoulder, great care is necessary in
diagnosis, as the condition is apt to be attributed to an injury to the
axillary (circumflex) nerve.

The _lower-arm type_ of paralysis, associated with the name of Klumpke,
is usually due to over-stretching of the plexus, and especially affects
the anterior branch of the first dorsal nerve. In typical cases all the
intrinsic muscles of the hand are affected, and the hand assumes the
claw shape. Sensibility is usually altered over the medial side of the
arm and forearm, and there is paralysis of the sympathetic.

_Infra-clavicular injuries_, as already stated, are most often produced
by a sub-coracoid dislocation of the humerus; the medial cord is that
most frequently injured, and the muscles paralysed are those supplied by
the ulnar nerve, with, in addition, those intrinsic muscles of the hand
supplied by the median. Sensibility is affected over the medial surface
of the forearm and ulnar area of the hand. Injury of the lateral and
posterior cords is very rare.

_Treatment_ is carried out on the lines already laid down for nerve
injuries in general. It is impossible to diagnose between complete and
incomplete rupture of the nerve cords, until sufficient time has elapsed
to allow of the establishment of the reaction of degeneration. If this
is present at the end of fourteen days, operation should not be delayed.
Access to the cords of the plexus is obtained by a dissection similar to
that employed for the subclavian artery, and the nerves are sought for
as they emerge from under cover of the scalenus anterior, and are then
traced until the seat of injury is found. In the case of the first
dorsal nerve, it may be necessary temporarily to resect the clavicle.
The usual after-treatment must be persisted in until recovery ensues,
and care must be taken that the paralysed muscles do not become
over-stretched. The prognosis is less favourable in the supra-clavicular
lesions than in those below the clavicle, which nearly always recover
without surgical intervention.