Alexis Thomson

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 physiological effects of complete division are that the muscles supplied by the nerve are immediately paralysed, the area to which it furnishes the sole cutaneous supply becomes insensitive, and the other structures, including tendons, bones, and joints, lose sensation, and begin to atrophy from loss of the trophic influence. ”

“ Tapping over the proximal end of a _newly divided nerve_, _e.g._ the common peroneal behind the head of the fibula, produces no tingling, but when in about three weeks axis cylinders begin to grow in the proximal end-bulb, local tingling is induced by tapping there. The downward growth of the axis cylinders can be traced by tapping over the distal segment of the nerve, the tingling sensation being elicited as far down as the young axis cylinders have reached. When the regeneration of the axis cylinders is complete, tapping no longer causes tingling. ”

“ In the large nerve-trunks of the limbs he has worked out the exact position of the bundles for the various groups of muscles, so that in a cross section of a particular nerve the component bundles can be labelled as confidently and accurately as can be the cortical areas in the brain. ”

“ The treatment by injection of alcohol is superior to the resection of branches of the nerve, for though relapses occur after the treatment with alcohol, renewed freedom from pain may be obtained by its repetition. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ They are usually excited by some trivial cause, such as moving the jaws in eating or speaking, touching the face as in washing, or exposure to a draught of cold air. Between the paroxysms the patient is free from pain, but is in constant terror of its return, and the face wears an expression of extreme suffering and anxiety. When the paroxysm is accompanied by twitching of the facial muscles, it is called _spasmodic tic_. ”

“ If, however, the tendons are divided as well as the nerve, there is insensibility to deep touch. The areas of epicritic and of protopathic insensibility are illustrated in Fig. 91. The division of the nerve at the elbow, or even at the axilla, does not increase the extent of the loss of epicritic or protopathic sensibility, but usually affects deep sensibility. ”

“ It is aggravated by movement, so that the patient walks lame or is obliged to lie up. It is aggravated also by any movement which tends to put the nerve on the stretch, as in bending down to put on the shoes, such movements also causing tingling down the nerve, and sometimes numbness in the foot. ”

“ In typical cases the patient is unable to take any active part in life. The attempt to eat is attended with such severe pain that he avoids taking food. In some cases the suffering is so great that the patient only obtains sleep by the use of hypnotics, and he is often on the verge of suicide. ”

“ The muscles rapidly waste, and within from three to five days, they cease to react to the faradic current. When tested with the galvanic current, it is found that a stronger current must be used to call forth contraction than in a healthy muscle, and the contraction appears first at the closing of the circuit when the anode is used as the testing electrode. ”

“ 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. ”

“ 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. ”

“ In aggravated cases the tips of the fingers disappear from progressive ulceration, and in the sole of the foot a perforating ulcer may develop. Arthropathies are occasionally met with, the joints becoming the seat of a painless effusion or hydrops, which is followed by fibrous thickening of the capsular and other ligaments, and terminates in stiffness and fibrous ankylosis. ”

“ These exercises, which may be preceded by massage, are carried out night and morning, and should be practised systematically by those who are liable to sciatica.
Benefit has followed the injection into the nerve itself, or into the tissues surrounding it, of normal saline solution; from 70-100 c.c. are injected at one time. If the pain recurs, the injection may require to be repeated on many occasions at different points up and down the nerve. Needling or acupuncture consists in piercing the nerve at intervals in the buttock and thigh with long steel needles. ”

“ The arm is to be kept at rest, with the affected muscles relaxed, and, as soon as tenderness has disappeared, daily massage and passive movements are employed. The reaction of degeneration can rarely be satisfactorily tested before the child is three months old, but if it is present, an operation should be performed. ”

“ Any constitutional tendency, such as gout or rheumatism, must be counteracted, and indigestion, oxaluria, and constipation should receive appropriate treatment. In acute cases the patient is confined to bed between blankets, the limb is wrapped in thermogene wool, and the knee is flexed over a pillow ”

“ The fibres of this system run with the motor nerves, and pass to muscles, tendons, and joints. Even division of both the ulnar and the median nerves above the wrist produces little loss of deep sensibility, unless the tendons are also cut through. ”

“ 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. ”

“ The limb is at first quite powerless, but the patient usually recovers sufficiently to be able to walk with a little support, and although the hamstrings are paralysed the knee can be flexed by the sartorius and gracilis. ”