Examples of this condition were seen in the case of nearly every nerve in the body. In frequency of occurrence, degree of severity, and in its selection of individual nerves considerable variation was met with. With regard to the two former points, personal idiosyncrasy, and degree of or peculiarity in the nature of the injury, are the only explanations I can suggest. Perhaps in some instances exposure to wet or cold in the early stages of the injury was of some import. Thus, I saw several severe cases of musculo-spiral neuritis in men who were wounded during the trying and wet march on Bloemfontein. I did not observe that suppuration or wound complications seemed important explanatory moments, as most of the cases occurred in wounds that healed rapidly.
With regard to the question of selection; the same nerves that appear particularly liable to suffer from idiopathic inflammations, toxic influences, or to be the seat of ascending changes (e.g. ulnar, musculo-spiral, and external popliteal), were those most often affected by secondary neuritis. Many of the most severe cases I saw were in the musculo-spiral nerve.
Scar implication.—The signs of this most commonly commenced with neuralgia, or painful sensations when such movements were made as to put the cicatrix on the stretch. Although such neuralgia might not be constant, it was often observed to be troublesome when the patients were exposed to cold in sleeping out at night, or to extra fatigue, as in long marches. The results in many cases stopped at this point, but the size and wide distribution of certain nerves rendered even such slight symptoms of importance; while in others well-marked signs of neuritis declared themselves, such as glossy skin, pain, muscular wasting, and paralysis.
Ascending neuritis.—In a few cases I observed very remarkable instances of ascending neuritis, after comparatively slight wounds. I will quote three of these as illustrations and make no further remarks as to the symptoms. It will be observed that one is a case of ulnar, both the others of external popliteal, neuritis:—
(108) Ulnar nerve: secondary ascending neuritis.—Boer wounded at Elandslaagte. Wound of hand, implicating anterior two-thirds of third metacarpal bone. This bone, together with the middle finger, was removed, and healing took place by granulation slowly.
The resulting gap allowed considerable overlapping of the fingers, and shortening of the corresponding digit; the index finger also became flexed as a result of destruction of the extensor tendons. Three months later the man was still in hospital in consequence of the tardiness with which the wound had healed: at this time pain was noted, which became very severe in the whole course of the ulnar nerve; superficial hyperæsthesia and deep muscular tenderness developed, but no wasting. Several crops of herpetic vesicles also developed over the distribution of the radial nerve in the hand. This pain was followed by spastic contracture, first of the ulnar fingers and later of the wrist and elbow, which could only be straightened by the application of considerable force. The limb was, therefore, kept straight by the application of a splint; and warm baths, and a blister applied over the course of the ulnar nerve, were resorted to: under this treatment the condition improved until the patient was well enough to be transferred as a prisoner, and I saw him no more.
(109) Peroneal nerve branches.—Wounded at Colenso. Entry, at the anterior margin of the fibula 5 inches above the external malleolus; the track crossed the anterior aspect of the leg obliquely, to its exit 1 inch above the centre of the ankle joint. Incomplete paralysis of the peronei muscles followed, combined with progressive wasting of the whole limb, which at the end of a month was marked, and then commenced to improve.
(110) In a second case the wound took a similar course in the centre of the leg, crossing the line of the branches of the musculo-cutaneous nerve. Motor paralysis of the peronei followed, together with general lowering of tactile sensation in the musculo-cutaneous area.
Traumatic neurosis.—In connection with the cases just quoted, mention must be made of the fact that the functional element was often somewhat prominent. The influence of this factor was not to be neglected in case 108; again, its presence was a feature in cases 132 and 134, of injury to the sciatic nerve and of peripheral injury to the seventh nerve (p. 355). A remark has been made as to the occurrence of functional paraplegia on p. 337. Again, in the case of the organs of special sense. Case 66, of injury to the occipital lobes, showed that a mixture of organic and functional phenomena might be a source of error, even in the determination of the visual field in the subject of an undoubted destructive lesion. On more than one occasion an injury was accompanied by loss of the power of speech; thus a patient who received a slight wound of the neck did not speak again until the application of a battery by my colleague, Mr. H. B. Robinson. A patient was also for a short time an inmate of No. 1 General Hospital, Wynberg, who had become deaf and dumb as a result of the explosion of a shrapnel shell over his head. This patient also did not recover his powers until he returned to the mother-country.
In many other cases of nerve concussion or contusion, the recovery of power and sensation, or the disappearance of neuralgia or contractures, was so sudden and rapid after prolonged continuance of the symptoms, as to suggest a very strong functional element in their origin. The influence of the general shock to the nervous system received by the patients had an important bearing on these phenomena, and their interest from a prognostic point of view was very great.