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 anæsthesia, 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 passed 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 semiprone, and the elbow flexed by a rigid biceps. Six months later the same position was maintained, but the contracture disappeared under an anæsthetic.
(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 1½ 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 anæsthetic median area became hyperæsthetic 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 buttock. The wound was followed immediately by complete peroneal paralysis, both motor and sensory. Fourteen days later hyperæsthesia 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 hyperæsthesia 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.