(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.). Hyperæsthesia 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 circumference 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 buttock 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 buttock fold; exit, at anterior aspect of thigh, 3½ 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 circumference 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 anæsthesia 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 passive 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 anæsthesia 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 anæsthesia, except in the hinder part of the region supplied by the mixed external saphenous. Slight hyperæsthesia 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 anæsthesia.—Shell wounds of the right popliteal space. Wounded at Belmont. Anæsthesia of the outer side of the calf, the leg and sole of foot. No motor paralysis. As cicatrisation progressed, the anæsthesia became more marked and was complete over the whole of the external saphenous area.