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to adisease which is as likely as not of infectious origin-namely, the purpurio type of erythema. In rare cases oftabes dorsalis small or even considerable subcutaneoushaemorrhages may follow paroxysms of lightning pains, so

that haemorrhage may certainly be due to nervous disturb-ance. Moreover, in urticaria, into which the neuroticelement enters largely, there may be exudation not onlyof serum but also of corpuscles. It is to be noted thatour patient was the subject of factitious urticaria. We mayadd that Professor Workman, as a result of his anatomicalexamination of the case, is disposed to accept the view whichwe adopted after careful clinical investigation and to regardthe haemorrhages as neurotic rather than infectious in theirorigin.

It should be mentioned that during life numerous remedieswere employed for the cure or relief of the disease or itsmost urgent symptoms but none of them exerted any verynoticeable influence. The drugs included antipyrin, ergot,opium, bromide of potassium, iodide of potassium, iron,arsenic, and calcium chloride. Counter irritation in the formof a seton at the back of the neck appeared to do almost asmuch good as any internal remedy.Glasgow.

BRACHIAL NEURITIS.1BY CHARLES W. BUCKLEY, M.D. LOND.

THE scanty attention which this subject has received inmodern text-books of medicine is remarkable and thereferences to it in current medical literature are few and farbetween, although it is as well defined as sciatica and quiteas painful and disabling. The same difficulty arises as insciatica in distinguishing between neuritis and neuralgia,but I wish as far as possible to confine my remarks to theformer. It is certainly becoming more common, as is thecase with many other affections of the nervous system, butwhether this is to be accounted for by a progressive increasein the vulnerability of the nervous structures which appearsto be a feature of modern life is a question which I shallnot attempt to discuss. The causes are very numerous butthe prominent symptom in every case is pain, sometimessudden in onset, but more often slight and occasional atfirst and only felt on making certain movements, notablythose of raising the arm, but it increases and becomesmore continuous with paroxysmal exacerbations ; it isdull and varying in character and appears to be greater thanin most forms of neuritis. It may be referred to the scapula,especially over the area of the suprascapular nerve, theshoulder-joint, or wrist, with or without the hand, accordingto the nerves chiefly affected. The form arising from injuryis perhaps the commonest and has received the most atten-tion, and I therefore propose to deal with it first and after-wards to point out in what respects those arising from othercauses differ from it. This form commonly results from afall broken by catching at some object, thus throwing theweight of the body suddenly upon the structures at theshoulder-joint. The results vary according to the extent ofthe injury and the nervous symptoms frequently do notshow themselves at once but come on gradually, perhapstwo or three weeks afterwards when the other symptoms aredisappearing. There is marked tenderness over the affectednerves and wasting and paralysis appear in varying degrees,but the reaction of degeneration is rarely present in itscomplete form though some modification of the electricalreaction is common. In all forms there is some limitationof movement, due more often to pain than to paralysis,and in severe cases passive movement is also limited bychanges in and around the joint, in which cracklingand grating may be perceived. The cause of thesechanges has been the subject of much discussion. Barwell2 2

points out that in some hysterical subjects crackling, whicharises in the subacromial bursa, may normally be perceivedon slight movement. Damage to this bursa is very likely toarise in such an accident as I have described, or may arisesecondarily from trophic causes, and the crackling may bedue to this cause alone, but in severe cases the joint alsoshares in the trophic effects and synovitis or arthritis results.

1 A paper read before the Medical Society of London on Feb. 22nd,1904.

2 Diseases of Joints.

Jarjavay has demonstrated that if the bursa is torn or other-wise injured it is quite capable in itself of giving rise tocoarse crackling and pain, and hence immobility.3 Duplay,in the only account of a necropsy which appears to berecorded describes the following changes : (1) chronic sub-acromial bursitis and subdeltoid cellulitis with obliterationof the bursa and formation of adhesions between the deltoidand the humerus ; (2) chronic inflammation of the capsuleleading to thickening ; (3) periarticular cellulitis internal tothe joint leading to formation of fibrous tissue; (4) con-

gestion of the ulnar and internal cutaneous nerves ;and (5) atrophy of the deltoid. The circumflex nerve

was not examined, but the author assumes that pain onpressure is due to inflammation of the nerve the result of

compression and traction by adhesions. There was also adislocation of the humerus and it seems probable that agood deal may have been attributable to this, for it isdifficult to see how such extensive damage could result froma simple strain or bruise of the shoulder, even making themost liberal allowance for trophic effects, but the accountthrows a good deal of light on the pathology of the sym-ptoms commonly accompanying the severer forms of neuritis.Duplay in illustration quotes five cases of neuritis fromsimple contusion with similar symptoms and compares them.Certainly very slight injuries may cause synbvitis or a

nerve lesion with far-reaching effects. Berne supports theview that peri-arthritis is the chief lesion 5 and Vietor putsforward the theory that the shoulder changes are trophiceffects from injury to the circumflex nerve, quoting WeirMitchell in support who says : "Any form of nerve lesionis capable of developing in the joints inflammatory condi-tions, usually subacute, and which so precisely resemblerheumatoid arthritis that no clinical skill can distinguishbetween the two." 6 Bowlby differs somewhat from this andsays that he has not seen cases of joint injury so severe asWeir Mitchell describes from nerve lesions, but that arthriticlesions of a less severe and more chronic kind are among themost common results of nerve injury. 7The evidence I have quoted seems to me sufficient to prove

that the effect of the neuritis upon the joint may be veryserious and even permanent, although such is not often thecase in non-traumatic forms, but cases presenting jointlesions closely resembling those of rheumatoid arthritis are byno means uncommon, and I have dwelt upon this question oftrophic joint changes thus fully because I believe that manycases are regarded as rheumatic simply because the joint isaffected and the question of injury is overlooked. Simonhas recently reported a series of cases of traumatic origin iand asserts that some violence is always necessary to thedevelopment of brachial neuritis ; but in this I cannot agreewith him and the analogy of sciatica should be sufficientevidence to the contrary. It must be admitted, however,that sufficient attention may not have been paid in the pastto any history of injury, however slight, for the positionof the plexus renders it more liable to injury than is thesciatic nerve. I think there is no doubt, however, that thetraumatic cases are the most severe of all. The neuritis, ashas been mentioned, is sometimes a late result of the injury,and this may mislead as to the cause. Vietor 9 reports acase due to a fall broken by catching at the handle of a door,which showed at the onset pain, weakness of the deltoid,and limited movement; these symptoms improved, but fourweeks later the patient suddenly became worse with mostintense pain and all the symptoms of a severe neuritis.This late onset was also clearly shown in a case of myown, and equally well by a series published recently byDistin.10Apart from injury gout is undoubtedly the most prominent

etiological factor and in many cases the only discoverablecause, while in others it acts merely as a predisposing con-dition. In men the neuritis may be accompanied by any ofthe ordinary manifestations of gout, and in women irregularforms are common accompaniments, while in either sex itmay be the only symptom and diagnosed as gouty in the lightof the family history. Trophic symptoms are rarely markedin this form and the chronic enlargement of the finger-joints commonly present in cases arising late in life are a

3 Gazette Hebdomadaire, 1867.4 Archives Générales de Médecine, 1872.

5 L’Union Médicale, 1897.6 Injuries of Nerves, Philadelphia, 1872.

7 THE LANCET, vol. i., p. 1021, 1887.8 Brit. Med. Jour., 1903, vol. ii.

9 L’Union Médicale, 1897.10 Brit. Med. Jour., 1904, vol. i.

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manifestation of the gouty diathesis rather than a result ofthe neuritis. The acute forms both in this and the followinggroup are probably in most cases at the outset acuteinflammations of the fibrous structures of the musclesrecently described by Gowers, J1 and for which he suggeststhe term "fibrositis." In these cases, which arise commonlyafter a chill, the onset is sudden with generalised painand tenderness of the shoulder muscles and the wholearm may be involved so that the patient cannot bear tomove in any direction, there are slight pyrexia and loss ofappetite, and this acute stage may last for a week or more.The mischief spreads from the muscles to the sheaths of thenerves and often to other fibrous structures in the vicinity,and when the acute condition subsides a chronic neuritis isoften left. This course was strikingly evident in one caseof my own but I have not often met with it, since cases sentto Buxton for treatment have usually reached the chronicstage or have been chronic from the commencement.Many cases are termed rheumatic, though probably true

rheumatism rarely plays any part in their causation. Theyoften arise from a chill, especially in a gouty subject, and inthe majority of cases I am inclined to believe have theirorigin in a general fibrositis and are acute at the onset likethe form I have already described. In two of my cases therewere cardiac symptoms ; in the first, a car%e commencing asan acute fibrositis, there was a loud systolic murmur whenthe patient first came under my observation, a month afterthe onset, but this, together with the accompanying dilata-tion, showed marked improvement under treatment and hadalmost disappeared when he left Buxton a month later. Thesecond case showed slight irregularity with weakness of bothsounds but the patient was 69 years of age and had had anattack of influenza during the course of the neuritis, so thatit is not probable that the cardiac condition was due torheumatism. With the cases of this type may also be in-cluded those occurring in coal-miners, which Charles hasrecently described, though there seems in these to be alsoa possibility of strain as a cause.12 Many cases occur inwomen at the menopause, some of which appear to be gouty,while others belong to the class of neuritis occurring in preg-nancy and the puerperium, as described by Turney in anexhaustive paper upon the subject.’3 I He attributes them totoxsemia and finds that when the neuritis is limited to the armthe median and ulnar nerves suffer the most, otherwise theposterior interosseous is chiefly affected. This differs some-what from the distribution in other forms, the circumflex

being affected by far the most frequently in my experience.The pain is often very severe and wasting may go on to anextreme degree, while, on the other hand, cases occur in whichthe extent of the neuritis is very limited and the symptomsare slight.

Reflex irritation appears to be responsible, in part at anyrate, for a certain number of cases, of which those due toaneurysm are the most important. With this exception theydo not call for special mention, but a case which came undermy notice, diagnosed as rheumatic, though without veryclear evidence, was interesting. There was a lipomasituated in the scapular region from which the painradiated and it was much worse if the tumour was lain

upon or the muscles in relation to it were called into play,the other symptoms being of the usual type. As the improve-ment was but slow I advised its removal and this was doneas soon as the patient returned home. The pain disappearedas the wound healed and the arm is now quite well exceptfor an occasional sensation of coldness and numbness. Inmost cases, however, a certain degree of psychic concentra-tion of the pain is present and neuralgia often persists as ahabit after the removal of the nerve lesion which originallystarted it. In another case of a lipoma in the same regiontreatment was sought because of neuralgic pains which,starting from the tumour, radiated down the arm as far asthe fingers.One of my cases was interesting in that it followed an

attack of lead poisoning, appearing some six months afterthe lead was detected. There were none of the usualsymptoms of lead neuritis and the case did not differ fromthe common type, but there was a well-marked lead linewith a considerable degree of saturnine cachexia, and thepatient was rather emaciated. There were a gouty familyhistory and a few doubtful symptoms of irregular goutMenstruation was regular and normal, whereas the great

11 Ibid. 12 Ibid.13 St. Thomas’s Hospital Reports, vol. xxv.

majority of cases in women occur after menstrual life hasceased.

To summarise, the prominent symptoms are pain, vary-ing in degree but often very severe when at its height ;tenderness of the affected nerve trunks, and of certaincutaneous areas related to them ; weakness of certain

muscles and limitation of movement, due partly to thisand partly to changes in the subacromial bursa, or inand around the joint; trophic changes, rarely severe;and sensory symptoms such as anaeathesia and hyper-sesthesia, which are often very slight but often persistafter the other symptoms have disappeared. It is certainlyopen to discussion whether the joint changes when presentare in all cases trophic or whether they may not have beenprimary, the mischief subsequently extending to the fibrousstructures in the neighbourhood, which would account forthe circumflex nerve being so commonly implicated, but, onthe other hand, this is the chief nerve supplying the shoulder-joint and if primarily affected the joint would probablysuffer secondarily to a greater or less extent. Or the fibrousstructures of the joint, muscles, and nerves may all be affectedat once in an acute attack of fibrositis, with only partialrecovery of the joint owing to the trophic influences of thedamaged nerves. In my opinion, however, the trophicorigin is by far the most common and the joint is more

frequently affected in the traumatic cases than in otherforms, though this may be partly the result of injury to thejoint itself independent of the nerves.The diagnosis may be difficult ; all nerve pains in the left

brachial region have, as Gowers has pointed out, a tendencyto resemble anginal pain and to be accompanied with cardiacdistress ; aneurysm is a possible source of error and tumoursof the cervical spine or of the bones of the shoulder may bypressure on the nerve closely simulate neuritis or causeneuralgia, while lesions of the cervical cord must not be

forgotten. Time will not permit me to discuss the differ-ential diagnosis but the influence of movement, the presenceor absence of tenderness, and, in some cases, the use of theRoentgen rays are important aids. *

As to the prognosis, the duration is probably never lessthan three or four months and may extend over a year ormore. The older the patient the more chronic the case islikely to be, while much depends on the degree of rest whichthe parts obtain. Relapses occasionally occur and recovery isoften incomplete, the limb remaining weak, with occasionaltingling pains or numbness, while there are frequentlyadhesions left in the shoulder-joint after a severe attack.With regard to treatment, in cases commencing acutely,

whether as part of a general fibrositis or as a simple neuritis,rest in bed is necessary at first with purgation and treatmentsuitable to the general condition ; colchicum and alkaliesmay be useful in gouty subjects or salicylates if the case is ofrheumatic origin. In the acute cases I have found aspirinwith or without phenacetin of much value and mesotan forexternal application is often very useful. Poultices and hotapplications generally give relief to the pain and where theyfail ice is sometimes of use. I have found the coal-taranalgesics when given in regular and sufficient doses moregenerally useful than opium or its derivatives for the reliefof pain, and in this the majority of recent writers agree, butin the most severe cases morphine becomes necessary. Whenthe acute stage is past, rest to the affected limb is still, as inthose cases chronic from the first, of the utmost importance ;this can usually be secured by the use of a sling butit is sometimes better to bandage the affected limb tothe side. In the chronic cases of gouty origin alkaliesand iodide of potassium are sometimes of value andchloride of ammonium may be tried but otherwise drugs,with the exception of analgesics, are of little use and,considering the long duration of the majority of cases,other measures for the relief of pain are desirablewhenever possible. I have found the greatest benefitin this respect from the free use of blisters along theaffected nerve trunks or over the tender points, while sub-sequently, or in cases in which the pain is less severe,galvanism has an anodyne effect and both undoubtedlyexert a beneficial effect upon the general course of thedisease. Other forms of electricity are of much less value,being, as Lewis Jones ("Medical Electricity") has pointedout, chiefly of use in those cases in which neuralgia persistsas a habit after the disappearance of the nerve lesion whichoriginally caused it. Faradism and the sinusoidal currentare, however, of use in the treatment of the wasted musclesand some authorities have found high frequency currents of

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benefit. Massage, in my own opinion, must never beused as long as the nerves are acutely inflamed ; later itis of value for the removal of the inflammatory effusion inthe nerve trunks and especially in traumatic cases witheffusion into and around the joints when it may often beadvantageously combined with radiant heat, but if it causes

any marked pain I am strongly of opinion that it does moreharm than good. In the rheumatic and gouty cases a courseof treatment at Bath or Buxton is of great benefit and themajority of cases find relief from the mineral baths, vapourbaths, and hot douches which are a feature of the treatmentat both places. The diet and digestion often call for atten-tion and tonic treatment by drugs and change of air is

generally desirable in view of the debilitating effect of thelong-continued pain. In choosing a place to which thepatient may be sent it is important to remember that thesea does not suit many cases and a bracing inland climateis more generally beneficial, though a clay soil should beavoided if possible. The combination of such a climatewith the advantages of balneological treatment rendersBaxton especially suitable for these cases. As is usuallythe case in such chronic and obstinate conditions, the ’number of remedies that have been suggested is legion butI have only advocated those which I have personally foundbeneficial.Buxton.

INTRACRANIAL RESECTION OF THESECOND DIVISION OF THE FIFTH

NERVE FOR EPILEPTIFORMNEURALGIA.1

BY J. HUTCHINSON, JUN., F.R.C.S. ENG.,SURGEON TO THE LONDON HOSPITAL.

SOME three years ago, in a paper on excision of the

Gasserian ganglion, I advanced the proposal "that theso-called excision of Meckel’s ganglion (always a verydifficult and uncertain proceeding involving disfigurement ofthe face) should be given up in favour of intracranial divisionof the superior maxillary trunk just above the foramenrotundum." 2 The recommendation was based on the follow-ing considerations :-

1. The more central the operation, the nearer to the brain,the more certain is the prospect of permanent cure. Inalmost every case of peripheral operation, including removalof Meckel’s ganglion, the neuralgia has returned after aninterval of a few months or years.

2. The surgeon who works through the walls of the antrumto the pterygo-maxillary fossa is greatly hampered by thedepth of the wound and by haemorrhage from the internalmaxillary artery. He may be successful in defining thetrunk of the superior maxillary nerve in the upper part ofthe fossa, but he is very likely to fail.

3. A depressed scar in the middle of the cheek is muchmore disfiguring than one hidden by the scalp in thetemporal region.

In the middle fossa of the skull the whole of the superiormaxillary trunk, before it has given off any branches, can beexposed. Here it can be not only divided but a considerableportion of it can be excised so that there will be no chance Jof subsequent union. The amount of the nerve available atthis point for excision varies somewhat in different subjects,but from one-third to half an inch can be resected. The

accompanying figure will make this plain. The trunk shouldbe divided just at the foramen rotundum and again where itleaves the Gasserian ganglion, as shown at A B. Cases inwhich such an operation is justified are not numerous and itwas only about a year ago that one presented itself to me.A ship’s officer, nearly 60 years old but of fine constitution,

had suffered for several years from intense pain in the rightcheek and the upper jaw. The neuralgia was typicallyepileptiform, the attacks becoming more and more frequentduring the last four years. He had had a number of teethremoved without the slightest relief and medicines wereequally unavailing. He struggled on with his duties on

1 A paper read at a meeting of the Clinical Society of London on IMarch 11th, 1904.2 Transactions of the Medical Society of London, vol. xxiii.

board a Cape liner and about Christmas, 1902, he consultedSir Frederick Treves with regard to operative measures whokindly sent him to me with a note suggesting the removal ofMeckel’s ganglion and the infra-orbital nerve. The dis-tribution of the neuralgia was always the same and the partswere very tender, though during an attack some relief wasobtained by the patient violently grasping the tissues of thecheek. The lower eyelid, both sides of the cheek, the palate,

Intracranial resection of the superior maxillary nerve. A B,Portion of nerve to be excised. C D, Wall of temporalfossa cut away in the operation. o D, Ophthalmic division.G, Gasserian ganglion.

and the gums on the right side formed the area involved.Lacrymation and congestion of the right eye were frequent.It might be suggested that exposure on deck to wind andwet was a predisposing cause of the neuralgia but theattacks were equally severe when he was on land and theyoccurred both by day and night. He had the aspect of greatsuffering and depression.My friend Mr. T. Crisp English assisted me at the opera-

tion, which was performed with the patient fixed in adentist’s chair in order to lessen the trouble from venous

hoemorrhage. A horseshoe flap was turned down from thetemporal region, having its base at the zygoma, the flapincluding part of the temporal muscle and the pericranium.With a large trephine and cutting forceps the subjacent bonewas removed and the dura mater was exposed. As in the

operation for removal of the Gasserian ganglion the duramater and the temporo-sphenoidal lobe were then carefullypushed upwards and inwards, making for the foramenrotundum as the landmark. (In this respect the twooperations differ, as in dealing with the Gasserian ganglionthe foramina spinosum and ovale are first sought for ) Con-siderable difficulty was met with owing to the thin andfragile character of the dura mater and some cerebro-spinalfluid escaped. Ultimately the trunk of the superiormaxillary division and part of the Gasserian ganglion werethoroughly exposed, a broad spatula of soft metal beingused to retract the dura mater and the brain. The whole oftha nerve W2,$then removed, a small drain was subsequentlyinserted, and the flap was sutured in position. None of thebone removed was replaced. Pi imary healing followed andno complication of any sort occurred. The patient returneda month later to his duties and has made regular oceanvoyages ever since.

I have waited 12 months before reporting the case in orderto ascertain that the relief is permanent and I am glad tostate that he has not had the slightest recurrence. Theanaesthesia is most marked over the cheek and the right