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CHAPTER XII.

TREATMENT-CONTINUED.

Neurotomy.-When every other means of relieving pain has been exhausted, the very grave question of the propriety of nerve section arises. As regards the simpler cases of lancet wounds and the like, requiring division of superficial filaments, nothing more need be added; but when the nerve to be divided is a great trunk, more serious considerations present themselves. In deciding for an operation, we are, of course, influenced by the extent and duration of the pain and by the fact that cases of common, aching, traumatic neuralgia depend very often on morbid nerve states, which, unless checked, gradually but surely extend up the nerve, and may thus get beyond the reach of the knife, and so make permanent the tortures they occasion. On the other hand, causalgia, in my experience, gets well in time; nor should we forget that in severing a great nerve we are probably condemning certain parts to perpetual functional idleness; yet the earlier the operation the lower down it may be done, and the less will be, therefore, the loss of motion and sensation.

When, after due regard to these points, an operation is decided upon, it becomes requisite to determine at what point it shall be done. To settle this, the limb concerned should be inspected with extreme accuracy, to learn what regions of skin or tissue seem to be painful, because it is essential to cut the nerve above all the painyielding branches.

Next the nerve should be examined with the utmost care, in order to ascertain how far up it is hardened and enlarged. The examination in these cases is far more easy than might be supposed, because in many instances, owing to muscular wasting, the nerve trunks can be readily felt. By rolling or compressing the diseased nerve under the finger-tips, an attentive observer can very often learn whether or not it has undergone inflammatory or sclerotic change.

It is, as a rule, desirable that the section should be made a short distance above the point at which the nerve ceases to feel enlarged and hard. If it be practicable to find even a little farther up the limb a spot where the nerve is neither swollen nor tender upon pressure, the operation should be done at that point. Usually, however, nerves long diseased are sensitive up to and into their parent plexus, so that in practice the surgeon must content himself with a division some distance above the point where the nerve is obviously diseased. When it lies too deep for examination, it will be safest to operate high up in the limb, and, indeed, as a rule, the older the neuralgia, if of traumatic origin, the wiser it is to divide the offending nerve as near to the body as possible.

The necessity for making section of the nerve at a point where its tissues are sound, arises out of the fact, so often insisted upon in these pages, that subacute neuritis and sclerosis inevitably travel inward along the nerve attacked, and that if above the line of division the surgeon should leave any considerable amount of diseased tissue, his operation may be useless, and the morbid change continue to ascend the nerve, inflicting new tortures, and perhaps calling for further operative interference. The popular medical view attributes the return of pain after neurotomy to a reunion of the nerve ends;

but unless there should be at the same time some return of the normal function of the divided trunk, it is more in accordance with the observed facts to believe that renewed pain, after section or exsection, is most often due to the presence or to the gradual increase in the central end of a nerve of the same disease which necessitated an operation. In other words, the section should have been made higher up the nerve.

Where the neuralgic cause is purely local, and the trunk unaltered by sequent changes, the operation ought of course to be done at the lowest point possible, and will then offer the best chance of success.

The operative procedure must vary with the nerve, but there are certain indications to be fulfilled in every instance. If, when the nerve has been fully exposed, it should prove to be hard, red, and congested, the track should be followed upward, or a new incision made above, until a healthy point has been found.

Simple division of the nerve is at present scarcely ever practiced. Not less than two inches of its length ought to be removed, our object being to make reunion impossible, or at least very remote in point of time. It has been advised to cauterize the cut ends, but a more sensible plan is that of Malgaigne, who counsels us to double the nerve ends on themselves,-a measure which I should think very unwise as regards the central end, while I see no reason why the peripheral extremity should not be thus reverted, and, if necessary, secured by a removable loop of silver wire.

With this precaution, reunion would be out of the question, but assurance may be made doubly sure by further following the French surgeon's advice, and interposing a piece of muscle or fascia.

Such precautions are not vain, since even where two inches of nerve have been cut out, function has returned,

and neuralgia also; and although, for reasons already stated, neither the return of sense nor of pain is in all cases conclusive as to the reunion of the nerve ends, it were wise to take every precaution against this occur

rence.

It is desirable also to make, at the time of operation, a rapid microscopic examination of the portion of nerve removed, because only the microscope is fully competent to decide whether or not we have reached the region of normal nerve tissue, and until this is done we can possess no certainty that the operation will prove successful.

On pages 288-291 will be found the statistics of these operations, but a careful study of the individual case and of the state of the nerve will offer far better ground for prognosis than any table of cases can ever furnish us.

Should the pain recur, it has been advised to amputate the member, and this grave step has been frequently taken, although I do not conceive that it can ever be justified except where more than one nerve is involved, or where grave injury has rendered the limb altogether useless.

We are certainly able to make neural reunion impossible, and, if so, I cannot see what advantage amputation offers which resection higher up does not also afford. Moreover, when resection has failed, this more extreme step is not always successful, as the following curious case will show:

Case 46.-A soldier had his leg crushed in a railway accident, August 1, 1862. Amputation was done August 12th, at the junction of the lower and middle third. The stump was conical, the bone bare. In 1863, after a journey, in which he was exposed to cold, he consulted Dr. Nott for intense neuralgia of the stump, which, in September, 1863, Dr. Bayless amputated without relief. In May, 1864, Dr. Nott removed the stump again, taking off

an inch of bone. Portions of two large nerves were found enlarged and engorged. The pain continued, and was intolerable.

June 1st.-Dr. Nott opened the popliteal space and took out an inch of the trunk of the sciatic, and apparently about three inches of the popliteal and peroneal nerves, all of which were enlarged. No relief followed, and in May, 1865, Dr. Nott, evidently thinking there might have been reunion, and, as he justly says, with "no very good physiological reason for so doing, dissected out the two large nerve trunks completely down to the extremity of the stump." He does not say whether or not there had been reunion. Naturally, no relief ensued, and, in despair, the thigh was removed four inches. above the knee, when the sciatic nerve was seen to be engorged and double its normal size. The neuralgia continued, and in August, 1865, Dr. Nott exsected the sciatic nerve at its point of pelvic exit, removing an inch and a quarter. The upper half only of this portion seemed healthy, but whether it was studied with the microscope or not we are nowhere informed. Some relief was thus obtained, but the next day the pain returned, and then, as always, was referred to the end of the existing stump, and not to the lost limb,-a rare anomaly.

Dr. Nott believes that his patient was really much eased by this final procedure, but that his craving for opium caused him to malinger.

As an illustration of the tendency of neuritis to pass centrally, of its sclerotic results, and of the need for early resection higher up the nerve, this case is most instructive.

I have stated in the accompanying table the more important particulars of twenty-three cases of exsection of portions of nerves for traumatic neuralgia, with one of simple division.

These include a variety of nerves, in five of which the

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