CHAPTER XIV.

NEURAL MALADIES OF STUMPS.

THE nervous affections of stumps are chorea, neuralgia, neuritis, and sclerosis. They have received but little. notice at the hands of neuro-pathologists, and, indeed, the physiology of stumps, a comprehension of which is necessary before studying their diseases, may be said to have been almost entirely neglected.

I have therefore thought it fitting to introduce here an original study of the vital conditions of stumps before speaking of their diseases.

Functional and other changes after amputation.—The amputation of limbs gives rise to certain functional and other conditions which have never as yet been fully studied. According to my own experience, removal of large limbs tends to cause plethora, more rapid pulse, and in very many cases greater tendency to sweat. The tissue changes in the stumps which follow amputation have been pretty fully described by surgeons, and need not be considered here, save as to certain practical points. In many cases the stumps, after wasting for a time, seem to gain in bulk, although this is not always the case, for it occasionally happens that both muscles and bone undergo remarkable and permanent atrophy. Perhaps in chosing a line of amputation, more attention should be paid to the points at which the nerves enter the muscles or the bones, since, if these can be respected, wasting will be less

likely to occur, and the mobility and nutrition of the stumps will benefit by the precaution.

Neuromata of stumps. -At the ends of the severed nerves, tumors of various size form. They are chiefly masses of connective tissue, over which the nerve filaments spread, and are finally lost to view. In most thin stumps these enlargements can be easily felt, and very often a thickened nerve trunk running from them is also readily perceptible. Perhaps no stump is altogether without these tumors, which are far too apt to be regarded by surgeons as the cause of neuralgia, a disease usually due in stumps to neuritis or the sclerotic state which it is apt to occasion. In all the stumps I have studied, these neuromata existed, and are, I think, to be looked upon as inevitable appendages.

In very many stumps, the neuromatous tumors in which the nerves end are united to one another, or are adherent to the bone and the cicatricial tissue of the muscles and skin. Owing to this fact, and to sclerotic conditions of the nerves which lessen their natural elasticity, they fail to yield readily when stretched, and for this reason are apt to suffer when the limb is suddenly and violently moved, as in spasm or by the will. Only in this manner. can I explain the occurrence of pain and inflammation due to such motion. A man previously well has an unusually violent and abrupt spasm of the deltoid, such as has often before occurred to him in a lighter form, and always with painful results; but on this occasion the pain is excessive and continuous; the nerves then become tender, neuralgia follows, and we have at last a wellmarked case of neuritis. Although these are rare cases, they are not to be overlooked in seeking for causes of inflammation, and seem to me to be explained by the facts I have mentioned.

Neuro-physiology of stumps.-When a limb has been

removed, the stump which forms is liable to certain nervous disorders, which are often intractable. The part which they affect exists under physiological conditions so new and peculiar that it is desirable to comprehend them as fully as possible before proceeding to study these maladies. So far as I am aware, there is but one essay on the physiology of stumps, and this by no means covers all the ground. My own information on the subject is derived from the careful study of ninety stumps, and from the statements of fourteen persons who have consulted me on account of neuralgia or choreiform movements of their stumps, as well as from dissections of such parts.

Sensibility. The sense of touch, which soon after amputation is oftentimes dull or deficient in limited areas of stumps, becomes in time more acute, but is rarely perfect. In cases of arm amputations remote from the date of operations, I have often found portions of the skin of the stump almost devoid of tactile feeling, while the rest of the stump showed as distinct an appreciation of the distance of two compass points as regions similarly placed in the corresponding limb.

Sense of pain.-A large proportion of stumps, especially those of the arm, are hyperæsthetic, or have some unpleasing sensation as a consequence of any, and especially of rough contacts. Lateral pressure is very annoying to many, and if long continued is apt to cause aching neuralgia; complete anæsthesia is much more rare. I have seen one case in which the entire end of the limb was insensible to a needle, but this was the remote, and, I may say, the fortunate consequence of a severe attack of painful neuritis.

The sensitiveness of stumps varies greatly with the season of the year, with the weather, and with constitutional conditions, while of course there are many in

stances of well-cushioned stumps which are no more sensitive than other parts. As a rule, great heat or imperfect ventilation of the stump where artificial limbs are worn occasions increased sensibility, with excessive cutaneous congestion; so that in our July weather many persons are unable to endure their false limbs.

Cold has usually the effect of causing pain in the part with referred sensations, and both cold and heat are apt, in rare cases, to occasion twitching or even choreic movements of the stump. So well are these facts known to many patients that they pay extreme attention to the temperature of the part, and prefer to guard it in winter by some unusual amount of covering, knowing perfectly well that it is singularly sensitive to thermal changes. I have found this to be more remarkably true of the arm than the leg, and especially so of thin stumps, perhaps because of the insufficient protection they afford to the nerves and of the defective circulation produced by want of exercise.

But besides the influence of palpable changes in temperature, stumps are subject to a variety of unpleasant or painful sensations whenever a change of weather is about to occur, from dry to wet, or rather when we are about to have an easterly storm. The certainty with which some persons who have had limbs amputated can predict such a change is curious and puzzling, and renders likely the existence of peculiarities in these storms which our instruments have as yet failed to dis

cover.

After questioning closely fifty persons, the following are the conclusions reached:

Less than half the number feel no nerve sensation upon the coming or during the continuance of an east wind; of the remainder, two-thirds insist upon their power to foretell such a change of weather, and are positive that

they are unaffected by the onset of a thunderstorm, or of southerly rains, although as to the latter point some of them feel doubtful.

I have never had the chance of absolutely testing the power of any such patients to predict a storm, but the intelligence and character of a few of my witnesses lend force to statements like their own coming from less responsible persons.

Aching pains and twitching of the stump muscles, with sensations of various kinds, motor or sensory, referred to the lost part, are the symptoms which are described as preceding an east wind,* and in many cases as persisting until their sudden cessation foretells an impending change of weather.

Many stumps are liable to slight pain during the performance of certain normal reflex actions. I have seen one person who has a sharp pang in the arm-stump (left) when he yawns, and others who always suffer more or less in leg-stumps (thigh) during defecation. The most common of such referred sensations is the pain which is felt in thigh-stumps during micturition. A highly intelligent gentleman first mentioned this to me, and assured me that it was quite frequent among the amputated, with numbers of whom his business had brought him into relation. Since then I have had repeated evidence of the truth of his statement. The pain comes on at the beginning of the act of passing water, and is felt in the stump, and sometimes down the lost leg. Professor Gross, in his Surgery, speaks of incontinence of urine as apt to follow for a time thigh amputations. I have only seen two persons in whom there was any such symptom at a later date. Both were high amputations.

* As every physician knows, these feelings are common to many sufferers from rheumatic disease or maladies of the bones.