CASE 
OF 
EXSECTION OF THE BRACHIAL PLEXUS OF NERVES 
FOR THE RELIEF OF 
PAINFUL NEUROMA OF THE SKIN. 
BY 
F. F. MAURY, M.D., 
SURGEON TO THE PHILADELPHIA HOSPITAL, 
AND 
LOUIS A. DUIIRINGr, M.D., 
CLINICAL LECTURER UPON DISEASES OF THE SKIN IN THE UNIVERSITY 
OF PENNSYLVANIA. 
[Reprinted from tlie American Journal of the Medical Sciences, for July, 1874,] 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1874. CASE 
OF 
EXSECTION OF THE BRACHIAL PLEXUS OF NERVES 
FOR THE RELIEF OF 
PAINFUL NEUROMA OF THE SKIN. 
BY 
F. F. MAURY, M.D., 
SURGEON TO THE PHILADELPHIA HOSPITAL, 
AND 
LOUIS A. DUIIRING, M.D., 
CLINICAL LECTURER UPON DISEASES OP THE SKIN IN THE UNIVERSITY 
OF PENNSYLVANIA. 
Reprinted from the American Journal of the Medical Sciences, for July, 1874,] 
PHILADELPHIA: 
COLLINS, PRINTER, T05 JAYNE STREET. 
1874. CASE 
OF 
EXSECTION OF THE BRACHIAL PLEXUS OF NERVES FOR THE 
RELIEF OF PAINFUL NEUROMA OF THE SKIN. 
Under the name of Painful Neuroma of the Skin, one of us (Dr. 
Duhring) reported in this Journal for October, 1878, a case remark- 
able for its many peculiarities. In that report the subject was dis- 
cussed from a dermatological point of view only; in the present 
communication the question will be considered in its surgical as- 
pect, as to the means of affording relief to the excruciating suffer- 
ings of the patient. 
When first described, the case was deemed to be an unique ex- 
ample of disease, and, after further investigation, there appears to 
be no reason to question the accuracy of that belief. It seems 
to stand alone in literature, with its distinctive symptoms, apart 
from all other cases to which, at first glance, it might be likened. 
To thoroughly comprehend the affection it is essential that its 
whole course be carefully investigated in all its details ; for, with- 
out accurate study of the various symptoms, viewed subjectively 
as well as objectively, it is impossible to arrive at a just apprecia- 
tion of its nature. In the number of this Journal just referred to 
will be found an accurate representation of the disease, as well as 
certain statements which should be borne in mind. 
In addition to the remedies already stated to have been tried, 
electricity and galvanism have been used perseveringly, with no 
perceptible amelioration of the symptoms. Quinia has also been 
administered, both in tonic as well as in larger anti-periodic doses, 
without benefit. Preparations of iron and arsenic, various quanti- 
ties of the bromide and iodide of potassium, all have been admin- 
istered in turn, without effect. 
The signal failure of all remedies, both constitutional and topical, 4 
led to the consideration of the propriety of resorting to a surgical 
operation for the relief of the unbearable suffering which the 
patient endured. It was thought that by this means only was 
there a chance of affording any relief. The question presented 
itself: What operation could be performed with this end in view? 
It will be remembered that the area of suffering extended over the 
shoulder, .radiating to a certain extent to the integument of the 
thorax anteriorly, and posteriorly to the scapular region, and down 
the entire arm, the central seat of pain being upon the arm at a 
point corresponding to the insertion of the deltoid muscle. It will 
be seen that a very large tract of surface was thus involved. After 
a careful study of the distribution of nerves to these regions, in 
which Dr. S. Weir Mitchell rendered valuable assistance, it was 
evident that to afford the best chance of subsequent immunity from 
suffering, it would be necessary to divide the entire brachial plexus 
of nerves; or better, to exsect a sufficient portion of nerve tissue 
to preclude any likelihood of reunion. It will be recalled to 
memory that the fourth, fifth, sixth, seventh, and eighth cervical 
nerves, together with the first dorsal, combine to form the plexus, 
these uniting by two main trunks or cords. During this investi- 
gation it was also found that the third cervical nerve supplied a 
portion of the integument of the neck and shoulder posteriorly ; 
but it was seen to be entirely impracticable to divide this nerve 
by the same operation that would reach the brachial plexus at its 
most eligible and desirable point. It may be mentioned here that 
the only recorded case for which any operation has been instituted 
for a kindred, but not like disease, is that of Drs. Sands and Seguin, 
of New York, carefully reported in the Archives of Scientific and 
Practical Medicine, No. 1, 1878. The operation in this case, how- 
ever, was done for a traumatic neuritis. 
The free consent of the patient was obtained, after a clear and 
truthful statement of the risks and dangers had been made, and 
the operation determined upon. 
On the 25th October, 1873, the patient was placed under careful 
surveillance, and the following notes recorded:— 
7 A. M. Patient had three paroxysms during the night, and 
one after dressing this morning. They each continued from ten 
to fifteen minutes. 5 P. M. Has had six paroxysms since this 
morning’s note, two of which lasted thirty minutes, two fifteen 5 
minutes, and the remaining two eight and ten minutes. Patient is 
fearful that the proposed operation will be of no benefit to him ; 
nevertheless, is willing to risk death rather than continue to suffer. 
26th, 8 A. M. Had three paroxysms through the night, one of 
which was very severe, and continued one hour; the others lasted 
each twenty minutes. P. M. Had two paroxysms to-day, fif- 
teen and thirty minutes in duration. 
27th, 8 A. M. Had two paroxysms during the night, and one 
this morning, of about fifteen minutes. 
28th, 8 A. M. Five attacks of pain since last note, two of which 
the patient states, were the most severe he has ever endured. 
29th, 8 A. M. The day appointed for the operation. Five par- 
oxysms since yesterday, three of which were very severe. 11 A. M. 
Is prepared for the operation. Is calm and in good spirits, thinking 
only of the pain that he may suffer after the operation. Has had 
two paroxysms within the last three hours. 
The operation was performed by Hr. F. F. Maury, assisted by 
Drs. W. II. Pancoast, J. II. Brinton, and S. W. Mitchell, in the 
amphitheatre of the Philadelphia Hospital in the presence of the 
clinical class. 
The patient having been thoroughly anaesthetized with ether, 
the following steps may be noted: The shoulders were well ele- 
vated, and the head allowed to drop backward with the face strongly 
inclined to the sound side, the integument of the neck of the af- 
fected side being rendered tense. This is a point of importance, 
causing the sterno-cleido-mastoid muscle to be prominently dis- 
played. It is, moreover, especially desirable that the posterior 
border of this muscle be clearly defined as a landmark for the first 
incision. The next important step consisted in rendering promi- 
nent the course of the external jugular vein, which commences in 
the substance of the parotid gland, upon a level with the angle of 
the lower jaw, and runs perpendicularly down the neck in the 
direction of a line drawn from the angle of the jaw to the middle 
of the clavicle. The finger of an assistant pressed immediately 
above the last-named point rendered this vein distended. The in- 
cision was L shaped, with the long arm extending along the pos- 
terior border of the sterno-cleido-mastoid muscle, beginning three 
inches above the clavicle; the short arm following the course of 
the collar bone, as in the operation for the ligation of the subclavian 6 
artery. The length of both skin incisions is to be regulated by 
the size of the neck of the patient. The knife was carefully guided, 
so that it divided only the skin, under which conspicuously ap- 
peared the external jugular vein; this was pulled aside by the 
finger. The handle of the knife and the finger were then used to 
tear and separate the fascia in searching for the tendon of the omo- 
hyoid muscle, the next important guide. Immediately underneath 
the posterior belly of the omo-hyoid muscle, which it was not 
necessary to cut, being readily held aside by the finger or a blunt 
hook, were found the two cords of the brachial plexus. The outer 
or upper cord, composed of a faciculus from the fourth, with the 
fifth, sixth, and seventh cervical nerves, was elevated by means of 
a curved aneurism needle armed with a silk ligature; the needle 
was withdrawn, the ligature left and loosely tied around the cord, 
was given to an assistant. The index finger of the left hand was 
then placed in the wound, and the exact position of the subclavian 
artery ascertained; it was found, and held well out of the wav and 
carefully protected. The trunk was next divided with blunt- 
pointed scissors, as near the finger of the left hand as possible, 
which was effected without difficulty. 
Another division was made above the point of the ligature as 
far up as practicable, care being taken not to interfere with the 
scalenus anticus muscle, across the body of which passes the phrenic 
nerve, which was not seen. By this means four-fifths of an inch 
of nerve substance, carefully measured immediately after exsection, 
was removed, and the marked retraction of the cut ends gave a 
space two and a quarter inches from each extremity. The inner 
cord was then sought for and found directly underlying the outer; 
this cord, it will be borne in mind, is composed of the eighth cer- 
vical and first dorsal nerves. It was secured by needle and ligature 
in the manner already mentioned, and the same amount of nerve 
exsected. Even greater care should be observed here in the pro- 
tection of the subclavian artery, as it lies in immediate proximity 
with the inner cord. No vessels were divided, not even the trans- 
versalis colli, it being held carefully aside with the posterior belly 
of the omo-hyoid. The operation was therefore bloodless; no 
ligature was required. 
The operation occupied one hour and a quarter, from the time 
of commencing etherization to the dressing of the wound. The 
incision was brought together, and covered with a pledget of oakum 7 
soaked with olive oil. The finger nails of both hands were stained 
with nitric acid, for the purpose of noting the growth of the nails. 
5 P. M. Patient still more or less under the influence of the anaes- 
thetic. The arm is completely paralyzed, and without pain. 104 
P. M. Has had no severe pain since operation; is restless. One- 
fourth of a grain morphia given hypodermically. 
30 th, 7 A. M. Rested well through the night. Suffers no pain 
of any kind. 7 P. M. Has been comfortable through the day, and 
has eaten heartily. Ordered xl grs. bromide of potassium. 
31si, 7 A. M. Slept well through the night until four o’clock, 
when he awoke and shortly after experienced a slight paroxysm 
of pain on the top of shoulder. It lasted five minutes, and was 
similar in character to the old pain. 4 P. M. Has been free from 
pain during the day; feels comfortable. 
Nov. 1, 7 A. M. Just after getting asleep last night, he was 
awakened with pain about the top of the shoulder; it lasted fifteen 
minutes. Had slight pain an hour ago. 
2d, 8 A. M. Did not sleep well; had a ringing sensation in his 
head. Complains of a tingling sensation in his arm. Slight par- 
oxysms this morning. Wound of neck somewhat reddish. 
3d, 7 A. M. Restless last evening; was ordered xxx grs. brorn. 
pot., with £ gr. morphia. Was annoyed with pain three times 
during the night, but the attacks were light. 
4th, 8 A. M. Rested well all night. While dressing this morn- 
ing a paroxysm came on. 
5th, 8 A. M. Had pain during the early part of the night, but 
slept comfortably during the night. Slight paroxysms while 
dressing wound. Stitches removed. Wound has united by first 
intention. 
6th, 7 A. M. One very light paroxysm through the night. 
7th, 7 A. M. Slept comfortably. One short attack of pain an 
hour ago. 
8th, 7 A. M. Had one paroxysm during the night. It may here 
be observed that all the pain has been seated about the top of the 
shoulder. 
11th. Still complains of the tingling sensation in the arm. 
17th. Has been doing quite well, but has had one or two slight 
paroxysms during the twenty-four hours. The appetite is good, 
and he sleeps well. The finger nails have not grown at all upon 8 
the left hand (side of disease and operation), while on right hand 
they have grown an eighth of an inch. Strong tincture of aconite 
root was ordered to be applied as a continual dressing to the top 
of the shoulder. 
24th. No relief has been obtained from the tincture. 
29th. Is in good general health and spirits. Still continues to 
have one or two slight paroxysms through the day. The left fore- 
arm has been somewhat oedematous for several days past. It has 
been rubbed with an ammonia liniment, the unpleasant numbness 
and tingling in the part being greatly relieved by this means. 
April 29, 1874. Since the foregoing notes were recorded, now 
five months, the patient has been under constant observation. 
During the month of January, a carbolic acid dressing, consisting 
of one part of the acid to three of glycerin, was applied to the 
painful shoulder. Vesication was produced, but without affording 
any relief. 
May 12th. Within the past twenty-four hours the patient has 
experienced one paroxysm, which came upon him without apparent 
cause. He has also suffered four very slight attacks, all of them 
produced by external causes, as a draft of air, nervous excitement, 
and the like. 
13th. A repetition of yesterday’s symptoms exactly. 
The following table exhibits, in a condensed form, the state of 
the pulse and the temperature of the body before and after the 
operation. The temperatures were taken with great care, the por- 
tion of the bulb of the thermometer not in contact with the skin 
being surrounded and protected from the air by a piece of scooped 
out cork. The thermometer was allowed to remain in position 
from ten to fifteen minutes. 
“Pulse and Temperature,” degrees Fahr. before Operation. 
Palse. 
Temperature. 
Left 
axilla. 
Right 
axilla. 
Left 
palm. 
Right 
palm. 
Surface 
of left 
shoulder. 
1873. 
• 
Oct. 25th, 
7 A. M. 
68 
9S4 
984 
96 
“ 25th, 
5 P. M. 
80 
97| 
974 
94 
“ 25th, 
8 A. M. 
70 
98 
98 
95 
“ 27th, 
8 A. M. 
76 
983 
98f 
95 
“ 28th, 
8 A. M. 
80 
97| 
973 
94 
“ 29th, 
8 A. M. 
80 
97f 
97 3 
94 
94f 9 
After operation. 
Oct. 29th, 
5 P. M. 
80 
100f 
98 
99 
91 
984 
“ 29th. 
10 P. M. 
88 
lOlf 
100 
100 
97 
lOOf 
“ 30th, 
7 A. M. 
92 
99§ 
98 
984 
98 
99 
“ 30th, 
7 P. M. 
80 
1004 
99| 
994 
984 
97f 
“ 31st, 
6 A. M. 
76 
• 984 
974 
974 
964 
964 
“ 31st, 
4 P. M. 
80 
994 
984 
994 
984 
97| 
Nov. 1st, 
7 A. M. 
76 
98 
974 
97 
964 
964 
“ • 1st, 
5 P. M. 
80 
994 
984 
984 
964 
994 
“ 2d, 
8 P. M. 
80 
99 
984 
974 
97 
97f 
“ 3d, 
7 A. M. 
84 
984 
97| 
97 
964 
954 
“ 5 th, 
7 A. M. 
76 
97-4 
974 
96-| 
96f 
“ 6th, 
7 A. M. 
72 
98 
97| 
974 
96| 
“ 9th, 
7 A. M. 
80 
97f 
974 
97 
964 
1874. 
April 29th, 
96 
994 
994 
94£ 
99^ 
May 2d, 
951 
924 
“ 3d, 
97^ 
S7f 
The thermal observations here given settle conclusively the 
mooted points as to the effect in man of nerve sections on tempera- 
ture. They coincide strikingly with the results obtained by Dr. 
Weir Mitchell in a case of section of median nerve (see present 
number of this Journal), and again fulfil the prediction made on 
this subject by the above-named author.1 
Before the operation and section in our own case, the left palmar 
temperature ranged from 94° to 96° F. It rose within three or four 
hours after the section to 99° F.; at 10 P. M. it was 100°, and up 
to Nov. 9th was never, save once, as low as 96|°, being usually a 
degree or more above that of the right palm. When again in 
April the temperature was taken it was, at 8 P. M., after a period 
of some pain and re-excitement; left palm 94|-°; right palm 99i°. 
Upon May 2d it was even lower; left palm 92£°; right palm 
95f°; and the following day the left palm was only 87f°; the 
right do. being 97^°. 
The result of the operation may be summed up as follows: Our 
patient suffers but one painful paroxysm, and some four slight at- 
tacks of pain, in the course of twenty-four hours. This statement 
may be received as an average of his sufferings since the operation, 
and the symptoms appear to be neither abating nor increasing at 
the present time. The general health is excellent. As a rule he 
1 Injuries to Nerves, p. 177. 10 
sleeps quite comfortably through the night, now and then awaking 
from an attack of pain. 
The muscles of the shoulder are conspicuously wasted, that of 
the deltoid being most notable, so that the head of the humerus 
has dropped at least an inch out of the glenoid cavity. The great 
and general oedema of the whole limb masks the lower atrophies 
in the forearm ; but on removing the oedema by a bandage the 
muscle-losses become plain, as well as the bone-like hardness of 
their contracting tissues. 
For two days after the operation an induced current of full 
power moved all the forearm muscles, but this capacity to respond 
declined by degrees, and at the fourth day a powerful galvanic 
current, interrupted and reversed, was needed to show them. The 
downward current acted best. April 29, no severity of any form 
of current moved the muscles, nor did they stir when galvanized 
through needles passed into their substance (75 cells), interrupted 
and reversed current. 
The skin of the arm and forearm is very dry and desquamates 
slightly. The fingers of the hand are all contracted, more or less, 
the third, fourth, and fifth most, partly owing to an old injury, but 
chiefly following the operation. The skin of the hand, especially 
about the knuckles, is reddish and smooth, accompanied with des- 
quamation of the epidermis. There is marked incurvation of the 
nails on both sides (turtle-back nails), but especially on the left 
side, where they are very greatly curved. The difference in the 
growth of the nails is still very evident from the old staining; it 
is a difference of at least one-half. 
As regards the appearance of the skin of the shoulder, and the 
nodules upon it, there is little change to note since the operation. 
It still retains its characteristics as described in connection with 
the history of the case, without any decided appreciable alteration. 
A careful study was made by Dr. Perry, the hospital resident, 
of the region of lost sensation; and in April Dr. Weir Mitchell 
and one of us (Dr. Duhring) repeated this examination, with no 
notably different results. Touch and pain, as tested by needle 
points, were absent in a region of skin which included all of the 
forearm and hand and face of the arm, bounded by an irregular 
line on the two sides, and above, on the front of the shoulder, by 
a still more irregular limit. The whole back and inner surface of 11 
the arm to the elbow was sensitive to touch and to the needle; but 
more so above than below. Even in the anterior arm space, where 
the needle entered painlessly, there were here and there regions in 
which distinct and well-localized pain was felt when Dr. Mitchell in- 
serted needle points into the dermis, and transmitted through them 
the current of 50 to 75 Collat. cells. The wire brush on the dry skin 
yielded us no signs of feeling. The diagram gives an idea of the 
limiting lines which bound the areas of lost or lessened feeling. 
The line a, a, a, on the outer surface of the arm, marks the boundary above and outside of which 
sensation is preserved. The dotted, line 6, b, marks the same for the inner surface of the arm. 
No new tubercles have appeared on the arm, though several 
small new ones are observed upon the back, about the scapular 
region; they are the size of split peas, and as yet are only painful 
upon pressure. 
When we consider then the state of our patient before the ope- 
ration, and his present condition, there is every reason to feel grati- 
fied with the result; for although the suffering has not been com- 
pletely removed, the relief afforded has been so great and so de- 
cided as to admit of no question. The patient himself bears fre- 
quent and willing testimony upon this point, stating that he is well 
satisfied with the success of the operation, and thankful for the 
ease obtained. ITe is now able to live in at least comparative 
comfort, whereas before he was in continuous pain, and this of so 
grievous a character as to be almost intolerable. The complete 
paralysis of the arm is of but little moment to the patient, and is 
scarcely worthy of consideration in comparison to his previous 12 
sufferings; for the limb had not only to be guarded, but preserved 
as free from all movement as possible, the least exertion or motion 
being followed by paroxysmal pain. We remark here, that abso- 
lute relief from pain was not expected from the division of the 
nerves operated upon; for, as is known, the third cervical nerve 
gives off branches which supply the skin of the top of the shoul- 
der, which would still continue to exert its influence. The result 
has realized the views entertained upon this point previous to the 
operation. It is, without doubt, from the cutaneous branches of 
the third cervical nerve that the pain which the patient now ex- 
periences proceeds. 
Concerning the operation, two practical points may be briefly 
referred to. In the first place, the facility with which the cords of 
the brachial plexus were reached ; the procedure being by no 
means so difficult a task as was imagined. Secondly, it is of par- 
ticular interest to note the total absence of shock following the 
operation, a condition which it was expected might readily follow 
such a serious systemic disturbance. 
Through the kindness of Dr. R. M. Bertolet, we are enabled to 
present the appended report of thejnicroscopic examination of the 
exsected nerve:— 
“ The excised portions of the nerves were, after the operation, at 
once placed in a 2 per cent, solution of chromic acid and hardened 
for section. Transverse cuts, stained in carmine and mounted in 
damar varnish, revealed the existence of what, at first sight, ap- 
peared to be an abnormally thick, hypertrophied enveloping sheath 
(neurilemma); but upon closer study, and on comparing with sec- 
tions of the normal brachial plexus, it was evident that this appa- 
rent excessive development of the connective tissue sheath was no 
more than proportional to the increased size of the nerve trunk 
itself in this region. 
“The connective tissue septa arising from the neurilemma, and 
subdividing the nerve trunks into secondary bundles, were scarcely, 
if any, more strongly developed than ordinarily; no marked pro- 
liferation of the connective tissue corpuscles existed. In the sec- 
ondary fasciculi of the nerve, however, at many places were seen 
accumulations of young migratory cells (‘ granulation’ of Virchow). 
The aggregation of these elements between the primitive nerve fibres 
was so great, at not a few points, as to press them widely asunder 13 
and lead to a corresponding atrophy of the individual fibres. The 
axis-cylinders were seen distinctly in every instance; the atrophy 
having taken place mostly at the expense of the surrounding me- 
dullary substance. The nerves that underwent these atrophic 
changes presented a very bright, highly refractive, glassy appear- 
ance under the microscope, strongly reminding one of amyloid 
degeneration, yet the iodine test failed to give any reaction ; this 
if present, however, would not have responded on account of the 
preservative fluid employed. These bright spots occurred in cir- 
cumscribed areas of the nerve bundles, while in the remaining 
portions the nerve fibres were unaffected ; there having been just 
the faintest suspicion of commencing proliferation of the interstitial 
substance. 
“In this specimen we do not have the same material growth of 
connective tissue, nor the attendant fatty metamorphosis, usually 
seen in marked cases1 of neuritis mterstitialis; yet the alterations 
found are sufficient to indicate that this nerve has already fully 
entered the earlier stages of these inflammatory changes.” 
In conclusion, we desire to express our thanks to Dr. Mitchell 
for valuable suggestions offered, as well as for the interest mani- 
fested in the study of the case. For the careful attention to the 
patient, and for notes after the operation, our thanks are tendered 
to Dr. H. M. Perry, one of the House-Surgeons to the Hospital. 
1 Virchow’s Archiv, Bd. 53, p. 441.