1915 Journal of the American Medical Association  
The patient whose photograph is shown herewith was a healthy youth (Canton Hospital No. 297, 1914) who fell from a tree a year before admission, landing in a half-sitting, half-lying posture, wounding the tissues overlying the ischial tuberosities. He was unable to walk for several months on account of weakness in the lower limbs. The large sloughing wounds healed very slowly; they would crust over and then slough away at the margins. On admission, unhealthy skin had formed over the ulcers,
more » ... superimposed crusts still present. The patient hobbled into the hospital. Examination showed weakness of calves and hamstring muscles, which were fatty and bulged on attempted contraction. Trophic disturbance was noted in elephantine thickening of skin around the wounds, between the buttocks, in the popliteal spaces and behind the heels, extending up the tendons of Achilles. There was pigment deposit in the thickened skin, in places dark brown to black. Sweating was present on the external aspects of the heels and feet. These changes all occurred after the injury. Analgesia and anesthesia were well defined in the areas shown in the illustration : the back of the scrotum, the perineum, the intergluteal cleft, the inner and lower two-. thirds of the gluteal areas down the backs of the thighs to Scars of wounds. The anesthetic areas are marked on the skin as tested. the midlevel of the calves, as shown. On the feet there were analgesia and anesthesia of the outer aspect of the heels, and hypesthesia of the outer thirds of the soles and the tips of the toes. On the right leg a strip running from the midcalf down and out to the external malleolus connected the upper and lower areas. There was no sphincter involvement and there is no pain now. The wounds over the tuberosities, from their appearance and history, must have healed under trophic disadvantages. The skin in the anesthetic areas has had bad trophic innervation, resulting in pigmentation and thickening. The motor areas involved are those supplied by the sciatic nerve ; the sensory involvement shows trouble chiefly in the lesser sciatic (posterior femoral cutaneous), including its long pudendal and gluteal, that is, clunial branches ; the external saphenous (sural), throughout its whole extent in the right leg, but only in its calcaneal and lateral dorsal cutaneous branches in the left. The injury, therefore, affected both bundles of the great sciatic and the whole of the lesser sciatic from the level of the tuberosities of the ischial bones. The motor damage is rapidly healing. The sensory damage affects the ' lesser sciatic and the sural especially, but is improving. No operation was advised, owing to the length of time that
doi:10.1001/jama.1915.25710410001021 fatcat:zl3345ry4nhttlwnadoh4cj5ee