Surgical Experiences in South Africa, 1899-1900 / Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre

by George Henry Makins

On the third morning two similar fits occurred, the first a severe one, during which the patient passed a motion involuntarily. The commencement of all three fits was observed by the nurse only, but in each the convulsions apparently commenced in the face and then became general.

Three months later no further fits had occurred, and the patient, who throughout had said he felt remarkably well, complained of nothing. The upper extremity was apparently slightly less rigid than before the exploration, and the patient said he walked somewhat better than before. The closure of the skull was perfect.

Treatment.—The treatment of fractures of the skull possesses a degree of surgical interest that attaches to no other class of gunshot injury, since operative interference is necessary in every case in which recovery is judged possible. The injuries are, without exception, of the nature of punctured wounds of the skull, and the ordinary rule of surgery should under no circumstances be deviated from. An expectant attitude, although it often appears immediately satisfactory, exposes the patient to future risks which are incalculable, but none the less serious. Happily the operations needed may be included amongst the most simple as well as the most successful, and expose the patient with ordinary precautions to no increase of risk beyond that dependent on the original injury.

Cases of a general character, or in which the base has been directly fractured other than in the frontal region, are seldom suitable for operation, since surgical skill is in these of no avail; but in all others an exploration is indicated. I use the word 'exploration' advisedly, since what may be called the formal operation of trephining is seldom necessary except in the case of the small openings due to wounds received from a very long range of fire; in all others there is no difficulty, but very great advantage, in making such enlargement of the bone opening as is necessary with Hoffman's forceps.

The scalp should be first shaved and cleansed; if for any reason an operation is impossible, this procedure at least should be carried out, with a view to ensuring, as far as possible, future asepsis, infection in head injuries being almost the only danger to be feared. The shaving may need to be complete, but local clearance of the hair suffices in many cases. The hair having been removed, the scalp is cleansed with all care, a flap is raised of which the bullet opening forms the central point, and the wound explored. In slight cases the entry opening is the one of chief importance, and the exit may be simply cleansed and dressed. In some instances, as in direct fracture of the roof of the orbit from above, the exit should not be touched.

The flap having been raised, if the wound be a small perforation, a 1/2-inch trephine crown may be taken from one side; but it is rare for the opening to be so small that the tip of a pair of Hoffman's forceps cannot be inserted. The trephine is more often useful in cases of non-penetrating gutter fractures where space is needed for exploration, and the elevation or removal of fragments of the inner-table. Loose fragments may need to be removed from beneath the scalp, but the important ones are those within the cranium. These may either be of some size, or fine comminuted splinters of either table, often at as great a distance as 2 inches or more from the surface. The cavity must be thoroughly explored and all splinters removed. I have seen more than fifty extracted in one case of open gutter fracture. The brain pulp and clot should then be gently removed or washed away, and the wound closed without drainage. Fragments of bone, as a rule, are better not replaced, but complete suture of the skin flap is always advisable in view of the great importance of primary union, and the fact that a drainage opening exists at the original wound of entry, and that the wound is readily re-opened to its whole extent, should such a step be advisable.

The detection of fragments is easiest and most satisfactorily done with the finger, and in all but simple punctures the opening should be large enough to allow thoroughly effective digital exploration; the remarks already made as to the factors determining the size of fragments are of interest in this connection. The determination of the amount of brain pulp which should be removed is somewhat more difficult; one can only say that all that washes readily away should be removed, and its place is usually taken up by blood.

Few fractures of the base are suitable for treatment; the only ones I saw were those of direct fracture of the roof of the orbit or nose, produced by bullets passing across the orbits; here the advisability of interference with the injured eye led to opening of the orbit, and sometimes exposed the fracture. Some patients recovered, even when the damage had been sufficient to cause escape of pulped brain into the orbit.

The after treatment simply consisted in keeping the patients as quiet as circumstances would permit, and the administration of a fluid diet. In some cases recurring symptoms pointed to the continued presence of bone fragments; these were usually indicated by signs of irritation, or often of local inflammation, in the latter case infection taking the greater share in the causation. Such cases needed secondary exploration, and the wonderful success of this operation, even when the wound was evidently infected, was perhaps one of the most striking experiences of the surgery in general.

I should add a word here as to the most satisfactory time for the performance of these operations; as in all cases the earlier they could be undertaken the better, but in the head injuries the advantages of early interference were more evident than in any other region. This depended on the fact that, as in civil practice, the scalp is one of the most dangerous regions as far as auto-infection of the wound is concerned, and one of the most difficult to cleanse, except by thorough shaving. Beyond this the extreme simplicity of the operative procedure needed, called for few precautions beyond those for asepsis, and very little armament in the way of instruments, &c.