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

Injuries to Special Nerves

Cranial nerves.—It will be convenient first to make a few remarks concerning the nerves of special sense.

Olfactory.—I observed temporary loss of smell on three occasions. In two instances this accompanied transverse wounds of the bones of the face in which the upper third of the nasal cavities was crossed; in the third a track passing obliquely downwards from the frontal region passed through the inner wall of the orbit, and crossed the nose at a lower level. In view of the small area of the olfactory distribution which was directly implicated, I was at first inclined to regard the loss of smell as dependent on the presence of dried blood on the surface of the mucous membrane, or on obstruction of the cavities from the same cause. Further observation, however, appeared to show that it was due to concussion of the branches of the olfactory nerve, since the loss of function persisted when the cavities were manifestly clear.

In all these cases we were confronted with the same difficulty which was experienced both in lesions of sight and hearing, the determination as to whether the concussion was of the branches or of the olfactory bulb. When the symptom was the accompaniment of a fracture of the roof of the orbit, the possibility of concussion of the olfactory lobe was manifest. In all, again, it was difficult to say what part the accompanying concussion of the branches of the fifth nerve took in the production of the symptom. In all three cases mentioned the return of function was gradual, but apparently fairly complete at the end of three weeks. In one it was noted that at first the patient was conscious of an odour before he was able to discriminate its actual nature; later he could determine the latter readily.

Optic.—Some remarks concerning lesions of the optic nerve have already been made under the heading of wounds of the orbit. Concussion and contusion of the nerve both occurred, but I was unable to differentiate between the effects of these on the nerve itself, apart from the effects on the globe of the eye, which usually accompanied wounds of the orbit.

In some cases the nerve was directly divided in orbital wounds, and either pressure on or division of the nerve in the intra-cranial portion of its course, or as it traversed the optic foramen, was not uncommon.

Auditory.—Loss of hearing was also not infrequent; thus it accompanied all three wounds of the mastoid process quoted under the heading of the seventh nerve, also two cases of fracture of the occipital bone near the ear quoted on p. 278. In all these instances it was impossible to attribute the deafness to lesion of the nerve alone, as the causative injury equally affected the internal ear, and in at least two the bullet implicated the tympanum as well in its course. The deafness was absolute in each case, and in none had any improvement occurred at the end of nine months. Deafness was a symptom in a certain number of the more severe cerebral injuries in which the course of the bullet was not so near to the internal ear: probably some of these were central in origin.

I only once observed any interference with the sense of taste.

Remaining cranial nerves.—I have little to say regarding the third, fourth, and sixth nerves. In the case of the third nerve, ptosis was occasionally seen in wounds of the skull involving the roof of the orbit, but the relative parts taken by injury to nerve and laceration or fixation of muscle respectively, were usually hard to determine. Again, the fourth and sixth nerves may have been damaged in some of the more extensive orbital wounds, especially those in which the globe suffered injury, but the signs under such circumstances were difficult to discriminate, and the injury was of slight practical importance, in view of the major injury to the globe itself.

Fifth nerve.—Concussion, contusion, or laceration of the different branches of the three divisions of the fifth nerve were common in wounds of the head, but most frequent in fractures of the upper or lower jaws. Localised anæsthesia was common from one or other of these causes, but for the most part transitory in the cases of contusion or concussion. I saw no case of entire loss of function in any one division, symptoms being mostly confined to certain branches, as the supra-orbital, the temporo-malar, the dental branches of the second division, the auriculo-temporal nerve, and the lingual, dental, and mental branches of the third division. I did not observe any cases in which modification of the special senses accompanied these injuries beyond those mentioned in the remarks already made on the subject of anosmia, and one case in which some modification of the sense of taste accompanied an injury to the floor of the mouth. It was a matter of surprise, considering the frequency with which subsequent neuritis was met with in the nerves generally, that trifacial neuralgia in some form was not more often met with. I never observed any serious case. Perhaps this is one of the fields in which a longer after-period may increase our knowledge. Lastly, I never observed motor paralysis in the case of the third division, although sensory symptoms in some of the branches were common, evident proof that injuries to the trunk were rare.