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

Tenth nerve.—The pneumogastric was implicated in many wounds of the neck. I never observed an uncomplicated case, but laryngeal paralysis was temporarily present in two of the cases of cervical aneurism in which the wound crossed above the level of origin of the recurrent laryngeal branch, while in two others the recurrent branch itself was in close contact with the wall of the aneurism (p. 135). In all such cases signs of concussion or contusion of the nerve would be expected, judging from the similar results observed in the brachial nerves when the neighbouring artery was implicated. The only obvious symptoms occurring, however, were laryngeal paralysis and acceleration of the pulse. As the latter symptom was often observed in the cases of arterio-venous communication, wherever situated, and as the sympathetic nerve also lay in close contiguity to the wound track, it was difficult to ascribe it with certainty solely to the vagus lesion. In the two cases of high vagus injury the laryngeal paralysis steadily improved, and at the end of six months was apparently well; in the two others it persisted at the end of three months and a year respectively.

The nerve must have been very frequently damaged in wounds of the neck; it is possible that this injury may have been an important factor in the death of some of the patients with cervical wounds upon the field.

Eleventh nerve.—I append the only case of localised spinal accessory paralysis I observed. This was one of my earliest experiences, and when I examined the neck, in the Field hospital, I assumed from the completeness of the sterno-mastoid and trapezius paralysis that the nerve was severed. The patient, however, made such a rapid recovery that it became evident that the nerve had been contused only, and that the recovery of function was not due, as is so often the case, to vicarious compensation by the cervical supply to the muscles.

(115) Entry, immediately to the right of the fourth cervical spinous process; exit, at the anterior border of the left sterno-mastoid opposite the angle of the mandible. The left shoulder was depressed, the head inclined to the injured side. There was evident spinal accessory paralysis, and marked hyperæsthesia of the whole left upper extremity, most severe in the circumflex area. The hyperæsthesia gradually disappeared in a few days, and was clearly due to concussion and possibly slight contusion of the cervical nerve roots. The spinal accessory paralysis improved, so that the patient returned to the front at the end of a month: when I saw him some four months later the shoulders were held quite symmetrically.

The twelfth nerve was occasionally damaged in wounds of the floor of the mouth. I saw no case of permanent paralysis.

Injury to the systemic nerves. Cervical plexus.—Evidence of injury to the superficial branches of the cervical plexus was not rare; thus I saw cases of small occipital anæsthesia, and great occipital neuralgia, but none of motor paralysis from injury to the deeper muscular branches. I take it that the smallness of the branches, and the multiple supply possessed by many of the muscles of the neck, would both take part in rendering certain evidence of the injury of an individual motor nerve rare.

Brachial plexus.—Injury to this plexus in the neck was common; the main peculiarity observed was the partial nature of the damage inflicted.

Thus injury to a single nerve, or to a complex of two or more, was far more common than one implicating the whole plexus. Again, while complete paralysis might affect one set of nerves, another might simply exhibit signs of irritation in the form of hyperæsthesia or pain.

The wounds producing these injuries varied much in direction; thus some crossed the neck transversely, some were obliquely transverse, while others took a more or less vertical course.

These same remarks hold good in the case of the nerves of the arm. In the upper half, especially, complex injury was not rare, while in the lower third affection of individual nerves was more common. Another important difference must be mentioned in regard to the upper and lower segments of the course of the brachial nerves; they are not only more widely distributed below, but also more fixed in position, a fact antagonistic to the escape of the nerve by displacement and liable to expose it to more severe contusion.