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

As favourable prognostic elements we may bear in mind: low velocity on the part of the travelling bullet, and with this a lesser degree of contiguity of the track to the nerve. The early return of sensation is a favourable sign, and in this relation the development of hyperæsthesia, whether preceded by anæsthesia or no, points to the maintenance of continuity of, and a moderate degree of damage to, the nerve. The early return of sensation, even if modified in acuteness, was always a very hopeful sign; also the production of formication in the area of distribution of the nerve on manipulation of the injured spot. As in the case of nerve injuries of every nature, the disposition and temperament of the patient exerted considerable influence on the course of the cases.

Complete section of the nerves in these bullet wounds only obtained special importance in two ways: first, in that a considerable portion of the trunk might be shot away in oblique tracks, and, secondly, in that very severe contusion might affect the nerve for a considerable distance beyond the point actually implicated. In point of fact, complete section when treated by suture was often more rapidly recovered from than an injury in which only a portion of the width of a trunk was divided. This was no doubt to be explained on the theory that the contiguous portion of the nerve suffered less when tension and resistance were lessened by complete severance of the cord.

The treatment of slight nerve contusion was simple; rest alone was necessary, and in the course of hours or days paralysis was recovered from. The symptoms were most troublesome in patients of a neurotic temperament, or those who had suffered from severe systemic shock.

In severe concussions and contusions the first care had to be devoted to the discrimination of the lesion from that of division. A period of rest then needed to be followed by one of massage and movement, to maintain the nutrition of the muscles. In a considerable portion of the cases a stage of neuritis had to be expected. In all cases, either of severe concussion, contusion, or complete section, accompanied by the fracture of a bone, especial care was necessary that the bandaging and fixation of the limb were not sufficiently tight to add the dangers of muscular ischæmia to those of the nerve injury already present.

Neuritis, whether dependent on local injury, implication in the scar, pressure from callus, or of the ascending variety, needed the same treatment: rest, preservation of the limb from cold or damp, and the local application of anodynes, as belladonna, or hot laudanum fomentations. In some cases a general anodyne, as morphia, was preferable; then always to be used with caution, as the patients soon craved inordinately for it, and were unwilling to give it up. Later, local blisters in the line of the nerve trunk, careful massage and exercise when muscular and cutaneous tenderness had subsided, the application of the continuous current to the nerves, and perhaps faradisation of the muscles, were all useful.

Splints were often temporarily required to resist contracture, or the assumption of false positions; in either case they needed to be frequently removed, and movement &c. made, in order to avoid any chance of troublesome stiffness.

Operative treatment.—Early interference was only warranted by positive knowledge that some source of irritation or pressure could be removed; thus a bone spicule, or a bullet, or part of one, particularly portions of mantles.

In case of contusion the expiration of three months is the earliest date at which any operation should be taken into consideration, and interference is only then advisable if there is good prospect of freeing the nerve from compressing adhesions. The two strongest indications for operation are (1) signs pointing to the secondary implication of the nerve in a cicatrix, especially when these are of such a nature as to indicate local tension, fixation, or pressure; (2) the possibility of the irritation being the result of the presence of some foreign body, such as a bone spicule, or portions of a bullet mantle; in such cases the X rays will often give useful help.

With regard to the early exploration of cases of traumatic neuralgia, it may be pointed out that when this was undertaken the results were as a rule very temporary. In many cases in which the measure was resorted to, either no macroscopic evidence of injury to the nerve was discovered, or a bulbous thickening was met with of such extent as to make excision inadvisable, even if it were considered otherwise the most suitable treatment.

Even when complete section of the nerve was assured by the absence of any power of reaction to stimulation by electricity from above on the part of the muscles, operation was better not undertaken until cicatrisation had reached a certain stage. If done earlier than at the end of three weeks, the sutured spot became implicated in a hard cicatrix, and any advantage to be obtained by early interference was lost. When partial division of a trunk was determined, the same date was the most favourable one for exploration, the gap in the nerve being freshened and closed by suture. There is little doubt, however, that in some cases such injuries were recovered from spontaneously.