Sensation in the limb at the same time returned to a considerable degree, anaesthesia persisting on the outer aspect of the thigh only.
At the end of four months very considerable improvement had taken place, but there was no return of motor power in the right leg, or the muscles supplied by the peroneal nerve in the left leg. There was some general oedema of the legs, especially of the right, possibly in connection with the herpetic eruption which was now disappearing. Muscular tenderness had disappeared. There was also definite improvement in the size and tone of the peroneal muscles, although no motor power was regained.
At the end of five months, slight gradual improvement was still taking place, but the loss of power was nearly as extensive as when the last note was taken. The skin of the right leg was glossy, that of the left apparently normal. At times some hyperaesthesia of the soles was noted, and the plantar reflex was very brisk.
The right anterior tibial and musculo-cutaneous groups of muscles reacted to the strongest faradic current, not to any galvanic current below 20-25 m.a., contraction very sluggish.
The same muscles in the left leg also reacted to the strongest faradic current, but only locally, with no sort of effect on the tendons. Similar contractions could be induced in the right quadriceps, but none in the left (Dr. Turney).
Appreciation of heat and cold applied to the skin was fair, but, in the case of heat, distinctly slow in the right leg and foot.
At the end of seven months improvement was still taking place; the patient could now stand, walk a little with crutches, and even ascend and descend a staircase.
_Severe concussion, contusion, or medullary haemorrhage producing signs of total transverse lesion, and complete transverse section._--The symptoms of these conditions will be taken together, because, with very slight variations, they may be considered as lesions of equal degree as to severity, bad prognosis, and unsuitability for active interference.
All were characterised by the exhibition of the same essential phenomena, symmetrical abolition of sensation and motor power on either side of the body, absence of any signs of irritation in the paralysed area, and loss of patellar reflex. In a small number of the cases of medullary haemorrhage some return of sensation was observed prior to death; in a still smaller, traces of motor power, and in one or two irritability of the muscles or feeble reflexes pointed to the fact that destruction of the cord was not absolute. As abstracts of a series of cases are appended on page 330, it is only necessary to add a few remarks as to any slight peculiarities which seemed directly dependent on the mode of causation.
It may be first stated that these severe injuries were accompanied by signs of a very high degree of shock. In fact, the shock observed in them was more severe than in any other small-calibre bullet injuries that I witnessed. The patients lay still with the eyes closed, great pallor of surface, sometimes moaning with pain, the sensorium much benumbed, or occasionally early delirium was noted. The pulse was small, often slow and irregular, and the respiration shallow. The originally quiet state was often changed to one of great restlessness of the unparalysed part of the body, with the appearance of reaction.
The degree of primary pain varied greatly, but as a rule it was considerable; in some cases it was excruciating in the parts above the level of the totally destructive lesion, and commonly of the zonal variety. A hyperaesthetic zone at the lower limit of sensation usually existed.
In the majority of the cases pain must have depended on meningeal haemorrhage. In one of the cases related, positive evidence was offered as to this particular by the autopsy, although this was made as long as six weeks after the original injury, since no other source of pressure or irritation was discovered. When I first saw this patient some twenty-four hours after the injury he was moaning with pain, although a strong and plucky man; I hastened to give him an injection of morphia, and a.s.sured him that it would relieve his suffering: as I left I heard him say to his neighbour: "That is no use; they gave me three last night, and I was no better," and his remark proved true.
In high dorsal and cervical injuries the temperature rose high, in one case to 108 F.; I had no opportunity, however, of observing the temperature in any case immediately before and after death. During the hot weather the profuse sweating of the upper part of the body contrasted very strongly with the dry skin of the paralysed part.
The heart"s action was often particularly irregular in the dorsal injuries, and the respiration slow and irregular; as these cases, however, were often complicated by severe concurrent injuries to internal organs, the irregularities could hardly be ascribed to the spinal-cord lesion alone. In cases of pure diaphragmatic respiration, the rate did not as a rule exceed the normal of 16 or 20 to the minute, and it was quite regular; this was noted soon after the injury and persisted throughout the course of the cases. As is usually the case, both respiration and the heart"s action were most embarra.s.sed in the cases in which abdominal distension was a prominent feature. In some of the neck cases the Cheyne-Stokes type of respiration was very strongly marked.
In cases of low dorsal injury intestinal distension was extreme, and I think more troublesome than the same condition as seen in civil practice. The distension was accompanied by most persistent vomiting, continuing for days, and in the cases that lived for some time severe gastric crises of the same type occurred in some instances.
Priapism was a common symptom; but, as is seen from the cases quoted, was rarely due to any gross direct laceration of the cord.
Trophic sores were both early to develop, and extensive; primary decubitus occurred in all the cases I saw, and steady extension followed. In one case a remarkable symmetrical serpiginous ulceration developed in the area of distribution of the cutaneous branches of the external popliteal nerve on the outer side of the leg.
The paralysis in nearly every case was of the utterly flaccid type, and wasting of the muscles was early and extreme. This was occasionally accentuated by the supervention of myelitis.
Opportunities for making observations on the quant.i.ty of urine secreted were not great, and I can offer no remark as to the occurrence of polyuria. In one rapidly fatal case, however, suppression of urine occurred.
(99) _Lumbar region. Transverse lesion._--Range under 1,000 yards. Wound of _entry_ (Mauser), over the seventh rib 1 inch from the left posterior axillary fold; _exit_, over the centre of the right iliac crest. Complete symmetrical motor and sensory paralysis of lower extremities, entire abolition of reflexes, retention of urine.
On the ninth day there was some return of sensation in the lower extremities, and a cremasteric reflex was to be obtained.
A large bedsore had developed over the sacrum. No further change occurred in the lower extremities. The patient became progressively emaciated and exhausted, cyst.i.tis persisted, the bedsore deepened. The man eventually developed signs of a large basal abscess in the left lung, and died on the forty-second day.
At the _post-mortem_ a fracture of the first lumbar lamina was discovered, with some splintering of the bone; the lumbar spinous process was attached and in its normal position.
Opposite the centre of the cauda equina were the remains of a considerable haemorrhage, both extra- and intra-dural, the nerves appearing somewhat compressed, but of normal consistency. The muscles of the back were infiltrated with putrid pus on both sides. A pulmonary abscess cavity the size of a hen"s egg occupied the upper part of the lower lobe of the left lung. The kidneys were congested, and the bladder thickened and chronically inflamed.
(100) _Cervico-dorsal region. Total transverse lesion._--Wound of _entry_ (Mauser), to the right of the sixth cervical vertebra: the bullet was removed on the field from the left of the seventh dorsal spinous process, which was somewhat prominent. Complete motor and sensory paralysis extended upwards to the third intercostal s.p.a.ce; the breathing was almost entirely diaphragmatic. Retention of urine. Entire abolition of reflexes in lower limbs and trunk. Hyperaesthesia was present in both upper extremities, with a zone of hyperaesthesia around the chest. The patient suffered greatly for some weeks from pain in the hyperaesthetic area, he developed severe cyst.i.tis and later incontinence of urine. A large trophic sacral bed-sore steadily increased in depth and size.
About ten days before death, which occurred on the fifty-third day from exhaustion and septicaemia, the patient complained of pains in his legs; but there was no return of sensation, motion, or reflexes.
At the _post-mortem_, the seventh dorsal spinous process was found to be loose and the laminae of the fifth, sixth, and seventh vertebrae were separated from the pedicles, and somewhat depressed on the left side. These laminae were adherent to the dura, as were also a few small separated bony spiculae. There was no sign of old haemorrhage. The spinal cord was practically gone between the levels of the fourth and seventh dorsal vertebrae, and diffluent from myelitis up to the third cervical.
(101) _Dorsal region; total transverse lesion._--Wound of _entry_ (Mauser), in the left supra-spinous fossa of the scapula; _exit_, between the eleventh and twelfth ribs of the right side. Complete motor and sensory paralysis, with absence of reflexes from mid-dorsal region downwards. Upper intercostals working. Retention of urine, p.e.n.i.s turgid.
Sensation perfect to lower extremity of sternum. Early trophic sacral bed-sores developed and steadily increased in depth and extent, slighter ones developed on the heels. The paralysis was flaccid throughout. The patient gradually emaciated with fever, and died on the seventy-eighth day.
At the _post-mortem_ the wound proved not to have penetrated the thorax, and both the vertebral spines and laminae were intact, no trace of bony injury being discoverable. Opposite the sixth dorsal vertebra, for a distance of 1-1/2 inch, the cord and dura were adherent, and over the same area the cord was represented by soft custard-like material. There was no sign of old haemorrhage.
(102) _Dorsal region; total transverse lesion; slight extra-dural haemorrhage._--Wound of _entry_ (Mauser), at the posterior aspect of the right shoulder; _exit_, 2 inches to the left of the spine below the ninth rib.
Complete motor and sensory paralysis below the site of the lesion, with absence of superficial and deep reflexes.
Retention of urine. Great abdominal distension, pain, and vomiting. Bed-sores over the sacrum developed on the third day; meanwhile the vomiting continued on and off for a week, and very severe girdle pain persisted.
One month later when seen at the Base hospital considerable improvement had occurred. Sensation had returned in both lower limbs; but flaccid paralysis persisted and both were wasted, especially the left. There was no return of reflexes in the lower limbs, the urine was pa.s.sed in gushes, and the patient was cognisant when these occurred. The sacral bed-sores were, however, very extensive and becoming larger and deeper.
At the end of the fifth week slight power was regained in the flexors and abductors of the right thigh, and the same muscles of the left limb could be made to contract feebly. Meanwhile the patient suffered with severe fever, accompanied by frequent rigors and profuse sweats; the bed-sore continued to extend, and the urine was foul and contained pus.
The patient continued in a similar condition, progressive emaciation and exhaustion taking place, and at the end of six weeks he died.
At the _post-mortem_ the bullet was found to have tracked beneath the right scapula, entering the chest by the fifth intercostal s.p.a.ce and lacerating the right lung; thence it entered the eighth dorsal centrum and tunnelled both this and the ninth diagonally, to escape beneath the ninth rib. On opening the spinal ca.n.a.l the tunnel was found to be separated only by the compact tissue of the centrum from the cavity, while a thin extra-dural haemorrhage separated the dura from the bones anteriorly. The spinal cord exhibited no sign of pressure and was firm and continuous, but up to the lower limit of the dorsal region there was septic myelitis and meningitis, the result of pus having tracked up the ca.n.a.l from the sacral bedsore. Suppurative cyst.i.tis and pyelitis were present. The patient was the subject of an old urethral stricture which had given rise to trouble during treatment.
(103) _Dorsal region; total transverse lesion; slight intra-dural haemorrhage._--Wound of _entry_ (Mauser), below spine of scapula, close to right axilla; _exit_, 2-1/2 inches to left of tenth dorsal spinous process.
Complete motor and sensory paralysis below ensiform cartilage, with well-marked hyperaesthetic zone around trunk. All reflexes absent. Retention of urine. Incontinence of faeces. Bed-sores in sacral region developed during the first two days, and seventeen days later well-developed serpiginous trophic sores developed on the outer side of each leg and continued to increase slowly until death. The paralysis remained of the absolutely flaccid variety. Great emaciation occurred, accompanied by hectic fever, the temperature ranging from normal to 102.5. During the third week double pleurisy developed.
At the _post-mortem_ no bone injury could be detected. The cord and dura-mater were adherent over an area corresponding to the fifth to the eighth dorsal vertebrae, and opposite the seventh the cord was soft and of the consistence of b.u.t.ter. A small intra-dural haemorrhage was still evident below the main lesion, not extensive enough to give rise to serious compression.
General adhesions in each pleura. Cyst.i.tis.
[Ill.u.s.tration: FIG. 79.--Appearance of Spinal Cord enclosed in membranes in case 103 after removal from the ca.n.a.l. When the membranes were opened a white custard-like substance took the place of the cord. Slight evidence of extra-dural haemorrhage existed]
(104) _Dorsal region; section of cord; retained bullet._--Wound of _entry_ (Mauser), in seventh right intercostal s.p.a.ce, 4-1/2 inches from the dorsal spinous processes, oval in outline; bullet retained.
Complete motor and sensory paralysis, with absence of reflexes below umbilicus. Retention of urine, incontinence of faeces.
Large sacral bed-sore developed rapidly. Right haemothorax.
The patient emaciated rapidly, and for the last fourteen days the temperature ranged to 104, the bed-sore steadily increasing in size. Death occurred on the forty-second day.
At the _post-mortem_ a Mauser bullet was found embedded in the centrum of the twelfth dorsal vertebra. The bullet was slightly curved; its anterior extremity had pa.s.sed across the spinal ca.n.a.l, and wounding the dura posteriorly rested against the left lamina. The plating of the mantle of the bullet was stripped from half the area of the tip. The dura was not adherent, and the cord was softened for half an inch above the point of section; above this it was normal, the vessels coursing normally to the softened spot. Below the point of section the cord was blanched, but offered no other macroscopic evidence of disease. No evidence of either intra- or extra-dural haemorrhage was detectible.
[Ill.u.s.tration: FIG. 80.--Complete division of Spinal Cord. The bullet is retained, and from its position can be seen to have struck the right half of the cord only. The nickel plating of half of the tip of the bullet is stripped off. Case No. 104]
The right pleura contained a large quant.i.ty of dark cocoa-like fluid. Extensive adhesions were present in both pleural cavities. The spleen was much enlarged. At the base of the bladder a large submucous haemorrhage had occurred, the blood-clot had a.s.sumed a dark orange colour, and on first opening the viscus the appearance was that of a ma.s.s of faeces.
The mucous lining elsewhere was slaty grey, with small haemorrhages. The kidneys were large, but no abscesses or pyelitis were present.
(105) _Cervico-dorsal region; total transverse lesion._--Wound of _entry_ (Mauser), opposite right sixth cervical transverse process; _exit_, on left side of third dorsal spinous process.
Slight grasping power was present in the hands, and the patient could hold his arms across his chest. Complete motor and sensory paralysis, with absence of all reflexes below. The pupils were moderately contracted. Retention of urine. On the second day blebs appeared on each b.u.t.tock, and the patient complained of very severe pain in the neck: the temperature rose to 103, and on the third day he died suddenly. No _post-mortem_ examination was made.
I observed two similar cases in the Field Hospital at Orange River, the patients dying on the third day; pain and high temperature were prominent symptoms in both. In one patient early delirium was present.
(106) _Dorsal region; Martini-Henry wound._--Wound of _entry_, oval, 1 inch 3-1/4 inches; long axis obliquely crossing infra-spinous fossa of right scapula; bullet retained (Martini-Henry). Spine of third dorsal vertebra loose, and a distinct thickening to its right side. Complete symmetrical paralysis extending up to upper extremities. No sensation on surface of trunk below cervical area. Respiration entirely diaphragmatic. Retention of urine, p.e.n.i.s turgid. Total absence of reflexes, superficial and deep. Reddening of b.u.t.tocks, but no bullae.