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

Three weeks later, the chest was moving symmetrically and well, sensation and motor power had returned in considerable degree in the left lower extremity, with marked increase in both the plantar and patellar reflexes; sensation had returned in both upper extremities, a slight amount of motor power was regained in the right, but the left remained entirely flaccid and incapable of movement.

At the end of a month power was regained over both bladder and rectum, some slight movement of the left thumb was possible, and a certain degree of hyperæsthesia developed over the back of the forearm.

At the end of six weeks there was little further alteration, but that in the direction of improvement. There was some wasting of the muscles of the left upper extremity, and this was most marked in the muscles supplied by the ulnar nerve.

At the end of ten weeks the patient had been up some days; he could stand and walk, but was unable to rise from the sitting posture without help. The plantar and patellar reflexes were much exaggerated, and there was ankle clonus, most marked in the left limb. The right upper extremity was normal, but weak; there was wrist-drop on the left side and the deltoid was wasted and powerless; on the other hand the fingers could be flexed, and although the elbow could not be, there were signs of returning power in the biceps, and some movements of the shoulder could be performed by the capsular muscles. It was remarkable that common sensation was more acute in the left than the right lower extremity, but I attributed this to the remains of hyperæsthesia on the left side. The patient left for home shortly after the last note.

In both these cases the absence of marked hyperæsthesia or pain points to medullary hæmorrhage (hæmato-myelia) as the pathological condition produced by the injury. In this particular they contrast well with case 94 quoted on page 315, where the degree of both hyperæsthesia and pain indicated a combination of pressure and irritation of the nerve roots by surface hæmorrhage on the affected side. In case 97 the persistence for four weeks of paralysis of the bladder and rectum suggested medullary hæmorrhage in addition, while the return of patellar reflex in the paralysed limb negatived the occurrence of an extensive destructive lesion.

In view of the extreme interest of these cases I will shortly detail one other in which the cauda equina alone was affected.

I must confess my inability to place the case definitely in the category either of concussion or medullary hæmorrhage. As so often happened, both conditions probably took part in the lesion. The immediate development of the primary symptoms is no doubt to be referred to concussion, while the patchy nature of the prolonged lesion and gradual recession of the symptoms point to the presence of hæmorrhages. We find here the link most nearly connecting the spinal cord and the peripheral systemic nerves. Such a case goes far to show that the condition which I have in the next chapter often referred to as nerve contusion may in fact be produced by an injury far short of actual contact.

(98) A trooper in the Imperial Yeomanry, while advancing in the crouching attitude, was struck by a bullet from his left front, at an estimated distance of 300 yards. The bullet traversed the right arm anteriorly to the humerus, entered the trunk in the line of the posterior axillary fold, 1½ inch below the level of the nipple, crossed the thoracic and abdominal cavities, deeply striking the lumbar spine, and finally lodged beneath the skin over the venter of the left ilium. The skin was broken, but the force of the bullet was not sufficient to cause it to pass through, and it was later expressed from the wound by the surgeon. The bullet was a Mauser, and not in any way deformed, although it must at any rate have struck the spine and perforated the ilium.

Immediate paraplegia resulted, both sensation and motor power were completely abolished, but there was no trouble either with the bladder or rectum. No symptoms of injury to either thoracic or abdominal viscera were noted.

Three days after the injury sensation and some return of motor power were observed in the left extremity, and some power of movement in the toes of the right foot.