During the next eight weeks steady but slow improvement took place; during the last three weeks of this period he made the voyage to England. Ever since the injury some elevation of temperature was noted, a rise at night to 100° or at times to 102°; for this no definite cause was discovered. In the tenth week the condition was as follows: The temperature has become normal. The patient has lost flesh to a considerable extent since the reception of the injury. The lower extremities are much wasted, especially the peroneal muscles. Patellar reflexes can be obtained, but the knee jerks are uncertain. Unevenly distributed paralysis exists in both lower extremities. Left—Sensation fairly good throughout. Quadriceps very weak; does not react to electrical stimulation. Calf muscles act fairly. Anterior tibial and musculo-cutaneous groups are paralysed. Right—Quadriceps acts better than on left, muscles below the knee paralysed, and in the same area there is complete absence of sensation. The patient complains of shooting pains in both legs, and there is some deep muscular tenderness.
Three weeks later an abundant crop of vesicles appeared over the front of the right thigh and leg, above and below the knee. Sensation in the limb at the same time returned to a considerable degree, anæsthesia 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 œdema 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 hyperæsthesia 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 hæmorrhage 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 hæmorrhage 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.