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, cystitis 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 hæmorrhage, 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 space; the breathing was almost entirely diaphragmatic. Retention of urine. Entire abolition of reflexes in lower limbs and trunk. Hyperæsthesia was present in both upper extremities, with a zone of hyperæsthesia around the chest. The patient suffered greatly for some weeks from pain in the hyperæsthetic area, he developed severe cystitis 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 septicæmia, 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 laminæ of the fifth, sixth, and seventh vertebræ were separated from the pedicles, and somewhat depressed on the left side. These laminæ were adherent to the dura, as were also a few small separated bony spiculæ. There was no sign of old hæmorrhage. The spinal cord was practically gone between the levels of the fourth and seventh dorsal vertebræ, 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, penis 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 laminæ were intact, no trace of bony injury being discoverable. Opposite the sixth dorsal vertebra, for a distance of 1½ 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 hæmorrhage.
(102) Dorsal region; total transverse lesion; slight extra-dural hæmorrhage.—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 passed in gushes, and the patient was cognisant when these occurred. The sacral bed-sores were, however, very extensive and becoming larger and deeper.