(106) Dorsal region; Martini-Henry wound.—Wound of entry, oval, 1 inch ×3¼ 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, penis turgid. Total absence of reflexes, superficial and deep. Reddening of buttocks, but no bullæ.
General hyperæsthesia of upper extremities, with severe spasmodic attacks of pain.
On the third day an exploration was decided upon, in view of the local deformity, and the severe pain in the upper extremities. The third dorsal spine was found to be loose, as a result of bilateral fracture of the neural arch; the bullet had crossed the right limit of the spinal canal, and destroyed the body of the vertebra, and passing onwards had entered the left pleural cavity, into which air entered freely from the operation wound.
The patient was relieved from his pain by the exploration, and lived four days. On the second day after operation, however, the temperature rose to 107°, while on the last two days the temperature was normal in the mornings, rising to 105° in the evenings. No alteration resulted in the trunk symptoms.
Diagnosis.—The pure question of the fact of injury of the spinal cord needs no discussion; but it is necessary to make some remarks on the discrimination between concussion, contusion and hæmorrhage, meningeal and medullary hæmorrhage, the latter condition and compression, and on partial and complete severance of the cord.
The sharp discrimination of cases of concussion from those of slight medullary hæmorrhage was necessarily impossible. I think the only points of any importance in diagnosing pure concussion were the transitory nature of the symptoms, and the uniformity of recovery, without persistence of any signs of minor destructive lesion. In medullary hæmorrhage the tendency for a certain period was towards increase in gravity in the signs. It goes almost without saying that the latter point was seldom accurately determined in patients struck on the field of battle; these perhaps lay out for hours before they were brought in, and when they were placed in the Field hospital the rush of work did not usually allow the careful observation necessary to clear up this difference in the development of the symptoms. Nevertheless it is preferable to consider the cases in which transitory symptoms persist for a period of hours, or even a couple of days, as instances of pure concussion, unless the existence of this condition can be disproved by actual observation.
Extra-medullary hæmorrhage, accompanied by only slight encroachment on the spinal canal, certainly results with some frequency from small-calibre wounds. Some of the quoted cases show this decisively by post-mortem evidence, others by such clinical signs of irritation as pain and hyperæsthesia. I think its presence may also be assumed in cases of total transverse lesion due to medullary hæmorrhage or severe concussion, accompanied by well-marked pain and hyperæsthesia above the level of paralysis. As affecting treatment, however, determination of its presence is of small importance.
The important conditions for discriminative diagnosis are those of local compression, actual destructive lesion, whether from concussion changes, contusion, or medullary hæmorrhage, and partial and total section of the cord.
First, with regard to compression of the cord, the possible sources are three; (i) extra-dural hæmorrhage, which may, I think, be dismissed with mention as rarely capable of producing severe symptoms. (ii) The displacement of bone fragments. This is of less importance than in civil practice, because an injury by a bullet of small calibre, capable of seriously displacing fragments, has probably at the same time produced grave changes in the cord. In the presence of severe immediate symptoms we may tentatively assume that a simultaneous destructive lesion has been produced. In such injuries pain, combined with a tendency to improvement in the paralytic symptoms and return of reflexes, is the only point in favour of bone pressure, unless considerable deformity of the spinal column can be detected by palpation or examination with the X-rays.
(iii) Pressure from the bullet. This is the most important form of compression, because the mere fact of retention of the bullet is evidence of a low degree of velocity, and therefore opposed to the existence of the most severe form of intramedullary lesion. In a case of apparent transverse lesion with retained bullet, shown to me at No. 3 General Hospital by Mr. J. E. Ker, the pain was very severe, and so greatly aggravated by movement that an anæsthetic had to be administered prior to the renewal of some necessary dressings. The general condition of this patient precluded a projected operation, and after death the bullet was found to be pressing laterally upon a cord not materially altered on macroscopic inspection. In the case of retained bullet recorded (No. 104), the slight degree to which the severed ends of the cord appeared altered has been already remarked upon.