parts supplied by the third, fourth, fifth, sixth, seventh, and eighth
nerves of the left side. The muscles moving the tongue not affected.
No interference with respiration or the action of the heart; no choked
discs. External tumors on each side of the neck, with a protuberance
of the left eye.
Pathology and Location: Involved the petrous portion of the temporal
bone, with a portion of the sphenoid bone of the left side, size of
walnut.
Remarks: James H. Hutchinson, _Philada. Med. Times_, vol. xiii., Sept.
22, 1883.
100. Sex and Age: F. 66.
Clinical History: One-sided convulsions; first left leg, next left
arm. Slow, syllabic speech, not aphasic. Abnormal, prolonged
somnolence, followed by voracious appetite. Later, incontinence of
urine. Apathetic. Muscles of left half of body, especially arm and
leg, contractured. Pupils contracted. No facial paralysis. Slight
ptosis upon right side. Conjugate deviation of eyes to right; fixed
and immovable. Head drawn to right and backward. Extremities cyanotic
and cold. Accentuated aortic sound; abdominal tympanitis. Taste,
smell, hearing doubtful. Sensibility retained. Electric irritability
rapidly exhausted; reflexes diminished. Unable to stand; constant
tendency to turn to right. No albumen or sugar. All symptoms
intensified; exhaustion; temperature below normal; death.
Pathology and Location: Sarcoma.
Growing from right half of fossa of body of sphenoid bone, and
extending outward and backward along petrous bone, only closely
adherent at basilar portion of sphenoid. Slight depression of middle
peduncle of cerebellum near entrance to pons. Basilar artery pushed to
left. Vessels thick and rigid. Gyrus fornicatus of right side,
temporal aspect, compressed. Right peduncle of cerebrum compressed.
Brain-substance dense; numerous serous cysts in brain and ganglia.
Remarks: Petrina, _op. cit._
{1090}
TUMORS OF THE SPINAL CORD AND ITS ENVELOPES.
BY CHARLES K. MILLS, A.M., M.D., AND JAMES HENDRIE LLOYD, A.M., M.D.
DEFINITION.—Under Spinal Tumors will be included the growths or
adventitious products which arise in the substance of the spinal cord
or spring from its envelopes, membranous or bony, in such manner as to
directly or by pressure involve the spinal cord. Tumors strictly
confined to the cord are extremely rare. First in order of frequency
are the new growths which develop from the spinal membranes, either
the dura mater or pia mater, most frequently the former. Tumors
originating in the bony spine, like those of the substance of the
cord, are comparatively rare.[1]
[Footnote 1: A “Table of Fifty Cases of Spinal Tumor” (which will be
frequently referred to) is appended to this article.]
ETIOLOGY.—Under the predisposing causes of spinal as of intracranial
growths are such diatheses or constitutional affections as cancer,
tuberculosis, and syphilis. Under Pathology a table will be given from
which it appears that of 50 tabulated cases, 3 were cancerous, 5
syphilitic, and 4 tubercular.
Traumatisms, such as a fall from a height, a blow on the back, a
wrench or twist of the spine, or a sudden concussion as in a railway
accident, sometimes serve as exciting causes of spinal tumors. Even
when a diathetic or infectious predisposition exists, the patient
might frequently escape from the special intraspinal localization of
the disease were it not for the accidental infliction of direct injury
to the axis. When no special predisposition is present, an injury is
more likely to produce an osteoma, fibroma, or sarcoma than some of
the other forms which will be mentioned, such as a glioma, myxoma,
neuroma, or psammoma.
Spinal tumors are said by most authors to occur much more frequently
in the male than in the female sex. Our tabulated cases, however, gave
22 cases among males, 21 among females, and 7 in which the sex was not
given.
Fifty cases of spinal tumor gave the following result as to age:
Under 10 years . . . . . 4 cases.
From 10 to 20 years . . 3 "
" 20 to 30 " . . 7 "
" 30 to 40 " . . 12 "
" 40 to 50 " . . 10 "
" 50 to 60 " . . 6 "
" 60 to 70 " . . 1 "
Age not given . . . . . 7 "
-------
50 cases.
{1091} SYMPTOMATOLOGY.—Can tumors of the spinal membrane be separated
by a study of symptoms from intramedullary tumors? While this may be
theoretically possible, in practice it will be found difficult, and of
little value even when it can be done. The spinal canal is of such
narrow calibre that a growth of any size either in the membranes or
the cord itself will soon directly or indirectly involve both. On this
subject Erb[2] speaks as follows: “The attempt has thus far been made
in vain to secure, from amongst the individual symptoms, at least a
few fixed points on which to base the diagnosis of intramedullary
tumors. The following have been claimed as such: A somewhat long
antecedent history of active local manifestations of irritation,
belt-like pains, eccentric pains, definite paræsthesiæ, local
paralysis, as in meningeal tumors; early and well-marked atrophy,
which points to a larger involvement of the gray substance; striking
fluctuations in the course of the disease, spontaneous improvement,
and equally spontaneous growing worse again (Schueppel); and, finally,
Schueppel has also tried to connect the occurrence of scoliosis
(curvature of the spinal column to the side on which the tumor is
situated) with the presence of a tumor. In this he is doubtless wrong,
as this manifestation merely depends on unilateral paralysis of the
muscles of the back, which may depend on all sorts of causes.”
[Footnote 2: _Ziemssen's Cycl. Prac. Med._, Am. trans., p. 754.]
In the discussion of symptomatology and diagnosis which follows
therefore no effort will be made to separate the phenomena of
meningeal and intramedullary growth. In most cases the symptoms
indicate involvement early of the membranes, and later compression of
the cord.
The symptomatology will differ according to the stage of the
affection. The symptoms can be arranged into those of a first or
early, a middle, and a late stage. As a rule, but not invariably, the
symptoms of the early stage are those of beginning irritation—such
sensory phenomena, for instance, as pain in the parts supplied by
certain nerves in the neck, arms, hands, abdomen, legs, or feet. This
pain is sometimes associated at an early period with more or less
stiffness, which later may become well-marked contracture. Pain in the
back is occasionally an early symptom. Paræsthesiæ, as numbness,
formication, constriction or girdle sensations, coldness or heat or
alternations of hot and cold feelings, are sometimes early symptoms,
but occur in a more positive manner in the middle stages of the
progress of the spinal growth. Hyperæsthesia is more likely to be
pronounced in the middle stage of the disease. A slight paresis, which
may vary a little from day to day for a time, slight twitchings or
spasms, usually localized to certain muscles or groups of muscles, are
also present, in some cases as an incipient manifestation. The
presence of these motor symptoms will depend largely upon the location
of the incipient growth with reference to the columns of the cord.
One general point of differentiation between intramedullary and
membranous tumors is the fact that irritative phenomena, such as pain
in the back and along nerve-tracts, spasmodic twitchings, etc., are
not likely to appear as early in the intramedullary cases as in the
meningeal or mixed forms.
In the middle period of the progress of a spinal tumor the irritative
phenomena, such as pain, paræsthesiæ, hyperæsthesia, twitchings,
cramps, stiffness, and paresis, will be found to persist and increase,
and in {1092} addition other manifestations will appear, chiefly those
of compression of the cord. Anæsthesia frequently develops, and, when
the posterior segment of the cord is the one chiefly implicated, soon
becomes profound; it is, however, often variable in distribution for a
time, and sometimes shows peculiar areas. One leg or one arm may be
partially involved, or both lower or both upper extremities, or
certain portions of any one of the limbs. Anæsthesia dolorosa—that is,
absence of sensation to objective tests, although the patient suffers
pain or distress in the affected part—is common. Hyperæsthesia, best
observed in this middle period, is sometimes cutaneous, but in other
cases follows certain nerve-trunks, probably indicating a neuritis
descending from the seat of the spinal growth. In this and in the last
stage the paresis advances to more or less complete paralysis, which
is also variable in distribution according to the localization of the
growth. Contractures and rigidity come on and changes in the reflexes
now become important symptoms. These may be increase of knee-jerk with
ankle-clonus, or diminished or abolished knee-jerk, according to the
position and the extent of the lesion.
The late symptoms of spinal tumors, especially of those which are
slowly developed, are—usually profound anæsthesia and paralysis of the
limbs, with rigidity and contractures, atrophy, marked changes in the
spinal reflexes, bed-sores, paralysis of bowels or bladders or their
sphincters, impotence, œdema, dyspnœa, vomiting, cardiac palpitation,
cystitis, and pyelitis, and, when the lesion is near the medulla
oblongata, dysphagia and certain intracranial symptoms, as amblyopia,
diplopia, deafness, contracted pupils, affections of speech, etc.
The size of the growth and the rapidity of its development will of
course influence the character and the time of appearance of certain
symptoms. According to the position of the growth, either as to its
level in the spinal axis or as to its relative position to the various
longitudinal segments of the spinal cord, the symptoms will also
differ at special stages. These differences will appear as
symptomatology and diagnosis are now further considered.
Pain in the back occurs, but is not as frequent a symptom as eccentric
pain. Unlike headache in intracranial tumors, it is not a constant
symptom. The headache of brain tumors is due in part at least to the
conditions of tension which are produced by the growth interfering
with the balance of pressure within the skull. Headache is also, as
has been pointed out in the article on Brain Tumors, frequently due to
the irritation of the membranes; but in this case the one great nerve
through which pain expresses itself is the trigeminal, which has its
distribution both within the skull and outside of it to all parts of
the head. In spinal tumors the pains are more likely to be eccentric,
because of the limited character of the lesion and the almost
exclusively peripheral distribution of the nerves. Twisting the trunk
or jarring the spinal column by blows on the head will sometimes cause
pain along the spine, most frequently when the bone is involved. It
sometimes cannot be elicited.
Leyden[3] pointed out the fact that the movement of the spinal column
is often difficult and painful in a certain direction, because this
motion brings a greater pressure upon the tumor.
[Footnote 3: Quoted by Erb.]
{1093} Pain on percussion over the spinal column might be expected
from the character of the affection, but has not been frequently
reported. Like spinal hypersensitiveness and inflexibility with
muscular rigidity, it is much more to be expected in those cases in
which the vertebral bones and cartilages are implicated.
Constriction or girdle sensations are of comparatively frequently
occurrence. When the cervical cord is involved, choking sensations or
a sense of constriction about the neck are common. Tumors located in
the lower cervical and dorsal region give girdle sensations most
frequently in the chest or abdomen. So far as the assistance afforded
by such sensations toward localizing the exact level of the growth is
concerned, however, it must not be forgotten that curious and
unexpected conditions sometimes occur. Thus, in one case (Case 16) a
myxoma at the level of the sixth and seventh cervical vertebræ caused
constriction sense about the legs and abdomen, and in another (Case
44), a glioma of the filum terminale, constriction of the chest.
The paralytic phenomena of spinal tumors have certain peculiarities
which are not exhibited by any other spinal or by cerebral affections.
A glance at the clinical history of a number of cases shows that many
of them began with paresis of a single limb or part of a limb, in
addition to the irritative phenomena. This paresis deepens after a
time into complete paralysis, or before this occurs one or more of the
other extremities become paretic. The progress toward bilateral
paralysis may be comparatively rapid. The appearance and progress of
the paresis or paralysis vary somewhat according to the level of the
cord at which the tumor is located. In tumors of the cervical cord the
paresis usually, but by no means invariably, first attacks the upper
extremity. The fact that the arms are first the seat of irritative
phenomena and paresis is in a case of spinal tumor indicative of a
cervical location or a location in the upper dorsal region; but, on
the other hand, not a few cases are recorded in which in tumors in
these locations the loss of power first exhibited itself in one or
both of the lower extremities. These cases are to be explained by the
manner in which the descending motor tracts are affected directly or
by pressure. In mid-dorsal tumors and those below this level the
paresis shows itself first in the legs, and generally becomes before
long a complete paraplegia.
To Brown-Séquard, more than to any other observer, we owe our accurate
practical knowledge of unilateral lesions of the spinal cord, both in
the cervical and other regions. When the lesion is localized in one
lateral half of the cord and is situated in the cervical region, we
have the affection known as spinal hemiplegia. The main symptoms of
this affection are motor paralysis of the arm and leg on the side of
the lesion and anæsthesia of the opposite limbs. Sensory fibres
decussate in the cord soon after entering it, while the motor tracts
cross at the anterior pyramids of the medulla oblongata; in which
physiological facts we have a simple explanation of the peculiar motor
and sensory phenomena presented by such a case. When the lesion is
below the cervical portion of the cord, instead of spinal hemiplegia
we have the affection known as spinal hemiparaplegia, in which the
paralysis and hyperæsthesia in one lower extremity stand out in strong
contrast to the anæsthesia and retained muscular power in the other.
With a lesion so strictly localized as a spinal {1094} tumor it might
be expected that these crossed phenomena would present themselves in
some cases. They are recorded, more or less distinctly, in Cases 4,
16, and 38, and it is probable that they would have been more
frequently observed if they had been anticipated and looked for
carefully.
Ataxia does not seem to have been a frequent symptom in reported
cases. It has probably been sometimes overlooked or confounded with
paresis. In a case of myxoma of the dura mater in the left dorsal
region ataxia of both leg and arms was present; but in this case,
however, the dura mater of the brain contained fluid and lymph. In the
light of the commonly accepted views as to the physiology of the
spinal cord regarding the posterior columns, as related in function
both to co-ordination and sensation, ataxic manifestations might be
frequently expected. Owing, however, to the narrowness of the spinal
canal, compression of the entire cord takes place so early as to make
paretic symptoms displace those of ataxia.
Atrophy which varies in distribution according to the extent of the
destructive involvement of the cord is frequently present. In a few
instances the atrophy will be of certain muscles or muscular groups.
When true atrophy is present the anterior horn will be involved
directly or indirectly, and accompanying changes in the electrical
reactions will also be found.
The electrical condition of the atrophy of the paralyzed parts will
vary with the extent of the trouble produced by the tumor. In a case
of tumor of the cervical enlargement, for instance, producing more or
less paralysis both of the upper and lower extremities, reactions of
degeneration will be present only in the muscles supplied by the
nerves which spring directly from the seat of lesion.
Spontaneous twitchings or spasms due to irritation of motor-centres or
tracts are comparatively frequent. More or less permanent contracture
in a limb or part is of frequent occurrence, particularly after the
growth has advanced. Forms of torticollis or retraction of the head,
strong flexures of the arms or legs, and, late in the history of many
cases, complete and extremely painful drawing up of the limbs upon the
body, may occur. Persistent subsultus was observed in one case, a
glio-myxoma involving the gray columns from the medulla oblongata to
the cauda equina. Fibrillary twitching is rare, and in our tabulated
cases was observed only in one instance, a glioma of the filum
terminale. General convulsions with unconsciousness are exceedingly
uncommon. In one case, however, a round-celled sarcoma at the level of
the seventh, eighth, ninth, and tenth cervical vertebræ, the patient
is recorded as having died in a fit. Nystagmus was observed once, but
probably had no significance so far as the spinal affection was
concerned, as the cerebral dura mater exhibited evidences of
inflammation.
The condition of the reflexes, both cutaneous and tendinous, is often
peculiar and almost diagnostic, but varies greatly according to the
position and extent of the lesion. Increase of reflex action is
sometimes a marked symptom. The slightest irritation of the soles of
the feet, the calves of the legs, palms of the hands, or other special
regions will often produce decided contractions, and sometimes that
symptom which has been designated by Brown-Séquard as spinal epilepsy,
in which both lower extremities are thrown into violent clonic spasms,
which may last {1095} for many seconds or even minutes. In tumors of
the dorsal region causing marked compression and preventing cerebral
inhibition, clonus and knee-jerk are also markedly exaggerated. The
so-called diplegic contractions—that is, contractions in one extremity
from irritation of the other—are observed, especially when a
transverse area of the cord, large or small, is involved in an
irritative or inflammatory process. They probably result from the
abnormal facility of transmitting impressions which has been acquired
by the cord. When the cervical or the lumbar enlargement of the cord
is completely compressed or destroyed by a tumor, reflex activity is
diminished or abolished in the region supplied by nerves originating
at the seat of lesion.
Alterations in the body-temperatures have been frequently noted in
lesions of the spinal cord, such as fractures of the vertebræ and
inflammatory changes in the cord and its membranes. Some of the
observations are almost incredible, as that of J. W. Teale,[4] who
records an axillary temperature of 122° F. The subject has been
somewhat obscured by physiological speculations. Thus, it has been
asserted that paralysis of motor centres and strands causes an
increase of temperature, while paralysis of sensory tracts produces a
diminution. The accepted clinical facts apparently are as follows:
after crushing the cervical cord a uniform rise in temperature occurs
if peripheral cooling is prevented. This rise is caused by a paralysis
of the vaso-motor nerves, which permits a paralysis of the vessels and
floods the parts with blood. This assumes, of course, that mere
increase of blood in a part means increase of heat. After a variable
period this increase is followed by a decrease which is permanent.
Hutchinson records[5] a case of fracture of the cervical spine at the
fifth vertebra in which the patient's body felt almost as cold as a
corpse and the rectal temperature was only 95° F. In Cases 4 and 16
the affected parts are recorded as cold, just as in atrophic and other
lesions of the cord. The tabulated cases do not show many exact
thermometric observations, but in Case 8 the average temperature for
two weeks before death is given as slightly below normal, while Case 7
shows a sudden rise on the day preceding death. It is probable that
the permanent decrease following crushing and compressing lesions
would also be found in cases of spinal tumors. The following exact
observations, made by one of us[6] upon a case of injury to the
cervical cord, are directly illustrative of this subject. The case was
of several months' standing. The patient could walk imperfectly, and
the right arm was more paretic than the left. The observations were
made at 10 o'clock A.M. on six successive days:
Right Axilla. Left Axilla.
First observation . . 98.2° 97.3°
Second " . . 99.8° 98.2°
Third " . . 96.4° 96.2°
Fourth " . . 95.6° 96.4°
Fifth " . . 97.2° 96.8°
Sixth " . . 95.2° 93.8°
It will be seen that the temperatures range higher in this series on
the more paretic side; but this did not hold in a series taken a few
weeks {1096} later. The fact is to be noted that all these
temperatures, with one exception, are below the normal.
[Footnote 4: _Lancet_, March 6, 1875.]
[Footnote 5: _Ibid._, August, 1875.]
[Footnote 6: _Hospital Gazette_, Nov. 7, 1879.]
Cystitis, pyelitis, and pyelo-nephritis are usually secondary
symptoms, due to retention of urine, distension of the bladder, etc.
in consequence of paralysis of this viscus. Bed-sores result in two
ways: in the first place, they may be due to emaciation and immobility
and the uncleanliness which it is almost impossible to prevent; or, in
the second, trophic eschars may arise because of the involvement of
nutritive regions of the cord. The so-called sacro-ischiatic eschars
are of this character. Febrile phenomena, such as chills, increased
temperature, increased respiratory action, are frequently secondary
phenomena due to bed-sores, cystitis, continued pain, exhaustion, or
septic infection.
Priapism was recorded in two of the fifty cases, both tumors of the
cervical cord. Impotence was only recorded once, a dorsal myxoma. It
is probable that both priapism and impotence, particularly the latter,
were present, but overlooked in other reports.
Headache was present in three of fifty cases. One of these was a
fibro-sarcoma at the level of the fourth cervical nerve; the other two
were low down in the spinal axis, one in the lumbar enlargement, and
the third, strange to say, in the filum terminale. Vertigo is a rare
symptom in the spinal tumors. In one case in which the growth was
located at the position of the third cervical vertebra its presence
was recorded.
Out of five cases in which vomiting was present, two were in the
cervical regions, one in the dorsal, one in the lumbar, one in the
filum terminale.
Tumors involving the upper cervical and bulbar region of course will
give rise to special symptoms indicating more or less involvement of
cranial nerves.
Unfortunately, very few ophthalmoscopic observations have been made in
cases of spinal tumor. Optic neuritis has been found in a few
cervico-dorsal cases, and in other cases located in the same region no
ophthalmoscopic alterations have been discoverable.
Mental disturbances were only especially recorded in four of the fifty
cases. Such symptoms were certainly not of frequent occurrence, except
those emotional manifestations which were due to the great suffering
which the unfortunate patient was called upon to endure. These
emotional disturbances, as in all forms of painful disease, varied
according to the mental stamina of the patient. In one case the mental
symptoms, in association with other phenomena and a probability of
dog-bite, led to the suspicion of hydrophobia.