Treatment.
—The treatment of spinal-cord tumors is purely surgical and should be instituted promptly so soon as diagnosis has been made. Only in tumors of syphilitic origin will internal treatment be of any avail. The therapeutic test having been made, should it seem wise, and proved futile, the case should be regarded at once as surgical. According to Krauss’ statistics nearly 40 per cent. of all operated cases have resulted in recovery, while in 35 cases of sarcoma 8 have resulted in recovery and 6 in improvement. This is really a more gratifying statement than can be made with regard to brain tumors, and should be regarded as lending encouragement to surgical procedure.
The operative details will be discussed later in this chapter.
THE PERIPHERAL NERVES.
The remarks made concerning the surgical affections of and operations upon nerves contained in the previous chapter, pertaining to the cranial nerves, will apply equally well to the peripheral nervous system.
Constant pressure as well as contusions of nerves will cause more or less paralysis. The surgeon occasionally sees manifestations of this kind in the so-called “crutch paralysis,” due to pressure upon the brachial plexus by the use of crutches, and in another form so generally associated with administration of an anesthetic as to be called “ether paralysis.” It is another form of pressure paralysis due to indifference in letting the arm, for instance, hang over the edge of an operating table during anesthesia or operation. It does not call for operation so much as for electricity, massage, and similar measures. Extreme consequences of nerve and vessel injury are portrayed in [Fig. 410].
Tumors of nerves are both benign and malignant, the former assuming the fibromatous type oftener than any other, and frequently involving more than one nerve trunk, attaining also considerable size and impairing or destroying function by pressure. In addition to the true fibroma of nerve sheaths we have the peculiar type of fibromas of nerve stumps seen after amputations, and the multiple neuromas, again largely of the fibromatous type, which involve many and in rare instances nearly all the peripheral nerves. Cases are on record where as many as 1600 small and large tumors have been found, strung like beads upon wires, along all the peripheral nerves throughout the body. Another variety of fibromas of nerves involves those of the skin and produces small painful subcutaneous nodules, although these may attain a considerable size. Within the past few years there has been a much better familiarity with that form of growth known as plexiform neuroma, in which entire nerve trunks are involved, so that they become elongated, thickened, and tortuous, and resemble a varicose condition of the veins. The plexiform neuromas are found in any part of the body; they produce little or no pain, but lead to disturbances of function, as well as to peculiar irregular swellings that may be mistaken for lymphangioma, and which are often accompanied by pigmentation of and growth of hair upon the overlying skin. (See chapter on [Tumors].)
For the various purposes already mentioned different nerve trunks and plexuses are made accessible for operation by the following methods.
The Brachial Plexus.
—The brachial plexus is reached through an incision similar to that for ligation of the subclavian artery. After opening the deep fascia the nerves are sought and found behind the subclavian vein and lying around the artery. This plexus is stretched especially for the relief of choreiform spasm or painful nervous affections. The various nerves of the upper extremity, after leaving the brachial plexus, are made accessible to operations for grafting or suture as below. (See [Fig 406].)