A system of practical medicine. By American authors. Vol. 5

by Unknown

SYNONYMS.—Spinal meningeal apoplexy, Hæmatorrhachis.

Spinal meningeal hemorrhage may take place between the dura mater and the walls of the vertebral canal, or between the dura and the pia mater—i.e. into the arachnoid space.

ETIOLOGY.—Penetrating wounds, injuries to the vertebræ, fractures and dislocations, and violent blows are apt to give rise to more or less hemorrhage into the spinal canal. Violent convulsions, as in tetanus, epilepsy, uræmic eclampsia, hydrophobia, may be followed by meningeal hemorrhage, owing to the disturbance of the circulation from asphyxia; and excessive muscular effort, as in lifting heavy weights, etc., has been said to cause it. In cerebral meningeal hemorrhage and in effusion into the substance of the brain the blood sometimes escapes into the spinal canal. An aneurism of the aorta has been known to communicate with the canal; such a case was reported by Laennec.¹² In certain diseases with hemorrhagic tendency, as purpura and scurvy, spinal extravasation is occasionally observed.¹³

¹² Traité d'Auscultation médiate, 4th ed., Paris, 1837, vol. iii. p. 443.

¹³ A case of scorbutic spinal hemorrhage is reported in the British Med. Journal, Nov. 19, 1881.

SYMPTOMS.—These vary according to the conditions under which the hemorrhage is produced and to the amount of bleeding. In traumatic cases the signs of hemorrhage are often completely overshadowed by those of the injury of the vertebræ, the membranes, or the cord, and are undistinguishable. When a large amount of blood is suddenly introduced into the spinal canal, it usually gives rise, by pressure on the cord, to paraplegia, which, however, is sometimes of only short duration. Thus in Laennec's case the bursting of an aneurism into the spinal cavity was signalized by a sudden paraplegia, but in half an hour the power of movement returned, though sensation did not. The patient died in a few hours from hemorrhage into the left pleural cavity. The amount of blood in the spinal cavity is not stated, and, in fact, it would appear that the spine was not opened. When the amount of blood is smaller the symptoms indicate irritation of the spinal nerves and of the cord. Pain in the back is always present, extending into the limbs, and is sometimes severe. Its seat corresponds to that of the effusion. There may be a feeling of tingling and numbness in the lower extremities, with anæsthesia or hyperæsthesia of the skin and more or less paresis. A feeling of constriction around the waist or the chest is sometimes complained of. In slight effusions the symptoms may be limited to numbness and formication of the extremities, with slight paresis. There is rarely fever in the early stages, unless the amount of blood is sufficient to give rise to inflammatory conditions of the cord or membranes. If the extravasation be moderate it is generally absorbed, with relief to the symptoms, although slight numbness and paresis of the extremities may continue for a long time.

PATHOLOGICAL ANATOMY.—In hemorrhage outside the dura the loose cellular tissue between the membrane and the bony canal contains more or less coagulated blood according to the circumstances of the case, especially in the posterior region of the canal and covering the nerve-roots. The dura is reddened by imbibition of the coloring matter of the blood. When the amount of the effusion is large, as in traumatic and aneurismal cases, or where cerebral hemorrhage has extended into the spine, the cord may be compressed by it. Hemorrhage into the arachnoid sac, except in cases of violence, etc., is usually of limited amount, sometimes only in the form of drops of blood upon the surface of the dura or pia. When more abundant it may surround the cord more or less completely, but in most cases it is limited in longitudinal extent, being confined to the space of one or two vertebræ. The cord may be more or less compressed, reddened, and softened. In all cases the spinal fluid is discolored and reddened in proportion to the amount of the hemorrhage.

DIAGNOSIS.—When the complications are such that symptoms attributable to hemorrhage are not observed, the diagnosis of spinal hemorrhage is impossible. This may happen in the case of wounds and injuries of the vertebræ and of the passage into the spinal canal of blood from an apoplectic effusion of the brain. In the convulsions of tetanus, epilepsy, etc. the amount of the hemorrhage is rarely sufficient to give rise to distinctive symptoms. In idiopathic and uncomplicated cases the chief diagnostic marks are suddenness of the attack; pain in the back, usually at the lowest part; disturbances of sensation in the extremities (anæsthesia, formication, etc.); paresis or paralysis of the legs; the absence of cerebral or spinal inflammatory symptoms; and, in many cases, the favorable course of the disease. Sometimes an ostensible cause, such as scurvy, purpura, suppressed menstruation, or hemorrhoidal flux, will aid in the diagnosis. The disease for which spinal hemorrhage is most likely to be mistaken is acute myelitis, but this is not sudden in its onset, is accompanied with fever, and gives rise to paralysis both of motion and sensation, and to loss of control over the sphincters, to bed-sores, etc. Hemorrhage of the cord would be accompanied by paraplegia and loss of sensation in the lower extremities and slight tendency to spasmodic manifestations; it is fatal in the majority of cases, or else is followed by permanent paralysis. Hysteria might be confounded with spinal hemorrhage, but the history of the case and the transient duration of the symptoms would clear up all obscurity.

PROGNOSIS.—In traumatic cases the hemorrhage is usually only one element in the gravity of the situation, which depends chiefly upon the character and extent of the original injury. In idiopathic and uncomplicated cases the prognosis, which must always be doubtful, will vary according to the severity of the symptoms as corresponding to the amount of the effusion. The danger is greatest during the first few days; if there should then be diminution of the more important symptoms, an encouraging opinion may be given. The immediate effects may, however, be less grave than the remote, such as bed-sores, cystitis, etc. Except in the very mildest cases the patient is likely to be confined to bed for several weeks. In more severe ones the convalescence may be very protracted, and permanent lameness, etc. may result.

TREATMENT.—In the early stage absolute rest in bed, with cold applications to the back and moderate purging, should be employed. Large doses of ergot are recommended, but there is little evidence of benefit from this medicine. In traumatic cases no rules for treatment of the hemorrhage can be laid down. If the extravasation evidently depends upon a constitutional diathesis, as in purpura, scurvy, etc., the remedies appropriate for these diseases should be employed, especially tonics and astringents, such as the tincture of the chloride of iron, in doses of from fifteen to thirty drops three times daily, quinine, and the vegetable acids. Should there be evidence of blood-pressure from suppressed discharge, as in amenorrhœa, arrested hemorrhoidal flow, etc., leeches should be applied to the anus, and blood may be taken from the region of the spine by cupping. In the later stages an attempt may be made to aid the absorption of the effused blood by the administration of the iodide of potassium or the protiodide of mercury, and by the application of blisters or strong tincture of iodine to each side of the spine. Pain must be relieved and sleep obtained, when necessary, by means of opium, chloral hydrate, or other anodynes. Electricity, rubbing, bathing, etc. will be useful for combating the paralytic symptoms which may remain after the disease itself is relieved.