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

by Unknown

It will be observed that the predominance in this list is decidedly in favor of the sarcomata and structures which are likely to be associated with or to graduate into them, such as the gliomata, myxomata, and the psammoma. In one instance the resemblance (Case 15) to psammoma is referred to by the reporter. The comparatively large number of unclassified, and the two cases referred to vaguely as cancer, would probably, on more exact report, have added several more to the group of the sarcomata. The table shows that next in frequency come the fibromata and gummata, while the carcinomata have but a single representative in the group. Tubercular tumors occurred with comparative frequency, no less than 8 per cent. being recorded. Although the exact origin of only somewhat more than one-half (29) of all the tumors is given, it is stated of this fraction that 17 sprang from the membranes, while of the remainder 8 were located in the cord itself and 4 in the vertebræ. Of the 3 oases of parasitic invasion, it is recorded of one (Case 43) that a hydatid cyst was also found in the liver; and it is probable that in any given case the spinal cord would not be the only part to suffer. Cobbold's work refers to one case of hydatid of the spinal cord. Erb refers to 13 cases, all but 2 external to the dura mater. In Case 43 of the table pains in the back and hip, simulating rheumatism, were present early.

The dimensions of the spinal tumors of whatever character are never very great, for the reason that they have but little space in which to enlarge, and that their presence soon causes such grave changes as to be incompatible with life. They rarely exceed an inch in their longest diameter, and not unfrequently are smaller than this. There is usually about them a more or less marked meningitis and an area of vascular fulness. Œdema of the membranes is sometimes noted. The substance of the cord beneath is compressed, atrophied, or softened, and this softening sometimes extends for a considerable distance both above and below the neoplasm. These changes were reported in Case 8, in which there was the addition of an abscess. Secondary degenerations would probably be found in all cases, unless very recent; and these changes, following the Wallerian law, would ascend the posterior and descend the lateral columns. Such degenerations are reported in some of the cases. The spinal nerves are sometimes compressed and atrophied. Old or recent hemorrhages are found, as in Case 18. Among the changes which occur, probably at a late stage, are the formation of cysts, either large or small, either in the substance of the cord or consisting simply of a dilatation of the central canal of the cord. This condition is known as syringo-myelia, and is of exclusive pathological interest. In Case 1 is recorded, apparently, a well-marked dilatation of the central canal (hydromyelus), and cyst-formation is recorded with gliomata, sarcomata, and gummata in other cases. Caries of the vertebræ is recorded in a number of cases, and occurred both in cases of gumma (Case 8) and carcinoma (Case 14). These cases were, however, exceptions to the general rule that the bony envelope of the cord does not furnish external evidence of the location of the tumor. It is worthy of note that the one instance of phlegmon or inflammatory exudate (Case 20) also presented infiltration of the tissues of the throat and mediastinal space. A case of organized blood-clot (Case 39) has been included in the list, although, properly, a spinal hemorrhage, because it became and acted as a tumor. The location of the single case of aneurism (Case 48) is not given. The symptoms were those of tumor in the dorsal spine.

As sequelæ of tumors of the cord may be mentioned especially bed-sores, which sometimes commit frightful ravages, as in a case (37) in which the spinal canal was laid open. The bronzing of the skin and diseased condition of the suprarenal capsules, as recorded in Case 41, were mere coincidences, and not probably at all connected in pathological sequence with the spinal lesion. Cystitis, pyelitis, and pyonephritis are not uncommon in cases of tumor of the cord, just as they are observed in other compressing and destructive lesions of that organ. In those cases in which the tumor is the result of a general taint, as in gummy and tubercular growths, the evidence of this taint is not usually wanting in other organs; thus in Case 37, of tubercle of the cord, tubercles were also found in the lungs, bowels, and uterus. In gummata of the cord it would not be likely to escape careful inquiry that the patient's history or his body presented evidence of the disease.

In a case (47) of congenital sacral neuroma amyilinicum the infant was also hydrocephalic and had a bifid spine—conditions of faulty development with which the patient cannot long survive.

In one case of psammoma (Case 5) a resemblance to endothelioma is noted, while in another (Case 15), already referred to, a sarcoma is said to have resembled a psammoma.

Vascular changes are usually notable. In addition to the congestion already spoken of, it is recorded in one case (No. 14) that the right vertebral artery was obliterated. This was a carcinoma which had partly destroyed one vertebra.

Virchow's case (No. 50) of a stillborn child with a large tumor of the size of the head of a child of two years, and containing bone, has some analogies in three cases, referred to by that author, in which both hair and bone were found.

In several cases a brown or yellow exudate (plastic lymph?) is mentioned as extending along the cord far beyond the immediate neighborhood of the tumor.

The histology of tumors of the whole cerebro-spinal axis will be found described in the article on Tumors of the Brain.

DIAGNOSIS.—The diagnosis of tumors of the spinal cord presents itself naturally under two heads—the differential, or general, and the local diagnosis. The conclusions reached in this paper are based on a careful study of the cases appended, two of which were personal observations, and the remainder were collected from American, English, French, and German literature. It cannot be denied that much obscurity rests upon the diagnosis of tumors of the spinal cord, and that the doubts expressed by Erb and other writers have much to support them. It is hoped that the systematized study presented in this table will do something to dispel this obscurity.