Chapter L: J. Lautenbach, in a recent communication to the Philadelphia (3)

Clinical History: Occipital headache. Movements weak; gait staggering. Inability to fix eyes; sight retained. Pupils unequal. Partial deafness in both ears. Vomiting. Sopor. Sudden death. History of fall upon head at twenty years of age, since which time much headache.

Pathology and Location: Tumor size of nut, compressing cerebellum and pons, situated between pons, middle peduncle of cerebellum, the cerebellum, and brain. Corpora quadrigemina atrophied.

Remarks: Luys, _Gaz. des Hôp._, 1867, 105, quoted by Bernhardt, p. 225.

74. Sex and Age: F. 52.

Clinical History: Violent and continuous headache. Gradual loss of sight. Very irritable. Psychic pain and complaints. Incoherence of ideas. In three to four years some anæsthesia of left leg; the left hand became rebellious to the will. Paralysis progressed; symptoms increased very slowly. Intense coryza, with running from the nose, accompanied with a feeling as if a strange body filled up this cavity. Great appetite. Had an attack of unconsciousness, preceded by violent pains and creepings in the left hand, and presenting the following conditions: Dorsal decubitus; flushed face; head strongly retracted; {1084} frowning; respiration difficult, but not stertorous; pupils large and insensible to light; the left eye widely opened, the right shut; very marked contraction in the orbicular muscle; stringy mucus in large quantities from right nostril; the left commissure of the lip strongly carried downward and backward. Tongue white, not deviated. Limbs of the right side not anæsthetic or paralyzed; the hand strongly shut. On the left arm painful pricking; the elbow flexed at a right angle, hand completely paralyzed. Motion diminished in left leg; sensibility not altered; intelligence obtuse, but the patient responds to questions. Nausea; hiccough. Finally, diaphragmatic breathing; asphyxia by strangulation.

Pathology and Location: Tumor size of hen's egg lodged between the superior surface of the cerebellum and cerebrum.

Remarks: M. Boullet, _Gaz. méd. de Par._, 1834, 2d S., vol. ii. p. 264.

75. Sex and Age: F. 64.

Clinical History: History of a fall down stairs. Headache. Frequent vomiting. Stupor, and when admitted to the hospital three weeks before death could not give any account of herself or of her complaint. Semi-comatose. No definite paralysis. She could move both arms and legs, but could not stand. Involuntary evacuations. No deviations of the eyes; apparently saw well. Pupils equal and moderately contracted; right disc a little redder than the left, but no swelling of the disc. Died in a convulsion, the right side being most affected.

Pathology and Location: Tumor size of a greengage plum, sprang from the dura mater just under the tentorium cerebelli on the left side. It had caused the deep depression of the left lobe of the cerebellum. Also a small clot, partly decolorized, just outside the right corpus striatum.

Remarks: B. Bramwell, quoted in _Med. and Surg. Rep._, vol. xxxiv., Mar. 11, 1876.

76. Sex and Age: F. 32.

Clinical History: Headache first. Then pain in right eye and numbness in right arm and leg; vision poor in right eye, with improvement. The left soon similarly affected, without improvement. Vomiting (patient was pregnant); vertigo. Ataxia marked. Patellar reflexes diminished. Tongue protruded to left. Right pupil dilated. Taste abolished on right side. The left field of vision showed hemianopia of the temporal side. Both eyes showed optic neuritis. Later, shooting pains in legs and left arm. Mind clear, but hysteroidal excitement frequent. Surface-temperature of head elevated. Toward end mental aberration, then unconsciousness. Died during labor.

Pathology and Location: Sarcoma.

A nodular tumor, size large horse-chestnut, on upper surface of right lateral hemisphere of cerebellum.

Remarks: J. T. Eskridge, M.D., _Journ. of Nerv. and Ment. Dis._, vol. xii. No. 1, Jan., 1885.

_Floor of Fourth Ventricle._

Directly or indirectly involved.

77. Sex and Age: F. —.

Clinical History: Vertigo only on standing. Sensibility normal. Walking and standing impossible. Ataxia of legs. No paralysis. Facial and trigeminus intact. Dysphagia. Double amaurosis. Eyeballs fixed, directed forward. Symmetrically dilated pupils. Hearing, smell, and taste normal. Consciousness clear.

Pathology and Location: Tumor of whole anterior part of vermiform process of the cerebellum, lying on floor of fourth ventricle. Corpora quadrigemina compressed to thinness of paper.

Remarks: Curschmann, _Berlin. klin. Wochenschrift_, 1877, p. 237, quoted by Bernhardt, 227.

78. Sex and Age: M. 6½.

Clinical History: Fell from a bench, striking the occiput. Headache for a day or two afterward. Slight irregularity in gait. For weeks restlessness, headache, and motor ataxia the chief symptoms. In three months speech became indistinct. “He screamed his words.” Defective memory. Apparent exophthalmus; ataxic movements of the head, and a look of profound stupidity; epistaxis; bulbar conjunctiva anæsthetic; left pupil dilated; vomiting. Ophthalmoscopic examination showed congestion of right optic nerve and left descending neuritis, going on to progressive atrophy.

Pathology and Location: Glioma.

Anterior portion of the fourth ventricle occupied by a rounded swelling of the pons; from under surface of the pons enlargement about equal on both sides. The anterior pyramids at entrance of pons seemed abnormally elevated, with the point of entrance also deeper than normal. Corpora quadrigemina much smaller than usual, and seemed pushed upward and flattened.

Remarks: V. P. Gibney, _Am. Journ. of the Med. Sci._, N. S. vol. lxx., July, 1875, p. 142.

{1085} 79. Sex and Age: M. 11.

Clinical History: Fronto-occipital headache. Vertigo. Staggering gait. Falls often, and to right. No paralysis. Diminution of sight. Irregularity of movements of eyes. Right strabismus (?). Vomiting.

Pathology and Location: Tubercle.

Size of hazelnut, in middle of vermiform process, above fourth ventricle. Some softening of surrounding tissue.

Remarks: Capozzi, quoted by Bernhardt, p. 224.

80. Sex and Age: M. 25.

Clinical History: Fronto-occipital headache. No anæsthesia. No paralysis; staggering gait. Loss of consciousness, with trembling of upper extremities. Vertigo. Falls to right. Double optic neuritis; amaurosis; nystagmus. Dementia; moroseness. Vomiting. Sudden death.

Pathology and Location: Between the amygdalæ of cerebellum; in front of cerebellum, bulging into fourth ventricle, merging with floor of fourth ventricle. Medulla oblongata pushed forward to right.

Remarks: Annusk, _V. Graefe's Arch._, Bd. xix., 1873, quoted by Bernhardt, 223.

81. Sex and Age: M. 58.

Clinical History: Headache, vertigo, diplopia; vomiting. Left facial paralysis. Ptosis of both eyes, worse in left. Contracture of left masseter. Speech nasal. Sense of pharyngeal obstruction. Both eyes diverted to right; on looking toward left the right eye turns to middle line, and left eye does not follow. Pupils contracted, left more than right. Anæsthesia of right face. Left ear slightly deaf. Smell and taste normal. Head movable, with deviation. Trunk and extremities not anæsthetic or paralytic. Later, smell of left side diminished. Reactions of degeneration in left face.

Pathology and Location: Floor of fourth ventricle to left of median line, involving motor root of fifth and nuclei of sixth, seventh, eighth, and ninth nerves on that side.

Remarks: C. Wernicke, _Arch. für Psychiatrie und Nervenkrankh._, vii. Bd. 5, iii. Heft., 1877, p. 513.

82. Sex and Age: F. 6½.

Clinical History: Symptoms of tubercular meningitis with a few irregular symptoms; conjugate deviation of the eyes to the left and upward. Cheyne-Stokes breathing.

Pathology and Location: Tubercular granulation about the size of a large pea springing from the left side of the fourth ventricle, just inside the posterior pyramid, midway between the cerebellar peduncle and calamus scriptorius; touched the under surface of the middle lobe of cerebellum. Head hydrocephalic. Miliary tubercles along Sylvian fissure, and a few elsewhere.

Remarks: Morris J. Lewis, _Trans. of Phil. Path. Soc._, 1879-81, vol. x. p. 172.

_Pons Varolii and Medulla Oblongata._

83. Sex and Age: F. 8.

Clinical History: Right external strabismus, with contraction of the right corner of the mouth; contraction disappeared, but squint remained. Persistent cough, with stringy mucous expectoration. Staggering. Left hemiparesis, with left partial hemianæsthesia. Severe constipation. Bowels opened only about once in five days. Water passed voluntarily once every two days. Difficulty of articulation. Squint had almost disappeared, but later returned for a few days, and then disappeared entirely. Became unable to walk, or even to sit, unsupported. Also became unable to speak, but produced strange inarticulate sounds. Difficulty in swallowing. A marked feature in this case was the absence of headache. The only pain suffered was the pain of dull character referred to the left ear, but which lasted only two days.

Pathology and Location: Occupied the lower half of the pons and the upper half of the medulla oblongata, bulging most at the lower border of the pons at the right side, and extending a little lower and higher at the right side than on the left. Floor of fourth ventricle bulged slightly, and appeared to be expanded in all directions, so that the median fissure was pushed decidedly to the left. Incision revealed the tumor to be a large cyst filled with bloody fluid and detritus. The lower part of the ventricular floor not involved.

Remarks: C. K. Mills, not before published.

84. Sex and Age: M. 32.

Clinical History: Thrown from a horse and kicked on the head. History of syphilis; headache, severe at first, always came on at night; became less severe later. Vertigo. {1086} Defective memory; apathy. Right hemiparesis; helplessness of all the limbs before death; partial ptosis of the right side. Sensation diminished in the left side of the face and in the right limbs. Pupils small before death. Descending optic neuritis. Conjugate deviations of the eyes and rotation of the head to the right. Persistent epistaxis; tendency to hemorrhage from mucous membranes. Constipation.

Pathology and Location: Gumma and fibroma.

(1) Gumma, half an inch in diameter, distinctly limited to the left upper quarter of the pons. (2) Fibroma, no larger than a pea, between the dura and pia mater, causing a slight depression in the first temporal convolution about the junction of its middle and posterior thirds, and halfway between the parallel fissure and the horizontal branch of the Sylvian fissure. Microscopical examination of the optic nerves showed a descending neuritis of subacute character.

Remarks: C. K. Mills, reported at the meeting of the Amer. Neurol. Assoc., June, 1881, and published in the _Journ. of Nerv. and Mental Dis._, July, 1881; and _Arch. Med._, vol. viii. No. 1, Aug., 1882.

85. Sex and Age: M. 35.

Clinical History: History of syphilis. Wounded in head by glancing bullet. Headache of great severity at intervals. Vomiting at time of headache. Vertigo. Failure of memory and depressed spirits. Epileptiform attacks. In the spasms lifted up the right side of his body and worked over toward the left. Occasional cramps in stomach and legs. Temporal and orbital neuralgias. Descending neuritis, and eventual atrophy of both optic nerves. Constipation. Died at the close of a series of convulsions, death being preceded by general paralysis.

Pathology and Location: Gumma.

A rounded mass, quarter of an inch in diameter, attached to the pia mater, just to the left of the centre of the anterior surface of the pons. The entire anterior central portion of the pons was softer and more doughy than usual. At the junction of the pons with the medulla oblongata was a recent hemorrhage, which had spread downward to about the middle of the latter.

Remarks: C. K. Mills, _Brain_, Jan., 1880, and _Arch. Med._, vol. viii. No. 1, Aug., 1882.

86. Sex and Age: M. 5.

Clinical History: At first left internal squint and nightly paroxysms of excessively silly laughter. Slight paralysis of right arm, with rigidity. Paresis of right leg, increasing to paralysis, with rigidity. During sleep arm and leg became relaxed. Difficulty in swallowing. Paralysis of left orbicularis palpebrarum and left external rectus muscles. Sensibility not impaired. Electro-muscular contractility present in all the paralyzed muscles (?). Speech lost, apparently from difficulty in articulation. Intelligence preserved till near the close. Sight, smell, and taste good. Later, suffered from intense headaches and frequent attacks of palpitation of the heart, with flushing of face and injection of left conjunctiva, and with increased rigidity of right arm and leg. Death from paralysis of the pneumogastric.

Pathology and Location: Glioma.

Gliomatous transformation of the pons, but no distinct separable neoplasm. Had encroached somewhat on cerebellum, particularly in region of left pneumogastric lobule.

Remarks: W. Pepper, _Trans. Phila. Path. Soc._, 1878-79, vol. ix. p. 136.

87. Sex and Age: M. 2.

Clinical History: Dysphagia; paresis of left arm and ptosis of left eye, which improved, followed by same symptoms on right side. “Legs affected.” Head very large. Dribbling. Paralysis of articulation. Contraction of orbicular muscle, causing ptosis (?). Clonic spasm of right side of mouth, and rhythmical jactitation of right arm on attempted movement. Unable to stand or sit. Optic discs normal. Evacuations involuntary. Left side of face paralyzed. Tonic spasms of right sterno-mastoid. Later, left arm jerked like right, and rigid contractions of legs. Retraction of head and occasional spasm of left sterno-mastoid. Impossible to gauge sensation.

Pathology and Location: Tubercle.

Tumor of left side of lower part of pons and central and posterior part of upper half of medulla. Cerebral fluid increased. Medulla oblongata was twice the normal size.

Remarks: J. M. Hobson, M.D., _Brain_, vol. iv. p. 531.

88. Sex and Age: M. 12.

Clinical History: Slight paresis of right side (arm and leg). He spoke thickly and swallowed badly. Slight headache. Was depressed. Delirious at night. Slight paresis of left face. {1087} Irregularity of pulse. Choked discs. Later, paralysis of sixth nerve. Sudden death, probably in a fit.

Pathology and Location: Glioma.

Membranes of base congested. Tumor, which appeared to occupy the whole left half of pons varolii. No trace of fifth nerve on left side.

Remarks: Hughlings-Jackson, _Med. Times and Gaz._, Lond., 1874, i. 151.

89. Sex and Age: F. 60.

Clinical History: Headache frontal, severe and almost constant. Paresis of right arm and leg. Painful spasm of right arm. Paresis gradually extended to left half of body. Persistent pain in right arm, with tremor; later, same symptom, less marked, in left arm, simulating paralysis agitans. Atheromatous arteries. Melancholic; talks to herself; very hard of hearing. Head directed constantly to right. Tremor increased on voluntary motion. Atrophy of muscles of arms. Flexors of legs contractured. Electro-muscular contractility reduced, especially on right side. Later, pain on touch in right arm. Febrile intermitting symptoms, simulating malaria. Still later, distinct contracture of neck. Conjunctivitis of left eye, with corneal dulness, followed by kerato-iritis, with ulceration of cornea. Dysphagia; swelling of submaxillary glands. Œdema of lungs.

Pathology and Location: Sarcoma.

Tumor of left side of pons and left cerebellar crus, extending toward transverse sinus.

Remarks: Petrina, _op. cit._

90. Sex and Age: M. 54.

Clinical History: Severe continuous headache. Eyes constantly turned to the right. No diplopia. Eyes, moved together, could not turn beyond the median line of the left, though the right eye alone could be turned for some distance to the left beyond the median line. Pupils equal and mobile. No paralysis or loss of sensation. Some dizziness and stagger in walking. Died of pneumonia.

After the autopsy the position of the head was regarded not as compensatory for the position of the eyes, but as due to a severing of fibres joining the rotatory muscles of the head with their reflex centres.

Pathology and Location: In the pons at a level one centimeter below the apparent origin of the fifth nerve on the left side. It was so situated in front of the eminentia teres that it involved the course of the fibres of the left abducens, and by a little prolongation across the raphé toward the right side interrupted the fibres of communication between the centres for the sixth and third nerves. It did not involve the common nucleus of the sixth and seventh. It interrupted the posterior-interior longitudinal bundle and the adjacent part of the raphé. No other lesion was found. The tumor was the size of a small nut.

Remarks: Quioc, _Lyon Méd._, 1881, July, Nos. 19 and 20, quoted by M. Allen Starr, _Journ. of Nerv. and Mental Dis._, vol. xi., July, 1884, p. 377.

_Crura Cerebri._

91. Sex and Age: M. 25.

Clinical History: No headache. Staggering some days before death. Apoplectic seizure, with right-sided hemiplegia. Ptosis of left side (some days before death). Loss of consciousness for three or four days. No vomiting.

Pathology and Location: Glioma.

In left crus cerebri, including also portion of right.

Remarks: Sutton, _Brit. Med. Journ._, Feb., 1870, quoted by Bernhardt, p. 163.

92. Sex and Age: M. 9.

Clinical History: Awkwardness in using right hand; soon almost complete paralysis in the right arm. Headache; nausea; vomiting; double vision, followed by strabismus, due to paralysis of the left abducens. Occasional twitchings in right hand, but no convulsions. Paralysis extended to the right leg; staggering gait. Ataxia and rigidity in the fingers of the paralyzed hand. Pain in the legs. Optic neuritis.

Pathology and Location: Sarcoma.

Pressing upon the left crus cerebri and the pons.

Remarks: E. C. Seguin, _Journ. of Nerv. and Ment. Dis._, Jan, 1882.

93. Sex and Age: M. 3.

Clinical History: Headache; unnatural drowsiness. Ptosis of right eye, with very marked divergent strabismus and fully-dilated pupil; similar paralysis in left eye, not quite so {1088} marked. Paresis of left leg. Very late, unconsciousness, constant motion of tongue and lips, and clonic spasms of left arm and leg. Twitching of right face. Convulsions, death. Duration, about one year.

Pathology and Location: Tubercle.

Size of a walnut in right crus, almost destroying the crus just at its junction with pons; making pressure on left crus. Third pair of nerves diminished in size and softened. Recent inflammatory changes at base. Increased cerebral fluid.

Remarks: S. Browne, _Dublin Q. J. Med. Sci._, 1849, vii. 496-499.

_Middle Region of Base of Brain and Floor of Skull._

94. Sex and Age: F. 35.

Clinical History: History of syphilis. Headache severe, at first with long intermissions; later, continuous, and often agonizing. Vomiting with paroxysmal headache, coming on late in illness. Vertigo, usually with headache. Excitable and irritable. Slight twitching of mouth, hands, and forearms. Left hemiplegia; upper as well as lower fibres of facial nerve paralyzed. Left internal strabismus. Electro-contractility diminished. Difficulty in enunciation. Sensibility diminished in left leg. Later, hyperæsthesia and great pain in paralyzed limbs. Conjunctivitis and necrosis of cornea of left eye; conjunctiva and cornea insensitive. Sight impaired. Descending optic neuritis. Hearing impaired on left side. Smell defective. Profuse perspiration, more marked on right side than on left. Constipation. Temperature, taken in right and left axilla for eleven weeks before death, gave the following averages: Right axilla, 99.1°, M.; 100°, E. Left axilla, 99.4°, M.; 101.4°, E. On some days remarkable falls in temperature to 96°, 95°, and even 94° and 93°. Average head-temperatures above the normal: for stations on right side of head averaging about 97°; on left side, about 94.3° F.

Pathology and Location: Gumma.

A twin-tumor, each mass about two-thirds of an inch in diameter, in front of the optic chiasm. The growths involved the basal termination of the corpus callosum, the peduncles of the corpus callosum, the lamina cinerea, and anterior perforated spaces. They also probably encroached upon the roots of the olfactory nerves, the optic nerves and commissure, and the anterior portions of the circle of Willis, which seemed to have been broken in front. The base of the brain, from the posterior line of the tumor backward to the pons, was markedly softened. Microscopical sections of optic nerves showed the appearances peculiar to descending neuritis in a somewhat advanced stage.

Remarks: C. K. Mills, _Philadelphia Medical Times_, March 23, 1879, in “Proceedings of the Pathological Society of Philadelphia;” also, _New York Medical Record_, Aug. 9, 1879, and _Arch. Med._, vol. viii. No. 1, Aug., 1882.

95. Sex and Age: F. 21.

Clinical History: Suffered for three years from excessive thirst and polyuria, with occasional vague pains in the head. A constant relation existed between the amount of fluid imbibed and of urine passed. Specific gravity of urine, 1002. No albumen nor sugar. Eight liters of urine passed in the twenty-four hours on an average. Slight headache and dimness of vision shortly before death; no other nervous symptoms. No ophthalmoscopic examination was made.

Pathology and Location: Sarcoma.

About the size of a chestnut at the base of the brain, at a spot corresponding to the sella turcica. It had caused complete degeneration of the optic chiasm, and had encroached considerably on the circle of Willis.

Remarks: F. Fazio, _Il Morgagni_, quoted in _Med. and Surg. Rep._, vol. xlii., May 8, 1880, p. 415.

96. Sex and Age: F. 73.

Clinical History: Suffered for several years from post-nasal catarrh, with enlargement of tonsils and granular pharyngitis. Fulness in right side of throat; muco-sanguinolent discharge from post-nasal space; bulging of soft palate. Severe pain through the right side of the head. Deafness of right ear and dimness of right eye. Mental failure. Paresis of levator palpebræ superioris and orbicularis; complete paralysis of external rectus; possibly slight paresis of the muscles supplied by the third nerve of the right side. Diminished sensibility of right half of face and cornea, and conjunctiva of right eye. Cornea opaque; conjunctival catarrh; vision almost nothing; ophthalmoscopic examination could not be made. Left {1089} eye showed some diminution in acuity of vision, with concentric narrowing of visual field; pigmentation.

Pathology and Location: Lobulated epithelioma.

Involved the cribriform plate of the ethmoid bone, the whole of the body of the sphenoid, and the anterior part of the basilar process of the occipital bone. These were softened to the consistency of cheese. Membranes and cerebral substance firmly adherent to the base of the skull at the inner portion of the bottom of the right cerebral fossa. Blood-clot in one of the large arteries of the optic papilla. Sclerosed blood-vessels. Atrophy of optic nerve and retina.

Remarks: W. Pepper, _Trans. of Philada. Path. Soc._ for 1878-79, vol. ix. p. 138.

97. Sex and Age: F. 25.

Clinical History: Headache (for six years), with vomiting. For three years had dimness of vision. For a year had blindness. Exophthalmus, with dilated pupils and fixation of eyeballs. Painful spasm of right face occasionally. Occasional paresis of left arm and leg, with pain. Severe vertical headache. Anosmia. Involuntary discharge of urine and feces. Convulsions. Stupor. No local paralysis of face or extremities. Death happened unexpectedly.

Pathology and Location: Cancer.

Tumor apparently springing from pituitary body, passing through infundibulum into right lateral ventricle. Tumor was “almost the shape and size of goose-egg.” It occupied anterior half of ventricle, and flattened out thalamus and corpus striatum. By pressure it had flattened the olfactory and optic nerves. The growth extended into the sphenoidal fissure, causing absorption of bone.

Remarks: Habershon, _Med. Times and Gaz._, 1864 (2), pp. 463, 464.

98. Sex and Age: M. 44.

Clinical History: No symptoms during life indicating any brain disease. The patient had died of phthisis.

Pathology and Location: Osteoma.

Consisting of true bone with Haversian canals, occupying position of infundibulum and corpora albicantia, which were totally absent. Not connected at all with dura mater. The pituitary body was apparently healthy.

Remarks: Bristowe, _Tr. Path. Soc. Lond._, vi. 25.

99. Sex and Age: F. —.

Clinical History: Intense supraorbital neuralgia. Paralysis of the 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.

In one case (31) an interesting observation was made of an anal sphincter reflex, with frequent stools. The tumor in this case is reported at the level of the tenth dorsal vertebra, which would be at the level of the eleventh dorsal segment. The tumor was tubercular, and therefore probably meningeal, so that the irritation to the anal centre, which is in the lumbo-sacral segment, may have been caused by extension of inflammation along the meninges.

PATHOLOGY.—We present in tabulated form the various kinds of tumors as found in the fifty cases which have been collected: {1097}

Aneurism . . . . . . . . . 1 | Myxoma . . . . . . . . 2
Cancer (?) . . . . . . . . 2 | Neuroma . . . . . . . 1
Carcinoma . . . . . . . . 1 | Organized blood-clot . 1
Cysticercus and hydatids . 3 | Osteoma . . . . . . . 1
Cyst (Dermoid?). . . . . . 1 | Phlegmon . . . . . . . 1
Fibroma . . . . . . . . . 5 | Psammoma . . . . . . . 2
Glioma . . . . . . . . . . 5 | Sarcoma . . . . . . . 7
Gumma . . . . . . . . . . 5 | Tubercle . . . . . . . 4
Myo-lipoma . . . . . . . . 2 | Unclassified . . . . . 6

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 {1098} 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.