THE Medico-Chirurgical Review, No. XXXIII. APRIL 1, TO JULY 1, 1832. I. A TREATISE ON THE INJURIES, THE DISEASES, AND THE DISTORTIONS OF THE SPINE; FOUNDED ON AN ESSAY TO WHICH THE JACKSONIAN PRIZE, FOR THE YEAR 1826, was ADJUDGED BY THE ROYAL COLLEGE OF SURGEONS. By R. A. Stafford, Surgeon to the St. Mary-le-bone Infirmary, &c. Octavo, pp. 302. London, 1832. MR. STAFFORD informs us, that his information on the subjects of which he professes to treat has chiefly been acquired at the bedside, from cadaveric investigations, or from morbid preparations. His arrangement is that proposed by the Jacksonian Committee of the College-first, the Congenital Diseases of the Spine-secondly, the Injuries-thirdly, the Diseases and Distortions of the Vertebræ-and lastly, those of the Medulla and its Membranes. Some of these subjects have been copiously discussed of late years, and little novelty can reasonably be expected from a fresh inquirer. Others, for instance the congenital malformations, are not likely, we suspect, to shine with any new or brilliant lights, whoever he may be, that ventures to bring them into public view. Perhaps a surgeon of great experience might communicate facts of which we are ignorant, and from them draw conclusions practically useful, respecting the injuries to which the spinal column is liable; but we doubt whether any young man can possibly do what Mr. Stafford confidently promises-compose a work on the diseases and injuries of the spine, which shall not be, for the most part, a compilation. We do not utter this opinion to derogate in the least from Mr. Stafford's merit, but we make the prediction with too firm an expectation, though not with any wish, of seeing it fulfilled. We shall pass without further preface to the examination of the volume. For the various malformations of the spine, Mr. Stafford particularly refers to the work of M. Ollivier. The first chapter, then, is on spina bifida, and, as it would be no disgrace to Mr. Stafford to pretend to no extended experience on a malformation comparatively rare, we find the best authorities freely quoted. As we have not space, however, for the opinions of those older writers, to whom diligent students and zealous inquirers can always refer, we shall pick out what new matter chances to present itself, and leave the remainder for the reader of the volume. The following short No. XXXIII. B extracts shew the seat of spina bifida, which is by no means confined to the lumbar region. "We now come to the seat of Spina Bifida; it has been usually described as a lumbar tumor, but it may occur in any part of the spinal column, from the cervical portion to that of the sacrum, and various authors relate well-authenticated cases where each part, and sometimes the whole of the canal, has been defective and involved in the disease. It is not necessary, however, to cite these cases; we have examples sufficient of a later date, and our museums teem with preparations illustrative of this fact. In some we see the whole spine defective in its spinous processes and rings; in others, two parts of the column are malformed, leaving the intermediate space perfect, and in others again, the cervical, the dorsal, lumbar, and the sacral. The cause of this imperfection of the vertebræ must be no doubt owing to the cessation of ossification, and to the imperfect closure of their rings during utero-gestation, and this is precisely analogous to all those malformations which originate from the want of union of the two halves of the fœtus while in progress of formation; such as a portion of the back part of the occipitis being deficient, cleft palate, hare-lip, and an incomplete junction of the parietes of the abdomen at the linea alba. Spina Bifida is often combined with one or other of these anomalies, and there is a preparation in the College of Surgeons which well illustrates the analogy between them. In the same fœtus, there is spina bifida in the dorsal region, and an incomplete closure of the parietes of the abdomen, and thus the peritoneum and the intestines protrude." 12. "This fluid is most frequently contained between the arachnoid membrane and pia mater, but occasionally it has been known to exist between the arachnoid membrane and dura mater, and sometimes between both at the same time. Portal, with others, speak of its having been contained in a canal which they all assert exists in the substance of the medulla; but the correctness of this fact is doubted by anatomists. In all those cases which were drawn on purpose to represent the distribution of the nerves, the fluid was contained between the arachnoid membrane and pia mater; but in drawing I. it existed in separate cells or cysts. In this case, when the tumor was punctured, all the fluid was not evacuated at once, but there remained behind small distended bladders of it, unconnected with the common cyst. This was seen more particularly in one on the right side, which being itself about the size of an orange, was obliged to be punctured, to let out its contents. Upon examining the tumor after death, there were found two large cysts, and a number of smaller ones, about the size of a pea, existing in the parietes of the tumor. The large cavity in drawing No. I. was no doubt the common cyst connected with the vertebral canal, with its neck, or the part joining immediately with the spine, filled up by newly-organized lymph, and thus closing up the communication. The smaller one of the two was quite impervious, and its internal surface was smooth; it appeared to be continuous with the external membrane, or what would have been the dura mater of the other cyst; and it is probable that it had been connected originally with it, and afterwards closed up, and then, if this conjecture be right, the fluid must have escaped through the arachnoid membrane and dura mater. The other cells also were quite impermeable, and it would be almost impossible to account for their existence." 18. In order to appreciate the value of any proposed plan of treatment, as well as to avoid rash measures on his own part, the surgeon should be aware of the condition and disposition of the spinal nerves in this complaint. "In spina bifida it appears that either part or all the filaments which form the posterior spinal nerves, corresponding to the solution of continuity of the vertebral canal, are distributed upon the internal walls of the tumour, and that they generally terminate there. These arise from the cord in various ways; sometimes only by single filaments, which pass out of the aperture of the canal through the fluid contained in the tumor, unattached to any thing until they arrive at its parietes, where they are dispersed. This is particularly well illustrated by the drawing,* No. V. fig. 1; here we see two of the nerves arising and distributing themselves in this manner. Sometimes, again, the posterior spinal nerves come out of the opening in the canal, and instead of going straight through the fluid, pass round the internal surface of the tumor, and thus form a network of nervous filaments. Burgius mentions a case of this description, where the internal surface of the tumor was so surrounded by nervous columns and fibres, that it resembled the internal structure of the auricles and ventricles of the heart. In other cases there arises a kind of peduncle in the middle of the tumor, of a nervous mass, resembling a mushroom, of which the stalk is formed of filaments of nerves bound together by cellular tissue, and the head by their extremities spread out and ending upon the upper and internal surface of the tumor. Brunner has particularly taken notice of this variety of distribution; and from the drawing,† No. V. fig. 2, one would almost imagine he was alluding to the same case. The posterior spinal nerves, which are distributed upon the internal walls of the tumor, do not always pass through the aperture connected with the vertebral canal; but sometimes they pierce as it were the tumor, and then distribute themselves on the internal surface. There are two preparations of this description in Mr. Llangstaff's Museum; in the one they pierce the tumor at its back part, and pass straight through the fluid; in the other they also pierce the back part of the tumour, but they immediately curl round its walls. There appears to be some degree of regularity of the distribution of the nerves when spina bifida occurs at the upper part of the canal; for here the posterior nerves are only involved in the disease, whilst, at the lower portion, the whole cord is continually influenced by it. Thus we see in some cases only a few nervous filaments erring in their course, while in others we find the whole bundle of nerves, which form the cauda equina, going out of the canal and attaching themselves to the top of the tumor, and returning into it again, as may be observed in drawing‡ V. fig. 3. Sometimes, again, we find that the whole of the medulla is brought out of its course through the aperture of the canal, and that it completely ends in the tumor, leaving the canal below quite hollow. Various authors, among whom are Brunner, Hoin, Apinus, and Sandifort, relate cases of this description; and, no doubt, if the owner of the preparation from which the drawing V. fig. 2, was taken, would permit a farther dissection to be made of it, we should find the canal of the sacrum quite hollow, and that the peduncle in the middle, and the nerves around, was the whole of the cauda equina terminating in the tumor; for it so exactly resembles that case before mentioned, described by Brunner, that one naturally would expect to find the same result. It does not appear, however, that the medulla, or the lower part of the canal, always deviates from its course, or that the nerves are altered in their distribution; for it may occasionally be seen that no alteration whatever takes place, and that neither itself nor its nerves are changed either in their arrangement or in their structure. This is exemplified by drawing V. fig. 4.§ Here we see the bundle of nerves, forming the cauda equina, following their usual course. The medulla spinalis also in spina bifida, at the part where the malformation of the canal occurs, becomes changed in its structure in various ways; sometimes it has been found inflamed-sometimes not so large as natural-and sometimes * Vide Drawing in the Library of the College of Surgeons, and Preparation, Museum St. Bartholomew's Hospital. t Ibid. B2 + Ibid. § Ibid. of a firmer consistence; sometimes, again, it has been rendered completely soft -and at other times has been found altogether deficient." 25. The remedial means proposed or adopted for this formidable complaint have been, ligature-seton-compression-and puncture with compression. The two former were proposed by Mr. B. Bell and Dessault; there are many obvious and serious objections to their employment. The two latter were recommended by Mr. Abernethy, and have frequently been employed. Compression is a palliative measure, and has proved no more. Puncture, with compression, appears to promise rather more, but we must not expect much from any treatment. A short time ago we saw a young girl, apparently, if our memory serves us, some fourteen years of age, who had had spina bifida since infancy. The tumour was in the sacral region, about the size of an orange but flatter, with thin but not inflamed parietes. The girl was in good health, though of strumous appearance, and seemed to suffer little inconvenience from the disease. We believe that compression and puncture had been tried, but latterly all applications were abandoned, and the tumour was not on the increase. We shall now mention some cases related by Mr. Stafford, as they will convey more information on such a point than descriptions. CASE 1. Dec. 10, 1826. Mary Cotterell, aged 11 days, has a large swelling situated over the whole of the posterior surface of the sacrum. It is 14 inches in circumference, tense, elastic, evidently containing fluid. The integuments on the right side are very much inflamed, and at several parts of it, points of ulceration have commenced. The child is healthy and seems to suffer little. The swelling was one-third less at birth, and has been daily increasing. As the fluid must soon have escaped from the progress of the ulceration, the tumour was punctured with a needle. By the next day a few drops only of fluid had escaped, and a small opening was therefore made with a lancet, and about two ounces of straw-coloured serum drawn off. Stickingplaster was applied over the opening. 14th. Tumour again punctured, and nearly three ounces of fluid discharged. 15th. Plaster removed, and two ounces allowed to escape-redness diminished, and integuments beginning to contract. 18th. Tumour more distended, and its parietes considerably thickened; two openings made, and a little blood discharged. 20th. Swelling almost as great as at first; small trocar introduced, and 4 ounces of bloody serum drawn off; parietes of tumour found very much thickened; child restless. 22d. Tumour less inflamed and distended; four ounces of thicker fluid, mixed apparently with pus, drawn off by trocar; two or three strips of plaster applied tightly over swelling, with roller round body. Child easier since 20th. 26th. Improved; tumour evidently decreased, and parietes thickening; almost all the fluid evacuated to day; it is fetid, with small flocculi-straps and roller re-applied. 28th. Two ounces of fetid fluid drawn off. From this time till the 8th Feb. small quantities of fluid were occasionally drawn off, fetid at first, thin and serous afterwards; the tumour decreased, its parietes thickened, and the child's health improved. On the 8th, the child was found to have pyrexia, with costive bowels. Aperients and antimonials were ordered, and in three days the child died in convulsions. The tumour was now only an inch above the level of the surrounding parts, and was nearly solid; the integuments were corrugated over it. Sectio Cadaveris. "On making a division of the tumor, along the course of the spine, there was found to be a deficiency of part of the rings and spinous processes of the two last lumbar vertebræ, and the space had been filled up by newly-organized matter. The walls of the tumour, were from about half an inch to an inch and a half in thickness, in different parts of it. The cavity itself of the tumor was complete without any adhesions, and about two inches in diameter; its internal surface was very irregular, having a thickish coating of lymph upon it; besides which, two or three layers of organized matter could be peeled from the part beneath. Upon making a minute dissection of the neck of the tumour, two filaments of nerves could be traced through the newly-organized lymph from the medulla spinalis into the cavity of the tumor, as seen in the drawing, No. III.* The parietes of the tumor were condensed and thickened; and in the substance of the newly-organized matter were found little cavities, about the size of horsebeans or peas, containing a limpid fluid; and the skin covering the tumor was much corrugated and thickened. At the upper part of the tumor, immediately beneath the skin and cellular substance, were observed two or three strata of condensed membrane, about the thickness of a five-shilling piece; this is beautifully shewn in the drawing, No. IV.† ; it had no doubt been the original boundary of the cavity of the tumor in which the fluid had been contained, and most probably was composed of arachnoid membrane and dura mater. From this original wall to the cavity of the tumor was the newly-organized matter, which, in different parts of it, was from half an inch to an inch and a quarter in thickness. On the right of this cavity there was another cyst, composed of a substance like thickened dura mater, about the size of a billiard-ball, quite impervious, and its internal surface smooth; the wall of this cyst could be traced into, and appeared to be a continuation of the external layer, or what would be the dura mater of the other tumor. This cavity was probably formed between the arachnoid membrane and dura mater, as on dividing the septum between the two, it was much thinner than the original parietes of the other cavity, and appeared to be bereft, as it were, of one layer of membrane. Here we may observe that the process by which the soft parts become consolidated, is very gradual; before this tumor was punctured, its parietes were nearly as thin as a bladder, and were much distended, being fourteen inches in circumference. For the first three times after puncture the tumor became as much distended as before, and but little alteration of its walls was perceived; but upon the fourth, fifth, and sixth days, the parietes began to thicken, and at length to contract, and so on until the 11th of January, when the tumor was evidently much diminished in size, and the adhesive inflammation going on. From this time till the 1st of February, a gradual thickening of the parietes, and diminishing of bulk of the tumor, was taking place, when, in a few days, the child died of fever, and the appearance of the tumor was exactly the same as represented in the drawing No. II." 41. With respect to the treatment, and the mode in which that treatment operates, Mr. Stafford makes the following remarks. "From the history and dissection of this case, as well as of those treated by Sir Astley Cooper and others, we may safely come to the conclusion that repeatedly puncturing the tumor, so as to let out the fluid as often as it * Vide Drawing in the Library of the College of Surgeons. t Ibid. 1 Ibid. |