A CONTRIBUTION TO THE STUDY OF 
TUMORS OF THE SPINAL CORD 
BY 
B. SACHS, M.D. 
Instructor in Diseases of the Mind and Nervous System at the New York Polyclinic 
Member of the American Neurological Association 
[Reprinted from the Journal of Nervous and Mental Disease, vol. xiii. 
No. ii, November, 18S6] A CONTRIBUTION TO THE STUDY OF TUMORS 
OF THE SPINAL CORD* 
By B. SACHS, M.D. 
THE study of tumors of the spinal cord and of its 
meninges has been considerably neglected of late 
years. This neglect must be attributed in part to the 
general belief (which I shall not be able to discredit) that 
it is difficult to establish a differential diagnosis between 
tumor and other chronic affections of the spinal cord, and 
that the close study of these tumors is, therefore, of little 
practical value. No less an authority than Erb1 expresses 
this opinion. The difficulties become still greater when we 
attempt to differentiate clinically between tumors of the 
spinal meninges and tumors of the spinal-cord substance. 
The latest authors on this subject, (Drs. C. K. Mills and J. 
Hendrie Lloyd3) have abandoned the attempt altogether. 
The great interest now being felt in syringomyelia will 
probably direct attention once more to the symptomatology 
of spinal tumors, for there is no doubt that there is an inti- 
* A preliminary report on the case here reported was made before the N. Y. 
Neurological Society at the stated meeting, April 6, 1886. Numerous other 
duties have prevented the earlier publication of this paper. 
1 Ziemssen’s Handbuch. Erb : “ Diseases of Spinal Cord,” vol. xi., 2, p. 
340, Germ. ed. 
1 Pepper’s System of Medicine, vol. v., p. 1091. 
Reprinted from the Journal of Nervous and Mental Disease, Vol. xiii„ 
No. ix, 1886. 2 
B. SACHS. 
mate clinical (and probably also pathological) relation be- 
tween these two forms of spinal disease. 
Those who will not be satisfied to pursue clinical studies 
unless some practical good shall be the outcome of such 
studies, should recognize the importance of differentiating 
for purely therapeutic reasons, if for no other, between 
chronic transverse myelitis, for instance, and tumor. Every 
case of tumor of the spinal cord, if verified by post-mortem 
examination, may help to clear up the mystery surrounding 
the symptomatology of these diseases. The case which I 
propose to discuss has special claims upon our attention for 
the following reasons, i. It was a tumor of the spinal-cord 
substance without involvement of the spinal meninges. 2. 
The. tumor gave rise to the first and most prominent symp- 
toms of a general tubercular diathesis. 3. The myelitis 
following in its wake was of unusual severity. 4. The case 
presented unusual sensory symptoms.—First, as to the 
history of the case : 
F. F., aged thirty-two, a man of considerable intelligence, 
unmarried, a dealer in bric-a-brac, presented himself at the 
Polyclinic for the first time on February 7, 1886. He com- 
plained of pains and weakness in his left arm, of inability to 
move the fingers, and of the glossy appearance of this left 
hand. The man was made the subject of a clinical lecture, 
in the course of which I elicited the following details : He 
was born in Brussels, where he lived until he came to this 
country six and a half years ago. His mother had epileptic 
fits consequent upon a severe mental shock ; cause of her 
death unknown. The father, a physician, was a heavy 
drinker, and died at the age of forty-two ; some heart 
trouble the immediate cause of his death. The patient has 
several sisters and brothers, all of whom are enjoying good 
health. Patient himself had typhoid fever when six years 
old; no venereal diseases, except gonorrhoea ; syphilis ab- 
solutely denied; acknowledges excessive sexual and al- 
coholic indulgence for many years ; he was in the habit of 
drinking daily from twenty to thirty glasses of beer, and 
had a special fondness for absinth. Two years ago he had 
a severe attack of articular rheumatism, which affected all TUMORS OF THE SPINAL CORD. 
3 
the joints of his extremities, and kept him in bed for some 
weeks : states that he has had rheumatic pains ever since. 
History of Present Trouble.—Four weeks ago (about Janu- 
ary 8th) he felt what he termed rheumatic pains in the left 
shoulder; these moved down to the left arm ; the hand 
grew weaker after the lapse of a week or more, and as the 
weakness increased, the fingers became puffy and the skin 
glossy. 
Present Condition.—Feb. 7th.—The patient has a glutton- 
ous and rather bloated look, but otherwise of excellent 
physique. On comparing the two arms, we observed that 
both arms could be raised above the head, but in dropping 
them the left arm dropped more readily than the right; the 
upper arm and forearm offered considerable resistance to pas- 
sive movements, and were in marked contrast to the muscu- 
lar power of the hand and fingers, which was almost nil; the 
fingers were slightly flexed ; voluntary extension or further 
flexion was impossible. The sensory disturbances were 
even more marked; there was hypersesthesia of the entire 
fore-arm and hand, which was greatest, however, over 
the distribution of the ulnar, and particularly over the 
outer dorsal surface. The mere touch with the finger 
was painful; the prick with the pin was so disagreeable 
that the sesthesiometer test had to be abandoned ; cold 
water dropped on the arm produced excessive pain (this 
the patient had noticed in washing also). Pressure with 
the finger over ulnar and radial nerve was objected to, 
whether or not in consequence of the cutaneous hyperaes- 
thesia, it is difficult to say. The vaso-motor or trophic 
symptoms noticeable during this first examination were a 
swelling of the skin between the joints of all the fingers of 
the left hand and a peculiar oedematous appearance of the 
skin of the entire hand including fingers. The electrical 
conditions were quite normal. Both nerves and muscles 
responded to faradic current of moderate strength; in con- 
sequence of hypersesthesia this examination had to be 
made hastily. The galvanic reactions were entirely normal; 
no unusually weak or strong currents were required to pro- 
duce contractions, and the order of contractions was not 4 
B. SACHS. 
reversed in the case of any nerve or muscle of the left arm. 
There was no ataxia in lower extremities ; no incoordination 
of movements in right arm; superficial reflexes could not 
be elicited, except, possibly a very slight scrotal reflex on 
right side. The other parts of the body were subjected to 
a careful examination; there were no other symptoms dis- 
coverable, except these: i. A slight dragging of the left 
foot, but no very marked diminution of gross muscular 
power, as tested when the patient was lying on his back. 
2. An increase of both knee-jerks, and presence of ankle 
clonus on both sides. In view of this peculiar complexity 
of symptoms, a definite diagnosis was not attempted at this 
time. 
In the course of the next two weeks I saw the patient at 
irregular intervals. During this time the symptoms in the 
left upper extremity remained unchanged. From February 
15th on (about a week after first examination) the impair- 
ment of power in left leg became more noticeable ; this in- 
creased until February 26th, when the patient could move 
the left leg with the very greatest difficulty only ; resistance 
to passive movements almost nil; the loss of power was 
distributed equally over thigh and leg. The right leg re- 
mained normal. In addition to the other symptoms general 
hvperaesthesia of left leg had been developed, but the vari- 
ous forms of sensibility in right leg was in no wise im- 
paired (tested with aesthesiometer points and cotton). Sub- 
jectively there was no pain in left leg, but a feeling of cold 
throughout the entire left lower extremity. These uni- 
lateral symptoms continued uninterruptedly until March 
2d (three weeks after first examination). 
In order to make a complete examination, I arranged to 
examine the patient at my leisure in the office. Up to 
Feb. 26th he had succeeded in walking about with the aid 
of a stick. March 2d he could walk about only with the 
support of a friend. 
On this day, March 2d, his condition was noted as fol- 
lows : no head symptoms ; pupils equal, and react promptly 
to light and during accommodation ; all ocular move- 
ments perfect; tongue straight when protruded ; no dis- TUMORS OF THE SPINAL CORD. 
5 
turbances in articulation or deglutition; no headache; 
sleeps well ; no atrophy of any muscles of body ; can raise 
both arms fairly well, but left arm behaves as on first ex- 
amination ; no changes as regards either upper extremity 
since first examination ; can still offer considerable re- 
sistance to passive movements with left upper arm and 
forearm ; the fingers are completely motionless, possibly in 
consequence of pain, and swelling of the skin ; no inco- 
ordination of movement of right arm ; pricking of pin felt 
as distinct pain over distribution of 1. ulnar nerve ; a cold 
sponge passed over this area causes him to cry out with 
pain ; fingers as puffy as ever ; no reflexes to be elicited in 
this upper extremity. Faradic response from nerves and 
muscles fair to moderately strong currents ; on this day 
galvanism was not tried. Left leg extremely paretic ; he 
can stand on it without using stick, but in trying to move it 
requires additional support ; his left leg, he states, feels 
like a piece of wood on a string, by which he means that it 
is entirely beyond his control; he cannot tell whether his 
foot is right in the shoe or not ; there is continued hyper- 
aesthesia of whole leg ; patient stated to-day for the first 
time that his right leg is growing weaker also, and on ex- 
amination resistance to passive movements in the leg is 
found to be diminished as compared with the condition of 
the right leg at the preceding examination ; he complains 
also of weakness of abdominal muscles ; cannot press pro- 
perly when he goes to stool ; sensation in right leg not dis- 
turbed at this time. The patient was urged to have him- 
self taken into hospital ; he had his own peculiar reasons 
for not wishing to go there. I ordered him to go home, and 
to remain strictly in bed, and put him on increasing doses 
of the iodides of potassium and sodium. I endeavored to 
have him as well cared for as his poverty-stricken surround- 
ings would permit. I saw him again two days later, and 
found him, contrary to my orders, sitting upright in a chair, 
smoking a pipe, reading a French novel, and hopeful that 
he would be all right in a few days. With the aid of chairs 
he moved toward the bed; his left leg could barely be 
dragged along; sitting on the edge of the bed he was this 6 
B. SACHS. 
day able to swing himself around, and to lift the left leg 
into bed with the assistance of the right. The left arm in 
statu quo; fingers slightly flexed, but flexion can be easily 
overcome, though the mere touch of the fingers, and par- 
ticularly of the finger-tips, causes intense pain. Forearm 
and hand tested again with aesthesiometer ; number of points 
could not be readily distinguished, as the pain-impressions 
were predominant on entire dorsal and volar surfaces ; cold 
water as painful as ever ; left leg cannot be lifted at all 
from bed. Muscular sense grossly at fault; cannot esti- 
mate the distances to which left leg has been raised from 
bed ; acknowledges his surprise when he opens his eyes and 
sees where his leg is ; gauges the position of right leg very 
accurately ; marked hyperaesthesia to touch or cold over en- 
tire left lower extremity; knee-jerks and ankle clonus about 
as before. One symptom which I observed this day deserves 
special notice. A plantar flexion of the left foot produced 
distinct contractions of the tibialis anticus ; once or twice 
this flexion movement was followed by a distinct ankle 
clonus, which was therefore evoked in a way diametrically 
opposed to the customary method. This contraction of the 
tibialis anticus I was inclined to regard at the time as an in- 
stance of paradoxical contraction, though this contraction 
generally ensues when the extreme ends of a muscle are 
approached to one another, and not removed from one 
another as they are in this case. Prof. Westphal,1 in a 
recent article on a curious group of symptoms associated 
with sclerosis of the posterior columns, refers to a para- 
doxical contraction produced in this way. I did not suc- 
ceed in producing this phenomenon in the course of subse- 
quent examinations. 
March 9th.—No marked change in the symptoms as de- 
tailed above, except that incontinence of urine has set in ; 
patient feels that he is growing worse. Left arm unchanged ; 
left leg absolutely paralyzed, and the right growing rapidly 
weaker; is not well able to use his right leg in lifting the 
left into bed, as he was two days ago. While there is still 
marked hyperaesthesia of the left leg, there is no percep- 
1 Arch. f. Psych., vol. xvi., 1885. TUMORS OF THE SPINAL CORD. 
7 
tible sensory disturbance on right leg. Muscular sense dis- 
turbed as above. On the trunk of the body, the limit of 
hyperaesthesia extended, exclusively on left side, as high up 
as level of third rib. Examined with electrical current 
again: no change in galvanic reactions, and faradic re- 
sponses from nerves and muscles of all extremities prompt 
to currents of moderate strength; even the ulnar responded 
in this way. 
March nth.—A slight cough, which the patient has had 
for a few days past, begins to annoy him as he has not suffi- 
cient muscular power to expectorate freely. Lungs and 
heart examined as carefully as the now helpless condition 
of the patient would permit: there were the usual catarrhal 
rales but no other physical signs of any import could be 
made out ; the action of the heart was rather feeble, but 
sounds were clear. The paralysis has markedly increased ; 
the patient is totally unable to move himself in and out of 
bed ; when raised in bed he complains of weak back; the 
head can be moved well from side to side, but not so 
well from before backward. There is some tenderness on 
pressure over the seventh cervical vertebra, and when the 
head is moved backward the pain is stated to be at the level 
of the vertebra and along both trapezii. The left hand un- 
changed ; but the grasp of the right hand is far weaker than 
it was, and the patient states that there is now also a numb- 
ness over the dorsal surface of right forearm. No puffiness 
of the fingers of the right hand ; the right leg has be- 
come very much more paretic; even this leg can now be 
lifted but three or four inches from the bed ; the muscular 
sense, as tested by raising leg from bed, is beginning to 
be impaired on right leg also ; the hyperaesthesia of left leg 
and of the left side of trunk as high up as seventh rib is 
giving way to loss of tactile sensibility; there is an area of 
hyperaesthesia still between seventh and third rib on left 
side. Tactile sensibility of back well preserved. Tenderness 
to touch most marked on the outer dorsal aspect and the 
whole of the volar surface of the forearm. Touching finger- 
tips with pin produces intense agony. (Eyes remain closed 
during test). Warm water applied to back does not excite 8 
B. SACHS. 
pain at any particular point. No bed-sores though there is 
slight reddening of skin over sacrum. Weight-sense was 
tested without any satisfactory results. Bowels have not 
moved in several days. Two days later, the only changes 
noticeable were the increasing paresis, amounting to com- 
plete paralysis of right leg, and a suspicious redness of the 
skin over the internal malleolus of the right foot, against 
which the left foot had pressed. Knee-jerks are still exag- 
gerated, though not as markedly so as they were; ankle 
clonus is not as easily excited as in the past. 
The day following, March 14th, I invited Dr. Starr to 
visit the patient with me. Our notes made independently 
agreed in all particulars and brought out the following facts 
regarding disturbances of sensibility. The hypersesthesia 
had given way still further to a gradually increasing anaes- 
thesia to touch ; while the hyperaesthesia had been confined 
exclusively to the left extremities and to the left half of the 
trunk, the anaesthesia now involved both sides of the body, 
but not all parts equally ; the only parts which at this time 
retained normal sensation were the neck, face, and head. 
Left arm and hand: persistent hyperaesthesia to mere 
touch, to hot and cold ; cold produced the greater pain ; 
warm was painful also but was recognized as “ warm ” 
(in these tests, a silver spoon dipped alternately into hot 
and cold water was used). Left leg : sensation to touch 
below the knee almost wholly abolished; above the knee 
very nearly abolished ; light touch of the finger and strok- 
ing with cotton were not perceived ; the finger drawn across 
thigh was felt and direction in which it moved was correctly 
stated. The following day touch of finger was perceived on 
dorsal surface of both feet; hot or cold could not be 
appreciated. 
Temperature sense distinctly altered ; heat was not felt, 
cold produced pain ; muscular sense (sense of position of 
muscles) entirely abolished. Right leg : sensations of touch 
and of pain more acute than in left leg, but less acute than 
in right arm and in face. Heat could not be appreciated 
while cold was painful; muscular sense far better than in 
left leg, but nevertheless considerably impaired. Trunk : TUMORS OF THE SPINAL CORD. 
9 
left side, which was at one time hyperaesthetic, has had its 
sensation to touch and pain somewhat dulled ; the cotton 
and pin tests were felt, and correctly located, but were not 
as distinctly felt as on the right side of the median line. 
Heat and cold could not be appreciated as such on left side, 
but were recognized on right side. Scratching left side of 
abdomen with a pin produced more redness than on right 
side. R. arm : much more sensitive to touch than left, yet 
the sensations were not as acute as on the neck and in the 
face. Muscular sense well preserved. In left arm it could 
not be tested, as the mere attempt to move any finger or 
the whole hand was exceedingly painful. Next day, no dis- 
tinct tenderness could be perceived over any part of spinal 
column ; cotton was perceived equally on both sides of 
back. The motor disturbance had increased to a complete 
paraplegia ; in the 1. upper extremity grasp of hand 
and all movements of hand almost nil, but patient retained 
considerable power in the pectoralis, deltoids, biceps, and 
brachialis; grasp of right hand much weaker than it has 
been ; abdominal muscles almost powerless and action of 
inspiratory muscles of thorax very weak ; complete relaxa- 
tion of muscles of back ; head could be moved freely in all 
directions; all ocular and facial movements perfect. The 
knee-jerks and ankle clonus not as marked as they were; 
cutaneous reflexes could not be elicited. 
I saw the patient again and for the last time two days later. 
No marked change had taken place. I took occasion to 
make an ophthalmoscopic examination of the eyes which I 
neglected to do in the earlier history of the case, but could 
detect no important changes. I may say again that the 
man continued reading in bed until a few days before 
death, and in answer to my questions invariably stated 
that vision was good. A few statements, which were not 
included in this chronological record of the case, will help 
to complete the history. The temperature was taken at 
different times during my visits and was never found to 
have exceeded in the axilla ; this would of course not 
exclude possible rise of temperature at other times; my 
visits were made generally late in the evening. Pulse small B. SACHS. 
and accelerated, often about 120. Respiration varied very 
much, generally about 25 ; on the last day I saw him they 
had gone up to 45. The urine was examined several times 
and found free from sugar and albumen. There was no dis- 
tinct history of night-sweats ; but according to his statement 
the patient had for a long time been subject to unilateral 
sweating of the right side. At the very first examination 
the beads of perspiration on the right side had attracted 
my notice. 
The patient’s objections to being taken to a hospital were 
finally overcome, and he was removed Wednesday, March 
17th, to the German Hospital. He arrived there feeling 
weak, but not particularly exhausted. On Thursday morn- 
ing about seven o’clock, he asked his neighbor in the ward 
to read a newspaper to him ; while this was going on, the 
patient died, and quietly at that, for his neighbor con- 
tinued reading until an attendant who stepped up to the 
bed found the man dead. 
Summarizing the main points in the history of this case, 
we may say that the trouble, which was supposed to be 
rheumatic, began with pain in the left shoulder which radi- 
ated down into the arm ; the pain became more intense, 
and for the first was confined chiefly to the area of the ulnar, 
spreading later on over entire dorsal and volar surface of 
left forearm and hand ; in addition to this hyperaesthesia 
and to puffiness of the fingers, we found considerable weak- 
ness of grasp in the left hand, with only slight loss of power 
in the muscles of the arm, forearm, and shoulder. The con- 
dition of this left upper extremity remains unchanged 
during the whole course of the disease—a period of about 
two months. A slight paresis, some hyperaesthesia of the 
left leg, exaggerated knee-jerks and ankle clonus were the 
only other symptoms discovered during the first few weeks 
of the disease. These symptoms, chiefly unilateral, con- 
tinued so until the close of the seventh week. Meanwhile 
the paresis of the left leg had developed into an almost 
complete paralysis, and the unilateral paresis is transformed 
in the eighth week to a complete paraplegia. The motor 
paralysis increasing affects also the abdominal muscles, and TUMORS OF THE SPINAL CORD. 
to some extent the respiratory muscles and the right upper 
extremity. Incontinence of urine and bed-sores were super- 
added. As for the sensory disturbances, there was devel- 
oped by degrees a general hyperaesthesia of the left half of 
the body below the level of the third rib ; this hyperaesthe- 
sia was changed later on into an anaesthesia which spread 
from the left half and finally involved the right leg and, to 
a lesser degree, the right half of the trunk and the right 
upper extremity. 
Now as to the interpretation put upon these symptoms 
during life. That the symptoms of the last two or three 
weeks were those of a cervico-dorsal myelitis there could 
be no manner of doubt, but the troublesome question 
was to decide the origin of the myelitis and to ex- 
plain the persistent hyperaesthesia and paresis of the left 
upper extremity, coupled as these were, strangely enough, 
with slight paresis of the left leg and with exaggerated 
knee-jerks and ankle clonus on both sides. With the ex- 
ception of these reflex movements, all symptoms were 
strictly unilateral for nearly four weeks after first examina- 
tion. At the outset I was inclined to the belief—and in 
view of the patient’s rheumatic record it was not an irrational 
one—that his was one of those rare afflictions, so rare that 
their existence may still be questioned, of an ascending 
neuritis giving rise to a myelitis. I soon abandoned this 
diagnosis, for the condition of the electrical reactions and 
the slight amount of, and unequally distributed, paresis made 
one rather sceptical as to the existence of a neuritis, and I 
could not imagine a myelitis spreading across the cross- 
section of the spinal cord so slowly that it should for weeks 
give rise to unilateral symptoms only. It was my surmise 
that a lesion involving the posterior root-fibres of the lower 
cervical segments could possibly explain all symptoms, but 
to the nature of the lesion I had no direct clue. Giving pa- 
tient the benefit of the doubt, from the wild life he had been 
leading I suspected the possible existence of a gumma in 
this vicinity, but the therapeutic results did not strengthen 
this suspicion. Tubercular disease, or any cachectic diathesis, 
I did not suspect; the physical signs were certainly not 12 
B. SACHS. 
marked enough,1 and the general appearance of the man, a 
strapping fellow, did not point that way. The autopsy has 
cleared up the mystery, and after I have given a short 
account of the post-mortem appearances, it will be in order 
for us to inquire whether this case furnishes sufficient points 
for a differential diagnosis between tumor and other affec- 
tions of the cord. 
Post-mortem Examination. 
The autopsy was made eight hours after death by Dr. 
YValdstein, pathologist to the Hospital ; the microscopic 
examination of the cord was made by the writer. 
The skull was thickened but symmetrical. The dura 
mater was easily detached from the brain, except over 
parietal vertex, where it was slightly adherent to the pia. 
The sinuses were well filled ; the vessels of the pia were 
somewhat more congested than normally. All blood-vessels 
were found normal in structure. No hemorrhage into the 
brain-mantle or the subcortical ganglia, and no malignant 
growths anywhere in the brain. The convolutions were a 
trifle narrrow, but not otherwise changed. 
No disease of the vertebrae. The spinal dura appeared 
entirely normal. The cord with its meninges was removed 
easily, except at its upper end. On opening the dural sac, 
a large amount of fluid escaped, and the vessels of the pia, 
along the entire length of the cord, were seen to be greatly 
congested. The lower portion of the cord exhibited no 
macroscopic changes except innumerable calcareous (not 
tubercular) deposits scattered over the pia of this portion of 
the medulla spinalis. 
The chief trouble was evidently limited to the lower 
cervical and upper dorsal segments. From the seventh 
cervical to the fourth dorsal segment the cord appeared to be 
a diffluent mass, revealing no trace of structure. Through- 
out this softened portion of the cord, whitish nodules 
appeared to be scattered here and there. As soon as the 
cord was partially hardened it was evident that the myelitis 
1 The very frequent respiration in the latter stage of the disease might have 
been caused by direct interference with the respiratory nerves. TUMORS OF THE SPINAL CORD. 
13 
had involved the posterior columns, part of the gray matter, 
and a small portion of the lateral columns, leaving perhaps 
half of the area of the lateral columns intact, as well as the 
anterior (ventral) portion of this region of the cord. Be- 
tween the sixth and seventh cervical segments (area de- 
termined by the character of the emerging root-fibres) we 
found a round tumor of the size of a hazel-nut pressing 
closely upon the emerging posterior fibres, without displac- 
ing these, and extending inward as far as the median line ; 
at its caudal end the tumor had exceeded the median line 
by a small fraction of an inch. The dura and pia had been 
readily detached from the spinal cord at the level of the 
tumor. There were no visible changes in the dura or pia 
except that a few very small tubercular deposits were found 
in the pia over the middle dorsal region. 
The tumor consists of an outer harder portion, encircling 
a soft, cheesy mass within. Inspection of the cross-section 
of this tumor in a comparatively fresh state, and later 
microscopical sections, proved this tumor to be a typical 
solitary tubercle of very respectable dimensions. Although 
the tumor takes up the entire thickness of the cord (dorso- 
ventrad), the amount of destruction is not as great in its 
immediate vicinity as it is at a level about one inch caudad 
of the lower end of the tumor. Unfortunately I am not 
able to state how far cephalad this myelitic process ex- 
tended, for, on removing the cord, this part was somewhat 
(perhaps unavoidably) lacerated. It is surely speaking within 
bounds to say that the myelitic process stopped short at 
about the third cervical segment. On the fresh cord no 
positive evidence of ascending or descending degeneration 
could be discovered. A portion of the left ulnar, median, 
and radial nerves were removed for microscopic examina- 
tion ; but the result was an entirely negative one. 
For the rest, the autopsy revealed very minute tubercular 
deposits scattered here and there throughout both lungs; 
in both apices there were incipient cavernous spaces ; there 
were also old pleuritic and pericarditic adhesions. The 
valves and tissues of the heart proper were entirely normal. 
In the intestines there was evidence of a general miliary 14 
tuberculosis. Spleen was enlarged ; liver and kidneys were 
normal. No evidence of alcoholism and none of syphilis. 
The post-mortem diagnosis would read : General tubercu- 
lar diathesis, with chief deposits in spinal cord, lungs, and 
intestines. In the spinal cord a solitary tubercle followed 
by a cervico-dorsal myelitis. 
B. SACHS. 
Microscopical Examination of Spinal Cord. 
For this purpose the cord was suspended at once in 
Muller’s fluid. It was watched most carefully, the fluid was 
changed frequently, and yet the hardening was not entirely 
satisfactory. The myelitic portion could not be rendered 
fit for cutting, and the exact amount of destruction could 
not be determined more accurately than in the com- 
paratively fresh specimen. Fortunately, the symptoms to 
be referred to this cervico-dorsal myelitis were so clearly 
marked that a pathological examination could not have 
been expected to throw much light upon them. The rest 
of the cord, after it had been sufficiently hardened, was 
subdivided and the single segments imbedded in celloidin. 
The sections were then stained either according to Weigert’s 
haematoxylin (old) method, or with acid fuchsin. Picro- 
carmine was used for sections through the level of the 
tumor. The sections most thoroughly examined were 
from the upper cervical, the mid-dorsal, and the upper 
lumbar levels. 
Sections at the level of the tumor showed that the tumor 
not only occupied the entire left side of cord but that it 
exceeded the median line more than inspection of the fresh 
specimen had led us to suppose. With its lower (caudal) 
end it had insinuated its way into the posterior columns of 
the right half of the cord, leaving the columns of Burdach 
almost undisturbed. It had grown around the central canal 
destroying the greater portion of the commissural gray 
matter, but left the greater portion of the gray matter of 
the right side entirely unmolested. The lateral columns of 
the right side and the entire ventral half (gray and white) 
of the right side were normal. Of the tumor itself, of which 
sections were made and stained in picrocarmine, little is to TUMORS OF THE SPINAL CORD. 
15 
be said, as the appearances of a solitary tubercle are suffi- 
ciently well known and do not require accurate description.1 
The rest of the cord yielded the one negative fact that 
there were no traces to be found either of any ascending de- 
generation in the posterior columns or direct cerebellar 
tract above the level of the tumor, or of descending degen- 
eration below the level. This fact was a great surprise to 
me. I can offer no other explanation but that the rapidly 
spreading myelitis effaced all traces of an ascending or de- 
scending degeneration. The myelitis was unusually severe 
and extensive, and before descending degeneration had 
time to follow upon the lowest level of myelitic change, 
death supervened. This explanation would not hold good 
if, as some authors would have it, degeneration, if it takes 
place at all, affects an entire system at once. But this 
whole question is still sub judice. (See Langley’s Digest, 
Brain, April, 1886, and JOURNAL OF Nerv. and Ment. 
DlS., Aug., 1886, p. 496.) 
Remarks. 
It will now be our duty to review the clinical symptoms 
of this case in the light of the autopsy. In analyzing these 
symptoms it will be important above all things to differ- 
entiate between the symptoms due to the tumor and those 
due to myelitis. 
The unilateral symptoms are to be placed entirely to the ac- 
count of the tumor; the bilateral symptoms are the expression 
of myelitic changes, except that the extension of the neo- 
plasm into the right half of the cord (surely a matter of the 
last few weeks only) may have given rise to sensory dis- 
turbances in the right extremities also. It is well in 
this connection to recall the following facts and dates: 
From Jan. 8th until March ist the symptoms continued 
one-sided (the period of tumor symptoms); from March 1st 
to March 18th they were distinctly bilateral (the period of 
advancing myelitis). Unilateral symptoms during eight 
weeks, bilateral symptoms during two and a half weeks. 
1 The outer harder portion was characterized by small cells scattered here and 
there among the fibrous tissue ; within the caseated mass there were found 
various cells in all states of decay, giant-cell formation, and a lot of detritus. 16 
B. SACHS. 
Regarded in this light, the symptoms would point to the 
fact that the myelitis spread almost as rapidly as any acute 
myelitis would. The question whether this myelitis was 
due solely to the presence of the tumor, or whether there 
was not possibly a tubercular myelitis in addition to the 
tumor and the myelitis directly caused by it, I must leave 
undecided for the present. 
The tubercle was first deposited in the left half of the 
cord, at the level of the sixth or seventh cervical segment, 
and in the immediate vicinity of the posterior roots. The 
pains in the shoulder, which radiated down the arms (and 
possibly the vaso-motor symptoms), must be ascribed to 
irritation of the posterior root-fibres; that the ulnar should 
have been chiefly involved is not surprising in view of the 
spinal-cord origin of this nerve. With the growth of this 
tubercle—a relatively slow growth at best—there was a 
gradual increase in the paresis of the muscles of the left 
hand and fingers; as the tumor increased still further in 
size, it encroached upon the lateral columns, and caused a 
paresis not only of the left hand and fingers, but also of the 
left leg. 
This slowness of growth is well proven by the fact that 
pains in the arms preceded the (motor) leg symptoms by 
several weeks, and that these motor symptoms progressed 
very leisurely during several weeks more, while the arm 
(ulnar) symptoms remained stationary. Pathological ap- 
pearances would indicate that the tumor had occupied fully 
one half of the cross-section of the spinal cord. It would 
be fair to ask, Why (in this case) paresis and not complete 
paralysis of the left leg? A double answer might be given: 
First, in its slow growth the tumor displaced rather than 
destroyed the motor-tract fibres; and secondly, post-mortem 
appearances are apt to deceive us as to the number of fibres 
or amount of spinal-cord substance capable during life of 
conducting volitional impulses. 
A similar explanation must be sought for the peculiar 
behavior of the sensory symptoms. I am now referring to 
those which preceded the onset of the distinctly myelitic 
symptoms. A tumor occupying one half of the cross-section TUMORS OF THE SPINAL CORD. 
17 
of the spinal cord would naturally interfere with conduction 
in that half of the cord ; the symptoms following in its 
wake should be very much the same as those following 
upon hemisection of the cord, viz.: motor paralysis of the 
same side and anaesthesia of the opposite side. The doc- 
trine of crossed anaesthesia from spinal-cord lesion, first 
enunciated by Brown-S6quard, has been confirmed an in- 
numerable number of times; the facts of human pathology 
and the results of experimental physiology are entirely in 
accord with this view, not even Ferrier,1 in his article on 
hemisection of the cord, having any fault to find with this 
portion of Brown-S6quard’s views. In the face of so much 
corroborative evidence I should be loath to attempt a con- 
tradiction from the facts of a single case, however convin- 
cing such facts might appear to be. Moreover, if we assume 
that in my case the tumor increased very slowly in size, 
and that it pushed aside some instead of destroying all the 
sensory paths, the fact of a partial and not a complete 
anaesthesia will be satisfactorily explained. It is strange, 
however, that the side which, according to Brown-S6quard, 
should have been anaesthetic retained greater tactile sensi- 
bility at a time when the originally hyperaesthetic side had 
become anaesthetic in consequence of the spreading myelitis. 
1 remind you of the statement in the notes of March 14th, 
that the sensibility to touch in the right leg, right half of 
trunk, and in the right upper extremity, though less acute 
than in the neck and face, was more acute than in the cor- 
responding left members. 
The behavior of the muscular sense calls for explanation 
also. On this point the views of Brown-S6quard and Fer- 
rier are diametrically opposed to one another. According 
to the former, the muscular sense is abolished on the side 
of the lesion, while Ferrier’s hemisection of the spinal cord 
of a monkey would go to show that the muscular sense is 
impaired on the side opposite the lesion. Ferrier says : 1 
“ The manifest difference between the use of the right 
(opposite) leg, with and without vision, clearly indicated 
the abolition of the sense of muscular contraction, and ina- 
1 Brain, vol. viii.f 1885. 
* Loc, cit,, p. 4, 18 
B. SACHS. 
bility to appreciate the position assumed by the leg except 
with the aid of vision.” When the animal was blindfolded, 
it was utterly unable to extricate its right leg from any 
opposition made to its intended movement; but if I under- 
stand Ferrier correctly, he makes no statement with regard 
to the leg on the same side as the lesion. The facts of my 
own case would argue in favor of Brown-S6quard’s and 
against Ferrier,1 for the patient exhibited in the earlier 
stages of his disease a grossly defective muscular sense on 
the left side, and normal muscular sense on the right side. 
Ferrier criticises Brown-Sequard for including under muscu- 
lar sense simply the power to direct movements, and to this 
criticism I subscribe, for if Brown-S£quard were right, every 
paralyzed limb would necessarily be minus the muscular 
sense; but while I accept the same definition of muscular 
sense as Ferrier does (the sense of the position of the 
muscles, and knowledge of the manner in which any member 
has been moved passively), I find that in my case the mus- 
cular sense was abolished on the side of the lesion and not 
on the opposite side, as Ferrier would have it. We should 
come to some definite understanding regarding the use of 
the term muscular sense, and the tests to be applied in ex- 
amining for the presence or absence of this form of sensi- 
bility. For the present we are grouping a number of 
heterogeneous phenomena under this term. This case cer- 
tainly raises doubts whether all sensory fibres cross at 
once to the opposite side of the cord, and whether there 
be not sensory fibres in the lateral as well as in the posterior 
divisions of the cord. The other sensory phenomena ob- 
served in this case point to the necessity of a more careful 
study of the various forms of sensibility and their relations 
to spinal-cord lesions. As long as so little is known of the 
sensory parts of the spinal cord, I cannot do more than 
to refer to the eccentric condition of the temperature- 
sense, for instance, without attempting an explanation of 
1 Ferrier says : “So far as I have been able to discover by examination of 
the published cases of hemispinal lesion, the assertion that the muscular sense 
is lost on the side of lesion and retained on the opposite side, is not supported 
by any satisfactory evidence.” Such evidence and such a case are here pre- 
sented. TUMORS OF THE SPINAL CORD. 
19 
these facts. You will remember, for instance, that while 
heat was not felt as such in the lower extremities in the 
later stages of the disease, cold was distinctly recognized 
and produced a sensation of pain. 
One other set of symptoms demands our attention. How 
can we explain the exaggerated knee-jerks and the presence 
of ankle clonus on both sides in the very earliest stage of 
the disease, at a time when there was only very slight paresis 
of the left leg and no paresis whatever of the right leg ? 
Had the knee-jerk and the ankle clonus existed on the side 
of the tumor only, I should have said that the tumor during 
that period had been sufficiently large to remove some 
inhibitory influence without interfering much with the 
transmission of volitional impulses. It is barely possible 
that there may have been another small tubercle somewhere 
in the lateral column of the opposite side, and that this 
tubercle has been lost sight of in the vast destruction of 
cord tissue. In this connection I wish to recall the fact that 
Prof. Pitres,' of Bordeaux, published not long ago, a short 
article on the early appearance of ankle clonus in which he 
records two cases of hemiplegia in which ankle clonus was 
observed eleven and fifteen hours respectively after the on- 
set of the apoplectic attack,—at a time, therefore, at which 
there could not have be:n degenerative changes in the 
lateral columns. If there be, as Langley suggests, commis- 
sural fibres connecting the lateral columns of one side with 
those of the opposite side, then lesion of one lateral column 
might remove enough cerebral inhibition from the opposite 
side to increase the deep reflexes on that side also. I 
question, moreover, whether the patient may not have had 
exaggerated knee-jerks and double ankle clonus before the 
onset of the disease. My suspicion is based upon observa- 
tions I have made on a number of cases of neurasthenia 
from sexual and alcoholic excesses. In all of these cases I 
have found the knee-jerks markedly exaggerated ; indeed I 
consider it a valuable symptom of the neurasthenic state, 
and can recall some cases in which I found even ankle clonus. 
It was stated above that no traces of chronic alcoholism were 
1 Brain, p. 310, 1885. 20 
B. SACHS. 
found post mortem; this, of course, referred to the condi- 
tion of the large abdominal organs. That the long-continued 
abuse of liquor may have exerted its influence mainly upon 
the spinal cord, is more than likely. I prefer to leave this 
field of speculation. There are several plausible explana- 
tions,1 and yet not one which is absolutely satisfactory. It is 
well for us to become conscious of the difficulties we may 
meet with in attempting to assign all clinical symptoms to 
their anatomical and physiological causes. With the ex- 
ceptions just referred to, all other symptoms can be readily 
explained as dependent either upon the tumor or the sub- 
sequent myelitis. 
The subject of tumor of the spinal cord is treated very 
briefly by our best authorities ; Charcot and Erb giving the 
fullest account of the symptoms due to such lesions, while 
Leyden, Bramwell, Wilks, and even Strumpell and Ross 
pass the subject by in great haste. It would not be wise for 
me to attempt a full rtsumd of the entire literature of the 
subject, nor to analyze a large number of cases with a view 
to the differential diagnosis of tumors of spinal cord. This 
work has been well done by Dr. C. K. Mills and Dr. Lloyd, 
who have not only discussed the subject carefully but have 
tabulated fifty cases in the most painstaking fashion. In 
conclusion, only a few remarks, which will be designed to 
secure for this case its proper position in the rank and file 
of tumors of the spinal cord. 
Extra-medullary tumors are by far more frequent than 
tumors of the spinal-cord substance; among intra-medullary 
tumors gliomata and tubercles2 are more common than gum- 
mata, sarcomata, or cancerous growths. Our case was one 
of intra-medullary tumor. These are most frequent in the 
cervical and lumbar segments, to which our case does not 
1 Strumpell and Moebius, in a recent short article in the Miinchener med. 
Wochenschr., refer exaggerated deep reflexes to hyperexcitability (irritation) of 
the ascending (sensory) division of the reflex arc. 
2 This statement is contradicted by Mills’ and Lloyd’s table, but this is due to 
the fact that these authors do not distinguish between extra- and intra-medullary 
growths, and that they have tabulated some fifty cases and by no means the fifty 
cases of spinal tumor. Glaser (Arch f. Psych., vol. xvi., p. 89) claims that 
tubercles have no great clinical interest, because they simply occur in the course 
of a general tubercular diathesis ; in my case the spinal symptoms preceded the 
appearance of general symptoms by a period of nearly two months. TUMORS OP THE SPINAL CORD. 
form an exception. The symptoms will naturally vary 
according to the position (level) of the tumor in the cord, 
and according to the histological character of the neo- 
plasm. Extra-medullary tumors are generally character- 
ized by pain in the back and by sensory disturbances due to 
compression of the posterior root-fibres ; in my case there 
was no lasting pain in the back, but there were marked 
sensory disturbances, for the posterior root fibres were 
affected by an intra-medullary tumor, so that this one 
point of differentiation between extra- and intra-medullary 
growths is not supported by my case. 
The focal symptoms 1 will vary greatly according to the 
seat of the tumor; there may be but slight sensory disturb- 
ances in a single area or in one limb ; the sensory disturb- 
ances may be unilateral; and these may or may not be asso- 
ciated with partial, with unilateral, or bilateral paralysis. 
The number of symptoms may vary from one to a legion 
of such. The differential diagnosis can not well be referred 
to such an indefinite basis. Any set of spinal, and more 
particularly, hemi-spinal symptoms, whether of a motor, 
sensory, or vaso-motor order, if they be slowly progressive, 
might suggest tumor. There will bz good reason to suspect 
tumor if there be in addition to some of the symptoms 
just referred to—some marked constitutional diathesis. In 
my case, I feel confident that no one who had seen the pa- 
tient would have diagnosticated general tuberculosis, and I 
find that in one of two cases of tuberculosis of the spinal cord 
reported by Chvostek 5 some years ago, the tubercular dia- 
thesis was not diagnosticated during life, and the chief mis- 
chief was done, as in my case, in the spinal cord. The pro- 
tracted course of the disease is supposed by some authors 
to be pathognomonic of tumor of the cord. The average 
duration is from six months to several years ; my case ran 
its full course in a little more than two months. Such state- 
ments as these could be easily multiplied to prove the diffi- 
culty in diagnosticating this special form of disease ; thus 
1 Indeed there may be no symptoms at all as in Simon’s case. Arch. f. Psych., 
vol. v., 1875. 
3 Med. Presse, 1873. , 22 
B. SACHS. 
Richard Schultze,1 a good observer, has recently published a 
case of tumor surrounding the cord from the cauda equina 
to the medulla oblongata, which was considered during life 
to be a case of myelo-meningitis. By a combination of 
favoring circumstances, I believe that a diagnosis of tumor 
of the spinal cord can be safely made; but in many cases, it 
will probably be, as Leyden says, a matter of chance whether 
or not the diagnosis can be made. 
From my experience with this case, and my present 
knowledge of the literature of the subject, I should be 
inclined to make a diagnosis of intra-medullary tumor of 
the cord if a case presented motor, sensory, or vaso-motor 
disturbances over a limited area of the body below the head, 
if such symptoms remained unchanged or progressed during 
a long period of time, if these symptoms were followed af- 
ter weeks or months by symptoms pointing to an advancing 
myelitis, and if there were reason to suspect some constitu- 
tional diathesis. In the case of extra-medullary tumors, 
evidences of disease of the vertebrae would greatly assist 
in establishing a diagnosis. 
1 Arch. f. Psych., 1886, p. 592. A similar mistake was made by Fried- 
reich in the case reported by Schultze. Arch. f. Psych., vol. viii., 1878. G. p. putnam’s sons, printers 
NEW YORK