Lumbar Puncture of an Intradural 
Haematoma of the Spinal Cord. 
BY 
OTTO G. T. KILIANI, M. D. 
REPRINTED FROM THE 
Neto ITork fUeJncal journal 
for March 1896. Reprinted from the New York Medical Journal 
for March Uh 1896. 
LUMBAR PUNCTURE 
OF AN INTRADURAL HAEMATOMA OF 
THE SPINAL CORD. 
By OTTO G. T. KILIANI, M. D. 
Dr. George W. Jacoby, in his paper on Lumbar Punc- 
ture of the Subarachnoid Space, concluded in the number 
of January 4, 1896, of this journal, mentioned a case of 
puncture of intradural haematoma of the spinal cord which 
I reported in the September number of the New Yorker 
medicinische Monatsschrift. 
As it appears that Dr. Jacoby's cases and mine are the 
only ones cn record, you may possibly see fit to publish a 
somewhat detailed report. 
T. S., forty-five years of age, fell on his back from a height 
of twenty feet, while working at Croton, N. Y., at four o'clock 
in the morning, July 1, 1895. Being slightly under the influ- 
ence of liquor at the time of the accident, he was unable to 
give an accurate account of his fall. He was found after a 
few hours, and was brought to the St. Francis Hospital, in 
this city, where he was admitted about five o'clock in the 
afternoon. Catheterism. 
On examination, the patient, who was apparently still under 
the influence of the shock, showed the typical clinical symp- 
Copyright, 1896, by D. Appleton and Company. 2 
LUMBAR PUNCTURE OF A SPINAL HEMATOMA. 
toms of an injury to the cord in the lumbar region and cauda 
respectively, complete motor paralysis of both lower extremi- 
ties, sphincter ani, lower part of the rectum, and bladder; com- 
plete anaesthesia of both limbs, reaching upward on the body 
to an imaginary transverse plane drawn through the third 
lumbar vertebra and a point about two centimetres below the 
umbilicus. This area of insensibility therefore included the 
peringeum, scrotum, and penis, both dorsal and inferior sur- 
faces. 
A careful examination of the spine showed a spot of ex- 
treme tenderness on the third lumbar vertebra, but no de- 
formity or crepitation, so far as could be ascertained. The 
region of the third lumbar vertebra was slightly ecchymotic. 
No patellar reflexes, no cremaster reflexes, no clonus of the 
foot. Abdominal reflexes present. 
Diagnosis.-Compression of the conus terminalis and the 
cauda, probably by haemorrhage (possibly by dislocation or 
fragment after fracture). The patient was comparatively 
easy in extension, with contra-extension at the head, on the 
water bed, and flatly refused an operation proposed on the 
following day (so-called laminectomy). 
There was absolutely no change in the condition of the 
patient in the next few days up to the 6th of July, with the 
exception of profuse diarrhoea, which could hardly be con- 
trolled. Repeated examinations showed absolutely no change 
in the area of motor and sensory paralysis, the outlines, of 
which had been marked with nitrate of silver. 
On the 6th of July the patient consented to a puncture, 
which was done without narcosis in the typical way so often 
described. The patient was rolled on the left side, with only 
slightly convex spine, on account of the possible danger of 
compression of the cord. A strong needle was inserted in the 
vertebral canal between the third and fourth lumbar verte- 
brae, about one centimetre and a half from the median line, 
after several attempts, on account of the muscular develop- 
ment of the heavily built patient. Aspiration of eight cubic 
centimetres of thickish, tar-colored blood, which presented 
somewhat the appearance of a haemarthros removed in the LUMBAR PUNCTURE OF A SPINAL HAEMATOMA. 
3 
second week. Aristol collodium on the point of puncture. 
This small operation was quite painful, but easy to bear. 
Examination One Hour after the Puncture.-The anaesthetic 
area, which had been again determined a few hours before 
the operation, was considerably diminished, so that the whole 
hypogastric region decidedly, although not quite normally, 
responded to mechanical stimulus (needle). In the dorsum 
penis sensibility has also returned, while the conditions on 4 
LUMBAR PUNCTURE OF A SPINAL HJEMATOMA. 
the inferior surface, as well as on the scrotum, remained un- 
changed. A zone of returning sensibility was marked upon 
the inner aspect of the thigh and leg, as is shown in the 
figure. Sensibility had also returned in the toes. In the back 
of the patient a certain decrease of the pain in the region of 
the third lumbar vertebra was noticeable. Besides, the upper 
limit of insensibility had receded some five centimetres. The 
gluteal and anal region was also improved to the extent 
shown in the diagram. The posterior portion of the peri- 
naeum showed the same improvement. 
The extensors of the left thigh were capable of slight 
voluntary contraction, which had not been observed before. 
An examination with electricity of the different muscles could 
not be effected for lack of a suitable apparatus. 
The paralysis of bladder and rectum remained persistent, 
and the patient had to be catheterized every four hours, and 
passed stools involuntarily. The above conditions remained 
unchanged until the 10th of July, 8.45 p. m., when the patient, 
in spite of every precaution, suddenly died while the bed was 
being changed, with symptoms of asphyxia. 
To my great regret, the autopsy was refused, so that I was 
only able to remove a portion of the spinal cord twenty 
hours after death. The cadaver showed rigor mortis in a 
very marked degree and an enormous lividity, which made 
the whole body look almost black. This may be assumed as 
a post-mortem symptom of the sudden death. Incision over 
the spinous processes of the lumbar region ; dissection of the 
longitudinal muscles; the arachnoidal space laid open by 
chisel from the first to the fifth lumbar vertebra; no disloca- 
tion or fracture found, neither of the body, arch, nor any of 
the processes (neither articular, transverse, nor spinous). It 
is nevertheless not at all impossible that a fissure or replaced 
dislocation might have been overlooked or not discoverable. 
It is only certain that no fragments compressed the cord. 
The dura, which was not severed or in any way opened, 
showed at a point corresponding with the intervertebral 
space between the third and fourth lumbar vertebras, to the 
left of the median line, a sharply circumscribed suggillation LUMBAR PUNCTURE OF A SPINAL HAEMATOMA. 
5 
the size of a large pinhead, which showed where the needle 
entered. After incision of the dura, the cauda showed no 
macroscopic signs of bruising; a few remnants of a half- 
coagulated haematoma were still to be found. Although this 
post-mortem, for reasons mentioned above, is very incomplete, 
it abundantly proves that the puncturing needle really entered 
the intradural space, and furthermore that the blood evacu- 
ated in the aforesaid operation was actually drawn from the 
intradural space. 
Omitting all the other details of my published report, I 
should like only to call attention to the therapeutic value 
of puncture in similar cases. 
Wherever the haemorrhage in the subarachnoidal space 
takes place, most of it will be collected in its blunt sac in 
the lumbar region. As it has been proved that compres- 
sion of the cord merely by blood is possible (by Baginski 
and others), it is clearly our duty to try to remove the 
pressure by such a small operation as the puncture. Even 
if it is not followed by any improvement, it may be of de- 
cided value for purposes of diagnosis. 
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