a drawing or constricted feeling. The skin over the neck anteriorly appeared to him as though it were covered over with collodion, and deeper in there was a sensation of pressure. The arms felt as though they weighed a ton, and were the seat of almost constant pain. The spine was not tender to pressure except in the upper cervical region. Forced movements of the arms or of the head from side to side or forward gave rise to pain in the upper cervical region. Carrying the head backward did not cause him pain. The electric reactions of the muscles of the arms and neck were not tested, on account of his feeble condition and the constant pain from which he suffered.

The bodily temperature was usually about normal or a little below. The pulse varied from 70 to 100. Respiration was entirely diaphragmatic, a little rapid, but no symptoms of dyspnea were observed unless he attempted to talk. In speaking, he had to stop after uttering two or three words and take a long, deep inspiration, during the effort at which his head would involuntarily be completely raised from the pillow.

Diagnosis.-The history that the patient gave of the development of his symptoms served to confuse rather than to enlighten one in the investigation of the case. He stated that the right leg was more affected than the left. Dr. Devlin, on the other hand, is confident that when he saw him in October, 1896, his right leg was much stronger than the left. At the time of my examination, March 2, 1897, a short time before his death, all symptoms were bilateral, and consisted in abolition of nearly all the functions of the entire spinal cord, and in great impairment of those intimately concerned in respiration. nosis lay between myelitis, tumor of the cord, syringomyelia, cervical pachymeningitis, and pressure myelitis, the compression being due to caries of the spine or from tumor arising from the bones or membranes.

The diag

Myelitis, focal in character, could not be excluded from the history alone, as this was so indefinite and some portions of it were so conflicting. A chronic myelitis, involving the upper cervical region of the cord and destroying tactile sensation as high as the second cervical nerve, with almost complete paralysis of nearly all the voluntary muscles innervated by the spinal nerves, and attended by marked wasting in the muscles of the hands, is incompatible with life, as the phrenic nerves would be seriously affected.

Tumor of the Cord in the upper cervical region sufficiently large to produce bilateral symptoms as grave as those existing in this case, like myelitis, would rapidly result in death.

Syringomyelia might, and sometimes does, give rise to most of the symptoms found in the case under discussion. The muscular wasting of the arms and hands, the disturbance in sensation as high as the lower border of the inferior maxillary bone, the paralysis and the increased knee-jerks might be produced by syringomyelia. syringomyelia the pain is rarely as severe as it was in this case, and is much less influenced, if influenced at all, by movements of the limbs or by changing the positions of the body. In this patient's case the pain was so great,

In

especially in the arms, as to require repeated injections of morphin to make life tolerable, and movements of the arms or head, thus putting the neck muscles on the stretch, as when turning the patient in bed, could not be made without giving rise to great suffering. In addition to the severity of the pain and the manner in which it was increased, the most important evidence against the existence of syringomyelia was the way in which sensation was affected. Tactile sense was abolished throughout the area of the distribution of the spinal nerves, except over a small surface on the back of the neck above the fourth cervical spine, over the posterior portion of the scalp, and over a small area of the face. Pain sensation, although delayed, was present throughout the entire surface of the body except over the hands and arms. In syringomyelia, pain and temperature sensations are abolished to a greater or less extent, and tactile sense is preserved, often to nearly a normal degree.

Cervical Pachymeningitis.—The character of the initial symptoms, loss of power, incoordination, numb and dead sensations in the hands and arms, without much pain, is decidedly different from that of cervical pachymeningitis, in which pain is the most prominent symptom for some time. Paralysis is not an early symptom in meningitis, neither does it become absolute until just before death. Besides, a pachymeningitis causing anesthesia throughout the distribution of all the spinal nerves would be incompatible with life.

Pressure Myelitis from some cause seemed to be the only lesion that would account for the symptoms. Was the pressure due to caries or tumor of the vertebræ, or to tumor of the membranes ?

Caries of the Cervical Vertebra, with deformity and pressure upon the cord, may cause sensory and motor paralysis, but under such circumstances there will be spinal tenderness, rigidity of the neck muscles, and deformity of the spine. Muscular rigidity was present in the case under discussion, but there was no spinal tenderness, and all deformity was absent; in fact, one of the most common symptoms of caries of the cervical spines— thickening of the tissues over the spine-was absent.

Tumor of the Cervical Vertebræ is attended by great pain on movement of the head, and all the symptoms of caries of the bones would be present in an aggravated form, especially the spinal tenderness. After a careful study of the history of the case, so far as it could be obtained, together with an analysis of the symptoms, I felt confident in excluding all lesions except tumor of the membranes, especially of the dura.

Tumor of the Membranes usually gives rise to motor symptoms on the side on which the tumor is located, and to sensory symptoms on the opposite side of the body; but in those cases in which the growth is situated high up in the cervical region, especially if the structures found in the foramen magnum are encroached upon, bilateral motor and sensory symptoms might result from the direct pressure of the tumor upon the cord and by displacement of the cord to the opposite side against the foramen magnum. A tumor located anteriorly or posteriorly to the spinal nerve-roots as they emerge from the cord might

give rise to bilateral sensory and motor symptoms without completely destroying the function of the upper cervical spinal nerve-roots. If, on the other hand, the growth should be situated on one lateral aspect of the cord, so as to directly involve the spinal nerve-roots on that side, bilateral symptoms would result in the cord below the site of the tumor on account of the direct pressure of the tumor against the cord and the displacement of the cord to the opposite side against the foramen magnum, but nerveroot symptoms on a level with the tumor would be more extensive on the side corresponding to that on which the tumor is located. As this difference of spinal nerve-root symptoms between the two sides was absent in this case, the tumor was thought to be situated anteriorly or posteriorly to the spinal nerve-roots.

Could all the symptoms present in this case be accounted for by the presence of a growth in the upper cervical region in the vicinity of the foramen magnum? Neither severe spinal tenderness nor deformity would result from a tumor in this situation, but muscular rigidity, paralysis, and loss of sensation would be likely to occur. These phenomena correspond with the symptoms found in the case here reported.

Location of the Tumor.-This patient had nearly normal sensation throughout the distribution of the cutaneous branches of the great and small occipital nerves and the great auricular branches of the cervical plexus. Tactile sense over the upper posterior portion of the neck, over the posterior portion of the scalp as far forward as the vertex, over the posterior surfaces of the pinnæ of the ears, and over the face just in front of and below the ears, is supplied by the first, second, and third cervical nerves. The lateral and anterior surfaces of the neck derive their cutaneous nerve-supply from the superficial branches of the cervical plexus, which is composed of nerve-filaments from the second and third cervical nerves. It will be observed that the function of the first cervical nerve was nearly intact, but that of the second and third cervical nerves was destroyed, so far as the superficial cervical filaments were concerned. Over the upper posterior portion of the neck and over the scalp both sensory and motor function were preserved to a fair degree. The muscles of the ears supplied by the upper cervical nerves moved freely. It was evident that the tumor was connected with the membranes, probably the dura, and was situated sufficiently high in the spinal canal to cause bilateral symptoms by displacement of the cord against the sharp edges of the foramen magnum. That it extended through the foramen magnum could not be determined.

Dr. McNaught accepted my diagnosis, and said that he would operate if I urged it, but he thought the man was too weak to undergo a severe operation. To this I entirely agreed, as the chances were that the patient would die on the table during the operation. He was extremely weak, greatly emaciated, took but little food, and had to be kept under the influence of morphin most of the time. He gradually sank, and died on April 1st-about four weeks after the examination.

Sectio Cadaveris, four hours after death. We were limited by the friends in our post-mortem examination to

No

the spinal column and the cord and its membranes. tumor, caries, or displacement of the bones was found. On exposing the dura from the sacral region to the foramen magnum, its external surface appeared normal, but at its extreme upper portion, at the foramen magnum, and extending an inch or more below, it was greatly distended. On opening the dura throughout its entire exposed posterior surface, a growth as seen in Fig. 2 was exposed.

The tumor was lobulated in character, seemed quite firm, lay on the right posterolateral surface of the cord, and was attached to the inner surface of the dura over an area about one-fourth of an inch in diameter. It extended from the fourth cervical nerve-root through the foramen magnum just into the cavity of the cranium. In size it was 134 inches in length by three-quarters of an inch in its greatest diameter, which was found to be just below the

Showing the tumor and cord in situ after removal of the laminæ, spinous processes, and posterior surface of the dura. foramen magnum. The end of the tumor that extended into the cranial cavity was rather small and conical in shape. The membranes of the cord seemed to be normal except at the point of attachment of the growth, where the inner surface of the dura was a little thickened. The medulla was cut across just above the tumor, which was a little below the calamus scriptorius, and the cord was carefully removed from the canal. It was found that the cord had two indentations, one on the side of the growth extending from the fourth cervical nerve-root to the second, with the greatest depression opposite the third cervical nerve-root, the other on the left side, and a little more anteriorly than that of the right side. The depression on the left side of the cord was caused by the displacement of the cord against the foramen magnum. The displacement of the cord was upward and to the left, so that the great indentation was on a level with that of the right

1 The nerve-roots had not been directly pressed upon by the tumor or edge of the foramen magnum.

side, or at a point corresponding to the third cervical nerve. On marking the cord into sections about threequarters of an inch in length, by incompletely cutting across its substance, the upper cervical portion seemed narrow and softened.

The cord and tumor were placed in Müller's fluid, and the fluid changed twice each day for four days. At the end of this time the specimens were put in a five-per-cent. solution of formalin and kept thus for three weeks. The microscopic examination of the specimens was made by Dr. E. R. Axtell, pathologist to the Hospital, and is as follows:

Sections were made of the tumor and of the spinal cord at the level of the first, second, third, and fourth cervical segments; at the mid-dorsal region, and across the lumbar and sacral regions. The tumor sections were stained in alum-carmine and in hematoxylin; the cord sections by Weigert's method.

Examination of the tumor sections shows the mass to be a spindle-celled sarcoma. The cells are arranged largely in rotating groups, and in several parts hyalin masses are seen similar in all respects to those found in psammomata. The tumor has almost no capsule and contains but very little delicate embryonic stroma. The blood-vessels, while not numerous, are fairly well developed, being more than simple embryonic vessels.

The microscopic examination of the first cervical segment shows the right half to be preserved, with the exception of some disintegration posterior to the gray commissure, while the left half is so softened and disintegrated that sections cannot be made, except through the left posterior and left anterior columns. The left posterior gray cornu is seen passing through the disintegrated area. The brunt of the inflammatory process seems to have been posteriorly and to the left. All of the tissues remaining here present evidences of inflammation with degeneration, increased interstitial tissue, destroyed nerve-fibers, thickened blood-vessel walls, and granular débris. The right half of this segment also presents evidences of inflammation, but to a less degree than the left side.

The entire left side of the second cervical segment is disintegrated except the left anterior column and a thin border along the posterior median fissure, a thread of white matter occupying the place of the lateral columns. All of these portions present the signs of inflammation as detailed above. The right side of this section is preserved, with the exception of the lateral columns and the sensory tract of Gowers, all of which are, however, infiltrated with blood elements.

The right side of the third cervical segment can be sectioned if thick sections are made. Under the microscope is seen a mass of nerve filaments and inflammatory edematous tissue in which no distinction can be made between the gray and white matter. The margin of this right half is very soft and quickly becomes detached from the rest of the section. Under the microscope it is seen to be badly degenerated. The left half of this portion of the cord could not be sectioned by any manipulation, being absolutely and completely disintegrated. Some of the

softened material was teased, and under the microscope abundant masses of granule corpuscle, débris, myelin masses and many corpora amylacea were found. In the tissues of this section that did remain, there is evidence of an increase in the interstitial tissue with an increase in the thickness of the blood-vessel walls.

In the fourth cervical segment, there is no absolute disintegration, but the inflammatory process of the third segment extends to this segment, and especially affects the posterior medium and external columns and to a slighter degree the posterior lateral columns.

The mid-dorsal segment shows a normal cord with the exception of degeneration of some fibers in the anterior and lateral columns.

The lumbar segment shows a normal cord, with the exception of slight sclerosis in the left lateral column. The sacral segment is normal or nearly so.

"

There are several points of interest connected with the clinical history and pathologic findings in the case reported in this paper. I shall only briefly refer to a few of them at this time. The macroscopic and microscopic appearance of the upper portion of the cord showed that greater damage had been done to that side of the cord opposite to the seat of the growth. Dr. F. W. Langdon of Cincinnati in Brain, 1895, vol. XV., p. 551 reported a case of Multiple Tumors of the Brain; Fibrocystoma of the Pons and Cerebellum, and Multiple Fibropsammomata of the Dura, Pia, Arachnoid and Cortex Cerebri," in which the symptoms indicated that the lesion of the pons was on the side opposite to that of the tumor. It appears, then, that tumors in the neighborhood of the foramen magnum, so situated as to cause displacement of the parts against the bone, may give rise to a greater lesion by indirect than by direct pressure. This is important to bear in mind in tumors above the foramen magnum, but is of less value in growths below the foramen magnum, even should an operation for the removal of the tumor be undertaken.

The position of the tumor and its slender attachment to the inner surface of the dura would have made it a comparatively easy matter to remove the growth in the case of my patient had he been seen early, or before he became so extremely weak.

The microscopic examination shows that the third cervical segment was almost completely destroyed, but that the first and second cervical segments were greatly damaged, especially on the left side. It is probable that considerable destruction of the cervical cord took place after I made a careful examination of the patient's condi tion, some weeks prior to his death.

From the macroscopic appearances of the cord, it seems evident that the third cervical segment must have been destroyed by compression and by subsequent inflammation. It appears, then, that the first and second cervical segments supply with tactile sense the posterior portion of the scalp, a narrow strip on the posterior portion of the neck as low down as the fourth spinal process, and the face in front of and below each ear.

Dr. M. Allen Starr' gives the second and third cervical "Familiar Forms of Nervous Diseases," p. 128.

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This method proved to be an impossible one, because as soon as the concentration of the solution exceeds forty per cent. a polymerization of the formalin occurs, with a precipitation of paraformaldehyde, and if the heating is continued this finally begins to burn. It was next attempted to obtain the gas from a solution of formalin in methyl spirit called holzin. This solution spatters badly, and not only is much costly alcohol wasted, but it is not possible to develop large quantities of formaldehyde vapor in a short space of time-a factor which is absolutely necessary for efficient disinfection. Attempts have also been made to develop the vapor by the oxidation of methyl alcohol in lamps, but as aldehyde forms only a small percentage of methyl alcohol, this method is both costly and wasteful, and a large number of lamps are required to disinfect even a small room. Good results in disinfection were first obtained by means of an apparatus in which formaldehyde solutions were superheated under a pressure of three atmospheres. This is necessarily expensive, and its use is attended with a certain amount of risk. Recently Schering has constructed an apparatus in which the solid polymerized formalin or paraform, called also tryoxymethylin, is used for the development of the formalin vapor. It consists of a cylindrical mantel, beneath which is a spirit-lamp with a suitable wick. In the upper part of the mantel hangs a vessel, into which the formalin pastiles are placed. The upper end of the vessel is provided with a number of slits, through which the gases formed by the combustion of the alcohol-carbonic acid and watery vapor-must escape. In their passage through the vessel there is a mixture of these vapors of combustion with the formalin vapors generated by the heating of the formalin pastiles. In such an apparatus from 100 to 150 pastiles, each weighing 15 grains, may be vaporized at once. This is sufficient, as careful experiments have shown that a room containing 3500 cubic feet of air space may be absolutely sterilized.

Suppurative Typhlitis and a Normal Appendix.-In the Revue de Medecin, August, 1897, LOP gives the details of a case of suppurative inflammation of the cecum with perforation at its external border, although the appendix was perfectly normal. An artificial anus was established, and after a convalescence, prolonged by hemorrhages from the wound and by pneumonia of the left lung, the patient's condition was greatly improved. Six weeks later the patient died from the effects of an operation which became necessary to relieve a stricture of the intestine near the site of the old wound.

Substitutes for Phenacetin and Antifebrin.-VAMOSSY and FENYVESSY (Therapeut. Monats., August, 1897), who have experimented with two new drugs, called phesin and cosaprin, draw the following conclusions: Both possess certain advantages over phenacetin and antifebrin, from which they are derived. They are easily soluble in water, and may therefore be given subcutaneously; they act quickly; they are less dangerous than the preparations from which they are derived; their action continues only a short time, but this may be overcome by the repeated administration of small doses.