EFFECT O F RADIUM ON THE SPINAL CORD
REPORTOF Two CASESOF MYELOMA
WILLIAM T. PEYTON
(From the Department o f Surgery and the Cancer Institute, Un~versityo l itiinnesota)
In the following pages there are reported two cases of myeloma in
which interstitial radium therapy was used. One of the cases was unifocal; both produced a paraplegia. Since there was little exact information available as to how much radium could be used with safety
around the spinal cord, a rather conservative dosage was employed, and
it was decided to discover, if possible, experimentally, the exact effect
of radiation on the spinal cord, to determine the amount required to
produce paralysis.
The literature contains little definite information as to the effect of
radium on the nervous system. Such statements as the following are
typical :
“Not much is known concerning radiosensitivity of the central nervoils system, ” “Very large doses produce changes which cause immediate death of the animal’’ (Witzleben, l), “Clinical observations have
given the impression that the central nervous system is quite resiRtant
to radiation.” “The spinal cord appears to be very resistant to radiation, and the peripheral nerves show a remarkable resistance” (Jiingling, 2).
There appear t o have been few attempts to determine what changes
occur in the spinal cord following radiation, or how much radiation is
necessary to produce paralysis. The results reported by those who
have made investigations are somewhat contradictory.
Danysz (3) was the first to study the effect of radium upon the
tissues of the central nervous system. T€e implanted one centigram of
n very active radium salt (filtration not specified) under the skin over
the spine and part of the skull of a mouse one month old. Ataxia and
paralysis occurred in three hours, convulsions in seven to eight hours,
If the tube was left in place, the convulsions became more and more frequent until the animal died in twelve to eighteen hours. Mice one year
old treated in this manner did not die until six to ten days after application of the same close of radium. I n yomg guinea-pigs, eight to twelve
days old, a similar application of radium over the lumbar cord for
twenty-four to forty-eight hours produced a complete paralysis in one
to three days and death with convulsions six to eight days later. A
large rabbit treated with an eight-hour application of the same tube
upon the dura mater was normal two days later but on the third day
showed a left hemiplegia. In view of these observations Danysz con1
Accepted for publication, Derenibcr 1932.
558
559
EFFECT O F ItADIUM ON THE SPINAL CORD
cluded that the nervous centers are extremely sensitive to the action of
radium.
Obersteiner (4),after diffuse radiation of the heads of mice, found
small hemorrhages into the brain, meclulla and meninges, and gross and
small hemorrhages and round-cell infiltration of the meninges along the
basal vessels of the brain, but the nerve cells were for the most part unaltered. Some of the tmterior horn cells of the cord showed changes in
the granules. With Marchi stain no myelin change was demonstrable.
Pendergrass et a1 ( 5 ) placed a radium tube on the dura of the spinal
cord of dogs after laminectomy. They reported as follows:
Dosc in Mg.Hrs.
Obscrvcd Rcsult
300
X o clinicltl signs.
(ioo
Weakness in hind legs followed by spasticity in six wccks.
Spastic paralysis in 7th wcek. Complete paraplegia.
0 0
Marked spasticity of hind legs in two weeks. Spastic
paraplegia in 3rd week.
1200
Animal Killed
48th day
4th week
....
Spastic paralysis of hind legs before end of 2nd wcek.
-
I n no dog was there disturbance of the sphincters. Attempts to
test for loss of sensation wcre unsatisfactory. The conclusion was
reached that considerable changes were to be found in the cord with exposures that gave no clinical symptoms and that the cord should never
be exposed to surface application of radium or radium implantations.
Cairns and Fulton (6) applied radon seeds extradurally along the
dorsal region of the spinal cord in cats and monkeys. The dosage
varied, but the seeds were always 1.5 cm. long and screened by 0.3 mm.
platinum. They were applied to the dorsal side of the cord. With an
overwhelming dose of 31 mc.! signs of weakness appeared thirty hours
after application. Paraplegia was always complete three or four days
after the onset of the first symptom. I n cats any dose greatcr than
9.5 mc. caused complete paralysis. Incomplete paraplegia was produced with doses between 4 mc. and I) mo. No obvious neurological
symptoms were produced by 4 mc. or lass. Monkeys were more resistant, 12 mc. producing only slight weakness.
Rachmanow (7) studied the changes in the central nervous system
after esposiire to x-rays. He used trypan hlne as a vital stain, injecting some of this dye both before and after exposure of the animal to
x-rays. The changes observed were slight and were chiefly in the
blood vessels.
EXPERIMENTAL
INVESTIGATION
OF EFFECT
OF RADIUM
ON
SPINAL
CORD
THE
Seven dogs were used. Laminectomy was performed in the lower
thoracic or lumhar Npine, and gold seeds containing radium emanation
500
WILLIAM T. PEYTON
were placed around the periphery of the cord. The walls of the gold
tubes were 0.2 mm. thick and the amount of emanation which they
contained was variable. I n five dogs they were placed just outside the
dura and in two (dogs No. 2 and 6) they were placed in the subarachnoid space. Depending upon the clinical course, the dogs were killed,
and the spinal cord removed, sometime between the second and the
eighteenth day after operation. Sections of the cord were taken at
measured distances, above and below, and at the site of application of
the radium. These sections were stained with either hematosylin and
cosin, or theonin, or with both of these stains. Thc details of each esperiment are given in Table I.
TABLEI
Mc. Hm2
Before
Paralysis
Total Extradural
Mc. Hrs.
or
Received Intradural
Days Between
Operation and
Post-mortem
Results Examination
Dog
No.
No. of
Implsnts
1.
3
1.7 mc.'
216
216
Ext(radura1
No clinical
symptoms
18
2.
2
2 mc.
-
255
Intradural
Immediate
paralysis
18
3.
4
2.8 mc.
340
350
Extradural
Paralysis
14th day
18
4.
5
4
mc.
316
480
Extradural
Paralysis
5th day
13
5.
5
5
mc.
278
341
Extradural
Paralysis
3rd day
4
6.
6
6
mc.
-
242
Intradural
Paralysis
immediate
2
7.
14
10.2 mc.
696
806
Extradural
Paralysis
4th day
5
1
Total
Dose
mc. = millicuries.
* mc. hrs. = millicurie hours.
Cord Changes
In those espcriments where the radium was placed intradurally the
results could not be considered as entirely due to radium reaction, since
there was apparently considerable trauma to the cord. It would probably be possible with improved technic to place the radium intradurally
with less trauma to the cord and the effect would be somewhat greater
than with extradural application, due to decreased distance. The difficulty of intradural as compared with extradural implantation was believed to be too grcat and the advantage too dight to justify its continuance.
I n reporting thc clinical tilid microscopic findings and also in drawing conclusions the experimciits (dogs 2 and 6 ) with intradural irn-
EFFECT OF RADIUM ON THE SPINAL CORD
561
plantation are not included. Excluding these two experiments, it is to
be noted in Table I that there was no paralysis in dog 1,in which 1.7 mc.
were implanted, but in all other dogs there was paralysis which very
definitely tended to occur earlier as the radium dosage was increased.
Paralysis in every case became complete within a few hours after its
onset. There was urinary retention.
I n every cord there was microscopic evidence of reaction. These
changes became more severe and involved a greater part of the various
structures of the cord as the dose of radium was increased. When the
dose was small, the effect was confined to the immediate level of the
FIQ.1. LOW-POWEE
VIER OF MENINQEAL
HEACTION IN no0 No. 3
2.8 me. of radiuin inrplantod extradurally ; autopsy cightocw days later. 8oction at the
site of implantation.
FIQ.2. I%IaH-POWEE VIEW OF INJUUED NERVE CELLS IN DOQ NO. 1
1.7 me. of radiunr emanation iinplanted extrailurally ; autopsy cightoen days later. Seetion at the site of implantation.
cord around which radium was inserted, but as the dose was increased
the cord was involved for a greater extent in the cephalo-caudad direction. In dog No. 7,in which 10.2 mc. were implanted, the cord was involved for 2 cm. on each side of the radium, a total extent of 4 cm. The
changes, however, were in every instance maximum at the level of application of the radium.
The meningeal reaction was similar to that seen in an infectious
meningitis, but was confined to a strictly localized area at the site of
implantation, never spreading in the proximo-distal direction, as would
be expected in an infectious process. The meningeal reaction consisted
of an infiltration of cells, polymorphonuclear and mononuclear in type
(Fig. 1).
562
WILLIAM T. PEYTON
Both the grey and the white matter in the cord were involved. With
small doses of radium (dog 1,with 1.7 mc.) the changes were minimal.
The nerve cells for the most part appeared normal, but a few were
found undergoing degeneration, demonstrated by chromatolysis (Fig.
2). In some areas even with this small dose there was increase in the
glial cells with gome protoplasmic glial cells present. This glial cell
proliferation was perhaps the most constant finding in all these cords,
being most extensive in the grey matter, and extending over a larger
FIQ.3.
HIGH-POWER
VIEW
OF
LEUXOCYTIC
INFILTRATION INTO
PROLIPERATION
IN Doa No. 4
THE CORD AND
GLIAL
4.0 me. radium eiiianation implanted extradurally ; autopsy thirteen days Inter.
at tho site of implantation.
CELL
Section
ANTERIORHORN WITH A [JINQLE NERVECELL REMAININQ,
16 DOGNo. 3
2.8 me. radium elltanation implanted extrndurally ; autopsy eighteen days 1Rter. Section
at the site of implantation.
Flu. 4. LOW-POWER
VIEW
OF O N E
segment of the cord than the other changes noted. I n the lighter doses
there was no demonstrable change in the myelin.
Cord changes became more severe with increasing dosage. A more
general and marked proliferation of glial cells occurred. These cells
became so large that they were very much like degenerating anterior
horn cells (Fig. 3). The latter are simultaneously decreased in number (Fig. 4). Vacuoles occurred in the white matter and diffuse hemorrhages were found throughout the cord. Finally with the maximizrn
dose implanted there was fragmentation of the grey matter, complete
destruction of the nerve fibers (Figs. 5 and G ) , and even areas of focal
VIEWS OF LATERAL
(FIG.
5 ) AND POSTERIOR (FIG. 6) COLUMNS,
FIGS.5 AND 6. HIGH-POWER
SHOWING
NERVE
FIBERINJURY,
I N DOGNo. 7
10.2 nic. radium euianation iniplnntrd cxtratlurally ; autopsy five days later. Section at
the site of implantation.
LOW-POWER
VIEW OF NECROSIS
AND IIENORRHAGE IYTO THE LATERAL
COLUMN
(Fio. 7 ) A N D HIGH-POWER
VIEWOF THICK-WALLED
BLOOD
VESSEL
(FIG.8) IN DOGNo. 7
10.2 mr. radium eninnation inlplanted extradurally ; autopsy five days Inter. Section in
Fig. 7 1 em. below site of iniplantntion; in Fig. 8 2 em. below site of imp1:intatiou.
FIGS.7
AND
8.
583
564
WILLIAM T. PEYTON
necrosis in the white matter (Fig. 7 ) , as well as extensive hemorrhages
into the white matter. With the larger doses polymorphonuclear infiltration was observed, these cells being most numerous in the immediate vicinity of blood vessels. Thick-walled blood vessels were found
(Fig. 8) only with large doses. The intensity of the changehl was always inversely proportional to the distance the section was cut, either
above or below the level of implantation.
REPORTOF Two CASM OF MYELOMA
CABE1: A farmer, forty-nine years of age, married at forty-two, was admitted July
28, 1930. The diagnosis under which he was referred was multiple sclerosis. H e had
been in good health until the spring of 1929, when he began to have pain over the xyphoid
PIQ. 9.
CASE
I: I)ESTRIlC;TION
OF [SIXTH THORACIC
VERTEBRA Ah'D
TUMOR
INVADINQ 80FT PAR'l!S
( FUSIMRM
SHADOW)
process, a sensation as of a lump in this region which he could neither get u p nor down,
There was no relation between the symptoms and quantitative or qualitative ingestion of
food. Later severe attacks of pain occurred across the upper abdomen. Heavy lifting
seemed to bring on these attacks. Some days there would be no pain at all; on others
it would last throughout the day but subside a t night. Two months after the onset of
these symptoms the patient consulted a physician, but nothing definite was found on
physical examination, or by x-ray study of the gastro-intestinal tract after the ingestion
of barium. H e was put on a diet, but the pain continued until Oct. 10, 1929, when
cholecystectomy was performed. The abdominal, pain has not recurred, but the patient
never completely regained his strength, though he was able to do light work around his
farm. I n March 1930, he began to notice that%is legs were weak, that it was diffleiilt
for him to lift his feet, and that he stumbledeasily. Often, while he was walking, the
toes of one foot would turn inward and strike the other foot, causing him to fall. About
this same time be began to experience numbness and tingling sensations in his feet, the
left being more affected than the right. I n May 1930, the symptoms had progressed to
such an extent that he couId walk only with the aid of a cane, and by June 1930 he was
anahle to walk at all and entered a hospital. At this time he could still lift his right
EFFEUT OF RADIUM ON THE SPINAL CORD
565
foot a little, but within two weeks he could not move any part of his lower extremities.
IIe had not lost control of the sphincters, however, even at the time of his admission to
the University Hospital, July 28, 1930.
The patient gave a history of having had an ulcer on the left leg which had been
present for twenty-one years, but had been entirely healed during the past two years.
He denied venereal infection. The family history revealed nothing essential.
Physical Examirratios: General exnmination demonstrated nothing of importance,
except that over the lower third of the medial aspect of the left leg there was an irregular
scar which was suggestive of syphilis. Neurologic examination demonstrated a spastic
paralysis of the lower extremities; loss of pain sensation below the level of the 7th
thoracic segment but retention, except in small spots, of light touch over this same area;
retention of deep sensibility in the lower extremities with loss of vibratory sense over
the same arens; bilateral ankle clonus and spinal mass reflex in the lower extremities.
The cranial nerves and spinal nerves above the 7th thoracic were essentially negative.
WO.10.
CASE
I: LIPIODOL
INJECTION DEMON ST RAT IN^ BWK
AT 6 T H
THORACIC
VERTEBRA
Special Examinations: On July 30, 1930, spinal puncture was performed. There
was too much leakage to measure the pressure. Queckenstedt’s test was positive, demonstrating a spinal block. The spinal fluid wns clear and colorless: it gave a positive
Wassermann reaction. The Nonne reaction was negntive.
X-ray films of the spine (Fig. 9) showed the Gth thoracic vertebra to be very much
compressed and rawfied, and the intervertebral disc between the 5th and 6th thoracic
vertebra to be nlmost ohliteratccl. X-ray films of the chest were also made but, except
for the changes reported in tlit! films of tho spine, showed nothing abnormal.
Laboratory Examinations: Blood examinntion showed the hemoglobin to be 110,
white blood cells 5050, polymorphonuclears 50, lymphocytes 47, eosinophiles 2, basophiles
1. The blood Wassermann renction was negative. Examination of the urine gave
essentially normal findings. The Bence-Jones test was not performed.
566
WILLIAM T. PEYTON
Because the spinal fluid Wassermann was found to be positive, the patient was
given antisyphilitic treatment in the form of four intravenous injections of neo-salvarsan,
but. without improvement. On August 28, 1930, cisternal puncture was performed and
2 C.C. of lipiodol injected. The patient was kept in the sitting posture for thirty minutes
and x-ray fllms of the spine were then taken (Fig. 10). These fllms show the lipiodol to
be partially blocked a t the level of the flfth thoracic vertebra.
No dcflnite preoperative diagnosis was made, but the possible diagnoses recorded
were : tumor, traumatic lesion (with infection), tuberculosis of the 6th thoracic vertebra.
Operatio?&:On Sept. 3, 1930, a laminectomy was performed. The soft parts had
been dissected free from the 3d to the 8th thoracic spinous processes, when parts of the
tumor mass appeared between the laminae. I t was soft, had a jelly-like appearance, and
had destroyed bone extensively. Portions of the lamina and transverse process of the
6th vertebra, as well as the head and neck of the 6th rib, were replaced by tumor, with
only a few spicules of bone imbedded in it. The dura and cord proper were not invaded,
alt,hough surrounded and compressed by tumor. A laminectomy was performed, exposing the cord throughout the extent of the tumor, which was about one vertebral level.
FIQ.11. CASE 1:
PHon>MIcaOaaaPH
OF PLASMA-CELL
MYELOMAOF
VEaTEsRA
Eleven radium needles (65 mg.) were inserted into the tumor mass and left in place
twrnty hours, giving a total dose of 1300 mg. hours with 0.5 mm. nickel steel as Alter.
The patient was given a blood transfusion two hours after operation because the systolic
blood pressure had dropped to 76 mm. Hg.
Microscopic examination of the tissue removed at operation demonstrated the tumor
to be composed of small, round cells with hyprchromatic nuclei with an occasional
initotic figure. There was a large amount of free blood throughout the cellular mass.
The pathological report was plasma-cell myeloma (Fig. 11).
0 1 1 October 8, 1930, high-voltage x-ray therapy was begun.
I n four treatments
over a six-day-period 132 per cent of a skin erythema dose was given to each one of
anterior and posterior fields, the factors being 200 kv., 1 mm. copper Alter plus 4 mm.
aluminum, 60 em. target skin distance.
Notes and Observations Made after Operation: On Sept. 8, five days after operation, tho patient complained of paresthesias in both lower extremities and involuntary
muscular contractions. On Sept. 11, seven days after operation, sensation was found
to be improved over both lower extremities, perceptibility to pin prick was acute on the
right and fair on the left. On Sept. 21, eighteen days after operation, there were still
involuntary muscular contractions in the lower extremities, and pain in the feet, espe-
EFFECT OF RADIUM ON THE SPINAL CORD
567
cially the left. On Sept. 25, twenty-two days after operation, the patient still had
considerable decrease in pin prick sensibility. At this time the reflexes in his legs were
interpreted as less active than before operation. On Sept. 27, twenty-four days after
operation, voluntary control of the muscles of the lower extremities had returned enough
so that it was discernible. The patient was now entirely free of pain and was transferred to a convalescent home.
The patient returned for check-up Aug. 24, 1931, approximately one year after
operation. He walked into the dispensary. He stated that about the first of November
1930, two months after operation, he was able to stand but was not strong enough to
walk. During December 1930, he began to walk with crutches. I n January 1931, four
months after operation, he found that he could walk without crutches and since then
there had lieen a gradual increase in strength, which was still improving. Examination
demonstrated hyperactive reflexes in hoth lower extreluities but no other positive findings.
X-ray films were taken of the thoracic spine. They showed essentially the same appearance as the films taken before operation, except for changes due to the laminectomy.
Some of the lipiodol was still present.
On Aug. 24, 1931, another series of x-ray treatments was instituted, 125 per cent of
n skin erythema to posterior and 65 pcr cent to anterior fields being given in 3 treatments
over five days, the same factors being iisutl as previously.
Dr. L. R. Gowan of I)uIutli kindly consented to assist in following up this patient.
On Feb. 19, 1932, approximately eighteen arid a half months after operation, Dr. Gowan
reported the following positive tinclings : hyperartive reflexes in the lower extremities,
more marked on the right; a positive Babinski reflex on the right; abdominal reflexes
absent; slightly diminishecl scrisation of all types over a narrow band corresponding to the
abdominal distribution of the 9th thoracic segment.
The patient was readmitted March 5, 1932. He still had pain across the upper
abdomen when he stooped over and he described a sensation of stiffness in the lower
extremities on getting up in the morning. The urine was now found to contain Bence
Jones bodies. X-ray films of the entire skeleton (lid not reveal m y additional lesions
of multiple myeloma. High-voltage x-ray therapy mas again given to the region of the
6th thoracic vert&ra.*
DISCUSSION
OF CASEI : Myeloma not infrequently produces neurologic
symptoms arid does so most frequently hy compression from involvement of the vertebral column, paraplegia arid other neural disturbances
being found in 40 per cent of cases according to Geschiclrter and Copeland (lo), who also state that multiplicity of tumors is a cardinal point
in diagnosis of myeloma. They reported that in only five instances had
the disease been found in a single focus. I t is evident that in one of
these five cases, reported by Schmorl (Il), the lesions were multiple;
in two others, those reported by l h d d (15) and Morax (13), there was
no reason to conclude from the reports given that the clinician considered the possibility of multiple lesions or had made any effort to
find other lesions. Ewald’s case w7as an extensive tumor mass in the
region of the left shoulder, having its origin apparently in the clavicle.
The report by Morax described a tumor having its origin in the region
of the orbit. I11 the oafie reported by Wallgren (14) (Case 13) physical
examination arid s-ray studies of other parts of the skeleton failed to
demonstrate multiple 1er;ions. The lesion descri1)ecl was in the alveolar
process of the right mnsilla. Hciice-Jones bodies were prefient in the
urine. The fifth cam, whirh Cre~cliickterand Copeland refer to as n
single lesion of the multiple myeloma typc, WRS reported by Gcschickter
2 This patient w:is still liviiig
27
iii
Frlmiary 19.14, hiit with generalized skelrtrtnl metastases.
568
WILLIAM T. PEYTON
(15) in 1930. The lesion was in the upper part of the left femur. The
diagnosis was established by exploration and microscopic examination
of the tissue removed. Physical examination and x-ray films of other
parts of the skeleton failed to demonstrate the presence of other lesions.
Rence-Jones bodies were not present in the urine. Coley (16) in 1930
reported two cases of solitary myeloma, Case VIT a solitary myeloma,
of the femur and Case IX a solitary myeloma of the humerus. The
diagnosis in both cases was confirmed by microscopic examination.
Simmons (17) iii 1931 stated that in his experience myeloma of a single
bone is more common than the multiple type. He reported three cases
of solitary myeloma, one involving the second lumbar vertebra, another
the entire humerus, and an intraspinal lesion. All of these were confirmed by microscopic examination, and “skeletal x-rays ’’ showed no
other involvement. The case here reported is given as another instance
of single lesion in myeloma of the multiple type.
This tumor was at first considered both clinically and histologically
to be angio-endothelioma, an error which might easily occur in classifying such a tumor. One of the six cardinal diagnostic features of
multiple myeloma was present, namely backache and paraplegia ; a
Hecond, Rence-Jones bodies in the urine, was not looked for, but was
later found to be present. The other four cardinal points were absent.
TheRe six cardinal diagnostic points stressed by Qeschickter are (1)
multiple involkement of the skeletal trunk in a person over thirty-five
years of age; ( 2 ) fracture of a rib; ( 3 ) Bence-Jones bodies in the urine;
(4)backache and paraplegia: ( 5 ) anemia and (6) chronic nephrosis
with nitrogen retention and low blood pressure.
It is not unreasonable to expect to find angio-endothelioma or
hemangioma, between which there is a gradual gradation without any
sharp line of demarcation, occurring as a single or multiple lesion in
the vertebrae. Bailey and Bucy (18), in 1929, were able to collect from
the literature 10 such cases in which the Bpine was involved and added
one of their own, all of which gave clinical symptoms. Many additional
cases have been reported as post-mortem findings with no history of
symptoms due to these lesions (Makrycostas, 19). Hemangio-endothelioma has been reported as involving other parts of the skeleton,
also, as a single or a multiple lesion (20, 21, 22, 23).
Our patient has been essentially free from symptoms eighteen nnd a
half months after therapy was instituted. Myeloma is at preRent quite
generally believed to be incurable and it is to be expected that he will
eventually die of this d i s e a ~ e . ~The average duration of the disease is
about two years. Temporary remissions may occur spontaneously.
The longest duration of life after onset of symptoms was given as five
years by Geschickter and Copeland, but Kolodny states that some cases
have been reported with a survival period of ten years and more after
the onset of clinical symptoms. These were probably not proved cases.
Sabrazes and his associates (24) reported a case with the patient
alive ten years after onset of clinical symptoms. The diagnosis was
3
See footiiote
011
page 567,
EFFECT OF RAIJIUM ON T H E SPINAL CORD
569
proved by biopsy, but there WILS a possihility of error in the (late of onset. Ten years hefoi-c thc ;tiithow had examiiicd the patient, he had
suffered pain in the rcgion of the pelvis and hips. Two years later he
fractured one femur following very slight trauma and this, the authors
considered to he a pathological fracture. During the succeeding eight
years he fractured both femurs, and multiple tumors, which were very
seiisitive to radiation, appeared in the subcutaneous tissues. At the
time of examination, ten years after the onset of pain, almost all the
Bones showed lesions. Simmons reports a myeloma involving the skull
and jaw which was operated upoii in 191.2. X-rays of the entire skeleton, taken in 1928, showed no evidence of disease and at the time of the
report (1931) the patient was still alive and well.
Myeloma is very radioseiisitive ; the end-results, however, have been
only palliative (Geschickter aiid Copeland, JColodny, and Moore, 2 5 ) .
The disease spreads to form other lesions, and finally death enmm
Qeschickter does not believe the duration of life is prolonged by radiation. This may be true for most cases, but certainly it is most probable
that in the case here repoi*ted,life was ~)rolongcd11y radiation and the
patient restored to useful, productive activity.
CASE11: This case is reported because the vertebral involvement was similar to that
in Case I. It also illustraks the fact that not much can be expected following lamincctomy without radiation. The patient was a male fifty-two years of age, admitted Feb.
26, 1932. H e dated the onset of his condition bark to Novrmlier 1930, when he began
to hnve pain in the interscapulai* region. H e obtninpd some relief with locnl npplication
570
WILLIAM T. PEYTON
of heat. 111 September 1931, he had all his teeth removed because they were believed to
have a causativc relation to the pain. I n October 1831, he began to notice numbness
below the umbilicus. It spread distally during the course of two weeks over tlie body and
lower extremities, arid a t tlie same time there was onset arid rapid progression of paralysis
of the lower extremities, so that at the end of the two-week interval he had developed
complete paraplegia. He coulcl riot void aiiil mas catheterized. On Nov. 3, 1931, films
of the spine were taken, which demonstrated a lesion of the 9th thoracic vertebra (Fig.
12). Lamineetomy was performed elsewhere, the preoperative diagnosis being tuberciilosis of the ninth thoracic vertebra. Microscopic examination of tissue removed a t
operation demonstrated it to be plasma-cell myeloma.
On Jan. 14, 1932, approximately two months after operation, the patient noticed
that he could move his toes. Approximately four months after operation, he was referred here for high-voltage x-ray therapy. The essential findings were pitting edema
of the feet and legs and almost complete paralysis of the lower extremities; the patient
c*ould flex and extend his toes to some extent and there were feeble contractions in Rome
of the other muscles, but insufficient to move the extremity; there was a bilateral Babinski
FIQ.13. CASE11: PHOTOMICROGRAPH
OF PLASMA-CELL
MYELOMAOF VERTEBRA
reflex; a very slight knee jerk reflex was present on the left, but there was a normal
knee jerk on the right. Pain sense, as elicited by pin prick, was absent up to the groin,
but light touch sensation mas present. The patient could not void. Laboratory examinations were essentially negative except that there was a very faint trace of BenceJones bodies in the urine. X-ray films were made axid again demonstrated compression
nntl absorption of the ninth thoracic vertebra, with a soft tissue maas around the
vertebra ; also a destructive process in several ribs, several rounded punched-out areas in
the skull, and a diffuse rarefaction of the pelvis.
On March 2, 1932, high-voltage x-ray therapy WRS started. I n two treatments, with
forty-eight hours intervening, the patient was given 120 per cent of a skin erythema dose
to a posterior field over the thoracic and upper lumbar spine, the factors being 200 kv.
1 mm. copper filter plus 4 mm. aluminum, 60 em. target skin distance. X-ray therapy
was also given to other meas of involvement.
The patient was readmitted June 13, 1932. At this time the general condition was
better, he was free from pain and could void urine. Sensation was also improved,
being now definitely impaired only below the knees. There was slight increase in
voluntary movements in the lower extremities.*
4
This patient died February
5, 1933.
EFFECT OF RADIUM O N THE S P I N A L CORD
571
DISCUSSION
OF CASEJI : The result obtained in Case 11 would indicate
that laminectomy alone is not siifficierit to relieve paraplegia in myeloma, and that deep x-ray alone is not as effective as a combination of
interstitial radiation and high-voltage x-ray therapy. It is true that
the x-ray dosage was smaller than in Case I.
A single lesion in myeloma is so rare that only a very few have been
treated with radiation, certainly not enough to say that the condition
cannot be cured. Thcrcforc, in the presence of a single lesion we should
attempt to give a curative rather than a palliativc dose. This can probably be best accomplished hy a combination of interstitial radiation and
high-voltage x-ray therapy.
SUMMARY
A N D CONVTAWTONS
The effect of radiation on the ~pinnlcord and the maximum safe
dose to which the cord may be cxposed arc iiot clearly defined in the
literature.
Experiments w"crc performed to cletcrmine the effect of r ad'ium on
the cord.
Changes produced in the meninges and in the cord proper by esposure to radium were: a meiiiiigeal reaction over a localized area a t
the site of implantation, characterized by infiltration of leukocytes,
nerve cell injury, and glial cell proliferntioii with smallcr closes ; with
larger doses there were nerve cell destruction, myeliii degeneration,
hemorrhages, and even fragmentation of the grey matter and focal
necrosis of the white matter. The maximum dose of radium placed
extradurally which was tolerated without resulting paralysis was 1.7
millicuries.
Two cases of plasma-cell myeloma arc reported. Case I is interesting because it is apparciitly another instance of plasma-cell myeloma occurring a8 a single lesion. Followine; laminectomy and radiation therapy there was recovcry of cord function and additional lesions had not
developed during an interval of eighteen and a half months since the
first treatment.'
Case I1 is included in this report because of the similarity of the
vertebral lesion as seen in the x-ray films with the lesion in Case I. It
is also reported to emphasize the eff'oct of radiation in contrast to the
effect of lamincctomy without radi at'ion.
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