TUMORS OF THE SPINAL CORD The pathologic and clinical picture of tumors of the spinal cord in the adult has recently attracted increased attention and has been made the subject of very thorough study. Interest in these neoplasms was aroused by the success achieved by intrepid operators working in con junction with able neurologists (the foremost among whom were Horsley and (lowers) in accurately determining the seat and then successfully' removing a tumor of the spinal cord. Important as is this achievement for adults suffering from this baneful disease, it finds but little applica tion in pediatrics because in the ease of children the tutnors are rarely extramedullary and sharply circumscHbed, being in most cases extensive neoplasms and quite frequently involving the medullary substance of the spinal cord. Since the most common tumors in the spinal cord are tubercles, the same operative difficulties that we have described in connection with brain tubercle are encountered.
Tumors of the cervical canal may be situated (1) in the bone, (2) in the meninges, and (3) in the spinal cord itself.
With regard to the incidence of these tumors, it appears from Schlesinger's analysis that bone neoplasms (carcinoma, sarcoma) are practically never seen in children, with the exmption of metastatic sarcomata, which are occasionally encountered. Among meningeal tumors mention should be made of sarcotnata, which usually attack the meninges priniarily and later spread to the spinal cord and to the brain or appear as secondary tumors in the form of gliosarcoma especially after orbital sarcoma. Lipoma of the spinal meninges is also observed in early childhood and is probably the result of some congenital forma tion. Within the spinal marrow tubercles are most common in child hood, either single or more frequently in the form of multiple tumors. Primary gliomata, which may become diffuse, are also seen. Gummata of the spinal cord are rare in children and are difficult to distinguish from inflammatory changes in the spinal marrow and from meningitis.
The incidence of spinal tumors during the different periods of life is as follows: in children under ten years of age tubercle is the commonest among intramedullary, as lipoma and sarcoma are the most frequent among extramedullary tumors. In the second decade of life tubercles
again preponderate within the spinal marrow, and gliomata are also seen. Outside of the medullary substance, primary or metastatic sarcomatosis is the affection most frequently observed.
The symptomatology of tumors of the spinal cord varies with the seat and character of the neoplasm. The widest variations are observed from cases in which the neoplasm either produces no symptoms at all or symptoms that are quite insignificant in comparison with those of a general disease, to the familiar clinical picture of the greatest gravity, presenting signs of EL neoplasm of the spinal cord, although the localiza tion is not always easy to determine. The indefinite character of the clinical picture in tumor of the spinal cord is illustrated by a carefully studied case of Heubner's in which there were present paralysis of both legs, with permanent flexion, great pain on passive movement, attacks of tonic spasms in the arms, besides blindness and atrophy of the optic nerve. The autopsy revealed multiple gliomata in the spinal marrow, gliomatous degeneration of the posterior columns, and hydrocephalus, probably caused by an ascending meningitis. In multiple sarcomatosis the course of the disease is sotnetimes stormy and accompanied by fever.
Aside from these unusual findings the picture of tumor of the spinal cord is about as follows: The first and niost important symptom is pain, radiating into one or more extremities according to the seat of the tumor, or in the form of girdle pain. These neuralgias, which are rarer in children than in adults, must be regarcled as direct symptoms of imitation of the nerve roots. Hypergsthesia is sometimes present in the affected part of the body. Motor symptoms of irritation are more rare. They include tonic contractures and possibly direct spasms, limited to one or more extremities. The stage of irritation of the nerve roots may bc quite protracted and is always present when the neoplasm begins outside of the medullary substance.