Paralytic phenomena occur both in the sensory and in the motor nerves. Accordingly we observe angsthesia, limited to one or two extremities or parts of extremities and, on the other hand, loss of power or atrophy in certain definite muscle groups. Depending on whether one half of the spinal cord or the entire cross-section is diseased, there is either a henliplegia or a complete transverse paralysis. The typical picture of paraly.sis due to unilateral lesion of the spinal cord is found in so-called Brown-Sequard paralysis. In this disease there is motor paralysis on the side of the tumor with exaggeration of reflexes and loss of the sense of position, and on the opposite side angsthesia of all varieties of sensation with the exception of the sense of position. On the side of the motor paralysis a hypertesthetic zone. which is the expression of nerve root irritation, is not infrequently observed at the height of the spinal disease. In explanation of this paralysis suffice it to say there that the motor disturbances on the same side are caused by disease of the spinal tracts which are uncrossed, whereas the sensory- tracts, which are responsible for the sensory disturbances, cross to the other side soon after entering the spinal cord. This Brown-Sequard paralysis is a very characteristic sytnptom of tumor of the spinal cord, because, with the exception of rare injuries, it does not occur in other diseases of the spinal marrow. Unfortunately, it is not always sharply defined; the sensory paralysis, particularly, is sometimes limited to certain kinds of sensation (pain, temperature).
If the tumor involves the entire spinal cord, the sy-mptoms of 13rown Sequard paralysis become indistinct and the picture of a transverse lesion gradually makes its appearance. Corresponding to the most frequent seat of tumors of the spinal cord in the thoracic portion, we find spastic paraplegia with antesthesia of both legs, disturbance of the bladder and rectum, and decubitus. When the neoplasm involves the cervical or lumbar enlargement, an extremely variable picture may be produced and the symptoms niay be exceedingly difficult to interpret, because in these cases, depending on the seat of the tumor, localized muscular atrophies may be added to the sensory and spastic paralysis.
The following points are of importance in determining the level of a spinal tumor.
Tumors situated in the upper cervical portion: At first unilateral paralysis or Brown-Sequard paralysis, later paralysis of all four extremi ties, pain in the distribution of the cervical plexus, paralysis of the muscles at the back of the neck, with possibly rapid fatal termination from paralysis of the phrenie nerve. Cervical enlargement: Flaccid
unilateral paralysis of the arm, often spastic paralysis of both legs, paralysis of the muscles of the trunk. If the tumor is not very extensive, there may be only paralysis of the individual muscles of the arm. Dorsal portion. Typical picture of 13rown-Sequard paralysis, then paraplegia and disturbance of the bladder and rectum. Lumbar enlargement: First, unilateral pain in the lumbar plexus radiating into one leg; atrophic paralysis of individual muscles of the thigh and leg; possibly Brown-Sequard's syndrome as regards the two legs; later, complete sensory and motor paralysis of the legs with abolition of the patellar reflex but preservation or exaggeration of the Achilles tendon reflex. Sacral portion: Atrophic paralysis of the leg, the foot, the gluteal mus cles and the levator ani; loss of sensation in the legs, the inner aspect of the thigh, the foot and the anal region; disturbance of the bladder and rectum; decubitus; loss of Achilles tendon reflex; the knee phenomenon is usually present. As a rule the tumors are so large that they involve both the lumbar and the sacral portions of the cord. Cauda eguina: Bilateral, rapidly developing parapleg,ia; intense pain, especially- in the sacrum and coccyx; anTsthesia in the region of the rectum.
The diagnostic difficulties presented by- a tumor of the spinal cord can readily be appreciated from the above description. The important points in the diagnosis are: Onset with pain when the tumor is extra medullary; Brown-Sequard paralysis when the tumor is situated in the medulla; and, finally, the symptoms of a transverse lesion as the entire spinal cord becomes in volved. But it must be specially emphasized that small tumors of the spinal cord, and especially tubercles, often fail to give rise to any special symptom sufficiently definite for localization, and frequently escape discovery until they are revealed at the autopsy. The conditions that would be considered in the differential diagnosis, assum ing that the possibility of tumor is thought of at all, arc: spinal meningitis and spondylitis, the diagnosis of which is rendered possible by the char acteristic symptoms which appear later.
The prognosis of tumors of the spinal cord is very- unfavorable. if the patients do not die of the disease itself, death often results from decubitus and paralysis of the bladder.
Aside from mere symptomatic remedial measures, the treatment consists logically in removal of the neoplasm. The difficulties of such a procedure in childhood have already been explained and, as a matter of fact, we know of no case in which a spinal tumor in a child was subjected to operative treatment.