“Take as an example a lesion in the centrum ovale of the occipito-temporal region. Such a lesion will produce hemianopsia, because it involves the visual tract of the projection system. It may also produce a peculiar mental condition known as word-blindness, in which the patient is no longer able to associate a word or letter seen with its corresponding sound or with the motion necessary to write it. Charcot has reported a case of this kind.... The man, who was a very intelligent merchant, was suddenly seized with right hemianopsia while playing billiards, and was surprised to find that he saw but one-half of the ball and of the table. Soon after he had occasion to write a letter, and after writing it was surprised to find that he could not read what he had just written. He found, however, that on tracing individual letters with the pen or fingers he became conscious of the letters—a few letters (r,s,t,x,y,z), however, being an exception to this rule. When a book was given him to read he would trace out the forms of the letters with some rapidity, and thus manage to make out the words. If his hands were put behind him and he was asked to read, he would still be observed to put his fingers in motion and trace the letters in the air. Speech was in no way interfered with, but reading aloud was only accomplished, like reading to himself, by the aid of muscular sense. Here, then, was an example of a lesion which had separated entirely the tract associating sight with speech—viz. the occipito-temporal tract—but had left intact the tract associating sight with muscular sense—viz. the occipito-central tract.”
39Med. Record, vol. xxix. No. 7, Feb. 13, 1886.
40Amer. Journ. of Neurology, Feb., 1883.
Our tabulated cases, although collected for the purpose of studying inductively the phenomena of intracranial tumors from all points of view,have been arranged to indicate, so far as is possible, the special symptoms which are produced by growths in special localities. Thus we have made thirteen subdivisions:
I. Superior antero-frontal region (5 cases).—The lateral and median aspects of the hemisphere from the anterior tip backward to the posterior thirds of the first three frontal convolutions, the region roughly bounded by the coronal suture.
II. Inferior antero-frontal or orbital region (5 cases).—From the anterior tip of hemisphere at the base backward to the optic chiasm and Sylvian fissures.
III. Rolandic region or motor cortex (15 cases).—From antero-frontal region backward nearly to mid-parietal lobe, including posterior thirds of superior middle and inferior frontal convolutions, ascending frontal and ascending parietal convolutions, and anterior extremities of superior and inferior parietal convolutions—lateral and median aspects.
IV. Centrum ovale, fronto-parietal region (5 cases).
V. Postero-parietal region (5 cases).—From Rolandic region to parieto-occipital fissure, including posterior two-thirds of the superior and inferior parietal convolutions and the præcuneus.
VI. Occipital region (9 cases).—Occipital lobe—cortex and centrum ovale.
VII. Temporo-sphenoidal region (4 cases).—Temporo-sphenoidal lobe.
VIII. Basal ganglia and adjoining regions (19 cases).—Caudate nucleus, lenticular nucleus, optic thalamus, internal capsule, corpora quadrigemina, and ventricles except the fourth.
IX. Cerebellum (9 cases).
X. Floor of fourth ventricle (6 cases).—(Directly or indirectly involved.)
XI. Pons varolii and medulla oblongata (8 cases).
XII. Crura cerebri (3 cases).
XIII. Middle region of base of brain and floor of skull (7 cases).—In the main, from optic chiasm backward to pons, in the middle basilar region, in some instances extending beyond this area in special directions.
Tumors of the antero-frontal regions can be diagnosticated with considerable certainty, partly by a study of the actual symptoms observed and partly by a process of exclusion. Headache of the usual type, vertigo, choked discs, inflammatory and trophic affections of the eyes, widely varying body-temperature, and high head-temperature are among the most positive manifestations. Mental slowness and uncertainty seem to be greater in these cases than in others. Mental disturbance of a peculiar character unquestionably occurs in cases of tumor, as of other lesions, in this region. This disturbance is exhibited chiefly in some peculiarity of character, showing want of control or want of attention. The speech-defects present in a number of cases were rather due to the change in mental condition than to any involvement of speech-centres. Under Symptomatology has been given in some detail a study of the psychical condition in one case of antero-frontal tumor. The absence of true paralysis and of anæsthesia is characteristic. Nystagmus and spasm in the muscles of the neck and forearm were present in one instance, but usually marked spasm is not to be expected. Vomiting is less frequent than in tumors situated farther back. Facial and other forms of paresis occasionally are present, but are not marked, and are probably due to involvementby pressure or destruction of surrounding tissue of neighboring motor areas. Hemianopsia, such as was observed in Case 10, showed involvement of the orbital region. Tumors of the inferior antero-frontal lobe give the same positive and negative characteristics as those of the superior frontal region, with the involvement in addition of smell and certain special ocular symptoms, such as hemianopsia.
Tumors of the motor zone of the cerebral cortex, the region surrounding and extending for some distance on each side of the fissure of Rolando, can be diagnosticated with great positiveness: 15 of the 100 cases are examples of tumors of this region, and in many of these the diagnosis of the location of the growth was accurately made during life. Localized spasm in peripheral muscles; localized peripheral paralysis; neuro-retinitis or choked discs; headache; pain elicited or increased by percussion of the head near the seat of the tumor; and elevated temperature of the head, particularly in the region corresponding to the position of the growth,—are the prominent indications. The spasmodic symptoms usually precede the paralysis in these cases. The spasm is often local, and generally begins in the same part in different attacks—in the fingers or toes or face of one side.
A study of cases of tumor localized to the cortical motor area will show that in almost any case a local twitching convulsion preceded the development of paresis or paralysis. Hughlings-Jackson41reports a case of sarcoma, a hard osseous mass on the right side of the head, of eighteen years' standing, subjacent to which was a tumor the size of a small orange growing from the dura mater. The patient was a woman aged forty-nine, whose symptoms were very severe headache and double optic neuritis, with paresis in left leg, followed by slighter paresis in left arm and left face. A very slow, gradual hemiplegia came on by pressure on the cortex without any fit. Jackson says this is the only case which he has seen in which the hemiplegia has not followed a convulsion where the lesion has been on the surface. In all very slowly oncoming hemiplegias which he has seen, except this one, the tumor was in the motor tract.
41Medical Times and Gazette, London, 1874, vol. i. 152.
As the white matter of the centrum ovale and capsules represents simply tracts connecting cerebral centres with lower levels of the nervous system, with each other, or with the opposite hemisphere, lesions of this portion of the cerebrum will closely resemble those cortical lesions to which the tracts are related. We have already referred to the peculiar symptoms referable to involvement of commissural and association fibres. Tumors of the centrum ovale of the fronto-parietal region, of which five examples are reported in the table, vary in symptomatology according to their exact location. Those situated in the white matter in close proximity to the ascending convolutions give symptoms closely resembling those which result from lesions of the adjoining cortical motor centres. In the cases of Osler, Seguin, and Pick (Cases 26, 27, 28, 29) spastic symptoms in the limbs of one side of the body, with or without loss of consciousness, were marked symptoms. In two of these cases some paresis preceded the occurrence of the spasms. They did not, however, fully bear out the idea of Jackson that the hemiparesis or hemiplegia in tumors of the motor tract comes on slowly before the appearance of spasm.
Tumors of the postero-parietal region present some characteristic peculiarities. In several cases tumors were located in this region, and in several others the white matter of the parietal lobe was softened as the result of the obliteration of blood-vessels by the tumors. In general terms, we might say that hemianæsthesia, partial or complete, and impairment of sight and hearing on the side opposite to the lesions, seemed to be the most constant peculiarities.
Tumors and other lesions of the occipital lobes have in the last few years received extended attention, and, where possible, exact study, because of the opportunities which they furnish for corroborating the work of the experimental physiologists. It is unfortunate that the records of older cases do not furnish the exact detail which would render these tumors among the most important and interesting to be met with in the brain: some cases have, however, been observed with great care, and a few such are included in the table. To understand the special significance of the symptoms of such tumors, it will be well briefly to state some of the well-established facts about the function of the occipital cortex. The investigations of Gratiolet and Wernicke especially have proved that this surface of the brain is in direct connection with the fibres (1) which are continued upward from the posterior or sensory columns of the cord through the posterior portion of the internal capsule, and (2) with the expansion of the optic nerve, or the tract which passes, according to Wernicke, from the thalamus to the occipital lobe. There is but a partial decussation of the optic nerves at the chiasm, so that each half of the brain receives fibres from both eyes. This arrangement is best stated by Munk (quoted by Starr) as follows: “Each occipital lobe is in functional relation with both eyes in such a manner that corresponding halves of both retinal areas are projected upon the cortex of the lobe of the like-named side;e.g.destruction of the left lobe produces loss of function of the left halves of both retinæ.” This, of course, causes the right halves of both fields of vision to appear black. This condition is known as lateral homonymous hemianopsia, and was exhibited in several of the tabulated cases (Cases 40, 41, 42, and 43). It is probable that the dimness of the right eye recorded in Case 38 was really right lateral hemianopsia, as patients mistake this condition for blindness of that eye alone which is on the side upon which the visual fields are blank. It follows that this condition of the eyes will be caused by a destructive unilateral lesion at any point upon the optic tract behind the chiasm; and its exact nature and location are to be inferred from other corroborating symptoms. Among these corroborating symptoms, as will be inferred from the other functions of the occipital cortex, is especially to be considered partial hemiplegia and partial hemianæsthesia. This was observed in Cases 38, 40. These most characteristic localizing symptoms of occipital tumor have usually others, which, if not of such special importance, yet help to form a special complexus. Among these diffused headache is referred to by some writers as characteristic, but it seems to us that a localized headache, with pain on percussion over the affected region, is the only kind in this as in other regions which could have special diagnostic importance. Affections of hearing are recorded by some. It is not at all uncommon to have an incomplete hemiplegia and local paralysis. In Case 41 complete hemiplegia with facial paralysis is recorded. Local palsies, ocular and facial,are recorded in Cases 36, 37, 38, and 39. It is doubtless by transmitted pressure, or by extension of the tumor, or the softening caused by it, toward the motor fibres, that these more or less incomplete paralyses are caused. The general symptoms, such as vertigo, vomiting, and convulsions, are frequently present with tumors of the occipital lobes. We are at a loss to know upon what data of theory or experience Rosenthal bases his statement that psychic disorders are more common in occipital tumors than in those of the anterior and middle lobes, unless he refers simply to the hebetude and late coma which seem to come generally in these cases.
Tumors of the temporo-sphenoidal region, so far as we have been able to study them, present few characteristic features. Physiology seems to point to the upper temporal convolutions as the cerebral centres for hearing; thus, according to Starr,42“disturbances of hearing, either actual deafness in one ear or hallucinations of sound on one side (voices, music, etc.), may indicate disease in the first temporal convolution of the opposite side. Failure to recognize or remember spoken language is characteristic of disease in the first temporal convolution of the left side in right-handed persons, and of the right side in left-handed persons. Failure to recognize written or printed language has accompanied the disease of the angular gyrus at the junction of the temporal and occipital regions of the left side in three foreign and one American case.” In two of our four cases of tumor in the temporo-sphenoidal region disturbances of hearing were noted, but in none was the sense studied with sufficient care to throw any light upon the actual character of the disorder. The case of Allan McLane Hamilton (Case 47), already referred to under Symptomatology, was interesting because of the presence of a peculiar aura connected with the sense of smell. Stupidity, want of energy, drowsiness, and general mental failure were marked in tumors of this region.
42American Med. Sci., N. S. vol. lxxxviii., July, 1884.
Tumors of the motor ganglia of the brain are seldom strictly localized to one or the other of these bodies. Growths occurring in this region usually involve one or more of the ganglia and adjacent tracts, and can only be localized by a process of careful exclusion, assisted perhaps by a few special symptoms. Paralysis or paresis on the side opposite to the lesion usually occurs in cases of tumor of either the caudate nucleus or lenticular nucleus; but whether this symptom is due to the destruction of the ganglia themselves, or to destruction of or pressure upon the adjoining capsule, has not yet been clearly determined. In a case of long-standing osteoma of the left corpus striatum (Case 49) the patient exhibited the appearance of an atrophic hemiplegia: his arm and leg, which had been contractured since childhood, were atrophied and shortened, marked bone-changes having occurred. Another case showed only paresis of the face of the opposite side. Clonic spasms were present in two cases, in one being chiefly confined to the upper extremities of the face. In this case paralysis was absent. Disturbances of intellect and speech have been observed in tumors of this region. According to Rosenthal, aphasic disturbances of speech must be due to lesions of those fibres which enter the lenticular nucleus from the cortex of the island of Reil.
Tumors of the optic thalamus usually cause anæsthesia or otherdisturbances of sensation in the extremities of the opposite side. They sometimes show third-nerve palsies of the same side in association with hemiplegia on the opposite side, these symptoms being probably due to pressure owing to the proximity of the neighboring cerebral crus. Speech and gait in such tumors are also often affected.
Tumors of the corpora quadrigemina give rise to disturbances of sight and special ocular symptoms, such as difficulty in the lateral movement of the eyes. Spasms were usually present. Automatic repetition of words was observed in one case, nystagmus in another, and diminished sexual inclinations in a third. In other cases peculiar ataxic movements or a tendency to move backward were noted; other symptoms, such as spasm, vomiting, headache, were general phenomena of intracranial tumors; still others, such as hemiplegia, hemiparesis, or anæsthesia, were probably simply due to the position of the growth in the neighborhood of motor ganglia and tracts.
Tumors of the cerebellum have some special symptoms, which also derive importance from their characteristic grouping. The symptoms which depend upon the lesion in the organ must be distinguished from those which are caused by pressure upon adjacent parts, although these latter symptoms are very important as corroborative evidence of the location. Among the special symptoms is occipital headache (often not present), especially when the pain is increased by percussion about the occiput or by pressure upon the upper part of the neck. In these cases weakness of the gait (Case 75) and other motor phenomena, which are usually described as inco-ordination, are of comparatively frequent occurrence. They are not so much true inco-ordination as tremor of the limbs, rotation (which is usually only partial), and the so-called movements of manége. These movements were present in one-third of the cases collected by Leven and Oliver (quoted by Rosenthal). Staggering gait is also present, and may be dependent upon the vertigo, which is apt to be unusually intense in this kind of intracranial tumor (Cases 69 and 71). The symptoms caused by pressure of cerebellar tumors upon adjacent organs are of importance, because in conjunction with the special symptoms they acquire unusual significance. Sight and hearing are the two special senses apt to be affected, because of pressure upon the geniculate bodies and upon the auditory nerve or its nucleus. Descending optic neuritis, progressing to total blindness, and varied forms of oculo-motor paralysis may be present. Strabismus convergens has been said to be a symptom, caused by the paralysis of the sixth nerve. A hemiplegia and hemianæsthesia result sometimes from pressure upon the tracts in the pons or medulla. Continued pressure upon the medulla may eventually, toward the termination of the case, according to Rosenthal, cause disorders of the pulse and of respiration and deglutition. This author gives absence of psychical symptoms as negative evidence which counts for tumors of the cerebellum, but our table shows several instances (Cases 70, 71, 74, and 76) in which were present hebetude, incoherence, or hysteroidal symptoms. It is probable, however, that such symptoms are not as common and distinct as in tumors of the cerebrum.
Certain symptoms—or, better, groups of symptoms—characterize tumors of the pons varolii, and serve to render the local diagnosis comparatively certain. These depend upon the fact that the pons combines in itself, orhas on its immediate borders, nerve-tracts, both motor and sensory, in great complexity, from or to almost every special or general region of the body. Among these symptoms may especially be mentioned alternating and crossed hemiplegia, paralysis of eye-muscles (strabismus), paresis of tongue, dysphagia, anæsthesia (sometimes of the crossed type), and painful affections of the trigeminus. Vaso-motor disturbances have also been noted. In one case persistent and uncontrollable epistaxis hastened the fatal termination of the case.
Conjugate deviation of the eyes, with rotation of the head, as stated under Symptomatology, is a condition often present in tumors of the pons varolii as well as in the early stages of apoplectic attacks. A paper43has been published by one of us on a case of tumor of the pons, and from it we will give some discussion of this subject.
43Journal of Nervous and Mental Disease, July, 1881; Case 84 of Table.
Vulpian was probably the first to study thoroughly conjugate deviation. The sign, when associated with disease of the pons, was supposed by him and by others to be connected in some way with the rotatory manifestations exhibited by animals after certain injuries to the pons. Transverse section across the longitudinal fibres of the anterior portions of the pons produces, according to Schiff, deviation of the anterior limbs (as in section of a cerebral peduncle), with extreme flexion of the body in a horizontal plane toward the opposite side, and very imperfect movements of the posterior limbs on the other side. Rotation in a very small circle develops in consequence of this paralysis.44The movements of partial rotation are caused, according to Schiff, by a partial lesion of the most posterior of the transverse fibres of the pons, which is followed in animals by rotation of the cervical vertebræ (with the lateral part of the head directed downward, the snout directed obliquely upward and to the side).
44Rosenthal'sDiseases of the Nervous System, vol. i. p. 125.
This deviation, both of head and eyes, occurs, however, not only from lesions of the pons and cerebellar peduncles, but also from disease or injury of various parts of the cerebrum—of the cortex, centrum ovale, ganglia, capsules, and cerebral peduncles. It is always a matter of interest, and sometimes of importance, with reference especially to prognosis, to determine what is the probable seat of lesion as indicated by the deviation and rotation.
Lockhart Clarke, Prevost, Brown-Séquard, and Bastian, among others, have devoted considerable attention to this subject. To Prevost we owe an interesting memoir. Bastian, in his work onParalysis from Brain Disease, summarizes the subject up to the date of publication (1875). Ferrier, Priestly Smith, and Hughlings-Jackson have investigated the relations which cortical lesions bear to the deviation of the eyes and head.
It has been pointed out by several of the observers alluded to that when the lesion is of the cerebrum the deviation is usually toward the side of the brain affected, and therefore away from the side of the body which is paralyzed. In a case of ordinary left hemiplegia it is toward the right; in one of right hemiplegia, toward the left. In several cases of limited disease of the pons, however, it has been observed that the deviation has been away from the side of the lesion. In our case (Case 84) the conjugate deviation was to the right, while the tumor was entirelyto the left of the median line, thus carrying out what appears to be the usual rule with reference to lesions of the pons.
During the life of the patient it was a question whether the case was not one of oculo-motor monoplegia or monospasm from lesion of cortical centres. It is probable, as Hughlings-Jackson believes, that ocular and indeed all other movements are in some way represented in the cerebral convolutions. In theBritish Medical Journalfor June 2, 1877, Jackson discusses the subject of disorders of ocular movements from disease of nerve-centres. The right corpus striatum is damaged, left hemiplegia results, and the eyes and head often turn to the right for some hours or days. The healthy nervous arrangement for this lateral movement has been likened by Foville to the arrangement of reins for driving two horses. What occurs in lateral deviation is analogous to dropping one rein; the other pulls the heads of both horses to one side. The lateral deviation shows, according to Jackson, that after the nerve-fibres of the ocular nerve-trunks have entered the central nervous system they are probably redistributed into several centres. The nerve-fibres of the ocular muscles are rearranged in each cerebral hemisphere in complete ways for particular movements of both eyeballs. There is no such thing as paralysis of the muscles supplied by the third nerve or sixth nerve from disease above the crus cerebri, but the movement for turning the two eyes is represented still higher than the corpus striatum.
It would seem a plausible theory that we have in this conjugate deviation of the eyes and head a distinct motor analogue to the hemianopsia which results from certain lesions high in the optic tracts. The fact that we never have a distinct oculo-motor monoplegia from high lesions, but always a lateral deviation of both eyes in the same direction, suggests that only a partial decussation of the fibres of the motor nerves of the eyes occurs, and that each hemisphere does not control the whole motor apparatus of the opposite eye, but half of this apparatus in each eye.
Alternating hemiplegia, or paralysis of one side of the body followed by a paralysis of the other side, is observed in tumors of the pons, and is readily accounted for by the close proximity of the motor tracts, a lesion which affects one tract first being very likely, sooner or later, to involve, partially at least, the other, as in Case 84. Cross-paralysis of the face and body may be seen, and like crossed anæsthesia (seen also in Case 84) depends upon the fact that both motor and sensory fibres to the limbs do not decussate at the same level as these fibres to the face. Trigeminal neuralgia, from involvement of the nerve by pressure or otherwise, is recorded in this characteristic group of symptoms. The association of the general with the local paralytic symptoms in the manner stated, the involvement of sensory functions, and the deviation of the eyes and head serve to distinguish tumors of the pons from cortical or high cerebral local lesions. Cases 81, 84, 89, and 90 illustrate these facts in various ways. Case 82, involving the floor of the fourth ventricle, appears to be an exception, as the deviation is toward the side of the lesion.
The special localizing symptoms which indicate a tumor of the crus cerebri are paralysis of the oculo-motor nerve upon the same side as the tumor, and especially the tendency of this paralysis to pass tothe other side later in the case; disturbance of the innervation of the bladder; and involvement of the vaso-motor functions. In considering these symptoms in detail it becomes very evident why we have the alternating paralysis of the two oculo-motor nerves. As this trunk arises from the crus, it is in direct risk of injury by the neoplasm, and the extension of the new growth even slightly must later in the case involve its fellow. Therefore a ptosis, followed by a similar symptom on the other side, or other third-nerve symptoms passing from one side to the other, with other characteristic and corroborating symptoms, furnish strong evidence of this lesion, as in Case 93. Rosenthal refers especially to involvement of the bladder, as difficulty of micturition, but the three cases in the table do not present such a symptom. He says that experiments prove that irritation of the peduncle is followed by contraction of the bladder, and that it has been shown that lesions of the crus abolish the influence of the will upon micturition. As this occurs at all levels of the cord, its occurrence with lesions of the crus is not to be considered a very distinctive symptom. The involvement of the vaso-motor functions is one of much interest. Its occurrence is not recorded in the cases of tumors of the crus included in the table, but in Case 94 of twin tumors in front of the optic chiasm it is recorded that profuse perspiration occurred. We believe that the centres for the vaso-motors are not well determined: they seem to be affected by various lesions, especially about the base of the brain. Among other corroborating symptoms may be mentioned rotatory movements and deviation of the head: these rotatory movements are probably caused by the action of the sound side not antagonized by the muscles of the paralyzed side. Lateral deviation of the head is referred to by some. Partial or complete hemiplegia, with facial paralysis on the side opposite to the lesion, may occur; whereas the oculo-motor palsy is seen on the same side as the lesion. Diminution of sensibility happens on the opposite side, or occasionally pain in the legs, as recorded in Case 92. It is of interest to note, with Rosenthal, that the reactions of degeneration are not likely to appear in the facial muscles in this lesion, as it occurs above the nucleus of that nerve, and thus causes a true centric paralysis. The absence of psychic symptoms is usually to be noted.
Tumors anywhere in the middle portion of the base of the brain and floor of the skull, the region of the origin of the various cranial nerves, can of course be diagnosticated with comparative ease by a study of the various forms of paralysis and spasms in the distribution of these nerves, in connection with other special and general symptoms. Varieties of alternate hemiplegia are to be looked for, and also isolated or associated palsies of the oculo-motor, pathetic, facial, trigeminal, and other cranial nerves. In studying these palsies it must be borne in mind that although the lesions producing them are intracranial, the paralyses themselves are peripheral.
In most cases apparent exceptions to the ordinary rules as to localization are capable of easy explanation; thus, for instance, in a case of tumor of the occipital lobe (Case 44) numbness and pain were present in the right arm, although the tumor was situated in the right hemisphere. The tumor was of considerable size, and may have affected by pressure the adjoining sensory tracts.
Hughlings-Jackson45reports a case of tubercular tumor, half the size of a filbert, in the pons under the floor of the fourth ventricle, in the upper third of the left side. A much smaller nodule was found in the right half of the pons. This patient, a man thirty-three years old, had inconstant headache, a gradual incomplete hemiplegia of the right side, with also paresis of the left masseter and right lower face. Sensation was diminished in the right arm, leg, and trunk. The optic discs were normal; the left pupil was smaller than the right. There was lateral deviation of the eyes to the right. Diplopia was present in some positions, and one image was always above the other. Aphasic symptoms were also present. Especial interest attaches to the fact that the facial paralysis in this case was on the same side as the hemiplegia, opposite that of the lesion; whereas usually in lesions of the pons facial paralysis is on the side opposite the hemiplegia. This is explained by the fact that the tracts of the facial nerve decussate in the pons below its upper third, and therefore in this case the lesion caught the nerve-tracts above their decussation.
45Med. Times and Gazette, London, 1874, p. 6.
PROGNOSIS.—The prognosis in intracranial tumors is of course usually in the highest degree unfavorable. The early recognition of the existence of a tumor syphilitic in origin will enable a comparatively favorable prognosis to be made. It is far from correct, however, to suppose that all or a majority of the cases of known syphilitic origin are likely to have a favorable termination. Amidon46puts this matter very correctly as follows: “Has a destructive lesion occurred? and if so, where is it located, and what is its extent? Indications of a destructive lesion should lead one to a cautious prognosis as regards perfect recovery, while the prognosis for life and a moderate amount of health may be good. A gummy intracranial or spinal growth, giving rise to alarming symptoms, may vanish as by magic upon prompt treatment. The symptoms of these frank, specific growths are, as a general thing, characteristic and widely different from those of the more insidious destructive lesions.
“An intracranial gumma often heralds itself by sharp, localized headache, gradually deepening paralysis, aphasia, epilepsy, and optic neuritis, while destructive lesions are more apt to have diffuse, dull headache, stationary or lessening paralysis or aphasia, rarely epilepsy or optic neuritis. Intraspinal gummata give rise to a painful paraplegia, while an inflammatory or destructive change gives rise to various and atypical sensory and motor manifestations.
“As to the pathology of these cases, I can say but little, as such discussion opens the whole subject of the pathology of syphilis. This I will say, that, so far as can be told without autopsies, no permanent pathological condition was present in these cases which might not have been brought about by other etiological factors which were often present. The periencephalitis might be caused by alcohol, mental strain, or excesses; the arterial occlusion might be due to previous disease not specific.”
46Medical News, vol. xlviii. No. 3, Jan. 16, 1886, p. 64.
TREATMENT.—The surgical treatment of tumors of the brain has recently received a great stimulus from the report of a case whichoccurred in the practice of A. Hughes-Bennett of London, and which was operated on by Rickman J. Godlee. The case has been included in the table (Case 24), where the symptoms and details of treatment may be read. This case has served to bring into sharp outline many of the difficulties and dangers of such an operation on the one hand, and the few possible and exceptional advantages of it on the other. It must be apparent, in the present state of knowledge and with the additional light of this interesting case, that success must largely depend upon the following conditions: The tumor must be exceptionally localized—i.e.not very large—and non-multiple; it must be cortical, or at least not very deep-seated; it is also quite essential that it be in the motor zone, in order to admit of accurate diagnosis. It would seriously impair the usefulness of the operation and the prognosis if the case were of long standing with much necrosis of brain-tissue, or if the growth were malignant and recurring. The secondary complications, as inflammation and sepsis, are of course possible in all surgical cases, and may be guarded against, as well in cerebral as in other surgery. If such a criticism narrows the field for the operation into almost hopeless limits, it may be reflected that one or two successful cases are better than a hundred experimental failures; that cases do occur in which the tumor is just so localized, single, and superficial; that the urgency of distressing symptoms, as pain and convulsions, urge the operation for palliation as well as cure; and that these cases, without relief, are necessarily fatal, and hence justify large risks.
By exclusion and a careful study of the symptoms we believe it may become possible hereafter in some cases to localize in two other accessible regions brain tumors with sufficient accuracy for purposes of operation: these are the antero-frontal region and the postero-parietal region.
The case of Bennett and Godlee was a most successful test of diagnosis, and as a surgical endeavor might have been more successful, as the operator himself suggests, if more careful antiseptic precautions had been used. In the discussion of this case before the Royal Medical and Chirurgical Society47it was stated by Hughlings-Jackson that three indications were of special importance for this diagnosis: (1) local persisting paralysis; (2) epileptiform convulsions, those beginning locally; (3) double optic neuritis, which is diagnostic of tumor as distinguished from a sclerotic patch. It is probable that permanent palsy would be left after a successful operation in which the cortical tissue were destroyed, but as this is compatible with life and comfort, it is not likely that, as an alternative, it would be rejected by the patient. McEwen's case, also given in the table (Case 25), is not as accurately reported48as Bennett's, but was partially successful. At the opening over the Rolandic region false membrane was removed, and an incision made which let out grumous red-colored fluid: this was followed by a decrease in the paralysis and improvement in other brain symptoms. It is difficult to understand why the opening was made in the occipital region. The necessity for antiseptic measures is to be especially considered in cerebral surgery. In a recent operation for a case of traumatic epilepsy, under the care of Mills and White, in the Philadelphia Hospital, in which quite extensive injury was done to the membranes in removing fragments of bone, rigidantisepsis was employed; and it is not too much to assume that the risks of the operation were much diminished by it and its success ensured in an old and crowded hospital building.
47Brit. Med. Journ., May 16, 1885, p. 988.
48Glasg. Med. Journ., xxi., 1884, p. 142.
In the medication of tumors of the brain we can unfortunately do but little more than treat the symptoms and ameliorate the various conditions as they arise. There is no specific for these growths, unless the syphilomata be an exception; and experience shows that specific treatment is usually disappointing even when applied to a syphilitic brain tumor. The dietetic and hygienic rules laid down by some are only such as are invariably recommended as routine practice in all kinds of disease; and it almost seems a mockery to offer them to a patient with an intracranial tumor with the same gravity and detail as we suggest them in a curable fever or a hopeful surgical case. It is possible that local depletion and revulsives, by controlling irritation and hyperæmia, may be beneficial, though we should hesitate to add to the sorrows of the patient the action of tartarized antimony, even, with Obernier, in special cases. Hot or cold effusions and the ether spray are worthy of mention. Local applications of the galvanic current might be tried for its catalytic action, but the observations are too few and the theory too inapplicable to allow us to attach much importance to the suggestion. The use of electricity to the limbs for paralytic symptoms certainly does not promise much in the case of an obstinate neoplasm in the brain.
Morphia and bromide of potassium are the two drugs which offer the most promise in these fatal cases. They can often control the most urgent and frightful symptoms. The headache, the obstinate vomiting, the epileptic seizures, are all more or less amenable to one or other of these remedies or a combination of them. Although the vomiting is of centric origin, it is possible that remedies addressed to the stomach might occasionally afford relief, just as we apply medicines to that viscus in reflex irritation, in pregnancy, and in debilitating diseases. The remedies which suggest themselves are the salts of bismuth and cerium, the more stimulating wines, as champagne, in small frequent doses, and cracked ice.
While morphia and bromide of potassium are, on the whole, the most useful remedies for the relief of pain and irritating symptoms of brain tumor, other remedies can often be used with great advantage as adjuvants. Ergot in the form of the solid or fluid extract has a beneficial influence in relieving the congestive symptoms. Cannabis indica in the form of the fluid extract in doses of five to ten minims, or the tincture in doses of fifteen to thirty minims, may be advantageously combined with morphia and a bromide, or sometimes may be tried alone. Hyoscyamus, either the fluid extract or tincture, in somewhat larger doses may also be tried. The great severity of the headache and the imperative demand, however, will usually compel the physician to fall back at last upon morphia in large dose by the mouth or hypodermically.
Leeches to the temples or behind the ears or to the mucous membrane of the nose, either wet or dry cupping to the back of the neck, and bladders or compresses of ice, or very hot water, may be used to the head.
The various serious complications which so often accompany intracranial tumors should be most carefully managed. Among the most important of these are such affections as the conjunctivitis and trophiccorneitis, with anæsthesia, present in a few cases, usually when the trigeminal is directly or indirectly involved. Cystitis and pyelitis must be appropriately treated, and patients must be carefully watched in order to prevent injurious consequences of over-distension of the bladder or enormous fecal accumulations.
TABLE OFONEHUNDREDCASES OFBRAINTUMOR.
TABLE OFONEHUNDREDCASES OFBRAINTUMOR.