The following are other illustrations of multiple tumors and of tumors
with other lesions out of a large number which we have collected:
M. 44.—Several severe falls on the head. Recent chancre with secondary
symptoms. Six months before death headache which grew worse; most
severe in right supraorbital region, and also obstinate vomiting,
vertigo, hiccough, insomnia. Some loss of power on both sides. Slow in
answering and indisposed to talk. Choked discs. Involuntary
evacuations. Some improvement under treatment, and then relapse.
Complete blindness. Polyuria. Specific gravity of urine as low as 1003
and 1005. Appetite at times ravenous. During last few weeks of illness
head inclined to the right side, probably from spasm. Intense thirst
throughout the illness.
(1) Large sarcoma in the white substance of the right parietal and
frontal lobes, involving ascending parietal convolutions. (2)
Softening and abscess of the right temporo-sphenoidal lobe and
posterior base of the right anterior lobe. Softened mass size of a
hickory-nut in the upper portion of the right ascending frontal
convolution. (3) Small cystic tumors of the choroid plexuses.[4]
[Footnote 4: J. T. Eskridge, _Trans. of Philada. Path. Society_, for
1878-79, vol. ix. p. 119.]
M. 5.—Convulsions, beginning either in right foot or in right face;
not unconscious during fits. Right-sided hemiplegia. Double optic
neuritis, followed by atrophy. Gradual increase in size of head, with
gaping sutures. Later, rigidity of right arm and leg. Shortly before
death the following symptoms suddenly set in: headache, convulsions of
right side with unconsciousness and retraction of head, rigidity of
right arm, and tremor of right leg. Later, both arms flexed, with
constant tremors of left arm, spreading over whole body. Right
sterno-cleido-mastoid was stiff; almost opisthotonos.
(1) Enormous tubercular tumor of left cerebral hemisphere, extending
from depth of Sylvian fissure and eroding skull. Corpus striatum soft
and diffluent. Weight, over eleven ounces. (2) Tumor, double size of
pea, in lower part of middle lobe of cerebellum.[5] This case was
especially interesting for the onset of the cerebellar symptoms late
in the case, caused probably by a late appearance of the cerebellar
tumor.
[Footnote 5: Hughlings-Jackson, _Med. Times and Gaz._, London, 1872-73
(2), p. 34.]
M. 2.—Screaming fits. Vomiting. Paralysis of left side of face,
including corrugator and orbicularis palpebrarum. Winking in both eyes
suspended. Paralysis of external rectus muscle. Agitation and
contractures of right arm and leg. Later, unsteady movement of head
and right arm and jerking of right leg.
(1) Small glioma in left hemisphere of cerebellum, and (2) a similar
tumor projecting from left lateral half of floor of fourth ventricle
at common nucleus of the abducens and facial nerves.[6]
[Footnote 6: W. H. Broadbent, _Proc. Clin. Soc. Lond._, v. 66-68.]
F. 45.—Epileptiform attacks for fourteen years. Vertigo, occipital
headache, disordered vision, intolerance of light, sleeplessness,
excitability, constipation, with paræsthesia of left side. Retraction
of head, {1033} vomiting. Very late, convulsive movements of right eye
and right side of mouth; then general clonic spasms, coma, and death.
No paralysis. For twenty-six years there had been an induration of one
breast, which toward end of life had a somewhat scirrhous appearance.
(1) Glioma in right hemisphere of cerebellum 1¾ inches in diameter.
(2) Glioma in centre of middle lobe of left hemisphere of the cerebrum
¾ inch in diameter. Surrounding nervous tissue softened and broken
down.[7]
[Footnote 7: William L. Bradley, _Tr. Conn. Med. Soc._, 1880, p. 39.]
M. 65.—Sudden attack of spasm of left arm, with paresis and coldness
and numbness. Headache and staggering. Wandering in mind. Not
unconscious. Twitching in eye. Two days later violent convulsion in
entire left half of body, with vomiting; not unconscious. After
convulsion left hemiplegia, with left deviation of tongue. Head and
eyes turned to right; vertigo. Partial anæsthesia of left face, body,
and limbs. Paræsthesia; painful nervous shocks through affected limbs.
Sounds in back of head. Later, mind cleared up and many symptoms
ameliorated. Very late, convulsion and coma. Cheyne-Stokes
respiration, involuntary evacuations. Duration, seven weeks.
(1) Tumor in ascending parietal convolution at junction of upper and
middle thirds. (2) Large tumor occupied entire occipital lobe, but did
not present on surface, reaching to convexity of descending cornu of
lateral ventricle.[8]
[Footnote 8: W. H. Broadbent, _Tr. Clin. Soc. Lond._, v. 233-236.]
* * * * *
Headache is the most frequent and positive symptom of brain tumor. It
is rarely absent; in most cases it has peculiar characteristics. Its
usual type might be described as continuous pain, sometimes of
persistent severity, but generally with exacerbations or paroxysms of
great violence. No suffering can surpass that which some of the
victims of intracranial neoplasms are compelled for months or years to
endure. It is only equalled by the torture produced by malignant
growths in the vertebral axis, the throat, or the bones of the pelvis.
The pain is not, however, always of this character. In a comparatively
few cases it is described by the patient as dull or moderate, or he
simply complains of distressing sensations of weight, pressure, or
constriction. Usually in these cases, however, the pain increases and
becomes less and less endurable. In 100 cases the headache is
described as agonizing, violent, severe, or torturing 20 times; as
moderate or dull, 26 times. It is simply mentioned 20 times, but here
presumably it was of the ordinary severe type. Thus in 66 cases, or 66
per cent., headache of some type was recorded. No mention was made of
headache at all in 29 cases, in some of which, however, it was
doubtless present. In only 5 cases was it stated not to have been
present: 3 out of these 5 were said to be gliomata, and of the other
2, one was probably gliomatous, and the other a cyst in the
brain-substance. Tumors of this kind, which exert comparatively little
pressure and which are not connected with the membranes, are probably
those which are least likely to cause pain. In several instances the
patients complained spontaneously of the pain being greatest in the
region of the head nearest the seat of growth. With reference to
cerebellar tumors, it somewhat generally supposed that occipital pain
is usually present. It {1034} sometimes is and sometimes is not. In 15
cases of tumor of the cerebellum and of the fourth ventricle the pain
was described as occipital twice, as fronto-occipital three times, and
as cervico-occipital once. Callender has noticed that cortical lesions
are more frequently accompanied by localized pains than lesions of
deeper parts.[9] Some of our cases would seem to bear out this view,
although the data are not numerous or complete.
[Footnote 9: _St. Bartholomew's Hospital Reports_, 1869, and Ferrier's
_Localization of Cerebral Disease_, p. 99.]
In a few cases percussion of the head elicited or intensified pain in
the region corresponding to the location of the tumors. We believe
that percussion of the skull may afford valuable aid in localizing
encephalic tumors, particularly when they are meningeal or cortical.
Ferrier[10] holds that percussion often elicits pain over the cranial
region beneath which a lesion is localized, and Alex. Robertson of
Glasgow[11] has also directed attention to the value of percussion of
the skull in the localization of disease on the surface of the brain.
[Footnote 10: _Brain_, January, 1879.]
[Footnote 11: _Abstr. Internat. Med. Congress_, 1881, p. 85, and
_Journal of Nervous and Mental Disease_, April, 1882.]
Vomiting is of frequent occurrence, although it does not usually come
on as early or remain as persistently as headache. It is more likely
to be paroxysmal, with longer or shorter intervals of relief. It
frequently occurs at the time of the exacerbations of the headache,
and between the paroxysms of vomiting, nausea, slight or great, is
often present. It probably occurs in about 50 per cent. of all cases
of brain tumor. It is recorded as having been present in 34 out of 100
cases. It was comparatively infrequent in antero-frontal growths,
occurring only twice out of 10 cases.
A case reported by one of us (Case 70) was a remarkable example of
persistent cerebral vomiting. For four weeks before her death the
patient vomited almost incessantly. The tumor in this case involved
the middle cerebellar peduncle and the adjacent region of the right
cerebellar hemisphere, and had grazed and superficially softened the
floor of the fourth ventricle.
We incline to agree with Ferrier[12] that the majority of cases of
cerebral vomiting can be ascribed to irradiation of irritation by the
nerves of the cerebral membranes or to the physical effects of acute
pain. The nuclei of the trigeminus and of the vagus are in close
anatomical relationship in the medulla oblongata. Irritative
impressions conveyed from the cerebral membranes, and particularly
from the dura mater, to the trigeminal nuclei in the medulla are
transferred to the vagus and give rise to vomiting. In tumors of the
cerebellum the vomiting may be brought about through the affection of
the centres of equilibration and the concurrent vertiginous sensations
(Ferrier), or it may be due to direct irritation by contiguity of the
floor of the fourth ventricle. In general, the tumors situated
farthest forward in the brain appeared to be the least likely to give
rise to vomiting.
[Footnote 12: _Brain_, July, 1879.]
Vertigo was noted in 31 out of 100 cases. Under this general
designation dizziness, giddiness, reeling, insecurity in the erect
posture, etc. have been included. The vertigo can be explained in
several ways {1035} besides by the view which refers it to an
affection of centres of equilibration in the cerebellum. Like headache
and vomiting, it seems sometimes to be the outcome of pure irritation
of the cerebral membranes. Alterations in the intracranial circulation
produced by the growth of the tumor is another probable cause.
Experiments have demonstrated the existence of a communication between
the arachnoid cavity and the labyrinth, and consequently the increased
intracranial tension present may result in pressure on the
labyrinthine fibres of the auditory nerve, and thus occasion vertigo.
The importance of ophthalmoscopic examinations in suspected cases of
brain tumor can scarcely be overestimated. They will often serve to
clinch the diagnosis in favor of tumor. Of the 100 tabulated cases,
choked discs were recorded in 8; optic neuritis or neuro-retinitis in
18. These results serve to show the importance of the examination of
the eyes. It will be seen that with Allbutt, Norris, and others we
make a distinction between choked disc, papillitis, congestion
papilla, or ischæmia of the discs, and descending or interstitial
neuritis. The differences between these two varieties of inflammation
of the interocular ends of the optic nerve are well presented by
Norris in a previous volume of this work,[13] which will make it
unnecessary for us to describe the conditions present in these cases.
An examination of the tabulated cases will show that true choked discs
were present in tumors situated in all portions of the encephalon.
They were not infrequently present in tumors of the convexity.
Descending neuritis would seem most likely to occur when the tumors
are so situated that inflammation set up by them can readily extend by
anatomical continuity along the membranes to the optic nerves. The
lymph-space theory best accounts for the occurrence of choked discs in
cases of tumor situated remotely from the base. In choked disc the
appearance is one of intense swelling and engorgement of the optic
papilla. In descending neuritis, as described by Graefe and Norris,
there is rather a dull-red suffusion of the disc. Some of the cases
reported as neuritis may have been choked discs, and the reverse, as
physicians often do not make any distinction.
[Footnote 13: Vol. IV. p. 771 _et seq._]
Several practical matters should be borne in mind in connection with
this subject of the condition of the eye-ground. In the first place,
sight is not always impaired in cases of even somewhat advanced
choking of the disc, so that when other symptoms and indications lead
to the suspicion of a brain tumor, unexpected confirmation may be
obtained by ophthalmoscopic examination. Some remarkable cases of this
kind have been reported, and doubtless have been observed by all
ophthalmologists and neurologists of large practice. In some cases of
growths of large dimensions also careful ophthalmoscopic examination
has shown neither choked disc nor neuro-retinitis to be present. In
two of Seguin's cases, for instance (Cases 28 and 29), these
appearances were absent. In one he reports no neuro-retinitis, but
only some fulness of the veins. In the other, a large sarcoma of the
centrum ovale, ophthalmoscopic changes were absent. The absence of
disturbance of vision, therefore, should not lead the physician to
overlook making a thorough ophthalmoscopic examination; nor should the
absence of ophthalmoscopic appearances lead him to make up his mind
that serious intracranial disease was not present. {1036} The presence
of double choked discs is in the highest degree significant of a brain
tumor.
Observations on the temperature of the head have been made in a few
cases of tumor of the brain. Full accounts of such observations in two
cases (1 and 3 of Table) have been published by one of us.[14] It is
not within the scope of the present paper to review the general
subject of cranial or cerebral thermometry. We will simply, in
passing, recall the labors of E. Seguin,[15] Broca,[16] Gray,[17]
Lombard,[18] Maragliano and Seppilli,[19] and Amidon.[20]
[Footnote 14: _Philadelphia Medical Times_, Jan. 18, 1879, and _New
York Medical Record_, Aug. 9, 1879.]
[Footnote 15: _Medical Thermometry and Human Temperature_, by E.
Seguin, M.D., New York, 1876.]
[Footnote 16: _Progrès médical_, 1877.]
[Footnote 17: _New York Medical Journal_, Aug., 1878.]
[Footnote 18: _Experimental Researches on the Temperature of the
Head_, London, 1881.]
[Footnote 19: Quoted in _Archives of Medicine_, 1879.]
[Footnote 20: _Archives of Medicine_, April, 1880.]
L. C. Gray[21] has recorded some observations in cerebral thermometry
in one case of tumor of the brain. The tumor, a soft jelly-like mass
the size of a hazelnut, was found between the horizontal branch of the
Sylvian fissure and the first temporal fissure, while the whole of the
right occipital lobe was converted into a colloid, extremely vascular
mass, which gave way under examination, this degeneration also
extending anteriorly to the tumor as far as the fissure of Sylvius.
Microscopical examination showed it to be a typical glioma.
[Footnote 21: _N. Y. Medical Journal_, August, 1878.]
The temperatures at different stations were as follows:
Left. Right.
Frontal . . . 96.75° 98.33°
Parietal . . 95° 99.75°
Occipital . . 96.75° 100.50°
The average of the left side was 96.16°; of the right, 99.52°; of the
whole head, 97.84°.
In a case of frontal tumor (Case 1 of Table) the average temperatures
of the different stations taken were as follows:
Middle frontal station . . 96.5°
" occipital " . . 95.5°
Right frontal " . . 95°
Left " " . . 94.7°
Right parietal " . . 94.7°
Left " " . . 94.4°
In another case, reported in full by one of us[22] (Case 94), a gumma
involved the basal termination of the corpus callosum, the peduncles
of the corpus callosum, the lamina cinerea, and anterior perforated
spaces; and the average temperatures at the different stations were as
follows:
Right frontal station . . . . . . . 97.1°
Left " " . . . . . . . 97.4°
Right parietal " . . . . . . . 97.6°
Left " " . . . . . . . 94°
Right occipital " . . . . . . . 97°
Left " " . . . . . . . 94.5°
Right anterior vertical station . . 97°
Left " " " . . 94°
Right posterior " " . . 96.6°
Left " " " . . 94.3°
[Footnote 22: _New York Medical Record_, Aug. 9, 1879.]
{1037} In a gumma in the cortical motor zone of the right side the
head-temperatures, taken once, were found to be for the right parietal
region, 97.2°; for the left, 96°. In another tumor of the right motor
zone the right frontal region gave a temperature of 98°; the left, of
96°. In a tumor of the left occipito-parietal region the temperatures
were for the right parietal region, 98°; for the left, 97.8°. Although
the temperature of the head was only taken once in each of these three
cases, the observations were carefully made with tested thermometers.
J. T. Eskridge, in a case of a tumor of the cerebellum with monocular
hemianopia (Case 76), made the following temperature observations:
Axillary . . . . . . . . . . . R. 98.6°; L. 98.6°
Head:
Anterior frontal station . . R. 98.4°; L. 98.4°
Posterior " " . . R. 98.5°; L. 98.6°
Superior " " . . R. 98.4°; L. 98.4°
Parietal " " . . R. 99.2°; L. 98.6°
Rolandic " " . . R. 98.8°; L. 99.1°
Occipital " " . . R. 99.4°; L. 99.1°
Posterior central " . . 99°.
Anterior " " . . 99°.
The normal average temperatures, as determined by Gray, were as
follows:
Left frontal station . . . . . . . . . . . . 94.36°
Right " " . . . . . . . . . . . . 93.71°
Left parietal " . . . . . . . . . . . . 94.44°
Right " " . . . . . . . . . . . . 93.59°
Left occipital " . . . . . . . . . . . . 92.66°
Right " " . . . . . . . . . . . . 91.94°
Left side of the head . . . . . . . . . . . 93.83°
Right " " . . . . . . . . . . . 92.92°
The whole head, exclusive of the vertex . . 93.51°
Motor region of the vertex . . . . . . . . . 91.67°
The whole head, inclusive of the vertex . . 92.66°
We conclude that in brain tumors the average temperature of the whole
head is elevated several degrees above the normal, and that the
elevation of temperature is usually greatest at the station nearest
the seat of the growth.
Mental disturbance of some description was present in about one-third
of all the cases studied. Doubtless they were not recorded in a large
number of cases. Obernier says: “If the psychical qualities of a
patient suffering from cerebral tumor be analyzed, and a careful
comparison made of the former with the existing mental condition,
certain symptoms of mental disturbance will be discovered in most
cases where the tumor is a growing one.” The disturbances may be in
any sphere of the mind—in intellection, volition, emotion, or
perception. Mental slowness and uncertainty, inability to fix the
attention, impossibility of continuous mental action, apathy, or
stupidity, with hesitation or slowness of speech, were strikingly
exhibited in cases of tumor of the antero-frontal region. In Case 1
the patient's mental condition was studied with great care, and in the
detailed report of the case[23] the following facts were noted: The
psychical manifestations were among the most important features of the
case. Although comparatively uneducated, he had been when {1038} in
health intelligent and energetic. He had never during his illness had
the gay humor or delirium of grandeur seen in the general paralysis of
the insane. His condition, on the whole, was one of intellectual
slowness and uncertainty. He seemed to have great difficulty in
receiving mental impressions and in directing the movements of his
body. His faculty of attention was, in great measure, destroyed. It
could only be fixed, and then but partially, by distinctly and
vehemently repeating a question or command. He could hear, but it was
necessary to make a tremendous external impression on his sense of
hearing in order to call out a mental response. He sometimes appeared
to me like a man dazed by a great catastrophe which he could not
understand. He was not aphasic, although he manifested certain
striking peculiarities of speech, or, rather, of the manner of
speaking. What he said, either spontaneously or in answer to
questions, was spoken clearly and distinctly and in a firm, loud
voice. His sentences were short, but complete; neither words nor
syllables were omitted; and he made no mistakes in articulation,
enunciation, or pronunciation. In answering he did not seem to be able
to retain for any length of time a hold upon the same idea or to
follow a particular train of thought. He did not wander from one
subject to another, but he would suddenly stop speaking, as if unable
to go farther. Often on being questioned he would try to reply, and
after a sentence or two would sob and burst into tears like a
violently hysterical woman. He would at times have what might be
termed volcanic outbursts of speech. When all was perfectly quiet in
the ward he would suddenly explode with a sentence or two, and then
again subside into stillness. Exclamations of this kind might be
repeated at intervals of a few minutes for hours together, or they
might recur only at intervals of hours. Sometimes what he said would
be connected with some past events of which he seemed to have a vague
recollection; often it would be a demand for something to eat or
drink; and often, again, it would be a paroxysm of profanity.
[Footnote 23: _Philadelphia Medical Times_, Jan. 18, 1879.]
Impairment of will is not uncommon in antero-frontal and other
cerebral tumors, and failure of memory, depression of spirits, and
even acute mania, occur. Many of the patients are emotional,
excitable, and irritable; they often sob and cry, apparently from the
great pain. In some cases, however, emotional conditions are present
which seem to be dependent on some special localization of the tumor.
Hallucinations were noted in two of our tabulated cases. In one case,
a tumor of the motor zone, the patient had delusions that some one was
about to take him away. There were also illusions of fear or
persecution. In another the patient had visual hallucinations.
Speech-defects of various kinds occur in connection with intracranial
growths. Ladame, quoted by Rosenthal, has cited forty-five cases of
disturbances of speech in which the tumor occupied the most varied
regions of the brain. Peculiar disorders of speech from special
localizations will be treated of under Local Diagnosis.
Local spasms, which go under various names, as cramps, twitchings,
epileptoid attacks, athetosis or athetoid movements, are common
symptoms, particularly of growths which involve the cortical motor
area. They are of great diagnostic value. They are commonly, although
not invariably, accompanied by paresis, which is usually most marked
in the {1039} part most affected by the spasm. These local spasms,
beginning in one extremity, in a finger or toe it may be, often spread
toward the centre, until they involve to a greater or less extent the
whole limb, the side of the face, or one-half of the body. Sometimes
instead of this they recur with the same definite movements over a
long period. They are the expression of irritation of cerebral centres
or tracts connected with the muscles or groups of muscles affected by
the abnormal movement. They should always lead the physician to
carefully consider the great probability of a lesion in some way
involving the motor area.