rise to general convulsions which closely simulate attacks of grave
epilepsy. These convulsions or general spasms are among the most
important symptoms of intracranial neoplasms. More than paralysis,
they may be regarded as general symptoms, as they are more likely to
occur from tumors situated in different and distant regions of the
brain than paralysis. They are by no means confined to cases in which
the lesion is situated in the so-called motor area of the brain or in
the cerebellum or pons-medulla region. Both physiological and
pathological experiments have shown that convulsions violent in
character, but having certain special characteristics, may originate
from severe irritation of the dura mater. According to Duret,[24]
irritation of the sensory nerves of the dura mater cause reflex spasms
or contractures of the muscles of organic life. These spasms or
contractures may occur in the face, eyeballs, neck, trunk, or limbs,
and sometimes on one side and sometimes on the other. They tend to
diffuse and invade neighboring groups of muscles. “They have never the
localization, the measured and purposed character, of the contractions
which belong to the lesions of the cortex. They frequently become
transformed into permanent contractures.” The application of these
facts and conclusions to brain tumors is evident. As neoplasms are so
frequently connected, either directly with the dura mater or with the
fused membranes, it is evident that the convulsive attacks from which
the patient suffers may occur from tumors located anywhere within the
cavity of the skull.
[Footnote 24: _Sur les Traumatismes cérébraux_, par H. Duret, chapter
iii., summarized in _Brain_. vol. i., 1878, p. 47.]
General convulsions, as well as local or unilateral spasms, are
present in many tumors of the motor cortex; but if their method of
origin and their progress are closely watched they will usually be
seen to begin with local twitchings.
A glance at the table will show examples of convulsion in almost every
region of the brain.
Contractures—conditions of tonic spasm which continue more or less
persistently—may be either early or late symptoms. They may occur in
one or several limbs, in the face, or rarely in the neck. They are
probably due in some cases to persistent irritation of the dura mater,
in others to comparatively slight but continuous irritation of motor
centres, and in still others to advanced degeneration of the motor
tracts.
Choreas and choreic movements are not frequent, unless some of the
forms of local spasm are regarded as local choreas. In one of
Petrina's cases, a glioma involving the substance of both frontal
lobes, choreic movements of the right arm were present, and in this
same case tremor {1040} in both arms was also a symptom. Tremor
simulating that of paralysis agitans or multiple cerebral sclerosis is
occasionally observed, and sometimes a tremor which is nervous or
hysteroidal in character is one of the results of the great suffering
of the patient.
Paralysis or paresis is of course one of the most frequent evidences
of the existence of an intracranial tumor. The palsies of cerebral
tumors are chiefly unilateral, but the loss of power may be in one or
both limbs, in one side of the face, or in the entire one-half of the
body, according to location and extent. Tumors of the cortical motor
zone usually begin their paralytic manifestations with paresis of one
member or one side of the face, which goes on, as the growth increases
in size, to more or less complete hemiplegia.
The paralysis which results from brain tumor is due either to pressure
or to absolute destruction of tissue. In the latter case the
destruction is brought about not only by the simple displacement of
brain-substance, but also through the obliteration of blood-vessels
and the consequent softening.
Peculiar forms of paralysis occur as the result of neoplasm growing in
special locations, as will be more clearly shown under Local
Diagnosis. Thus we have the alternating paralyses from tumors of the
crus cerebri or of the lower part of the pons, and paraplegia, or
perhaps what might be better called double hemiplegia, from multiple
tumors which affect both sides of the brain. In rare cases paralysis
of all four extremities has resulted from a growth in the middle line
of the base of the brain. Some form of paralysis is recorded to have
been present in 20 cases out of 100.
Apoplectiform attacks sometimes take place suddenly during the
progress of cases of brain tumor. A patient who has been suffering for
months with the general symptoms of tumor, and who may or may not have
had some paresis of the limbs or face, has an attack of
unconsciousness, from which he arouses after a time, and is then found
to be almost completely hemiplegic. After such attacks, in some cases,
the symptoms of brain-irritation, particularly the headache and
vomiting, subside or greatly improve. Such attacks may be explained in
several ways—from the occurrence of congestion with œdema, of
intercurrent hemorrhage, or of softening from obliteration of
blood-vessels by the advancing growth; and the temporary subsidence or
more permanent disappearance of the headache and other symptoms is
probably, in some cases at least, owing to the diminution of tension
because of the breakdown of tissue in the neighborhood of the growth.
Sometimes the seizures which occur during the progress of the case are
both epileptiform and apoplectiform in character.
Sometimes in cases of intracranial tumor there are present in the
cranial nerve-trunks and the muscles supplied by them the changes
known as the reactions of degeneration. These changes are
characteristic of the peripheral palsies, and indeed sharply
distinguish them from paralyses of central origin. The exception to
this rule in cases of intracranial growths is, of course, only
apparent and not real, because these palsies, when caused by the
pressure of a tumor on a nerve-trunk, even within the cavity of the
skull, and not upon their proper centres or intracerebral tracts, are
as much peripheral as though the injury was caused by compression of
these {1041} nerve-trunks outside of the skull. These reactions of
degeneration are briefly as follows: The nerve-trunk gradually,
sometimes rapidly, loses its response to both the galvanic and faradic
currents. The muscle loses its response to faradism coincidently with
the nerve-trunk, but to galvanism it is apt to exhibit first increased
excitability, then gradually lessening excitability: and with this
lessening response it puts on the so-called qualitative changes. These
consist of the serial alterations—_i.e._ the negative pole, instead of
exciting the more active reaction at closure, gives a less response
than the positive pole at closure, and also calls forth a response at
opening which may be greater than the opening contraction of the
positive pole, which may be abolished. In health the positive pole
causes often an active response, and the negative pole none, or almost
none, at opening. Finally, occur modal alterations in the affected
muscles, which consist of a slow, lazy contraction instead of a quick,
lively one as in health, and a tendency in the muscle to remain
contracted (tetany) while the current is passing. The many
modifications—or, better, the partial exhibitions of these changes and
the conditions underlying them—are to be sought in detail in special
treatises. It is sufficient to say that they have been reported in a
number of cases of brain tumor, and that the nerves in whose
distributions they would be especially seen are the motor oculi, or
third, the abducens, or sixth, and the facial, or seventh. It is
doubtful if a very exact electrical examination could be made of many
muscles supplied by these nerves, except in the case of the facial,
and possibly the elevator of the upper eyelid. It is in the case of
the seventh nerve that the recorded observations have been made. It
will be noticed, by reference to the table, that the third, sixth, and
seventh nerves are frequently involved in tumors of the crus and
pons-medulla region, and that the paralysis is usually on the side of
the lesion. These are the cases which would exhibit the reactions of
degeneration. It has been said that in ordinary hemiplegia, and also
in paralyses from tumors of the brain high in the motor region, the
affected side exhibits simply a qualitative increase to electrical
excitation; and this may be explained by the increased excitability to
all stimuli of the lower or spinal-cord centres when cut off from the
brain. The statement, however, which has been made, that in tumors of
the cerebellum the sound side exhibits a quantitative decrease, sounds
like a paradox, and requires further tests before being accepted as a
fact in electro-diagnosis.
Ataxia has been observed in cases of brain tumor situated in various
locations. The symptom described as ataxia, staggering, or staggering
backward, is more particularly observed in cases of tumor of the
cerebellum, pons, and corpora quadrigemina.
Changes in the state of the reflexes are somewhat frequent. Usually
the skin and tendon reflexes will be increased on the side opposite
the lesion, although some striking exceptions, probably due to the
positions of the growth, occur.
Atrophy of the limbs is sometimes present, but usually in brain tumor,
as the lesions are above the nutritive connection of the nerve, true
atrophies do not occur.
True neuralgias are frequent, particularly in the distribution of the
trigeminal. Trigeminal neuritis also undoubtedly occurs in lesions
{1042} involving this nerve at its origin, in its course, or in the
Gasserian ganglion.
Anæsthesia, either in the form of local or hemianæsthesia, was
observed in about 20 per cent. of the cases. It is rarely present as
an isolated symptom, but frequently accompanies unilateral paresis. In
a partial or variable form it most frequently is seen in connection
with tumors of the Rolandic region. It is a marked symptom in
postero-parietal growths and those involving the posterior part of the
internal capsule. It may take the form of loss of sensation to pain,
touch, pressure, temperature, etc.
Hyperæsthesia occurs so commonly as to be almost regarded as a general
symptom of brain tumor. Sometimes it is confined to the head;
sometimes it is generally diffused; more frequently it is present in
the limb or limbs affected with the paralysis. With hyperæsthesia the
patients often complain of spontaneous pain in the limbs.
Diplopia or double vision is a somewhat frequent symptom, occurring
most commonly, of course, when the ocular nerves are involved directly
or indirectly by the tumor; hence tumors of the floor of the skull, of
the crus cerebri, of the pons, or of the cerebellum are most likely to
give rise to this symptom. A close study of the character of diplopia
and of other symptoms which go with it will usually enable a local
diagnosis to be made. Diplopia, however, does sometimes occur in
tumors situated remotely from the base, either because of pressure,
because of general nervous weakness, or possibly because of
involvement of cortical oculo-motor centres.
Ptosis is another symptom, generally unilateral, and most frequently
present in connection with strabismus, diplopia, and dilatation of the
pupil from involvement of the third nerve. Dilatation of the pupil and
contraction of the pupil may be present as general symptoms of tumors.
The latter is most probably due to meningeal irritation.
Hemianopsia is another ocular symptom sometimes present in cases of
brain tumor, as it may also be in other forms of encephalic lesion. It
was present in 5 of 100 cases. Norris[25] gives a full description,
brought well up to the present time, of this symptom, and a discussion
of the lesions upon which it depends. Seguin[26] also discusses this
subject. Starr[27] has collected a large number of cases of lesion
causing this symptom, some of which have been reproduced in our table.
We will not go into any details as to the character of this symptom,
referring the reader to the sources indicated. In the first case given
in our table (Case 10) the hemianopsia was produced by a tumor in
front of, and impinging upon, the optic chiasm; in the other four
cases (Cases 40, 41, 42, and 43) the tumor was situated in the
occipital lobe, and was surrounded by an area of destroyed tissue.
Hemianopsia is not, strictly speaking, a symptom of brain tumor, but
is likely to be present in cases occurring in certain regions of the
brain. Starr's conclusions with reference to lateral homonymous
hemianopsia when it is not produced by a lesion of one optic tract are
that it may result from a lesion situated either (1) in the pulvinar
of one optic thalamus; (2) in the posterior part of one interior
capsule or its radiation backward toward the occipital lobe; (3) in
the medullary portion of the occipital lobe; or {1043} (4) in the
cortex of one occipital lobe. The conclusions of Seguin are only
different in so far as they more closely limit the position of the
lesion.
[Footnote 25: Vol. IV.]
[Footnote 26: Pp. 84, 85 of present Volume.]
[Footnote 27: _Amer. Journ. Med. Sci._, N. S., vol. lxxxvii., January,
1884, p. 65.]
Phosphenes, or subjective sensations of light, occur in various
forms—simply flashes or sheets of light, scintillations, balls of
fire, etc. They are not very common as isolated phenomena, and
probably are dependent in most cases upon irritation of the nerve and
retina in some of the stages of neuro-retinitis. Even visual
hallucinations are occasionally present, as in one of Bennett's cases
of tumor of the Rolandic region.
Conjugate deviation of the eyes, with rotation of the head, a symptom
of the early stages of apoplectic attacks, is also sometimes observed
in brain tumor. The patient is found with both eyes turned to one side
and slightly upward, as if looking over one or the other shoulder, the
head and neck being usually rotated in the same direction. Sometimes
the deviation is slight, sometimes it is marked. Frequently the
muscles of the neck on one side are rigid. The eyes are commonly
motionless, but occasionally exhibit oscillations. This sign, well
known to neurologists, usually disappears in cases of apoplexy in a
few hours or days, although it occasionally persists for a long time.
It will be more fully considered under Local Diagnosis.
Diminution or loss of hearing, tinnitus, and hyperæsthesia of hearing
are all occasionally observed. The most decided disturbances of this
sense are those which are found in connection with tumors of the base
or of the cerebellum in such a position as to involve the auditory
nerve or auditory tracts. Tinnitus, acoustic hyperæsthesia, with
complete or partial deafness, accompanying facial paralysis, with or
without paresis of the limbs of the opposite side, indicate clearly a
tumor of the base so situated as to involve the superficial origin or
intracranial course of the auditory and facial nerves.
The sense of smell is affected, of course, when the olfactory bulbs
are involved in the growth, either directly or by pressure, as in
certain tumors of the antero-frontal region (Cases 4 and 8).
Disturbances in the power of consciously perceiving odors, or abnormal
perceptions of odors or hallucinations of smell, are sometimes present
in cerebral tumors involving certain convolutions. The lower
postero-parietal region or the temporo-sphenoidal region of the base
would seem, from the few reported cases, to be implicated when this
sense is centrally affected. Smell was lost or impaired in two cases
of tumors of the postero-parietal region, in one limited to the
supramarginal convolutions. In a case reported by Allan McLane
Hamilton (Case 47), an induration of the lower part of the right
temporo-sphenoidal lobe involving the uncinate gyrus, the patient,
preceding light epileptic attacks, always had an olfactory aura of a
peculiar character—a disagreeable odor, sometimes of smoke and
sometimes of a fetid character. In this case the olfactory nerves were
examined and found to be healthy.
Taste may be involved in several ways. In the first place, subjective
sensations of taste, particularly the so-called metallic taste, may be
present when the growths involve the cranial nerves in such a way as
to cause irritation to be conveyed to the nucleus of the hypoglossal.
When it is remembered that a mild galvanic current applied to the nape
of the neck or face will often cause this metallic taste, it can be
seen {1044} that the irritation of a tumor situated at almost any
point of the base might lead to abnormal taste-phenomena. Neoplasms
involving the trunk of the portio dura may of course cause diminution
or loss of taste on the anterior extremity of the tongue by the
involvement of the chorda tympani nerve. In the very few cases in
which the hypoglossal trunk may be involved disturbances of taste
posteriorly may occur. In two cases (Cases 33 and 36) some possible
indications as to the cortical areas of taste are given. One was a
tumor so situated as to cause pressure on the orbital, and possibly
anterior, portion of the temporo-sphenoidal lobe; the other was a
lesion closely localized to the supramarginal lobule.
Trophic disturbances of decided character are sometimes present in
cases of brain tumor. Their presence, character, and extent depend
upon the position of the tumor and the cranial nerves involved.
Trophic disorders of the eye have been noted in cases of tumor of the
antero-frontal region, and also of various positions at the base,
especially those so situated as to involve the trigeminal nerve. In a
fibroma of the superior antero-frontal region (Case 1) conjunctivitis
and corneitis of the left eye, with anæsthesia of the conjunctiva,
were present, and were very marked symptoms. This patient, who was
under the care of one of us at the Philadelphia Hospital, was examined
by O. E. Shakespeare, ophthalmologist to the hospital. At his first
examination the bulbar conjunctivæ were slightly injected and the
cornea clear. The sensibility of the cornea was possibly a little
lowered. Ten days later, at a second examination, the central corneal
epithelium of the left eye was found to be hazy and the whole bulbar
conjuntivæ much congested. “This condition soon developed into a
severe superficial corneitis, which was mainly limited to a central
area of an extent about equal to three-fourths of the diameter of the
cornea, which threatened to slough, a narrow peripheral ring of the
cornea being comparative unaffected. At the same time the engorgement
of the bulbar conjunctiva increased. The sclera, the iris, and the
deeper parts were apparently not involved in the inflammatory
process.”
Disturbances of respiration were observed in a number of cases in
various stages. Cheyne-Stokes breathing was usually a late symptom. In
a case of tubercular meningitis with a tubercular granulation
springing from the left side of the fourth ventricle (Case 82) it was
present. Extraordinary slowing of respiration occurred in a tumor of
the right middle cerebellar peduncle and cerebellar hemisphere which
caused irritation and softening of the floor of the fourth ventricle.
The respirations ran as low as four and five per minute two weeks
before death.
Persistent epistaxis and a tendency to hemorrhage from the mucous
membranes were interesting vaso-motor phenomena in a case situated in
the upper left quarter of the pons (Case 84). Profuse perspiration,
more marked on one side, was observed in a case of tumor in front of
the optic chiasm. Polyphagia was observed in two cases, one a growth
of the cerebellum and the other on the floor of the skull. Polyuria
was a very marked symptom in Case 95, a tumor at the base of the brain
at a spot corresponding to the sella turcica, and diabetes was present
in a case of frontal tumor. Albuminuria was recorded twice—once in the
same case in which diabetes was present, and again in a case of {1045}
multiple tumor of the supramarginal convolution of one side and the
angular gyrus of the other. Somnolence was occasionally observed.
Constipation or torpor of the bowels occurs somewhat frequently in the
early stages of the brain tumor, giving place in the terminal periods
to involuntary evacuations. The conditions of the bladder are
practically the same. It is either not involved or suffers from torpor
or paresis of the muscular walls early in the disorder, and later, and
especially very late, incontinence from paralysis of the sphincter
results.
DURATION, COURSE, AND TERMINATION.—The duration of cases of
intracranial tumor is very uncertain. In many of the reported cases no
definite information is given as to the exact length of time from the
initial symptoms until the fatal termination. The few cases in which
the time was recorded showed a duration of from three months to as
many years.
In a few cases, even in some which are not syphilitic in character, a
remission of all the symptoms and what appears to be an approximate
cure sometimes take place, the general symptoms, such as headache,
vertigo, vomiting, spasms, etc., disappearing for a time. Even the
condition of the eyes and the paralysis in rare instances make marked
improvement. In these cases, in all probability, the progress of the
growth of the tumor is arrested either by the remedies employed or
spontaneously, and the acute or subacute phenomena of congestion,
œdema, etc. around the tumor subside. These patients may remain for a
long period or until cut off by some other disease without any change
for the worse; but the sword constantly hangs above their heads, and
any excitement, traumatism, the abuse of alcohol or other narcotics,
an attack of fever, or some other special exciting cause, may again
light up the intracranial disorder, to then progress more or less
rapidly to a fatal termination.
This fatal termination may occur in various ways. Sometimes a sudden
apoplectic attack occurs. This may be an intercurrent hemorrhagic
apoplexy, although our personal experience would not lead us to
believe this mode of termination is common. In a few cases the
enormous irritation of the cerebral growth suddenly or gradually
inhibits the heart's action through the impression made on the
pneumogastric. Apoplectic attacks which may or may not terminate
fatally sometimes are the result of a sudden giving way of necrosed
brain-tissue, the necrosis having resulted from the obliteration of
numerous blood-vessels by the advancing growth. Blood-poisoning
occasionally takes place from abscesses in proximity to the tumor. In
some cases the patients slowly but surely emaciate, or are exhausted
and worn out by the agonizing pain and incessant vomiting which they
are called upon to endure. Occasionally a more or less diffused and
violent meningitis hastens the fatal issue.
COMPLICATIONS AND SEQUELÆ.—Tumors of the brain may be complicated with
other affections due to the same cause. Thus, for example, in a case
of gumma other evidences of syphilis may be present in the form of
nodes, eruptions, etc. A sarcoma or carcinoma of the brain may be
associated with similar disease in other organs. Such affections as
cystitis, pyelitis, keratitis, etc., which have been discussed under
Symptomatology, are secondary complications of cases of tumor. As
{1046} intracranial tumors almost invariably terminate fatally,
strictly speaking we have no sequelæ.
PATHOLOGY.—We present in tabular form the various classes of tumors
found in the one hundred cases of brain tumor in the table appended to
this article:
Carcinoma . . . . 7 | Glio-sarcoma . . 1
Cholesteotoma . . 1 | Gumma . . . . . 13
Cyst . . . . . . 2 | Lipoma . . . . . 1
Echinococcus . . 2 | Myxo-sarcoma . . 1
Enchondroma . . . 1 | Myxo-glioma . . 2
Endothelioma . . 1 | Osteoma . . . . 2
Fibro-glioma . . 2 | Sarcoma . . . . 15
Fibroma . . . . . 4 | Tubercle . . . . 13
Glioma . . . . . 16 | Unclassified . . 16