various forms. In children tubercular meningitis sometimes closely
simulates brain tumor. Tumors of the brain are comparatively rare in
children, but, as has already been shown, gliomata and other tumors do
sometimes occur in early life. The course of tubercular meningitis,
whether in children or in adults, differs from that of brain tumor. It
is more irregular in its method of advance, or if it shows the
regularity which is sometimes present, and which has led authors to
subdivide it into three more or less completely separable stages, the
symptoms of these stages do not correspond with any closeness to those
of the initial, middle, and terminal periods of brain tumor, as
already given. Headache is usually present in both affections,
although the absence of headache in some cases of gliomata in children
must be here borne in {1054} mind. When headache is present in
tubercular meningitis, it is less likely to be localized, and, on the
whole, it is not so severe as the terrible torture of the neoplasm.
Irregular but very decided febrile phenomena are more likely to be
present in meningitis than in tumor. Like brain tumor, tubercular
meningitis of the convexity may give psychical disturbances, palsies,
local spasms, general convulsions, sensory disturbances, peculiar
disorders of the special senses, etc.; but these symptoms in the
former usually come on more irregularly and are accompanied less
frequently with paroxysmal exacerbations of headache, vomiting,
vertigo, etc. Tubercular meningitis of the base can be more readily
distinguished from cases of tumor by the fact that one cranial nerve
after another is likely to become involved in the diffusing
inflammatory process. Tubercular meningitis is of shorter duration
than the majority of cases of brain tumor, and in it delirium and
mental confusion come on more frequently and earlier. A history and
physical evidences of more or less generalized tuberculosis favor the
diagnosis of tubercular meningitis. In both affections the
ophthalmoscope may reveal choked disc or descending neuritis. It will
be seen that the differentiation between the affections is not always
very clear, although in some cases the decision may be quickly reached
from a study of the points here suggested.
Some of the forms of chronic hydrocephalus are difficult to
distinguish from tumors, especially gliomata. In hydrocephalus, when
not the result of, or not accompanied by, tubercular meningitis, the
disease advances more slowly and with less irritative symptoms than in
cases of tumor. Headache, vertigo, vomiting, and the other symptoms of
meningeal irritation are not so frequently present, although the
ophthalmoscopic appearances are often the same.
Rosenthal speaks of the necessity of diagnosticating brain tumor from
the chronic cerebral softening of Durand-Fardel, from acquired
cerebral atrophy, and the cerebral hypertrophy of children. An
elementary knowledge of the general symptomatology of intracranial
tumors will, however, be sufficient to prevent mistakes of
differentiation in these cases. Neither of these affections presents
the violent paroxysmal symptoms, the affections of the special senses,
or the severe motor and sensory phenomena of intracranial growths.
Acute mania and paretic dementia are sometimes confounded with
intracranial growths. A case of brain tumor is more likely to be
regarded as one of acute mania than the reverse. In some comparatively
rare instances in the course of their sufferings the cases of tumor
become maniacal, but even a superficial study of general
symptomatology in such a case will be sufficient to clear up the
doubt.
Paretic dements are occasionally supposed to be cases of brain tumor,
because of the epileptiform attacks and isolated pareses which occur
as the disorder progresses. It is only necessary to refer to this
matter, as the mistake would not be likely to be made by one having
any familiarity with dementia paralytica.
L. J. Lautenbach, in a recent communication to the Philadelphia
Neurological Society, which embodied a large number of ophthalmoscopic
examinations of the insane at the State Insane Hospital, Norristown,
Pennsylvania, and the Insane Department of the Philadelphia Hospital,
and also the results of the investigations of the fundus of the eye in
{1055} cases of insanity by other observers, showed that about 16 per
cent. of cases of acute mania presented well-defined papillitis—a
condition which he described as one of swelling and suffusion of the
disc, corresponding to cases reported as choked disc, descending
neuritis, and severe congestion of the optic nerve. No reports of
post-mortem examinations were made of these cases, but they did not
present the clinical history of meningitis or brain tumor. It
therefore follows that the existence of papillitis in a case of acute
mania does not necessarily point to a gross lesion, such as tumor or
meningitis.
In the early stage of posterior spinal sclerosis some of the symptoms
of the initial or middle stage of intracranial growths in certain
positions are likely to be present; more particularly, such eye
symptoms as diplopia from deficiency or paresis of the ocular muscles
and disorders of the bladder may mislead. In posterior spinal
sclerosis, however, some at least of the pathognomonic symptoms of
locomotor ataxia, such as lancinating pains, absent knee-jerk, or
Argyle-Robertson pupil, will almost invariably be present. Those
tumors of the cerebellum, pons, tubercular quadrigemina, etc. which
give rise to ataxic manifestations are usually readily discriminated
from posterior spinal sclerosis by the headache, vomiting, and other
general symptoms of brain tumor, which rarely occur in ataxia. It is
far more difficult to separate non-irritative lesions of certain
cerebellar and adjoining regions from the spinal disorder.
Strange to say, one of the most frequent mistakes of diagnosis is that
which arises from confounding brain tumor with grave hysteria. In
several of our tabulated cases the patients at different periods of
the disease and by various physicians had been set down as suffering
from hysteria. One of Hughes-Bennett's cases (Case 30), a wayward,
hysterical girl of neurotic family, had had her case diagnosticated as
hysteria by one of the highest medical authorities of Europe, and yet
after death a tumor the size of a hen's egg was found in the cerebrum.
In a case reported by Eskridge (Case 76) hysterical excitement and
special hysterical manifestations were of frequent occurrence, and
misled her physicians for a time. Eskridge remarks, in the detailed
report of this case, that to such a degree was the emotional faculty
manifest that had no ocular lesion been present there would have been
great danger of mistaking the case for one of pure hysteria; and,
indeed, a careful physician of many years' experience, not knowing the
condition of the eyes, pronounced the woman's condition to be
pregnancy complicated by hysteria. A close study of such objective
phenomena as choked discs and paralysis will usually be of the most
value.
Even malaria has been confounded in diagnosis with brain tumor.
Holt[37] reports a case which presented the history of a fever, at
first periodical, with marked splenic enlargement, great muscular
soreness, and incomplete paralysis, which was diagnosticated to be
chronic malarial poison. The patient for a time improved under
quinine, but eventually grew worse, and on an autopsy a glioma-sarcoma
was found on the inferior surface of the cerebellum. Several years
since a physician about fifty years of age was brought to one of us
for consultation, and in his case a similar mistake had been made. The
case was a clear one of {1056} tumor, probably cerebellar, with
headache, neuritis, vertigo, and other general symptoms, which pointed
to an organic lesion. This patient, who came from a malarial district
in the West, had doctored himself, and had been treated by others with
enormous doses of quinine and arsenic.
[Footnote 37: _Med. Record_, March 1, 1883.]
LOCAL DIAGNOSIS.—Niemeyer would hardly say to-day that the brilliant
diagnoses where the precise location of a tumor is fully confirmed by
autopsy are not usually due to the acumen of the observer, but are
cases of lucky diagnosis. It can be asserted with confidence that the
exact situation of a tumor can be indicated during life in at least
two or three locations. Great caution should be exercised, as insisted
upon by Nothnagel,[38] in the localization of tumors of the brain,
because, among other reasons, of the frequent polypus-like extension
of such tumors.
[Footnote 38: _Wien. Med. Bl._, 1, 1882.]
The subject of local diagnosis can be approached in several ways,
according to the method of subdividing the brain into regions. Thus,
Rosenthal discusses, in the first place, tumors of the convexity of
the brain, but as this is a very general term, covering portions of
several lobes, we can see no advantage in making such a subdivision.
A few general remarks might be made in the first place, however, with
regard to the general symptoms presented by surface or cortical
growths as compared with those which are produced by deep-seated
neoplasms. The direct or indirect involvement of the membranes in
nearly all cortical tumors makes the symptoms of irritation referable
to these envelopes very numerous and important.
The various centres so called, motor, sensory, and of the special
senses, which have their highest differentiation in the cerebral
cortex, are each and all represented by well-defined tracts of white
matter in the centrum ovale and capsules which connect these centres
with the lower brain, the spinal cord, and the periphery of the
organism. It therefore follows that symptoms produced by localized
lesions of the cortex will be reproduced in other cases by those of
the tracts which go to or come from these centres. We may thus have a
monoplegia or a hemiplegia, a partial anæsthesia or a hemianæsthesia,
a hemianopsia, a word-blindness or word-deafness, a loss of power to
perceive odors or to appreciate gustatory sensations, from a
peculiarly limited tumor or other lesions of either the gray centres
of the cortex or of the white matter of the central area of the brain;
but these specialized symptoms are more likely to arise from cortical
lesions in the case of intracranial neoplasms, because of the much
greater frequency with which these adventitious products arise from
membranes and therefore involve the cortex.
Peculiar symptoms arise in the case of lesions of the centrum ovale
from the fact that it contains not only projection-fibres which more
or less directly connect cerebral centres with the outer world; but
also a system of commissural fibres which unite corresponding regions
of the two cerebral hemispheres by way of the corpus callosum and
commissures, and a system of association-fibres which connect
different convolutions together, in special cases even those which are
situated remotely from each other, but are associated in function.
It is evident, therefore, as asserted by Starr,[39] that a peculiar
set of additional symptoms will be referable to the destruction or
irritation of these commissural and association fibres. For example,
failure to {1057} perform easily corresponding bilateral motions in
face, hands, or feet would indicate some obstruction to conduction in
the commissural fibres joining the motor convolutions. “Integrity of
both occipital lobes, and simultaneous, connected, and harmonious
action in both, are necessary to the perfect perception of the whole
of any object when the eyes are fixed upon one point of that object.”
Starr gives the following examples of the methods of detecting a
lesion of such fibres: “In the case of the fibres associating the
auditory with the motor speech-area the symptoms to be elicited seem
to be very simple. Can the patient talk correctly? Can he repeat at
once a word spoken to him? These are the questions which any one will
ask who examines a case of aphasia. But this is not all. The patient
must be further questioned. Can he read understandingly to himself,
and tell what he has read? This will test the occipito-temporal tract.
Can he read aloud? This will test the occipito-temporo-frontal tract.
Can he write what he sees? This will test his occipito-central tract.
Can he write what he hears? This will test the temporo-central tract.
Can he write what he says, speaking to himself in a whisper? This will
test his fronto-central tract. Can he name an odor or a color? Brill
has recorded[40] a case of lesion of the cuneus associated with
color-blindness to green, and he states that the patient had
difficulty in naming various colors on account of the presence of a
slight degree of amnesic aphasia.... Can the patient write the name of
an odor? Can he tell how a surface feels—smooth, or warm, or heavy?
Such questions as these will suggest themselves at once to any one who
studies the association of ideas subjectively.
“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.”
[Footnote 39: _Med. Record_, vol. xxix. No. 7, Feb. 13, 1886.]
[Footnote 40: _Amer. 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, {1058} 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 involvement
{1059} by 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-Jackson[41] reports 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.
[Footnote 41: _Medical 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.
{1060} 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.