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, {1061}
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.
[Footnote 42: _American 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 other {1062}
disturbances 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, or {1063} has 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
paper[43] has 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.
[Footnote 43: _Journal 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.[44] The 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).
[Footnote 44: Rosenthal's _Diseases 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 on _Paralysis 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 entirely {1064} to 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 the _British Medical Journal_ for 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 to
{1065} the 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.
{1066} Hughlings-Jackson[45] reports 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.
[Footnote 45: _Med. 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. Amidon[46] puts 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.”
[Footnote 46: _Medical News_, vol. xlviii. No. 3, Jan. 16, 1886, p.
64.]