received a great stimulus from the report of a case which {1067}
occurred in the practice of A. Hughes-Bennett of London, and which was
operated on by Rickman J. Godlee. The case has been included in the
table (Case 24), where the symptoms and details of treatment may be
read. This case has served to bring into sharp outline many of the
difficulties and dangers of such an operation on the one hand, and the
few possible and exceptional advantages of it on the other. It must be
apparent, in the present state of knowledge and with the additional
light of this interesting case, that success must largely depend upon
the following conditions: The tumor must be exceptionally
localized—_i.e._ not very large—and non-multiple; it must be cortical,
or at least not very deep-seated; it is also quite essential that it
be in the motor zone, in order to admit of accurate diagnosis. It
would seriously impair the usefulness of the operation and the
prognosis if the case were of long standing with much necrosis of
brain-tissue, or if the growth were malignant and recurring. The
secondary complications, as inflammation and sepsis, are of course
possible in all surgical cases, and may be guarded against, as well in
cerebral as in other surgery. If such a criticism narrows the field
for the operation into almost hopeless limits, it may be reflected
that one or two successful cases are better than a hundred
experimental failures; that cases do occur in which the tumor is just
so localized, single, and superficial; that the urgency of distressing
symptoms, as pain and convulsions, urge the operation for palliation
as well as cure; and that these cases, without relief, are necessarily
fatal, and hence justify large risks.
By exclusion and a careful study of the symptoms we believe it may
become possible hereafter in some cases to localize in two other
accessible regions brain tumors with sufficient accuracy for purposes
of operation: these are the antero-frontal region and the
postero-parietal region.
The case of Bennett and Godlee was a most successful test of
diagnosis, and as a surgical endeavor might have been more successful,
as the operator himself suggests, if more careful antiseptic
precautions had been used. In the discussion of this case before the
Royal Medical and Chirurgical Society[47] it was stated by
Hughlings-Jackson that three indications were of special importance
for this diagnosis: (1) local persisting paralysis; (2) epileptiform
convulsions, those beginning locally; (3) double optic neuritis, which
is diagnostic of tumor as distinguished from a sclerotic patch. It is
probable that permanent palsy would be left after a successful
operation in which the cortical tissue were destroyed, but as this is
compatible with life and comfort, it is not likely that, as an
alternative, it would be rejected by the patient. McEwen's case, also
given in the table (Case 25), is not as accurately reported[48] as
Bennett's, but was partially successful. At the opening over the
Rolandic region false membrane was removed, and an incision made which
let out grumous red-colored fluid: this was followed by a decrease in
the paralysis and improvement in other brain symptoms. It is difficult
to understand why the opening was made in the occipital region. The
necessity for antiseptic measures is to be especially considered in
cerebral surgery. In a recent operation for a case of traumatic
epilepsy, under the care of Mills and White, in the Philadelphia
Hospital, in which quite extensive injury was done to the membranes in
removing fragments of bone, rigid {1068} antisepsis was employed; and
it is not too much to assume that the risks of the operation were much
diminished by it and its success ensured in an old and crowded
hospital building.
[Footnote 47: _Brit. Med. Journ._, May 16, 1885, p. 988.]
[Footnote 48: _Glasg. Med. Journ._, xxi., 1884, p. 142.]
In the medication of tumors of the brain we can unfortunately do but
little more than treat the symptoms and ameliorate the various
conditions as they arise. There is no specific for these growths,
unless the syphilomata be an exception; and experience shows that
specific treatment is usually disappointing even when applied to a
syphilitic brain tumor. The dietetic and hygienic rules laid down by
some are only such as are invariably recommended as routine practice
in all kinds of disease; and it almost seems a mockery to offer them
to a patient with an intracranial tumor with the same gravity and
detail as we suggest them in a curable fever or a hopeful surgical
case. It is possible that local depletion and revulsives, by
controlling irritation and hyperæmia, may be beneficial, though we
should hesitate to add to the sorrows of the patient the action of
tartarized antimony, even, with Obernier, in special cases. Hot or
cold effusions and the ether spray are worthy of mention. Local
applications of the galvanic current might be tried for its catalytic
action, but the observations are too few and the theory too
inapplicable to allow us to attach much importance to the suggestion.
The use of electricity to the limbs for paralytic symptoms certainly
does not promise much in the case of an obstinate neoplasm in the
brain.
Morphia and bromide of potassium are the two drugs which offer the
most promise in these fatal cases. They can often control the most
urgent and frightful symptoms. The headache, the obstinate vomiting,
the epileptic seizures, are all more or less amenable to one or other
of these remedies or a combination of them. Although the vomiting is
of centric origin, it is possible that remedies addressed to the
stomach might occasionally afford relief, just as we apply medicines
to that viscus in reflex irritation, in pregnancy, and in debilitating
diseases. The remedies which suggest themselves are the salts of
bismuth and cerium, the more stimulating wines, as champagne, in small
frequent doses, and cracked ice.
While morphia and bromide of potassium are, on the whole, the most
useful remedies for the relief of pain and irritating symptoms of
brain tumor, other remedies can often be used with great advantage as
adjuvants. Ergot in the form of the solid or fluid extract has a
beneficial influence in relieving the congestive symptoms. Cannabis
indica in the form of the fluid extract in doses of five to ten
minims, or the tincture in doses of fifteen to thirty minims, may be
advantageously combined with morphia and a bromide, or sometimes may
be tried alone. Hyoscyamus, either the fluid extract or tincture, in
somewhat larger doses may also be tried. The great severity of the
headache and the imperative demand, however, will usually compel the
physician to fall back at last upon morphia in large dose by the mouth
or hypodermically.
Leeches to the temples or behind the ears or to the mucous membrane of
the nose, either wet or dry cupping to the back of the neck, and
bladders or compresses of ice, or very hot water, may be used to the
head.
The various serious complications which so often accompany
intracranial tumors should be most carefully managed. Among the most
important of these are such affections as the conjunctivitis and
trophic {1069} corneitis, with anæsthesia, present in a few cases,
usually when the trigeminal is directly or indirectly involved.
Cystitis and pyelitis must be appropriately treated, and patients must
be carefully watched in order to prevent injurious consequences of
over-distension of the bladder or enormous fecal accumulations.
TABLE OF ONE HUNDRED CASES OF BRAIN TUMOR.
_Superior Antero-frontal Region._
1. Sex and Age: M. 35.
Clinical History: Syphilis and traumatism.
Headache; vertigo; mental slowness; loss of attention; hysterical.
Nystagmus. Tonic spasm of neck and forearm. Movements weak and
uncertain. Explosive speech. Gradual blindness; choked discs.
Conjunctivitis and corneitis of left eye. Anæsthesia of conjunctiva.
Polyphagia. Constipation alternating with involuntary evacuations and
urination. Temperature 97°-101°. Head-temperature above normal;
highest at frontal station; average, 96.5.
Pathology and Location: Fibroma.
Anterior superior half of second frontal and anterior superior and
inner half of first frontal; anterior segment of gyrus fornicatus, and
anterior half inch of corp. callosum.
Remarks: C. K. Mills, _Philada. Med. Times_, Jan. 18, 1879 and _Arch.
of Med._, vol. viii. No. 1, Aug., 1882.
2. Sex and Age: M. 50.
Clinical History: Headache, dizziness, and slight right facial
paralysis. Dimness of vision. Day before death had an attack of
unconsciousness, from which he emerged in half an hour. In two hours
had another attack; became comatose; Cheyne-Stokes respiration;
temperature 102.3°; pulse 150. Reflexes completely abolished.
Pathology and Location: Fibroma.
One and a half inches in diameter in the left antero-frontal lobe,
located so as to involve the middle portions of the first and second
frontal convolutions and white substance beneath them almost to the
orbital surfaces. White matter softened posterior to tumor. Adherent
to pia mater.
Remarks: C. K. Mills. Not before published.
3. Sex and Age: M. 16.
Clinical History: Frontal headache, vertigo, staggering gait toward
right. Later, paresis of sphincter of bladder. Some muscles of right
face paretic. Some weakness of mind: emotional. Choreic movements of
right arm, increased with mental excitement. No deafness, loss of
taste, or of tactile or heat sense. Slight traces of sugar. Blurring
of papilla and hyperæmia of retina. Later, vomiting. Urine sp. gr.
1031. Irritability of mind, with erotic conduct. Reduction of
pulse—54. Progressive emaciation and mental failure. Tremor in both
arms, and in right arm automatic movement. Boil on left hand. Scaphoid
abdomen. Later, temperature below normal; also pulse and respiration.
Right facial paralysis unchanged. Still later, contracture of both
elbows. Pupils react tardily. Apathetic. Very late, small quantity
albumen, no sugar.
Pathology and Location: Glioma.
Frontal convolutions flattened; brain-substance doughy; cortex
gray-red; medullary substance reddish-white. Corpus callosum arched
upward; lateral ventricles enlarged in posterior horns. Tumor in
medullary substance of both frontal lobes, springing from septum and
radiating toward parietal lobes, almost filling both anterior lobes,
and also adhering to walls (apparently) of ventricles. At base
extended backward full extent of frontal lobe.
Remarks: Petrina. _Vierteljahrschr. f. die Prakt. Heilk._, 1 Bd.,
1877, p. 126.
4. Sex and Age: M. 36.
Clinical History: History of injury to the head. Frontal and occipital
headache. Vomiting and giddiness. Memory much affected. Double
internal strabismus with unequal pupils. Double optic neuritis.
Hearing unaffected; sense of smell lost. Lies on back. Stumbles on
trying to walk. Answers questions with difficulty; speech slow and
hesitating. Pain in head, apparently increased by percussion to right
frontal region.
Pathology and Location: Endothelioma.
In right frontal lobe anterior portion. Three inches in diameter.
Surrounded by soft diffluent cerebral tissue. Right frontal bone had
on its internal surface a much greater concavity than the left, and at
its upper and outer part was rough, deeper in color, and thin. Dura
mater adherent.
Remarks: Philipson, _Medical Times and Gazette_, vol. ii., for 1882,
Sept. 16, 1882, p. 355.
{1070} 5. Sex and Age: F. 32.
Clinical History: History of chancre with secondary and tertiary
lesions of syphilis. Frontal node. Constant headache. Epileptiform
convulsions. Marked exophthalmus, with impairment of sight in both
eyes. Improved under iodide of potassium. Grew worse again. Dimness of
vision; pain in head constant, and worse at night. Ophthalmoscope
revealed neuro-retinitis with commencing atrophy of optic nerves.
Pathology and Location: Gumma.
From dura mater into the brain-substance at the anterior portion of
the anterior lobe of the left hemisphere. Brain-substance softened
around tumor. Left ventricle dilated, and filled with fluid.
Remarks: H. Knapp, _Arch. of Ophthalmology and Otology_, vol. iv. p.
245.
_Inferior Antero-frontal or Orbital Region._
6. Sex and Age: M. 27.
Clinical History: Loss of sight, increasing to total blindness.
Gradually increasing loss of hearing, of smell, and of taste, in order
named. No anæsthesia. No paralysis mentioned.
Pathology and Location: Fibro-sarcoma.
Involving inferior portion of right anterior lobe. The first and
second pair of nerves were involved, but no other nerves.
Remarks: L. Howe, _Buffalo Med. and Surg. Journ._, xxi. p. 299.
7. Sex and Age: F. 33.
Clinical History: Paralysis and wasting of right leg since childhood.
Sudden severe general convulsions with loss of consciousness, followed
by paresis of right upper extremity. No facial or ocular paralysis.
Special and general sensibility normal. Recurrent convulsions, both
tonic and clonic. Severe frontal headache; continued paresis of right
arm. Apathetic. Right face partially paretic, and right oculo-motor
weakened.
Pathology and Location: Cholesteatoma.
Growing from pia mater at the base between both frontal lobes,
extending to anterior margin of corpus callosum and to optic chiasm.
Remarks: Petrina, _op. cit._, p. 126.
8. Sex and Age: F. 20.
Clinical History: Vomiting. Loss of sight and hearing; inability to
speak. Somnolence. Pupils widely dilated. Later, all special senses
involved. Tongue protrudes to right. Pulse irregular. Right face
anæsthetic. Neuro-retinitis in both eyes, worse in right; left eye
retained some vision. Hearing and taste perfect; smell impaired. No
paralysis. Pain constant over eyes. No convulsions.
Pathology and Location: Under left anterior lobe and extending from
falx cerebri, to which it was adherent, over the cribriform plate of
the ethmoid, involving left olfactory nerve, backward and diagonally
across the sella turcica to right petrous bone, where the end of it
pressed on fifth nerve of right side at its point of exit. Pressed
upon optic chiasm.
Remarks: E. Williams, _Med. Record_, 1868, pp. 29-31.
9. Sex and Age: M. 49.
Clinical History: Vertigo. Always excessively stupid, allowing himself
to be made a fool of. Violent bleeding from the mouth and nose ten
years before death, followed by nasal discharge. Frontal headache,
especially on left side. Failure of sight. Small tumor in inner upper
angle of left orbit, which dislocates left eye outward; right eye also
deviated outward without any apparent mechanical reason. Pupils
dilated and sluggish. Sight much diminished. Mouth slightly drawn to
one side. Speech slow, but not hesitating. Gave replies to questions
slowly, and did not usually keep to the point, but clothed his answers
in general remarks. A certain amount of self-esteem pervaded his
conversation. Continuous headache. Very late, had convulsions which
began on the left side and extended to the right.
Pathology and Location: Tumor the size of a large walnut to the right
of the middle line, external to the dura mater at a point
corresponding to position of right olfactory bulb. Vitreous table of
the frontal bone and crista galli of the ethmoid completely destroyed.
On the inner side of dura mater another tumor fills the right anterior
fossa and a large portion of the left.
Remarks: Obernier, _Virch. Arch._, vol. xxxvi. p. 155, and _Ziemssen's
Cycl. Pract. of Medicine_, Am. ed., vol. xii. p. 268.
10. Sex and Age: M. —.
Clinical History: Diminution of vision. At first much reduced, without
any ophthalmoscopic changes. Slight headache; loss of appetite;
restless sleep; rapid pulse. Vision sank rapidly until completely
extinguished. Remained thus for nineteen days; then sight began to
return, first in the right eye, and then in the left. Increased, so
that an examination of the eccentric fields could be undertaken; this
showed absence of the external halves of the fields of {1071}
vision—hemianopsia. “The transition of the existing portions of the
fields of vision to the lost portions was effected by a region which,
by a low light, should be reckoned to the latter, so that then the
boundary-line of the defect fell somewhat to the outside of the
fixation-point running in the right eye in a vertical direction, and
in the left diagonally from the inside and above downward and outward.
Within the next four weeks the central vision increased in the right
to V = 1/2, and in the left to V = 1/20, while the defect in the
eccentric vision continued in the way described.”
Patient died of symptoms of acute meningitis.
Pathology and Location: Sarcomata.
Two tumors: one about the size of a pigeon's egg between the optic
trunks in front of the chiasm, surrounded by the optic nerve in a
forked manner, the nerve-fibres being parted by it. A second tumor
situated beneath the pons, raising the dura mater. It had probably
originated in cavernous sinus.
Remarks: Saemisch, _Klin. Monatsblätter_, 1865, p. 51, quoted by
Obernier, _Ziemssen's Cycl. of the Pract. of Medicine_, Am. tr., vol.
xii. p. 269.
_Rolandic Region—Motor Cortex._
11. Sex and Age: F. 38.
Clinical History: History of syphilis. Blows on the head. Headache,
with agonizing paroxysms. Top and right side of head sensitive to
percussion and headache severest in these regions. Vomiting; vertigo.
Great mental irritability. Severe left-sided spasms, beginning with
twitchings in left toes and foot. Partial paralysis of right leg and
arm, most marked in leg. Hyperæsthesia. Impaired sight. Choked discs.
Head-temperature taken once: right parietal region, 97.2° F.; left
parietal region, 96° F.
Pathology and Location: Gumma.
Attached to the fused membranes of the right convexity. Involved the
upper fourth of the ascending frontal and a smaller segment of the
ascending parietal convolution, crossing Rolandic fissure at its upper
extremity. A good example of strictly cortical lesion.
Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, August, 1882.
12. Sex and Age: F. 30.
Clinical History: No history of causation. Headache continuous,
sometimes agonizing. Percussion of head caused most pain in right
parietal region. Vomiting when headache was most severe. Vertigo. Mind
clear, but acted slowly: emotional. Spasm, beginning with twitching of
fingers of left hand: most severe on left side, and especially in left
arm. Upper as well as lower fibres of left facial nerve partially
paralyzed; nearly complete paralysis of left arm; slight paralysis of
left leg. Bowels and bladder partially paralyzed. Impaired sensibility
in limbs of left side. Left patellar reflex diminished. Sight very
imperfect. Choked discs. Hearing defective in right ear.
Pathology and Location: Carcinoma.
The tumor involved the middle portion of the ascending parietal
convolution and the upper part of the inferior parietal lobule,
pushing aside the interparietal fissure. The anterior extremity of the
tumor was about one-fifth of an inch back of the centre of the fissure
of Rolando. On the inner side of the tumor the white matter of the
brain was broken down. Adherent to the pia mater; the pia and dura
mater were united by strong adhesions.
Remarks: C. K. Mills, reported at the meeting of the American
Neurological Association, June, 1881, _Arch. Med._, vol. viii. No. 1,
Aug., 1882.
13. Sex and Age: M. 31.
Clinical History: Evidences of tuberculosis. Headache continuous, with
severe exacerbations; most severe at vertex. Vertigo. Some
irritability and emotionality; hallucination that some one was going
to come and take him away. Spasm confined to left arm. Partial
paralysis of left arm and leg, and, late in his illness, of left side
of face. Left hemianæsthesia, at first partial, but later complete and
persistent. Sight impaired; right pupil dilated and left contracted
before death. No ophthalmoscopic examination. Hearing defective in
left ear; tinnitus aurium. Head-temperature taken once: right frontal
region, 98° F.; left frontal region, 96.3° F. Cheyne-Stokes breathing
on day of death.
Pathology and Location: Tubercular tumor.
Dura and pia mater adherent over the tumor, which involved the
posterior extremities of first and second frontal and upper thirds of
both ascending convolutions of right hemisphere. Interior of
hemisphere broken down; the parts destroyed included white matter of
the parietal lobe, the posterior third of lenticular nucleus, and the
adjacent portion of internal capsule. Miliary tubercles in pia mater
around and near the tumor.
Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, Aug., 1882.
{1072} 14. Sex and Age: M. 19.
Clinical History: First symptom, headache; then vertigo. Sudden right
brachial monoplegia; possibly some paresis of leg. Recovered use of
arm; went to work; was kicked by a mule, and became worse. Headache
and right-sided paresis returned. Increasing stupor; paralysis of
right arm complete; of leg almost; right facial paresis; ptosis of
right side. Partial anæsthesia on right side of face; pain on right
side. Slight clonic spasms of right arm. Paralysis of bowels and
bladder in last week. Tendency to Cheyne-Stokes respiration. No
vomiting. Eyes not examined.
Pathology and Location: Gumma.
A large tumor in the ascending frontal convolution, at junction of
middle and upper thirds: one-third of mass on convexity of
convolution, the remainder in fissure of Rolando. Smaller tumor at
inferior angle of right lobe of cerebellum. Some basal meningitis with
effusion.
Remarks: C. K. Mills, _Med. and Surg. Rep._, vol. li., Aug. 2, 1884,
p. 119.
15. Sex and Age: M. 56.
Clinical History: Sickness began with an epileptiform seizure lasting
about ten minutes; flexing movements of right arm. Next day dragged
his right leg slightly. Partial convulsions, without loss of
consciousness, followed, and became very frequent. Two months before
death convulsions ceased, but absolute paralysis of the arm and
paresis of the leg remained. One month later complete palsy of right
half of face occurred. Mind became impaired. Complete aphasia.
Right-sided anæsthesia. Reflexes of right foot less marked than those
of the left. Rectal temperature, 100.4° F. At times deviation of the
head and eyes to the left. Left frontal and temporal regions tender to
pressure. Very late nystagmus. No headache.
Pathology and Location: Glioma.
In the left ascending frontal convolution, occupying the upper third
of this convolution. The tumor extended backward to the fissure of
Rolando, and in front was bounded by a vertical line which would meet
the upper extremity of the vertical frontal fissure. The inferior
boundary was distant about one and three-quarter inches from the
longitudinal fissure. Surrounding convolutions flattened and widened.
Remarks: Samt, _Arch. gén. de Méd._, Jan., 1876, from _Berlin. klin.
Wochenschr._, Nos. 40, 87.
16. Sex and Age: M. 49.
Clinical History: Irritability and loss of memory. Paresis, passing to
paralysis, of left arm; paresis of left leg. Slight left-sided
paralysis of tongue. No facial paralysis; no optic neuritis.
Ankle-clonus and exaggerated knee-jerk on left side. No wasting of
muscles or abnormal electrical reactions. Toward end paroxysmal
twitchings of left side, including side of face, with left-sided
paresis of face. Hebetude. Visual hallucinations. Complete left
hemiplegia. Paralysis of sphincter. Vomiting. Strong contraction of
pupils. Duration about two months.
Pathology and Location: Glioma.
Involving the middle portion of the right ascending frontal
convolution and posterior end of middle frontal convolution, extending
as a spheroidal mass downward to roof of lateral ventricle.
Remarks: A. Hughes Bennett, _Brain_, vol. v., 1882, p. 550.
17. Sex and Age: M. 30.
Clinical History: Convulsions for twelve years prior to death.
Character of fit: first, cramping of right big toe, then twitching of
calf-muscles and drawing up of leg and knee. Most of the fits stop
here, without loss of consciousness. In some fits the arm is convulsed
after the leg, beginning in fingers, and consciousness is lost.
Paralysis of right leg. Slight convulsive action of left leg.
Sensation of right leg unimpaired. Temporary aphasia at beginning of
attack; on one occasion the aphasia was present without fit. The right
arm probably paretic after each seizure. No facial palsy. Has as many
as thirty fits daily. Marked cessation of seizures at one time. Three
days before death became hemiplegic, with exaggerated deep reflexes on
paralyzed side; also ankle-clonus. During later years fit sometimes
began in hand. No optic neuritis while under observation.
Pathology and Location: Glioma.
Left hemisphere, including posterior half of superior frontal
convolution and upper half of ascending frontal convolution, except
the extreme end. The superficial area was defined by fissure of
Rolando posteriorly, superior frontal fissure externally, and
longitudinal fissure internally. Anteriorly, the tumor gradually
merged into normal brain. In the longitudinal fissure the growth
extended to calloso-marginal fissure.
Remarks: J. Hughlings-Jackson, _Brain_, vol. v., 1882, p. 364.
18. Sex and Age: F. 58.