A system of practical medicine. By American authors. Vol. 5

by Unknown

TUMORS OF THE BRAIN AND ITS ENVELOPES.

BY CHARLES K. MILLS, A.M., M.D., AND JAMES HENDRIE LLOYD A.M., M.D.

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DEFINITION.—Under the head of Tumors of the Brain and its Envelopes will be considered all forms of growths occurring within the skull, whether these involve the cranium itself, the membranes of the brain, the brain-substance, or several of these parts conjointly. A large majority of these growths spring from the brain-membranes.¹

¹ To this article will be appended a table of one hundred cases of brain tumor. Our researches included the investigation of many more cases, four to five hundred in all. Such a table, indeed, could be indefinitely extended. Our object, however, has been not so much to present a large number of cases, and these in great detail, but rather in the most condensed manner to give a definite number, carefully selected, from which to draw conclusions. The cases have not been chosen with the view of upholding any peculiar or preconceived views as to pathology, diagnosis, localization, etc., but because of the carefulness with which they have been recorded. They have been selected also, as will be seen, with the view of determining by clinico-pathological data the possibility of localizing such growths during life. Many of our general conclusions as to pathology, symptomatology, and diagnosis have been drawn from this table.

With the exception of such merely substitutional terms as cerebral or intracranial growths, neoplasms, or adventitious products, we have no general synonyms for brain tumors.

The literature of the subject of brain tumors is second only to that of such subjects as syphilis and hysteria. Vol. ii. of the Index Catalogue of the Library of the Surgeon-General's Office, U. S. A., contains no less than 632 references to this subject: number of books, 43; articles, 589. The books and papers occur in different languages, as follows: British, 142; French, 174; German, 133; American, 91; Italian, 30; Latin, 15; Swedish, 14; miscellaneous, 33.

ETIOLOGY.—Under predisposing or constitutional causes are first to be classed such special inheritances as tuberculosis or carcinoma and tendencies to vascular degeneration. The occurrence of syphilis of course predisposes its victims to cerebral or membranous growths, as it does to other so-called tertiary forms of this disorder.

Hereditary predisposition only enters in so far as the individual inherits a general tendency to the development of such affections as cancer and tubercle. Hereditary tendency to a brain tumor per se does not exist, but the individual who is of the tuberculous or cancerous diathesis under special causes may develop an intracranial growth. As to the comparative frequency with which diathetic tumors originate, a reference to the tabular statement which will be given under Pathology will be sufficient. Gliomata are very common, but with them vie in frequency sarcomatous, tubercular, and gummatous growths. Any table, unless it includes a very large number of cases—at least a thousand or more—would be misleading as to the proportionate frequency of these different forms of intracranial constitutional diseases; but it is safe to say that syphilitic, tuberculous, and carcinomatous or sarcomatous tumors are of comparatively frequent occurrence.

Tumors of the brain occur oftener among men than women. This fact is dependent largely upon the difference between the habits and occupations of the two sexes. Men, in the first place, are much more addicted to alcoholic, venereal, and other abuses which give rise to special degenerations or constitutional infection; and secondly, they are more exposed to traumatisms. In 100 cases the tumors occurred among males in 58 cases, among females in 40 cases, and sex was not recorded in 2 cases.

Statistics show that intracranial growths are more likely to occur between puberty and middle age. Although gliomata may be found at any age, brain tumors in children are more likely to be of this character. This is what might be expected from the nature of these growths. Histologically, gliomata are most closely allied to the embryonal stage of the connective tissue, and, according to Cohnheim, tumors generally are the result of a surplusage of embryonal tissue—tissue which has remained over after the requirements of normal development have been met. Of 16 gliomata, 3 occurred in patients under ten years, 2 between the ages of ten and twenty, and 4 between twenty and thirty.

One hundred cases gave the following results as to age:

Under 10 years	10	cases.
From 10 to 20 years	12	cases.
From 20 to 30 years	18	cases.
From 30 to 40 years	24	cases.
From 40 to 50 years	12	cases.
From 50 to 60 years	13	cases.
From 60 to 70 years	3	cases.
Over 70 years	1	cases.
Not recorded	7	cases.
	100	cases.

It is now generally admitted that injuries play a most important part as exciting causes of brain tumors. Frequently in our experience an apparently direct relation has existed between a head injury and the origin of the neoplasm. In 6 out of 12 cases reported by one of us,² a history of traumatism was present, although in 5 of these a history of syphilis was also present. The great frequency with which injuries of all kinds occur must of course not be overlooked in this connection. It is said by those who oppose the idea of the direct causal relations of injury that almost every one could trace such disease to falls or blows which few escape. In some of the cases of brain tumor, however, the history of injury bears a direct relation in time to the initial symptoms of the tumor. Certain tumors, as the fibromata, osteomata, angiomata, would appear to be of more frequent occurrence as the direct result of traumatism. The part played by injuries in the production of carcinomata and sarcomata, whether in the brain or elsewhere, has not infrequently been the subject of dispute. We have no doubt that, a constitutional predisposition existing, an injury frequently leads directly to the development of some form of malignant growth. In not a few of the syphilitic cases the history would appear to show that an injury to the skull had localized the constitutional poison.

² Archives of Medicine, vol. viii. No. 1, August, 1882.

Echinococci and cysticerci are found within the cranium, and sometimes give rise to tumors, but the statement of Obernier can hardly be regarded as true, that they play an important part in the production of cerebral tumors. Our table shows only two cases of this kind.

SYMPTOMATOLOGY.—The symptoms of intracranial tumors from the standpoint of the course or progress of the affection can be divided into an early or beginning, a middle or developed, and a late or terminal stage.

Headache, vertigo, and vomiting are early symptoms, varying in severity from slight to very serious manifestations, and slight and changing mental phenomena are present. Eye symptoms, such as slight diminution or blurring of vision, may or may not show themselves; the ophthalmoscope may reveal the earliest appearances of choked disc or neuro-retinitis.

In the second or middle stage, the period of the fully-developed disease, we have an intensification and greatly increased constancy of all the general symptoms, with some additional manifestations. Mental disorder increases; headache becomes more violent, and sometimes more localized; amblyopia tends to advance to complete blindness, with marked swelling of the papilla, or special disorders of vision, such as hemianopsia, occur; palsies, ataxia, convulsions, contractures, rigidity of limbs, altered reflexes, local spasms, anæsthesia, hyperæsthesia, paræsthesiæ, neuralgias, appear according to the extent and location of the growth. Certain special phenomena, according largely to the seat of the tumor, may also appear, such as disorders of hearing, taste, or smell, polyuria, diabetes, albuminuria, polyphagia, or dysphagia.

In the third or terminal stage paralysis, anæsthesia, convulsions, etc. become more profound; mentality sometimes decreases to nearly complete imbecility, although in many cases a fair amount of mental power is preserved almost to dissolution. Involvement of the bowels and bladder becomes a distressing symptom, involuntary evacuations adding to the torments of the patient. Bed-sores, acquired or trophic, appear; the patient's limbs are painfully contractured; great emaciation is usually present. With agonized head, often blind or deaf, with torturing pains in anæsthetic, paralyzed, and wasted limbs, covered with painful sores, filthy involuntarily, imbecile or demented, death comes as a thrice-happy relief.

Cases have been reported in which intracranial tumors of considerable size were discovered on autopsy, and had evidently been present for years without their presence having been discovered or even suspected; but these are extremely rare. In general terms, however, it may be said that every case of brain tumor must give rise to symptoms. These symptoms may be few or many, slight or severe, brief or protracted, constant or paroxysmal, according to circumstances. Our experience and study of the literature of the subject lead us to the conclusion that the pathological character of the growth would have some influence as to the severity and prominence of symptoms. Gliomata—which are sometimes hard to distinguish from the brain-substance, particularly the soft gliomata, producing comparatively little pressure—when located in certain so-called latent areas of the brain might escape detection during life; so might also very small tumors of any kind situated deeply in the substance of the brain.

The position taken by Obernier, that individuality has much to do with the activity of symptoms of brain tumor, has some strength. He refers particularly to the psychical response to the irritation caused by brain tumors, which differs very much in different individuals. The fact, which has been pointed out in the article on Hysteria, that hysterical symptoms are often present in cases of brain tumor as well as in other forms of organic disease, is also sometimes the cause of mistake by the diagnostician. The cases of Hughes Bennett and Eskridge will be referred to in this connection under Diagnosis.

When the subject of local diagnosis is considered farther on, those regions which are most active and those which hold an intermediate position in the production of particular and distinctive symptoms will be more particularly discussed.

The possibility of the existence of multiple tumors should never be overlooked. These are of comparatively frequent occurrence, and sometimes give rise to a puzzling symptomatology. In our search through the literature of the subject for cases we met with many examples of multiple tumors. In preparing our table multiple tumors were usually omitted. They give sometimes symptoms and signs so conflicting as to make a local diagnosis impossible, and even to confuse the expert as to general diagnosis. In other cases, however, one growth of larger size or in an active region takes command of the situation, and leads clearly to its diagnosis in spite of other less significant tumors. This was shown, for example, in one of our cases (Case 14). From the symptoms not only was the presence of the larger tumor diagnosticated, but its exact location was indicated during life. Post-mortem examination, however, showed a smaller tumor at the inferior angle of the right lobe of the cerebellum, and also some basal meningitis with effusion which had not been suspected. The first tumor was one of the ascending frontal convolution, extending into the fissure of Rolando. Its presence and location had been diagnosticated by the right brachial monoplegia and paresis of the leg, which later increased to paralysis of the limb, with right facial paresis, ptosis, partial anæsthesia of right side of face, and slight clonic spasms of the right arm. At the present time, when the question of operating for the removal of brain tumors is so prominently before the profession, and is now generally regarded as justifiable for growths in this one location, the cortical motor area, the possibility of the coexistence of another tumor should be carefully weighed. In this case, owing to the clear diagnostic indications, the question of operation was considered at the time of consultation, but fortunately—in large part because the patient was almost in extremis—it was decided not to operate. The operation would have been futile, the autopsy showing that the probable immediate cause of death was the basilar effusion which accompanied the cerebellar growth.

In another case reported by one of us³ three gummata were found in three different locations: one in the prefrontal region, another in the retro-central fissure, and a third in the supramarginal convolution. The general symptoms of brain tumor were present in this case, but no localization was possible.

³ Arch. Med., viii. No. 1, August, 1882.

The following are other illustrations of multiple tumors and of tumors with other lesions out of a large number which we have collected:

M. 44.—Several severe falls on the head. Recent chancre with secondary symptoms. Six months before death headache which grew worse; most severe in right supraorbital region, and also obstinate vomiting, vertigo, hiccough, insomnia. Some loss of power on both sides. Slow in answering and indisposed to talk. Choked discs. Involuntary evacuations. Some improvement under treatment, and then relapse. Complete blindness. Polyuria. Specific gravity of urine as low as 1003 and 1005. Appetite at times ravenous. During last few weeks of illness head inclined to the right side, probably from spasm. Intense thirst throughout the illness.

(1) Large sarcoma in the white substance of the right parietal and frontal lobes, involving ascending parietal convolutions. (2) Softening and abscess of the right temporo-sphenoidal lobe and posterior base of the right anterior lobe. Softened mass size of a hickory-nut in the upper portion of the right ascending frontal convolution. (3) Small cystic tumors of the choroid plexuses.⁴

⁴ J. T. Eskridge, Trans. of Philada. Path. Society, for 1878-79, vol. ix. p. 119.

M. 5.—Convulsions, beginning either in right foot or in right face; not unconscious during fits. Right-sided hemiplegia. Double optic neuritis, followed by atrophy. Gradual increase in size of head, with gaping sutures. Later, rigidity of right arm and leg. Shortly before death the following symptoms suddenly set in: headache, convulsions of right side with unconsciousness and retraction of head, rigidity of right arm, and tremor of right leg. Later, both arms flexed, with constant tremors of left arm, spreading over whole body. Right sterno-cleido-mastoid was stiff; almost opisthotonos.

(1) Enormous tubercular tumor of left cerebral hemisphere, extending from depth of Sylvian fissure and eroding skull. Corpus striatum soft and diffluent. Weight, over eleven ounces. (2) Tumor, double size of pea, in lower part of middle lobe of cerebellum.⁵ This case was especially interesting for the onset of the cerebellar symptoms late in the case, caused probably by a late appearance of the cerebellar tumor.

⁵ Hughlings-Jackson, Med. Times and Gaz., London, 1872-73 (2), p. 34.

M. 2.—Screaming fits. Vomiting. Paralysis of left side of face, including corrugator and orbicularis palpebrarum. Winking in both eyes suspended. Paralysis of external rectus muscle. Agitation and contractures of right arm and leg. Later, unsteady movement of head and right arm and jerking of right leg.

(1) Small glioma in left hemisphere of cerebellum, and (2) a similar tumor projecting from left lateral half of floor of fourth ventricle at common nucleus of the abducens and facial nerves.⁶

⁶ W. H. Broadbent, Proc. Clin. Soc. Lond., v. 66-68.

F. 45.—Epileptiform attacks for fourteen years. Vertigo, occipital headache, disordered vision, intolerance of light, sleeplessness, excitability, constipation, with paræsthesia of left side. Retraction of head, vomiting. Very late, convulsive movements of right eye and right side of mouth; then general clonic spasms, coma, and death. No paralysis. For twenty-six years there had been an induration of one breast, which toward end of life had a somewhat scirrhous appearance.

(1) Glioma in right hemisphere of cerebellum 1¾ inches in diameter. (2) Glioma in centre of middle lobe of left hemisphere of the cerebrum ¾ inch in diameter. Surrounding nervous tissue softened and broken down.⁷

⁷ William L. Bradley, Tr. Conn. Med. Soc., 1880, p. 39.

M. 65.—Sudden attack of spasm of left arm, with paresis and coldness and numbness. Headache and staggering. Wandering in mind. Not unconscious. Twitching in eye. Two days later violent convulsion in entire left half of body, with vomiting; not unconscious. After convulsion left hemiplegia, with left deviation of tongue. Head and eyes turned to right; vertigo. Partial anæsthesia of left face, body, and limbs. Paræsthesia; painful nervous shocks through affected limbs. Sounds in back of head. Later, mind cleared up and many symptoms ameliorated. Very late, convulsion and coma. Cheyne-Stokes respiration, involuntary evacuations. Duration, seven weeks.

(1) Tumor in ascending parietal convolution at junction of upper and middle thirds. (2) Large tumor occupied entire occipital lobe, but did not present on surface, reaching to convexity of descending cornu of lateral ventricle.⁸

⁸ W. H. Broadbent, Tr. Clin. Soc. Lond., v. 233-236.

Headache is the most frequent and positive symptom of brain tumor. It is rarely absent; in most cases it has peculiar characteristics. Its usual type might be described as continuous pain, sometimes of persistent severity, but generally with exacerbations or paroxysms of great violence. No suffering can surpass that which some of the victims of intracranial neoplasms are compelled for months or years to endure. It is only equalled by the torture produced by malignant growths in the vertebral axis, the throat, or the bones of the pelvis. The pain is not, however, always of this character. In a comparatively few cases it is described by the patient as dull or moderate, or he simply complains of distressing sensations of weight, pressure, or constriction. Usually in these cases, however, the pain increases and becomes less and less endurable. In 100 cases the headache is described as agonizing, violent, severe, or torturing 20 times; as moderate or dull, 26 times. It is simply mentioned 20 times, but here presumably it was of the ordinary severe type. Thus in 66 cases, or 66 per cent., headache of some type was recorded. No mention was made of headache at all in 29 cases, in some of which, however, it was doubtless present. In only 5 cases was it stated not to have been present: 3 out of these 5 were said to be gliomata, and of the other 2, one was probably gliomatous, and the other a cyst in the brain-substance. Tumors of this kind, which exert comparatively little pressure and which are not connected with the membranes, are probably those which are least likely to cause pain. In several instances the patients complained spontaneously of the pain being greatest in the region of the head nearest the seat of growth. With reference to cerebellar tumors, it somewhat generally supposed that occipital pain is usually present. It sometimes is and sometimes is not. In 15 cases of tumor of the cerebellum and of the fourth ventricle the pain was described as occipital twice, as fronto-occipital three times, and as cervico-occipital once. Callender has noticed that cortical lesions are more frequently accompanied by localized pains than lesions of deeper parts.⁹ Some of our cases would seem to bear out this view, although the data are not numerous or complete.

⁹ St. Bartholomew's Hospital Reports, 1869, and Ferrier's Localization of Cerebral Disease, p. 99.

In a few cases percussion of the head elicited or intensified pain in the region corresponding to the location of the tumors. We believe that percussion of the skull may afford valuable aid in localizing encephalic tumors, particularly when they are meningeal or cortical. Ferrier¹⁰ holds that percussion often elicits pain over the cranial region beneath which a lesion is localized, and Alex. Robertson of Glasgow¹¹ has also directed attention to the value of percussion of the skull in the localization of disease on the surface of the brain.

¹⁰ Brain, January, 1879.

¹¹ Abstr. Internat. Med. Congress, 1881, p. 85, and Journal of Nervous and Mental Disease, April, 1882.

Vomiting is of frequent occurrence, although it does not usually come on as early or remain as persistently as headache. It is more likely to be paroxysmal, with longer or shorter intervals of relief. It frequently occurs at the time of the exacerbations of the headache, and between the paroxysms of vomiting, nausea, slight or great, is often present. It probably occurs in about 50 per cent. of all cases of brain tumor. It is recorded as having been present in 34 out of 100 cases. It was comparatively infrequent in antero-frontal growths, occurring only twice out of 10 cases.

A case reported by one of us (Case 70) was a remarkable example of persistent cerebral vomiting. For four weeks before her death the patient vomited almost incessantly. The tumor in this case involved the middle cerebellar peduncle and the adjacent region of the right cerebellar hemisphere, and had grazed and superficially softened the floor of the fourth ventricle.

We incline to agree with Ferrier¹² that the majority of cases of cerebral vomiting can be ascribed to irradiation of irritation by the nerves of the cerebral membranes or to the physical effects of acute pain. The nuclei of the trigeminus and of the vagus are in close anatomical relationship in the medulla oblongata. Irritative impressions conveyed from the cerebral membranes, and particularly from the dura mater, to the trigeminal nuclei in the medulla are transferred to the vagus and give rise to vomiting. In tumors of the cerebellum the vomiting may be brought about through the affection of the centres of equilibration and the concurrent vertiginous sensations (Ferrier), or it may be due to direct irritation by contiguity of the floor of the fourth ventricle. In general, the tumors situated farthest forward in the brain appeared to be the least likely to give rise to vomiting.

¹² Brain, July, 1879.

Vertigo was noted in 31 out of 100 cases. Under this general designation dizziness, giddiness, reeling, insecurity in the erect posture, etc. have been included. The vertigo can be explained in several ways besides by the view which refers it to an affection of centres of equilibration in the cerebellum. Like headache and vomiting, it seems sometimes to be the outcome of pure irritation of the cerebral membranes. Alterations in the intracranial circulation produced by the growth of the tumor is another probable cause. Experiments have demonstrated the existence of a communication between the arachnoid cavity and the labyrinth, and consequently the increased intracranial tension present may result in pressure on the labyrinthine fibres of the auditory nerve, and thus occasion vertigo.

The importance of ophthalmoscopic examinations in suspected cases of brain tumor can scarcely be overestimated. They will often serve to clinch the diagnosis in favor of tumor. Of the 100 tabulated cases, choked discs were recorded in 8; optic neuritis or neuro-retinitis in 18. These results serve to show the importance of the examination of the eyes. It will be seen that with Allbutt, Norris, and others we make a distinction between choked disc, papillitis, congestion papilla, or ischæmia of the discs, and descending or interstitial neuritis. The differences between these two varieties of inflammation of the interocular ends of the optic nerve are well presented by Norris in a previous volume of this work,¹³ which will make it unnecessary for us to describe the conditions present in these cases. An examination of the tabulated cases will show that true choked discs were present in tumors situated in all portions of the encephalon. They were not infrequently present in tumors of the convexity. Descending neuritis would seem most likely to occur when the tumors are so situated that inflammation set up by them can readily extend by anatomical continuity along the membranes to the optic nerves. The lymph-space theory best accounts for the occurrence of choked discs in cases of tumor situated remotely from the base. In choked disc the appearance is one of intense swelling and engorgement of the optic papilla. In descending neuritis, as described by Graefe and Norris, there is rather a dull-red suffusion of the disc. Some of the cases reported as neuritis may have been choked discs, and the reverse, as physicians often do not make any distinction.

¹³ Vol. IV. p. 771 et seq.

Several practical matters should be borne in mind in connection with this subject of the condition of the eye-ground. In the first place, sight is not always impaired in cases of even somewhat advanced choking of the disc, so that when other symptoms and indications lead to the suspicion of a brain tumor, unexpected confirmation may be obtained by ophthalmoscopic examination. Some remarkable cases of this kind have been reported, and doubtless have been observed by all ophthalmologists and neurologists of large practice. In some cases of growths of large dimensions also careful ophthalmoscopic examination has shown neither choked disc nor neuro-retinitis to be present. In two of Seguin's cases, for instance (Cases 28 and 29), these appearances were absent. In one he reports no neuro-retinitis, but only some fulness of the veins. In the other, a large sarcoma of the centrum ovale, ophthalmoscopic changes were absent. The absence of disturbance of vision, therefore, should not lead the physician to overlook making a thorough ophthalmoscopic examination; nor should the absence of ophthalmoscopic appearances lead him to make up his mind that serious intracranial disease was not present. The presence of double choked discs is in the highest degree significant of a brain tumor.

Observations on the temperature of the head have been made in a few cases of tumor of the brain. Full accounts of such observations in two cases (1 and 3 of Table) have been published by one of us.¹⁴ It is not within the scope of the present paper to review the general subject of cranial or cerebral thermometry. We will simply, in passing, recall the labors of E. Seguin,¹⁵ Broca,¹⁶ Gray,¹⁷ Lombard,¹⁸ Maragliano and Seppilli,¹⁹ and Amidon.²⁰

¹⁴ Philadelphia Medical Times, Jan. 18, 1879, and New York Medical Record, Aug. 9, 1879.

¹⁵ Medical Thermometry and Human Temperature, by E. Seguin, M.D., New York, 1876.

¹⁶ Progrès médical, 1877.

¹⁷ New York Medical Journal, Aug., 1878.

¹⁸ Experimental Researches on the Temperature of the Head, London, 1881.

¹⁹ Quoted in Archives of Medicine, 1879.

²⁰ Archives of Medicine, April, 1880.

L. C. Gray²¹ has recorded some observations in cerebral thermometry in one case of tumor of the brain. The tumor, a soft jelly-like mass the size of a hazelnut, was found between the horizontal branch of the Sylvian fissure and the first temporal fissure, while the whole of the right occipital lobe was converted into a colloid, extremely vascular mass, which gave way under examination, this degeneration also extending anteriorly to the tumor as far as the fissure of Sylvius. Microscopical examination showed it to be a typical glioma.

²¹ N. Y. Medical Journal, August, 1878.

The temperatures at different stations were as follows:

	Left.	Right.
Frontal	96.75°	98.33°
Parietal	95°	99.75°
Occipital	96.75°	100.50°

The average of the left side was 96.16°; of the right, 99.52°; of the whole head, 97.84°.

In a case of frontal tumor (Case 1 of Table) the average temperatures of the different stations taken were as follows:

Middle frontal station	96.5°
Middle occipital station	95.5°
Right frontal station	95°
Left frontal station	94.7°
Right parietal station	94.7°
Left parietal station	94.4°

In another case, reported in full by one of us²² (Case 94), a gumma involved the basal termination of the corpus callosum, the peduncles of the corpus callosum, the lamina cinerea, and anterior perforated spaces; and the average temperatures at the different stations were as follows:

Right frontal station	97.1°
Left frontal station	97.4°
Right parietal station	97.6°
Left parietal station	94°
Right occipital station	97°
Left occipital station	94.5°
Right anterior vertical station	97°
Left anterior vertical station	94°
Right posterior vertical station	96.6°
Left posterior vertical station	94.3°

²² New York Medical Record, Aug. 9, 1879.

In a gumma in the cortical motor zone of the right side the head-temperatures, taken once, were found to be for the right parietal region, 97.2°; for the left, 96°. In another tumor of the right motor zone the right frontal region gave a temperature of 98°; the left, of 96°. In a tumor of the left occipito-parietal region the temperatures were for the right parietal region, 98°; for the left, 97.8°. Although the temperature of the head was only taken once in each of these three cases, the observations were carefully made with tested thermometers.

J. T. Eskridge, in a case of a tumor of the cerebellum with monocular hemianopia (Case 76), made the following temperature observations:

Axillary	R. 98.6°;	L. 98.6°
Head:
Anterior frontal station	R. 98.4°;	L. 98.4°
Posterior frontal station	R. 98.5°;	L. 98.6°
Superior frontal station	R. 98.4°;	L. 98.4°
Parietal frontal station	R. 99.2°;	L. 98.6°
Rolandic frontal station	R. 98.8°;	L. 99.1°
Occipital frontal station	R. 99.4°;	L. 99.1°
Posterior central station	99°.
Anterior central station	99°.

The normal average temperatures, as determined by Gray, were as follows:

Left frontal station	94.36°
Right frontal station	93.71°
Left parietal station	94.44°
Right parietal station	93.59°
Left occipital station	92.66°
Right occipital station	91.94°
Left side of the head	93.83°
Right side of the head	92.92°
The whole head, exclusive of the vertex	93.51°
Motor region of the vertex	91.67°
The whole head, inclusive of the vertex	92.66°

We conclude that in brain tumors the average temperature of the whole head is elevated several degrees above the normal, and that the elevation of temperature is usually greatest at the station nearest the seat of the growth.

Mental disturbance of some description was present in about one-third of all the cases studied. Doubtless they were not recorded in a large number of cases. Obernier says: “If the psychical qualities of a patient suffering from cerebral tumor be analyzed, and a careful comparison made of the former with the existing mental condition, certain symptoms of mental disturbance will be discovered in most cases where the tumor is a growing one.” The disturbances may be in any sphere of the mind—in intellection, volition, emotion, or perception. Mental slowness and uncertainty, inability to fix the attention, impossibility of continuous mental action, apathy, or stupidity, with hesitation or slowness of speech, were strikingly exhibited in cases of tumor of the antero-frontal region. In Case 1 the patient's mental condition was studied with great care, and in the detailed report of the case²³ the following facts were noted: The psychical manifestations were among the most important features of the case. Although comparatively uneducated, he had been when in health intelligent and energetic. He had never during his illness had the gay humor or delirium of grandeur seen in the general paralysis of the insane. His condition, on the whole, was one of intellectual slowness and uncertainty. He seemed to have great difficulty in receiving mental impressions and in directing the movements of his body. His faculty of attention was, in great measure, destroyed. It could only be fixed, and then but partially, by distinctly and vehemently repeating a question or command. He could hear, but it was necessary to make a tremendous external impression on his sense of hearing in order to call out a mental response. He sometimes appeared to me like a man dazed by a great catastrophe which he could not understand. He was not aphasic, although he manifested certain striking peculiarities of speech, or, rather, of the manner of speaking. What he said, either spontaneously or in answer to questions, was spoken clearly and distinctly and in a firm, loud voice. His sentences were short, but complete; neither words nor syllables were omitted; and he made no mistakes in articulation, enunciation, or pronunciation. In answering he did not seem to be able to retain for any length of time a hold upon the same idea or to follow a particular train of thought. He did not wander from one subject to another, but he would suddenly stop speaking, as if unable to go farther. Often on being questioned he would try to reply, and after a sentence or two would sob and burst into tears like a violently hysterical woman. He would at times have what might be termed volcanic outbursts of speech. When all was perfectly quiet in the ward he would suddenly explode with a sentence or two, and then again subside into stillness. Exclamations of this kind might be repeated at intervals of a few minutes for hours together, or they might recur only at intervals of hours. Sometimes what he said would be connected with some past events of which he seemed to have a vague recollection; often it would be a demand for something to eat or drink; and often, again, it would be a paroxysm of profanity.

²³ Philadelphia Medical Times, Jan. 18, 1879.

Impairment of will is not uncommon in antero-frontal and other cerebral tumors, and failure of memory, depression of spirits, and even acute mania, occur. Many of the patients are emotional, excitable, and irritable; they often sob and cry, apparently from the great pain. In some cases, however, emotional conditions are present which seem to be dependent on some special localization of the tumor. Hallucinations were noted in two of our tabulated cases. In one case, a tumor of the motor zone, the patient had delusions that some one was about to take him away. There were also illusions of fear or persecution. In another the patient had visual hallucinations.

Speech-defects of various kinds occur in connection with intracranial growths. Ladame, quoted by Rosenthal, has cited forty-five cases of disturbances of speech in which the tumor occupied the most varied regions of the brain. Peculiar disorders of speech from special localizations will be treated of under Local Diagnosis.

Local spasms, which go under various names, as cramps, twitchings, epileptoid attacks, athetosis or athetoid movements, are common symptoms, particularly of growths which involve the cortical motor area. They are of great diagnostic value. They are commonly, although not invariably, accompanied by paresis, which is usually most marked in the part most affected by the spasm. These local spasms, beginning in one extremity, in a finger or toe it may be, often spread toward the centre, until they involve to a greater or less extent the whole limb, the side of the face, or one-half of the body. Sometimes instead of this they recur with the same definite movements over a long period. They are the expression of irritation of cerebral centres or tracts connected with the muscles or groups of muscles affected by the abnormal movement. They should always lead the physician to carefully consider the great probability of a lesion in some way involving the motor area.

Tumors of the cerebellum, pons, and medulla oblongata sometimes give 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.

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 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 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 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. Norris²⁵ gives a full description, brought well up to the present time, of this symptom, and a discussion of the lesions upon which it depends. Seguin²⁶ also discusses this subject. Starr²⁷ 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 (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.

²⁵ Vol. IV.

²⁶ Pp. 84, 85 of present Volume.

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 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 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 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

The histology of tumors of the brain does not in the main differ from that of the same growths as found in other parts of the body, so that a detailed description of their structures, even though founded upon original research, could not offer many novel facts in a field which has been so thoroughly cultivated. Such a description would probably repeat facts which have already been presented in other parts of this work, and which are better and more appropriately put forth in special treatises devoted to the science of pathology. It is proper, however, for the sake of convenience and thoroughness, to make brief mention of the structure of brain tumors, and especially to dwell upon certain features of these morbid growths which may be considered characteristic of their encephalic location, and hence have not only pathological but also clinical interest. It is hardly worth while to refer to speculations which aim to elucidate the very foundations of the science, except that in a few of these theories we gain an additional insight into both the structure and conduct of some very characteristic brain tumors.

Cohnheim's theory was that tumors are formed from foci of embryonal tissue which had been non-utilized or left over in the intra-uterine development of the body. Many have not accepted this idea, but have rather considered that in tumors we witness a reversion of tissue to lower or embryonic types.²⁸ Whether we accept either or neither of these propositions, the idea sought to be conveyed is that in all these morbid structures we have a tissue of low or degraded character, springing in most instances from a connective or non-differentiated tissue. This fact is brought out very clearly in many of these intracranial growths. Virchow²⁹ has said that tumors originate in the cells of the connective tissue, although his law has been condemned as not of sufficient breadth, since it seems to ignore the epithelial and myomatous tumors. Dermoid cysts, of which an example is given in the table of spinal tumors,³⁰ are said to illustrate the embryonic function revived—i.e. the tendency of lower tissues to spontaneously differentiate into higher and more complex ones.

²⁸ Article “Pathology” in Brit. Encyc., by C. Creighton.

²⁹ Quoted by Cornil and Ranvier.

³⁰ Page 1107.

The gliomata are among the most common and characteristic tumors of the cerebro-spinal axis, to which system and its prolongation into the retina they are confined. They invariably spring from the neuroglia or connective tissue of the nerve-centres, and reproduce this tissue in an embryonal state. They greatly resemble the brain-substance to naked-eye inspection, but have, histologically, several varieties of structure. These variations depend upon the relations of the cell-elements to the fibres or felted matrix of the neoplasm. In the hard variety the well-packed fibrous tissue preponderates over the cell-elements, and we have a tumor resembling not a little the fibromata (Obernier). The second variety, or soft gliomata, show a marked increase of cells of varied shapes and sizes, with a rich vascular supply which allies these growths to the sarcomata. The elements of gliomata sometimes assume a mucoid character, which allies them, again, to the myxomata.

FIG. 43.

Flat Glioma-cell with its Fibrillar Connections (Osler).

FIG. 44.

(1) Homogeneous translucent fibre-cell; (2) cells like unipolar ganglion-cells; (3) giant cell (Osler).

W. Osler has recently described³¹ to the Philadelphia Neurological Society the structure of certain of these tumors, from which we abstract the following facts: One point referred to is that gliomata sometimes contain larger cells and coarser fibres than are usually shown. The structures are (1) The “spinnen” or spider-cells (characteristic of glioma), which present variations in size; (2) large spindle-shaped cells with single large nuclei (some of the largest cells met with in tumors); (3) cells like the ganglion-cells of nerve-centres, with large nuclei and one or more processes: some are balloon-shaped with single processes; they are larger than the spider-cells; (4) translucent band-like fibres, tapering at each end, without nucleus or granular protoplasm, regarded as a vitreous or hyaline transformation of the large spindle-cells. Klebs (quoted by Osler) holds that the ganglion-like cells are derived from the nerve-cells of the gray matter, “and that in the development of this variety all elements of the nerve-tissue participate.” Osler examined the advancing region of the tumor, and was not able to satisfy himself that the nerve-cells were in process of proliferation. He thinks they are connective-tissue elements. He has seen but two out of five cerebral gliomata which were of small-celled type.

³¹ “Structure of Certain Gliomas,” Philada. Med. News, Feb. 20, 1886.

The gliomata are subject to fatty degeneration, which usually occurs in the central (older) portions of the mass. The more vascular forms are also peculiarly liable to hemorrhage, which is probably caused in some instances by this process of retrograde metamorphosis. These hemorrhages resemble apoplexies, not only in their clinical features, but also on gross examination. Great care is therefore often necessary at the autopsy to distinguish such a hemorrhage, occurring as it does in a brain-like neoplasm, from one caused by the rupture of a diseased artery. The hypertrophy of the pineal gland, sometimes noted, is caused by the formation of gliomatous tissue. Under the microscope it is necessary carefully to distinguish some forms of inflammatory new formations from the gliomata. We have recently seen, by the courtesy of E. N. Brush of the Pennsylvania Hospital for the Insane, photographs of microscopic sections from the ependyma of the lateral ventricles in a case of general paresis, which showed the structure of this degenerated tissue to be a compound of fibres and cells of marked resemblance to gliomatous tissue.³²

³² These micro-photographs were prepared in the laboratory of the State Lunatic Asylum, Utica, New York, by Theodore Deecke.

Sarcomata of the brain are common, as our table shows. In them the cell-elements predominate, both in the large- and small-celled variety. They are malignant and grow rapidly. The form known as alveolar sarcoma, which has a distinct stroma, is to be distinguished from the cancers; which has probably not always been done.

Tubercle, according to Ross, is the most common of all forms of brain tumor. Our table shows 13 cases out of 100, the gliomata and sarcomata being in larger number. Its favorite seat is in the cortex of both the cerebrum and cerebellum: some observations appear to show that it is more common in the cerebellum and mid-brain region than in the fore-brain, and in children than in adults; some of which points distinguish it from the gummata, which are more common in adults and occur anywhere. Tubercle is another form of development from the connective tissues, usually dependent upon a constitutional taint or predisposition: in it the cell-elements have generally undergone a degeneration into an amorphous cheesy mass. It is apt to be multiple and accompanied by a similar deposit in other organs of the body.

True neuromata are probably very rare growths, and it is likely that some tumors which have been described as such are really connective-tissue tumors of a gliomatous nature, in which some of the cell-elements have been mistaken for the ganglion-cells. Obernier³³ says that these tumors are small and grow from the gray matter on the surface, also on the ventricular surfaces. They are also found in the white matter. He says they are only found in persons having some congenital or acquired aberration; by which is probably meant some other well-marked neurosis or psychosis. The one hundred tabulated cases afforded no examples of neuromata.

³³ Op. cit.

Myxomata are not, histologically, to be distinguished from the gliomatous tissues by anything but the peculiar mucoid changes which their structures have undergone. They are more rare in the brain, as our tables show, than in the spinal cord.

Lipomata are very rare in the brain, according to most observers. The table shows but one example. These tumors, as their name signifies, are made of fat-bearing tissues—another of the connective-tissue class.

The angiomata, somewhat rarely found within the skull, are noted for their abnormal development of the vascular tissues: they are composed mainly of blood-vessels and the connective tissue, which supports them in closely-packed masses. They also present cavernous enlargements. They are of especial interest in cerebral pathology, because the lesion known as pachymeningitis hæmorrhagica, often found in dementia paralytica, is considered by some to be angiomatous; although by far the most generally accepted view of this latter condition is that it is due to arterial degeneration, and in part is an inflammatory exudate.

Syphilitic tumors, or gummata, are, like tubercle, a special development with degeneration from the connective tissue, due to a constitutional taint. This new growth is sometimes single, sometimes multiple. The corpuscles of the neuroglia are the apparent points of origin of the tumor, the substance of which is the firm, peculiarly gummy, and non-juicy material from which the name is derived. It would be impossible in our allowed space to trace this neoplasm through the successive stages of its development. It has especial clinical interest, inasmuch as it and its damage are probably amenable to specific treatment when it has not progressed to too great a destruction of brain-tissue.

The true cancers, or epithelial neoplasms, are not a common form of tumor of either the brain or spinal cord. They present, as in other parts of the body, a stroma forming alveolar spaces in which are contained the nests of epithelial cells. These tumors thus present characteristic differences in their histology from the connective-tissue or mesoblastic groups, but clinically no very special interest attaches to them. Their location, the rapidity of their growth, and their fatal import are points which they share with most other new growths of the cranial cavity.

The cholesteotomata, or pearl cancers, consist of hardened epithelial cells which have undergone a sort of fatty degeneration.

The psammomata are loosely described as tumors containing sand-like bodies, which bodies are normal about the pineal gland. These sand-like bodies are found in tumors of some histological diversity, and do not appear to have much identity of their own. They occur in sarcomata and carcinomata, and are probably not to be distinguished from mere calcareous infiltration and degeneration. They are most common in sarcomata, as this is one of the most common of cerebral tumors.

True osteomata—i.e. tumors with the structure of true bone—are probably rare in the brain, although more common on the inner table of the cranium; but the deposition of calcareous salts has been recorded in a variety of conditions. F. X. Dercum, in a recent paper read before the Philadelphia Pathological Society,³⁴ has recorded the autopsy of a paretic dement in which case calcareous deposits were scattered throughout both hemispheres and the cerebellum. He believes that “the areas in which the concretions were found were probably foci of encephalitis of greater intensity than elsewhere. In these foci inflammatory changes in the walls of the vessels became pronounced; besides which the vessels increased enormously in size and number; so marked is this increase that these foci could, with perfect propriety, be called angiomata.” This is followed by proliferation of the neuroglia, compression and destruction of nerve-tissue, and deposit of the calcareous salts especially about and upon the coats of the vessels. This case illustrates in the simplest manner the formation of both vascular and sand tumors.

³⁴ The Medical News, April 24, 1886, p. 460.

Pacchionian bodies are very common in the brain, and are really small fibromata. They may form true tumors (Cornil and Ranvier) capable of wearing away the bones of the cranium. In fact, even when small they may have corresponding indentations in the skull. They are not to be mistaken for tubercle. Clouston³⁵ has described excrescences from the white matter of the brain, growing through the convolutions, projecting through the dura mater, and indenting the inner table of the skull; which new growths he calls hernia of the brain through the dura. We have not seen such a condition described elsewhere, and think that we have here probably Pacchionian bodies growing from the pia mater. They were found in a case of tumor of the cerebellum.

³⁵ Journ. Ment. Sci., xviii. p. 153.

A cystic formation, constituting a veritable tumor, not unfrequently occurs in the pituitary body and mounts into the third and lateral ventricles. Echinococci and hydatids also occur, and have the same natural history as these parasitic offspring have when found in other parts of the human body.

Obernier refers to an enchondrosis of the basilar process. Our table presents one case of enchondroma.

Some of the gross appearances found on autopsies of tumors of the brain are worthy of note. Often an area of congestion or inflammation, especially of the membranes, is seen about the new growth, and the brain-substance in its immediate vicinity is much more frequently softened. The cerebro-spinal fluid is increased, and, especially when direct pressure has been exerted upon the veins of Galen, are found distended lateral ventricles. When a tumor does not approach the surface, but has attained some size, the hemisphere in which it is located often has a bulging appearance, crowding over upon its neighbor, and the convolutions are flattened by the pressure. The cranial nerve-trunks are occasionally involved in or stretched by the tumor, and also occasionally the bones of the vault or base of the cranium are extensively eroded. This happens especially in cancer and osteo-sarcoma.

A few remarks should be made about the methods of making post-mortem examinations and the gross appearances and conditions likely to be found in brain-tumor cases. As not a few intracranial tumors are connected with the bone or with the dura mater, the latter being adherent to the skull-cap in some positions because of inflammation arising from the seat of the growth, especial care should be taken in removing the calvarium. Examination of the external surface of the dura mater will sometimes reveal the presence of a growth beneath or incorporated with this membrane. The dura mater should not be roughly dragged from the surface of the brain, but should be carefully removed by a process of partial dissection. During this process a meningeal growth will sometimes be found growing apparently from the fused membrane. In such cases it is usually better to so proceed as not to entirely separate the outer membrane from the growth. Indeed, this cannot be done sometimes without injury directly to the specimen, and especially to its cerebral surroundings. The dura mater having been removed, a marked opacity, sometimes a dirty-brown hue shading off into a lighter color, will indicate to the eye the probable presence of a tumor beneath and growing from the pia mater of the cortex. In such a case, and even when no such appearance is present, but a tumor is suspected, the fingers passed carefully over the cerebral surface will feel a hard, and it may be nodulated, mass at some position. A growth, having been located in this way, should not be roughly handled or at once examined by section. An effort should be made to accurately localize it, not only with reference to lobes, but also with reference to convolutions and fissures, and even special portions of these. This is best done, after a thorough examination has been made of the pia mater, by carefully stripping the pia mater from the brain, beginning at points some distance from the growth and gradually approaching it, and leaving the pia mater for a short distance around the growth connected with it. The location having been fixed and other portions of the brain having been examined, if it is not possible or desirable to retain the entire brain as a specimen, a block should be removed embracing a considerable portion of healthy brain-tissue on all sides of the tumor. In order to study the gross internal appearance of the tumor, it is a good plan to make a clean section through the middle of the tumor. From each side of this cut fragments can be taken for microscopical examination without deranging appreciably the size and appearance of the tumor.

When the tumor is not meningeal or cortical, or not situated at the base or floor of the skull, its presence may be revealed, when it is in centrum ovale and of considerable size, by either hardness or fluctuation of the hemisphere in which it is located, this fluctuation not being due to the tumor itself so much as to the breakdown of tissue around it. Large sections in known positions with reference to convolutions and ganglia should be made when examined for tumors deeply situated. If possible, sections close to and just before and behind the growth should be made, so as to assist in the accurate localization.

Small tumors are not infrequently overlooked by careless observers, and even growths of considerable size have escaped discovery by one examiner to be found by another. Tumors in certain special localities, as between the temporo-occipital lobe and the superior surface of the cerebellum in the great longitudinal fissure, or small growths in the substance of the cerebellum or deep in the Sylvian fissure, are more likely than others to be passed by, although this, of course, is not likely to occur when the examination is made by a competent or careful physician.

DIAGNOSIS.—The diagnosis of the existence of an intracranial tumor, as a rule, is not difficult. It can be made with greater certainty than that of almost any other serious encephalic disease.

It is sometimes important to decide as to the nature of an intracranial neoplasm, particularly whether or not it is syphilitic. Little is to be gained by following the plan adopted by some physicians, of treating all cases as if they were due to syphilis, on the principle that these are the only forms of tumor which can be reached by treatment. The pitiable condition of such patients is sometimes thus made worse. In every case careful and persistent efforts should be made to obtain an authentic previous history from the patient. Whenever possible the physician should search directly for the physical evidences of the former existence of syphilis—for cicatrices on the genitals and elsewhere, for nodes and depressions, for post-cervical and other swellings, etc. A history of previous disease of the throat and of pains in bones and nerves, of epileptiform attacks, of headache, and eye symptoms which have disappeared under treatment, should be sought out. It is not well to give too much credence to the stories of patients, who are not always willing to admit their past lapses from virtue; but, on the other hand, the plan of suspecting everybody who presents advanced cerebral symptoms is often a grievous wrong. Not infrequently external cranial nodes are present in cases of intracranial syphilis.

Carcinomata and sarcomata, particularly the former, are comparatively rapid in their progress. They sometimes involve the bones of the skull, even to the extent of perforation.

The existence of an inherited tendency and of tuberculosis in other organs, with the special phenomena of general tuberculosis, assists in the diagnosis of tubercular tumors.

The frequent occurrence of gliomata in early life, and the comparatively frequent absence of severe irritative symptoms, with the well-preserved general nutrition of the patient, speak for these growths.

Cerebral abscess is, on the whole, more difficult to diagnosticate from intracranial tumor than any other affection. Abscess, however, more frequently than tumor, can be traced directly to a traumatism. It is often associated with disease of the internal ear. Obernier speaks of the headache of cerebral abscess as slight, but this does not correspond with usual experience. Headache, on the whole, may be oftener absent or less agonizing in abscess than in tumor, but it is frequently present, and sometimes of great severity. Its greater mildness in a few cases is to be explained by the fact that abscess does not produce so much pressure within the intracranial cavity, and does not so frequently cause irritation of the branches of the trigeminus in the dura. Undoubtedly, the symptoms of abscess often remain for a long time comparatively latent, with then a sudden outburst of violent symptoms. The course of brain tumor is more uniformly and steadily progressive, and febrile phenomena, the results of pyæmia, are of more frequent occurrence in abscess than in tumor.

In old cases of tumor it is sometimes necessary to differentiate between it and the results of various forms of apoplexy, such as hemorrhage, thrombosis, and embolism. Cerebral hemorrhage, embolism, or thrombosis leaves a condition of paralysis, sometimes with, but usually without, accompanying spasm or convulsion, which simulates closely the paralysis and other permanent conditions of cases of tumor occurring in the same cerebral locality. In these cases, in the first place, the history of the disease will throw considerable light upon the diagnosis. In both hemorrhage and embolism the history is usually one of a sudden attack without special premonitory symptoms. Hemorrhage gives usually a precedent history of diseased kidneys, hypertrophied heart, or atheromatous blood-vessels, and occurs generally in advanced life; embolism, a history of rheumatism and valvular disease of the heart, occurring at any period of life, early or late. In brain tumor the previous history is usually one of traumatism, of constitutional infection, or of a special predisposing diathesis. Blows and falls upon the head are common antecedents, or a history of syphilis, tuberculosis, scrofula, or cancer is present. Tumor, like embolism and unlike hemorrhage, may occur at any time of life. While slight or dull headache, with more or less vertigo, may be present in cases of hemorrhage and thrombosis, the severe and often agonizing headache, with vomiting and serious vertiginous attacks, which precedes the paralytic or other phenomena of tumor, is a much more conclusive symptom in the latter cases than in the former. Choked discs and optic neuritis are much more likely to occur in tumor than in the other affections.

Brain tumor must sometimes be diagnosticated from the head symptoms of some form of Bright's disease. A case not long since presented itself to one of us with a history of having suffered at frequent intervals for two years with headache of gradually increasing severity. Dimness of vision and slight temporary œdema of the feet, circumscribed and painful swellings along the lymphatics of the thighs and legs, with some mental irritability, were other marked symptoms. The patient had been attended by several physicians of prominence, one of whom had diagnosticated tumor of the brain. The violent, apparently agonizing headache, with the diminution of vision, and the absence of marked symptoms indicating other organic disease, made the diagnosis of a growth in some non-excitable region of the cerebrum most probable. Examination of the urine showed no albumen. Careful examination of the eye-ground with the ophthalmoscope, however, revealed the appearances of retinitis albuminurica. Under a treatment directed to the relief of chronic nephritis the patient's headache and other symptoms improved.

It must not be forgotten just here, however, that, on the one hand, ophthalmoscopic appearances very similar to those of albuminuric retinitis are sometimes present in rare cases of brain tumor, and also in other constitutional disorders, such as leukæmia; and, on the other hand, that, as stated by Norris,³⁶ exceptional forms of albuminuric retinitis have been reported where the only change seen in the fundus oculi was pronounced choking of the disc.

³⁶ Op. cit.

Intracranial tumors must be diagnosticated from meningitis in its 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 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 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. Holt³⁷ 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 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.

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.

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 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 recorded⁴⁰ 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.”

³⁹ Med. Record, vol. xxix. No. 7, Feb. 13, 1886.

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, 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 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-Jackson⁴¹ 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.

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.

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.

Tumors and other lesions of the occipital lobes have in the last few 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, 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.

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 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 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 paper⁴³ 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.

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).

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 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 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.

Hughlings-Jackson⁴⁵ 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.

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. Amidon⁴⁶ 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.”

⁴⁶ Medical News, vol. xlviii. No. 3, Jan. 16, 1886, p. 64.

TREATMENT.—The surgical treatment of tumors of the brain has recently received a great stimulus from the report of a case which 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 Society⁴⁷ 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 reported⁴⁸ 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 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.

⁴⁷ Brit. Med. Journ., May 16, 1885, p. 988.

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 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.

No.	Sex and Age.	Clinical History.	Pathology and Location.	Remarks.
Superior Antero-frontal Region.
1	M. 35.	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.	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.	C. K. Mills, Philada. Med. Times, Jan. 18, 1879 and Arch. of Med., vol. viii. No. 1, Aug., 1882.
2	M. 50.	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.	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.	C. K. Mills. Not before published.
3	M. 16.	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.	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.	Petrina. Vierteljahrschr. f. die Prakt. Heilk., 1 Bd., 1877, p. 126.
4	M. 36.	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.	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.	Philipson, Medical Times and Gazette, vol. ii., for 1882, Sept. 16, 1882, p. 355.
5	F. 32.	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.	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.	H. Knapp, Arch. of Ophthalmology and Otology, vol. iv. p. 245.
Inferior Antero-frontal or Orbital Region.
6	M. 27.	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.	Fibro-sarcoma. Involving inferior portion of right anterior lobe. The first and second pair of nerves were involved, but no other nerves.	L. Howe, Buffalo Med. and Surg. Journ., xxi. p. 299.
7	F. 33.	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.	Cholesteatoma. Growing from pia mater at the base between both frontal lobes, extending to anterior margin of corpus callosum and to optic chiasm.	Petrina, op. cit., p. 126.
8	F. 20.	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.	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.	E. Williams, Med. Record, 1868, pp. 29-31.
9	M. 49.	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.	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.	Obernier, Virch. Arch., vol. xxxvi. p. 155, and Ziemssen's Cycl. Pract. of Medicine, Am. ed., vol. xii. p. 268.
10	M. —.	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 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.	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.	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	F. 38.	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.	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.	C. K. Mills, Arch. Med., vol. viii. No. 1, August, 1882.
12	F. 30.	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.	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.	C. K. Mills, reported at the meeting of the American Neurological Association, June, 1881, Arch. Med., vol. viii. No. 1, Aug., 1882.
13	M. 31.	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.	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.	C. K. Mills, Arch. Med., vol. viii. No. 1, Aug., 1882.
14	M. 19.	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.	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.	C. K. Mills, Med. and Surg. Rep., vol. li., Aug. 2, 1884, p. 119.
15	M. 56.	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.	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.	Samt, Arch. gén. de Méd., Jan., 1876, from Berlin. klin. Wochenschr., Nos. 40, 87.
16	M. 49.	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.	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.	A. Hughes Bennett, Brain, vol. v., 1882, p. 550.
17	M. 30.	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.	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.	J. Hughlings-Jackson, Brain, vol. v., 1882, p. 364.
18	F. 58.	General headache, most marked in the occipital region, and always worse at night. Sore, stiff feeling in neck; at times nausea and vomiting. Trembling of left hand; later, paresis. Two sorts of movements of left arm—one, a fine tremor; the other, attacks of jerking. Paresis of left arm increasing, with some contracture; slight paresis of left leg. Sight failing; later, semi-stupor; pupils small and fixed, the right larger. Right internal rectus weak. Left lower face paretic. Strong contractures of left arm and hand. Good knee-jerk. Choked discs. Some days bright, others almost moribund. Case advanced to complete paralysis of left arm and leg; involuntary evacuations; divergent strabismus and ptosis; indistinct speech; delirium and coma.	Alveolar carcinoma. An ovoid tumor in the upper part of the ascending frontal convolution and in its subjacent white matter. It extended well across the fissure of Rolando.	E. C. Seguin, Opera Minora, p. 495, and Journal of Nervous and Mental Disease, vol. viii. No. 3, July, 1881.
19	M. 50.	History of syphilis and severe fall on the head. Vertigo. Prickling sensation in left foot, extending to thigh, finally to arm and head, followed by unconsciousness and convulsion. Stupor after convulsion. After this, convulsive attacks at intervals. Eighteen months before death an apoplectic attack, in which was unconscious for several hours. Spasmodic attacks, preceded by a peculiar twisting of the fingers of the left hand. Paresis of the right hand and arm. Some diminution of sensation, not well made out. Slight want of use of the left leg.	Gumma. One-third of an inch in thickness at the middle of the ascending frontal convolution. Membranes fused; tumor adherent to them. Œdema of the brain. Gumma in the lungs.	H. C. Wood, “Proceedings of the Philada. Neurological Society,” Medical News, vol. xlviii. No. 9, Feb. 27, 1886, p. 248.
20	M. 59.	Gradual loss of speech—aphasia. Gradual paralysis of right side. No headache prior to this. No anæsthesia. Taste, smell, hearing, and sight intact. Apathetic face. Middle branch of facial nerve paralyzed, especially the muscles of the right corner of the mouth. Wrinkles of forehead less strongly marked. Right upper and right lower extremity in strong contracture. Leg swollen. Increasing torpor of bladder. Normal electrical reactions, except speedier and increased reaction of the right facial nerve. Reactions of convulsibility in the right arm with ten to twenty cells. Very late, unconsciousness and paralysis of bowels and bladder.	Myxo-glioma. In front of the left ascending frontal convolution, bounded below by the Sylvian fissure and the upper convolution of the island of Reil; seems to immediately enter into the structure of the island. Left optic thalamus and corpus striatum moist, but completely separated from the tumor. Convolutions flattened.	Petrina, op. cit.
21	M. 35.	Had epileptic fits for two years before his death. Occasionally the spasms began in the left half of the face and extended to the arm and leg, but did not become general. After such attacks sensation was lost in the left arm, and the arm was paretic for some hours. Toward the close of life the paresis became permanent, and extended from the arm to the leg, and sensibility was somewhat impaired in these limbs. The temperature was 2.5° F. higher over the right parietal eminence than over the left.	Gumma. Arising from the membranes, two inches in diameter, but very thin, involved the gray matter of the posterior extremities of the first and second frontal convolutions, the upper and middle thirds of the ascending frontal convolution, and the adjacent border of the ascending parietal convolution of right hemisphere.	F. H. Martin, Chicago Med. Journ. and Exam., vol. xlvi. 21.
22	F. 57.	After excitement lost consciousness. Paresis and heaviness of the right upper extremity. Aphasia; used words inaccurately; short of words and enunciation impaired. Second attack of loss of consciousness. Twitching in right half of body and face. Paralysis of right upper extremity. Severe pains in right arm and leg. Another attack of loss of consciousness, with spasms of right half of body. Right lower extremity and right lower face paretic. Slight trismus; right masseter contracted. Dull headache. Organs of sense not affected. Understands all that is said to her, although aphasic. Sensibility good. Right-sided pneumonia; œdema of lung.	Fibro-glioma. Tumor size of fist occupied the whole of the lower and middle portion of the parietal lobe, imbedded in both ascending convolutions. Ascending frontal convolution pushed aside; the annectant gyrus and island of Reil compressed and flattened. Fissure of Sylvius arched over by tumor. White substance also pushed toward the corpus striatum. Meninges congested. Left parietal bone somewhat excavated.	Petrina, op. cit.
23	F. 39.	Began to suffer with epilepsy two weeks after a blow on the left parietal region. The fits were preceded by formication in the right hand and tongue, and began with spasm in the right hand, which was weak for some hours afterward. A permanent right facial paresis developed one month after the blow, and two months later the tongue, arm, and hand were also paretic on the right side. Disturbance of vision due to choked discs had developed, and temporary attacks of aphasia occurred after the frequent convulsions. She sank into a condition of stupor and aphasia four months after the first symptoms. The skull was then trephined at the seat of the old injury in hopes of evacuating a chronic abscess, but no pus was found. One week after this she died.	Gumma. A gumma one inch in diameter was found on the surface of the left hemisphere, at the junction of the middle and lower thirds of the ascending parietal convolution, and involving also the convolution posterior to this. The membranes were adherent to the gumma.	H. B. Sands, Med. News, April 28, 1883.
24	M. 25.	Four years previous to death had received a blow on the left side of the head. A year later, twitching in the tongue and the left side of the face. Twitching of the left arm. Twitching increased. Paroxysmal spasm and general convulsions, with loss of consciousness. Paresis, and then slowly-developed paralysis, of the forearm and hand. Some paresis of left leg. Double optic neuritis. Violent headache. This patient was in charge of Hughes-Bennett at the Hospital for Epilepsy and Paralysis, London. He diagnosticated brain tumor, and suggested its removal. Rickman Godlee trephined over suspected region, and removed a glioma of the size of a walnut. The operation was performed November 25th. The patient did well until December 16th, when he was seized with a rigor, followed by fever, sickness, and pain in the head. A hernia cerebri of large dimensions supervening, he died December 23d.	Glioma. Meningitis was found at the lower border of the wound, spreading downward toward the base of the brain.	Hughes-Bennett and Rickman Godlee, British Medical Journal, Nov. 29, 1885.
25	F. —.	Syphilitic history. Tingling sensation and numbness of the left arm and leg, which increased until it ended within six weeks from its commencement in complete motor paralysis, with a deficiency in the perception of touch. Left side of the face also slightly paretic. Mental confusion and loss of memory.	After antisyphilitic treatment and counter-irritation, trephining was performed over the middle of the ascending parietal and frontal convolutions. Internal table of the disc removed was found softened and thicker than usual, having on its internal surface projections or roughnesses. A second opening was made over the occipital region, and a similar thickening was found. Opposite first opening the dura mater pale and thickened. It was elevated, and a false membrane of yellow color was removed. An incision was made in the direction of the paracentral lobule, when a gush of grumous, red-colored fluid escaped. Day after the operation much better; on third day moved her toes; within a week lifted her leg; fingers moved within a week. Mind greatly changed for the better.	Macewen, “Proceedings of Path. and Clin. Soc. of Glasgow,” Glasgow Med. Journ., vol. xxi., 1884, p. 142.
Centrum Ovale—Fronto-parietal Region.
26	F. 16.	Fell when sixteen months old from the table on her head. Left hand, five months later, noticed at times to be stiff and firmly closed. Three months later the leg became similarly affected, and two months later general paroxysms. Many seizures for periods of weeks or months, then intervals of freedom. Spasm began by contraction of the left hand: she would lie down and jerk for a half minute or minute, laughing or talking all through it, never losing consciousness. In about six years left leg became paretic. Seizures became much worse and more frequent; unconscious for six weeks, and fifty to eighty spasms in twenty-four hours. Ten months without spasms until a week before death, when they returned with great violence. Spasms always began in the left hand; appeared to extend to the leg first, and then to the face. Intellect clear.	Fibro-glioma. In the white matter, but touching upon the gray at several spots at the position of the upper end of the ascending frontal convolution of the right hemisphere. The tumor occupied largely the anterior portion of the paracentral lobule.	Osler, Medical News, vol. xliii., Jan. 19, 1884, in “Proceedings of Medico-Chirurgical Society of Montreal;” also, Am. Journ. Med. Sci., N. S. vol. lxxxix., Jan., 1883, p. 31.
27	M. —.	Severe fall, followed by insensibility. Paralysis of the left side followed injury, but improved. Three years later, epileptic convulsions: sudden fall, general spasm, biting tongue. These attacks replaced by partial or localized epilepsy without loss of consciousness: tonico-clonic spasm of muscles of left side of face and neck and of left upper extremity, especially of the thumb and index finger. Left pupil a trifle larger than right; left cheek paretic, left arm and forearm absolutely paralyzed; left leg weak. Marked tactile anæsthesia on left side. Ophthalmoscope showed fulness of veins, but no neuro-retinitis. Late, some opisthotonos. Deafness in right ear; axillary temperature, 36.4° C. Pain in right arm and leg and in posterior part of head on right side. Conjugate deviation of head and eyes from palsied side. No neuro-retinitis. Localized and general convulsions recurred from time to time.	Sarcoma. Larger than a hen's egg in white substance of right hemisphere, occupying the whole thickness of the hemisphere above the opto-striate bodies. Exerted much pressure upon these bodies, on convolutions near, and even upon the inner surface of the left hemisphere. Adherent to the dura mater. Right half of the brain much enlarged, and lateral ventricle and septum lucidum forced over to the left. Two depressions on the top of the skull; dura mater depressed and adherent to convolutions. Some pachymeningitis.	E. C. Seguin, Opera Minora, p. 215; reprinted from the Transactions of the Amer. Neurol. Ass., vol. ii., 1877.
28	M. 34.	Attacks of right-sided epilepsy every four or six weeks; later, every week or oftener. Spasms wholly restricted to the right arm or leg; the slightest attacks only momentary shocks on the right side of the body. No spasm in the face. Only very rarely lost consciousness. Never frothed at the mouth, bit his tongue, or micturated in the attacks. In intervals had good use of his right hand and leg up to a late period. Paresis of right limbs came on with indefinite numbness of right leg. Diffused headache, mostly frontal. No facial palsy; no anæsthesia. Knee-jerk absent on left side and strong on right. Later, complete paralysis of right arm and leg, with œdema. Violent headaches, more to the left of the median line at the vertex; photophobia, nausea, and vomiting. No neuro-retinitis. Still later, paresis, and then paralysis of right face. Atrophy; contractures; bed-sores; semi-coma; profuse sweating; high temperature; conjugate deviation of the eyes to the right; head straight.	Sarcoma. In centrum ovale, underneath the left cortical motor area, and completely undermining it, was a large cavity which contained a large amount of coffee-red serum, and also a tumor lying on its inner side near the paracentral lobule. The tumor was connected behind with the falx cerebri in the region of the paracentral lobule.	E. C. Seguin, Opera Minora, p. 499, and Journ. of Nerv. and Mental Dis., July, 1881.
29	M. 22.	First symptom was a fit, which was followed by a rigor. After this fit paresis of right arm and leg, with inability to articulate properly. Could not raise the affected arm, but could grip objects weakly. Paralysis of right side of face and tongue. Was quite rational. No loss of sensation. Later, violent headache, followed by vomiting. Slight amelioration of many symptoms, soon followed by second attack of violent headache, which could not be localized; complete right hemiplegia and aphasia. Later, dysphagia. Death rather sudden. Patient had had amputation of thigh about six months before for sarcomatous enchondroma of head of the tibia. Had also had chancre four years before.	Enchondroma. In left hemisphere, between anterior part of corpus striatum and “surface of frontal lobe.” The cortex over tumor and the outer and anterior portion of corpus striatum were softened and broken down.	T. P. Pick, St. George Hosp. Rep., vol. ix. p. 663.
30	F. 16.	Patient was a wayward, hysterical girl of neurotic family, precocious, and with abnormal sexual instincts and indulgences. Had a sudden attack of total blindness, then sudden recovery; sudden blindness again, and deafness; then restoration of hearing; loss of power in lower limbs, ending with total blindness, deafness, and paraplegia. Had dilated pupils and some hyperæsthesia; also marked hysteroidal attacks, becoming at last maniacal. Negatively, no constant headache or affection of ocular, facial, or lingual muscles, no convulsions or vomiting; no abnormal ophthalmoscopic appearances (except slight choked disc). The case had been diagnosticated by many doctors and one of the “first authorities in Europe” to be hysteria.	Tumor in right hemisphere, size of hen's egg, translucent, and nodulated, soft, highly vascular, with small extravasations of blood on its surface, occupied medullary substance of middle lobe superior to lateral ventricle causing bulging of roof of ventricle.	A. Hughes-Bennett, Brain, 1878, vol. i. p. 114.
Postero-parietal Region.
31	M. 25.	Kicked on the head. Headache, nearly continuous, with violent paroxysms. Vomiting at intervals, most when headache was most violent. Vertigo. Mental confusion; sometimes maniacal. Left convergent strabismus. Partial right hemianæsthesia. Patellar reflexes slightly exaggerated; slight ankle-clonus on the right side. Blind in both eyes; sight of right eye lost first. Choked discs, and eventually optic atrophy. Hearing defective in right ear. Constipation. Head-temperatures taken once; right parietal region, 98° F.; left parietal, 97.8° F.	Fibroma. Adherent to membranes, and involving the left postero-parietal and occipital region to within half an inch of longitudinal fissure. The brain-tissue around softened and broken down, the parts disintegrated being chiefly the white matter of the postero-parietal and occipital lobes.	C. K. Mills, Arch. Med., vol. viii. No. 1, August, 1882.
32	M. 49.	Dropping of left hand at intervals, with power regained in about an hour. Brief attacks of loss of speech, and numbness in lips and tongue on both sides. Numbness in tips of his fingers and the left hand. Slight paroxysms of general rigidity. Severe frontal headache. No vomiting. Loss of sight, gradually increasing to total blindness. Involuntary micturition. Increasing hebetude. Slow but probably correct intellection. Left upper extremity, toward last, paretic. Was able to stand, but could scarcely walk. Hearing and taste preserved. Some doubt as to smell. Later, imbecile. After a severe fit of general convulsions he died. Duration, about four months.	Carcinoma. It occupied nearly exactly the site of the right “poster-parietal lobule” (superior parietal). It was clear of the ascending parietal convolution in front, and behind did not quite touch the external parieto-occipital fissure; below it extended just short of the intraparietal fissure, and on inner face of hemisphere reached for half an inch into quadrilateral lobe. Below tumor toward ventricle brain-substance softened.	James Russell, Brit. Med. Journ., 1876, ii. p. 709.
33	F. 36.	Right-sided temporal and orbital neuralgia. Anæsthesia of left arm. Epileptic attacks. Slighter attacks of spasm, without unconsciousness, in left face, left arm, and hand. Paresis of left arm. Blindness. Optic neuritis. Pupils dilated and immobile. Later, loss of smell and taste. Mental depression.	Gummata. In right supramarginal lobule two tumors size of pea, lying superficially.	Broadbent, Lancet, Jan., Feb., 1874, quoted by Bernhardt, p. 68. Beitrage zur Symptomatologie und Diagnostik der Herngeschwülste, von Dr. M. Bernhardt, Berlin, 1881.
34	——	Left hemiplegia with some anæsthesia. Deafness developed in the left ear, with a total inability to localize the origin of sounds.	Tumor size of an apple in middle of ascending parietal convolution and backward. Around the tumor white softening, which extended forward as far as the fissure of Rolando, and backward throughout the right parietal lobe, and beneath almost into the central ganglia.	Strümpell, Neurolog. Centralb., Aug. 15, 1882.
35	M. 54.	Middle finger of the right hand began to jerk violently, also some of the flexor tendons. Twenty minutes after this he had a fit, in which he became unconscious and beat himself violently on the chest with the right arm. Had three of these fits. Aphasic after this for two weeks. Had high fever at the time of the seizures; was rubbed all over the body with ice. The fingers became paretic, not the forearm or arm. Arm became numb at times, especially after exertion. With dynamometer, left hand, 75; right hand, 55. Headache, which ceased after some months. Right optic disc abnormally red, but not choked; left disc normal. Had a convulsive attack in the Philadelphia Hospital, in which the four fingers of the right hand rapidly vibrated, contracting and extending without pain; no loss of consciousness or other disturbance. The tongue was also affected, so that speech was impossible. Later, the patient had a general convulsion, preceded by a drawing sensation in the face; convulsive movements began in right hand. Tongue bitten. Attack preceded by severe headache. Had another attack without loss of consciousness or convulsion, preceded by a sensation as of a knife cutting through the flesh, which travelled up from the left hand to the shoulder, and then to the head. Increasing loss of sensation in the fingers of the right hand. Increasing difficulty of speech, with spells of melancholia and crying. Right side of face markedly paralyzed. Right arm almost entirely paralyzed and much swollen. Speech much affected; difficulty in swallowing. Paralysis involves the right leg.	Gliomata. A small tumor occupies the lower end of the left supramarginal convolution, just where it joins the foot of the ascending parietal convolution. The latter convolution was not involved in the tumor, but was distinctly pressed upon in its lower third. The ascending frontal convolution was entirely healthy. In right hemisphere a similar gliomatous growth in the foot of the angular convolution where it runs into the middle temporo-sphenoidal convolution, involving also the upper part of this convolution, and to a slight extent the deepest portions of the superior temporo-sphenoidal convolution.	H. C. Wood. Not before published.
Occipital Region. Occipital lobe—cortex and centrum ovale.
36	M. 57.	Headache. Vertigo. Paresis of left side. Left facial paralysis, especially middle branch. Vomiting. Right pupil dilated. Tongue not involved. Uvula directed to left. Left velum palati relaxed. Taste, smell, sight, and hearing normal; sensibility of whole body normal. Reaction of degeneration on left side of face. Left side of body shows reaction of convulsibility. Slight quantity of albumen. Paresis declined with exception of facial nerve. Apathetic. Œdema of lung.	Glioma. In middle of right occipital lobe; lobe softened. Right lateral ventricle narrowed and left dilated. Right posterior horn and right thalamus opticus compressed.	Petrina, op. cit.
37	M. 27.	Dysphagia, most marked with liquids, caused by paresis of pharynx, more marked on left. Left hemiparesis for three years. Headache (frontal and temporal), which is of a boring, tearing character. Failure of memory. Speech guttural and monotonous. Puriform expectoration. Later, feeble voice, hiccough, yawning, somnolence.	Fibroma. On posterior face of left petrous bone and inferior occipital fossa, extending behind occipital foramen and to right of cerebellar falx. A prolongation involving the pneumogastric and glosso-pharyngeal, and spinal accessory. Also cerebellar abscess.	Cruveilhier, Bull. de la Soc. Anat., 1855, xxx. 475-479.
38	F. 20.	Headache. Dimness in right eye, then in left; finally, blindness in both. Convulsions. External strabismus; right pupil dilated, left contracted. Coma, alternating with consciousness. Vertigo. Optic discs congested, presenting small hemorrhages; exophthalmus. Paresis of right arm and leg; partial anæsthesiæ on same side. Earache. Vomiting, not frequent. Coma and death. Duration, about three months.	Sarcoma? Occupied all the posterior part of right hemisphere of cerebrum, pressing upon and indenting opposite hemisphere and right half of the cerebellum.	S. O. Habershon, Guy's Hosp. Rep., 3d S., xx. 330-334.
39	M. 18.	Periodical headaches. Pains in the neck and vertebral column. Points of exit of trigeminal nerve sensitive. Staggering gait. Diplopia. Confused sounds in right ear. Tetanoid contractions of neck.	Echinococcus. In right occipital lobe.	Visconti, Annal. Univer., Oct., 1869, quoted by Bernhardt, p. 98.
40	F. 21.	Right hemianopsia. Central vision good. Other symptoms: headache, dysarthria, anæsthesia of the right half of the face. No paralysis, no mental symptoms. Choked discs. Duration seven months.	Cystic glioma. In the left occipital lobe; had reached and destroyed the cortex of the lobe at its apex, and had extended inward, nearly reaching the inferior cornu of the lateral ventricle. The entire inner half of the occipital lobe was thus destroyed.	Jany, Knapp's Archiv f. Augenheilk., vol. xi. p. 190, quoted by Starr, Am. Journ. Med. Sci., N. S., lxxxvii., Jan., 1884, p. 72.
41	M. 42.	Right hemianopsia. Central vision good. Other symptoms: aphasia, right complete hemiplegia, with facial paralysis.	In left occipital lobe, surrounded by a zone of softening, reaching inward to and involving the pulvinar of the left optic thalamus. Optic tracts normal.	Hirschberg, Deut. Zeitsch. f. Prakt. Med., 1878, No. 4, quoted by M. Allen Starr, Am. Journ. Med. Sci., N. S., lxxxvii., Jan., 1884, p. 69.
42	M. 42.	Right hemianopsia, not quite reaching the point of fixation. Central vision good in both eyes. Ophthalmoscopic examination negative. Other symptoms: vertigo, loss of memory, aphasia, and partial agraphia, with temporary right hemiplegia.	Gelatinous sarcoma. In the left occipital lobe, involving all three of its convolutions, as well as the præcuncus. Softening extended inward through the white substance to the posterior cornu of the lateral ventricle. Thalamus and optic tracts normal.	Jastrowitz, Arch. f. Augenheilk., 1877, p. 254, quoted by Starr, Am. Journ. Med. Sci., N. S., lxxxvii., Jan., 1884, p. 71.
43	M. 40.	For seven years epileptic seizure, beginning with spasm of left leg and going on to general convulsions; motions more violent on left side. An aura consisting of a darkness, coming gradually over the field of vision from the left side, always preceded the attack. During the intervals left-sided headache was the chief symptom. It seems probable that a temporary left hemianopsia preceded the attack.	Cyst filled with serum. In white matter of the right occipital lobe, surrounded by a zone of softening which did not involve either the cortex or the wall of the lateral ventricle.	Traube, Gesammt Beitrage zu Pathologie, ii. 1083, quoted by Starr, Am. Journ. Med. Sci., N. S., vol. lxxxvii., Jan., 1884, p. 73.
44	M. 52.	Headache. Numbness down right arm. Later, paroxysms of headache lasting twenty to forty minutes, generally preceded by pain and numbness in right hand and arm, ascending to head, and so intense as to produce profuse perspiration. Delirium (lasting two days) during these attacks. No paralysis or previous fit, nor vomiting. Few hours before death had convulsions. The pain and numbness were in right arm, although tumor was in right hemisphere.	Malignant tumor. Size of pullet's egg at inferior portion of posterior lobe on right side in substance of cerebrum, approaching within a few lines of surface.	J. C. Langmore, Trans. Path. Soc. Lond., iii. pp. 246-248.
Temporo-sphenoidal Region. Temporo-sphenoidal lobe.
45	M. 33.	History of syphilis. Blows on the head. Headache, continuous, usually dull, occasionally severe. Occasional vomiting. Stupidity, want of energy, drowsiness. One general convulsion a few hours before death. Partial anæsthesia on the right side. Hyperæsthesia of left side. Sight impaired. No ophthalmoscopic examination. Hearing defective in right ear. Constipation.	Gumma. One and a quarter inches in diameter, attached to adherent membranes, and involved the middle portions of the first and second temporal convolutions of left hemisphere. A layer of brain-substance both anterior and posterior to the tumor was softened. The tumor grazed the ascending parietal and inferior parietal convolutions. A large foyer of greenish-yellow pus was found to the inner side of the tumor.	C. K. Mills, Arch. Med., vol. viii. No. 1, August, 1882.
46	M. 42.	At first an attack of vertigo which lasted over twenty-four hours: some unconsciousness for a time. Continued headache; loss of memory; giddiness and vomiting, the latter occurring without connection with the state of the stomach as to food. Partial bilateral deafness, which the patient stated was of long duration. No paralysis, but right hand a little weaker than left. Distinct mental failure during last two weeks of life; incoherence and faulty memory.	Epithelioma. Ovoid tumor about one and a half inches in diameter in the central portion of the temporo-occipital region. Hippocampal convolution grazed. Some surrounding softening and meningitis. One corner of tumor had produced a small spot of softening in the cerebellum.	H. C. Wood, “Trans. of Path. Soc. of Philada.,” 1880, Med. Times, vol. xi., Jan. 29, 1881.
47	F. 40.	Suffered from a light form of epilepsy dating from tenth year, which resulted, it was believed, from a fall. Rarely bit her tongue, but usually frothed at the mouth. No history of one-sided spasms. Always had an aura of a peculiar character. She suddenly perceived a disagreeable odor, sometimes of smoke, sometimes of a fetid character, and quite uncomplicated by other sensory warning. Developed phthisis, her attacks occurring from time to time until her death.	At lower part of right temporo-sphenoidal lobe a shrinking and induration involving the uncinate gyrus and parts of the adjacent convolution. The olfactory nerves were not involved. A form of low-grade hemorrhagic pachymeningitis present.	Allan McLane Hamilton, New York Med. Journ. and Obstet. Review, vol. xxxv., June, 1882, p. 575.
48	F. 39.	Attacks of convulsion seven weeks before her death. In two weeks mind affected; drowsy and stupid; condition of dementia. Passed into a state of semi-consciousness. No eye symptoms. No paralysis. Percussion on left side of head painful.	Sarcoma. Occupied the posterior part of the fourth and fifth temporal convolutions, and the third convolution was atrophied. Did not involve the lateral ventricle. Under surface flattened and resting partly upon the left lobe of the cerebellum.	W. H. Draper, New York Hosp. Histories, N. S. vol. x. p. 445, quoted by M. Allen Starr, Am. Journ. Med. Sci., N. S. vol. lxxxvii., April, 1884, p. 383.
Basal Ganglia and Adjoining Regions.
49	M. 59.	Contractures of right arm and leg since childhood. Death from accident. The arm was atrophied and shortened, flexed at elbow and wrist; disappearance of some cartilages at wrist and wasting of joint-surface of radius. Femur flexed at hip; knee-joint flexed; ankle-joint in position of equinus. Other bone-changes. Right leg shortened.	Osteoma. Tumor in left corpus striatum on “surface of anterior thick half,” projecting outward into white substance of brain, and inward into anterior portion of optic thalamus.	A. Bidder, Arch. f. Path. Anat. und Physiologie, und f. Klinische Med. Virchow, 1882, p. 91.
50	M. 30.	Right frontal and occipital headache. Vertigo. Paræsthesia of the toes, particularly the right. Face drawn to the right. Left face paretic. Right eye smaller than left. Weakness and fatigue of limbs. Convulsions. Vomiting. Slow pulse.	Myxo-sarcoma. In right corpus striatum protruding into right lateral ventricle and cortex.	Schüppel, Arch. d. Heilk., p. 357, 1867.
51	M. 34.	Walked a mile to an infirmary, and in less than one hour went into a series of severe epileptic attacks, which continued for four hours. The spasms were clonic, and chiefly in upper extremities, with violent contortions of face; the latter most marked on left side and in zygomatici. Between the fits there was deep coma, especially three hours before death, when, after another violent fit, he died, seven hours after first seizure. No paralysis, and report says nothing about any previous fits.	Myxomatous glioma. It exactly occupied the place of right nucleus caudatus, extending outward as far as white fibres, but not involving them. Brain-tissue in proximity normal.	Dowson, Med. S. and Gaz., London, 1878, p. 333.
52	——	Partial anæsthesia of right half of trunk. Hyperæmia of retina, and capillary hyperæmia of left optic disc. Left pupil dilated; left ptosis; left diverging strabismus. Paralysis of right side and extremities. Paralysis of muscles around right corner of mouth. Incontinence of feces and urine. Redness of face. Variations in temperature.	Tubercle. In left optic thalamus. Partial destruction of left peduncle of cerebrum.	Fleischmann, Wien. med. Wochenschrift, 6, 7, 8, 9, 1871, quoted by Petrina.
53	F. 44.	Severe headache on left side. Sensibility lessened in left extremities, at same time frequent pain. Intelligence diminished. Speech retarded. Strabismus of left eye. Amblyopia. Left pupil alternately dilated and contracted. Left lagophthalmos. Chattering of the teeth. Twitchings on the left paralyzed half of the face. Tongue and uvula tending toward the left.	Sarcoma. Right optic thalamus. Corpora quadrigemina compressed.	Friedreich, quoted by Petrina, op. cit.
54	F. 38.	Headache. Creeping sensations in right arm and leg. Right facial paresis. Paresis of left extremities. Convulsions. Dimness and confusion of sight. Diplopia. Hardness of hearing. Failure of memory. Difficulty in speaking and swallowing. Improvement under iodide of potassium.	Glioma. Left optic thalamus.	Bruzelius and Blix, 1870, quoted by Bernhardt, 153.
55	F. 14.	Headache, vertigo. Epileptic attack. Right hemiplegia. No anæsthesia. Slight dilatation of pupils.	Sarcoma. In left optic thalamus. The right optic thalamus also affected. Corpora quadrigemina enlarged and pushed backward.	Rusconi, Gaz. Med. Ital., 1874, No. 11.
56	M. 30.	Headache. Left ptosis; fixation of left eyeball. Drowsiness. Retarded speech. Gait unsteady. Paresis of right hand and foot. Emaciation; incontinence of urine.	Serous tumor. Large as a nut, in posterior half of right optic thalamus.	Troschel, Med. das ver. für Heilk. in Preussen, xliii., 1839, quoted by Petrina.
57	F. 36.	Imbecile. Speech inarticulate. Pupils contracted. Spasms in arms, but light in limbs.	Cancer. Left optic thalamus and corpus striatum without definite boundary, extending into brain-mass.	Brenner, quoted by Petrina, op. cit.
58	F. 33.	Headache and vomiting for three weeks: for one week had been maniacal. Convulsions. Apoplectiform attack, marked by unconsciousness, general muscular flaccidity, and stertorous breathing. Paralysis of left face; twitching of right face.	Glioma. Between left optic thalamus and hippocampus minor, extending from the ventricle to the under surface of the brain. Corpus striatum and optic thalamus unaffected. Hemorrhage on under surface.	Owen, St. George's Hosp. Rep., ix., 1877-78, p. 150.
59	M. 45.	Vertigo, headache, and tinnitus. Five years before attack had fallen and struck the back of his head. Much exposed to the sun. One day in August a general feeling of numbness came over him. This was followed by vertigo, etc., as above. Staggered and stumbled in walking as if intoxicated. Unable to maintain his balance in the dark or with his eyes closed. Some numbness in legs and arms, but no actual loss of sensibility. No neuro-retinitis; no paralysis. When erect had a constantly increasing tendency to stagger backward. Divergent squint and diplopia appeared. Potassium, iodide blisters, and seton were used. Noises and headaches disappeared. During last two or three weeks some difficulty in swallowing. Involuntary evacuations. Occasional hallucinations.	Glio-sarcoma. Tumor size of walnut in third ventricle, moulded to the interior. Extending to base of brain just above corpora albicantia, and forward as far as anterior commissure. A caudate prolongation completely blocked up the Sylvian aqueduct. Owing to this obstruction, a large quantity of serum had been imprisoned, enormously distending the fourth and lateral ventricle. The growth invaded left optic thalamus. Superior surface of cerebellum softened from median line to middle of right hemisphere.	F. Woodbury, Am. Journ. of the Med. Sci., N. S. lxxvi., July 1, 1878.
60	M. 15.	Epileptic from childhood: had had no fits for last three years. Had tremors and was dull. Short-sighted, and had a habit of absurdly frequent winking. Nothing else wrong with eyes. Suddenly, after a mental disturbance, had intermitting pulse. Cold surface, dulness, head and face swollen and flushed. Then tonic spasms, loss of consciousness, involuntary micturition. General tremors, dilated pupils, stupor. Next diffused dusky-red flush of both cheeks, also over back of hands and forearms. Temperature depressed to 92° in axilla. Automatic repetition of words. Taste and smell normal. He recognized himself in looking-glass on the day he died.	Sarcoma. In third ventricle, lying between corpora striata and optic thalami of opposite sides. It completely enveloped optic commissure, and partially involved track of optic nerves issuing from front. The sole organic connection of tumor was with the commissure. The tuber cinereum was distinct from its tissue.	Russell, Med. Times and Gaz., 1873 (1), p. 522.
61	M. 19.	Periodical headaches. Unsteady gait. Left hemiparesis. Peculiar swelling of face. Delirium. Convulsions and sudden death. Bad-smelling discharge of the nose.	Echinococcus. In left lateral ventricle; the whole of the ventricle a sac.	Yates, Med. Times and Gazette, Aug., 1870.
62	M. 14.	Convulsions; vomiting; internal strabismus of right eye; gradually increasing paresis of left leg and arm. Reeling toward left side. Occipital headache. Pain and numbness in left arm. Lateral movements of eyes lost; paralysis of accommodation; nystagmus. Oscillation of left hand. Left leg ataxic. Patellar reflex exaggerated, and ankle-clonus present on left side. Superficial reflexes increased on right side. Partial anæsthesia on left side. Sight good; double optic neuritis. Left-sided hearing impaired. Taste and smell normal. Toward end, increasing torpor; left hemiplegia, except slight power retained in face, with anæsthesia and analgesia. Tonic fits. Right pupil dilated, and external strabismus in right eye. Slow respiration. Ankle-clonus and increased knee-jerk in right.	Glioma. Involved right anterior tubercle of corpora quadrigemina; also right optic thalamus, posterior part of internal capsule, and tegmentum of crus cerebri. The enlarged optic thalamus pressed back upon right anterior portion of cerebellum and middle peduncle, and exerted some transmitted pressure upon medulla oblongata.	David Ferrier, Brain, vol. v. p. 123.
63	F. 29.	Cervico-occipital headache. Vertigo. Convulsions. Right facial paresis. Tendency to fall backward. Uncertain gait. Optic neuritis. Double amblyopia. Difficulty in moving both eyes toward the left. Diminished intelligence. Vomiting.	Glioma. In corpora quadrigemina. Cerebellum not involved. Tumor lay upward and outward from the left cerebellar crus ad pontem.	Annuske, Von Graefe's Arch., 1873, Bd. xix., quoted by Bernhardt, 167.
64	M. 21.	Right temporo-frontal headache. Vertigo. Pains in right leg. No anæsthesia. Right leg paretic. Tinnitus. Atrophy of the right optic nerve. Abnormal somnolence. Sexual inclination diminished. Vomiting. Blindness, first of the right and then of the left. Right divergent strabismus. Pupils dilated.	Lipoma. Tumor compressed corpora quadrigemina and geniculate bodies.	Hirtz, Bull. de Société Anat., Mars and April, 1875, quoted by Bernhardt, 168.
65	F. 3.	Right hemiparesis. Right-sided tremor. Contraction of the right elbow. Late, loss of sight in left eye. Ptosis, dilatation of the left pupil. Stupidity. Peculiar movements when seated from right backward to the left.	Tubercle. At site of corpora quadrigemina, springing into the third ventricle. Left cerebral peduncle compressed.	Pilz, Jahrbuch. für Kinderkrankh., iii., 1870, 2, 133, quoted by Bernhardt, 168.
66	M. 25.	Cervico-cephalic pains. Vertigo. Uncertain gait. No paralysis. Tension of muscles of neck. Optic neuritis. Double amaurosis. Tinnitus. Diminution of hearing. Intelligence clear until within fourteen days of death. Insensibility, delirium, coma. Small irregular pulse.	Glioma. Tumor displaced corpora quadrigemina and pineal gland. Projected into the third ventricle through aqueduct of Sylvius and into fourth ventricle.	Duffin, Lancet, June 17, 1876.
67	M. 7.	Occipital pains. Staggering gait toward right and backward. Hydrocephalic cries. Tendency of head forward. Alternating diverging strabismus. Double optic neuritis. Sudden death in paroxysm of pain. Paresis of bladder. Vomiting.	Tumor took the place of posterior part of corpora quadrigemina and velum. Cyst in the midst of the cerebellum, reaching the fourth ventricle.	Kohts, Virch. Arch., Bd. lxvii., 1876, quoted by Bernhardt, 168.
Cerebellum.
68	M. 1.	Frontal headache. Slight control over arms and legs. Stiff neck. Dilated pupils. Sopor. Vomiting. Duration, one year.	Glioma. Size of an orange in the middle of cerebellum. Chronic hydrocephalus.	H. Green, Trans. Path. Soc., vol. xx., 1870.
69	F. 21.	Fall from a swing upon the head, followed by loss of consciousness for a few minutes. Occasional headache during eleven years, always located at the occipital region. Eight months before death severe paroxysmal headaches, increased to one every five or six days, and lasting three to four days. Great hyperæsthesia of the head. Choked discs in both eyes. Complete blindness. Slight paresis of left side of body; twitching of muscles of left side of face. Staggering gait; sometimes complained of a momentary swinging or rotary sensation. Intellect clear. During last few days of life loss of power of deglutition, and also of taste, smell, and hearing.	Tubercle. In left and middle lobe of cerebellum, involving the pia mater. Over the tumefaction leptomeningitis.	H. F. Formad, Tr. of Philada. Path. Soc., 1879-81, vol. x. p. 178.
70	F. 27.	History of syphilis. Headache, with paroxysmal exacerbations. Vomiting, frequently recurring; for four weeks before death vomited almost incessantly. Vertigo; impossible to sit or stand because of vertigo late in illness. Slowness of mind and hebetude. General muscular weakness. Right partial hemiplegia and hemianæsthesia. Trigeminal neuralgia. No ophthalmoscopic examination, but sight impaired. Marked slowness of respiration; respirations ran down as low as four and five per minute two weeks before death.	A nodulated mass involved the right middle cerebellar peduncle and the adjacent region of the right cerebellar hemisphere. The right upper half of the floor of the fourth ventricle superficially softened. A small area of softening was also found involving the under outer surface of the left optic thalamus, the breadth of the internal capsule, and a small segment of the lenticular nucleus.	C. K. Mills, Arch. Med., vol. viii. No. 1, August, 1882.
71	F. 13.	Tubercular history. Headache, with severe paroxysms; most marked in frontal and occipital regions. Vomiting; vertigo; attacks of reeling and falling. Mental dulness. Weakness of limbs, but no distinct paralysis. Hyperæsthesia; severe pains in limbs. Gradually went blind, first in left eye, and then in right. Descending neuritis determined nearly a year before death; marked optic atrophy observed a month before death. Constipation.	Tubercle. A large nodulated mass occupied the lower two-thirds of the right cerebellar hemisphere; one small nodule extended across the posterior extremity of the superior vermiform process, destroying altogether about one-third to one-half of a cubic inch of its substance. Internal hydrocephalus.	C. K. Mills, Arch. Med., vol. viii. No. 1, Aug., 1882.
72	F. 20.	Headache. Occasional vomiting, but only upon a full stomach and at the beginning of a paroxysm of headache. No impairment of intellect; no paralysis; no convulsion; no inco-ordination. During last few days, when in paroxysms of headache, her face would be drawn toward left side, accompanied by a rigid drawing backward of the head, by pain in left shoulder and arm, and by a marked diminution of sensation in the same shoulder and arm. Head-pain excruciating, at first involving the whole cranium, afterward only the forehead and temples, but finally only the back of the head and nape of the neck. Died of sheer exhaustion. Symptoms and physical signs of phthisis.	Tubercle. In right lobe of cerebellum. Tubercular disease of both lungs with pleuritic adhesion. Fatty liver.	L. S. Clark for A. S. Gerhardt, Tr. of Philada. Path. Soc., 1878-79, vol. ix. p. 144.
73	M. 45.	Occipital headache. Movements weak; gait staggering. Inability to fix eyes; sight retained. Pupils unequal. Partial deafness in both ears. Vomiting. Sopor. Sudden death. History of fall upon head at twenty years of age, since which time much headache.	Tumor size of nut, compressing cerebellum and pons, situated between pons, middle peduncle of cerebellum, the cerebellum, and brain. Corpora quadrigemina atrophied.	Luys, Gaz. des Hôp., 1867, 105, quoted by Bernhardt, p. 225.
74	F. 52.	Violent and continuous headache. Gradual loss of sight. Very irritable. Psychic pain and complaints. Incoherence of ideas. In three to four years some anæsthesia of left leg; the left hand became rebellious to the will. Paralysis progressed; symptoms increased very slowly. Intense coryza, with running from the nose, accompanied with a feeling as if a strange body filled up this cavity. Great appetite. Had an attack of unconsciousness, preceded by violent pains and creepings in the left hand, and presenting the following conditions: Dorsal decubitus; flushed face; head strongly retracted; frowning; respiration difficult, but not stertorous; pupils large and insensible to light; the left eye widely opened, the right shut; very marked contraction in the orbicular muscle; stringy mucus in large quantities from right nostril; the left commissure of the lip strongly carried downward and backward. Tongue white, not deviated. Limbs of the right side not anæsthetic or paralyzed; the hand strongly shut. On the left arm painful pricking; the elbow flexed at a right angle, hand completely paralyzed. Motion diminished in left leg; sensibility not altered; intelligence obtuse, but the patient responds to questions. Nausea; hiccough. Finally, diaphragmatic breathing; asphyxia by strangulation.	Tumor size of hen's egg lodged between the superior surface of the cerebellum and cerebrum.	M. Boullet, Gaz. méd. de Par., 1834, 2d S., vol. ii. p. 264.
75	F. 64.	History of a fall down stairs. Headache. Frequent vomiting. Stupor, and when admitted to the hospital three weeks before death could not give any account of herself or of her complaint. Semi-comatose. No definite paralysis. She could move both arms and legs, but could not stand. Involuntary evacuations. No deviations of the eyes; apparently saw well. Pupils equal and moderately contracted; right disc a little redder than the left, but no swelling of the disc. Died in a convulsion, the right side being most affected.	Tumor size of a greengage plum, sprang from the dura mater just under the tentorium cerebelli on the left side. It had caused the deep depression of the left lobe of the cerebellum. Also a small clot, partly decolorized, just outside the right corpus striatum.	B. Bramwell, quoted in Med. and Surg. Rep., vol. xxxiv., Mar. 11, 1876.
76	F. 32.	Headache first. Then pain in right eye and numbness in right arm and leg; vision poor in right eye, with improvement. The left soon similarly affected, without improvement. Vomiting (patient was pregnant); vertigo. Ataxia marked. Patellar reflexes diminished. Tongue protruded to left. Right pupil dilated. Taste abolished on right side. The left field of vision showed hemianopia of the temporal side. Both eyes showed optic neuritis. Later, shooting pains in legs and left arm. Mind clear, but hysteroidal excitement frequent. Surface-temperature of head elevated. Toward end mental aberration, then unconsciousness. Died during labor.	Sarcoma. A nodular tumor, size large horse-chestnut, on upper surface of right lateral hemisphere of cerebellum.	J. T. Eskridge, M.D., Journ. of Nerv. and Ment. Dis., vol. xii. No. 1, Jan., 1885.
Floor of Fourth Ventricle. Directly or indirectly involved.
77	F. —.	Vertigo only on standing. Sensibility normal. Walking and standing impossible. Ataxia of legs. No paralysis. Facial and trigeminus intact. Dysphagia. Double amaurosis. Eyeballs fixed, directed forward. Symmetrically dilated pupils. Hearing, smell, and taste normal. Consciousness clear.	Tumor of whole anterior part of vermiform process of the cerebellum, lying on floor of fourth ventricle. Corpora quadrigemina compressed to thinness of paper.	Curschmann, Berlin. klin. Wochenschrift, 1877, p. 237, quoted by Bernhardt, 227.
78	M. 6½.	Fell from a bench, striking the occiput. Headache for a day or two afterward. Slight irregularity in gait. For weeks restlessness, headache, and motor ataxia the chief symptoms. In three months speech became indistinct. “He screamed his words.” Defective memory. Apparent exophthalmus; ataxic movements of the head, and a look of profound stupidity; epistaxis; bulbar conjunctiva anæsthetic; left pupil dilated; vomiting. Ophthalmoscopic examination showed congestion of right optic nerve and left descending neuritis, going on to progressive atrophy.	Glioma. Anterior portion of the fourth ventricle occupied by a rounded swelling of the pons; from under surface of the pons enlargement about equal on both sides. The anterior pyramids at entrance of pons seemed abnormally elevated, with the point of entrance also deeper than normal. Corpora quadrigemina much smaller than usual, and seemed pushed upward and flattened.	V. P. Gibney, Am. Journ. of the Med. Sci., N. S. vol. lxx., July, 1875, p. 142.
79	M. 11.	Fronto-occipital headache. Vertigo. Staggering gait. Falls often, and to right. No paralysis. Diminution of sight. Irregularity of movements of eyes. Right strabismus (?). Vomiting.	Tubercle. Size of hazelnut, in middle of vermiform process, above fourth ventricle. Some softening of surrounding tissue.	Capozzi, quoted by Bernhardt, p. 224.
80	M. 25.	Fronto-occipital headache. No anæsthesia. No paralysis; staggering gait. Loss of consciousness, with trembling of upper extremities. Vertigo. Falls to right. Double optic neuritis; amaurosis; nystagmus. Dementia; moroseness. Vomiting. Sudden death.	Between the amygdalæ of cerebellum; in front of cerebellum, bulging into fourth ventricle, merging with floor of fourth ventricle. Medulla oblongata pushed forward to right.	Annusk, V. Graefe's Arch., Bd. xix., 1873, quoted by Bernhardt, 223.
81	M. 58.	Headache, vertigo, diplopia; vomiting. Left facial paralysis. Ptosis of both eyes, worse in left. Contracture of left masseter. Speech nasal. Sense of pharyngeal obstruction. Both eyes diverted to right; on looking toward left the right eye turns to middle line, and left eye does not follow. Pupils contracted, left more than right. Anæsthesia of right face. Left ear slightly deaf. Smell and taste normal. Head movable, with deviation. Trunk and extremities not anæsthetic or paralytic. Later, smell of left side diminished. Reactions of degeneration in left face.	Floor of fourth ventricle to left of median line, involving motor root of fifth and nuclei of sixth, seventh, eighth, and ninth nerves on that side.	C. Wernicke, Arch. für Psychiatrie und Nervenkrankh., vii. Bd. 5, iii. Heft., 1877, p. 513.
82	F. 6½.	Symptoms of tubercular meningitis with a few irregular symptoms; conjugate deviation of the eyes to the left and upward. Cheyne-Stokes breathing.	Tubercular granulation about the size of a large pea springing from the left side of the fourth ventricle, just inside the posterior pyramid, midway between the cerebellar peduncle and calamus scriptorius; touched the under surface of the middle lobe of cerebellum. Head hydrocephalic. Miliary tubercles along Sylvian fissure, and a few elsewhere.	Morris J. Lewis, Trans. of Phil. Path. Soc., 1879-81, vol. x. p. 172.
Pons Varolii and Medulla Oblongata.
83	F. 8.	Right external strabismus, with contraction of the right corner of the mouth; contraction disappeared, but squint remained. Persistent cough, with stringy mucous expectoration. Staggering. Left hemiparesis, with left partial hemianæsthesia. Severe constipation. Bowels opened only about once in five days. Water passed voluntarily once every two days. Difficulty of articulation. Squint had almost disappeared, but later returned for a few days, and then disappeared entirely. Became unable to walk, or even to sit, unsupported. Also became unable to speak, but produced strange inarticulate sounds. Difficulty in swallowing. A marked feature in this case was the absence of headache. The only pain suffered was the pain of dull character referred to the left ear, but which lasted only two days.	Occupied the lower half of the pons and the upper half of the medulla oblongata, bulging most at the lower border of the pons at the right side, and extending a little lower and higher at the right side than on the left. Floor of fourth ventricle bulged slightly, and appeared to be expanded in all directions, so that the median fissure was pushed decidedly to the left. Incision revealed the tumor to be a large cyst filled with bloody fluid and detritus. The lower part of the ventricular floor not involved.	C. K. Mills, not before published.
84	M. 32.	Thrown from a horse and kicked on the head. History of syphilis; headache, severe at first, always came on at night; became less severe later. Vertigo. Defective memory; apathy. Right hemiparesis; helplessness of all the limbs before death; partial ptosis of the right side. Sensation diminished in the left side of the face and in the right limbs. Pupils small before death. Descending optic neuritis. Conjugate deviations of the eyes and rotation of the head to the right. Persistent epistaxis; tendency to hemorrhage from mucous membranes. Constipation.	Gumma and fibroma. (1) Gumma, half an inch in diameter, distinctly limited to the left upper quarter of the pons. (2) Fibroma, no larger than a pea, between the dura and pia mater, causing a slight depression in the first temporal convolution about the junction of its middle and posterior thirds, and halfway between the parallel fissure and the horizontal branch of the Sylvian fissure. Microscopical examination of the optic nerves showed a descending neuritis of subacute character.	C. K. Mills, reported at the meeting of the Amer. Neurol. Assoc., June, 1881, and published in the Journ. of Nerv. and Mental Dis., July, 1881; and Arch. Med., vol. viii. No. 1, Aug., 1882.
85	M. 35.	History of syphilis. Wounded in head by glancing bullet. Headache of great severity at intervals. Vomiting at time of headache. Vertigo. Failure of memory and depressed spirits. Epileptiform attacks. In the spasms lifted up the right side of his body and worked over toward the left. Occasional cramps in stomach and legs. Temporal and orbital neuralgias. Descending neuritis, and eventual atrophy of both optic nerves. Constipation. Died at the close of a series of convulsions, death being preceded by general paralysis.	Gumma. A rounded mass, quarter of an inch in diameter, attached to the pia mater, just to the left of the centre of the anterior surface of the pons. The entire anterior central portion of the pons was softer and more doughy than usual. At the junction of the pons with the medulla oblongata was a recent hemorrhage, which had spread downward to about the middle of the latter.	C. K. Mills, Brain, Jan., 1880, and Arch. Med., vol. viii. No. 1, Aug., 1882.
86	M. 5.	At first left internal squint and nightly paroxysms of excessively silly laughter. Slight paralysis of right arm, with rigidity. Paresis of right leg, increasing to paralysis, with rigidity. During sleep arm and leg became relaxed. Difficulty in swallowing. Paralysis of left orbicularis palpebrarum and left external rectus muscles. Sensibility not impaired. Electro-muscular contractility present in all the paralyzed muscles (?). Speech lost, apparently from difficulty in articulation. Intelligence preserved till near the close. Sight, smell, and taste good. Later, suffered from intense headaches and frequent attacks of palpitation of the heart, with flushing of face and injection of left conjunctiva, and with increased rigidity of right arm and leg. Death from paralysis of the pneumogastric.	Glioma. Gliomatous transformation of the pons, but no distinct separable neoplasm. Had encroached somewhat on cerebellum, particularly in region of left pneumogastric lobule.	W. Pepper, Trans. Phila. Path. Soc., 1878-79, vol. ix. p. 136.
87	M. 2.	Dysphagia; paresis of left arm and ptosis of left eye, which improved, followed by same symptoms on right side. “Legs affected.” Head very large. Dribbling. Paralysis of articulation. Contraction of orbicular muscle, causing ptosis (?). Clonic spasm of right side of mouth, and rhythmical jactitation of right arm on attempted movement. Unable to stand or sit. Optic discs normal. Evacuations involuntary. Left side of face paralyzed. Tonic spasms of right sterno-mastoid. Later, left arm jerked like right, and rigid contractions of legs. Retraction of head and occasional spasm of left sterno-mastoid. Impossible to gauge sensation.	Tubercle. Tumor of left side of lower part of pons and central and posterior part of upper half of medulla. Cerebral fluid increased. Medulla oblongata was twice the normal size.	J. M. Hobson, M.D., Brain, vol. iv. p. 531.
88	M. 12.	Slight paresis of right side (arm and leg). He spoke thickly and swallowed badly. Slight headache. Was depressed. Delirious at night. Slight paresis of left face. Irregularity of pulse. Choked discs. Later, paralysis of sixth nerve. Sudden death, probably in a fit.	Glioma. Membranes of base congested. Tumor, which appeared to occupy the whole left half of pons varolii. No trace of fifth nerve on left side.	Hughlings-Jackson, Med. Times and Gaz., Lond., 1874, i. 151.
89	F. 60.	Headache frontal, severe and almost constant. Paresis of right arm and leg. Painful spasm of right arm. Paresis gradually extended to left half of body. Persistent pain in right arm, with tremor; later, same symptom, less marked, in left arm, simulating paralysis agitans. Atheromatous arteries. Melancholic; talks to herself; very hard of hearing. Head directed constantly to right. Tremor increased on voluntary motion. Atrophy of muscles of arms. Flexors of legs contractured. Electro-muscular contractility reduced, especially on right side. Later, pain on touch in right arm. Febrile intermitting symptoms, simulating malaria. Still later, distinct contracture of neck. Conjunctivitis of left eye, with corneal dulness, followed by kerato-iritis, with ulceration of cornea. Dysphagia; swelling of submaxillary glands. Œdema of lungs.	Sarcoma. Tumor of left side of pons and left cerebellar crus, extending toward transverse sinus.	Petrina, op. cit.
90	M. 54.	Severe continuous headache. Eyes constantly turned to the right. No diplopia. Eyes, moved together, could not turn beyond the median line of the left, though the right eye alone could be turned for some distance to the left beyond the median line. Pupils equal and mobile. No paralysis or loss of sensation. Some dizziness and stagger in walking. Died of pneumonia. After the autopsy the position of the head was regarded not as compensatory for the position of the eyes, but as due to a severing of fibres joining the rotatory muscles of the head with their reflex centres.	In the pons at a level one centimeter below the apparent origin of the fifth nerve on the left side. It was so situated in front of the eminentia teres that it involved the course of the fibres of the left abducens, and by a little prolongation across the raphé toward the right side interrupted the fibres of communication between the centres for the sixth and third nerves. It did not involve the common nucleus of the sixth and seventh. It interrupted the posterior-interior longitudinal bundle and the adjacent part of the raphé. No other lesion was found. The tumor was the size of a small nut.	Quioc, Lyon Méd., 1881, July, Nos. 19 and 20, quoted by M. Allen Starr, Journ. of Nerv. and Mental Dis., vol. xi., July, 1884, p. 377.
Crura Cerebri.
91	M. 25.	No headache. Staggering some days before death. Apoplectic seizure, with right-sided hemiplegia. Ptosis of left side (some days before death). Loss of consciousness for three or four days. No vomiting.	Glioma. In left crus cerebri, including also portion of right.	Sutton, Brit. Med. Journ., Feb., 1870, quoted by Bernhardt, p. 163.
92	M. 9.	Awkwardness in using right hand; soon almost complete paralysis in the right arm. Headache; nausea; vomiting; double vision, followed by strabismus, due to paralysis of the left abducens. Occasional twitchings in right hand, but no convulsions. Paralysis extended to the right leg; staggering gait. Ataxia and rigidity in the fingers of the paralyzed hand. Pain in the legs. Optic neuritis.	Sarcoma. Pressing upon the left crus cerebri and the pons.	E. C. Seguin, Journ. of Nerv. and Ment. Dis., Jan, 1882.
93	M. 3.	Headache; unnatural drowsiness. Ptosis of right eye, with very marked divergent strabismus and fully-dilated pupil; similar paralysis in left eye, not quite so marked. Paresis of left leg. Very late, unconsciousness, constant motion of tongue and lips, and clonic spasms of left arm and leg. Twitching of right face. Convulsions, death. Duration, about one year.	Tubercle. Size of a walnut in right crus, almost destroying the crus just at its junction with pons; making pressure on left crus. Third pair of nerves diminished in size and softened. Recent inflammatory changes at base. Increased cerebral fluid.	S. Browne, Dublin Q. J. Med. Sci., 1849, vii. 496-499.
Middle Region of Base of Brain and Floor of Skull.
94	F. 35.	History of syphilis. Headache severe, at first with long intermissions; later, continuous, and often agonizing. Vomiting with paroxysmal headache, coming on late in illness. Vertigo, usually with headache. Excitable and irritable. Slight twitching of mouth, hands, and forearms. Left hemiplegia; upper as well as lower fibres of facial nerve paralyzed. Left internal strabismus. Electro-contractility diminished. Difficulty in enunciation. Sensibility diminished in left leg. Later, hyperæsthesia and great pain in paralyzed limbs. Conjunctivitis and necrosis of cornea of left eye; conjunctiva and cornea insensitive. Sight impaired. Descending optic neuritis. Hearing impaired on left side. Smell defective. Profuse perspiration, more marked on right side than on left. Constipation. Temperature, taken in right and left axilla for eleven weeks before death, gave the following averages: Right axilla, 99.1°, M.; 100°, E. Left axilla, 99.4°, M.; 101.4°, E. On some days remarkable falls in temperature to 96°, 95°, and even 94° and 93°. Average head-temperatures above the normal: for stations on right side of head averaging about 97°; on left side, about 94.3° F.	Gumma. A twin-tumor, each mass about two-thirds of an inch in diameter, in front of the optic chiasm. The growths involved the basal termination of the corpus callosum, the peduncles of the corpus callosum, the lamina cinerea, and anterior perforated spaces. They also probably encroached upon the roots of the olfactory nerves, the optic nerves and commissure, and the anterior portions of the circle of Willis, which seemed to have been broken in front. The base of the brain, from the posterior line of the tumor backward to the pons, was markedly softened. Microscopical sections of optic nerves showed the appearances peculiar to descending neuritis in a somewhat advanced stage.	C. K. Mills, Philadelphia Medical Times, March 23, 1879, in “Proceedings of the Pathological Society of Philadelphia;” also, New York Medical Record, Aug. 9, 1879, and Arch. Med., vol. viii. No. 1, Aug., 1882.
95	F. 21.	Suffered for three years from excessive thirst and polyuria, with occasional vague pains in the head. A constant relation existed between the amount of fluid imbibed and of urine passed. Specific gravity of urine, 1002. No albumen nor sugar. Eight liters of urine passed in the twenty-four hours on an average. Slight headache and dimness of vision shortly before death; no other nervous symptoms. No ophthalmoscopic examination was made.	Sarcoma. About the size of a chestnut at the base of the brain, at a spot corresponding to the sella turcica. It had caused complete degeneration of the optic chiasm, and had encroached considerably on the circle of Willis.	F. Fazio, Il Morgagni, quoted in Med. and Surg. Rep., vol. xlii., May 8, 1880, p. 415.
96	F. 73.	Suffered for several years from post-nasal catarrh, with enlargement of tonsils and granular pharyngitis. Fulness in right side of throat; muco-sanguinolent discharge from post-nasal space; bulging of soft palate. Severe pain through the right side of the head. Deafness of right ear and dimness of right eye. Mental failure. Paresis of levator palpebræ superioris and orbicularis; complete paralysis of external rectus; possibly slight paresis of the muscles supplied by the third nerve of the right side. Diminished sensibility of right half of face and cornea, and conjunctiva of right eye. Cornea opaque; conjunctival catarrh; vision almost nothing; ophthalmoscopic examination could not be made. Left eye showed some diminution in acuity of vision, with concentric narrowing of visual field; pigmentation.	Lobulated epithelioma. Involved the cribriform plate of the ethmoid bone, the whole of the body of the sphenoid, and the anterior part of the basilar process of the occipital bone. These were softened to the consistency of cheese. Membranes and cerebral substance firmly adherent to the base of the skull at the inner portion of the bottom of the right cerebral fossa. Blood-clot in one of the large arteries of the optic papilla. Sclerosed blood-vessels. Atrophy of optic nerve and retina.	W. Pepper, Trans. of Philada. Path. Soc. for 1878-79, vol. ix. p. 138.
97	F. 25.	Headache (for six years), with vomiting. For three years had dimness of vision. For a year had blindness. Exophthalmus, with dilated pupils and fixation of eyeballs. Painful spasm of right face occasionally. Occasional paresis of left arm and leg, with pain. Severe vertical headache. Anosmia. Involuntary discharge of urine and feces. Convulsions. Stupor. No local paralysis of face or extremities. Death happened unexpectedly.	Cancer. Tumor apparently springing from pituitary body, passing through infundibulum into right lateral ventricle. Tumor was “almost the shape and size of goose-egg.” It occupied anterior half of ventricle, and flattened out thalamus and corpus striatum. By pressure it had flattened the olfactory and optic nerves. The growth extended into the sphenoidal fissure, causing absorption of bone.	Habershon, Med. Times and Gaz., 1864 (2), pp. 463, 464.
98	M. 44.	No symptoms during life indicating any brain disease. The patient had died of phthisis.	Osteoma. Consisting of true bone with Haversian canals, occupying position of infundibulum and corpora albicantia, which were totally absent. Not connected at all with dura mater. The pituitary body was apparently healthy.	Bristowe, Tr. Path. Soc. Lond., vi. 25.
99	F. —.	Intense supraorbital neuralgia. Paralysis of the parts supplied by the third, fourth, fifth, sixth, seventh, and eighth nerves of the left side. The muscles moving the tongue not affected. No interference with respiration or the action of the heart; no choked discs. External tumors on each side of the neck, with a protuberance of the left eye.	Involved the petrous portion of the temporal bone, with a portion of the sphenoid bone of the left side, size of walnut.	James H. Hutchinson, Philada. Med. Times, vol. xiii., Sept. 22, 1883.
100	F. 66.	One-sided convulsions; first left leg, next left arm. Slow, syllabic speech, not aphasic. Abnormal, prolonged somnolence, followed by voracious appetite. Later, incontinence of urine. Apathetic. Muscles of left half of body, especially arm and leg, contractured. Pupils contracted. No facial paralysis. Slight ptosis upon right side. Conjugate deviation of eyes to right; fixed and immovable. Head drawn to right and backward. Extremities cyanotic and cold. Accentuated aortic sound; abdominal tympanitis. Taste, smell, hearing doubtful. Sensibility retained. Electric irritability rapidly exhausted; reflexes diminished. Unable to stand; constant tendency to turn to right. No albumen or sugar. All symptoms intensified; exhaustion; temperature below normal; death.	Sarcoma. Growing from right half of fossa of body of sphenoid bone, and extending outward and backward along petrous bone, only closely adherent at basilar portion of sphenoid. Slight depression of middle peduncle of cerebellum near entrance to pons. Basilar artery pushed to left. Vessels thick and rigid. Gyrus fornicatus of right side, temporal aspect, compressed. Right peduncle of cerebrum compressed. Brain-substance dense; numerous serous cysts in brain and ganglia.	Petrina, op. cit.