The Surgery of the Skull and Brain

by Louis Bathe Rawling

Fig. 68. The Cortical Motor and Sensory Areas.

Incontinence of urine has been observed, independent of the condition of the patient—in other words, without a sufficient degree of coma to account for the state.

When the tumour is of considerable size, some degree of paresis of the contralateral side of the body may result, due to backward pressure exercised by the tumour on the corona radiata preceding from the pre-Rolandic motor area. Associated with this paresis the deep reflexes may be increased with extensor plantar reflex (Babinski) and some diminution of superficial reflexes. The more posterior the tumour the greater the degree of paresis, and the more exaggerated the reflexes. When the tumour is situated on the left side the motor speech centre may be affected.

Fine tremors may be noticed, usually involving the muscles of the upper extremities, and best demonstrated by asking the patient to hold his arms horizontally with the palms downwards.

Paresis on the contralateral side may be preceded by or associated with fits, these partaking of the Jacksonian type and accompanied by conjugate deviation of the eyes towards the side opposite to that on which the tumour is situated. This association of fits suggests that the tumour occupies the second frontal convolution.

(B) To the excito-motor frontal region.

In the early stages symptoms of irritation predominate, the patient suffering from fits of a focal or Jacksonian type (see [p. 189]), whilst, later on, paresis of a progressive type, involving the face or extremities unequally, becomes evident. In children, however, the rapid transference of impulses from one motor area to another causes the fits to soon lose their focal character, general convulsions taking their place.

If the tumour occupies the left side of the brain (in right-handed individuals) the motor speech centre of Broca may be involved, with difficulty in or failure of the power of speech.

Apraxia may be present, a condition characterized by inability on the part of the patient to perform certain familiar purposive movements, such as sewing, turning a key in the lock, &c.

The contralateral pupil may be contracted from irritation, or dilated from paralysis; the ipsolateral is variable, more commonly dilated.