Mental and psychic disturbances after head injuries have been long known and the suggestion to operate upon the skull in cases of so-called traumatic insanity is not new. In a general way it may be said that whenever distinct mania follows a recognized lesion of the vertex of the skull, and fails to subside within a reasonable time and under proper treatment, there are the best of reasons for raising the scalp, trephining, and exploring as to the deeper conditions. Patients might be released from asylums who have long been inmates had this measure been practised at the beginning of their mental alienation.
The same measure will give relief in certain cases of cephalalgia, or headache, where the pain is always ascribed to a particular region, and especially when there is tenderness over this region. These operations are, of course, empirical, yet, as the result of altered nutrition and allayed irritation, relief follows in a fair proportion of instances.
INTRACRANIAL TUMORS.
Until within recent years these were regarded as having interest mainly for the pathologist and clinician, but as essentially hopeless so far as surgical help is concerned. Recent discoveries in the field of cerebral localization and recent experience with extensive openings into the cranium have shown, however, that a small proportion of intracranial tumors are of such a character and so located as to make them amenable to surgical relief. These tumors occur with about equal frequency in childhood and adult life. In the order of frequency they stand about as follows: Tuberculous gumma, glioma, sarcoma, cysts, carcinoma, and syphilitic gumma, with a small proportion of fibroma, etc.
Of 100 cases of brain tumor selected at random not more than 5 to 7 per cent. are so placed as to justify surgical attack. In as many more, at least, the tumors are so located as to justify opening the cranium for mere relief of pressure without any notion or endeavor to attack the tumor itself. Before opening the cranium diagnosis should be made as carefully as possible—first, as to location; second, as to whether cortical or subcortical; third, as to the number of tumors present; fourth, as to their general character. Location is determined in the main by study of pain complained of, by watching patients during convulsive seizures, by determining the extent of local or general paralysis, by careful history which shall reveal the method and rate of extension of these symptoms, and by the study of the optic disks, of vision, and by noting the presence or absence of stupor, nausea, coma, slow pulse, or other compression symptoms.
Symptoms.
—A brief epitome of the principal features attending cases of brain tumor will include:
1. Pain and headache, rarely localized with much accuracy; the former sometimes increased by percussion or pressure, occasionally periodical and usually intense. The location of the pain sometimes corresponds with that of the tumor.
2. Vomiting, usually without pain or nausea, and often projectile. I have repeatedly seen obstinate constipation in brain-tumor cases which has gone almost to a degree of acute obstruction, and which has caused serious error in diagnosis.
3. Vertigo, independent of indigestion or the condition of the stomach or bowels. It is most frequent in cerebellar tumors, but occurs in about 50 per cent. of all cases. It is sometimes quite severe.