4. Eye symptoms such as optic neuritis, choked disk, usually double, indicating pressure, but telling little or nothing as to the location of the tumor causing blindness. Ophthalmoplegias are of little value by themselves as symptoms. Hemianopsia, when homonymous, usually indicates a lesion of the cuneus of the same side, the blind half, according to the patient, indicating the side.
5. Localizing symptoms which may be due to the destruction of brain tissue or to indirect pressure. Those of importance comprise paralysis or spasms, indicating involvement of the motor area; sensory aphasia, indicating trouble in Broca’s area, ataxia or staggering, due to cerebellar lesions; loss of sense of position, sometimes seen in lesions of the parietal regions; anesthesia, which is rare unless the internal capsule is involved. Other symptoms are: word-deafness, which indicates a lesion of the posterior part of the first temporal convolution; agraphia, indicating deep lesions under Broca’s speech centre, and alexia, usually produced by lesions of the lower left parietal lobe. Tumors in the sensory zone affect vision and speech, and reveal themselves by irritative symptoms. For instance, a patient with verbal deafness and marked hemiplegia probably has tumor involving the left superior or dorsotemporal gyrus, which, as it grows, would involve loss of muscle sense and anesthesia on the opposite side of the body. A patient with headache, vomiting, choked disk, stupor, increasing hemianesthesia, lateral hemianopsia, without spasm or hemiplegia, probably has a tumor in the white substance of the occipital lobe. If hemianopsia alone be present there is almost always a tumor upon the inner aspect of the occipital lobe, on the side opposite to the dark half-fields, which by downward growth may cause cerebellar symptoms. Psychic and mental disturbances are present in many cases, but not in all; most frequently in frontal lesions. They are met with in about one-third of the cerebellar tumors and two-thirds of the temporal tumors; they assume the epileptic type, with hallucination, mania, or sometimes convulsions of Jacksonian type, the latter, of course, indicating lesions of the motor area.
6. Finally there are frequent constitutional disturbances, including anomalies of thirst and appetite, and disturbances of heart and respiration. In two or three instances the writer has seen such serious obstruction of the bowel as to lead to mistake in diagnosis, the obstruction in each case being finally fatal, but apparently not justifying operation.
The above symptoms pertain to the brain tumors in general. When it comes to tumors of the cerebellum these constitute, in a measure, a class by themselves. Those which are operable comprise tumors located in one lateral lobe, or invading the vermis or middle lobe, or those found at the junction point of the cerebellum, medulla, and pons, those first mentioned being by far the more favorable for attack. It is not relatively difficult to decide upon the presence of a tumor in the cerebellum, but to minutely locate it is extremely difficult. In addition to the symptoms already rehearsed above the following features may be mentioned: Headache is often intense, sometimes agonizing. While usually referred to the back of the head it is occasionally frontal. Nausea and vomiting are generally present, at least for a time. Sometimes they subside to recur later. Optic neuritis and choking of the disk occur earlier and oftener than in other tumors. Blindness sometimes comes on promptly. Vertigo, as in other brain tumors, is commonly due to irritation of those branches of the fifth nerve which supply the inner surface of the dura, this irritation being reflected to the bulbar nuclei of the fifth, and thence to the nuclei of the pneumogastric. This is partly true of those growths which are in relation with the dura, though sometimes it is true of tumors which make pressure at the base of the brain. It is important to distinguish, if possible, between mere vertigo and cerebellar ataxia. The more directly focal symptoms are: nystagmus, which may be present when the eyes are quiet or only when they are in use; paralysis, when the pyramidal tracts are involved; muscle weakness, seen more often in the legs, which is nearly always a cerebellar symptom; and sometimes a peculiar posture of the head, where the spinal column becomes concaved toward the affected side, the face looking almost backward. Incoördination is a common indication; in about four-fifths of the cases patients stagger in their gait.
To determine whether a given tumor is an irritative or destructive lesion special study should be made of the spastic or non-spastic condition of the limbs, and note to which side the eyes are turned. Tonic spasms and contractures are rare in cerebellar tumors. A tremor of the head and upper part of the body is not infrequent, and muscle sense is rarely lost.
Between cerebellar tumors and those of the parietal region the chief diagnostic points are muscular and cutaneous sensibility in the former, with nystagmus and peculiar and extreme vertigo. From frontal growths they may sometimes be differentiated by the clearness of the mental processes and the absence of those symptoms which point especially to involvement of the temporocortical region, e. g., aphasia. In cerebellar tumors convulsions, one-sided or general, are not infrequent, and incontinence of urine and feces is often noted. The convulsions are accompanied by subjective sensations and noises, vertigo, and by sudden blindness, with loss of consciousness, while such tonic spasms as occur are generally of the extensor type, and last from one to ten minutes.
Basal tumors of the cerebrum produce a collection of symptoms which sometimes are significant. Owing to their location they involve the functions of several of the special nerves. In tumors in the anterior fossa there is involvement of the optic, the oculomotor, and the first branch of the fifth. In tumors of the pituitary body there is involvement of the optic, the chiasm, the oculomotor, and the first branch of the fifth, as well as the abducens. In tumors resting on the middle fossa and situated above the dura the oculomotor, the patheticus, and the chiasm are involved. If situated beneath the dura there is paralysis of the three ocular nerves and also the fifth nerve. In tumors of the posterior fossa there is involvement of the facial, the trigeminus, the auditory, the glossopharyngeal, the vagus, the accessorius, and the abducens.
Neurofibroma of the Acoustic Nerve.
—Fränkel and Hunt have recently shown that basal tumors spring from the acoustic nerve, which are essentially neurofibromas. They have their site upon the nerve at the point where it merges from the junction of the pons and the medulla; in other words, where the function of the nerve is more or less disturbed, and the patient thereby made to complain of deafness, tinnitus, and vertigo. They slowly displace surrounding tissues. They vary in size from a cherry to that of a robin’s egg, are loosely attached, and when exposed easily enucleated. Their general symptoms are those common to all brain tumors, but focal symptoms may include ataxia, paralyses (especially of the fifth, sixth, and seventh nerves), inequality of the pupils, and loss of coördinate movements of the eyes; these symptoms are in addition to those of the auditory already mentioned.
Access to these tumors is a serious matter. It should be undertaken in two stages: the first including a large lateral exposure, with or without an osteoplastic flap, comprising the lower portion of the squamous, a part of the occipital, and perhaps even the posterior aspect of the mastoid. Drainage will be required for a few hours as in other similar operations.