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.