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).