Hughlings-Jackson45 reports a case of tubercular tumor, half the size of a filbert, in the pons under the floor of the fourth ventricle, in the upper third of the left side. A much smaller nodule was found in the right half of the pons. This patient, a man thirty-three years old, had inconstant headache, a gradual incomplete hemiplegia of the right side, with also paresis of the left masseter and right lower face. Sensation was diminished in the right arm, leg, and trunk. The optic discs were normal; the left pupil was smaller than the right. There was lateral deviation of the eyes to the right. Diplopia was present in some positions, and one image was always above the other. Aphasic symptoms were also present. Especial interest attaches to the fact that the facial paralysis in this case was on the same side as the hemiplegia, opposite that of the lesion; whereas usually in lesions of the pons facial paralysis is on the side opposite the hemiplegia. This is explained by the fact that the tracts of the facial nerve decussate in the pons below its upper third, and therefore in this case the lesion caught the nerve-tracts above their decussation.
45 Med. Times and Gazette, London, 1874, p. 6.
PROGNOSIS.—The prognosis in intracranial tumors is of course usually in the highest degree unfavorable. The early recognition of the existence of a tumor syphilitic in origin will enable a comparatively favorable prognosis to be made. It is far from correct, however, to suppose that all or a majority of the cases of known syphilitic origin are likely to have a favorable termination. Amidon46 puts this matter very correctly as follows: “Has a destructive lesion occurred? and if so, where is it located, and what is its extent? Indications of a destructive lesion should lead one to a cautious prognosis as regards perfect recovery, while the prognosis for life and a moderate amount of health may be good. A gummy intracranial or spinal growth, giving rise to alarming symptoms, may vanish as by magic upon prompt treatment. The symptoms of these frank, specific growths are, as a general thing, characteristic and widely different from those of the more insidious destructive lesions.
“An intracranial gumma often heralds itself by sharp, localized headache, gradually deepening paralysis, aphasia, epilepsy, and optic neuritis, while destructive lesions are more apt to have diffuse, dull headache, stationary or lessening paralysis or aphasia, rarely epilepsy or optic neuritis. Intraspinal gummata give rise to a painful paraplegia, while an inflammatory or destructive change gives rise to various and atypical sensory and motor manifestations.
“As to the pathology of these cases, I can say but little, as such discussion opens the whole subject of the pathology of syphilis. This I will say, that, so far as can be told without autopsies, no permanent pathological condition was present in these cases which might not have been brought about by other etiological factors which were often present. The periencephalitis might be caused by alcohol, mental strain, or excesses; the arterial occlusion might be due to previous disease not specific.”
46 Medical News, vol. xlviii. No. 3, Jan. 16, 1886, p. 64.
TREATMENT.—The surgical treatment of tumors of the brain has recently received a great stimulus from the report of a case which occurred in the practice of A. Hughes-Bennett of London, and which was operated on by Rickman J. Godlee. The case has been included in the table (Case 24), where the symptoms and details of treatment may be read. This case has served to bring into sharp outline many of the difficulties and dangers of such an operation on the one hand, and the few possible and exceptional advantages of it on the other. It must be apparent, in the present state of knowledge and with the additional light of this interesting case, that success must largely depend upon the following conditions: The tumor must be exceptionally localized—i.e. not very large—and non-multiple; it must be cortical, or at least not very deep-seated; it is also quite essential that it be in the motor zone, in order to admit of accurate diagnosis. It would seriously impair the usefulness of the operation and the prognosis if the case were of long standing with much necrosis of brain-tissue, or if the growth were malignant and recurring. The secondary complications, as inflammation and sepsis, are of course possible in all surgical cases, and may be guarded against, as well in cerebral as in other surgery. If such a criticism narrows the field for the operation into almost hopeless limits, it may be reflected that one or two successful cases are better than a hundred experimental failures; that cases do occur in which the tumor is just so localized, single, and superficial; that the urgency of distressing symptoms, as pain and convulsions, urge the operation for palliation as well as cure; and that these cases, without relief, are necessarily fatal, and hence justify large risks.
By exclusion and a careful study of the symptoms we believe it may become possible hereafter in some cases to localize in two other accessible regions brain tumors with sufficient accuracy for purposes of operation: these are the antero-frontal region and the postero-parietal region.
The case of Bennett and Godlee was a most successful test of diagnosis, and as a surgical endeavor might have been more successful, as the operator himself suggests, if more careful antiseptic precautions had been used. In the discussion of this case before the Royal Medical and Chirurgical Society47 it was stated by Hughlings-Jackson that three indications were of special importance for this diagnosis: (1) local persisting paralysis; (2) epileptiform convulsions, those beginning locally; (3) double optic neuritis, which is diagnostic of tumor as distinguished from a sclerotic patch. It is probable that permanent palsy would be left after a successful operation in which the cortical tissue were destroyed, but as this is compatible with life and comfort, it is not likely that, as an alternative, it would be rejected by the patient. McEwen's case, also given in the table (Case 25), is not as accurately reported48 as Bennett's, but was partially successful. At the opening over the Rolandic region false membrane was removed, and an incision made which let out grumous red-colored fluid: this was followed by a decrease in the paralysis and improvement in other brain symptoms. It is difficult to understand why the opening was made in the occipital region. The necessity for antiseptic measures is to be especially considered in cerebral surgery. In a recent operation for a case of traumatic epilepsy, under the care of Mills and White, in the Philadelphia Hospital, in which quite extensive injury was done to the membranes in removing fragments of bone, rigid antisepsis was employed; and it is not too much to assume that the risks of the operation were much diminished by it and its success ensured in an old and crowded hospital building.