HEALTH SCIENCES S I ANUAHU 
 
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 COLLEGE OF PHYSICIANS 
 AND SURGEONS 
 
 Reference Library 
 
 Given by 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/pathologydiagnosOOknap 
 
Fiske Fund Prize Dissertation, No. XLI. 
 
 THE 
 
 PATHOLOGY, DIAGNOSIS AND 
 TREATMENT 
 
 INTRA-CRANIAL GROWTHS. 
 
 BY 
 
 PHILIP COOMBS KNAPP, A.M., M.D. (Harvard). 
 
 CLINICAL INSTRUCTOR IN DISEASES OF THE NERVOUS SYSTEM, HARVARD MEDICAL 
 SCHOOL; PHYSICIAN FOR DISEASES OF THE NERVOUS SYSTEM TO OUT- 
 PATIENTS, BOSTON CITY HOSPITAL; MEMBER OF THE AMERICAN 
 NEUROLOGICAL ASSOCIATION; FELLOW OF THE 
 MASSACHUSETTS MEDICAL SOCIETY, 
 ETC., ETC. 
 
 Color che vanno 
 Con cosa in capo non di lor saputa. 
 
 Purg., xii, 127. 
 
 BOSTON : 
 
 PRESS OF ROCKWELL AND CHURCHILL. 
 
 1891 . 
 
Copyiight, 1S91, 
 By PHILIP COOMBS KNAPP, M.D. 
 
THE Trustees of the Fiske Fund, at the annual meeting of the Rhode 
 Island Medical Society, held at Providence, 12 June, 1890, announced 
 that they had awarded a premium of three hundred dollars to an Essay 
 on " The Pathology, Diagnosis and Treatment of Intra-cranial Growths," 
 
 bearing the motto — 
 
 " Color che vanno 
 Con cosa in capo non di lor saputa." 
 
 The author was found to be Philip Coombs Knapp, M.D., of Boston, 
 Mass. 
 
 JOHN W. MITCHELL, M.D., Providence. 
 WILLIAM H. PALMER, M.D., Providence. 
 ROBERT F. NO YES, M.D., Providence. 
 
 Trustees. 
 G. L. COLLINS, M.D., Providence. 
 
 Secretary of the Trustees. 
 
VI 
 
 CONTENTS. 
 
 III. Pathology .... 
 
 IV. General Symptomatology 
 
 Headache 
 
 Vertigo . 
 
 Vomiting 
 
 Optic Neuritis 
 
 Convulsions 
 
 Psychical Disturbances 
 
 Surface Temperature 
 
 V. Special Symptomatology 
 
 i. Tumours of the Cerebral Cortex 
 
 VI. 
 
 VII 
 VIII 
 
 Cases I-XIV 
 
 a. Tumours of the Pre-frontal Region. Cases I-IV, 
 
 b. Tumours of the Central Region. Cases V-VIII, 
 
 c. Tumours of the Posterior Parietal Region. Case 
 IX 
 
 d. Tumours of the Occipital Region. Cases X-XI, 
 
 e. Tumours of the Temporo-sphenoidal Region 
 Cases XI I-XIV 
 
 2. Tumours of the Corpus Callosum. Cases XV-XVI 
 
 3. Tumours of the Optico-Striate Region. Cases XVII- 
 XXI .... 
 
 4. Tumours of the Crus Cerebri 
 
 5. Tumours of the Corpora Ouadrigemina and Pineal 
 Gland. Cases XXII-XXIII . . 
 
 6. Tumours of the Pons and Medulla. Case XXIV 
 
 7. Tumours of the Cerebellum. Cases XXV-XXIX 
 
 8. Tumours of the Hypophysis. Case XXX . 
 
 9. Tumours of the Base of the Skull and Cerebellar Pe 
 duncles. Cases XXXI-XXXV 
 
 10. Multiple Tumours. Cases XXXVI-XL 
 Diagnosis 
 
 1 . The Diagnosis of the Existence of a Tumour 
 
 2. The Diagnosis of the Location of a Tumour 
 
 3. The Diagnosis of the Nature of a Tumour 
 Course, Duration, and Prognosis 
 Treatment 
 
 1. Medical Treatment 
 
 2. Surgical Treatment 
 
 Tables of Operations 
 References . . . . . . • 
 
 PAGE 
 28 
 
 3° 
 31 
 
 33 
 33 
 34 
 39 
 4i 
 42 
 
 44 
 46 
 46 
 
 52 
 
 63 
 65 
 
 69 
 75 
 
 ' 79 
 86 
 
 86 
 92 
 
 97 
 105 
 
 108 
 
 115 
 123 
 123 
 126 
 127 
 129 
 132 
 132 
 
 135 
 141 
 163 
 
INTRODUCTION. 
 
 SINCE this essay was presented for the Fiske prize, in 
 May, 1890, I have been enabled, by the kindness of the 
 Trustees of the Fiske Fund, to make a thorough revision of 
 it. I have not, however, departed from the original plan. 
 At that time I decided to present a collection of new cases, 
 although many of them were defective and did not pre- 
 sent characteristic features, rather than to collect more 
 typical published cases from the immense number now 
 reported. The essay is therefore based on the records of 
 forty cases with autopsies. Of these thirty-eight were 
 patients at the Boston City Hospital, and I wish here to 
 thank my colleagues at the hospital for their kindness in 
 permitting me to make use of this material, without which 
 I could not have written the essay. My thanks are 
 especially due to Dr. S. G. Webber, who has aided me 
 with notes and sketches. Some of these cases came 
 under my own observation, and a few of them have 
 already been reported. The greater number, however, 
 have never been published. I have added a case seen 
 by me while interne at the Boston Lunatic Hospital and 
 already reported by Dr. T. W. Fisher, and another case 
 seen in private practice. 
 
viii INTRODUCTION. 
 
 Although I have not collected illustrative cases I have 
 of course availed myself freely of the literature of the 
 subject, without undertaking the enormous task of contin- 
 uing the work of Ladame and Bernhardt. The discussion 
 of special symptomatology, therefore, is based rather upon 
 the literature than upon the data furnished by the few 
 cases reported. 
 
 In the chapter on treatment I have departed from the 
 principle above laid down in giving a tolerably complete 
 list of the cases operated upon. I should be glad to 
 have any omissions called to my attention. My thanks 
 are due to Dr. J. T. Eskridge of Denver for his kindness 
 in placing at my disposal the records of an unpublished 
 case. 
 
 Boston, May, 1891. 
 
I. ETIOLOGY. 
 
 By an intra-cranial growth or cerebral tumour we mean 
 any form of new growth within the cavity of the skull. Such 
 a growth may develope primarily from the bones of the skull, 
 the cerebral membranes or blood-vessels, or the brain sub- 
 stance itself, or it may develope in any of these tissues as 
 a metastatic growth secondary to a new growth arising prim- 
 arily in some other organ. In other cases a morbid growth 
 outside of the cranial cavity may, by direct extension, pene- 
 trate the cavity, and thus become intra-cranial. 
 
 The aetiology of such growths is as obscure as is the 
 aetiology of tumours elsewhere. The brain from its great 
 vascularity affords an excellent seat for morbid growths, par- 
 ticularly if they be due to infection from micro-organisms ; 
 yet the determining cause of their developement within the 
 skull is seldom clear. Certain factors, such as sex, age, 
 heredity and trauma have some influence upon their devel- 
 opement, and these may be briefly considered. 
 
 Sex. — The male sex is much more disposed to cerebral 
 tumours, as the following table will show : — 
 
 TABLE I. 
 
 Men. Women. 
 
 Personal cases ........ 28 12 
 
 Bernhardt ' and Ladame 2 ...... 440 210 
 
 Seppilli 3 .......... 89 40 
 
 Lebert 3 51 38 
 
 Friedreich 3 . 28 15 
 
 Hasse 3 .......... 9 5 
 
 It is probable that the different writers above cited have in 
 some instances drawn their figures from the same cases, but 
 
2 INTRA-CRANIAL GROWTHS. 
 
 it is manifest that fully two-thirds of the collected cases have 
 occurred in males. Gowers 4 states that tubercle and glioma 
 are even commoner in males than other forms of tumour, and 
 adds that the preponderance in favour of males is seen in 
 children as well as in adults. In fact after the age of fifty the 
 proportion between the sexes is more nearly equal. Other 
 writers have sought to explain this greater frequency of cere- 
 bral tumours in males to greater cerebral activity and to the 
 fact that men are much more exposed to certain noxious in- 
 fluences, such as syphilis and trauma, which might favour the 
 developement of new growths. 
 
 Age. — The forty cases collected from the hospital reports 
 show the following results : — 
 
 TABLE II. 
 
 Under 10 I 
 
 II to 20 2 
 
 21 to 30 . . . . 10 
 
 3* t0 40 9 
 
 4i ^ 50 7 
 
 51 to 60 . . . . 7 
 
 Age not stated . . . . . . . . 4 
 
 It must be borne in mind, however, that very few children 
 are received at the Boston City Hospital except those suffer- 
 ing from acute infectious diseases and surgical affections. 
 Gowers' statistics show that one-third of the cases occur before 
 the age of twenty, two-fifths from twenty to forty, and one- 
 fifth from forty to sixty. Steffen 5 cites a case in a four weeks' 
 old infant, and he and Starr 6 have found, in children and 
 youths up to twenty years of age, that cases are commoner 
 before the age of eight than after it. 
 
 The frequency with which the different varieties of tumours 
 occur is markedly influenced by age. The majority of cere- 
 bral tumours in children are tubercular, and tubercle is not 
 
ETIOLOGY. 3 
 
 common except in the young. Glioma occurs chiefly in 
 young adults. Sarcoma and cancer usually develope in the 
 brain, as elsewhere, after the period of maturity. Gumma 
 also is seldom seen except in adults. Cerebral lesions are in- 
 frequent in cases of hereditary syphilis, and, when they do 
 occur, they are more commonly diffuse, only rarely taking 
 the form of isolated tumours. 
 
 Heredity. — Heredity seems to be of little influence upon 
 the developement of new growths, although it may have some 
 effect upon their nature, especially in the case of cancer. It is 
 still a matter of doubt whether the " invalid brain," subject 
 to some neuropathic taint, is more susceptible to the still 
 obscure causes that tend to the developement of a tumour. 
 
 Trauma. — The laity are prone to attribute every form of 
 new growth in any part of the body to injury, but in many 
 cases the injury, on inquiry, proves to be comparatively 
 slight or to have preceded the appearance of the growth by 
 so long a period as to render its potency as a cause rather 
 doubtful. It is, however, beyond question that injury may 
 act as the exciting cause of a tumour, even of an infectious 
 granuloma, for growths have been found arising from the 
 scar of the injury. I have myself seen a case of probable 
 tubercle of the cerebellum, in a patient still living, where the 
 symptoms dated quite definitely from a fall on the head. 
 
 Other serological factors are of less importance. In some 
 cases the symptoms develope after great nervous strain, de- 
 bilitating influences, or alcoholic or other excesses, but it is 
 not easy to determine how far such influences may act as a 
 true cause of the growth. 
 
INTRA-CRANIAL GROWTHS. 
 
 II. PATHOLOGICAL ANATOMY. 7 - 8 
 
 INTRA-CRANIAL growths may develope from the skull, 
 from the membranes of the brain (including their prolonga- 
 tions into the brain, such as the falx or the choroid plexus), 
 and from the brain itself. 
 
 Tumours developing from the skull itself are distinctly 
 rare. Such growths are usually of the connective tissue 
 type, sarcoma being the commonest. Exostoses of the 
 skull may occasionally develope without causing any symp- 
 toms, the brain gradually accustoming itself to the slow 
 growth. Malignant growths are more apt to cause external 
 symptoms as well, than to give rise merely to cerebral symp- 
 toms due to the pressure of the growth. 
 
 Tumours of the dura are also most frequently of the 
 connective tissue type, although tubercular and syphilitic 
 thickenings are occasionally seen ; they may sometimes 
 attain such a size as to cause remote symptoms from press- 
 ure. The commonest growth, however, is the sarcoma, 
 which usually forms a fiat, rather widely- extended growth, 
 sometimes as large as an apple, spreading over the surface 
 of the brain. In some cases these growths show prolifera- 
 ting granulations, and they may even perforate the skull 
 (fungus haematodes). In other cases they grow inwards and 
 give rise to more pronounced cerebral symptoms. The 
 variety of sarcoma called endothelioma not infrequently has 
 its seat in the dura. Bony and cartilaginous growths, when 
 they do not develope from the bone itself, usually develope 
 from the dura or falx. Cancer, too, is not uncommon in the 
 dura as a metastatic growth. 
 
PATHOLOGICAL ANATOMY. 5 
 
 The pia is the favourite seat for new growths of an infectious 
 type. Syphilitic growths almost invariably, and tubercular 
 growths very commonly, have their starting-point in the pia, 
 and follow its folds, or some blood-vessel, into the interior of 
 the brain. Cancer not uncommonly developes from the 
 plexuses. Cholesteatoma is most frequent in the membranes 
 of the base. Other forms of neoplasms may also arise from 
 the pia. All these growths, as they extend, may either exert 
 marked pressure upon the brain beneath them, or actually 
 penetrate into the brain substance. 
 
 The tumours which develope primarily in the nervous 
 tissue are the glioma and the neuroglioma ganglionare. 
 Almost all the other forms of neoplasm, however, may 
 occur within the nervous tissue, and it is frequently difficult 
 to determine whether a given tumour has originally devel- 
 oped in the brain substance or has arisen from a fold of the 
 pia, a penetrating blood-vessel, the lining of the ventricle, or 
 from the choroid plexus, and invaded the brain later. In the 
 consideration of the individual forms of new growths further 
 details as to the seat of origin and the appearance of the 
 different growths will be given. 
 
 The accompanying tables show clearly the nature of the 
 various new growths found in the brain, the relative frequency 
 of their occurrence, and the frequency with which they are 
 found in the different regions of the brain. The first table 
 is compiled from Bernhardt's treatise, 1 the second is taken 
 from Birch-Hirschfeld 7 and undoubtedly includes many of the 
 same cases, the third is made up from three hundred cases 
 in children collected by Starr 6 who includes some of Bern- 
 hardt's cases, and the. fourth is made up from the cases I 
 have collected from the hospital reports. In a large percent- 
 age of Bernhardt's and of my own cases the nature of 
 the growth is not given. 
 
INTRA-CRANIAL GROWTHS. 
 
 1 
 
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PATHOLOGICAL ANATOMY. 
 
 TABLE IV (Birch-Hirschfeld). 
 
 
 
 
 
 
 
 
 
 • 
 
 
 
 
 
 
 
 
 
 
 g 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Location of Growth. 
 
 <t> 
 
 
 rt 
 
 
 ee 
 
 re 
 
 
 
 
 
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 g 
 
 g 
 
 rt 
 
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 2 
 
 
 
 
 
 
 
 
 
 
 
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 3 1 
 12 
 
 2 
 
 9 
 6 
 
 7 
 21 
 
 6 
 
 12 
 
 I 
 
 
 
 
 
 
 22 
 
 2 
 
 
 
 1 
 
 64 
 
 35 
 8 
 
 
 
 
 
 
 I 
 
 4 
 
 
 
 
 
 
 
 3 
 
 3 
 
 4 
 5 
 
 
 
 
 
 6 
 
 
 
 
 
 
 
 
 4 
 3i 
 88 
 
 
 19 
 4i 
 
 7 
 
 126 
 
 3 
 3 
 1 
 
 27 
 
 4 
 
 17 
 
 6 
 
 
 
 
 
 
 
 6 
 
 
 
 Medulla 
 
 3 
 
 5 
 
 1 
 
 7 
 
 
 
 18 
 
 
 1 
 
 2 
 
 
 Total 
 
 70 
 
 76 
 
 3H 
 
 
 TABLE V (Starr) Children. 
 
 Location of Growth. 
 
 Si 
 
 3 
 
 H 
 
 re 
 S 
 
 3 
 
 e 
 
 c 
 
 
 re 
 
 1 
 
 
 re 
 3 
 
 >> 
 
 
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 13 
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 6 
 
 14 
 
 16 
 
 19 
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 1 
 
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 1 
 
 3 
 
 1 
 
 10 
 
 1 
 
 5 
 
 5 
 
 3 
 
 5 
 
 1 5 
 
 3 
 
 1 
 1 
 1 
 1 
 
 4 
 11 
 
 3 
 30 
 
 
 TT 
 
 I 
 
 15 
 1 
 
 35 
 27 
 
 III. 
 
 Cerebral axis. 
 
 1. Basal ganglia and 
 
 lateral ventricle . . . 
 
 2. Corpora quadrigemina 
 
 and crura cerebri. . 
 
 
 2 
 
 1 
 1 
 
 1 
 
 9 
 2 
 
 30 
 
 
 
 38 
 6 
 
 
 4. Medulla 
 
 2 
 I 
 I 
 
 3 
 
 
 
 1 
 
 1 
 
 1 
 
 10 
 
 3 
 
 34 
 
 I 
 I 
 
 5 
 8 
 
 TV 
 
 
 47 
 34 
 
 iS 
 
 96 
 42 
 
 V 
 
 Multiple 
 
 
 
 
 ] 
 
 
 Total 
 
 l S 2 
 
 37 
 
 5 
 
 10 
 
 299 
 
 
 
INTRA-CRANIAL GROWTHS. 
 
 TABLE VI (Personal Cases). 
 
 Location of Growth. 
 
 o 
 
 XI 
 
 h 
 
 3 
 i 
 
 E 
 
 5 
 O 
 
 2 
 
 £ 
 
 5 
 
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 u 
 
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 2 
 
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 5 
 
 1 
 
 
 
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 2 
 
 
 
 1 
 1 
 
 
 2 
 
 5 
 5 
 
 Multiple . 
 
 2 
 
 
 
 I 
 
 
 1 
 
 
 Total 
 
 9 
 
 8 
 
 6 
 
 1 
 
 4 
 
 IO 
 
 40 
 
 
 
 1 One of these also contained cholesteatomatous nodules. 
 
 From these tables it will be seen that tubercle is the 
 commonest form of intra-cranial growth ; next come the 
 two forms of connective-tissue growths, sarcoma and glioma, 
 with their varieties ; and next, with a long interval, gumma, 
 cancer, and parasitic cysts. Other forms of new growth are 
 exceptional. 
 
 Tumours of the brain do not differ anatomically from 
 tumours elsewhere, except that glioma and neuroglioma 
 ganglionare are peculiar to the central nervous system. It 
 will be well, however, to note their characteristic features, 
 dwelling upon any peculiarities incidental to their situation, 
 before noting the changes produced by them in the brain 
 itself and their pathological action. 
 
PATHOLOGICAL ANATOMY 
 
 i. Infectious Granulomata. 
 
 The infectious granulomata owe their origin to the 
 presence of some form of schizomycetes. In the majority 
 of cases this micro-organism has been positively determined. 
 In the case of syphilis the precise micro-organism is not yet 
 absolutely accepted, but Lustgarten's bacillus is regarded as 
 the possible cause of infection, and no one doubts that the 
 disease is due to some micro-organism. Whether the mor- 
 bid processes are the direct result of an infectious irritation, 
 or are due to a lesion of tissue caused by the infectious irrit- 
 ation is still uncertain. It is probable that the micro-organ- 
 isms in their growth give rise to ptomaines, which in their 
 turn cause morbid processes in the tissues. 
 
 Although anatomically the invasion of the brain by these 
 schizomycetae always leads to similar processes, nevertheless 
 we must distinguish clinically between acute processes which 
 give rise to more or less extensive lesions of an inflammatory 
 character, where the new formations are of small size, but 
 multiple ; and the more chronic processes, where the new 
 formations are present as single large masses, more closely 
 resembling tumours. This distinction is most marked with 
 tubercle and syphilis, and it will be considered more fully 
 in the description of such growths. 
 
 The" infectious granulomata are usually secondary to an 
 infectious process elsewhere. They are locally progressive 
 growths, and grow from the periphery outwards. The 
 central portion is the oldest, and contains few blood-vessels, 
 and therefore it is prone to degenerate, the degeneration 
 usually assuming the cheesy form. The forms most com- 
 monly met with in the brain are tubercular or syphilitic. 
 Other forms occur only very rarely, and none are to be 
 found in the cases collected in any of the tables given 
 above. 
 
IO INTRA-CRANIAL GROWTHS. 
 
 Tubercle. — As the tables show, tubercle is by far the com- 
 monest form of brain tumour, being found most frequently 
 in the cortex, the pons, or the cerebellum. As I have 
 already said, it is more common in children and in young 
 adults. It is due to an infection of the brain with the 
 bacillus tuberculosis of Koch, the morbid process in the 
 brain being usually, if not invariably, secondary to some 
 tubercular process elsewhere. 
 
 Anatomically speaking, we cannot make any distinction in 
 the forms of cerebral tuberculosis, but clinically, of course, 
 such a distinction is apparent. The bacilli enter the brain 
 either through the blood-vessels or through the lymphatics ; in 
 the latter case the meninges are first affected. In tubercular 
 meningitis, for instance, we see a collection of round cells 
 and miliary tubercles about the vessels of the pia, following 
 these vessels into the brain. In a part of the . cases the 
 infection is general, numerous miliary nodules form in the 
 meninges, an active inflammation is set up, and the patient 
 succumbs before any one of these nodules attains any size. 
 In other cases the process is slower, and some of the nodules 
 attain considerable size. Among the cases I have collected 
 will be found one or two of tubercular meningitis, where such 
 nodules were foand. It is, however, not easy to distinguish 
 such cases from others where the solitary nodule is primary, 
 and leads to a secondary general infection. 
 
 In other cases we have a different clinical picture, corre- 
 sponding to that seen with other forms of cerebral tumour. 
 Here the process is more chronic. One or two regions of the 
 brain are infected with tubercle bacilli, the bacilli being prob- 
 ably not very numerous or of very rapid growth. These bacilli 
 enter only one or two small branches of one of the meningeal 
 arteries. Here tubercular nodules are formed, which gradu- 
 ally increase in size and penetrate more or less deeply into 
 the brain substance. The growth of these nodules is slow, and 
 
PATHOLOGICAL ANATOMY. I I 
 
 they may attain a considerable size, a diameter of three or 
 four centimetres or more. These are the so-called " solitary " 
 tubercles, an ill-chosen name, for, as the tables show, such 
 growths are often multiple, and the individual tumour is in 
 many cases formed by the agglomeration of several smaller 
 nodules. Tubercular disease of the dura is rare, except in 
 combination with similar disease in the pia or the skull. 
 These " solitary " growths arise most commonly from the 
 pia, or some penetrating fold thereof; and, when they occur 
 within the brain apart from the pia, they probably spring 
 •from a blood-vessel, through which the bacilli have been 
 carried to the affected spot. 
 
 These growths are usually irregular in shape, with various 
 projections, indicating the agglomeration of several distinct 
 nodules. The surrounding brain-substance may be softened 
 or sclerosed about the growth, but sometimes the periphery 
 becomes fibrous, forming a capsule to the tumour. In long- 
 standing cases this capsule may become calcified. On section 
 the growth is found to have a grayish-red, translucent peri- 
 phery and a yellowish centre, which is sometimes cheesy, 
 and occasionally shows a concentric marking. The growth 
 extends along the lymphatic sheaths, and, when blood- 
 vessels are met with, it causes thrombosis. Sometimes, 
 however, the growth may penetrate a vessel, and the blood 
 may become re-infected with bacilli, and thus give rise to a 
 fresh and more acute infection of the brain, a secondary 
 tubercular meningitis. 
 
 Under the microscope we find in the periphery of these 
 growths an abundance of newly-formed round cells, nuclei, 
 giant cells with many nuclei, and epithelioid cells. Here, 
 too, may usually be found a certain number of bacilli. The 
 exact origin of these cells, whether from endothelium in the 
 serous cavities, lymph cavities, or adventitia, or from con- 
 nective tissue or lymph corpuscles is still uncertain. Occas- 
 
12 INTRA-CRANIAL GROWTHS. 
 
 ionally we see a reticular network between the cells, the 
 remains of the destroyed connective tissue. The growth, 
 as I have said, contains very few vessels, and the centre, 
 deprived of blood, undergoes coagulation necrosis and 
 cheesy degeneration. Here we find only a fatty-granular 
 homogeneous detritus, with, perhaps, an occasional cell still 
 preserved, and, rarely, a few bacilli. 
 
 Gumma. — What has been said of cerebral tuberculosis 
 holds true in large part of cerebral syphilis. The bacilli (?) 
 enter through the blood-vessels and give rise to inflammatory 
 processes and cell-proliferation in the meninges. The 
 favourite seat of this process is at the base of the brain, 
 especially in the loose meshes of connective tissue about the 
 optic chiasma. 9 The products of such an inflammation often 
 form dense masses, composed largely of connective tissue, 
 with some round-cell infiltration, and give rise to symptoms 
 resembling those caused by a tumour. One or two such 
 cases will be cited later. Anatomically such a growth is to 
 be regarded as a meningitis, and not as a tumour; but the 
 process is histologically the same in both cases, and the 
 distinction drawn in tuberculosis cannot be so well main- 
 tained. All syphilitic processes in the brain are gummatous ; 
 sometimes the process is limited, and the inflammatory 
 products attain a considerable bulk in one spot, — the gumma 
 or syphilitic tumour, as distinct from the syphilitic inflamma- 
 tion. 
 
 The discrete tumour or gumma is comparatively rare, 
 much rarer than gummatous meningitis. Such growths 
 are found most commonly in the cortex or the pons, and 
 usually develope from the meninges, starting perhaps from a 
 local meningitis ; in rare instances they seem to arise from 
 the vessels. Gumma is rarely seen in children. Starr, 6 in 
 300 cases, found but one, and that in a youth of eighteen ; 
 and Rumpf 10 has collected only two. Cerebral lesions are 
 
PATHOLOGICAL ANATOMY. 1 3 
 
 rare in hereditary syphilis, and gumma even rarer than other 
 forms. These growths are irregular or wedge-shaped, and 
 may attain considerable size. They are usually surrounded 
 by softened brain tissue, but in some cases they are infil- 
 trated ; capsule formation is rare. On section of a tumour 
 of good size and average duration we find a reddish-gray, 
 translucent periphery, the newest part of the tumour, and 
 within this one or more dry, yellowish centres of caseation. 
 The growth contains very few vessels, and the vessels in and 
 near it show periarteritis and endarteritis. In a later stage, 
 perhaps as a result of treatment, there is a considerable 
 developement of connective tissue in the tumour (a character- 
 istic change in syphilitic growths), and the tumour becomes 
 hard, shrunken, and fibrous, — an indurated cicatrix. 
 
 Under the microscope the grayish-red periphery is found 
 to be made up of small round cells, spider cells, spindle cells, 
 and even giant cells, with the remains of the elements of the 
 original tissue. A characteristic feature of syphilitic growths 
 is the presence of fibrous tissue, mixed with the round cells. 
 The cell formation is primary, and leads to the formation of 
 fibrous tissue as a sort of cicatrix. The fibrous tissue 
 occasionally has a somewhat alveolar arrangement, enclosing 
 the cells in its meshes ; this is commoner in the growths that 
 develope from softer tissues. The cheesy portions are more 
 irregular in their distribution than are those of tuberculosis, 
 and they consist of a fine granulardetritus, shrivelled nuclei, 
 and granular cells. The distinction between gumma and 
 tubercle is not always easy. The presence of other syphilitic 
 lesions, especially endarteritis, the irregular shape and the 
 irregular distribution of the cheesy nodules, the character- 
 istic developement of fibrous tissue, and the absence of 
 the bacillus of tubercle will usually render the distinction 
 possible. 
 
 Actinomyces. — In rare cases actinomycosis extends from 
 
14 1NTRA-CRANIAL GROWTHS. 
 
 the face and neck, its favourite seat, through the occipital 
 foramen into the brain, leading to a diffuse purulent inflam- 
 mation of the pia, with granulating nodules, or, in some cases, 
 to abscess formation. Bollinger 8 reports a case, as yet 
 unique, where a granulation tumour the size of a hazel-nut 
 was found in the third ventricle, and where no other traces 
 of actinomycosis could be found. The growth was, like 
 other actinomycotic tumours, made up of connective tissue 
 and round cells, with the peculiar nodules of the specific 
 micro-organism. 
 
 Other infectious granulomata play no part in the con- 
 sideration of intra-cranial growths. Ziegler 6 states that in 
 leprosy and glanders the brain may become involved, but, in 
 the extremely rare cases where this happens, the process is 
 diffuse and does not lead to tumour-formation. Mycosis 
 fungoides and rhinoscleroma never, so far as is known, attack 
 the brain. 
 
 2. Connective Tissue Tumours. 
 
 Second only to the infectious granulomata in importance 
 and frequency come the connective tissue tumours, develop- 
 ing from the tissues of the mesoblast. Of these there are 
 many varieties and also mixed forms. They may develope 
 primarily in the brain, or secondarily from metastases within 
 the skull. Among them we find, next in frequency to 
 tubercle, sarcoma and glioma, the latter being in the strictest 
 sense a brain tumour. Other forms are rare, but require a 
 word of description. 
 
 Glioma. — The glioma is peculiarly a " brain" tumour, for 
 it developes from the cells which form the foundation of 
 the central nervous system, from the neuroglia, and it is 
 found only in the central nervous system or in its prolonga- 
 tion into the retina. It is usually a solitary growth, and is 
 found most commonly in the cerebrum, and next, although 
 
PATHOLOGICAL ANATOMY. I 5 
 
 less frequently, in the cerebellum and the brain stem. It 
 never forms metastases and is probably malignant only from 
 its situation, although, when removed, it has a tendency to 
 recur. It may attain the largest size of any of the intra-cranial 
 growths, sometimes having a diameter of eight or ten 
 centimetres and a weight of a hundred or a hundred and 
 fifty grammes. Developing, as I have said, from the 
 neuroglia, it is primarily sub-pial, and involves the mem- 
 branes, if at all, only secondarily during its growth. 
 Ordinarily the external form of the brain is unchanged, and 
 only by touch or by some change in colour, or perhaps by 
 some swelling do we recognize that there is a growth beneath. 
 The growth is of varying density, usually not differing very 
 materially in density from the brain substance. In rare cases 
 the tumour is distinct from the brain substance, but usually it 
 is hard to distinguish the boundary between the tumour and 
 normal brain tissue. Occasionally the brain about the tumour 
 is softened, and the softening may go on to the formation of 
 cysts. On section the growth may closely resemble either 
 pale or hyperaemic gray matter, but more commonly it is 
 gray or grayish-red, somewhat yellowish, and translucent; 
 the section having a variegated appearance with whitis'h and 
 hemorrhagic spots. The vessels within the growth are often 
 increased in size and number, and sometimes a part or al- 
 most the whole of the growth may be destroyed by a 
 haemorrhage, so that only by a microscopic examination is 
 it possible to detect the remains of the new growth. Under 
 the microscope the tumour is found to be made up of glia 
 cells with fine fibrous prolongations (Spinnenzellen), and a 
 delicate intercellular fibrous tissue. These cells may vary 
 considerably, both in size and number. Osier 11 has described 
 cells occasionally met with which resemble ganglion cells, 
 and he has also found large spindle-shaped cells and trans- 
 lucent band-like fibres. When the cells are small and few 
 
1 6 INTRA-CRANIAL GROWTHS. 
 
 in number the growth is harder and denser. Sometimes 
 some of the cells are collected in groups ; others have 
 several nuclei. The tumour probably grows from the 
 periphery by increase and division of the glia cells. The 
 nerve-fibres and ganglion cells in the parts invaded by the 
 growth finally disappear, but they may resist destruction for 
 a long time. When the pia is invaded it usually shows a 
 marked increase of connective tissue. In some cases of 
 haemorrhage we see agglomerations of cells. Corpora 
 amylacea also occur. 
 
 In some cases the vessels are so greatly developed in the 
 growth as to warrant the name of teleangiectatic glioma. 
 When the fibrous tissue is increased in the growth we speak 
 of a fibro-glioma. If there is within the tumour a develope- 
 ment of mucous tissue we speak of a myxo-glioma. In 
 some cases where the cells are very abundant the tumour 
 may closely resemble a sarcoma; in other cases there is a 
 true proliferation of round or spindle-shaped cells, a glio- 
 sarcoma. 
 
 Neuroglioma ganglionare. — This is a new growth occas- 
 ionally seen in the brain, and is always to be referred to 
 some disturbance of developement. The growth may be 
 either an increase of substance in the brain without any 
 sharp contour, or it may exist in the form of a somewhat 
 circumscribed nodule. Like glioma it is found only in the cen- 
 tral nervous system. The pia is usually not much altered over 
 the growth, but on section the normal distinction between 
 the cortex and the white matter is lost, and the growth has a 
 uniformly white or grayish-white appearance, with occas- 
 ional gray spots scattered through it. In consistency it is 
 harder than the brain substance. Under the microscope the 
 growth is found to consist of glia tissue, in structure resem- 
 bling somewhat the nodules of multiple sclerosis. In addition 
 medullated fibres are found in some portions of the tumour. 
 
PATHOLOGICAL ANATOMY. IJ 
 
 In other portions large and small ganglion cells are to be 
 found, either isolated or in groups. 
 
 Sarcoma. — Sarcoma is about equal to glioma in frequency, 
 being one of the commonest forms of new growth next to 
 tubercle. It may develope from the dura, from the pia, or 
 from within the brain substance ; in the latter case it probably 
 arises from the pial sheath of a blood-vessel. Sarcomata are 
 generally solitary but they may be multiple. They may 
 develope primarily within the cranial cavity, when they are 
 either flat, and fungus-like (if of dural origin) or wedge- 
 shaped, or they may arise as metastases from growths else- 
 where, when they form roundish nodules. Wernicke 12 states 
 that they are of slow growth and poor in vessels, but this is 
 not universally the case. The intra-cerebral growths are 
 usually distinct from the brain substance, and the interior 
 of the growth may show haemorrhages, caseation, cyst- 
 formation, or fatty degeneration. Sarcoma is a tumour of the 
 connective-tissue type, made up of cells, the cells predomi- 
 nating over the intercellular substance. The softer forms are 
 white or grayish, with many cells ; the harder forms pass 
 over into the fibromata. 
 
 Histologically the sarcoma is made up of cells, the char- 
 acter of the cells giving the growth its name. We find 
 large or small round cells, large or small spindle cells, 
 giant cells, stellate cells, and a mixture of the various 
 forms. The small round cell sarcoma is the most malig- 
 nant (except the melanotic form), but the question of the 
 malignity of an intra-cerebral growth has not thus far been 
 of much importance. It has, however, recently assumed 
 importance in connection with the surgical treatment of 
 intra-cranial growths. This form of sarcoma shows on section 
 a miiky white surface from which a juice exudes. The 
 spindle-cell sarcoma is less malignant, firmer, translucent, 
 and of a gray or yellowish white colour, often containing 
 
1 8 INTRA-CRANIAL GROWTHS. 
 
 considerable fibrous tissue. Sarcomata have a granular, 
 fibrous intercellular substance, and some of them have a 
 structure much like that of a lymph-gland {lymphosarcoma) . 
 The spindle-cell and polymorphous types are the commonest 
 forms found in the brain. When the fibrous tissue is well- 
 marked we speak of a fibro-sarcoma, a transition form be- 
 tween the sarcoma and the fibroma, which is rare in the 
 brain. In a very few cases the inter-cellular substance is 
 found to be mucous in character — myxo-sarcoma or cylin- 
 droma. I have already stated that cysts are in rare cases 
 found in the growth — cysto-sarcoma. In some cases the 
 cells contain pigment — melano-sarcoma. In these cases the 
 melanotic deposit in the brain is generally multiple and 
 secondary to a growth elsewhere. Melanotic growths, 
 whether sarcomatous or carcinomatous, are intensely malig- 
 nant, and, when they occur in the brain, the cerebral symp- 
 toms are apt to be subordinated to the symptoms caused 
 by the growth elsewhere. Bramwell 13 figures an exquisite 
 specimen where the brain was studded with numerous 
 melanotic nodules. I have spoken above of the glio-sarcoma. 
 I am disposed to believe that in a portion of the reported 
 cases of sarcoma the new growth contained also gliomatous 
 tissue, overlooked by the observer. If this be true, sarcoma 
 should be ranked as third in frequency among cerebral 
 tumours. Some sarcomata are highly vascular, telangiectatic 
 sarcomata, while others seem to consist of cells assembled 
 about an enlarged plexus of vessels, plexiform angiosarcoma. 
 In some cases these growths become calcareous, angiolitJiic 
 sarcoma. 
 
 Sarcomata of the dura are most commonly of the 
 spindle-cell type. They may be of alveolar structure, 
 with clusters of cells within a connective tissue stroma, the 
 so-called endothelioma ; these may contain endothelial cells 
 from the lymphatics, and occasionally the remains of a 
 
PATHOLOGICAL ANATOMY. 1 9 
 
 lymph vessel may be traced in them. At times these dural 
 growths develope calcareous deposits, giving rise to the 
 psammoma, which may also arise from purely fibrous 
 growths. Sarcomata of the dura are flat or spongy growths, 
 with extensive roots in the dura; they may grow inwards, 
 compressing the brain beneath, or outwards, perforating the 
 skull at times, as one form of the fungus hsematodes. The 
 precise nature of endothelioma has been in dispute, some 
 writers confusing it with epithelioma. The histological dis- 
 tinction is by no means easy. Ziegler 8 lays some stress on 
 the presence of lymph-vessels. Birch-Hirschfeld 7 states 
 that " all tumours arising from the connective tissue, in which 
 the endothelium stands in the same relation to the bundles 
 of connective tissue or to the vessels as in physiological 
 connective tissue, are to be regarded as sarcomata or connect- 
 ive tissue tumours ; but when the newly-formed endothelium is 
 arranged in the alveoli of a vascular stroma after the manner 
 of the epithelial cells of carcinoma (in distinction from sarc- 
 omata, where the vessels are also equally distributed among 
 the cells in the alveoli) we should use the term endothelial 
 cancer." The anatomical distinction between alveolar 
 sarcoma and epithelioma is sometimes, however, almost im- 
 possible ; and we can distinguish only by determining the 
 genesis of the growth. 
 
 Sarcomata of the pia are either soft nodules or flat and 
 more extensive growths. They may in rare cases involve a 
 very large extent of the meninges in an endothelial growth. 
 They develope partly from the adventitia and partly from 
 the endothelium of the membranes. The polymorphous 
 or alveolar endothelial forms are commonest, but other 
 forms of sarcoma, and myxo-sarcoma and angio-sarcoma 
 also occur. 
 
 Within the brain sarcomata are usually wedge-shaped, 
 sharply defined, and made up of spindle or polymorphous 
 
20 INTRA-CRANIAL GROWTHS. 
 
 cells. Haemorrhages and softening may occur within the 
 growth. The surrounding brain substance is sometimes 
 softened, and, if the growth be sub-pial, the meninges are in- 
 flamed and thickened. 
 
 Fibroma. — Fibroma is rarely found in the brain. When it 
 does occur it is usually a rounded growth, dense and hard in 
 character. Under the microscope it is found to consist of 
 fibrous tissue containing a few cells. The transition form, 
 fibro-sarcoma, has already been mentioned. In some instances 
 concretions occur in the growth, as we have seen may happen 
 with sarcoma, and then we have one form of the psammoma. 
 The Pacchionian bodies, so common as hardly to be consid- 
 ered abnormal, are small fibromata. Fibrous thickenings are 
 also seen at times in the epithelium of the ependyma, as a sort 
 of organized thrombus. 
 
 Osteoma. — As a rule osteoma, composed of true bony 
 tissue, developes from the skull, either as an exostosis or as 
 a more irregular growth. In some cases it may arise from 
 the dura, the falx, or the tentorium, and a few cases are on 
 record where osteomata developed within the brain substance. 
 Mixed forms, such as osteo-fibroma or osteosarcoma may also 
 occur. 
 
 Enchondroma. — Enchondroma is also rare. It usually 
 forms a flattened growth arising from the bones of the skull 
 or from the dura and lying like a plate upon the brain. It 
 is composed of ordinary cartilage. Sometimes the growth 
 takes on in part a bony character, osteo-encJwndroma. 
 
 Myxoma. — The mixed forms of myxoma, myxo-sarcoma 
 and myxo-glioma, have already been mentioned. The true 
 myxoma is much less common. It is a soft, round, fairly 
 well-defined growth, and, under the microscope, shows a 
 pronounced mucous ground-substance, containing mucine, 
 with cells. 
 
 Lipoma. — A few cases are on record where fatty tumours, 
 
PATHOLOGICAL ANATOMY. 2 1 
 
 composed of ordinary fat tissue, have been found in the brain. 
 They are so rare as to possess no importance. 
 
 Angioma. — I have already spoken of the telangiectatic 
 forms of sarcoma and glioma. In a few instances growths made 
 up of enlarged vessels have been found ; in most of these 
 cases careful examination has revealed also cells which indic- 
 ate the gliomatous or sarcomatous nature of the growth. 
 
 Neuroma. — Virchow gave this name to a heterotopy of 
 gray or white matter, occasionally seen as a congenital mal- 
 formation. Such a growth is probably more properly to be 
 regarded as a neuroglioma ganglionare. A few cases of neuro- 
 mata are on record, similar to neuromata elsewhere, develop- 
 ing within the cranium from the cranial nerves. It is not clear 
 whether these growths are true neuromata, composed of nerve 
 fibres, or the so-called false neuromata, that is, fibromata aris- 
 ing from the nerve sheaths. They may attain considerable 
 size and give rise to symptoms like those of any other intra- 
 cranial growth. 
 
 3. Epithelial Tumours. 
 
 Epithelial growths develope from the tissues of the upper 
 and lower layers of the blastoderm, and contain epithelial 
 cells as well as a vascular connective tissue stroma. The type 
 of normal growth to which they approximate is that of 
 glandular organs, but in the brain they generally assume 
 atypical forms. They rank third in importance among the 
 new growths of the brain, and it is probable that they are 
 much less common than was formerly held. The most im- 
 portant form is cancer, but even this is rare, occurring in 
 only about five per cent, of Bernhardt's cases. 
 
 Adenoma. — Adenoma is one of the more typical epithelial 
 growths, developing from glandular structures and resem- 
 bling gland-tissue in its composition. It forms a rather soft 
 spongy growth, which, under the microscope, resembles 
 
22 INTRA-CRANIAL GROWTHS. 
 
 acinous or alveolar glands, masses of epithelium in a connect- 
 ive tissue stroma, or tubes which show in the stroma on sect- 
 ion cavities lined with epithelium. As these growths develope 
 from gland-tissue it is obvious that they can occur in but one 
 part of the brain, namely, in the hypophysis, which developes 
 from the pharynx, and is really a bit of the pharyngeal tissue 
 enclosed within the skull. The anterior lobe of the hypo- 
 physis consists normally of a vascular connective tissue stroma, 
 with follicles filled with epithelium. In this adenoma may 
 develope. Weigert e also describes cystic degeneration and 
 hyperplasia of the hypophysis, with the formation of cysts 
 containing colloid material. Such glandular hyperplasia may 
 attain the size of a hen's egg. 
 
 Carcinoma. — Cancer of the brain is often secondary, but 
 it may be primary, in which case it usually arises from the 
 meninges. In the cases collected there was no case of cancer, 
 but I found in the hospital records one case of cancer of the 
 vertebrae with myelitis, where a secondary nodule had formed 
 in the skull, penetrating the cranial cavity for a depth of two 
 millimetres. There were no cerebral symptoms, the mem- 
 branes and brain substance were -healthy, and therefore I have 
 not reported it. Cancer may arise, as this case shows, from 
 the bones of the skull, when it usually perforates the skull, 
 giving rise to one form of fungus haematodes. Cancerous 
 growths of the dura are usually secondary, appearing as 
 rather soft roundish nodules, usually multiple. When cancer 
 developes primarily from the pia it is very apt to take its origin 
 at the base, from the epithelium covering the choroid plexus, 
 and to penetrate into the ventricles. Less 'frequently it arises 
 from the epithelium of the ependyma. The stroma not 
 uncommonly grows in projecting papillae, hence the name 
 formerly used, of papilloma. The growths may, . in such 
 cases, attain a considerable size, and are usually of a 
 soft, spongy consistency, often containing haemorrhages 
 
PATHOLOGICAL ANATOMY. 23 
 
 and being vascular. In some cases they assume a colloid 
 character. Whether cancer may develope primarily elsewhere 
 in the brain is still uncertain ; it may possibly do so in the 
 hypophysis or in the transverse fissure. 
 
 Cancer may develope in the brain substance as multiple 
 secondary nodules from primary growths in the ventricles, 
 or from primary growths outside the skull. In either case 
 the nodules are small, multiple, and rounded, and are often 
 arranged somewhat symmetrically. 
 
 Cancer of the brain is usually soft, and often of a colloid 
 character. Under the microscope may be seen nests of 
 epithelial cancer cells, arranged in a connective tissue 
 stroma, but not displaying any definite glandular structure. 
 The cells are most commonly of a cylindrical type, but 
 other forms may occur. In these nests of cells epithelial 
 " pearls " may sometimes develope, which closely resemble 
 the pearls in epithelial growths of the skin, and are in strik- 
 ing contrast to the cylinder epithelium. The stroma not in- 
 frequently undergoes mucous degeneration, and later, the 
 mucus being absorbed, cysts may form. 
 
 Cholesteatoma. — We occasionally see in the brain pearly 
 white bodies, usually of small size, situated in the pia at 
 the base or near the great fissures. They consist of epithel- 
 ial cells arranged in concentric layers, resembling the cells 
 of the epidermis. They contain cholesterine, and in very 
 rare cases minute hairs. Their exact nature is unknown. 
 Birch-Hirschfeld allies them to retention cysts, but most 
 authors consider that they are offshoots of the epithelium of 
 the medullary tube, arising from the outer layer of the 
 blastoderm, and existing in the brain as malformations. At 
 times they may grow to considerable size, and, very rarely, 
 they may assume a clinical significance. Case XXII, how- 
 ever, is peculiar, as showing a connection, possibly fortuitous, 
 between. a cholesteatoma and a sarcoma. 
 
24 intra-cranial growths. 
 
 4. Aneurysms. 
 Aneurysms of the arteries at the base of the brain are 
 much rarer than actual neoplasms, and I have been able to 
 find no record of a case at the hospital, and only one case 
 has come under my observation. Many cases, however, are 
 upon record, and they naturally give rise to symptoms re- 
 sembling those of a new growth. They arise from primary 
 degeneration of the blood-vessels, syphilis, injury, or embol- 
 ism. The importance of miliary aneurysms in the genesis of 
 cerebral haemorrhage is familiar. Larger dilatations of the 
 vessels are much rarer. In about half the cases death is 
 caused by rupture of the aneurysm. Aneurysms are rather 
 commoner on the left side of the brain,' and, like aneurysms 
 elsewhere, may be true or false. Gowers, 4 tabulating 154 
 cases, gives the following distribution : — 
 
 TABLE VII. 
 
 Middle cerebral artery .......... 44 
 
 Ba<ilar artery . . . . . • • • • • • • 4 1 
 
 Internal carotid artery .......... 23 
 
 Anterior cerebral artery . . . . ■ • • • • • '4 
 
 Posterior communicating artery ......... 8 
 
 Anterior communicating artery . . . . , . . . .8 
 
 Vertebral artery ............ 7 
 
 Posterior cerebral artery .......... 6 
 
 Inferior cerebellar artery .......... 3 
 
 As there are two middle cerebral arteries it becomes appar- 
 ent that the favourite seat of aneurysms is in the basilar artery. 
 
 5. Cysts. 
 
 I have already spoken of the cystic degeneration which 
 
 many forms of new growths may undergo. In cases of 
 
 haemorrhage cysts may also develope from absorption of the 
 
 clot. These cysts are secondary and therefore need no sep- 
 
PATHOLOGICAL ANATOMY. 25 
 
 arate mention. In addition small retention (?) cysts are 
 often found in the plexuses, but they rarely have any clinical 
 significance. Finally a very few cases are on record where 
 a dermoid cyst {teratoma) has been found in the brain, prob- 
 ably of congenital origin, and usually arising from the 
 meninges. 
 
 6. Parasitic Growths. 
 
 Parasitic cysts, in Bernhardt's table, play an important part, 
 and the Australian journals report numerous cases. In 
 America they are rare, and the hospital records show very 
 few cases of hydatid cysts anywhere in the body, and none in 
 the brain. Parasitic cysts may be due either to ecJiinococci 
 (hydatids) or cysticerci. 
 
 Hydatid cysts may be small or large, single or multiple. 
 They usually lie upon the brain, compressing it, and they 
 may give rise to softening of the contiguous brain substance. 
 
 Cysticerci may assume the ordinary form of small bladders 
 with scolices, or the racemose form, with sterile bladders 
 hanging from one another like a bunch of grapes. 
 
 7. Changes in the Brain Consecutive to Intra- 
 cranial Growths. 
 
 The growth of a tumour causes, of course, an increase in 
 the contents of the cranium and a consequent increase of 
 pressure within the skull. This is manifested in various 
 ways. The cerebral fluid is diminished and the pia appears 
 dry and anaemic ; the convolutions are compressed and flat- 
 tened, and the sulci are less deep ; secondarily to this, the 
 gray matter of the convolutions may become thinner and 
 undergo atrophy from pressure. The growth may also exert 
 pressure on the aqueduct of Sylvius or the venae Galeni, and 
 cause a dropsy of the ventricles, the hydrocephalus thus 
 
26 INTRA-CRANIAL GROWTHS. 
 
 increasing the pressure. This increase of pressure may also 
 be manifested in the membranes of the brain and in the 
 bony structures ; the dura becomes thinned, and the skull 
 may become as thin as paper and may even be perforated, 
 as in Case XXIII. In such cases the thinning of the bones is 
 irregular, and the marks of the convolutions may be seen on 
 the skull. In some cases the pressure is such as to produce 
 considerable displacement of the brain, and thus it may 
 cause a marked distortion of the brain and the brain stem. 
 The cranial nerves may be directly compressed by the 
 growth, as in Case XXVIII, and thus become atrophied, or 
 they may atrophy by reason of the increased general press- 
 ure, as in Case XXXV. It is still a matter of dispute 
 whether the inflammation of the nerves, sometimes seen, is 
 due to pressure or to direct irritation. This will be dis- 
 cussed later in the consideration of optic neuritis. 
 
 The new growth may, of course, cause a direct destruct- 
 ion of tissue in the part where it deveiopcs, and it may 
 further lead to a softening of the brain substance in the 
 neighbourhood of the tumour, as has already been stated. 
 This softening is due, in the first place, to the pressure on 
 the vessels, with blood-stasis and oedema from pressure. In 
 this form small haemorrhages are often seen in the softened 
 portions, and thrombosis may occur in the smaller vessels in 
 the neighbourhood of the growth. Furthermore, by the 
 direct irritation of the growth, an obliterating arteritis may 
 develope, with subsequent softening. This is most common 
 with the granulomata. 
 
 Larger haemorrhages are more apt to occur in the tumour 
 itself, especially in gliomata. Cyst-formation, either second- 
 ary to the haemorrhage or due to retention, is sometimes 
 seen. Where the growth reaches the membranes a localized 
 meningitis is not uncommon, and if the growth be of an 
 infectious character, especially in cases of tuberculosis, this 
 
PATHOLOGICAL ANATOMY. 27 
 
 inflammation may become general. With tubercle it is prob- 
 able that the growth is the primary lesion and general men- 
 ingitis is secondary, but the reverse is of course not 
 infrequently the case. 
 
 In some cases, as a result of the destruction of brain 
 tissue by the growth, secondary degeneration may ensue. 
 This occurs, of course, most frequently where the motor 
 tract is destroyed. It seems to be less common than in 
 cerebral haemorrhage or in lesions which more suddenly 
 cut across the motor fibres, but Case VIII presents the 
 clinical features of a descending degeneration. 
 
28 INTRA-CRANIAL GROWTHS. 
 
 III. PATHOLOGY. 
 
 FROM what has been said of the anatomical changes found 
 in the brain in cases of cerebral tumour, the pathological 
 action of such growths may readily be inferred. This action 
 may be classed, under the three heads of pressure, destruct- 
 ion and irritation. 
 
 Every intra-cranial tumour must add to the contents of 
 the cranium and thus, while it grows, increase the intra- 
 cranial pressure. Of course, by the ordinary physical laws, 
 the mechanical action of pressure can be exerted only by a 
 growing tumour, and when it ceases to grow it ceases to 
 exert pressure, although naturally the effects of past pressure 
 remain. As the brain itself is a solid the pressure is not uniform, 
 but it is more manifest where the brain is forced into recesses 
 of the cranium or against an unresisting surface. This general 
 compression gives rise to many functional disturbances, some 
 of which will be pointed out later. Soft tumours do not ex- 
 ert very much local pressure, but the harder and denser 
 growths, beside causing general compression of the brain, 
 may exert local pressure on adjacent parts, thus giving rise 
 to disturbances of function in those parts. 
 
 Intra-cerebral growths, much more than intra-cranial 
 growths which do not involve the brain substance, destroy 
 the portion of the brain in which they grow, and second- 
 arily, by the processes of softening, degeneration, etc., 
 already noted, they cause destruction of adjacent portions 
 of the brain. In this way they give rise to symptoms due to 
 the loss of function of the parts destroyed, symptoms of 
 deficit (Ausfallserscheinungen), such as paralysis, anaes- 
 thesia, blindness, deafness, aphasia, etc. 
 
PATHOLOGY. 29 
 
 Tumours of the brain, especially during their growth, act 
 as irritants. The irritation thus caused may be mechanical, 
 and exerted chiefly and primarily at the periphery of the 
 new growth, or it may be chemical, the growth causing cer- 
 tain chemical changes in the blood and the lymph ; in con- 
 sequence of such chemical changes irritation may extend 
 to more remote regions of the brain. As a result, of these 
 irritations, whatever their cause, there arise various symptoms 
 of irritation (Reizerscheinungen), which, in their nature, are 
 precisely the opposite of the symptoms of deficit; among 
 them may be mentioned convulsions, contracture and pain. 
 
 As the tumour grows symptoms of irritation may develope 
 in more remote parts, which become involved in the morbid 
 process (symptoms of invasion) ; and these symptoms may 
 be followed later on, when the morbid growth has entirely 
 destroyed the part, by symptoms of deficit. 
 
 Finally, the altered conditions of the blood supply may 
 have a marked effect on the symptoms presented by the 
 growth. The changes in the vessels in the parts surrounding 
 a tumour have already been mentioned, but very vascular 
 growths are subject to variations in size from the variations in 
 the amount of blood in them. This is seen especially in 
 aneurysms, and, as is evident, it may give rise to" temporary 
 variations in the clinical picture. 
 
30 INTRA-CRANIAL GROWTHS. 
 
 IV. GENERAL SYMPTOMATOLOGY. 
 
 It may be said here once for all that tumours of the brain 
 may exist with hardly any symptoms. It may be, as Hugh- 
 lings-Jackson has suggested, that they cause a certain slight 
 deficiency in mental power, in apprehension, or in the power 
 for continuous exertion, and that careful study of the highest 
 intellectual faculties may reveal a falling off, or a limitation of 
 the mental field ; but symptoms such as would lead to the 
 suspicion of any real disease may be wholly wanting. In 
 other cases there is evidence of disease, but the evidence is 
 not clear enough to warrant the diagnosis of a cerebral tumour. 
 In a third class of cases the existence of a new growth in the 
 brain may be diagnosticated with much probability, but there 
 are no symptoms which warrant a localization of the growth. 
 Finally, the symptoms may be so clear and so definite as to 
 make it probable, not only that there is a new growth within 
 the cranium, but that that growth is located in one definite 
 region. These distinctions will appear in the consideration of 
 the individual cases. Out of the forty cases here collected, six 
 presented no symptoms of cerebral disease, and in five other 
 cases the cerebral symptoms may well have been due to 
 other co-existing affections. In thirteen cases there were 
 symptoms of some cerebral trouble, but the symptoms were 
 not definite enough to permit a correct diagnosis. In eight 
 cases there were symptoms definite enough to warrant the 
 diagnosis or at least a strong suspicion of an intra-cranial 
 growth. Finally, in eight cases it was possible to make a 
 correct focal diagnosis, as well as a diagnosis of the existence 
 of a growth. These rather surprising results are in part to 
 
GENERAL SYMPTOMATOLOGY. 3 I 
 
 be accounted for by the fact that the principle of selection 
 here employed was not to select cases dying from brain 
 tumour, but to collect all cases where at the autopsy a new 
 growth was found. In this way eleven cases are reported 
 which are not strictly cases of brain tumour, but cases where 
 the patient died of some other disease, and the tumour was 
 merely a co-existing lesion, giving rise during life to no 
 apparent disturbance. Excluding these cases, however, the 
 figures still give a striking manifestation of the limitations of 
 our ability to diagnosticate correctly intra-cranial growths. 
 
 The symptoms presented by intra-cranial growths are of 
 two sorts, first, those due to the presence of a tumour some- 
 where in the cranial cavity, — general or diffuse symptoms ; 
 and, second, those due to the presence of a tumour in some 
 definite region of the brain, — focal or localizing symptoms. 
 The former may, speaking broadly, be ascribed to the gen- 
 eral effect which the tumour produces upon the brain, the 
 latter chiefly to the destruction or irritation of certain 
 regions. In some cases, however, a tumour may, either from 
 remote pressure, from some reflex action, from irritation con- 
 veyed along association fibres, from chemical changes, or 
 from various unknown causes, give rise to disturbances in 
 some more or less remote part of the brain, and thus lead to 
 errors in diagnosis. 
 
 The chief general symptoms to be considered are head- 
 ache, vertigo, vomiting, optic neuritis, convulsions, psychical 
 disturbances, and disturbances of the general functions. 
 
 Headache. — This was noted in 27 cases and is one of the 
 most constant symptoms of an intra-cranial growth. Mary 
 Putnam Jacobi, 14 tabulating the cases of Ladame and 
 Bernhardt, found it in 401 out of 614 cases, the percentage 
 being the largest with tumours of the cerebellum and corpora 
 quadrigemina. The greater frequency of headache with 
 cerebellar growths she ascribes to the increase of pres- 
 
32 INTRA-CRANIAL GROWTHS. 
 
 sure in the narrow space beneath the tentorium. In tu- 
 mours of the corpora quadrigemina she thinks the connec- 
 tion with the cerebellum has some influence, but in this 
 region a new growth is pretty apt to block up the aqueduct 
 of Sylvius, press on the venae Galeni, and give rise, as in 
 Cases XXII and XXIII, to marked hydrocephalus and to a 
 very great increase of the intra-cranial pressure. The prob- 
 able cause of headache in a majority of cases is the irritation 
 of the highly sensitive dura by the increased pressure. In 
 some cases the new growth may affect the dura, and here 
 the pain becomes more distinctly localized, and there is 
 sometimes local tenderness on percussion. 
 
 The character of the headache in cases of brain tumour 
 may vary exceedingly. Sometimes the pain is slight, tem- 
 porary, and of a dull character ; in other cases it may be 
 most intense and unendurable, causing the utmost suffering 
 and driving the victim to suicide or making him insane; the 
 pain may be dull or sharp, transitory, intermittent, or con- 
 stant. It is often aggravated by stooping, exercise, mental 
 exertion or any cause that may lead to cerebral hyperaemia. 
 
 Oppenheim 15 has found that the location of the head- 
 ache bears no relation to the situation of the growth, an 
 opinion with which I am disposed to agree. Out of sixteen 
 cases where the headache was more or less ^constantly local- 
 ized in one part of the head, in only six did the pain at all 
 correspond to the part of the brain in which the tumour 
 was situated. 
 
 With tumours of the occipital lobe and cerebellum some 
 writers think that the pain is more apt to be in the back of 
 the head, and in tumours of the frontal lobe the pain may 
 be in the front of the head, but this rule is by no means 
 without exceptions. With tumours of the base or pons ( the 
 fifth nerve may be affected, giving rise to a trigeminal 
 neuralgia which is to be distinguished from true headache. 
 
GENERAL SYMPTOMATOLOGY. 33 
 
 Oppenheim thinks that localized tenderness is of more 
 value than localized headache as indicating the probable 
 seat of the growth, but, as Case XXIX will show, this is not 
 an invariable rule. Data are lacking, in my cases, to permit 
 me to give statistics on this point. 
 
 Vertigo. — Vertigo was noted in 12 of my cases, and in 31 
 per cent, of those reported by Mills and Lloyd. 11 It is so 
 common a symptom in all sorts of affections that it has com- 
 paratively little significance as diagnostic of a tumour. Some 
 writers think that it is most suggestive of tumour when it 
 comes on after rising from a recumbent position ; but 
 vertigo is not uncommon on such movements in any case 
 of ansemia or in any disturbance of the cerebral circula- 
 tion. Vertigo is said to be commoner with tumours in 
 the posterior part of the brain, as in seven out of my twelve 
 cases. The causes of this vertigo are probably numerous. 
 In some cases it may be due to oculo-motor paralysis, in 
 others to the digestive disturbances, and in others still to dis- 
 turbances in the cerebellum, or to the general pressure which 
 is conveyed to the labyrinth. 
 
 Vomiting. — Vomiting was noted in 172 of 568 cases 
 tabulated by Jacobi and in 17 of my own cases. Another 
 of my cases had nausea without vomiting. In 13 of my 18 
 cases the growth involved the basal ganglia and the posterior 
 portions of the brain, and other writers confirm the idea that 
 vomiting is commoner with tumours in the posterior part of 
 the brain. Vomiting is especially common in cerebellar 
 growths, and here, more than elsewhere, it may be most 
 persistent and severe. Sometimes, especially with cerebellar 
 growths, the vomiting may be unattended with pain or 
 nausea and may be independent of the ingestion of food ; 
 but even with cerebellar growths the vomiting may be 
 attended with nausea and very severe pain, as in Case XXIX. 
 In some cases the patient may vomit without warning, and 
 
34 INTRA-CRANIAL GROWTHS. 
 
 the vomiting closely resembles the regurgitation of infants. 
 In other cases the vomiting is attended with great pain or 
 distressing nausea. 
 
 The vomiting is probably due to various causes. Fer- 
 rier 26 ascribes it in the majority of cases to irradiation of 
 irritation by the nerves of the meninges, or to the physical 
 effects of acute pain. Painful impressions conveyed by the 
 branches of the fifth nerve to its nucleus in the medulla may 
 be transmitted to the contiguous vagus nucleus. Vomiting 
 may also arise from vertigo, or from irritation of the vomiting 
 centre in the medulla by pressure or direct irritation, apart 
 from any irritation of the fifth nerve. 
 
 Optic Neuritis. — Certain writers, of whom one of the latest 
 is Oppenheim, 10 endeavour to make a distinction between 
 a true optic neuritis and the so-called " choked disc " 
 (Stauungspapille). Oppenheim follows Uhthoff in his dis- 
 tinction between the two, speaking of choked disc when there 
 is a prominence of the nerve of at least two-thirds of a 
 millimetre (a difference of refraction of two dioptrics). 
 
 Deutschmann, 16 however, has found, histologically, no 
 difference in the cases of so-called choked disc and cases of 
 optic neuritis. In every case there was a true degenerative 
 inflammation of the nerve fibres. I have therefore not 
 attempted to make any distinction. 
 
 Optic neuritis is the most important general symptom of 
 an intra-cranial growth. It is, of course, not pathognomonic 
 of a tumour, but an ophthalmoscopic examination should be 
 made in every case of suspected brain disease. Oppenheim 
 has shown the importance of making such an examination, 
 not merely once, but repeatedly during the progress of the 
 disease, as it may be a symptom of late developement. The 
 presence of double optic neuritis should always lead us to 
 suspect a tumour. The frequency of optic neuritis is not 
 definitely known, owing to the imperfection of many of the 
 
GENERAL SYMPTOMATOLOGY. 35 
 
 records, and the neglect of examining the eyes. In my own 
 cases, 11 had neuritis, 2 atrophy (probably post-neuritic) 
 and 5 a normal fundus, but in these five cases repeated 
 examinations were not always made. In Cases XIV, XVI, 
 and XXIV, however, examinations were made repeatedly, until 
 shortly before death, but there was no neuritis. Neuritis 
 was therefore present in over two-thirds of the cases ex- 
 amined. Of the other 21 cases two had some dimness 
 of vision noted, but this is not satisfactory evidence for 
 or against the existence of neuritis, for tolerable vision 
 may exist with marked neuritis. Thus Cases XXIII 
 and XXIX had a vision of |{} and T |- respectively, 
 although neuritic changes in the eyes were marked. 
 Annuske and Reich, 3 in 88 cases, found neuritis absent in 
 only five per cent., which is probably a little too large ; 
 Gowers 4 thinks that neuritis probably exists in four-fifths of 
 the cases; Bernhardt 1 found atrophy or neuritis in 25 per 
 cent., amblyopia in 20.4 per cent., and normal vision or a 
 normal fundus in 6.8 per cent., 47.8 per cent, of the cases 
 giving no data. He recognizes that neuritis may have 
 existed in some of the so-called "normal cases." Oppenheim 
 found that in 82 per cent, of his 23 cases there was neuritis 
 on one or both sides; in 13 cases he found choked disc and 
 in 5 neuritis, and he accepts Annuske's view as to the fre- 
 quency of neuritis. Gowers says that neuritis is rather 
 commoner when the brain itself is invaded by a growth, and 
 that the size of the growth has no influence on the existence 
 of neuritis, in other words that increased intra-cranial 
 pressure is not a factor. In four of my cases of neuritis 
 there was a great increase of intra-cranial pressure, in two 
 other cases and in one of the cases of atrophy there was 
 some increase, in the rest no statement is made. In two of 
 the cases with normal fundus there was marked increase of 
 
36 INTRA-CRANIAL GROWTHS. 
 
 pressure, in two others the increase was moderate, and in the 
 fifth no statement is made. 
 
 The pathology of neuritis has been much discussed, and 
 many theories have been advanced to explain it. These 
 may be classified as (i) the increased pressure theory, (2) 
 the descending neuritis theory, (3) the vaso-motor theory, 
 (4) the irritation-pressure theory. 
 
 1 . Von Graefe 16 advanced the hypothesis that the increased 
 intra-cranial pressure, so common in cases of tumour, caused 
 compression of the cavernous sinus, checked the outflow from 
 the ophthalmic vein, and gave rise to a venous stasis in the 
 eye, producing the " choked disc." This hypothesis was later 
 disproven by Sesemann, who showed that the ophthalmic 
 vein anastomosed with the facial, so that stasis could not be 
 produced in this way. The increased pressure theory took 
 a new form, which has, in the main, been accepted until 
 recently, after Schwalbe showed that the intra-vaginal space 
 surrounding the nerve communicated with the sub-arachnoid 
 tissue. Hence Schmidt and Manz argued that, with increased 
 pressure, the fluid is forced into this space, compressing 
 the nerve, and they showed that injections into the sub- 
 arachnoid tissue actually reached this space. Kuhnt argued 
 further that there was a lymph stasis from the vessels of the 
 lamina cribrosa, and Ulrich and Parinaud advanced the 
 hypothesis that there was an oedema of the nerve. Schulten 
 claims to have established the hypothesis of Schmidt and 
 Manz by injecting substances into the cranial cavity, thereby 
 causing an increase of pressure, after which he found signs 
 of a beginning choked disc ; he supposed from this that a 
 greater pressure would produce the true choked disc. 
 
 I have already said that Gowers believes that increased 
 pressure is not the cause of neuritis, and my own cases show 
 that increased pressure may exist without neuritis. Various 
 arguments have been brought forward against this theory, 
 
GENERAL SYMPTOMATOLOGY. 37 
 
 of which the most conclusive are those of Leber and Deutsch- 
 mann. Deutschmann 16 claims that choked disc is an in- 
 flammatory condition, like the neuritis of meningitis or of 
 Bright's disease, that there is no anatomical difference 
 between it and neuritis, and that there is in the nerve in all 
 cases a true neuritis. Leber found neuro-retinitis in the 
 earliest stages of choked disc. Deutschmann found choked 
 disc without dropsy of the nerve sheath, and with no com- 
 pression of the central vessels. Even when there is dropsy 
 of the sheath it is slight and the vessels are not compressed. 
 Further experiments by Deutschmann were still more con- 
 clusive. He found that by injecting sterilized agar-agar into 
 the sheath of the nerve, with strict antisepsis, choked disc 
 could be obtained only when the vessels were absolutely 
 compressed. Injections of agar- agar into the cranial cavity 
 never produced choked disc, no matter how great the 
 pressure. His further experiments will be considered later. 
 
 2. Von Graefe also made an alternate hypothesis that a 
 tumour gave rise to meningitis, which, in turn, set up a de- 
 scending neuritis ; subsequent writers have supported this 
 view. In many cases, however, there is no meningitis, the 
 neuritic changes are chiefly, if not wholly, in the bulbar 
 end of the nerve, and Deutschmann argues that the neuritis 
 may also be ascending. Neuritis may also improve, and, in 
 such cases, relapses are never noted. In unilateral neuritis 
 the neuritis is usually on the side opposite to the tumour. 
 Finally, a descending neuritis in other cranial nerves is, to 
 say the least, rare. Descending neuritis may account for 
 some of the cases, but probably only for a minority. 
 
 3. The vaso-motor theory, that the tumour by irritating 
 the vaso-motor nerves in the brain, causes vascular dis- 
 turbances in the nerve and hence neuritis, has met with little 
 acceptance. The old hypothesis that vaso-motor alterations 
 produce inflammatory changes is well nigh abandoned, and 
 
38 INTRA-CRANIAL GROWTHS. 
 
 the presence of vaso- motor nerves in the brain is not yet 
 proven. Other irritations, which might well cause vaso- 
 motor changes, do not produce neuritis, and disturbances 
 are not found in other regions, although we should expect 
 them on such a hypothesis. 
 
 4. Leber was the first to advance the hypothesis that the 
 " products of tissue metamorphosis of new growths, mingled 
 with the inflammatory transudations, act as irritants, enter 
 the sheath of the nerve with the cerebro- spinal fluid, reach 
 the bulb and give rise to neuritis and papillitis." Deutsch- 
 mann supplemented the experiments already referred to by 
 others which support Leber's views. He injected staphylo- 
 cocci into the sheath of the nerve, and produced neuritis. 
 Injections of staphylococci into the brain, however, proved 
 speedily fatal. He was more successful with tubercle, and suc- 
 ceeded in producing a neuritis, not of the descending type, by 
 injecting tubercle into the brain. He finds, moreover, that the 
 lymph-currents of the cerebro-spinal fluid are centrifugal, and 
 that increased pressure favors the process. "The inflammatory 
 affection of the papilla, which increases to choked disc, has 
 nothing to do with a stasis from pressure. It is the effect of 
 inflammatory irritants which enter the optic sheath with the 
 cerebro-spinal fluid from the cavity of the skull, remain at 
 the bulbar end, and set up an infective action." " Pure in- 
 crease of pressure in the cranial cavity does not lead to 
 disease of the intra-ocular end of the optic nerve ; the chief 
 factor is to be found in the inflammatory irritants which enter 
 the sheath from the cranial cavity." Whether these irritants 
 are chemical or parasitic is still uncertain. Deutschmann, 
 having found various cocci in the vicinity of a tumour, is 
 somewhat inclined to the latter view, thinking the immediate 
 neighbourhood of a new growth a good field for the develope- 
 ment of bacteria. 
 
 Leber and Deutschmann seem to have overthrown the in- 
 
GENERAL SYMPTOMATOLOGY. 39 
 
 creased pressure theory. The increase of pressure, however, 
 is regarded by them as very important in the production of 
 neuritis, since it forces the irritants into the optic sheath. 
 Their theory seems to me the most plausible for the majority 
 of cases, but in some there is very likely a true descending 
 inflammation. The irritants which are supposed to cause 
 the neuritis are still unknown. It is a curious fact, which 
 none of the above theories throws light upon, that, in cases of 
 tumour, neuritis of other cranial nerves apparently does not 
 occur, at least not with any great frequency, except when 
 the nerves are directly involved in the growth. 
 
 Convulsions. — Ten of my cases had convulsions of a 
 more or less general type ; in one of these, however, the 
 symptom was probably due to tubercular meningitis, and in 
 two others the convulsions were undoubtedly uraemic from 
 chronic Bright's disease. These attacks were of a general, 
 epileptiform character. Gowers 4 distinguishes two forms, 
 one a typical epileptic seizure, the other an attack of petit 
 mal. Such attacks may come on with a new growth in 
 almost any part of the brain, and they have no localizing value. 
 They do not seem in any way related to the size of the 
 tumour. Most writers assume that they are caused by the 
 increased pressure, but Gowers has shown very conclusively 
 that this is not the case. 
 
 The consideration of partial epilepsy will, perhaps, throw 
 some light upon the pathology of general convulsions. 
 Four of my cases had spasm or convulsive seizures begin- 
 ning in or limited to a definite portion of the body. This 
 symptom has been considered of very great value in the 
 focal diagnosis of cerebral disease, and Seguin 17 lays 
 much stress upon the study of the special distribution of 
 the spasm which inaugurates the convulsion of Jacksonian 
 epilepsy, as a signal symptom. In some cases there is a 
 sensory aura in the part of the body in which the spasm 
 
40 INTRA-CRANIAL GROWTHS. 
 
 begins, followed by a tonic or clonic spasm of a group of 
 muscles, the spasm remaining limited to this region, or ex- 
 tending to the entire limb, to one half the body, or to the 
 whole body. This spasm in its extension follows the distribu- 
 tion of the motor centres in the cortex. If it begins in the face 
 it extends first to the arm and then to the leg, never to the 
 leg and then to the arm ; so, also, if it begins in the leg, it 
 extends first to the arm and then to the face. The details 
 of this " march " of the convulsions will be spoken of later. 
 This type of epilepsy was at first supposed to be due to 
 organic disease of the cortex in or near the motor area, and 
 to be almost pathognomonic of such a lesion. This hypoth- 
 esis, however, no longer obtains. The theory that every 
 epileptic seizure, partial or general, is due to a discharge in 
 the cerebral cortex has steadily gained ground, and seems 
 to be the most reasonable one. The discharge, however, 
 is not always due to disease in the cortex, but it may arise 
 from irritation of the cortex from more remote lesions. The 
 same may be said of partial epilepsy. The researches of 
 Seppilli l5 and L6vvenfeld 1J have shown that partial epilepsy, 
 due probably to a discharge in the motor cortex, may be 
 brought about by a gross lesion in the neighbourhood of the 
 cortex or even in the basal ganglia. Furthermore, partial 
 epilepsy may occur, not only as a symptom of organic brain 
 disease, but as a symptom in uraemic convulsions, in hysteria, 
 or in idiopathic epilepsy. The existence of partial epilepsy 
 in the latter affection has until recently been denied, Rol- 
 land 20 claiming that the two have nothing in common, but 
 Lowenfeld seems to have established the fact. 
 
 It is evident, then, that partial epilepsy cannot be regarded 
 as a decisive focal symptom. Rolland asserts that it is due 
 more often to irritative than to destructive lesions; hence 
 with a large cortical growth the epilepsy might be due to 
 irritation anywhere in its periphery. The most we can say 
 
GENERAL SYMPTOMATOLOGY. 4 1 
 
 is that partial epilepsy is most commonly due to organic 
 disease in or near the motor cortex, and that if it is present 
 in any case of cerebral tumour, the tumour very likely 
 involves the special motor centres which preside over the 
 movements exhibited in the convulsions. The growth, how- 
 ever, may be remote from the centres, and may even be 
 situated in the basal ganglia. 
 
 Psychical Disturbances. — In 29 cases there was more or 
 less psychical disturbance; and Jacobi 14 records it in 49 per 
 cent, of the cases collected, I believe, however, that in 
 every case some change can be found by a competent 
 observer who has known the patient intimately before ; in 
 other words that there can be no gross lesion of the brain 
 without some disturbance, greater or less, in the psychical 
 functions. This may consist only in some slight impairment 
 of the higher intellectual powers. A good French scholar 
 may become unable to read French without translating it ; a 
 mathematician may have less power to solve intellectual 
 problems ; a musician may have a slightly diminished power 
 to play a new and difficult piece at sight, — powers not 
 present even in health in the average hospital patient. In 
 other cases there may be lack of power of persistent applica- 
 tion, undue irritability, or marked inertia. Other patients 
 may be delirious, maniacal, or exhibit various delusions. 
 Others, still, may become dull, childish, and utterly de- 
 mented, or present the clinical picture of paretic dementia. 
 
 Oppenheim 15 lays stress upon a condition of somnolence, 
 which he thinks is very common in cases of tumour of the 
 brain. The patient may be aroused and he will answer ques- 
 tions intelligently but he will drop off to sleep almost immed- 
 iately after answering. In other cases this somnolence 
 goes on increasing, finally concluding with coma. In four- 
 teen of my cases this condition was present in a greater or 
 less degree, but in a number of these cases it was merely a 
 
42 INTRA-CRANIAL GROWTHS. 
 
 terminal symptom, making its appearance only in the last 
 few weeks of life. It depends, I suspect, chiefly upon the 
 degree of intra-cranial pressure, and I am disposed to think 
 it by no means a constant symptom. It is due simply to an 
 increase of general pressure or to destruction of certain 
 portions of the brain. 
 
 Surface Temperature. — In only two cases was the surface 
 temperature noted, and here it was above the normal, as laid 
 down by Gray. 21 Mills and Lloyd 11 from an analysis of 
 seven cases conclude that " in brain tumours the average 
 temperature of the whole head is elevated several degrees 
 above the normal, and that the elevation of temperature is 
 usually greatest at the station nearest the seat of the growth." 
 Case XXIX does not warrant such a conclusion. Much 
 more evidence, however, is required in order to settle this 
 question. 
 
 Beside these symptoms, which may be present in any case, 
 tumours of the brain present certain more or less definite focal 
 symptoms, according to their situation. These symptoms will 
 be dwelt upon in connection with the special symptomatology 
 of the individual cases. Most of them are symptoms of deficit 
 or irritation, among them being the various forms of paralysis, 
 anaesthesia, and disturbances of special sense. In addition 
 there are other general symptoms of value in corroborating 
 the diagnosis, among which the symptoms of increasing 
 pressure are of chief importance. Beside the steady increase 
 of the symptoms already noted we may observe a slow pulse, 
 disturbed respiration, dilated or contracted pupils, and in the 
 later stages strabismus. Pseudo-apoplectic attacks are occa- 
 sionally described, the origin of which is uncertain. Some 
 of them are doubtless true apoplexies, from haemorrhage in 
 or about the tumour. As the disease progresses signs of 
 physical exhaustion appear, anaemia, emaciation, digestive 
 disturbances and the like. The appetite often is poor, but 
 
GENERAL SYMPTOMATOLOGY. 43 
 
 in a few cases it becomes ravenous. Toward the close of 
 life somnolence and coma, as has been said, may develope. 
 Finally we meet with the ordinary group of symptoms which 
 mark the end of so many nervous diseases — incontinence 
 of urine and faeces, general paretic symptoms, bed-sores, 
 cystitis, Cheyne-Stokes' respiration, and death. 
 
44 INTRA-CRANIAL GROWTHS. 
 
 V. SPECIAL SYMPTOMATOLOGY. 
 
 It is hardly necessary to repeat the statement already 
 made, which will be confirmed in part by some of the cases 
 that follow, that tumours may exist in almost any part of the 
 brain either without any symptoms referrible to a new 
 growth, or without any focal symptoms. In the forty cases 
 collected, as I have said, in only eight were the symptoms 
 so definite that a correct localization was possible before 
 death. 
 
 It is, furthermore, not always possible to determine from 
 records of autopsies made before the question of localization 
 assumed such importance, the precise location qf new 
 growths ; nor can we speak with confidence of the presence or 
 absence of symptoms from clinical records made before the 
 significance of those symptoms was appreciated, or from 
 records made in haste by hospital internes from hasty or 
 unskilled observation of patients who spent perhaps only a 
 few days in the hospital. 
 
 In the tables of Bernhardt, 1 a division is made between tu- 
 mours of the cortex and tumours of the lobes, but tumours of 
 the occipital cortex are put in the same table with tumours of 
 the central region. It seems to me more important to differ- 
 entiate between tumours of the various cortical regions than 
 to make a hard and fast distinction between cortical and sub- 
 cortical growths. Cortical tumours, if of any size, also involve 
 the subjacent white matter, and tumours in the white matter, 
 in many cases, cut off communication with the adjacent cor- 
 tical centres, and give rise to symptoms of irritation or deficit 
 much like those caused by disease of the cortex itself. 
 
SPECIAL SYMPTOMATOLOGY. 
 
 45 
 
 Other growths, more deeply seated, have a similar relation 
 to tumours of the optico-striate region. Therefore, although 
 in the chapter on diagnosis I shall speak of the symptoms 
 which enable us to differentiate between cortical and sub- 
 cortical growths, I shall not make such a distinction in the 
 classification of the cases here reported. 
 
 Fig. i (Eberstaller). Lateral aspect of 
 
 the brain. The doited lines indicate the 
 
 divisions into regions. 
 
 .'>=Trunk of the fissure of Sylvius. 
 
 Si = Fissure of Sylvius. 
 
 Si asc. = Posterior ascending branch of the 
 fissure of Sylvius. 
 
 S2=z Anterior ascending branch of the fis- 
 sure of Sylvius. 
 
 S^ = Anterior horizontal branch of the fis- 
 sure of Sylvius. 
 
 c. = Central fissure. 
 
 rff. = Lower transverse sulcus. 
 pci. = Inferior precentral sulcus. 
 pcs.= Superior precentral sulcus. 
 pern. = Median precentral sulcus. 
 
 rtc. i.= Inferior retro-central sulcus. 
 rtc. .?. = Superior retro-central sulcus. 
 rtc. tr. = Transverse retro-central sulcus. 
 •?/>. = Subfrontal fissure. 
 fl = Superior frontal sulcus. 
 /2 = Inferior frontal sulcus. 
 73 = Median frontal sulcus. 
 d.=z Diagonal sulcus. 
 r. = Radiate sulcus. 
 
 fmi,fm2,fm$= Fronto-marginal sulcus. 
 //>. = Interparietal sulcus. 
 /<?.=: Parietooccipital fissure. 
 ore. ant.= Anterior occipital sulcus. 
 occ. lat. = Lateral occipital sulcus. 
 t\ = First temporal sulcus. 
 t\ asc. = Ascending branch of the first tem- 
 poral sulcus. 
 
 t2= Second temporal sulcus. 
 
 (2 asc.= Ascending branch of the second 
 temporal sulcus. 
 
 A= Anterior central convolution. 
 
 B = Posterior central convolution. 
 
 F\ = Superior or first frontal convolution. 
 
 F2 = Middle or second frontal convolution. 
 
 F2 med.= Median part of the second frontal 
 convolution. 
 
 F2 lat. = Lateral pnrt of the second frontal 
 convolution. 
 
 F$ = Posterior or third frontal convolution. 
 
 p. bas.— Basilar part ) of the opercular part 
 p. asc. = Ascending | of the third frontal 
 part ) convolution. 
 
 /. tr iang.= Triangular part of the third 
 
 frontal convolution. 
 /. orb. = Orbital part of the third frontal 
 convolution. 
 
 i = Lateral root of the first frontal convolu- 
 tion. 
 
 2= Lateral root of the second frontal con- 
 volution. 
 
 Pi = Superior parietal lobule. 
 
 JP2= Inferior parietal lobule. . 
 
 G. spin. = Supra-marginal gyrus f of the in- 
 
 G. ang'. = Angular gvrus J ferior 
 
 G. par. post. = Posterior parietal ) parietal 
 gyrus I lobule. 
 
 Ti = First temporal convolution. 
 
 Ti = Second temporal convolution. 
 
 7J =s Third temporal convolution. 
 
4 6 
 
 INTRA-CRANIAL GROWTHS. 
 
 i. Tumours of the Cerebral Cortex. 
 
 mgr. 
 
 a. Tumours of the P re-frontal Region. 
 
 Case I. M. R. CLVII-52.* William M., 44, salesman, 
 was admitted to the hospital the 17th of February, 1879. 
 There was a history of probable syphilis. Three weeks before 
 he entered the hospital he caught cold, and complained of 
 weakness and pain in the back and legs. On admission he 
 was observed to be weak and quiet, and he ate very little. 
 On the 2 1st he became semi-comatose and ate noth- 
 He moved when the skin was pinched, seemed to 
 
 have no paralysis, and 
 could be roused. The 
 pupils were somewhat 
 contracted and did not 
 react to light. The 
 next day the coma be- 
 came deeper, the right 
 pupil was dilated, and 
 both pupils were im- 
 mobile. There was 
 some general tremor 
 of the limbs, and the 
 patient died. 
 
 Autopsy. — There was some oedema of the lungs. The 
 convolutions of the brain were flattened, and in the lower 
 part of the right frontal lobe there was a tumour the size of a 
 hen's egg, round, of a mahogany colour, containing several 
 distinct haemorrhages, and surrounded by yellow softening. 
 
 Case II. M. R. CCXLI-16. George S., 40, married, 
 a wool sorter, entered the hospital the 25th of March, 1886. 
 On admission he was found to be wandering, and no history 
 
 Fig. 2 (Dalton). Case I. The shaded portion in- 
 dicates the location of the tumour. The fissures are 
 indicated in Fig. 7. 
 
 * These numbers refer to the hospital records, medical, surgical, and nervous. 
 
SPECIAL SYMPTOMATOLOGY. 
 
 47 
 
 could be obtained. He muttered, picked at the bed-clothes, 
 and apparently saw imaginary persons about him. His tem- 
 perature was 102.2° F. ; his pulse 104. There were bron- 
 chial respiration and fine rales. The abdomen was tender, 
 the pupils reacted to light. On the 28th there was carpho- 
 logia and subsultus tendinum. He grew more delirious, the 
 pupils became sluggish; he had no paralysis, but there was 
 incontinence of urine and faeces, and he died. 
 
 Autopsy. — Tubercular meningitis. The two frontal lobes 
 
 were adherent, and at the point of adhesion there was a 
 nodule the size of a pecan-nut in the brain substance, pale 
 red in colour, with the vessels of the pia passing through it. 
 
 Case III. N. R. XVI-42. Ella H., 23, married, dom- 
 estic, entered the hospital the 26th of August, 1882. Five 
 
 weeks before entrance she began to complain of headache 
 
 and vomiting, the headache being severe and constant. 
 
 There was vertigo and blurring of vision un getting out of 
 
 bed. For four weeks 
 
 before entrance she had 
 
 been in bed most of 
 
 the time, suffering from 
 
 headache. She com- 
 plained also of poor 
 
 sleep and bad dreams. 
 
 On the 6th of Septem- 
 ber she had cramps in 
 
 the right hand and leg 
 
 and numbness of the 
 
 right arm. There was optic neuritis. On the 11th the 
 
 right pupil was dilated, the respiration grew slow and feeble, 
 
 and she became comatose and died. 
 
 Autopsy. — The dura was found adherent to the pia on the 
 
 left side; the pia was dry and the convolutions flattened. 
 
 Fig. 3 (Dalton). Case III. 
 
48 INTRA-CRANIAL GROWTHS. 
 
 The dura was also adherent on the right side. In the cen- 
 tral part of the left frontal convolutions there was a sarcoma 
 the size of an English walnut, gray in colour and homogene- 
 ous ; the white substance surrounding it was softened. 
 
 f CASE IV. Mrs. E., 54 years old, was seen by me the 
 1 6th of March, 1890. Her parents died of apoplexy, and she 
 had had a severe nervous strain for a year and a half. Three 
 years before she had a bilious attack. In the autumn of 
 1889 she began to complain of pain across the forehead and 
 failure of vision. The liver was also slightly enlarged. In 
 January, 1890, she had severe vomiting, with pain in the fore- 
 head and further failure of vision. She lost control of the 
 bladder. She had a very weak pulse, which varied between 
 fifty and ninety, and at times failed almost entirely, becoming 
 imperceptible at the wrist. She seemed intelligent, but when 
 she spoke her sentences were very short. At that time she 
 was in bed for a week and passed her water in bed. ' Later 
 on, the right pupil was a trifle larger than the left, and her 
 ability to speak diminished. She used only monosyllables, 
 lay on her back and apparently had much headache. Early 
 in February she had a slight convulsion affecting the right 
 side of the body, including the face ; the convulsion did not 
 become general. Since then she had had other convulsions 
 which were more severe and were attended with a tonic 
 spasm in the leg and rigidity of the arms. The face at 
 times was drawn to the left — the pulse was rapid, seventy 
 to ninety, at times becoming very weak and thready, and 
 suddenly failing. She had attacks of stupor lasting for days, 
 during which she would neither answer nor protrude the 
 tongue. At times she was apparently unable to speak. 
 She would occasionally say "no" for "yes," and once in 
 a while she would say a few words, but the speech was 
 
 t Cases marked thus came under my own observation at some part of their course. 
 
SPECIAL SYMPTOMATOLOGY. 49 
 
 more or less affected. There was occasional vomiting, com- 
 ing on without warning, and not accompanied with nau- 
 sea. There was no control over the bladder or rectum. 
 For ten days the right eye did not close as well, and 
 there was marked mental failure. These symptoms, how- 
 ever, varied, and some days she seemed quite bright. She 
 put her hand frequently to her head as if there were pain 
 there. The rigidity of the right arm was quite slight and 
 disappeared on passive motion. There was double optic 
 neuritis. At my examination she did not answer when 
 spoken to and would not do anything she was asked. The 
 right pupil was larger than the left; both reacted to light. 
 The eyes moved well and there was no ptosis. She used 
 both arms, but the right arm was used less than the left; 
 the reflexes were normal. Her condition continued practic- 
 ally unchanged for some time, with periods of temporary 
 improvement. Later on she had other convulsions, some- 
 times beginning in the left side but more frequently on the 
 right. At last she had right hemiplegia. During the sum- 
 mer she died without my seeing her again. 
 
 Autopsy. — An infiltrating glioma, the size of a hen's egg, 
 was found well forward in the left frontal lobe. 
 
 In the pre-frontal region I include all the anterior end of 
 the cerebrum, in front of a line drawn as an extension of the 
 anterior ascending branch of the fissure of Sylvius. This 
 falls a little in front of the pre-central sulcus, and thus the 
 posterior extremities of the frontal convolutions are not in- 
 cluded. This boundary has been adopted by Mills. 11 
 
 The region in question lies just in front of the great motor 
 region of the cortex, and is supposed to be the region chiefly 
 concerned in the higher psychical processes. It probably 
 includes, however, the centres for movements of the head and 
 eyes to the opposite side ; at least in the monkey's brain, 
 
50 INTRA-CRANIAL GROWTHS. 
 
 according to Horsley and Schaefer, 22 these centres lie in front 
 of the boundary line given. This pre-frontal region has 
 been regarded as one of the so-called latent regions of the 
 brain, in which lesions give rise to no definite localizing 
 symptoms. In a certain number of cases, however, the 
 diagnosis of a new growth in the frontal lobe can be made 
 with considerable assurance. In addition to the general 
 symptoms of an intra-cranial growth already discussed, the 
 most marked symptoms of a tumour in this region are of a 
 psychical character. This was especially noticeable in Case 
 IV. In such cases we meet with failure of the power of 
 attention and judgement, mental slowness and uncertainty 
 passing on to marked hebetude, dementia or stupor, and a 
 general and marked decline in all the higher intellectual 
 powers. Less frequently there may be irritability, excite- 
 ment, or delirium, as in Case II. Such symptoms may 
 occur, of course, in almost all cases of tumour, but where 
 the tumour is in the pre-frontal region they are probably of 
 much earlier onset. Such mental symptoms, then, coming 
 on early and associated with the general symptoms of head- 
 ache, optic neuritis, vomiting and vertigo, with the absence 
 of any special focal symptoms, may lead us to suspect a 
 tumour in this region. 
 
 In addition to these symptoms the anatomical position of 
 the growth may in some instances give rise to other symptoms 
 of much localizing value. By pressure upon or exten- 
 sion of the growth into one olfactory lobe we may find uni- 
 lateral anosmia, or in rare cases hallucinations or perversions 
 of the sense of smell from irritation. Invasion of one optic 
 nerve may cause neuritis to appear in the eye of the affected 
 side, although this is very rare. Blindness of one eye from 
 pressure on the nerve is also possible. In other cases, when 
 the chiasma is involved, we may discover homonymous, tem- 
 poral hemianopsia. In other cases pressure on the orbit 
 
SPECIAL SYMPTOMATOLOGY. 5 I 
 
 may give rise to exophthalmos. Localized headache, as has 
 been said, is of some significance. 
 
 Much more important, however, are the symptoms caused 
 by the backward growth or pressure of the tumour — symp- 
 toms of invasion of the motor region. Cases III and IV 
 present examples of this. The tumour first irritates the 
 adjacent motor centres, and we get spasm or partial epilepsy 
 of the leg, the arm, or the face ; or, if the left hemisphere be 
 involved, symptoms of beginning motor aphasia. The more 
 exact focal significance of these symptoms will be apparent 
 in considering the different motor areas and their arrangement 
 in the cortex. Later on the advance of the growth causes 
 destruction of the motor centres, and paralysis and anaes- 
 thesia succeed the spasm and sensory aura. In tumours of 
 the left frontal lobe symptoms of aphasia then become more 
 marked. 
 
 Although partial epilepsy, by itself, is of no very exact 
 significance, yet, when it is superimposed upon the clinical 
 picture already given, it leads to a very strong probability, al- 
 though not to an absolute certainty, that the tumour is in the 
 pre-frontal region. In but two of the above cases is it pos- 
 sible from the data given to diagnosticate a tumour. In 
 Case II the tumour was secondary to the meningitis in its 
 effect upon the symptoms. Case III showed the invasion 
 symptoms clearly, but the record of the psychical state, which 
 might have made the focal diagnosis possible, is unfortunately 
 lacking. In Case IV a focal diagnosis was made before 
 death and confirmed by the autopsy. Here the question of 
 operation was brought forward ; but, owing to the weakness 
 of the heart and the probable vascular nature of the growth, 
 it was deemed inadvisable to operate. 
 
52 
 
 INTRA-CRANIAL GROWTHS. 
 
 Fig. 4 (Dalton). Case V 
 
 b. Tumours of the Central Region. 
 
 CASE V. M. R. CXX-8. Henry L., 40, single, entered 
 
 the hospital the 16th of February, 1884, with advanced 
 
 phthisis, which he had had for four years. He suddenly 
 
 became unconscious. 
 There were respiratory 
 disturbances, and he 
 died on the 4th of 
 March. 
 
 Autopsy. — Pulmon- 
 ary tuberculosis. Over 
 the left central convolu- 
 tions, three centimetres 
 from the median line, 
 there was a firm, dense, 
 cartilaginous mass, 
 
 measuring twelve millimetres each way, and about two milli- 
 metres in thickness. The brain was otherwise healthy. 
 CASE VI. M. R. XCIII-165. Michael M. entered the 
 
 hospital the 28th of September, 1873. He had been drunk for 
 
 nine weeks, had taken 
 
 little food, and had had 
 
 much vomiting. For 
 
 three weeks his mind 
 
 had been wandering — 
 
 he stared at vacancy 
 
 and muttered to himself. 
 
 He was stupid, but he 
 
 had no active delirium. 
 
 For two weeks he had 
 
 dragged the right leg 
 
 in walking. He passed 
 
 urine and fasces in bed. Six days after entrance he died. 
 
 Fig. S (Dalton). Case VI. 
 
SPECIAL SYMPTOMATOLOGY. 
 
 53 
 
 Autopsy. — The dura was adherent to the skull. The con- 
 volutions were flattened. In the left second frontal convol- 
 ution was a tumour two inches in diameter, harder than 
 the brain, somewhat translucent, of a brownish-gray colour. 
 Beneath this was a cyst containing an ounce of clear yellow 
 fluid. In the upper part of the left medulla was a haem- 
 orrhage the size of a marble. 
 
 Case VII. N. R. IV-218. Simon F., 55, single, a 
 hostler, entered the hospital the 2d of September, 1878. 
 Eight years before entrance he received a blow on the left 
 side of the face, without any bad result. Nine months before 
 entrance he complained 
 of pain in the left tem- 
 poral region, the pain 
 varying from dull to 
 severe. His memory 
 was poor and his mind 
 sluggish. The left side 
 of the face could be 
 moved better than the 
 right. There was ad- 
 vanced phthisis. On 
 the 7th he became rest- 
 less and could hardly be aroused. He failed rapidly, and 
 the next day he had carphologia, subsultus tendinum, 
 and twitching of the masseters. He became comatose 
 and died. 
 
 Autopsy. — There was tuberculosis of the lungs and 
 kidneys. The dura was adherent to the skull and to the 
 pia, and there were opacities of the pia. In the left 
 fissure of Sylvius the artery and vein were surrounded by 
 a dense inflammatory mass, half an inch by an inch in 
 extent. 
 
 Fig. 6 (Dalton) . Case VI I. 
 
54 INTRA-CRANIAL GROWTHS. 
 
 t Case VIII.* S. R. CLXIV-9. Arthur G., 32, married, 
 a florist, entered the hospital the 17th of December, 1888. 
 In 1868 he received an injury to his head, followed the next 
 day by seven convulsions. He had no further trouble, and 
 the previous history was otherwise negative. In 1886 he 
 began to have nausea, vomiting, and some pain in the head. 
 In the beginning of 1887 he had stiffness and weakness of 
 the hands. In March, 1887, he had a convulsion, with ex- 
 tension and abduction of the left arm. About the same 
 time there was loss of power in the left arm and leg and 
 numbness in the left hand, and there developed left hemi- 
 plegia, with exaggerated reflexes and slight contracture. 
 There was failure of vision, with increase of paralysis and 
 continuance of convulsions. These convulsions began with 
 a sensory aura in the left hand and a clonic spasm of the 
 left wrist, extending to the elbow. Sometimes these seizures 
 were attended with loss of consciousness, and the convuls- 
 ions became general. In March, 1888, the convulsions 
 still continued, and some of them were not attended with 
 loss of consciousness. He complained of a tired feeling in 
 the back, with vertigo and a suffocated feeling. In January, 
 1888, he was obliged to give up work. About this time he 
 had very severe pain in the back of the head ; his memory 
 failed, and his speech was slow. He had burning in the 
 stomach, and occasional attacks of slight delirium. In 
 November, 1888, when I first saw him, examination showed 
 impaired movement of the eyes to the left. He had double 
 optic neuritis, paralysis on the left side of the bqdy, includ- 
 ing the face, with contracture and exaggerated reflexes. 
 There was left hemianaesthesia, most marked in the arm, 
 comprising anaesthesia for touch, temperature, localization, 
 
 * Dr. Bradford and I have reported this case in full in the Boston Medical and Surg, 
 ical Journal for 4, 11, 18 April, 1890, and in the Medical and Surgical Reports of the 
 Boston City Hospital, Vol. IV, p. 103. 
 
SPECIAL SYMPTOMATOLOGY. 
 
 55 
 
 position and movement. There was no tenderness of the 
 skull. The surface temperature was somewhat above nor- 
 mal, but there were no differences in temperature over the 
 different portions of the head. A convulsion was observed 
 to begin with spasm of the face, abduction, pronation and 
 tremor of the arm. Another began in the shoulder, another 
 in the wrist. His 
 ears, nose, throat 
 and urine afforded 
 nothing abnormal 
 on examination. 
 He was trephined 
 on the 28th of 
 December by Dr. 
 E. H. Bradford, 
 and a tubercular 
 tumour, weighing 
 35 grammes, and 
 
 Consisting of tWO Fig. 7 (Dalton). Case VIII. The black spot indicates 
 
 1 the centre of the trephine hole, 
 
 masses partly Sepa- 5 = Fissure of Sylvius. 
 
 rated, was removed *=F«sureof RoWo. 
 
 IP= Inter-parietal sulcus, 
 from the middle Of f\;fo = First and second frontal sulci, 
 
 , , . _/3 = Precentral sulcus. 
 
 tile tWO ascending tl> {i = First and secon( j temporal sulci. 
 
 convolutions on the 
 
 right. The tumour measured seven by four by three centi- 
 metres and lay about a centimetre below the cortex. The 
 patient died from the shock in about three-quarters of an 
 hour. There was no autopsy. 
 
 The anterior boundary of this region has already been 
 given ; the fissure of Sylvius forms its lower boundary, and 
 the intra-parietal sulcus, and a line drawn as a prolongation 
 of this sulcus to the upper end of the ascending branch of 
 the calloso-marginal sulcus forms the posterior bound- 
 ary (Mills 11 ). This is the great psycho-motor region of the 
 
56 INTRA-CRANIAL GROWTHS. 
 
 cortex, in which lie the centres which preside over move- 
 ments of the opposite half of the body. It is to be expected, 
 therefore, that a destroying lesion in this region will give 
 rise to symptoms of motor deficit, and an irritating or dis- 
 charging lesion to symptoms of motor irritation ; or, in 
 other words, that a destroying lesion will cause paralysis 
 and a discharging lesion spasm. This is precisely what is 
 found in many cases. Of the few cases here collected only 
 Case VIII is typical. Case V gives no symptoms, as 
 might be expected from the slight character of the lesion. 
 The exact location of the lesion in Case VI is not easy to de- 
 termine ; it may have involved the leg centre, although from 
 the facts reported at the autopsy, it is difficult to see why 
 the arm centre was not also affected. The lesion in the 
 medulla, however, may have produced the paralysis. Case 
 VII must, of course, have affected only the lowest part of 
 the region, if it affected it at all. This is not, strictly speak- 
 ing, a tumour, but the inflammatory product was so large 
 that it may fairly be regarded as such. 
 
 Physiological experiment and clinical and pathological 
 research have firmly established the theory that this region 
 contains the centres presiding over the movements of the op- 
 posite side of the body. Furthermore, it is pretty clearly 
 proven that the centres for the face lie in the lower part of 
 this area, the centres for the arm in the middle part, and the 
 centres for the leg and trunk in the upper part. Hence a 
 destructive lesion of one of these regions ought to produce 
 paralysis in the corresponding portion of the other half of 
 the body. The cases under consideration, while few in num- 
 ber, help to confirm this view. It is safe to say that any 
 tumour in this region, excepting slow-growing tumours of the 
 dura which press on the centres without destroying them, 
 will cause paralysis of greater or less extent. Bramwell 13 
 gives a remarkable example of one of these slow dural 
 
SPECIAL SYMPTOMATOLOGY. 57 
 
 growths in the Rolandic region, which attained a large size 
 and compressed this portion of the cortex without causing 
 any focal symptoms. 
 
 These centres, however, are not divided from one another 
 by any sharp boundary. Each half of the body undoubtedly 
 has some motor representation in the cortex of the same 
 side, through the uncrossed fibres of the pyramidal tract, 
 and in the centre for one segment of the body other seg- 
 ments have probably some representation. Luciani 23 was 
 the first to point out that, although, for instance, the chief 
 representation for movements of the leg was in the upper part 
 of the Rolandic region, nevertheless, there was some repre- 
 sentation in the middle part, and perhaps very slight repre- 
 sentation in the lower part. Horsley, Schaefer and Beevor 22 ' 24 
 have confirmed this hypothesis of the overlapping of centres, 
 or, more strictly speaking, of the more general representa- 
 tion of different segments of the body. 
 
 Subsequent research has rendered it probable that we can 
 subdivide this great motor area much more minutely. In 
 the neighbourhood of the pre-central sulcus, lying just in 
 front of the sulcus, and possibly a little back of it in the 
 ascending frontal, and running upwards and overlapping on 
 the medial aspect of the hemisphere, Horsley and Schaefer 22 
 place the centres for conjoined movements of the head and 
 eyes to the opposite side. In the upper portion of the face 
 centre they place the centres for the movement of the eye- 
 lids. Below this are the centres for elevation and retraction 
 of the angle of the mouth, for the tongue, for opening the 
 mouth, for mastication and for the muscles of the pharynx 
 and larynx. In the lower end of the ascending frontal 
 anteriorly Semon and Horsley 25 place a centre for the 
 vocal cords. In the arm area Beevor and Horsley 24 find the 
 muscles represented from above downwards, in the order of 
 shoulder, elbow, wrist, finger, thumb, the elbow below the 
 
58 
 
 INTRA-CRANIAL GROWTHS. 
 
 shoulder and posterior, the wrist next below and anterior, 
 the fingers lower and also anterior, the thumb lowest 
 and posterior, about opposite the lowest point of the 
 intra-parietal sulcus. Even the movements of these joints 
 have been separately mapped out, the shoulder from 
 above downwards showing movements of advance, abduction, 
 rotation outwards and adduction ; the elbow, movements of 
 extension, confusion, flexion ; the wrist, extension, then flex- 
 ion and pronation, confusion, and supination. In the 
 
 Fig. 8 (Horsley). Motor centres in the monkey's brain. 
 
 fingers and thumb they find that extension is more marked 
 in the anterior region and flexion in the posterior. The 
 movements of the leg have a less extensive representation 
 in the cortex and the centres are less highly differentiated. 
 The centre for the hallux is about the upper end of the 
 fissure of Rolando. The toes are represented behind this, 
 the knee and ankle in front; the knee being nearer the 
 median line than the ankle, and the hip still farther forward. 
 The ankle has very little primary representation, and the 
 knee is feebly represented over the whole area. The 
 shoulder and arm are represented slightly in the median 
 aspect just back of the head. Then further back, extending 
 
SPECIAL SYMPTOMATOLOGY. 59 
 
 in monkeys almost to the parieto-occipital fissure, are the 
 centres for extension of the hips, flexion of the knee, and 
 movements of the toes and foot. In this whole region the 
 most distinctive areas are those for the most highly pur- 
 posive movements, while joints which are very rarely called 
 upon for a primary purposive movement, such as the knee 
 and elbow, are only diffusely represented. 
 
 The recent work of Horsley, Schaefer and Beevor is more 
 elaborate than any yet undertaken. It is probably to be 
 accepted in its main lines, although certain special points 
 are still in abeyance. The finest differentiation comes from 
 the results of electrical stimulation, although the results of 
 ablation confirm the main features. It is doubtful whether a 
 destroying lesion in the human brain small enough to cause 
 a deficit of a single motor representation often occurs, or, if 
 it does occur, whether it would give rise to enough other 
 symptoms to render a diagnosis possible. With a growth 
 the size of that in Case VIII we should expect a deficit 
 in all the motor representations of the arm, as actually 
 happened. Nevertheless, a careful consideration of these 
 finer subdivisions of the motor centres may often prove of 
 value in the study of paralysis from cortical growths. 
 Oppenheim 15 has recently shown once more that local para- 
 lyses do not necessarily indicate a growth in this region — a 
 fact of which I have already spoken. 
 
 I have already spoken of the significance of partial epi- 
 lepsy as an indication of irritation of the cortical motor 
 centres. These same researches give the anatomical reasons 
 for the order of march of the spasm, which was first laid 
 down by Hughlings-Jackson from clinical observation. In 
 stimulating the upper part of the arm centre, the order of 
 motion, or of spasm, is shoulder, elbow, wrist, and hand ; in 
 stimulating the lowest part, the thumb, fingers, wrist, elbow, 
 and shoulder. In the mid-region in the parietal the move- 
 
60 INTRA-CRANIAL GROWTHS. 
 
 ment begins with the elbow, in the frontal with the wrist. 
 In the leg the spasm is more apt to begin in the hallux or 
 toes, the order of march being hallux, toes, ankle, hip, 
 knee ; in the other and rarer forms of movement, originating 
 in the other joints after stimulation, the order of march 
 respectively was ankle, toes, hip, knee ; knee, hip, ankle, 
 toes ; and hip, knee, ankle, toes. This is true for the 
 monkey, and clinical observation seems to confirm this 
 march in man ; but Horsley and Beevor have failed to pro- 
 duce the march in the orang-outang. 
 
 Although spasm following this type is not proof of a gross 
 lesion of the cortex, as I have already said, it is nevertheless 
 more probably due to such a lesion than to any other disturb- 
 ance. If, therefore, the partial spasm is accompanied with par- 
 tial paralysis the evidence of a cortical or subcortical growth 
 becomes very strong. The spasm, unlike the paralysis, has 
 comparatively little value for exact localization. It may 
 arise from irritation in almost any part of the periphery of a 
 growth, or even from comparatively remote irritation, and 
 Case VIII shows how the initial spasm may vary in its dis- 
 tribution at different times, owing doubtless to irritation at 
 different points in the periphery of the growth. Spasm 
 helps to localize the lesion in the motor cortex as distinct 
 from other parts of the motor tract, but paralysis is a much 
 more important symptom for the exact localization of the 
 lesion in the cortex. 
 
 Case VIII presents another symptom which must be con- 
 sidered here, — namely, the disturbance of sensation. Ac- 
 cording to Ferrier 26 the functions of the Rolandic region are 
 purely motor, and the centres for sensation lie on the 
 median aspect of the brain in the limbic lobe. This view is 
 supported by Schaefer 27 and Mills, 28 and to a degree by Hors- 
 ley, 2 '' who thinks, however, there is some sensory representa- 
 tion in the Rolandic region. Munk 30 and Luciani, 23 however, 
 
SPECIAL SYMPTOMATOLOGY. 6 1 
 
 hold that the sensory centres are situated in the same region 
 with the motor centres in the central convolutions, and Sep- 
 pilli, 23 Starr 31 and Dana 32 have supported the results of their 
 experiments by a mass of clinical evidence. I will not 
 discuss the question here, but I hold to the views of 
 Munk and Luciani, without necessarily committing myself 
 to the entire doctrine of Munk that this region is purely 
 sensory and that the motor disturbances are due to the 
 total loss of muscular and other sensibility. A case 
 under my own observation affords one of the most exact 
 experiments on man yet reported.* The patient had 
 cortical degeneration following an old injury. Before the 
 operation his sensibility in all its forms was tested, and 
 found normal — the reaction time, owing to his mental im- 
 pairment, being a trifle slow. He was trephined, and during 
 the operation the cortex of the left ascending parietal, about 
 on a level with the first frontal sulcus, was somewhat lacer- 
 ated in the effort to tie a vessel; a small bit of the cortex, 
 about three by six millimetres and two millimetres thick was 
 excised in the same region. A circle of a centimetre and a 
 half in diameter would have covered the whole area where 
 the cortex was injured. Two days later, and for a period 
 of at least seven weeks after the operation, he had anaes- 
 thesia of the right arm up to the elbow for touch, pressure, 
 motion and position ; sensibility to pain, heat and cold was 
 retained. There was also impairment of highly purposive 
 movements, inco-ordination from loss of muscular sense, and 
 a little athetosis. The tactile anaesthesia persisted for at 
 least seven weeks, but the other symptoms improved some- 
 what. Beevor and Horsley have found, on the whole, more 
 pronounced motor representation in the ascending frontal 
 than in the ascending parietal. It may be that sensory 
 representation is -greater in the ascending parietal. At all 
 
 * Trans. Amer. Neurol. Assoc. 1890. 
 
62 INTRA-CRANIAL GROWTHS. 
 
 events, I believe that in this central region of the cortex are 
 the centres for tactile sensibility of the opposite half of the 
 body, the leg above and the face below, the arrangement 
 being the same as with the motor centres. The clinical 
 evidence of sensory disturbance from lesion of the limbic 
 lobe seems to me very slight. 
 
 In some cases of paralysis we find the post-paralytic dis- 
 turbances of motion. Contracture is, of course, the com- 
 monest, and is found with any destructive lesion of the motor 
 tract, whether cortical or capsular. Other disturbances, 
 athetosis, chorea, ataxia, and the like, are much more rare. 
 The\% too, have no special focal significance, occurring with 
 disease anywhere in the motor tract. 
 
 Tumours in the left central region may give rise to other 
 symptoms of a very definite localizing character. Tumours 
 situated at the posterior end of the left third frontal con- 
 volution in right handed people give rise to true motor 
 aphasia. The power of voluntary speech is lost, unless 
 perhaps for a phrase, an interjection, or an oath, but the 
 comprehension of written or spoken language, and the ability 
 to express ideas by writing or gesture may remain intact. 
 Where the centre is not absolutely destroyed, but merely in- 
 vaded or irritated by a growth in the neighbourhood the 
 power of speech is not wholly lost, but there is more or less 
 difficulty, either hesitancy of speech or imperfect articulation, 
 or failure to. recall names or nouns. It has been suggested, 
 too, that in the posterior end of the left second frontal con- 
 volution is a motor centre for written language, differentiated 
 from the motor centres for the hand and arm. Destruction 
 of such a centre would produce inability to write, ability 
 to speak and to understand written or spoken language being 
 retained. As the existence of such a centre is still doubtful 
 no definite rules for diagnosis can be laid down. Should 
 agraphia be found, without any other speech disturbance, we 
 
SPECIAL SYMPTOMATOLOGY. 
 
 63 
 
 might fairly suspect a lesion in this region, but it would 
 probably be attended with some motor disturbance of the 
 hand or arm. 
 
 c. Tumours of the Posterior Parietal Region. 
 Case IX. N. R. IX-124. James P. entered the hospital 
 
 the 14th of August, 1880. He had suffered with cedema of 
 the feet and dyspnoea for two years. The heart was enlarged 
 and systolic murmurs were heard. There was also crepita- 
 tion and dullness in the lungs. The urine showed albumen 
 and casts. There was 
 choroiditis and redness 
 of the optic discs, and 
 the vessels of the fun- 
 dus were not very full ; 
 the condition was as- 
 cribed to tobacco and 
 not to nephritis. He 
 was sluggish and stu- 
 pid, and had much diar- 
 rhoea. A week after 
 entrance there was 
 
 some swelling in front of the right ear ; his voice was husky, 
 and he had an epileptic convulsion. Three days later, on the 
 24th, he had spasmodic twitchings and died. 
 
 Autopsy. — There was advanced nephritis. A tumour the 
 size of an English walnut was found adherent to the dura 
 over the right parietal lobe an inch and a quarter from the 
 median line. There was slight compression of the brain. 
 
 The antero-superior boundary of this region has already 
 been described. The boundary between the parietal and 
 temporal and occipital lobes is indeterminate. Obersteiner 33 
 suggests as a boundary a line drawn as a projection of the 
 
 Fig. 9 (Dalton) . Case IX. 
 
64 INTRA-CRANIAL GROWTHS. 
 
 internal parietooccipital fissure, and another drawn from the 
 end of the fissure of Sylvius to the lateral occipital sulcus, 
 which is not very constant, and these boundaries I adopt for 
 convenience. 
 
 The present case teaches us little, and all its symptoms 
 may have been due to nephritis. The functions of this re- 
 gion are still in dispute, and exact localization of lesions in 
 it is not easy. 
 
 The collection of cases by Naunyn 34 and Starr 35 makes 
 it probable that in the neighbourhood of the left angular 
 and supra-marginal gyri is the visual centre for language. A 
 lesion here will give rise to the symptom of word-blindness, 
 where the power of vision, of voluntary speech, and of the 
 auditory perception of language are retained, but the ability 
 to understand written or printed words is lost. The visual 
 centres may also extend into the lower portion of the inferior 
 parietal lobule toward the angular gyrus, so that a lesion 
 here may give rise to a certain degree of soul-blindness. 
 This, however, will be spoken of in the next section. 
 
 The weight of authority seems to be in favour of the view 
 that in the inferior parietal lobule are the centres for the 
 various forms of muscular sense. The growth in Case VIII 
 probably involved this region, but the results of the opera- 
 tion just cited confirm the views of Munk and Horsley that 
 the muscular sense has a representation, perhaps only partial, 
 in the Rolandic region. My patient recovered a part of his 
 muscular sense in the seven weeks that followed the opera- 
 tion. The sense of position was fairly good, that of motion 
 was still diminished. Further research may enable us to 
 speak more definitely. Loss of muscular sense without 
 paralysis might lead to a suspicion of lesion in this region. 
 
 In some cases of lesion about the angular gyrus, ptosis 
 has been observed on the opposite side, and some authori- 
 ties think that the upper facial centre may be in this region. 
 
SPECIAL SYMPTOMATOLOGY. 65 
 
 Munk 30 places the oculomotor centre near here, in close 
 relation with the visual centre. Schaefer 27 and Brown 36 ob- 
 tained conjugate movements of the eyes by stimulating the 
 angular gyrus and the occipital lobe. Horsley, 24 however, as 
 I have said, places the- centres for the eyelids and conjugate 
 movements of the head and eyes near each other in the 
 Rolandic region. We cannot therefore, as yet, draw 
 any positive conclusions from oculo-motor disturbances, 
 which will enable us to localize lesions in this region. 
 
 Ferrier 26 holds that in the angular gyrus is the centre for 
 distinct vision of the opposite eye, and that this whole 
 region is the chief visual centre, lesion of which causes 
 a crossed ambly opia. This subject will be discussed in the 
 next section more fully. Lesions of the gyrus, if deep- 
 seated, may involve the optic radiations of Gratiolet and thus 
 cause hemianopsia, but I do not believe that the gyrus itself, 
 at any rate in man, has much to do with vision, nor does it 
 seem at all probable, in spite of the views of Charcot and 
 Gowers, that the retina of one eye is entirely represented in 
 the opposite half of the brain. 
 
 d. Tumours of the Occipital Region. 
 
 Case X. M. R. CCXXXV-129. Johanna S., 40, 
 married, was admitted to the hospital on the 6th 
 of November, 1885. She was very stupid and had indulged 
 freely in beer. For a month she had had pain in the head, 
 weakness and diarrhoea. For three weeks she had had a 
 cough, chilly feelings, thirst and epistaxis. There were dry 
 rales and dullness over the right lung and the liver was en- 
 larged. Two days later she suddenly died. 
 
 Autopsy. — There was chronic adhesive pleurisy, intersti- 
 tial pneumonia, and a fatty and cirrhotic liver. There was 
 a calcareous nodule in the posterior part of the occipital 
 lobe. 
 
66 
 
 INTRA-CRANIAL GROWTHS. 
 
 Case XI. N. R. X-262. Mary S., 55, married, en- 
 tered the hospital the 3d of January, 1881. Ten weeks 
 before entrance she had trouble in the head and vomiting 
 which lasted for three weeks. Four weeks before entrance 
 the pain returned and became intense in the head and face. 
 There was excessive vomiting. For three weeks she had 
 been unable to talk plainly. She knew what she wanted to 
 say and could understand what was said to her but she could 
 not herself be understood. Two or three weeks before en- 
 trance she had some difficulty 
 of vision. It was found on ex- 
 amination that she moved the 
 left side somewhat better than 
 the right. Two days later, she 
 would answer questions only by 
 the word, " yes." She was noisy 
 and somewhat delirious. She 
 used her left hand more than 
 she did her right. On the 10th 
 she talked considerably but did 
 not seem to understand what 
 was said. On the 26th there 
 was considerable irregular action 
 of the right arm and hand, and a tumour, which pulsated 
 slightly, was noticed in the neck under the sterno-mastoid. 
 A few days later she died. 
 
 Autopsy. — There was old pleurisy and some phthisis. 
 The inner surface of the dura was snuff-coloured, with de- 
 tachable bits of membrane hanging from it. The dura was 
 adherent on the inferior surface of the left posterior lobe, 
 where there was a tumour the size of a lemon, with varie- 
 gated surface, whitish, with radiating lines and opaque 
 yellow masses. Gumma. 
 
 The boundary of this region is also uncertain. The oc- 
 
 Fig. 10 (Ecker). Case XI. 
 
SPECIAL SYMPTOMATOLOGY. 67 
 
 cipital and temporal lobes run into one another, and there is 
 no distinct division between them. Giacomini 37 assumes as 
 a boundary the line of the upper margin of the petrous por- 
 tion of the temporal bone, which sometimes leaves a slight, 
 temporary furrow on the fresh brain. Obersteiner's 33 bound- 
 ary, which I shall adopt, is the projection of the internal 
 portion of the parieto-occipital fissure on the external as- 
 pect of the hemisphere. 
 
 The two cases just cited afford us little, if any, information. 
 In Case X the tumour was probably an old tubercle which 
 had become calcified and inert, producing no symptoms. 
 In Case XI the location of the tumour, as given in the 
 autopsy records, is vague ; and we have no information in 
 regard to certain important symptoms, especially in regard 
 to any disturbance of vision. Whether the disturbances of 
 speech and motion were due to downward pressure on the 
 medulla or not we cannot say. It is not probable from what 
 we know of the localization of cerebral functions that such 
 disturbances should be due to lesion in this neighbourhood, 
 but without further knowledge this case cannot be made use 
 of for any definite contribution to our knowledge of the local- 
 ization of function. 
 
 Ferrier, in the first edition of his work on the Functions 
 of the Brain, held that the centre for vision was in the angu- 
 lar gyrus. Munk 30 opposed that view and maintained that 
 the centres for vision were in the occipital lobes, the right 
 halves of each retina being represented in the right lobe, the 
 left halves in the left ; each eye was therefore represented in 
 both hemispheres. Munk's views have received further con- 
 firmation from the researches of Luciani 23 and Schaefer, 27 ' 36 
 and Ferrier 26 has modified his views so far as to admit that 
 both the gyrus and the cuneus are visual centres. A large 
 amount of support for this theory has been obtained from 
 human pathology, notably by Wilbrand, 3e Seguin 3 ' J and 
 
68 INTRA-CRANIAL GROWTHS. 
 
 Hun. 40 The weight of evidence, therefore, goes to prove, as 
 Nothnagel 34 maintains, that the centres for vision of the 
 homonymous halves of the retina are situated in the cuneus 
 and probably in the first occipital convolution on the same 
 side. Luciani failed to confirm Munk's hypothesis that the 
 different segments of the retina were represented in different 
 portions of the visual centre in the cortex, but Hun's remark- 
 able case seems to confirm Munk's view. Here a lesion of 
 the lower half of the cuneus caused blindness of the corres- 
 ponding lower quadrants of the retinae on the same side, and 
 consequently there was limitation of the field of vision in the 
 corresponding upper quadrants of the field on the opposite 
 side. 
 
 It is to be remembered that the image projected on the 
 retina is reversed by . mental adjustment, and therefore, 
 although the retina is blind in its homonymous halves on the 
 same side as the lesion, the blind fields are so projected as to 
 seem on the side opposite the lesion. Lesion of the optic 
 tract, anywhere from the cuneus to the chiasma, as will 
 appear later, will give rise to lateral homonymous hemianop- 
 sia ; but if the lesion be in front of the occipital lobes, there 
 will probably be motor or sensory symptoms in addition. 
 In lesions of the cuneus there are no focal symptoms except 
 hemianopsia. Tumours involving this region, therefore, may 
 be localized if, in addition to the general symptoms, this 
 symptom is present. 
 
 Wilbrand 41 and Hun, furthermore, support the view of 
 Munk, that the remainder of the occipital lobe serves as a 
 centre for the higher visual representations, and that, if it be 
 destroyed, soul blindness follows. In such cases the power 
 of sight is retained, but the power to recognize what is seen 
 is lost. Word blindness is, in fact, only a sub-division of 
 soul-blindness. The value of this symptom in the focal dia- 
 gnosis of brain tumours is yet to be determined, but, when 
 
SPECIAL SYMPTOMATOLOGY. 
 
 6 9 
 
 present without hemianopsia, it should lead us to expect a 
 lesion in the occipital lobe, outside the true visual centres in 
 the cuneus and first occipital. 
 
 e. Tumours of the Temporo-spJienoidal Region. 
 
 CASE XII. N. R. XVI-80. William W., 40, married, a 
 baker, was admitted to the hospital the 5th of September, 
 1882. For a year he had complained of pain in both sides 
 of the head, and for two months he had had constant frontal 
 headache. He had occasionally had delirium lasting for a 
 few days. No other symptoms were noted. A week after 
 admission he was seized 
 with convulsions and 
 vomiting. He became 
 comatose ; his temper- 
 ature rose ; the pupils 
 were motionless, the 
 eyes turned to the left, 
 the head turned to the 
 right. He remained 
 comatose and died on 
 the 17th. 
 
 A utopsy. — The dura 
 was about two millimetres in thickness over a space four 
 by fifteen millimetres over the right convexity. In the 
 right middle fossa the dura was adherent to the pia over 
 an area of two square centimetres. There was a nodule 
 the size of a pea in the cortex of anterior portion of right 
 temporal lobe. There was a soft, pulpy area a centimetre 
 in diameter, with the surrounding tissue red and softened, 
 in the left corpus striatum. There was chronic endarteritis. 
 
 Case XIII. N. R. XXXVIII-124. Daniel H., 49, 
 married, entered the hospital the nth of June, 1887. There 
 
 Fig. 11 (Dalton). Case XII. 
 
7o 
 
 INTRA-CRANIAL GROWTHS. 
 
 was a history of some alcoholic excess. Six weeks before 
 entrance he had a sudden attack of vertigo, followed by loss 
 of consciousness which lasted half an hour. Ever since then 
 he has had constant pain in the head, especially on the right 
 side. There was great weakness, but no paralysis. He 
 slept poorly. The vision was good. The appetite was 
 good, but he had lost flesh. He had a cough and some ex- 
 pectoration. There was a systolic murmur at the apex of 
 the heart, and rales at the apex of the right lung. The knee- 
 jerks were somewhat increased ; the sensibility to touch was 
 slightly diminished. There was considerable mental im- 
 pairment. Romberg's symptom was present. On the 17th 
 he was very weak, unable to stand, and several times he fell 
 out of bed. The mind was much affected ; he did not know 
 where he was, how long he had been in the hospital, or 
 what month it was. The headache increased. On the 2 1st 
 he was sleeping poorly ; he complained of much frontal 
 
 headache, and required 
 restraint. An examin- 
 ation of the eyes showed 
 considerable optic neur- 
 itis. On the 26th left 
 hemiplegia developed. 
 On the 28th there was 
 no facial paralysis, but 
 he could not get his 
 tongue beyond his teeth. 
 He spoke very little, and 
 that indistinctly. He be- 
 came drowsy and was very hard to rouse. The drowsiness 
 increased to coma and on the 2d of July he died. 
 
 Autopsy. — There was pulmonary oedema, hydrothorax, 
 ascites, and an atheromatous aorta. A tumour the size of 
 a small lemon was found in the right temporo-sphenoidal 
 
 Fig. 12 (Dalton). Case XIII. 
 
SPECIAL SYMPTOMATOLOGY. 7 1 
 
 lobe ; at its outer aspect was a clot, and on its inner aspect 
 softening. 
 
 t Case XIV. N. R. XLIII-i 14. Angus M., 42, married, 
 a carpenter, came to the out-patient department of the hospi- 
 tal the 3d of February, 1888. The history he gave was rather 
 contradictory. His previous history had been good. He 
 'denied syphilis, but he admitted an excessive use of tobacco 
 and a moderate use of alcohol. He had had considerable 
 trouble and anxiety. Three years before this time he had 
 poor appetite and thickness of speech, with failure of mem- 
 ory. There was no history of any apoplectic seizure. The 
 memory improved after rest, but within six months the 
 thickness of speech had increased. He had much headache, 
 which was worse at night, and was usually on the left side of 
 the head. There was some pain about the knees but none in 
 the shin bones. For a year and a half he had not done his 
 work as well ; and the memory had again failed. The hands 
 were somewhat numb, and he thought the left side was weaker. 
 The speech was jerky, thick and hesitating, the syllables were 
 slurred, and he stumbled over them. He occasionally used the 
 wrong word. He understood what was said but he seemed 
 slow of comprehension. Somewhat later, in the course of con- 
 versation, he said a few words but he could not remember what 
 he wished to say to complete the sentence, being unable to 
 recall the name of the object. He could strike a high note 
 with his voice and hold it fairly well. There was no trouble 
 in swallowing. He thought there was a blur before the left 
 eye. There was considerable mental dullness when the 
 headache was severe. His strength failed; he was some- 
 what depressed but he had no delusions. The vision was 
 tested and found to be good. The movements of the eyes 
 and pupils were normal, and the fundus of the eyes was also 
 normal. There was a little tenderness over the back of the 
 neck to the left of the spine. There was no fibrillary tremor 
 
72 INTRA-CRANIAL GROWTHS. 
 
 of face or tongue, or tremor of the hands. His grip was 
 strong; the knee-jerk was normal; the heart was enlarged, 
 with a murmur at the apex. The urine showed a trace of 
 albumen. The hand-writing was quite suggestive of para- 
 lytic dementia. Three weeks later, on the 23d, he entered 
 the hospital. At that time the pupils were found to be a 
 trifle sluggish, but equal. The gait was unsteady, he swayed 
 with the eyes shut. The sensibility to touch in the legs was 
 a trifle diminished. The knee-jerk was exaggerated and 
 there was slight ankle clonus on re-enforcement. The 
 speech became more and more incoherent and finally he 
 scarcely spoke. He was stupid, delirious, and required re- 
 straint. The appetite was at first good, but finally grew 
 poor. He was costive, and passed his urine and faeces in 
 bed. He had repeated convulsive seizures, with twitching of 
 the arms, especially of the left arm. Bedsores developed ; 
 he had strabismus; the knee-jerks were lost; the convul- 
 sions became more frequent, and on the 10th of April he 
 died. 
 
 Autopsy. — Acute pleurisy; hsemorrhagic infarction of the 
 lung; thrombosis of the pelvic plexus. The calvaria was 
 slightly thickened; the convolutions were flattened, The left 
 hemisphere was less tense, and was flaccid and fluctuating. 
 The cavity of the left lateral ventricle was distorted. In the 
 middle of the centrum ovale there was a cavity the size of a 
 lemon with smooth walls, and containing a clear yellow fluid. 
 From the anterior wall projected a vascular mass the size 
 of a small peach, which, on section, showed alternate grayish 
 gelatinous and also opaque yellow portions. From the wall 
 of the cavity projected numerous sessile masses the size of 
 small peas and of a structure similar to the large mass. The 
 cavity reached to within four millimetres of the fissure of 
 Sylvius and had distorted it greatly. Microscopic examina- 
 tion showed the tumour to be a glioma. 
 
SPECIAL SYMPTOMATOLOGY. /T, 
 
 It may be doubted whether this last case can be classed 
 among the tumours of the temporal lobe, but a growth of 
 this size involving the basal ganglia and having these rela- 
 tions with the fissure of Sylvius, would probably involve a 
 considerable portion of the lobe, together with the surround- 
 ing parts. 
 
 The temporal lobe may fairly be regarded as one of 
 the latent regions of the brain, and most writers agree that 
 lesions here apparently give rise to no focal symptoms. The 
 external aspect, especially the posterior portion of the upper 
 temporal convolutions is believed to be the centre for hear- 
 ing. Ferrier, 26 Munk 30 and Luciani 23 substantially agree 
 on this point, but Schaefer 27 and Sanger Brown 36 maintain 
 that this region has nothing to do with hearing ; that com- 
 plete extirpation of both lobes causes no deafness. It is 
 believed, moreover, by some anatomists, that, after destruction 
 of the auditory apparatus, degeneration can be traced up- 
 wards into the temporal lobe; and one or two cases are on 
 record where disease of both temporal lobes caused deaf- 
 ness. I think it probable that this centre contains the audi- 
 tory centres. Luciani holds that each ear is represented in 
 both hemispheres, in a manner similar to the representation 
 of the eyes. This would explain why a unilateral lesion does 
 not cause deafness. Our tests for hearing are still so incom- 
 plete in comparison with those for vision, that we have no 
 knowledge as to any changes in hearing from disease of one 
 temporal lobe, with one exception. As the centre for 
 visual perception of language is unilateral, so is the centre 
 for auditory perception of language ; and the clinical re- 
 searches of Seppilli, 23 ' 42 Naunyn 34 and Starr 35 bring much 
 evidence in favor of the belief that the posterior end of 
 the left first temporal convolution contains the centre for the 
 auditory perception of speech. A lesion here, then, will 
 cause word-deafness, where hearing, voluntary speech, and 
 
74 INTRA-CRANIAL GROWTHS. 
 
 the ability to read are preserved, but where the power to 
 understand the spoken word is lost. It is, moreover, prob- 
 able that in this region are also centres for soul deafness, 
 where the ability to comprehend the meanings of sounds 
 apart from articulate language is also lost; butthis fact is by 
 no means so sharply to be distinguished from the faculty to 
 understand the spoken word as is soul blindness from word 
 blindness. 
 
 I have already spoken of the theory, supported by Ferrier 
 and Schaefer, that the centres for tactile sensibility lie in the 
 median aspect of the temporal lobe and the gyrus fornica- 
 tus. Cases XIII and XIV showed some diminution of sensi- 
 bility, but the distribution in Case XIV did not suggest 
 anaesthesia from unilateral cerebral disease, both legs being 
 affected. In this case, however, the patient's mental condi- 
 tion was such as to render his answers to inquiries about 
 sensibility quite untrustworthy. 
 
 There is some reason for supposing that the temporal lobe 
 bears a relation to the sense of smell ; the hippocampus 
 is well developed in osmatic animals and less developed in 
 anosmatic animals. Ferrier is disposed to locate the senses 
 of smell and taste in the anterior part of the temporal 
 lobe. Our knowledge of the disturbances of those senses is 
 still too vague to render it of much help in the localization 
 of disease, so that we can lay slight stress upon such disturb- 
 ances for focal diagnosis. 
 
 Cases XIII and XIV present one symptom^ — the swaying 
 with the eyes shut — which is not very common in brain 
 disease, and may, perhaps, arise from the presence of a lesion 
 near the organs of equilibrium, — the semi-circular canals. 
 This may on further investigation prove of some help in 
 diagnosis. Case XIII presents motor symptoms which may 
 have been due to pressure. Case XIV presents symptoms 
 of slight motor aphasia, with apparently no word deafness. 
 
SPECIAL SYMPTOMATOLOGY. 75 
 
 This, again, seems to me due rather to a slight impairment 
 of some of the speech centres from remote pressure than to 
 actual destruction of the centres by a growth. Beyond this 
 the symptoms in all three cases were general, and all pre- 
 sented, to a marked degree, mental impairment. In only 
 one (Case XIII) was the diagnosis of a tumour made ; Case 
 XIV was regarded by every one who saw it as a typical case 
 of paretic dementia. None of them presented any definite 
 localizing symptoms, thus justifying the statement already 
 made that the temporal lobe, with the exception of the pos- 
 terior end of the left first temporal convolution, is a latent 
 region, in which neoplasms give rise to no focal symptoms. 
 
 2. Tumours of the Corpus Callosum. 
 
 Case XV. N. R. VIII-17. James W., 42, single, a 
 salesman, entered the hospital the 26th of December, 1879. 
 He had had malaria but he denied having had syphilis. Six 
 weeks before coming to the hospital he had gonorrhoea, and, 
 with that, he had severe pain in the neck extending to the head, 
 a pain which continued at intervals. Four weeks before enter- 
 ing the hospital his knees grew weak, he staggered in walking, 
 and was afraid to go down stairs without assistance. A few 
 days after he had tremor in the feet, extending all over the 
 body, and while it lasted he was perfectly helpless. His 
 memory failed, and he was delirious and violent. There was 
 no numbness or prickling in the legs, and no pain in the legs 
 except that due to varicose veins. There was no awkward- 
 ness in using the arms. There was a slight tremor of the 
 legs ; the knee-jerks were normal. The pulse was slightly 
 irregular, 102. The urine contained albumen and casts. 
 There was no optic neuritis. On the 1st of January he had 
 nausea and vomiting and some delirium. The headache 
 increased, the appetite failed, and later on the pupils became 
 
■J6 INTRA-CRANIAL GROWTHS. 
 
 dilated, although not immobile, and there was a hesitancy in 
 the movements of the right eye. On the ioth of February 
 he died. 
 
 Autopsy. — The convolutions were flattened. There was a 
 tumour the size of a turkey's egg, involving the whole corpus 
 callosum, grayish, vascular, sharply denned, with a soft cen- 
 tre, and containing a yellowish fluid. The corpus striatum 
 and other basal ganglia were flattened. Back of the tumour 
 in the right hemisphere was a small haemorrhage. 
 
 fCASE XVI. N. R. XX-112. Peter M., 58, widower, a 
 cabinet maker, entered the hospital the 13th of August, 1883. 
 The previous history was good. He had used alcohol mod- 
 erately. On the 3d of July he did considerable lifting, after 
 which he had an attack of vertigo. Since then the vertigo 
 had recurred with considerable frequency, and in some of the 
 attacks everything looked dark, and he lost consciousness and 
 fell. No information could be obtained as to any convulsion. 
 These attacks became less frequent and less severe. There 
 was no tinnitus or diplopia. The vision was good. The 
 memory and mental power were somewhat diminished. He 
 slept well. He complained of numbness and prickling in the 
 hands, and said that the left leg had lost strength, and that 
 he could not use it as he wished in walking. There were no 
 thoracic or digestive symptoms. Micturition was attended 
 with some pain in the back. He was obliged to pass water 
 in the night, the demand being imperative, and, if it were not 
 answered, vertigo would come on. The reflexes were nor- 
 mal. The arms were of equal strength. The left leg was 
 weaker than the right. The urine was normal. He could 
 hear the tick of a watch with either ear at a distance of one 
 foot. The movements of the eyes, field of vision, and fundus 
 were normal. There was no facial paralysis. A week after 
 entrance he complained of headache, a heavy feeling in the 
 head, and some vertigo. He grew somewhat delirious and 
 
SPECIAL SYMPTOMATOLOGY. JJ 
 
 confused. He tried to walk but fell on the floor. On the 22d 
 he had left hemiplegia coming on gradually and affecting the 
 tongue, arm and leg. The watch was heard at only one 
 inch from the left ear. He became restless, delirious and 
 demented. Five days after the hemiplegia appeared he had 
 contracture and exaggerated reflexes on the paralyzed side, 
 with vaso-motor paralysis. He complained of a crowded 
 feeling at the root of the nose. He grew suddenly weaker 
 and more demented, restless, and delirious, passing urine and 
 faeces in bed. The left side of the face became paralyzed ; 
 he had difficulty in swallowing. On the 6th of September 
 the contracture of the left arm was much diminished, and on 
 the I ith he died, having gradually grown weaker and become 
 comatose. 
 
 Autopsy. — There was pulmonary oedema and emphysema, 
 leptomeningitis, ependymitis, and dilated ventricles. The 
 convolutions were flattened, the pia dry. The posterior 
 two thirds of the corpus callosum, the posterior half and 
 pillars of the fornix, and the right gyrus hippocampus were 
 made up of a firm pale-red mass, a vascular sarcoma, which 
 extended into the hemispheres, one centimetre on the right 
 and half a centimetre on the left. The basal ganglia were 
 not compressed. 
 
 Tumours of the corpus callosum are rare. Bernhardt 1 - cites 
 only three cases in four hundred and eighty-five, and few 
 writers have classified them under a separate heading. 
 Bristowe, 43 however, has reported four cases, and he thinks 
 that the symptoms may sometimes be sufficiently character- 
 istic to justify a diagnosis. The characteristic features, he 
 says, are: " ist, their ingravescent character, a character 
 which they possess in common with other cases of cerebral 
 tumour; 2d, the gradual coming on of hemiplegia; 3d, the 
 association of paralysis of one side with vague hemiplegic 
 symptoms of the other; 4th, the supervention of stupidity, 
 
78 INTRA-CRANIAL GROWTHS. 
 
 associated for the most part with extreme drowsiness, a 
 puzzled inquiring look when awake, a difficulty of getting 
 food down the throat, and cessation of speech ; 5th, the 
 absence of implication of the oculo-motor nerves, and of 
 direct implication of other cerebral nerves ; and 6th and 
 last, death from coma. None of these symptoms, however, 
 seem to be especially characteristic, with the exception of 
 the developement of paralysis, gradually affecting both sides 
 of the body. The other symptoms, as we have seen, are by 
 no means rare with tumours elsewhere. 
 
 Case XV seems to present no very definite symptoms. 
 Case XVI corresponds in many respects with Bristowe's 
 description. In several of the cases reported the duration 
 of the symptoms seems to have been very brief, as it was in 
 Case XVI, and it is difficult to imagine that a tumour could 
 have attained such a size in only two months. It must be 
 supposed, therefore, that many of the symptoms, especially 
 the onset of hemiplegia, are due, not to the growth in the 
 corpus callosum itself, but to the invasion of the hemispheres. 
 With our present lack of knowledge in regard to the associ- 
 ation tracts in the brain we are unable to recognize any 
 deficit in the great association tract between the hemispheres, 
 but it is possible that in the future we may be able to do so. 
 The mental failure which seems common in these cases is 
 perhaps due to the destruction of these tracts, but the 
 failure is no greater than in other cases of intra-cranial 
 growth. The gradual onset of hemiplegia is to be regarded, 
 as I have said, as due to the invasion of the hemispheres. 
 As optic neuritis and any marked headache and vomiting 
 may be absent, the diagnosis between a tumour of the corpus 
 callosum and a slowly progressing thrombotic softening 
 seems at present impossible, even when the symptoms 
 mentioned by Bristowe are present. If well-marked general 
 symptoms of tumour are present a probable diagnosis can 
 
SPECIAL SYMPTOMATOLOGY. 79 
 
 sometimes be made. It will be seen that Case XVI presented 
 a lesion, probably involving the hippocampus, without any 
 sensory disturbance. 
 
 3. Tumours of the Optico-striate Region. 
 
 Case XVII. M. R. CXLIX-122. Lizzie S., 5, entered the 
 hospital the 17th of May, 1878. For three weeks she had 
 had a bad cough, with frontal headache and delirium. The 
 pupils were dilated. She had no photophobia or convul- 
 sions. On the 19th she was cyanotic, the respiration was 
 irregular, the pulse weak, and she took no notice of anything. 
 On the 20th there was ptosis. The next day she became 
 unconscious, and on the 22d she died. 
 
 Autopsy. — There was tuberculosis of the meninges, lungs, 
 spleen, liver, kidneys and peritonaeum. In the right lateral 
 ventricle a yellowish- gray mass the size of a bean was found, 
 attached to the ependyma, toward the posterior part of the 
 corpus striatum, opposite the centre of the optic thalamus, 
 but not implicating it. 
 
 CASE XVIII. M. R. CX-214. Mrs. K. was brought to 
 the hospital the 31st of October, 1874, in convulsions. No 
 history could be obtained. The eyes were turned to one side 
 and at times turned upwards, — a clonic spasm. There was 
 coma in the intervals of convulsions. The jaws were set. 
 There was oedema of the ankles. She could be roused a 
 little, but died in ten hours. 
 
 Autopsy. — Advanced nephritis and pleurisy. There were 
 ulcers in the large intestine and congestion of the brain. A 
 tumour the size of a bean, with partly solid contents, was 
 found in each choroid plexus. 
 
 Case XIX. M. R. CCIV-132. Andrew W., 53, single, 
 a labourer, entered the hospital the 12th of September, 
 1882. His parents died of pulmonary disease. He had 
 
80 INTRA-CRANIAL GROWTHS. 
 
 had malaria. He had had a cough, with expectoration, for ten 
 days. He had dyspepsia, anorexia and nausea, but no vom- 
 iting and no headache. He had chills daily. He became 
 apathetic and then unconscious. On the 24th he refused 
 food. On the 27th he was completely unconscious. He 
 moved his arms and legs freely on pinching ; the right cheek 
 was flattened ; the pupils were equal but they did not react 
 alike; the extremities were cold. On the 28th he had a con- 
 vulsion in which his legs were thrown about, the arms being 
 motionless. The left pupil was larger than the right. His 
 head was drawn to the right, the right eye was closed. The 
 arms were not paralyzed ; the left side of the face was less 
 sensitive than the right ; the face was drawn to the right. 
 The left pupil finally became very much larger than the 
 right. He died the same day. 
 
 Autopsy. — Pulmonary tuberculosis, contracted kidneys and 
 oedema of the brain. There was a fibrous mass the size of a 
 pea depending from the fornix. 
 
 Case XX. S. R. CXXXI-270. Mary H., 58, widow, a 
 domestic, was brought to the hospital the 15th of February, 
 1886. She was run over by a wagon and had a compound 
 comminuted fracture of the great toe, which was amputated. 
 The wound did poorly ; she vomited a good deal. She grew 
 more and more stupid. The head was turned to the left. 
 On the 2 1st of March right tactile hemianaesthesia was dis- 
 covered, the right eye also being involved ; the pupils were 
 contracted, the reflexes were increased. On the 2d of April 
 she had right facial paralysis for a few 1 days with some hem- 
 iplegia on the right side. On the same day she was for a 
 time quite rational, but later she grew very stupid, and died 
 on the 6th of April. 
 
 Autopsy. — Half an inch below the surface of the occipital 
 lobe there was a recent clot the size of a small orange, sur- 
 rounded by much softened periphery. In front of this was 
 
SPECTAL SYMPTOMATOLOGY. 8 1 
 
 an old puckered cicatrix, surrounded by an area of soft, 
 yellowish- red brain tissue. From this, projecting into the 
 left lateral ventricle, was a new growth (gumma) the size of 
 the end of the thumb, quite dense, three-quarters of an inch 
 long. 
 
 Case XXI. N. R. XXXI-114. Edgar M., 22, single, a 
 hatter, entered the hospital the 9th of August, 1886. He 
 had used alcohol somewhat, and there was a suspicion of 
 syphilis. He was said to have had severe and constant pain 
 in the back of the head for several months. Three weeks 
 before entrance, he went out, drank some liquor, returned 
 and fell unconscious, without any convulsion. After that 
 the symptoms increased. The patient stated that three 
 weeks before coming to the hospital he was seized with a 
 sudden and severe pain in the right side of the head, 
 both front and back. He vomited freely, the vomiting 
 having no relation to the taking of food. There was great 
 mental torpor, and also weakness in the legs and sleep- 
 lessness. He had a poor appetite, diarrhoea and constipa- 
 tion. There was considerable vertigo. There was a steady 
 increase in the symptoms. It was hard to get an answer; he 
 seemed to understand what was said and to answer rationally, 
 but he was stupid and torpid. Examination of the chest 
 and abdomen was negative. There was albumen in the 
 urine. The temperature was 99.4 ; the pulse 80. The 
 tongue was protruded straight. The pupils were equal and 
 reacted to light. The movements of the eyes were normal. 
 There was left lateral homonymous hemianopsia; and there 
 was also drooping of the right eyelid. The grasp of the left 
 hand was weaker and he used that hand less than the right. 
 There was much tremor of the right arm, and some tremor 
 of the left arm and tongue. There was left hemianaesthesia 
 for touch and localization, extending not quite to the median 
 line. The elbow and knee jerks were much increased 
 
82 
 
 INTRA-CRANIAL GROWTHS. 
 
 ankle clonus was present; the skin reflexes were • active, 
 and the reflexes were alike on the two sides. On August ioth 
 he was more stupid. There was a slight left facial para- 
 lysis. On the iith he was unable to recognize his friends. 
 He passed urine and faeces in bed. On the 13th there was 
 found to be optic neuritis in the left eye ; the right eye could 
 not be examined. On the 14th he was drowsier, and there 
 was less movement of the left arm and leg. The left facial 
 
 paralysis was greater. On the 
 1 5th he recognized his friends. 
 On the 1 6th he was again 
 somnolent, he could not be 
 aroused, and he did not rec- 
 ognize any one. He moved 
 the right arm in a purpose- 
 less way without co-ordina- 
 tion. It was hard to get him 
 to take food. Later in the 
 day he had tonic convulsions ; 
 the limbs were rigid and ex- 
 tended. The pupils were 
 unequal and immobile, the 
 right pupil dilated and the 
 left contracted. There was 
 a slight tonic extensor spasm 
 in the arms. He became 
 comatose and died. 
 Autopsy. — There was venous engorgement of the organs 
 of the body and small haemorrhages in the lungs. The cal- 
 varia was thin, the inner surface roughened, showing grooves 
 made by the convolutions. The dura was injected, the pia 
 dry ; the convolutions were flattened, the sulci obliterated ; the 
 fissure of Sylvius was shallow, the brain flabby. The right 
 lateral ventricle was one-half larger than the left, the ependyma 
 
 Fig. 13 (Edinger). Case XXI. 
 
 LV = Lateral ventricle. 
 3V = Third ventricle. 
 NC = Caudate nucleus. 
 OT = Optic thalamus. 
 
SPECIAL SYMPTOMATOLOGY. 83 
 
 granular. In the middle horn of the right lateral ventricle was 
 a dark red, vascular, gelatinous, globular, lobulated mass, 
 measuring antero-posteriorly 5.5 centimetres, transversely 5 
 centimetres, vertically 3 centimetres, lying laterally' to the 
 optic thalamus, posteriorly to the caudate nucleus, the long 
 diameter of the latter being nearly transverse. Between this 
 and the cerebellum, and behind the optic thalamus, was a 
 similar mass, half a centimetre thick, and three centimetres 
 in diameter. The posterior cornu of the lateral ventricle 
 was the size of a lemon, with a granular surface. A sec- 
 tion of the larger growth showed that it was firm, opaque, 
 yellow, with gelatinous areas — the outside was soft, purple, 
 and homogeneous. The smaller growth was purplish, 
 soft and homogeneous. The external capsule, on a level 
 with the anterior tip of the optic thalamus, was yellow and 
 softened. The lenticular nucleus, on a level with the 
 middle part of the optic thalamus, was softened and yellow; 
 behind this, the three parts of the nucleus were soft and 
 yellow. The right centrum ovale next the tumour was 
 soft and yellow for one centimetre. The right crus and in- 
 ternal capsule were intact. The left side of the brain was 
 normal. Under the microscope the central portion of the 
 tumour was found to contain large granular capsules and 
 fatty, degenerated cells. In the periphery were large cells 
 in masses, with fine granular protoplasm and distinct nuclei. 
 There was a mucine reaction. There was great develope- 
 ment of the blood-vessels. The tumour was found to be 
 an endothelioma arising from the choroid plexus, — a 
 tumour of the sarcomatous type developing from connective 
 tissue. 
 
 The optico-striate region embraces the corpora striata, with 
 the two divisions thereof, the optic thalami, the external and 
 internal capsules, the claustrum, and the adjacent ventricles. 
 In point of fact, growths in this region most commonly arise 
 
84 1NTRA-CRANIAL GROWTHS. 
 
 from the choroid plexus, the corpus striatum, or the optic 
 thalamus, involving the capsules only by extension. 
 
 Cases XVII, XVIII and XIX are merely examples of 
 the small growths in the choroid plexus, often cystic, which 
 are found at the autopsy and give rise to no symptoms during 
 life. All the symptoms in these cases - were doubtless due to 
 the disease elsewhere which caused death. Such growths 
 seldom have any significance, but in rare cases, as Edes 44 has 
 shown, they may interfere with the circulation of the cerebro- 
 spinal fluid in the ventricles and cause an increase of 
 pressure. 
 
 Cases XX and XXI present more definite symptoms, the 
 former hemiansesthesia and partial paralysis ; the latter 
 hemianopsia, hemiansesthesia and hemiplegia. 
 
 It is probable that tumours in this region give rise' to no 
 focal symptoms unless the internal capsule be involved. It is 
 probable that the corpus striatum has some connection with 
 motor impulses, and the optic thalamus with sensory impres- 
 sions and perhaps' with inhibition, but our knowledge of the 
 exact functions of these organs is still vague, nor do we know 
 what effect a destructive lesion of either of them produces. 
 At any rate growths limited strictly to the thalamus, the 
 lenticular or the caudate nucleus apparently cause no focal 
 symptoms. As the growth becomes larger and involves the 
 internal capsule, symptoms develope which may enable us to 
 localize it, but only when the posterior limb of the capsule is 
 involved. If the anterior two-thirds are alone affected we 
 have an ordinary hemiplegia, with a more or less gradual onset, 
 often associated with dysarthria or even motor aphasia if 
 there be right hemiplegia. In such a hemiplegia convulsions 
 are rare and anaesthesia is absent, thus differing from paralysis 
 from cortical disease. Should the growth involve the 
 posterior third of the capsule, hemiansesthesia may be 
 present, usually more general than the anaesthesia from cor- 
 
SPECIAL SYMPTOMATOLOGY. 85 
 
 tical disease. In such cases the pulvinar is also apt to be 
 involved, and the fibres of the optic tract, and, as in Case 
 XXI, we get homonymous hemianopsia on the opposite 
 side, differing from cortical hemianopsia in being associated 
 with hemianaesthesia or hemiplegia. With such an associa- 
 tion of symptoms we can be reasonably sure of our diagnosis 
 as to the location of the growth. 
 
 Beevor and Horsley 40 have very carefully studied the ar- 
 rangement of the motor fibres in the internal capsule and 
 have found that the most anterior fibres are those for the 
 movements of the eyes ; then come fibres for the movements 
 of the head, the shoulder, elbow, wrist, fingers, thumb, 
 trunk, hip, ankle, knee, hallux and small toes, which 
 are the most posterior. A study of their diagrams, how- 
 ever, shows that the lesion which would affect one set of 
 these fibres must be so extremely small as to cause prac- 
 tically no other disturbance; so that the probability of a 
 limited paralysis from a lesion in this region is extremely 
 slight. 
 
 Oulmont 46 and Raymond 47 hold that lesions just in front 
 of the sensory tract, toward the posterior part of the optic 
 thalamus, give rise to the symptoms of post-hemiplegic dis- 
 turbances of movement, especially athetosis or hemichorea, — 
 an opinion which has some support from the recorded 
 cases, and with which many writers agree. Should such 
 symptoms arise in any case presenting the symptoms already 
 mentioned, they would help to confirm the diagnosis. Case 
 XXI presented some motor disturbance but it was on the 
 same side as the lesion. If the disturbance come on at the 
 close of life then I am inclined to believe the symptom due 
 to pressure. I do not, however, believe that post-hemiplegic 
 disturbances of motion by themselves have any distinct local- 
 izing value. I have seen athetosis in cases of cortical lesion, 
 multiple neuritis, and chronic hydrocephalus, and I believe 
 
86 INTRA-CRANIAL GROWTHS. 
 
 these disturbances may arise from lesions almost anywhere 
 in the motor tract. 
 
 4. Tumours of the Crus Cerebri. 
 
 Tumours of the crus are rare and no true case has 
 been found in the hospital records, although Case XXIV 
 was sufficiently high up in the pons to present symptoms 
 similar to those of tumour of the crus. The striking feature 
 of new growths in the crus is crossed paralysis — a paralysis 
 of the oculo-motor nerve on the same side as the lesion 
 and of the face and limbs on the opposite side. For a further 
 discussion of these symptoms, however, I must refer to the 
 sections on tumours of the pons and tumours of the base of 
 the skull. 
 
 5. Tumours of the Corpora Quadrigemina and 
 Pineal Gland. 
 
 | Case XXII. * Frank C, 24, single, was admitted to the 
 Boston Lunatic Hospital the 15th of February, 1884. There 
 was a history of phthisis in the family. At the age of five 
 years he had epileptic attacks. His previous history was 
 otherwise good except that latterly he had had headaches. 
 A year before admission, he had an attack of neuralgia on 
 the left side of the head, the pain being accompanied with 
 vertigo. About the same time he had dimness of vision 
 and diplopia. At times there was vertical diplopia, when 
 the eyes were turned to the right, horizontally, or upwards, 
 but this diminished. The head was carried backward, in 
 order to correct the diplopia. Later on he had some spasm 
 of accommodation. In August, 1883, he began to have 
 scruples in regard to his conduct, and a feeling of unworthi- 
 
 * This case has already been reported by Dr. T. W. Fisher, American Journal of 
 Insanity, January, 1885. 
 
SPECIAL SYMPTOMATOLOGY. 87 
 
 ness. After this the headaches returned. At times he 
 lost control of the movements of his hands. With this loss 
 of control there was some difficulty in swallowing, and a loss 
 of power in the right hand. He grew childish and lost his 
 initiative and his power of attention. The vision of the left 
 eye began to fail in September and by December he was 
 entirely blind ; about the same time his hearing failed. In 
 September he began to go to the left in walking, and fell 
 backwards to the left. The gait was reeling and the hands 
 unsteady. There was nystagmus and squint. It was hard 
 to determine the condition of his sensibility, but it probably 
 was not much impaired. In February, just before entering 
 the hospital, he lost consciousness and had a convulsion in- 
 volving both arms. On entrance, the examination showed 
 small pupils and right internal strabismus. There was double 
 optic neuritis. He responded somewhat to .irritation of the 
 skin, showing no marked paralysis. The knee jerk was very 
 slight on the left and exaggerated on the right. He ap- 
 parently was entirely deaf and blind. The skin reflexes were 
 normal. He swallowed his food well. He passed urine and 
 faeces in bed. On the 16th the knee jerks were found to be 
 equal. On the 20th pressure over the cervical vertebrae 
 was apparently painful. There was marked plantar flexion 
 of the feet. He lay perfectly quiet making no response. 
 He spoke voluntarily only once during the time he was in 
 the hospital. On the 22d there was right external strabis- 
 mus. He grew steadily weaker and died on the 22d. 
 
 Autopsy. — Acute pleurisy, broncho-pneumonia, hypoplas- 
 tic aorta. There was a haemorrhage between the dura and 
 periosteum in the cervical region of cord. The calvaria was 
 very thin (i| millimetres). The inner table was absorbed, 
 and the diploe exposed. The brain weighed 1605 grammes. 
 The pia was pale and dry ; the convolutions were flattened ; 
 the sulci obliterated. The Lateral ventricles each contained 
 
88 INTRA-CRANIAL GROWTHS. 
 
 75 cubic centimetres of clear fluid. The region of the cor- 
 pora quadrigemina and pineal gland was occupied by a soft 
 reddish -gray globular mass measuring thirty centimetres in 
 all its diameters and extending to the corpora geniculata. 
 Over it lay the velum interpositum. There was no trace of 
 the pineal gland or of the anterior corpora quadrigemina. 
 On the posterior surface of the tumour the posterior corpora 
 formed a layer only two millimetres in thickness. The 
 tumour was made up of small round cells in a delicate mesh, 
 with abundant vessels. ' Other parts showed an alveolar 
 structure. The tumour also contained pearly nodules, cho- 
 lesteatoma. The growth was a vascular sarcoma with choles- 
 teatomatous portions, growing probably from the velum 
 interpositum. 
 
 Case XXIII. M. R. CC-50; N. R. XV-88 ; XVI-125. 
 Adolph S., 23, single, a sailor, entered the hospital the 8th 
 of May, 1882. There was a family history of phthisis. He 
 had had typhoid and yellow fevers, but he denied syphilis. 
 About the last of April he began to have severe paroxysmal 
 headache, with pain in the back and vomiting. There was 
 slight photophobia and vertigo. He lost strength. The 
 vision was good. He slept and ate well. He had no dis- 
 turbance of respiration or micturition. On May 30th it was 
 found that he had diplopia for distant vision. June 2d it 
 was recorded that the headaches usually came on before break- 
 fast and were attended with vomiting. There was beginning 
 optic neuritis. On June 16th he was found to have paralysis 
 of the right external rectus. There was some mental im- 
 pairment; he acted strangely, but he had no memory of his 
 actions afterwards. On the 28th of June he had less headache 
 and no vomiting. For some weeks his gait was somewhat 
 like festination. The left side felt as if a cloth were between 
 it and the object touched. July 15th, he had marked optic 
 neuritis, but vou = |--{}. On the 24th he had various delu- 
 
SPECIAL SYMPTOMATOLOGY. 89 
 
 sions — some of them delusions of persecution. His gait was 
 staggering; there was no headache; he was quite stupid, 
 but he knew enough to elude the attendants. He soiled him- 
 self regularly. July 30th he was somewhat brighter ; he 
 had no memory of his delusions ; and said he had been 
 asleep. His headache was more severe. August 13th he 
 was free from headache and delusions. He had moderate 
 hemiansesthesia on the left side, and some vertigo. Septem- 
 ber 1st, the neuritis was more marked. September 5th, the 
 vision had grown poor. He did not walk as well, which was 
 attributed to his poor vision. On October 4th there was 
 slight paralysis of the lower part of the left side of the face ; 
 the left eye did not move outwards beyond the median line ; 
 the right eye tended to turn inwards, but it could be moved 
 out beyond the median line; he had diplopia on looking 
 downwards. He had left hemianopsia and slight hemianses- 
 thesia. The knee jerks were equal and lively ; the plantar 
 reflex greater on the left- October 5 th, he had a tendency 
 to totter backwards, and could not put the toes down to the 
 floor. Hemianopsia was less marked. October 7th, he 
 could not move his arms, and lay in bed, being very stupid. 
 October 10th, there was more paralysis of the right external 
 rectus. October 18th, the right eye moved out' better. 
 October 25th, there were slight tremors on the left side 
 several times a day on intended movements. The tongue 
 was tremulous when protruded. He followed the finger with 
 his eyes when it was moved to the right; the left eye moved 
 outwards only to the median line, and he seemed to lose 
 sight of the finger when it was moved to the left. On 
 November 6th the left arm was stiff and he had more left 
 internal strabismus. November 16th, there was spasm of 
 the arms and legs. On November 18th there was nystag- 
 mus of the right eye with a tendency of the eye to turn 
 inwards; the left pupil was larger; there was less motion 
 
go INTRA-CRANIAL GROWTHS. 
 
 in the left eye, which could be turned inwards somewhat. 
 On the 1 8th he became comatose and died. 
 
 Autopsy. — The calvaria showed the impress of the convo- 
 lutions and was very thin, three millimetres in its thickest 
 part, and as thin as paper in the thinnest part, with an actual 
 perforation of the skull. There were pearly nodules, the 
 size of a pin-head on the inner surface of the dura. The 
 convolutions were flattened ; the pia dry. The left optic tract 
 and abducens were smaller and flatter than usual, and the 
 abducens was less translucent. The lateral ventricles were 
 twice the normal size. The cavity of the third ventricle, 
 the anterior half of the right lateral ventricle, and the fifth 
 ventricle were occupied by a soft, pale, custard-like mass, 
 eleven by six by three and a half centimetres, adherent only 
 by small vessels to the floor of the ventricle. The growth 
 could not have arisen from brain substance. The corpus 
 callosum and anterior fornix were enormously stretched and 
 lying on the tumour. There was no velum interpositium. The 
 tumour was most adherent near the septum lucidum. The 
 growth had greatly compressed the pineal gland and 
 the corpora quadrigemina, on which it lay. On examina- 
 tion it proved to be a small round cell sarcoma. 
 
 The anatomical situation of tumours in this region causes 
 compression of the aqueduct and venae Galeni, and thus 
 produces hydrocephalus, giving rise to greater intra-cranial 
 pressure than growths in any other region. 
 
 These two cases present the two symptoms recently laid 
 down by Nothnagel 48 as characteristic of tumours involving 
 the corpora quadrigemina, namely, inco-ordination in walking 
 and oculo-motor paralysis. Although Nothnagel 49 had sug- 
 gested the importance of these symptoms in the diagnosis 
 of growths in this region in 1879, it is only in his recent 
 paper that, after a study of eighteen cases (including Case 
 XXII) he takes the definite position that this combin- 
 
SPECIAL SYMPTOMATOLOGY. 9 1 
 
 ation of symptoms, coming on early in the progress of the 
 disease, is characteristic. Gowers, and the majority of 
 writers before this, have ascribed the disordered gait to 
 pressure on the vermis cerebelli, but Nothnagel cites a case 
 where the tumour was too small to exert much pressure, and 
 emphasizes the fact that, as in Case XXII, the disturbed gait 
 was one of the early symptoms. In Case XXIII the dis- 
 turbance seems to have come on somewhat later, but it is 
 very possible that the corpora quadrigemina were only later 
 involved in the growth. Oculo-motor symptoms have long 
 been recognized as frequent in lesions in this region. We 
 must therefore regard the combination of these two symp- 
 toms, if observed early in the disease, as indicative of lesions 
 of the corpora quadrigemina. 
 
 The anatomy of this region shows that a large portion of 
 the optic nerve fibres arise from the anterior corpora, and 
 that they also receive or are traversed by many of the fibres 
 of the optic radiations coming from the occipital lobe. 
 Hence, a priori, we might expect that a lesion in this region 
 would cause blindness, even before optic neuritis had 
 developed, and various writers, among others Edinger, 50 
 regard such an amaurosis, when not due to neuritis, as 
 of some value in the focal diagnosis. Nothnagel opposes 
 this view. Case XXIII would seem to support Nothnagel's 
 opinion ; but it must be borne in mind that in this case the 
 tumour merely pressed upon the corpora quadrigemina and 
 did not destroy them, and that later, perhaps as the pressure 
 destroyed the subjacent parts, the vision began to fail. 
 
 Some of the optic fibres arise from the thalamus and the 
 external geniculate body. A good-sized tumour of the 
 corpora quadrigemina may involve this region or the posterior 
 part of the internal capsule, and thus give rise to hemian- 
 opsia or hemianesthesia, as in Case XXIII. It is doubtful 
 in this case just where the growth originated, but it so dis- 
 
92 INTRA-CRANIAL GROWTHS. 
 
 tinctly presented symptoms like those ascribed to tumours 
 of the corpora quadrigemina, that I have ventured to put 
 it in this section. 
 
 Flechsig 51 has recently called attention anew to the con- 
 nection between the acoustic fibres, especially those of the 
 cochlear nerve, and the posterior corpora quadrigemina. 
 The clinical importance of this relation has not yet been 
 worked out, but the deafness of Case XXII may perhaps 
 have some connection with this anatomical condition. 
 
 6. Tumours of the Pons and Medulla. 
 
 | Case XXIV. N. R. XX-258. Samuel K., 46, married, a 
 waiter, entered the hospital the 8th of October, 1883. He 
 had indulged freely in alcohol, and had had gonorrhoea and 
 a sore, but he denied any secondary symptoms. Eleven 
 months before he entered the hospital he began to have 
 pains across the loins, in the right leg, left shoulder and left 
 leg, the pains being sharp and shooting in the right leg. 
 After this he had numbness in the legs and right arm. Two 
 or three months later he had trouble in walking, the right 
 leg being most affected ; and he did not go out much for 
 fear of falling. He also had stiffness and cramps in the leg; 
 the right arm was weaker than the left and was somewhat 
 stiff. Ht thought that the tactile sensibility was normal. 
 For six weeks he had constant frontal headache, and also 
 lumps on the scalp. He had diplopia and poor vision ; he 
 required glasses for reading; his hearing was good. There 
 were no special respiratory, circulatory or digestive symp- 
 toms. There was a trace of albumen in the urine, and one or 
 two hyaline casts. About the time he began to have trouble 
 in walking, he had some vertigo but the pains in the legs 
 grew less. On examination the left eye was found to be 
 more prominent ; the left pupil was found to be twice the 
 
SPECIAL SYMPTOMATOLOGY. 93 
 
 size of the right ; both reacted feebly to light, the right 
 reacting more than the left. The eyes moved freely in all 
 directions, and, at the time of the examination, there was no 
 diplopia. The tongue was protruded to the left. The facial 
 muscles responded naturally to the will. The right arm was 
 weaker ; the movements, when the eyes were shut, were 
 irregular and jerky; the left arm moved naturally. The 
 movements of the right foot were less extensive and 
 weaker ; the plantar reflex was diminished on the right. 
 The knee jerks were exaggerated, being greater on the right 
 side than on the left. There was patellar clonus but no 
 ankle clonus ; all the deep reflexes were exaggerated in 
 the arms and legs. On the ioth he had slight deficiency in 
 the action of the left external rectus. The right eye was 
 open during sleep ; the right naso-labial fold was less 
 marked ; the left eye moved less readily to the right. The 
 fundus oculi was normal. The right hemiplegia increased ; 
 the tongue protruded to the left; the left eye moved only 
 by the action of the external rectus and oblique ; there was 
 ptosis of the left eye and the pupil of that eye was widely 
 dilated. The right eye was constantly kept open. The 
 muscles of the face on the two sides reacted alike to a weak 
 faradic current. He was dull and stupid and had much 
 headache. The sensibility was not much affected. He grew 
 steadily worse ; bed sores formed ; he became comatose and 
 died on the 5th of November. 
 
 Autopsy. — Chronic adhesive pleurisy and bronchitis. 
 The calvaria was of normal thickness, and adherent to 
 the dura, which was thickened and opaque. The pia was 
 thickened, opaque and slightly oedematous. Both vertebral 
 arteries were adherent to the medulla ; the other vessels were 
 normal. The vessels of the brain were well filled with blood. 
 In the anterior inferior portion of the left lenticular nucleus 
 was a reddened, softened area, measuring about 8 millimetres 
 
94 
 
 INTRA-CRANIAL GROWTHS. 
 
 antero-posteriorly, 1 1 millimetres transversely, and 3 millime- 
 tres vertically. The antero-posterior length of the pons was 
 32 millimetres. On the anterior surface were two reddish- 
 gray areas. On the left half was an area 15 millimetres 
 antero-posteriorly, 13 millimetres transversely, overlapping 
 
 the median line to the 
 right 2 millimetres, 
 and beginning 10 mil- 
 limetres from the ante- 
 rior boundary of pons. 
 On the right anterior 
 pyramid of the medulla 
 was a similar discol- 
 oured spot measuring 
 six millimetres each 
 way, beginning at the 
 median line and five 
 millimetres from the 
 pons. On the left half 
 of the medulla at the 
 fissure between the an- 
 terior pyramid and the 
 olivary body, implicat- 
 ing many of the fibres 
 of the hypoglossal nerve, was a grayish-yellow spot five 
 millimetres by six millimetres, two millimetres from the 
 border of the pons, and four millimetres from the median 
 line. Over these two spots in the medulla the vertebrals 
 were adherent. On section of the pons and medulla these 
 areas were found to correspond with nodules. That of 
 the pons was a single nodule, measuring 15 millimetres 
 antero-posteriorly by 20 millimetres transversely, firmer 
 than the brain substance, reddish-gray for about 6 milli- 
 metres about periphery, with an opaque yellow centre. In 
 
 Fig. 14 (Foster). Case XXIV. 
 of pons. 
 
 Frontal aspect 
 
SPECIAL SYMPTOMATOLOGY. 
 
 95 
 
 the periphery were reddish streaks, evidently vessels. The 
 nodule in the right anterior pyramid was six by four milli- 
 
 Fig. 15 (Foster). Case XXIV. Section through upper growth. 
 
 metres, with a red periphery and yellow centre, occupying 
 nearly the whole of the pyramid. That on the left was 
 six millimetres antero-posteriorly and one millimetre trans- 
 versely. Gummata. 
 
 This case presents many pe- 
 culiarities ; the left third and 
 twelfth nerves were unmistak- 
 ably paralyzed, and there was 
 right hemiplegia. The hemi- 
 plegia was due undoubtedly 
 to the large nodule in the pons, 
 but the lesion in the left len- 
 ticular nucleus may also have 
 taken part in it. The lesion in 
 the pons is also responsible for 
 the paralysis of the left oculo-motor nerve. The lesion at the 
 root of the left twelfth nerve in the medulla is the cause of 
 the paralysis of that nerve. These lesions were diagnosti- 
 
 Fig. 16 (Foster). Case XXIV. Section 
 through lower growth. 
 
 XI = Spinal accessory nerve. 
 
 XII = Hypoglossal nerve. 
 
g6 INTRA-CRANIAL GROWTHS. 
 
 cated before death. The lesion in the right pyramid is not as 
 easy to understand. It apparently gave rise to no symptoms. 
 Whether it did not penetrate deeply enough into the pyramid 
 to cut off motor conduction, or whether it developed only at 
 the close of life when the patient's condition was such as to 
 render a slight left hemiplegia unnoticeable is impossible to 
 say. I think, however, that the record is inaccurate, and 
 that the deeper growth should be on the left. This would 
 correspond with a sketch of a section of the medulla fur- 
 nished me by Dr. S. G. Webber. 
 
 The symptoms of new growths in this region of the brain 
 are often most complex. Careful observation may help us 
 to a correct localization after a study of the distribution of 
 the paralysis. 
 
 The pons and medulla contain the nuclei of most of the 
 cranial nerves, and the great motor and sensory tracts con- 
 necting the cortex with the periphery. The sensory tract 
 probably passes upwards in the tegmentum, the motor tract 
 passes downwards in the middle portion of the anterior 
 border of the crusta. The nerves most commonly affected are 
 the fifth, sixth and seventh ; lower down in the medulla the 
 ninth and twelfth may be involved. As is well known, the 
 motor fibres for the limbs decussate at the lower part of 
 the medulla. A unilateral lesion in the region above ought 
 therefore to produce paralysis of the limbs on the opposite 
 side, and disturbance of the nerve whose nucleus was in- 
 volved on the same side. In the medulla we should there- 
 fore find a crossed paralysis of the tongue and limbs, in the 
 lower pons crossed paralysis of the face and limbs ; higher 
 in the pons crossed paralysis of the limbs with facial anaes- 
 thesia or neuralgia, and still higher in the crus the crossed 
 paralysis of the oculo-motor nerve and the limbs, to which I 
 have already referred. 
 
 Small lesions of the pons may, rarely, affect only one or 
 
SPECIAL SYMPTOMATOLOGY. 97 
 
 more nerve nuclei, and spare the great motor or sensory 
 tract. Other lesions may affect the motor tract alone, caus- 
 ing ordinary hemiplegia. With facial paralysis, if the nucleus 
 of the facial nerve itself be involved, we may get electrical 
 changes of degeneration in the facial muscles. Sensory dis- 
 turbances, except of the fifth nerve from irritation or destruc- 
 tion of its nucleus, seem less common. With tumours lower 
 down in the medulla symptoms of bulbar paralysis may be 
 present, or glycosuria or albuminaria may be present from 
 disturbances in the floor of the ventricle. 
 
 One symptom is of some significance in diagnosis of le- 
 sions of the pons, — conjugate deviation of the head and 
 eyes. It is not an uncommon symptom in cerebral disease, 
 where, in a case of paralysis, the head and eyes are turned 
 away from the paralyzed side, and the patient looks toward 
 the lesion. In cases of unilateral spasm, however, the con- 
 dition is reversed, and the patient looks away from the lesion 
 and toward the convulsed side ; although this is less constant 
 than with paralysis. In lesions of the pons this state of 
 things may be reversed. The patient looks toward the par- 
 alyzed side and away from the lesion ; away from the spasm 
 and toward the lesion. The distinction is of some impor- 
 tance and may afford us help in diagnosis, but it is far from 
 constant, and is by no means a certain guide. 
 
 7. Tumours of the Cerebellum. 
 
 Case XXV. M. R. CLXXXIII-143. John S. ( 28, 
 single, entered the hospital the 9th of April, 1881. A year 
 before entrance he was attacked with nausea and vomiting, 
 the vomiting coming on after taking food, and usually con- 
 taining a dark -brown substance. This persisted, coming on 
 regularly four hours after eating, and three times a day. He 
 had dull pain in the epigastrium. He grew thin, pale and 
 
98 INTRA-CRANTAL GROWTHS. 
 
 weak. Two months before entrance to the hospital the 
 vomiting ceased but the pain persisted. He was anaemic, 
 and had oedema of the legs. He failed rapidly, without 
 marked symptoms. He had considerable dyspnoea and died 
 on the 15th. 
 
 Autopsy. — He had ulcer of the pylorus, penetrating to the 
 pancreas and liver. There was oedema of the lungs, and 
 thrombosis of both common iliac arteries, most marked on 
 the left side. In the posterior extremity of the right lobe 
 of the cerebellum was a mass three-quarters of an inch in 
 diameter, with a hard calcareous shell and putty-like con- 
 tents. 
 
 Case XXVI. M. R. CXV-154. John G., 28, was ad- 
 mitted to the hospital the 25th of May, 1875. No history 
 could be obtained. The eyes were staring, the head twitch- 
 ing ; he threw the bed-clothes off and tried to get out of bed. 
 He passed urine and faeces in bed. He was stupid, tore his 
 hair and slapped himself. His pulse was slow and full. On 
 the 26th he had taches bleuatres. On the 29th he was very 
 stupid, the pulse grew more rapid, the pupils dilated ; he 
 frothed at the mouth, the eyes were motionless and staring, 
 and he did not respond to a touch. His hands were cold, 
 his face livid. On the 30th he was somewhat better and 
 understood what was said, but he failed steadily and died the 
 1st of June. 
 
 Autopsy. — There was tuberculosis of the lungs, peri- 
 tonaeum and intestines. A cheesy mass, the size of an 
 acorn, was found in the cerebellum. 
 
 Case XXVII. N. R. IX-125. Louis H., 30, single, 
 farmer, was admitted to the hospital the 14th of August, 
 1880. He had twice had acute rheumatism. Two months 
 before entrance he had headache and vertigo, which were 
 increased on sudden movements. He had nausea and 
 vomiting in the morning, vomiting the food taken. He had 
 
SPECIAL SYMPTOMATOLOGY. 99 
 
 severe headache, which was most marked in the vertex. 
 His vision was dim. An examination of the eyes showed 
 that the discs were injected, and the outlines indistinct, but no 
 haemorrhages or white patches were seen. On the 19th the 
 right pupil was larger than the left. On the 20th he com- 
 plained of general malaise, and vomited occasionally; he had 
 less headache, but he was dull and heavy. On the 24th he 
 seemed dull, but he answered questions intelligently. A 
 few minutes later respiration became feeble and he died 
 suddenly. 
 
 Autopsy. — The brain was soft and waxy. In the right 
 lobe of the cerebellum was a gelatinous tumour, the size of an 
 English walnut, not encapsulated. The cerebellum was 
 softened about it. The growth was a small round-celled 
 sarcoma. 
 
 Case XXVIII. N. R. VII-259. Tyner S., 14, single, 
 entered the hospital the 13th of December, 1879. A sister 
 died of convulsions. Three years before entrance to the 
 hospital he was said to have had his head bumped on 
 the floor and to have been struck in the belly, causing vomit- 
 ing. After that he had headache and vomiting. Since that 
 time he had vertigo on going down stairs, and he could not 
 walk straight; he walked as if drunk. Every day there was 
 pain in the back of the head below the occipital protuber- 
 ance. He was sleepy and gaped a good deal. For nine 
 months his vision failed. He had six attacks in which he 
 vomited and could not move, but he had no convulsive 
 movements. These attacks were sometimes preceded by a 
 numb feeling extending over the body, and he was sleepy 
 after them. The left side of the head and tongue at times 
 felt prickly, and these attacks of prickly feeling somewhat 
 resembled petit mal. He was somewhat unsteady on walking 
 with his eyes open, the left foot coming down more heavily; 
 he was more unsteady with his eyes shut. He had atrophy 
 
IOO INTRA-CRANIAL GROWTHS. 
 
 of both optic nerves. The sensibility of the right hand was 
 less than that of the left. He had an indurated scar on the 
 back of the head. On the 19th of January he had an attack 
 which began with a tickling feeling in the chin, running over 
 the mouth and the back of the head. The body was some- 
 what stiff. This lasted about ten minutes ; he was conscious 
 after it and said that his mouth felt dry and that he had a 
 pain in the back of the neck. He died that afternoon. 
 
 Autopsy. — The convolutions were flattened. The ventri- 
 cles contained 15 ounces of serum. On the under surface 
 of the cerebellum, in the median line between the cerebellum 
 and medulla, slightly more to the left than to the right, was 
 a tumour measuring three inches across, extending into both 
 lobes of the cerebellum. The tumour contained five cysts, 
 two very large, two very small, and one projecting just be- 
 low the corpora quadrigemina. Several nerves from the 
 medulla were thinner and less white than normal. 
 
 f CASE XXIX. S. R. CXCII-i 12. Robert W., 28, single, 
 a lawyer, was seen by me on the 30th of October, 1890. At 
 the age of seventeen months he had had spinal infantile para- 
 lysis, and the left leg was paralyzed and much wasted. The 
 family history was good. He had used tobacco freely. For 
 two or three years he had had more or less indigestion and 
 constipation. Two years before I saw him he began to have 
 headaches ; it was hard to get on with him ; he disagreed 
 with his family and left home for a time. About fifteen 
 months before I saw him, he began to have severe pain in 
 the right occipital region, and soon after this the vision be- 
 gan to fail. The headache began in the spring of 1889 
 and continued with increased severity during the summer. 
 Early in October he was in bed for a week on account of 
 it; when he got up again his vision was affected; he had 
 occasionally diplopia — sometimes seeing three or even six 
 objects. An examination of the eyes showed that the 
 
SPECIAL SYMPTOMATOLOGY. 10 1 
 
 field of vision was good. The vision was \^ after a 
 slight error of refraction was corrected. There was double 
 optic neuritis. Later there were attacks of nausea and 
 vomiting followed by intense pain in the head. Soon after 
 the failure of vision he lost his sense of smell. The mind 
 was perfectly clear throughout his trouble. After that he 
 had several attacks in which he would cry out, froth a little 
 at the mouth and fall on the floor. The headache, nausea 
 and vomiting persisted after that. The' right eye failed 
 more than the left, and in August, 1890, he was totally 
 blind. About the middle of September he began to 
 complain of poor hearing, especially in the left ear, and of 
 a peculiar distorted, swollen feeling in the mouth, and 
 some numbness of the hands. He talked perfectly intel- 
 ligibly, but he said his speech seemed to him thick. He 
 had been taking iodide off and on for a year, and there was 
 some iodide eruption. He said his forehead felt as if there 
 were a bar through it. He had sudden sharp pains in 
 the head, especially on the left side. The left side of the 
 face was a little swollen. He walked rather unsteadily, but 
 until his vision failed he said he walked perfectly well. The 
 eye-lids drooped, but he could open them easily. The pupils 
 were equal and dilated ; they reacted to convergence but not 
 to light. The left hand was a little weaker than the right and 
 was used a little more awkwardly. The knee-jerk was nor- 
 mal on the right and absent on the left. The sense of smell 
 was lost. The hearing was very poor in the left ear and some- 
 what diminished in the right. The deafness was thought by 
 Dr. J. O. Green to be of nervous origin. The sensibility to 
 touch was good. There was no paralysis. There was a little 
 tenderness on pressure over the right temple. He complained 
 steadily after this of numbness in the face, a stiff feeling in 
 the lips, and an uncomfortable numb feeling in the hands. 
 As the headache grew more severe I advised him to enter the 
 
102 INTRA-CRANIAL GROWTHS. 
 
 hospital for operation. The focal symptoms were too few to 
 enable me to localize the growth, but it was thought best to 
 trephine simply to relieve the intra-cranial pressure. He 
 entered the hospital on the 12th of January, 1891. He com- 
 plained rather more of numbness of the hands, and the 
 movements of the hands were at times uncertain, but the 
 muscular sense was good. Observations of surface tempera- 
 ture gave temperatures of 95.5 to 98.3 F., the highest tem- 
 perature being over the temples, the temperature being equal 
 over the two temples. He was trephined by Dr. E. H. Brad- 
 ford over the tender spot in the right temple on the 19th of 
 January, the dura being opened, and the brain incised. The 
 wound healed promptly, there was no rise of pulse or tem- 
 perature, and he did well. On the 27th there was left facial 
 paresis, the tongue going to the left. The hands were unaf- 
 fected. There was a cerebral hernia the size of half an orange. 
 He returned home the 28th. For about ten days after re- 
 turning home he was somnolent and irritable, he complained 
 much of soreness at the seat of the operation, but the old head- 
 aches had nearly ceased. The paresis increased to nearly 
 complete left hemiplegia and there was left hemiansesthesia. 
 Then the edges of the wound separated, and there was some 
 oozing of serum, blood, and bits of brain matter. On the 14th 
 of February there was an abundant discharge of clear serous 
 fluid from the wound, which continued. On the 16th, he be- 
 came brighter, sat up, was perfectly clear mentally, and com- 
 plained only of some soreness about the wound. The headache 
 had ceased. He continued in this condition for some time, 
 but the hernia sloughed more and more ; and finally on the 
 7th of March he began to have severe pain, and he became 
 comatose, and died on the 9th. 
 
 Autopsy. — Pericranial ecchymosis near the seat of oper- 
 ation. Trephine opening. A large cerebral hernia involving the 
 right upper temporal and lower frontal convolutions and the 
 
SPECIAL SYMPTOMATOLOGY. 103 
 
 base of the. ascending convolutions. Adhesion of the men- 
 inges to the trephine opening. A large tumour was found 
 involving most of the left lateral lobe of the cerebellum, lying 
 close to the transverse fissure. The examination of the brain 
 is not yet complete. 
 
 The tumour in Case XXV had no connection with the 
 symptoms and had probably existed for years, having long 
 ceased to grow or to give rise to any disturbance. The 
 tumour in Case XXVI also had comparatively little to do 
 with the symptoms presented. Cases XXVII and XXIX 
 presented the general symptoms of a brain tumour, without 
 any localizing symptoms. Case XXVIII presented fairly 
 typical symptoms of a cerebellar growth. 
 
 The functions of the cerebellum are still obscure. Mercier 53 
 holds that it is the organ for the co-ordination of movements in 
 simultaneity, the cerebrum being the organ for the co-ordina- 
 tion of movements in succession. Gowers 53 thinks that the 
 middle lobe exerts no downward influence, but that it is a 
 regulating centre for centripetal impulses, having a special 
 relation to motor processes and the maintenance of the equi- 
 librium; the cerebellum having, possibly, an inhibitory influ- 
 ence on the cerebral cortex. It is to be borne in mind that 
 no centrifugal tracts have yet been discovered coming from 
 the cerebellum. All the sets of fibres which have yet been 
 studied run upwards from the cord and basal ganglia into the 
 cerebellum, or from the cerebrum into the cerebellum. It 
 is therefore difficult to see how any impulses can be con- 
 veyed from the cerebellum to the spinal cord or the 
 brain. It is uncertain whether there are any nerve 
 tracts conveying impulses from the cerebellum to the 
 brain or the basal ganglia; at any rate none have yet 
 been discovered. Luciani 54 holds that the inco-ordination 
 seen immediately after ablation of the cerebellum in dogs 
 is due to the phlogistic effects of trauma, and that cere- 
 
104 INTRA-CRANIAL GROWTHS. 
 
 bellar ataxia is due to asthenia, caused by the insufficient 
 energy and imperfect tonus of the motor nervous system, 
 which is manifested later by a rapid decline in nutrition. 
 This rapid decline in nutrition, however, has not been es- 
 pecially noted in lesions of the cerebellum in man. 
 
 Most observers agree that the lateral lobes are latent re- 
 gions, and that tumours situated in them, as in Cases XXVII 
 and XXIX, give rise to no focal symptoms. Tumours of the 
 middle lobe, however, give rise to well-defined symptoms, 
 which have recently been reviewed by Seguin, 55 but which have 
 been recognized by other observers previously, especially by 
 Nothnagel. 49 Case XXVIII is a good example. Seguin thinks 
 optic neuritis commoner from tumours in this region than from 
 tumours elsewhere. The headache is often occipital, and in 
 some cases it is most intense. Vomiting is often more fre- 
 quent than with growths elsewhere, and it may be independent 
 of the ingestion of food, coming on without warning and being 
 unattended with nausea. Nystagmus is not uncommon. 
 Mercier 5 ' 2 and Hughlings-Jackson hold that the spasm in cere- 
 bellar lesions begins with the trunk muscles, extending to the 
 limbs, and being tonic in character. Later observers, how- 
 ever, deny that cerebellar convulsions have this distinctive 
 character. The convulsion in Case XXVIII approaches this 
 type. The convulsion in Case XXIX, however, is at least 
 not typical. The symptom which is said to be character- 
 istic of a tumour of the middle lobe of the cerebellum is the 
 peculiar gait of cerebellar ataxia, titubation, wholly unlike the 
 stamping, throwing gait of tabes dorsalis, and resembling 
 closely the reeling gait of the drunkard. This ataxia is said 
 to be observed only when the patient tries to walk ; when in a 
 recumbent position the legs can be moved accurately. This 
 distinction between tumours of the middle lobe of the cere- 
 bellum and tumours of the lateral lobes is not, however, fully 
 justified. Cases have been reported in which the character- 
 
SPECIAL SYMPTOMATOLOGY. 1 05 
 
 istic gait was seen, although the lesion was in the lateral 
 lobes, and in one of the operative cases cited in Table VIII 
 there was a large cyst outside the cerebellum, but pressing 
 upon one lateral lobe, and yet there was a typical cerebellar 
 gait. Whether such a gait may be due to pressure from 
 without upon the middle lobe is still uncertain, but it seems 
 clear that the typical gait is not necessarily indicative of a 
 tumour which involves the middle lobe. Absence of oculo- 
 motor paralysis may aid us in excluding growths in the 
 corpora quadrigemina, where this ataxic gait has also been 
 observed. With the general symptoms, especially with fre- 
 quent vomiting and with the ataxic gait, if there be no oculo- 
 motor paralysis, we may be reasonably certain that the growth 
 involves the cerebellum, and probably its middle lobe. 
 
 Tumours of the cerebellar peduncles are sometimes at- 
 tended with characteristic symptoms. These will be referred 
 to in the section on tumours at the base of the skull. 
 
 8. Tumours of the Hypophysis. 
 
 Case XXX. N. R. XXIX-182. Eliza S., 58, came to 
 the out-patient department of the hospital on the 15th of 
 February, 1882. She had always been weak, dyspeptic and 
 costive. At this time she complained of headache in the 
 left temporal region, tinnitus of the left ear, failure of vision, 
 pain in the left eye, and formication in the left cheek. The 
 memory was poor. She had vertigo. Some months before 
 she had numbness of the left side. She had paresis of the 
 left side of the face, and weakness of the left side of the 
 body, with some difficulty in articulation, the tongue being 
 protruded to the left. She was sleepy and easily confused, 
 and had frequent dizzy spells. There was also otitis of the 
 left ear, with symptoms of neuralgia on the left side of the 
 face. Soon after she had pain in the right eye. There was 
 
106 INTRA-CRANIAL GROWTHS. 
 
 partial atrophy of the optic nerves, and the field of vision 
 was limited. There was tenderness over the fifth nerve on 
 pressure on the left side. She had left hemicrania, the pain 
 often extending to the left arm and chest. In the middle of 
 April there was tenderness of the left median nerve and 
 transitory hemianopsia. She had nausea and headache. 
 There were pains in the throat and cheek, and numbness in 
 the left ulnar region. On the 1 8th of April, 1886 she en- 
 tered the hospital. At that time she said that in 1 88 1 she 
 had a general swelling of the body, and had vomited blood. 
 She had occasional diarrhoea. Three weeks before entering 
 the hospital, the vision of the right eye had failed suddenly 
 and she was nearly blind. At that time she had headache, 
 vomiting, sleeplessness, pain in the stomach, thirst, anorexia, 
 nervousness, deafness, and a poor memory. The urine con- 
 tained a trace of albumen and a few casts. There were rales 
 heard over the right lung. She was drowsy much of the time, 
 and often complained of headache. The right eye turned 
 outwards, and the lids drooped. The pupils did not react to 
 light. On the 2d of May the right pupil was larger than the 
 left, and both were dilated and immobile. The right eye- lid 
 drooped. She would answer questions rationally; she was 
 drowsier but she could be aroused. On the 4th it was noted 
 that she had optic atrophy in both eyes. On the 7th she 
 had pain in the abdomen, and vomited. On the 14th there 
 was the beginning of a bed-sore. Her strength failed rap- 
 idly ; she became unable to sleep, and died on the 23d of 
 May. 
 
 Autopsy. — Acute general miliary tuberculosis, with pyelo- 
 nephritis and cystitis. Ulcer of the duodenum with per- 
 foration and gangrene of the adjacent parts. There was 
 a depressed yellow area smaller than the little finger-nail 
 in the anterior part of the left caudate nucleus. In the 
 hypophysis the sella turcica was occupied by an ovoid body 
 
SPECIAL SYMPTOMATOLOGY. IOJ 
 
 the size of a walnut, soft, gray and vascular, which proved to 
 be a sarcoma. Both optic nerves, which lay upon this, were 
 flattened. There was a depression in the chiasma ; the left 
 third nerve lay below the tumour and was flattened. 
 
 Tumours of the hypophysis of course closely resemble 
 tumours situated in the anterior fossa and can hardly be dis- 
 tinguished from them. In some cases Seppilli 3 thinks they 
 may be differentiated by the early developement of amaur- 
 osis, often without neuritis, and of oculo-motor symptoms 
 caused by the pressure on the nerves. If one eye be first af- 
 fected it points more definitely to a lesion of the base. From 
 the situation of such a growth we should expect as an early 
 symptom a bi-temporal hemianopsia, followed by the symp- 
 tom of invasion of the oculo-motor nerves. In this case the 
 record as to hemianopsia is vague. The oculo-motor symp- 
 toms were slight, but the fifth nerve was much affected ; the 
 left third nerve, which was found flattened at the autopsy, 
 seems to have performed its functions very well. The left 
 hemiplegia was an early symptom, but it soon disappeared. 
 Some observers have noted polyuria or glycosuria; — others 
 an increase of subcutaneous fat. 
 
 In the autopsies which have been made in the cases of acro- 
 megaly there has been a distinct enlargement of the hypophys- 
 is ; and some writers have considered the enlargement of the 
 hypophysis to be a cause of the acromegaly. Cases, how- 
 ever, of tumours of the hypophysis may exist, like this one, 
 without any acromegaly. It therefore seems more rational 
 to consider the enlargement of the hypophysis in cases of 
 acromegaly to be merely a secondary symptom, an enlarge- 
 ment of an axpov of the body, rather than as a cause of 
 the disease. The chief symptoms of tumours in this region 
 arise from implication of the cranial nerves. I will there- 
 fore refer to the following section for further consideration 
 as to localization. 
 
108 intra-cranial growths. 
 
 9. Tumours of the Base of the Skull. 
 
 Case XXXI. M. R. LXI-24S. Julia P., 44, widow, 
 entered the hospital the 6th of February, 187 1. There was 
 no known heredity. Four years before entrance she had 
 headache for a year, which returned for a time two years 
 later, and again eight weeks before entrance to the hospital. 
 She had sore throat and necrosis of the palate. For two 
 weeks she had trouble in swallowing, weakness, anorexia, * 
 costiveness and frontal headache ; she was thought to be 
 hysterical. On the 8th, she was wandering, and became 
 speechless and unconscious. No paralysis was noted. She 
 passed her urine and faeces in bed. On the 9th she died. 
 
 Autopsy. — The dura was rough and villous, and was 
 thickened over the left fissure of Sylvius, attaining a thick- 
 ness of -A of an inch. The brain was adherent to the dura 
 
 1 O 
 
 just anterior to the middle part of the posterior lobe and 
 was softened over a space half an inch in diameter. Below 
 the anterior cornu of the left lateral ventricle, resting on the 
 base of the skull, was a gray tumour, with a yellow centre, 
 -| of an inch deep and an inch long. The bone beneath 
 was eroded. 
 
 CASE XXXII. N. R. LIII-268. George D., 33, married, 
 a shipping clerk, entered the hospital the 12th of July, 1889. 
 Two years before entrance, he had probably had syphilis. 
 He complained of headache, and pain in the stomach, and 
 vomited for ten days. For a week he had acted strangely 
 and his memory was very poor. He had great pain in the 
 frontal region. For a few days he was stupid and forgetful. 
 Two days before entering the hospital he had an attack of 
 right hemiplegia. His appetite was poor ; he was somnolent. 
 The tongue was protruded to the right; the left pupil was 
 larger than the right and irregular in shape, but the irregu- 
 larity was due to an old iritis. The knee-jerks were exag- 
 
SPECIAL SYMPTOMATOLOGY. IO9 
 
 gerated ; the elbow jerk was greater on the left. On the 
 20th he seemed brighter. On the 25th he was weaker, and 
 could hardly speak. He failed rapidly, became comatose, 
 and died. 
 
 Autopsy. - — The pia at the base was thick and opaque in 
 patches with puckered radiations. The left anterior cere- 
 bral and anterior communicating arteries were nearly oblit- 
 erated by endarteritis. Beneath the pia in the frontal lobe, 
 close to the anterior communicating artery, was a yellow 
 nodule with a red periphery, the size of a hemp-seed. The 
 anterior third of the left caudate nucleus was depressed and 
 red. The tissue of the caudate nucleus, the internal cap- 
 sule, and the anterior tip of the lenticular nucleus could be 
 made out, but the whole was softer, with a yellow centre and 
 a red periphery, containing fatty-degenerated ganglion cells, 
 granular capsules, fat drops, and fine granules with broken- 
 down nerve fibres and vessels with ischsemic softening. 
 
 CASE XXXIII. N. R. VII-210. Russell R., 35, single, 
 a piano-maker, entered the hospital the 16th of November, 
 1879. He had used tobacco and alcohol to excess. He 
 was distinctly anaemic Twelve or fourteen years before he 
 had received a blow on the back of the head, and had had more 
 or less headache ever since. Four years before entrance the 
 vision began to fail. Six or eight weeks before entrance he 
 had severe headache and was unconscious for half an hour. 
 There were no convulsions or paralysis. Three days before 
 entrance he had severe headache, went to bed, and became 
 unconscious. He was unable to answer questions, but he 
 had no paralysis. On the 17th he was able to answer quest- 
 ions ; he was found to be nearly blind in the right eye, and 
 wholly blind in the left. The urine contained albumen and 
 casts. On the 21st he was delirious. On the 26th the 
 pupils were widely dilated. He had not answered questions 
 for two or three days, and he died on the 26th. 
 
110 INTRA-CRANIAL GROWTHS. 
 
 Autopsy. — At the base of the median line, from the front 
 of the pons to beyond the fissure of Sylvius, was a tumour two 
 by two and a half inches, the size of the fist, with an irregu- 
 lar, lobulated, flaky surface, with blood vessels over the 
 surface. The convolutions were flattened. The brain was 
 soft and contained a puriform fluid over the tumour. The 
 bones at the base of the skull were rough and carious, and 
 the base of the sphenoid and its lesser wings were ulcerated 
 through. 
 
 Case XXXIV. M. R. CCXLI-62. Andrew F., 46, 
 single, painter, entered the hospital the 1st of April, 1886. He 
 had indulged somewhat in alcohol, and had had gonorrhoea. 
 For three weeks he had a cough, with expectoration, dys- 
 pnoea, orthopncea, palpitation, headache, oedema of the 
 feet, indigestion, and frequent micturition. Sibilant rales 
 were heard over the chest. The urine contained albumen, 
 fat and casts. On the 8th he was very violent and abusive, 
 and had Cheyne-Stokes respiration. On the 9th he became 
 unconscious, gradually failed, and died on the 10th. 
 
 Autopsy. — Cardiac hypertrophy, interstitial pneumonia, 
 emphysema, and bronchitis. Contracted kidney. Stricture 
 of the urethra and hypertrophy of the bladder. Below the 
 left half of the cerebellum, where the middle peduncle is 
 given off, was found in the pia a firm, translucent, lobulated 
 nodule, the size of a cherry. 
 
 Case XXXV.* M. R. LXI-80. Mary S., 19, single, 
 a domestic, entered the hospital the 2d of January, 1871. 
 For over a year she had had neuralgic headaches, with occas- 
 ional vomiting, increasing in frequency and severity. For 
 six months she had had neuralgia of the right side of the face. 
 For a year there was a change in her voice. She had much 
 vertigo, and her gait was like that of a drunken person. The 
 
 * This case has been reported by Dr. S. G. Webber. Archives of Scientific and 
 Practical Medicine, February, 1873. 
 
SPECIAL SYMPTOMATOLOGY. 
 
 Ill 
 
 head was tremulous, the grasp stronger on the right. A 
 month before entrance the right eye became inflamed, and 
 rapidly became destroyed. There was a general flushing of 
 the skin, and slight facial paralysis on the right. There was 
 nose-bleed ; the right nostril was narrower and was full of 
 mucus. The right side of the mouth could not be perfectly 
 closed, and there was an excessive amount of saliva flowing 
 from it. The tongue was protruded straight and was some- 
 what flatter on the right side. The senses of touch and taste 
 were better on the left side of the tongue. The food stuck 
 in the right side of the mouth, and the right side of the 
 palate was flabbier. The ticking of a watch could be heard 
 at three inches from the left ear ; gradually she became 
 totally deaf in that ear. Later there was optic neuritis in the 
 left eye and the pupil of that eye was dilated. There was 
 anaesthesia in the distribution of the right trigeminal nerve. 
 The headache increased. Later she had paresis of the left 
 leg. She suddenly became blind, and the blindness was 
 followed by a slight return of vision and intense pain. Some 
 hours later there was spasm of the right side, she became 
 comatose and died on the 30th. 
 Autopsy. — The skull was 
 thin in the temporal region. 
 The convolutions were flat- 
 tened. Just below the tento- 
 rium was a gliomatous tumour 
 an inch and a half in diameter, 
 growing from the meninges, 
 and spherical in shape. There 
 was a haemorrhage in the centre 
 of the growth, the colour of 
 the growth being gray. The 
 pons, medulla, and middle pe- 
 duncle were pressed upon on 
 
 Fig. 17 (Webber). Case XXXV. 
 V = Trigeminal nerve. 
 VI = Abducens nerve. 
 VII = Facial nerve. 
 VIII = Auditory nerve. 
 
I I 2 INTRA-CRANIAL GROWTHS. 
 
 the left side and the pons and medulla were pushed to the 
 right. The right fifth nerve was softened, probably from 
 pressure ; the left fifth nerve was displaced but it was not 
 pressed upon ; the right nerve was somewhat degenerated. 
 The eighth nerve on the left was involved in the growth, the 
 left seventh nerve was not affected. 
 
 Of these cases only one presented any distinct symptoms. 
 Case XXXI presented only vague general symptoms, largely 
 hysterical in appearance. Case XXXII presented no special 
 symptoms of basal trouble, the symptoms being due very 
 largely, if not almost wholly, to the softening of the basal 
 ganglia. Case XXXIII is a striking example of the few 
 symptoms that an extensive lesion may sometimes cause. 
 Case XXXIV had no symptoms that could not be accounted 
 for by the renal disease. In Case XXXV the symptoms were 
 due to remote pressure, and not to the tumour itself. In this 
 case the lesion was thought to be on the right side, involving 
 the fifth nerve upon that side ; instead of that, it involved the 
 fifth nerve upon the left and the right nerve was affected 
 only by the remote pressure. 
 
 The focal symptoms of tumours of the base are due chiefly 
 to the affection of the cranial nerves. According as the 
 growth lies in the anterior, the middle, or the posterior fossa, 
 the symptoms will vary. Tumours of the anterior fossa may 
 be attended in the first place with disturbances of smell, from 
 involvement of the olfactory nerve. If the tumour attains a 
 considerable size we may expect mental impairment similar 
 to that seen in cases of tumour of the frontal lobe; but this 
 impairment is distinctly less than in the cases where the lobe 
 itself is affected. In a few cases the growth has pressed 
 downwards upon the roof of the orbit, and has either pressed 
 the roof downwards or has penetrated into the orbital cavity, 
 giving rise to exophthalmos. If the tumour extend further 
 backwards in the anterior fossa the optic chiasma will be 
 
SPECIAL SYMPTOMATOLOGY. I I 3 
 
 involved. Tumours in this region will, of course, resemble 
 closely tumours of the hypophysis; the visual disturbance 
 will be prominent. This disturbance may take the form of 
 unilateral blindness from affection of one nerve ; a bitem- 
 poral hemianopsia from affection at the chiasma itself, or 
 homonymous hemianopsia from an affection of the nerve 
 back of the decussation. If blindness begins in one eye and 
 then goes to the other it is suggestive of a lesion at the base 
 involving first one nerve and then the other. 
 
 The characteristic symptoms of tumours of the middle 
 fossa arise from pressure on the third and fifth nerves. A 
 tumour situated in the anterior portion of this fossa may 
 involve the optic chiasma, and produce symptoms similar to 
 those spoken of with tumours of the anterior fossa. Isolated 
 paralysis of the fourth nerve, from a growth at the base, is 
 exceedingly difficult to diagnosticate, and it can be done only 
 by careful tests for double vision, when one eye is covered 
 by a coloured glass. The symptoms of paralysis of the third 
 nerve are much more striking and much easier to determine. 
 Where single muscles supplied by the third nerve are 
 paralyzed the trouble is more apt to be due to a lesion of the 
 nuclei, but this is by no means always the case. In syphil- 
 itic basilar meningitis transitory paralyses of single muscles 
 are not infrequent, but a tumour affecting the nerve outside 
 of the brain will be much more apt to cause a paralysis of all 
 the muscles supplied by the nerve. Tumours in this region 
 may also exert pressure upon the crus cerebri, and thus give 
 rise to hemiplegia. In such a case the symptoms may 
 closely resemble those of a tumour of the crus, which have 
 already been spoken of. Here the oculo-motor paralysis is 
 more apt to precede the hemiplegia, while with tumours in 
 the crus the opposite condition obtains. 
 
 Tumours of the posterior fossa may present symptoms 
 similar to those of the crus, pons or medulla, crossed para- 
 
114 INTRA-CRANIAL GROWTHS. 
 
 lyses in various forms predominating. These paralyses are 
 due, of course, to pressure upon the motor tract before it 
 decussates, and upon the cranial nerves which have already 
 decussated. The nerves which go off from the brain stem in 
 this fossa are the fifth, sixth, seventh, eighth, ninth, tenth, 
 eleventh, and twelfth. The symptoms due to lesions of the 
 nerves usually precede the general motor and sensory symp- 
 toms. Where the fifth nerve is involved there will be neuralgia 
 in the nerve, followed by anaesthesia in its distribution, and 
 perhaps by neuro-paralytic ophthalmia and weakness of the 
 muscles of mastication, as in Case XXXV. Anatomical con- 
 siderations will explain certain other features. The sixth nerve 
 may be affected without any conjugate action of the opposite 
 internal rectus, such as is seen in disease of the pons. The 
 facial and auditory nerves are affected together, although it 
 is to be borne in mind that the facial nerve from its denser 
 consistency, is much more tolerant of disease than is the 
 auditory. 
 
 I have not spoken under a separate heading of tumours 
 involving the middle peduncle of the cerebellum, yet this 
 peduncle was pressed upon, if not directly involved, in Cases 
 XXXIV and XXXV. Lesions of the middle peduncle of the 
 cerebellum cannot readily be separated from lesions of the 
 base involving the peduncle. In some cases lesions of this 
 region give rise to so-called forced movements or rotatory 
 movements toward the opposite side. Should this occur, 
 especially if associated with disturbance in the distribution of 
 the cranial nerves, which go off near the peduncle, we may 
 reasonably infer that the growth has involved the peduncle ; 
 yet these forced movements were absent, or at least not 
 noted, in these two cases. 
 
special symptomatology. i i 5 
 
 10. Multiple Tumours. 
 
 Case XXXVI. M. R. CCLXXXVI-94. Mary W., 
 29, married, entered the hospital the 18th of May, 1889. 
 Her previous history is uncertain. For three months she 
 had had pain in the head, neck and abdomen, with obstinate 
 vomiting. Four months before entrance she was confined, 
 and three weeks after that she was attacked by the present 
 trouble and steadily grew worse. Her temperature was 103. 
 The lower portion of the abdomen was tender; the spleen 
 was enlarged, and a round body was felt in the vicinity 
 which could be moved to the right side. There was an 
 offensive leucorrhcea. The uterus was movable, retroverted 
 and much eroded. During the first week she was in the hos- 
 pital she lay with her face covered. She had much head- 
 ache, and one or two attacks of loss of consciousness in 
 which the eyes were rolled up. The back of the neck 
 seemed tender. On the 27th she was noisy, cried consider- 
 ably, and seemed stupid. On the 29th there was retention 
 of urine. She would not answer questions intelligently, but 
 would put out her tongue when asked. The pupils were 
 sluggish ; the right was larger than the left. The abdomen 
 was distended and tender. On the 30th there was marked 
 strabismus. On the 31st she became comatose; her pulse 
 was weak and rapid ; she had difficulty in swallowing. On 
 the 1st of June she died. 
 
 Autopsy. — General tuberculosis, tubercular meningitis. 
 There was an opaque cheesy nodule about the posterior part 
 of the left fissure of Sylvius ; another outside the right optic 
 thalamus; another in and below the medulla; and still 
 another in the cerebellum. There were thirteen of these 
 growths in various parts, from the size of a small pea to the 
 size of a cherry. 
 
 Case XXXVII. M. R. CCLXVI-38. Robert G., 22, 
 
Il6 INTRA-CRANIAL GROWTHS. 
 
 single, a farmer, entered the hospital the 2d of February, 
 1888. The family history was good, and he had always 
 been in good health. Five weeks before entering the hospi- 
 tal he was attacked with nausea, vomiting and vertigo. He 
 vomited yellow, bitter matter immediately after eating. 
 These symptoms continued, and he had also constant sweat- 
 ing. There was no pain in the abdomen. There was very 
 severe frontal headache, which was worse at night. His 
 appetite was poor and he was very costive ; he slept little. 
 During the month following entrance he had much headache 
 and vomited a good deal. He grew steadily weaker. On 
 the 9th of March there was retraction of the abdomen. 
 Several purple spots were seen over the lower abdomen 
 and tache cerebrale was noted. On the 21st optic neuritis 
 was noted, which was most marked in the right eye. There 
 was slight paresis of the right oculo-motor nerve. On the 
 2 1st he failed rather suddenly, his pulse became weaker and 
 rapid, and he died. 
 
 Autopsy: — The calvaria was half the usual thickness, and 
 showed the impression of the convolutions. The dura was 
 red and vascular; the pia dry; the convolutions were 
 flattened ; the sulci obliterated. The lateral ventricles were 
 twice the usual size. In the floor of the right lateral ventri- 
 cle, near the tip of the caudate nucleus, was a pale, gray, 
 gelatinous, ovoid, projecting nodule the size of a pea, 
 another the size of a filbert meat. In the floor of the third 
 ventricle was a similar flat nodule the size of a filbert meat. 
 The cavity of the fourth ventricle was occupied by a soft, 
 grayish, translucent growth, adherent to the whole of the 
 floor except over an area the size of a finger nail, and also 
 involving the roof of the ventricle and cerebellum as far as 
 the olivary body. The upper surface of the cerebellum was 
 elevated. The growths were gliomata. 
 
 CASE XXXVIII. N. R. XLVIII-150. Charles B., 39, 
 
SPECTAL SYMPTOMATOLOGY. I I 7 
 
 married, a grocer, entered the hospital the 26th of October, 
 1888. He denied any venereal disease. For a year he had 
 been in poor health. Six weeks before entrance he found 
 himself very weak on rising in the morning, although he was 
 as well as usual the night before. He could stand and 
 walk, but he could not articulate plainly. He was in a con- 
 fused mental state, and could not attend to business. He 
 kept about his work for two weeks and then gave up. At 
 that time it was thought that his right arm was not as strong 
 as his left. There was occasional diplopia. He was costive 
 and slept poorly. The pulse was rather slow — 58. The 
 urine contained a trace of albumen. There was a slight 
 amount of paresis of the right side of the face. On the 1st 
 of November he complained a good deal of headache, but 
 his general condition improved. On the 9th his mental con- 
 dition was duller ; his answers were irrelevant, his speech 
 indistinct. The disturbance of speech became more marked ; 
 he was unable to whistle; his pulse was still slow. He was 
 given iodide of potassium which diminished the headache. 
 On the 11th he answered still more irrelevantly; the paresis 
 of the face was more marked. That afternoon he became 
 unconscious; he had some expiratory dyspnoea with cyan- 
 osis, and died early the next morning. 
 
 Autopsy. — The dura was tense ; the piadry; the convol- 
 utions flattened ; the sulci obliterated. The lateral ventri- 
 cle was somewhat dilated. In the under surface of the left 
 frontal lobe, at the entrance of the fissure of Sylvius, corre- 
 sponding to the anterior tip of the temporal lobe, was a 
 reddish-gray nodule with an opaque, yellow centre, the size 
 of a large pea, imbedded in the brain and intimately con- 
 nected with the pia. The brain surrounding it was yellower 
 and softer. In the brain substance anterior to and outside 
 of the caudate nucleus was a similar growth, the size and 
 shape of a peanut meat; three centimetres back of this was 
 
I I 8 INTRA-CRANIAL GROWTHS. 
 
 another, the size of a walnut, just outside of the nucleus and 
 extending to the pia at the base. In the outer segment of 
 the left lenticular nucleus was a cavity the size of a filbert. 
 The white matter of the left centrum ovale, outside the 
 anterior half of the basal ganglia, was pale yellow and the 
 consistency of baked custard. There were haemorrhages 
 between the circular fibres of the pons four millimetres below 
 the floor of the fourth ventricle. The tumours were found 
 to be gummata. 
 
 Case XXXIX. N. R. IV-163. William B., 31, married, 
 a printer, entered the hospital the 30th of July, 1878. Three 
 months before entrance he had an attack of hiccoughs, 
 which had recurred. There was pain in the legs, left arm, 
 and wrist for two weeks ; these pains were increased on 
 walking. The knee-joints were tender. Two days before 
 entrance he had three fits within an hour. The mouth was 
 drawn to the right; he frothed at the mouth and lost con- 
 sciousness. He had a cough and signs of phthisis in the left 
 lung. On the 2d of August his mind wandered, and he 
 answered questions less quickly. He failed rapidly, and died 
 on the 3d. 
 
 Autopsy. — Tuberculosis of the lungs, liver, kidneys, in- 
 testines, testicles, and supra-renal capsules. The dura was 
 adherent. There was a yellow band along the fissure of 
 Sylvius. The pia was thick, the vessels injected. There 
 was a cheesy tumour the size of a bean, in front of the pre- 
 central sulcus, between the second and third frontal convolu- 
 tions ; another, the size of a bean, in the anterior part of the 
 right first temporal convolution. There was a tumour, half 
 an inch in diameter, on the right side of the pons, on a level 
 with the fifth nerve, between the point of exit and the 
 median line. There was a tumour a quarter of an inch in 
 diameter in the lower part of the olivary body. There were 
 others in the anterior and under surfaces of the cerebellum. 
 
SPECIAL SYMPTOMATOLOGY. 119 
 
 CASE XL. M. R. XXIX-34. Martha B. was brought to the 
 hospital unconscious on the 17th of March, 1886. She was 
 said to have suffered from exposure and privation, and to 
 have been unconscious for four days. She was somnolent 
 but she could be roused to slight consciousness. The re- 
 spiration was quiet, with some remissions ; the pulse was 
 weak and intermittent. The pupils varied independently of 
 light, the right pupil being larger. The eyes at times 
 moved independently. She resisted passive movements of 
 the limbs. The heart was enlarged, and a systolic murmur 
 was heard at the apex. She opened her eyes and moaned ; 
 she protruded the tongue straight ; there was no paralysis. 
 The temperature was 100.6. On the 18th she was conscious, 
 but slow to answer. She complained of headache, and said 
 her attack was due to a fall. There was tremor of the 
 tongue, lips, and hands. The pupils reacted to light. The 
 temperature was normal. On the 25th she was drowsier, 
 but she talked occasionally. There was some trouble in 
 swallowing. The arms were rigid. The left arm was moved 
 less than the right. There was no paralysis. The knee- 
 jerks were normal. The tremor still persisted. She had 
 cystitis. On the 31st she was harder to rouse; she lay with 
 her head and eyes turned to the right, and she turned them 
 to the left only with effort and apparent pain. The scalp 
 and back of the neck were very sensitive to pressure. She 
 swallowed very slowly and with great difficulty. April 1st, 
 she was unable to swallow and could not be roused. She 
 lay with her mouth open and the lips drawn. There was 
 divergent strabismus. The left pupil was dilated, the right 
 contracted; neither reacted to light. On the 3d the mouth 
 at times was drawn to the left. It was hardly possible to 
 make her swallow or answer. The night before she had a 
 spasmodic attack lasting for ten minutes, the twitching being 
 confined to the left side, including the face. After this the 
 
120 INTRA-CRANIAL GROWTHS. 
 
 mouth was drawn still more to the left. The left side of the 
 forehead was wrinkled, the right side smooth. She was 
 very dull. The arms were rigid; the rigidity was greater 
 on the left side. The knee-jerks were normal. The right 
 leg could be raised, and she gave signs of pain when it was 
 pinched. She would try to draw up the left foot when it 
 was pinched but she could scarcely move it; she would 
 draw up the right. For three days there were no voluntary 
 movements of the hands or eyes. The neck and head were 
 less sensitive. On the 4th the face was not drawn so much 
 to the left. The pulse and respiration varied. The pupils 
 were contracted and equal, dilating upon pinching the arm. 
 She could not be roused. On the 5th she could not swallow, 
 and choked when food was given her. She had not 
 spoken since the 2d. Portions of the face were flushed at 
 times. There was occasional divergent strabismus in the 
 right eye. The head was very much retracted. There was 
 no rigidity on the left side. On the 7th the respiration and 
 pulse became very rapid ; respiration 108, pulse 160. The 
 respiration diminished to 60, the pulse increased to 210. 
 She was unable to swallow. The rigidity had disappeared. 
 The pupils were of moderate size. The weakness and coma 
 increased and she died. 
 
 Autopsy. — Emphysema, bronchitis, bronchopneumonia, 
 and pericranial ecchymoses. The calvaria was thin ; the 
 piadry; the convolutions were flattened. At the apex of 
 the right fissure of Sylvius, and in the corresponding part 
 of the first temporal convolution were two yellow patches in 
 the pia six millimetres in diameter; on section these proved 
 to be two firm, yellow, opaquen odules in the brain sub- 
 stance, the size of a split pea, both surrounded by gray, 
 translucent tissue two millimetres thick. In the middle of 
 the corpus callosum, extending three centimetres to the 
 right, there was a nodule the size of a large horse-chestnut 
 
SPECIAL SYMPTOMATOLOGY. 121 
 
 partly yellow and firm, partly reddish, involving the right 
 centrum ovale from the roof of the ventricle about two 
 centimetres vertically. In the right parietal lobe, just back 
 of the fissure of Sylvius, there was a dark red nodule, the 
 size of a filbert, like clotted blood, in a cavity whose walls 
 were of brain substance except at the anterior part, where 
 there was a firmer vascular area uniting the clot to the brain 
 substance. In the middle of the right optic thalamus was a 
 circumscribed globular nodule, the size of a filbert, of the 
 same red vascular structure. At the junction of the right 
 parietal and temporal lobes there was a similar nodule in the 
 white matter near the cortex, the size of a filbert meat. 
 The white matter of the right centrum ovale was bluish- 
 white, showed no puncta cruenta, and was much denser than 
 the rest of the brain. Some of these growths were ex- 
 amined and proved to be gummata. 
 
 To these cases we ought of course to add Cases XXI 
 and XXIV, but as in these cases the growths were all in 
 one region, I was led to place them elsewhere. 
 
 Case XXXVI had general tubercular meningitis; Case 
 XXXVII presented the general symptoms of tumour but 
 hardly any focal symptoms; Case XXXVIII presented still 
 fewer general symptoms and no definite focal symptoms,; 
 and Case XXXIX showed also no general symptoms of tum- 
 our, and only obscure symptoms of brain disease. Case 
 XL, also, showed symptoms of meningitis rather than of 
 tumour, and was certainly suggestive of a general syphilitic 
 basilar meningitis, involving some of the cranial nerves, but 
 not completely destroying them. 
 
 In rare cases, especially where there are only two tum- 
 ours, they may each present such definite focal symptoms 
 as to render the diagnosis of a multiple growth possible, as 
 happened, for instance, in Case XXIV, where the location 
 of two growths was diagnosticated during life, although the 
 
122 INTRA-CRANIAL GROWTHS. 
 
 presence of the third was not suspected. In other cases 
 one tumour gives rise to definite focal symptoms, and the 
 other growths cause no distinctive phenomena, or the two 
 growths may lie close together in the same region, each, 
 perhaps, being accountable for the symptoms. Case VIII 
 and Case XXI came near to answering this requirement. In 
 other cases we have only general symptoms of tumour. In 
 other cases still, as in those just reported, the diagnosis of 
 multiple growths becomes impossible. We may suspect 
 such a condition in certain general dyscrasiae (tubercle, 
 cancer, and' melanotic growths), but it is rarely possible to 
 make a definite diagnosis. As the statistics show that in at 
 least one-seventh of the cases of brain tumour the growths 
 are multiple, and as it is impossible absolutely to exclude 
 multiplicity when the symptoms can all be attributed to 
 the presence of a single growth in one definite region, the 
 importance of multiple growths in the surgical treatment of 
 brain tumours is evident. 
 
DIAGNOSIS. 123 
 
 VI. DIAGNOSIS. 
 
 MUCH has already been said on the question of diagnosis. 
 It will be well to recapitulate briefly the more important 
 features to be borne in mind. The problems to be solved 
 are, first, to decide as to the presence of an intra-cranial 
 growth; second, to decide as to the location of the growth ; 
 and, third, to decide as to the nature of the growth. 
 
 1. The Diagnosis of the Existence of a Tumour. 
 
 The diagnosis of an intra-cranial growth must be based 
 chiefly upon the general symptoms already discussed ; the 
 focal symptoms, while of much value as corroborative evid- 
 ence, are usually of secondary importance, for they are due 
 to the seat of the lesion rather than to its nature. Given the 
 characteristic general symptoms with the addition of focal 
 symptoms, the diagnosis becomes easy. With general 
 symptoms alone it is often hard to exclude other affections. 
 
 Of cerebral affections which may be confused with brain 
 tumour we may mention abscess, meningitis, thrombosis or 
 haemorrhage, lead encephalopathy, hysteria, migraine, and 
 paretic dementia ; of other affections contracted kidney and 
 hypermetropia are those most likely to be mistaken for a 
 tumour. 
 
 The distinction between abscess and tumour is often diffic- 
 ult. Optic neuritis is less common in abscess, and chills or 
 rise of temperature may be present. The presence or 
 absence of these symptoms, however, is by no means 
 distinctive. The chief argument against abscess is the 
 
1 24 INTRA-CRANIAL GROWTHS. 
 
 absence of any source for suppuration, especially suppurative 
 disease of the middle ear or the nose. 
 
 It is easy to distinguish between typical cases of meningi- 
 tis and tumour. Localized meningitis of chronic course can 
 often not be distinguished from a tumour. As we have seen 
 in the chapter on pathology, tuberculosis or syphilis may give 
 rise to diffuse meningeal changes or to more discrete lesions 
 which, if of chronic course, become actual neoplasms ; and, in 
 the cases recorded, we have found the two conditions of tumour 
 and meningitis frequently co-existing. A chronic course, 
 symptoms of increased pressure, optic neuritis, and certain 
 marked focal symptoms, such as aphasia or monoplegia, 
 are more suggestive of tumour ; but the distinction can 
 seldom be made with certainty, except in the cases when we 
 can definitely localize the trouble within the brain substance. 
 In a few cases a tumour may give rise, to symptoms 
 resembling those of haemorrhage or thrombosis, as in Case 
 XVI. Here the difficulty is due to the absence of the more 
 characteristic signs of a tumour, optic neuritis, headache, etc. 
 In ordinary cases the presence of these symptoms and the 
 nature of their onset will render a diagnosis possible. 
 
 Inasmuch as lead may give rise to optic neuritis, headache, 
 vomiting, convulsions, and mental impairment, it is not 
 strange that lead encephalopathy may be mistaken for 
 tumour. The distinction must rest on the history of ex- 
 posure, the detection of other symptoms of lead poisoning, 
 and the presence of lead in the urine. 
 
 Case XXXI was thought to be hysterical ; I recall a case 
 of profound hysteria that was for weeks thought to be 
 brain tumour. The mistake has been made by more than 
 one skilled neurologist. Headache, vomiting, partial epi- 
 lepsy, anaesthesia, amaurosis, monoplegia, may all be seen 
 in hysteria. Optic neuritis and hemianopsia are strong evid- 
 ence in favour of organic disease. In many cases, however, 
 
DIAGNOSIS. 125 
 
 the decision can be made only after prolonged and careful 
 observation. The impression which a hysterical patient 
 makes on the observer is often of much value. Facial or 
 oculo-motor paralysis is rarely if ever seen in hysteria, 
 while the presence of the hysterical stigmata is evidence in 
 favour of that affection. 
 
 It is usually easy to distinguish between tumour and 
 migraine, but if the headache of tumour be of varying 
 intensity and there be no neuritis or focal symptoms, and if 
 the early history of long-continued attacks of headache be 
 wanting some difficulty may arise. 
 
 Case XIV presented a fairly typical picture of paretic 
 dementia, and all who saw him made that diagnosis. Such 
 cases are rare, and ordinarily no confusion would arise. The 
 speech, handwriting, fibrillary tremors and facial expression 
 of paretic dementia on the one hand, and optic neuritis, 
 headache, vomiting, and vertigo of tumour on the other 
 make the distinction easy. 
 
 When uraemic symptoms develope in cases of contracted 
 kidney the patient may have headache, vertigo, vomiting, 
 and partial epilepsy. There may be retinitis with white 
 spots and haemorrhages in the macular region, which may 
 be mistaken for the neuritis of brain tumour,- although in 
 the former the changes are more marked in the retina, and 
 in the latter in the nerve. Repeated examinations of the 
 urine, as to quantity as well as quality, determination of 
 the size of the heart, and a study of pulse-tracings may give 
 valuable evidence in favour of contracted kidney. In the 
 forty cases here collected, however, renal disease and a 
 tumour have sometimes both been present. In such cases 
 the problem becomes much more difficult, and its solution, 
 as we have seen, is often impossible. 
 
 It sometimes happens that with hypermetropia the patient 
 may have not only severe headache but also a little swelling 
 
126 INTRA-CRANIAL GROWTHS. 
 
 and haziness of the discs if the eyes have been much used. 
 Such a case once caused me to be for a day or two some- 
 what suspicious of a new growth. The absence of other 
 symptoms, and the detection of hypermetropia by careful 
 ophthalmoscopic tests and tests with lenses will usually solve 
 any doubts. 
 
 2. The Diagnosis of the Location of a Tumour. 
 
 In the preceding section the focal symptoms of a tumour 
 have been gone over sufficiently to render it unnecessary to 
 speak in much detail here as to the focal diagnosis. I will, 
 therefore, cite very briefly the striking focal symptoms of 
 tumours in the various regions of the brain. 
 
 Pre-Frontal Region. — Marked mental impairment ; symp- 
 toms of invasion (partial epilepsy, aphasia) ; disturbances of 
 smell. 
 
 Central Region. — Partial epilepsy; monoplegia; partial 
 anaesthesia; motor aphasia. 
 
 Posterior Parietal Region. — Word blindness; disturbance 
 of muscular sense ( ?) ; homonymous hemianopsia. 
 
 Occipital Region. — Homonymous hemianopsia ; soul 
 blindness. 
 
 Temporo- Sphenoidal Region. — Latent region. Word- 
 deafness; disturbances of taste, smell, and hearing (?). 
 
 Corpus Callosnm. — Latent region. Progressive hemi- 
 plegia, often bilateral, from invasion. 
 
 Optico-Striate Region. — Hemiplegia ; contracture. In 
 posterior part, hemianaesthesia, homonymous hemianopsia, 
 post-paralytic chorea, athetosis. 
 
 Cms Cerebri. — Crossed paralyses of oculo-motor nerve 
 and limbs. 
 
 Corpora Quadrigemina . — Oculo-motor paralyses ; reeling 
 gait; blindness (?); deafness (?). 
 
DIAGNOSIS. 127 
 
 Pons and Medulla. — Crossed paralyses of face and 
 limbs or tongue and limbs. Other cranial nerve lesions. 
 
 Cerebellum. — Marked cerebellar ataxia ; marked vomiting; 
 often a latent region. 
 
 Base, Anterior Fossa. — Mental , impairment, disturbance 
 of smell and sight, exophthalmos. 
 
 Base, Middle Fossa. — Disturbance of sight ; oculo-motor 
 disturbances; hemiplegia. 
 
 Base, Posterior Fossa. — Trigeminal neuralgia ; neuro- 
 paralytic ophthalmia ; paralyses of face and tongue ; dis- 
 turbance of hearing; crossed paralyses. 
 
 Hypophysis. — Disturbances of vision; oculo-motor dis- 
 turbances. 
 
 In addition to determining the seat of a tumour, it often 
 becomes of some importance, in tumours of the cerebrum, 
 to determine whether they are in or near the cortex or deeper 
 down in the white matter. The symptoms are often much 
 the same, but Seguin 17 has formulated certain rules which 
 are of some value, although, as he states, the distinction is 
 often only conjectural. " In favour of a strictly cortical or 
 epicortical lesion are these symptoms, none of them having 
 specific or independent value: localized clonic spasm, epilep- 
 tic attacks beginning by local spasm, followed by paralysis ; 
 early appearance of local cranial pain and tenderness ; 
 increased local cranial temperature. In favour of subcorti- 
 cal location of a tumour: local or hemiparesis followed 
 by spasm ; predominance of tonic spasm ; absence, small 
 degree, or very late appearance of local headache and of 
 tenderness on percussion ; normal cranial temperature." 
 
 3. The Diagnosis of the Nature of a Tumour. 
 
 The diagnosis of the nature of an intra-cranial growth is, 
 in the present state of our knowledge, only conjectural. 
 The determination of the seat renders it possible to suspect 
 
128 INTRA-CRANIAL GROWTHS. 
 
 certain forms of growth ; thus, in the cerebellum, growths 
 are more apt to be tubercular, and in the white substance of 
 the cerebrum, sarcomatous or gliomatous ; multiple growths 
 are more commonly tubercular or syphilitic. 
 
 Certain other symptoms may give us some help. The 
 discovery of cancer or sarcoma in other organs may lead us 
 to suspect a metastatic deposit in the brain. The presence 
 of a marked cachexia strengthens this suspicion. Evidence 
 of tuberculosis elsewhere, or of a tubercular diathesis, or 
 symptoms of syphilis may help us in our diagnosis. A denial 
 of previous syphilis is, of course, of little value. The age of 
 the pati-ent may also be a guide, tubercle being especially 
 common in young subjects. Heredity may throw a little 
 light, especially with cancer and tubercle. 
 
 So far as the actual svmptoms of tumour go, they give 
 comparatively little help. Frequent apoplectic attacks, and 
 a moderately slow progress are said to point to a glioma. 
 Sudden changes in the symptoms, as in Case IV, may be due 
 to a varying amount of blood in very vascular growths. If, 
 with a tumour localized at the base, we get a distinct bruit, 
 or if we can localize the growth distinctly in the neighbour- 
 hood of a vessel, we may suspect an aneurysm, but Gowers 4 
 thinks the bruit is rare in such cases. In very few cases, 
 however, can we be at all positive as to the nature of a 
 growth. 
 
COURSE, DURATION, AND PROGNOSIS. 1 29 
 
 VII. COURSE, DURATION, AND 
 
 PROGNOSIS. 
 
 * 
 
 Course. — Some of the cases reported show that a limited 
 number of intra-craniai growths, especially tubercular growths, 
 may be situated in a so-called latent region or may be- 
 come encapsulated and calcareous and remain in the brain 
 for years giving rise to no symptoms. Other growths may 
 give rise to a few symptoms, but they cause little disturbance 
 and the patient may die of some other disease. The cases 
 collected show that the percentage of tumours which appar- 
 ently cause no symptoms worth mentioning is much larger 
 than we are ordinarily led to suppose. In many cases, how- 
 ever, the symptoms steadily progress to a fatal termination. 
 In such cases we note first, as a rule, symptoms of irritation, 
 headache, vertigo, vomiting, or spasm ; and later symptoms 
 of deficit, paralysis, neuritis, mental failure and anaesthesia. 
 The cases reported show, however, that such a course is by 
 no means constant. Fluctuations in the severity of the 
 symptoms are not uncommon. The patient may rally after 
 rather marked symptoms and go on for a number of months 
 in comparative comfort. Where, however, the symptoms of 
 tumour are well developed, the course is, in the main, pretty 
 steadily progressive. 
 
 Duration. — The duration of tumours is very uncertain. 
 In the first place we can never say how long the tumour has 
 been growing before it gives rise to symptoms ; in the 
 second place, the statement as to the first onset of symptoms 
 is seldom trustworthy. Following the symptoms of these 
 cases as recorded, I find that in thirty-two cases the shortest 
 
130 INTRA-CRANIAL GROWTHS. 
 
 duration of the symptoms was twenty-five days, the longest 
 twelve years, with an average duration of about sixteen 
 months. One of Seguin's cases of cerebellar tumour had 
 definite symptoms for eighteen years. 
 
 In regard to the termination of the disease eleven died of 
 intercurrent disease, generally Bright's disease, general 
 tuberculosis or tubercular meningitis. Twelve died of 
 exhaustion, in one or two cases from bed-sores and cystitis, 
 and twelve died comatose. Two died from the effects of 
 operation. In several cases I have known patients suddenly 
 to become comatose and to die in a few hours or days, with- 
 out any special symptoms to account for the sudden change 
 in their condition. Such danger of sudden death should 
 always be borne in mind. 
 
 Prognosis. — The prognosis of intra-cranial growths is 
 usually regarded as hopeless. This I think to be an extreme 
 view. We have seen in some cases that the growth, if tuber- 
 cular, may take on a capsule which becomes calcareous, and 
 that it may exist for years without giving rise to any definite 
 symptoms. I was led several years ago to give a distinctly 
 unfavourable prognosis as to life in a case of probable 
 tubercle of the cerebellum, where the patient has apparently 
 made a fair recovery. The optic neuritis has left him blind. 
 All other symptoms, however, have ceased. He is in good 
 health, bright and intelligent. He was for some time unable 
 to walk, but he has now regained the power to do so. He 
 has learned to read with the blind alphabet, and is doing 
 very well. The prognosis in children, where there is a 
 probable tubercle of the brain, is generally better than 
 with any other form of new growth. Other cases, as 
 has been seen, may go on for a number of years with few, 
 if any, signs of cerebral trouble and the patient may finally 
 die of some intercurrent disease. In some cases of syph- 
 ilitic new growths proper treatment may bring about resolu- 
 
COURSE, DURATION, AND PROGNOSIS. 131 
 
 tion ; but, in the chapter on pathology, it has been pointed 
 out that the gumma is composed partly of round cells and 
 partly of cicatricial tissue. In many cases remedies may 
 bring about partial resolution ; the round cells may disappear, 
 but I doubt if treatment can ever succeed in removing the 
 connective tissue, and, if much of that has formed, there is 
 left, in spite of all our treatment, a hard, dense mass, 
 somewhat smaller than the original growth. In fact 
 the more I see of cerebral syphilis the more doubtful I feel 
 as to the permanent benefit of treatment in the average case. 
 In the majority of cases, however, where the symptoms are 
 sufficiently clear to enable us to make a diagnosis of an 
 intra-cranial growth, the prognosis is bad. The symptoms 
 gradually progress, and the patient finally succumbs. 
 
132 INTRA-CRANIAL GROWTHS. 
 
 VIII. TREATMENT. 
 
 i. Medical Treatment. 
 
 A consideration of the efficacy of the medical treatment 
 of tumours of the brain naturally leads one into a state of 
 pessimism. It is obvious that our only hope of a radical 
 cure by means of drugs is in those cases where the new 
 growth is of a syphilitic character. A glance at the preced- 
 ing tables, however, will show that such growths form only a 
 small percentage of the whole number, even if, as in 
 Table VI, cases of syphilitic meningitis be included. 
 Furthermore, in the preceding chapter I have called attent- 
 ion to the anatomical reasons which render it probable that 
 in a part even of the syphilitic cases treatment will be of 
 little avail. If the syphilitic process be taken early, while 
 there is as yet only a round cell infiltration, it may yield 
 to treatment; but, when fibrous cicatricial tissue is formed, 
 or when portions of tissue become cheesy and necrosed, 
 treatment cannot remove the cicatrix or replace the destroyed 
 cells. 
 
 Nevertheless, small as the chances are of the success of 
 anti-syphilitic treatment, we must bear in mind Hebra's 
 dictum, "Jeder Mensch kann syphilitisch sein," and give 
 the patient the benefit of the doubt. To this end both 
 mercury and iodide should be given. The former may 
 be given by inunction, by the mouth, or by subcutaneous 
 injection. Of the last method I have had no experience; 
 of the other two I prefer inunction as less likely to disturb 
 the stomach. In whatever form mercury is given it should 
 be pushed rapidly until slight salivation is produced. Iodide 
 
TREATMENT. 1 33 
 
 of potassium should be given freely. If small doses be given 
 they do little good and there is greater danger of producing 
 iodism. We should begin with doses of at least two 
 grammes three times a day given in a large amount of 
 water ; Vichy or Giesshubler water is better than plain water. 
 The dose should be pushed as rapidly as possible, unless the 
 stomach will not tolerate it, until the patient takes at least 
 six grammes three times a day. If possible, even larger 
 doses, ten to twenty grammes or more, should be given, and 
 these doses are often well borne, especially if the patient be 
 syphilitic. If, in four weeks, no signs of improvement are 
 seen, the treatment may as well be abandoned. Seguin 55 is of 
 the opinion that iodide is also of some benefit in tubercle. 
 
 Failing this our treatment must be largely symptomatic. 
 The most distressing symptom to combat is undoubtedly the 
 headache. This may be met at first by milder remedies, 
 evaporating lotions, cold, massage, or a mild galvanic current ; 
 but these will soon prove unavailing. The newer analgesics, 
 phenacetine, antipyrine, antifebrine, and the rest, often give 
 admirable results. For a year phenacetine, in doses of one 
 or two grammes two or three times a day, greatly relieved 
 the headache in Case XXIX and kept the patient comfortable 
 without any bad effect. A bromide salt, either alone or 
 combined with iodide of potassium or chloral, is sometimes, 
 although less frequently, of benefit. Later on, however, all 
 these drugs fail, and we are forced to employ morphine, the 
 dose of which must gradually be increased. In some cases 
 even this proves useless against the intense headache. 
 
 Against convulsions our main resource is in the bromides, 
 which are to be used as in idiopathic epilepsy. One or two 
 grammes of bromide, preferably the sodium salt, will often 
 hold the convulsions in check. It is seldom, in fact, that the 
 convulsions prove a very serious complication, but in some 
 cases they are so frequent as to demand interference. In 
 
134 INTRA-CRANIAL GROWTHS. 
 
 several cases I have known the bromides to work admirably, 
 almost wholly checking the convulsions. Even though the 
 preliminary treatment with large doses of iodide of potas- 
 sium has failed, it is often of benefit to give it in small 
 doses, about half a gramme, in addition to the bromides. 
 
 Where there is severe vomiting the diet must first be 
 regulated. This is, indeed, an important element in the 
 treatment of these cases. Sometimes the vomiting is of rare 
 occurrence, the digestion is good, and convulsions are seldom 
 seen ; in such cases it is often better to let the patient grat- 
 ify his fancy in regard to food than to lay down strict and 
 annoying rules. In other cases, it becomes necessary to 
 follow a pretty strict regimen. Here I should advise such a 
 diet as would be suitable for an epileptic; an avoidance of 
 alcohol, tea and coffee, and highly seasoned foods, a very 
 limited indulgence in meat or fish, and as near an approach as 
 possible to a milk diet. In cases of severe and persistent vom- 
 iting the diet must be still more limited. Here cracked ice, 
 peptonized food, milk and lime water, milk and soda water, 
 koumyss, matzoon, or champagne frappe may be all that can 
 be borne. In extreme cases the stomach should be given 
 complete rest and nutriment should be given by the rectum. 
 In addition to a regulation of the diet it may be necessary in 
 the prevention of vomiting to precede the administration of 
 food by cocaine given by the mouth or by hypodermic inject- 
 ions of morphine. 
 
 In other respects the ordinary precepts are to be observed. 
 The bowels, bladder, and skin require close attention, espe- 
 cially in bed-ridden cases. In addition to this our efforts 
 should be directed to promoting the patient's comfort, aiding 
 nutrition, procuring sleep, and relieving pain. In many 
 cases such a task is, unfortunately, beyond our powers. 
 
TREATMENT. I 3 5 
 
 2. Surgical Treatment. 
 
 When on the 25th of November, 1884, Mr. Godlee 
 removed a tumour from the brain of one of Hughes Bennett's 
 patients a new hope dawned for the victims of intra-cranial 
 growths. The patient, to be sure, died; but it was shown 
 that he died from preventable causes, and subsequent opera- 
 tions have proven that it is possible to remove an intra- 
 cranial growth and that the patient may recover from the 
 operation. 
 
 Subsequent investigation, however, has shown that this 
 hope is limited. It is a self-evident proposition that those 
 tumours alone are accessible to operation which are near the 
 surface of the brain. It is not probable that any advance in 
 cerebral surgery can make it possible to cut into the optic 
 thalamus, the corpora quadrigemina, or the pons with safety. 
 The cases thus far operated on, however, indicate that it is 
 possible to remove cortical tumours, and even tolerably 
 deep-seated sub-cortical tumours, from any part of the 
 external- surface of the cerebrum, especially in the Rolandic 
 region, and the percentage of success thus far obtained 
 proves that the operation is a justifiable one. Of course, 
 tumours in the convolutions at the base of the brain, and on 
 the median aspect of the hemispheres, except those near the 
 surface, must remain inaccessible. 
 
 Although the external aspect of the cerebrum is accessible 
 to the surgeon, it unfortunately happens that our present 
 knowledge of cerebral localization does not enable us to de- 
 termine the situation of neoplasms in every part of the cortex. 
 At present we can diagnosticate with some accuracy lesions 
 involving the ascending convolutions, and the parts of the 
 frontal and parietal convolutions immediately adjacent, 
 lesions of the posterior part of the first temporo-sphenoidal 
 convolution on the left, lesions of the occipital lobes involv- 
 
136 INTRA-CRANIAL GROWTHS. 
 
 ing the cuneus, lesions of the cerebellum, and, perhaps, lesions 
 in the prefrontal region, the inferior parietal convolution and 
 the angular gyrus, — rather a limited portion of the region 
 accessible. 
 
 Unfortunately it only too often happens that tumours are 
 situated, not in these regions, but in the inaccessible parts. 
 Out of four hundred and eighty-five cases collected by Bern- 
 hardt, 1 only fifty-seven were in the cortex; and on examining 
 the summaries of the reports of these cases, it seems as if 
 twenty-seven might have been localized. Out of these twenty- 
 seven cases, in three there were growths elsewhere ; in two 
 there was also tubercular meningitis ; and in one the growth 
 was a cancer, — leaving twenty-one possible cases. In one 
 hundred and twenty-four cases of tumours of the white sub- 
 stance of the cerebrum I find fifteen more which might prob- 
 ably have been localized ; but in one of these, again, the 
 growth was a cancer, and in one the tumours were multiple, 
 leaving thirteen cases. Thus, out of four hundred and eighty- 
 five cases, thirty-four, that is, seven per cent., might possibly 
 have been localized successfully, and have been more or' less 
 accessible to the knife ; but it is not easy to say, from the 
 tables of Bernhardt, just how deeply seated the cases in the 
 second category were. The estimate that I have made errs 
 rather through being too liberal. The examination of Mills' 
 and Lloyd's 11 table of one hundred selected cases is rather 
 more favourable, for ten of these seem to have been cases 
 that could have been operated on. 
 
 Hale White 56 in an elaborate analysis of one hundred 
 autopsies of cases of tumour of the brain at Guy's Hospital, 
 thinks that, including cerebellar growths, ten might well 
 have been operated on, but six of these were cerebellar. In 
 four more, one of which was cerebellar, an operation was 
 possible. On the one hand, however, he excludes very large 
 tumours which can, perhaps, be successfully removed, and 
 
TREATMENT. 1 37 
 
 also infiltrated growths, which, as is shown by a number of 
 cases, may sometimes be in part removed with temporary 
 benefit; but, on the other hand, in the absence of clinical 
 histories, we do not know in how many of these cases symp- 
 toms existed which would permit of localization. 
 
 Starr 57 has made an admirable study of three hundred cases 
 of tumour in children, with special reference to the question 
 of surgical interference. Out of these three hundred cases he 
 finds that fifty-six involved the cortex or the centrum ovale ; 
 of these he found that forty cases gave sufficient data to 
 draw some conclusion from. Of these forty cases an opera- 
 tion was indicated in nineteen ; but it would have succeeded 
 in only sixteen (five per cent.), two being infiltrated, and 
 one multiple. In adults, however, Starr finds that cortical 
 and subcortical tumours are relatively more frequent than in 
 children, in whom, on the contrary, cerebellar growths are 
 commoner. 
 
 In the forty cases here collected only fourteen (I, III, IV, 
 VI, VIII, IX, X, XI, XII, XIII, XXV, XXVII, XXVIII, 
 XXIX) could, by the most liberal interpretation, be regarded 
 as situated in regions accessible to the surgeon, and of these 
 only four (III, IV, VIII, XXVIII) presented symptoms 
 which could have made the local diagnosis possible. Of 
 these four one (IV) was deeply seated and infiltrated, and 
 probably could not have been successfully removed ; and 
 another (XXVIII) involved almost the whole of the cerebel- 
 lum, leaving only two cases or five per cent, in which an 
 operation was likely to have been successful. 
 
 If we add cerebellar growths, our percentage of operable 
 cases becomes larger. Hale White gives seven cerebellar 
 tumours which might have been operated on, out of a total 
 of one hundred. Starr finds ninety-six cerebellar tumours 
 out of three hundred in children, about one-third of which 
 could have been removed. Mills and Lloyd give nine cases 
 
138 INTRA-CRANIAL GROWTHS., 
 
 out of one hundred, four of which could have been localized, 
 and three removed. Bernhardt gives ninety out of four hun- 
 dred and eighty-five, of which forty-one, making a very liberal 
 estimate, might have been localized, and nineteen removed. 
 Thus, about three or four per cent, of all cases are cerebellar 
 growths which can be localized and removed. 
 
 The chance for operative treatment of cerebral tumour, 
 therefore, is not great, the percentage of cases situated in 
 accessible regions, and giving rise to definite focal symptoms, 
 varying from five to seven per cent., if we exclude tumours 
 of the cerebellum. Including these growths the percentage 
 rises from eight to fifteen at the most. 
 
 It has been a matter of some discussion whether it were 
 justifiable to attempt to remove a growth which was believed 
 to be in the cerebellum. The first three cases operated on 
 died, and it was questioned whether a portion of the cerebel- 
 lum could be removed without fatal results. Although the 
 cases are still very few there is fortunately no need of further 
 a priori reasoning upon the subject, for two cases at least 
 are now on record where a growth has been removed from 
 this region and the patient has recovered. 
 
 Further limitations of the field of operation for intra-cranial 
 growths are set by the nature of the growth. The successful 
 removal of tubercles and gummata shows that granulomata 
 may be operated on. Von Bergmann " 8 shows that with tuber- 
 cle there is a much greater chance of multiplicity, that there 
 is probably tuberculosis elsewhere, and that, if the growth be 
 not encapsulated, there is difficulty in removing it completely 
 and risk of further infection of the brain. These arguments 
 must, therefore, be weighed carefully. The same arguments, 
 however, may be urged against operating for tubercular dis- 
 ease elsewhere, tubercular glands or joints, and in some 
 cases they may be strong enough to decide against operat- 
 ing; but, unless the patient be in an advanced stage of tuber- 
 
TREATMENT. 139 
 
 culosis, or unless we can be quite sure that there are two 
 growths or a co-existing meningitis, we should not be deterred 
 from trephining. 
 
 I have already spoken of the possibilities of success in the 
 treatment of gummata by drugs, and argued that drugs will 
 not remove cicatricial tissue. Von Bergmann doubts whether 
 the artificial cicatrix which follows the knife be less injurious 
 than the cicatrix of a syphilitic process after thorough anti- 
 syphilitic treatment. To decide this point more time is re- 
 quired, but a clean, surgical cicatrix is probably smaller and 
 less disturbing than the hard irregular cicatrix of an old 
 syphilitic process, and the successful removal of some 
 syphilitic growths should lead us to venture upon further 
 operations. 
 
 The accompanying tables (Tables VIII and IX) give the 
 most complete list yet published of operations for removal 
 of cerebral tumours. They give us further information in 
 regard to the limitation set by the nature of the growth. 
 Infiltrating growths, unless the growth be small, cannot be 
 completely removed, for, to remove them properly we must 
 cut out the healthy tissue which surrounds them. There- 
 fore, as the cases show, the operation is often incomplete, 
 and the growth may recur. This is, of course, especially true 
 of malignant growths, particularly sarcoma. When the growth 
 is surrounded by softened brain tissue, moreover, the possi- 
 bility of a successful operation is further limited. Neverthe- 
 less partial removal often affords great although temporary 
 relief. 
 
 From what has been said as to the diagnosis of the nature 
 of the growth it is evident that we can only rarely know much 
 as to the nature of the growth that we have to deal with in 
 any given case. In some cases we can decide as to the ad- 
 visability of removal only after the brain has been exposed'; 
 in others, perhaps, we can have some grounds for believing 
 
140 INTRA-CRANIAL GROWTHS. 
 
 that the growth is highly vascular and probably infiltrating, 
 and that therefore an operation will have slight chances of 
 permanent success. 
 
 Case IV shows another limitation to the field for opera- 
 tion, which is apparent to every one, but which has not been 
 made prominent. In this case I was consulted because the 
 family were anxious for an operation. The condition of the 
 heart, however, rendered it almost certain that the patient 
 would die from any attempt at operation, and perhaps even 
 from the ether. In addition the growth was believed to be 
 quite vascular, infiltrated, and deep seated, but the condi- 
 tion of the heart led me to decide against operation. Never- 
 theless Horsley has operated successfully on a patient in 
 extremis, who had been comatose for ten days, and similar 
 successful operations are on record. 
 
 Table IX shows another limitation. The growth may be 
 so large or so deeply seated as to render it hazardous if not 
 impossible to remove it. This again can rarely, if ever, be 
 determined before the skull is opened ; hence we must expect 
 that in a certain percentage of cases the operation will have 
 to be abandoned. 
 
 Such are the limitations upon the operation presented by 
 the situation, size and nature of the growth ; and from them 
 we see that the percentages given above, small at the best, 
 must be still farther reduced. In only a very small number 
 of cases of intra-cranial growth, therefore, can we hope for a 
 cure by surgical interference ; yet this is probably a larger 
 number than we can hope to cure by medical treatment, and 
 thus the operation becomes justified. 
 
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TREATMENT. 145 
 
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152 
 
 INTRA-CRANIAL GROWTHS. 
 
 
 
 
 
 
 
 
 
 
 
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154 
 
 INTRA-CRANIAL GROWTHS. 
 
 Summary of Tables VIII and IX. 
 
 Tumours of 
 
 Recovered. 
 
 Died. 
 
 Result 
 Unknown. 
 
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 2 
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 72 
 
 
 Note. — These tables are based on an investigation made for me by Dr. 
 Lorini, at the Library of the Surgeon-General's Office in Washington. This inves- 
 tigation, however, extended only to May, 1890. I have endeavoured to add the 
 cases since, but, owing to the impossibility of getting certain journals or of obtain- 
 ing further assistance at Washington, owing to Dr. Lorini's removal, the record is 
 incomplete. I have not included cases of perforating tumours of the skull where 
 external manifestations were the sole guide for operation. 
 
TREATMENT. 1 55 
 
 A study of these tables will make apparent certain 
 other factors, independent of the seat or nature of the growth, 
 which tend to make the benefits of operation still more 
 limited. Out of 73* trephinings therein collected 27, or over 
 one-third of the whole number, were ineffectual in that the 
 growth was not removed. In sixteen cases this was due to 
 errors in diagnosis, in three the growth was found but from 
 its size and extent it could not be removed, in one the 
 patient died before the skull was opened, and in seven the 
 trephining was not done with the expectation or intention 
 of removing the growth, but merely to relieve pressure. 
 
 Turning now to the table of cases where a new growth has 
 actually been removed we find that the results have been 
 distinctly favourable. Out of 46 cases we note 30 recoveries 
 and 15 deaths. This is, of course, a shade too favourable, 
 for in four cases the growth recurred, with fatal conse- 
 quences. Even then, however, we have a mortality of less 
 than half the number of cases. The cases in Table IX show 
 a much greater mortality. Here, out of twenty cases when 
 the tumour was not found or could not be removed, only four 
 recovered from the operation. It would almost seem as if 
 the operation had some bad influence upon the processes in 
 the brain when the new growth was left in it, were it not that 
 all the cases operated on to relieve pressure have recovered. 
 
 In a very small percentage of cases, then, we can make a 
 correct diagnosis, the tumour is of such a nature that it can 
 be completely removed, and in the majority of these cases 
 the patient will survive the operation. With advancing 
 knowledge of cerebral localization and greater skill in dia- 
 gnosis this percentage may be increased, but it will always be 
 small. Nevertheless, in view of the gloomy prognosis with- 
 out surgical interference, it is something to give the victims 
 of intra-cranial growths this small hope of recovery. Even 
 
 * Fischer's case, No. 24 of Table VIII, was twice operated on. 
 
156 INTRA-CRANIAL GROWTHS. 
 
 in the successful cases, however, the patient is not always re- 
 stored to his former condition. Blindness or paralysis, the 
 result of the morbid process or of the knife, only too often 
 leave him crippled. 
 
 At the International Medical Congress at Berlin in 1890 
 Horsley suggested a new application of surgical procedure 
 for the relief of intra-cranial growths. In cases of inaccessi- 
 ble or malignant growths, or in cases where there are no 
 focal symptoms, yet where the patients suffer from intense 
 headache or from other symptoms of increased intra-cranial 
 pressure, he suggests the propriety of trephining to relieve 
 pressure. This beneficial result had been obtained in some of 
 the cases of Table IX, although the object of the operation 
 had been primarily to remove the tumour or to explore. In 
 six cases Horsley has operated to relieve pressure, in every 
 case with success. Unfortunately he does not give the details 
 of his cases. In Case XXIX there were no symptoms which 
 warranted a focal diagnosis, but the headache was so severe 
 that I advised an operation simply to relieve pressure. The 
 benefit was somewhat questionable. The operation probably 
 hastened the patient's death, but while he lived he had very 
 little of his former headache. Two one-inch trephine holes 
 were made close together, and these were connected by 
 rongeur forceps. Were I to advise the operation again I 
 should certainly have a larger opening made. It would prob- 
 ably be well to tap the lateral ventricles in addition. At any 
 rate the escape of cerebro-spinal fluid seemed to cause great 
 relief. Of course such an operation is simply palliative, but 
 its results in these seven cases certainly warrant a further 
 trial. 
 
 Surgical interference, then, is warranted in all cases where 
 there is a reasonable probability that there is a new growth 
 in an accessible situation. In such cases trephining is neces- 
 sarily exploratory, because errors in focal diagnosis are pos- 
 
TREATMENT. 1 57 
 
 sible and because we are unable to tell whether the growth be 
 infiltrated or whether it may not extend into deeper parts of 
 the brain. In cases where the focal diagnosis is uncertain, 
 and where there are symptoms due to increased intra-cranial 
 pressure, especially where there is intense headache, relief 
 may be obtained by the removal of a large piece of the 
 skull. 
 
 The details of the operation require a little consideration. 
 In the first place I hold that it should be done early. 
 Seguin 5J has suggested that it may be done too early, before 
 the tumour is large enough to be found. This suggestion 
 is not without value, but, on the other hand, if we wait too 
 long the optic neuritis may progress so as to cause incurable 
 blindness, and the patient's strength may be so much re- 
 duced as to diminish his chances of surviving the operation. 
 The contra-indications to an operation, beside those relating 
 to the seat and nature of the growth to which I have already 
 referred, are those of any severe surgical operation. Optic 
 neiiritis is, of course, not a contra-indication, as it was present 
 in many of the successful cases. 
 
 On the day before the operation the patient's head should 
 be shaved, which will afford an opportunity to observe any 
 scars or depressions in the skull. The important fissures and 
 the probable seat of the growth should be marked out with 
 a dilute solution of nitrate of silver. This is the only thing 
 that will resist the antiseptic solutions, but too strong a 
 solution will destroy the epidermis. 
 
 The most important fissure is the fissure of Rolando, for 
 the majority of operations are done for growths in this re- 
 gion. I have elsewhere shown,* from measurements of 
 heads and skulls, the inaccuracy of Broca's method. The 
 Thane-Horsley method 60 is the one to be employed, and the 
 cyrtometer devised by Wilson renders this easy. The prin- 
 
 Bo ion Medical and Surgical fournal, 4, n, 18 April, 1890. 
 
158 INTRA-CRANIAL GROWTHS. 
 
 ciple is to measure backwards from the glabella to the inion 
 (occipital protuberance) 55.7 per cent, of the whole dis- 
 tance. Then draw aline forwards and downwards at an angle 
 of sixty-seven degrees for 5.6 centimetres. This will give 
 very accurately the upper two-thirds of the fissure. The 
 lower third runs a trifle more vertically for two centimetres 
 more. For the fissure of Sylvius draw a vertical line from 
 the stephanion to the middle of the zygoma. Draw a hor- 
 izontal line from the external angular process to the highest 
 part of the squamous suture, curving it up until it reaches 
 the parietal eminence. The two lines will join at the begin- 
 ning of the fissure. The horizontal line will correspond with 
 the horizontal branch of the fissure. The vertical branch is 
 about 2.5 centimetres long and is inclined a little forwards 
 from the vertical line. For the parieto-occipital fissure find 
 the lambda, or, measuring from the inion, take 22.8 per cent, 
 of the distance from the inion to the glabella, which will 
 give the lambda. Then take a point three millimetres in 
 front of the lambda, and draw a line 2.25 centimetres 
 long at right angles to the median line. The superior occi- 
 pital curved line corresponds fairly to the transverse fissure. 
 These rules will enable us to determine the main fissures, 
 which are the chief landmarks in operating. For further 
 details I must refer to Dana's 01 careful study of cranio- 
 cerebral topography. 
 
 Having drawn the lines desired the head should be care- 
 fully scrubbed with alcohol and a corrosive solution, or with 
 whatever other antiseptic solution is desired, and protected 
 by a bandage. The next day the bowels should be moved, 
 the head again washed, and a subcutaneous injection of 
 morphine (^ grain) given. The operation must be abso- 
 lutely aseptic. It is still a question whether chloroform is 
 preferable in such an operation. Most American surgeons 
 would prefer to avoid the risk of chloroform and use ether, 
 
TREATMENT. 1 59 
 
 but this probably causes greater congestion of the head. A 
 rubber tube tied tightly around the head is sometimes effica- 
 cious in controlling haemorrhage from the scalp, although 
 I have found comparatively little benefit from it in one or 
 two of my cases. The precise point of operation can best 
 be determined by driving a small tack into the skull, which 
 will keep in position after the flap is laid back. 62 After the 
 flap is once laid back it is difficult to determine with accuracy 
 any part on the skull by the aid of skin markings. The skull 
 should be laid bare by a curved incision, with the convexity 
 pointing upwards and backwards. This incision should be 
 made straight to the bone, and the flap reflected. The 
 haemorrhage is often great and it must be controlled before 
 proceeding farther. 
 
 In Case XXIX the operation was done with the patient in a 
 sitting position, which Bradford advises, as affording an easy 
 method of combatting beginning collapse ; since, should this 
 occur, by putting the patient in a horizontal position, more 
 blood can at once be brought to the brain. By operating 
 in this position there is likely to be less bleeding. One 
 of the cerebellar cases was operated on with the patient lying 
 on his belly and the head bent downwards over the edge 
 of the table. 
 
 Our methods of opening the skull are still somewhat de- 
 fective. A dental engine, or an electric motor, if at hand, 
 affords the best device. A large opening must be made, and 
 a large trephine will not act well on a curved surface, while 
 to make repeated openings with a small trephine, connecting 
 them by a saw or rongeur forceps, prolongs the operation 
 and adds to the shock. If there be oozing from the diploe, 
 it should be checked by plugging the bone with the follow- 
 ing wax, which is recommended by Horsley: — 
 
l60 INTRA-CRANIAL GROWTHS. 
 
 R. 
 
 Cerse flavse I part. 
 
 Vaselini 4 parts. 
 
 Acidi Carbolici ^ ... 
 Cerse albse, ana q. s. 
 
 Tt\. Boil before using. 
 
 There seems to be an objection raised by many against 
 opening the dura, if nothing appears on removing the bone. 
 If the operation be aseptic I cannot see that it adds materially 
 to the risk ; if the operation be not aseptic nothing should 
 be done. To fail to open the dura seems to me like hiring 
 a locksmith to open a trunk in search of an article, and then 
 to fail to lift up the tray within the trunk. On removal of 
 the bone the dura will probably bulge. It should be opened, 
 not by the old crucial incision, but by a curved incision 
 near the edge of the opening of the skull. 
 
 Horsley 6 " lays some stress upon a discolouration of the 
 brain over a new growth. If this be not seen the brain 
 should be very gently palpated. If nothing is felt, and the 
 focal diagnosis is reasonably certain an incision maybe made 
 in the cortex, vertically to its surface, and the finger inserted. 
 Palpation, if the opening be large, can be practised under 
 the edge of the opening, and thus be extended over a con- 
 siderable area. Prolonged manipulation of the brain should 
 be avoided. If a tumour be found it can be removed by the 
 finger or by means of a scoop. All bleeding vessels should 
 then be tied. A ten per cent, cocaine solution may check 
 any troublesome oozing from the brain. 
 
 The question of drainage is still in dispute. It is perhaps 
 better to drain for twenty-four hours. Keen and Park are 
 in favour of drainage, but Horsley has abandoned it. 
 
 Having removed the growth the dura should be sewn up, 
 the bone, which should be kept warm and aseptic, should 
 
TREATMENT. l6l 
 
 be cut up into fragments and replaced upon it, the skin 
 sewn up, and an antiseptic dressing applied. 
 
 The after treatment requires little discussion, as it differs 
 in no way from the after treatment in any severe operation. 
 In favourable cases patients do surprisingly well. After 
 trephining for epilepsy, when a bit of brain tissue was re- 
 moved, I have known a patient to sit up and read in two days, 
 and to be walking about the ward in a week. 
 
 The risks of operation are, first of all, shock. This is 
 to be prevented by. an early and rapid operation, and by 
 the ordinary methods at our disposal, such as stimulants, 
 heat, etc. The second risk is sepsis, which, of course, is to 
 be avoided by the most rigid adherence to the principles of 
 antiseptic surgery. Haemorrhage has proved fatal in a few 
 cases. The risk of oedema of the brain from the sudden 
 removal of the growth, on which von Bergmann 58 lays stress, 
 seems to be exceptional. 
 
REFERENCES. 
 
 See, also, Tables VIII and IX. 
 
 Bernhardt. — Beitrage zur Symptomatologie unci Dia- 
 gnostik der Hirngeschwiilste. 
 
 Ladame. — Symptomatologie unci Diagnostik der Hirn- 
 geschwiilste. 
 
 Seppilli. — Tumori cerebrali. II sistema nervoso centrale, 
 ii, 410 et seq. 
 
 4. Gowers. — Diseases of the Nervous System, ii, 454, et seq. 
 
 5. Steffen. — Die Krankheiten des Gehirns im Kindesalter. 
 
 Gerhardt's Handbuch v, 1. ii, 545 et seq. 
 Starr. — Intra-cranial Tumours. Keating's Cyclopaedia, iv, 
 551 et seq. 
 
 7. Birch-Hirschfeld. — Lehrbuch der pathologischen An- 
 
 atomie. 
 
 8. Ziegler. — Lehrbuch der allgemeinen und speciellen path- 
 
 ologischen Anatomie und Pathogenese. 6te Aufl. 
 
 Oppenheim. — Zur Kenntniss der syphilitischen Erkrank- 
 ungen des centralen Nervensystems. 
 
 Rumpf. — Die syphilitischen Erkrankungen des Nerven- 
 systems. 
 
 Mills and Lloyd. — Tumours of the Brain and its 
 Envelopes. Pepper's System, v, 102S, et seq. 
 
 Wernicke. — Lehrbuch der Gehirnkrankheiten, iii, 1. et 
 seq. * 
 
 13. Bramvvell. — Intra-cranial Tumours. 
 
 14. Jacobi. — Hysteria and Brain Tumour. 
 
 15. Oppenheim. — Archiv fur Psychiatric und Nervenkrank- 
 
 heiten. xxi, 560, 705. xxii, 37. 1889, 1890. 
 [6. DEUTSCHMANN. — Ueber Neuritis optica. 
 
1 64 REFERENCES. 
 
 17. Seguin, and Weir. — American Journal of the Medical 
 
 Sciences. July, August, September, 18SS. 
 
 18. Seppilli. — Rivista sperimentale di freniatria. X, 1, 2. 
 
 1SS4. XII, 1, 1886. 
 
 19. Lowenfeld. — Archiv fur Psychiatric und Nervenkrank- 
 
 heiten. xxi, 1,411. 1SS9. 
 
 20. Rolland. — De l'Epilepsie Jacksonienne. 
 
 21. Gray. — New York Medical Journal. August, 187S. 
 
 22. Horsley and Schaefer. — Philosophical Transactions. 
 
 B 20. 1888. 
 
 23. Luciani e Seppilli. — Le localizzazioni cerebrali. 
 
 24. Beevor and Horsley. — Philosophical Transactions. B 6, 
 
 B 2S, 1S8S. 
 
 25. Semon and Horsley. — Philosophical Transactions. B, 
 
 1890. 
 
 26. Ferrier. — The Functions of the Brain. 2d ed. 
 
 Brain. April, iSSS. 
 
 27. Schaefer. — Brain. January, April, July, 18S8. 
 
 28. Mills. — Transactions American Congress of Physicians 
 
 and Surgeons. 18S8. 
 
 29. Horsley. — Transactions American Congress of Phy- 
 
 sicians and Surgeons. iSSS. 
 
 30. Munk. — Die Functionen der Grosshirnrinde. 2te Aufl. 
 
 31. Starr. — Journal of Nervous and Mental Disease. July, 
 
 1S84. 
 
 32. Dana. — Transactions American Neurological Association. 
 
 188S. 
 
 33. Obersteiner. — Anleitung beim Studium des Baues der 
 
 nervosen Centralorgane. 
 
 34. Nothnagel und Naunyn. — Verhandlungen des sechs- 
 
 ten Congresses fur inneren Medicin. 1S87. 
 
 35. Starr. — Transactions American Congress of Physicians 
 
 and Surgeons. 1SS8. 
 
 36. Schaefer and Brown. — Philosophical Transactions. B 
 
 30. 1888. 
 37- Giacomini. — Guida alio studio delle circonvoluzioni cere- 
 brali dell' uomo. 2cla ediz. 
 
REFERENCES. 1 65 
 
 3S. Wilbrand. — Ueber Hemianopsie. 
 
 39. Seguin. — Journal of Nervous and Mental Disease. Janu- 
 
 ary, 1 886. 
 
 40. Hun. — American Journal of the Medical Sciences. Janu- 
 
 ary, 1SS7. 
 
 41. Wilbrand. — Die Seelenblindheit. 
 
 42. Seppilli. — Rivista sperimentale di freniatria. X, 1, 2. 
 
 18S4. 
 
 43. Bristowe. — Brain. October, 1884. 
 
 44. Edes. — Philadelphia Medical News. 21 January, 1888. 
 
 45. Beevor and Horsley. — Philosophical Transactions. B 
 
 52. 1S90. 
 
 46. Oulmont. — Etude clinique sur l'athetose. 
 
 47. Raymond. — Etude anatomique, physiologique, et clin- 
 
 ique sur l'hemichoree. 
 
 48. Nothnagel. — Biain. July, 1SS9. 
 
 49. Nothnagel. — Topische Diagnostik der Gehirnkrank- 
 
 heiten. 
 
 50. Edinger. — Zwolf Vorlesungen iiber den Bau der nervosen 
 
 Centralorgane. 
 
 51. Flechsig. — Neurologisches Centi'alblatt, 15 February, 
 
 1890. 
 
 52. Mercier. — The Nervous System and the Mind. 
 
 53. Gowers. — Neurologisches Centralblatt. 1 April, 1890. 
 
 54. Luciani. — Rivista sperimentale di freniatria. X, 1. 1884. 
 
 55. Seguin. — Journal of Nervous and Mental Disease. April, 
 
 1887. 
 
 56. Hale White. — Guy's Hospital Reports, xliii, 117. 1S85. 
 
 57. Starr. — Philadelphia Medical News. 12 January, 1889. 
 
 58. v. Bergmann. — Die chirurgische Behandlung von Hirn- 
 
 krankheiten. 2te Aufi. 
 
 59. Seguin. — Boston Medical and Surgical Journal. 5 Feb- 
 
 ruary, 1 89 1. 
 
 60. Horsley. — American Journal of the Medical Sciences. 
 
 April, 1887. 
 
 61. Dana. — New York Medical Record, 12 January, 1S89. 
 
 62. Park. — Transactions American Congress of Physicians 
 
 and Surgeons, 1S88. 
 
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