Structural Analysis 5Th Edition Aslam Kassimali Solutions Manual Full Chapter PDF

Structural Analysis 5th Edition Aslam
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Mental disorder increases; headache becomes more violent, and
sometimes more localized; amblyopia tends to advance to complete
blindness, with marked swelling of the papilla, or special disorders of
vision, such as hemianopsia, occur; palsies, ataxia, convulsions,
contractures, rigidity of limbs, altered reflexes, local spasms,
anæsthesia, hyperæsthesia, paræsthesiæ, neuralgias, appear
according to the extent and location of the growth. Certain special
phenomena, according largely to the seat of the tumor, may also
appear, such as disorders of hearing, taste, or smell, polyuria,
diabetes, albuminuria, polyphagia, or dysphagia.
In the third or terminal stage paralysis, anæsthesia, convulsions, etc.

become more profound; mentality sometimes decreases to nearly
complete imbecility, although in many cases a fair amount of mental
power is preserved almost to dissolution. Involvement of the bowels
and bladder becomes a distressing symptom, involuntary
evacuations adding to the torments of the patient. Bed-sores,
acquired or trophic, appear; the patient's limbs are painfully
contractured; great emaciation is usually present. With agonized
head, often blind or deaf, with torturing pains in anæsthetic,
paralyzed, and wasted limbs, covered with painful sores, filthy
involuntarily, imbecile or demented, death comes as a thrice-happy
relief.
Cases have been reported in which intracranial tumors of

considerable size were discovered on autopsy, and had evidently
been present for years without their presence having been
discovered or even suspected; but these are extremely rare. In
general terms, however, it may be said that every case of brain
tumor must give rise to symptoms. These symptoms may be few or
many, slight or severe, brief or protracted, constant or paroxysmal,
according to circumstances. Our experience and study of the
literature of the subject lead us to the conclusion that the
pathological character of the growth would have some influence as
to the severity and prominence of symptoms. Gliomata—which are
sometimes hard to distinguish from the brain-substance, particularly
the soft gliomata, producing comparatively little pressure—when
located in certain so-called latent areas of the brain might escape
detection during life; so might also very small tumors of any kind
situated deeply in the substance of the brain.
The position taken by Obernier, that individuality has much to do with

the activity of symptoms of brain tumor, has some strength. He refers
particularly to the psychical response to the irritation caused by brain
tumors, which differs very much in different individuals. The fact,
which has been pointed out in the article on Hysteria, that hysterical
symptoms are often present in cases of brain tumor as well as in
other forms of organic disease, is also sometimes the cause of
mistake by the diagnostician. The cases of Hughes Bennett and
Eskridge will be referred to in this connection under Diagnosis.
When the subject of local diagnosis is considered farther on, those

regions which are most active and those which hold an intermediate
position in the production of particular and distinctive symptoms will
be more particularly discussed.
The possibility of the existence of multiple tumors should never be

overlooked. These are of comparatively frequent occurrence, and
sometimes give rise to a puzzling symptomatology. In our search
through the literature of the subject for cases we met with many
examples of multiple tumors. In preparing our table multiple tumors
were usually omitted. They give sometimes symptoms and signs so
conflicting as to make a local diagnosis impossible, and even to
confuse the expert as to general diagnosis. In other cases, however,
one growth of larger size or in an active region takes command of
the situation, and leads clearly to its diagnosis in spite of other less
significant tumors. This was shown, for example, in one of our cases
(Case 14). From the symptoms not only was the presence of the
larger tumor diagnosticated, but its exact location was indicated
during life. Post-mortem examination, however, showed a smaller
tumor at the inferior angle of the right lobe of the cerebellum, and
also some basal meningitis with effusion which had not been
suspected. The first tumor was one of the ascending frontal
convolution, extending into the fissure of Rolando. Its presence and
location had been diagnosticated by the right brachial monoplegia
and paresis of the leg, which later increased to paralysis of the limb,
with right facial paresis, ptosis, partial anæsthesia of right side of
face, and slight clonic spasms of the right arm. At the present time,
when the question of operating for the removal of brain tumors is so
prominently before the profession, and is now generally regarded as
justifiable for growths in this one location, the cortical motor area, the
possibility of the coexistence of another tumor should be carefully
weighed. In this case, owing to the clear diagnostic indications, the
question of operation was considered at the time of consultation, but
fortunately—in large part because the patient was almost in extremis
—it was decided not to operate. The operation would have been
futile, the autopsy showing that the probable immediate cause of
death was the basilar effusion which accompanied the cerebellar
growth.
In another case reported by one of us3 three gummata were found in

three different locations: one in the prefrontal region, another in the
retro-central fissure, and a third in the supramarginal convolution.
The general symptoms of brain tumor were present in this case, but
no localization was possible.
3 Arch. Med., viii. No. 1, August, 1882.
The following are other illustrations of multiple tumors and of tumors

with other lesions out of a large number which we have collected:
M. 44.—Several severe falls on the head. Recent chancre with

secondary symptoms. Six months before death headache which
grew worse; most severe in right supraorbital region, and also
obstinate vomiting, vertigo, hiccough, insomnia. Some loss of power
on both sides. Slow in answering and indisposed to talk. Choked
discs. Involuntary evacuations. Some improvement under treatment,
and then relapse. Complete blindness. Polyuria. Specific gravity of
urine as low as 1003 and 1005. Appetite at times ravenous. During
last few weeks of illness head inclined to the right side, probably
from spasm. Intense thirst throughout the illness.
(1) Large sarcoma in the white substance of the right parietal and
frontal lobes, involving ascending parietal convolutions. (2) Softening
and abscess of the right temporo-sphenoidal lobe and posterior base
of the right anterior lobe. Softened mass size of a hickory-nut in the
upper portion of the right ascending frontal convolution. (3) Small
cystic tumors of the choroid plexuses.4
4 J. T. Eskridge, Trans. of Philada. Path. Society, for 1878-79, vol. ix. p. 119.
M. 5.—Convulsions, beginning either in right foot or in right face; not

unconscious during fits. Right-sided hemiplegia. Double optic
neuritis, followed by atrophy. Gradual increase in size of head, with
gaping sutures. Later, rigidity of right arm and leg. Shortly before
death the following symptoms suddenly set in: headache,
convulsions of right side with unconsciousness and retraction of
head, rigidity of right arm, and tremor of right leg. Later, both arms
flexed, with constant tremors of left arm, spreading over whole body.
Right sterno-cleido-mastoid was stiff; almost opisthotonos.
(1) Enormous tubercular tumor of left cerebral hemisphere,

extending from depth of Sylvian fissure and eroding skull. Corpus
striatum soft and diffluent. Weight, over eleven ounces. (2) Tumor,
double size of pea, in lower part of middle lobe of cerebellum.5 This
case was especially interesting for the onset of the cerebellar
symptoms late in the case, caused probably by a late appearance of
the cerebellar tumor.
5 Hughlings-Jackson, Med. Times and Gaz., London, 1872-73 (2), p. 34.
M. 2.—Screaming fits. Vomiting. Paralysis of left side of face,

including corrugator and orbicularis palpebrarum. Winking in both
eyes suspended. Paralysis of external rectus muscle. Agitation and
contractures of right arm and leg. Later, unsteady movement of head
and right arm and jerking of right leg.
(1) Small glioma in left hemisphere of cerebellum, and (2) a similar

tumor projecting from left lateral half of floor of fourth ventricle at
common nucleus of the abducens and facial nerves.6
6 W. H. Broadbent, Proc. Clin. Soc. Lond., v. 66-68.
F. 45.—Epileptiform attacks for fourteen years. Vertigo, occipital

headache, disordered vision, intolerance of light, sleeplessness,
excitability, constipation, with paræsthesia of left side. Retraction of
head, vomiting. Very late, convulsive movements of right eye and
right side of mouth; then general clonic spasms, coma, and death.
No paralysis. For twenty-six years there had been an induration of
one breast, which toward end of life had a somewhat scirrhous
appearance.
(1) Glioma in right hemisphere of cerebellum 1¾ inches in diameter.

(2) Glioma in centre of middle lobe of left hemisphere of the
cerebrum ¾ inch in diameter. Surrounding nervous tissue softened
and broken down.7
7 William L. Bradley, Tr. Conn. Med. Soc., 1880, p. 39.
M. 65.—Sudden attack of spasm of left arm, with paresis and

coldness and numbness. Headache and staggering. Wandering in
mind. Not unconscious. Twitching in eye. Two days later violent
convulsion in entire left half of body, with vomiting; not unconscious.
After convulsion left hemiplegia, with left deviation of tongue. Head
and eyes turned to right; vertigo. Partial anæsthesia of left face,
body, and limbs. Paræsthesia; painful nervous shocks through
affected limbs. Sounds in back of head. Later, mind cleared up and
many symptoms ameliorated. Very late, convulsion and coma.
Cheyne-Stokes respiration, involuntary evacuations. Duration, seven
weeks.
(1) Tumor in ascending parietal convolution at junction of upper and

middle thirds. (2) Large tumor occupied entire occipital lobe, but did
not present on surface, reaching to convexity of descending cornu of
lateral ventricle.8
8 W. H. Broadbent, Tr. Clin. Soc. Lond., v. 233-236.
Headache is the most frequent and positive symptom of brain tumor.
It is rarely absent; in most cases it has peculiar characteristics. Its
usual type might be described as continuous pain, sometimes of
persistent severity, but generally with exacerbations or paroxysms of
great violence. No suffering can surpass that which some of the
victims of intracranial neoplasms are compelled for months or years
to endure. It is only equalled by the torture produced by malignant
growths in the vertebral axis, the throat, or the bones of the pelvis.
The pain is not, however, always of this character. In a comparatively
few cases it is described by the patient as dull or moderate, or he
simply complains of distressing sensations of weight, pressure, or
constriction. Usually in these cases, however, the pain increases and
becomes less and less endurable. In 100 cases the headache is
described as agonizing, violent, severe, or torturing 20 times; as
moderate or dull, 26 times. It is simply mentioned 20 times, but here
presumably it was of the ordinary severe type. Thus in 66 cases, or
66 per cent., headache of some type was recorded. No mention was
made of headache at all in 29 cases, in some of which, however, it
was doubtless present. In only 5 cases was it stated not to have
been present: 3 out of these 5 were said to be gliomata, and of the
other 2, one was probably gliomatous, and the other a cyst in the
brain-substance. Tumors of this kind, which exert comparatively little
pressure and which are not connected with the membranes, are
probably those which are least likely to cause pain. In several
instances the patients complained spontaneously of the pain being
greatest in the region of the head nearest the seat of growth. With
reference to cerebellar tumors, it somewhat generally supposed that
occipital pain is usually present. It sometimes is and sometimes is
not. In 15 cases of tumor of the cerebellum and of the fourth ventricle
the pain was described as occipital twice, as fronto-occipital three
times, and as cervico-occipital once. Callender has noticed that
cortical lesions are more frequently accompanied by localized pains
than lesions of deeper parts.9 Some of our cases would seem to
bear out this view, although the data are not numerous or complete.
9 St. Bartholomew's Hospital Reports, 1869, and Ferrier's Localization of Cerebral
Disease, p. 99.
In a few cases percussion of the head elicited or intensified pain in
the region corresponding to the location of the tumors. We believe
that percussion of the skull may afford valuable aid in localizing
encephalic tumors, particularly when they are meningeal or cortical.
Ferrier10 holds that percussion often elicits pain over the cranial
region beneath which a lesion is localized, and Alex. Robertson of
Glasgow11 has also directed attention to the value of percussion of
the skull in the localization of disease on the surface of the brain.
10 Brain, January, 1879.
11 Abstr. Internat. Med. Congress, 1881, p. 85, and Journal of Nervous and Mental
Disease, April, 1882.
Vomiting is of frequent occurrence, although it does not usually come

on as early or remain as persistently as headache. It is more likely to
be paroxysmal, with longer or shorter intervals of relief. It frequently
occurs at the time of the exacerbations of the headache, and
between the paroxysms of vomiting, nausea, slight or great, is often
present. It probably occurs in about 50 per cent. of all cases of brain
tumor. It is recorded as having been present in 34 out of 100 cases.
It was comparatively infrequent in antero-frontal growths, occurring
only twice out of 10 cases.
A case reported by one of us (Case 70) was a remarkable example

of persistent cerebral vomiting. For four weeks before her death the
patient vomited almost incessantly. The tumor in this case involved
the middle cerebellar peduncle and the adjacent region of the right
cerebellar hemisphere, and had grazed and superficially softened
the floor of the fourth ventricle.
We incline to agree with Ferrier12 that the majority of cases of

cerebral vomiting can be ascribed to irradiation of irritation by the
nerves of the cerebral membranes or to the physical effects of acute
pain. The nuclei of the trigeminus and of the vagus are in close
anatomical relationship in the medulla oblongata. Irritative
impressions conveyed from the cerebral membranes, and
particularly from the dura mater, to the trigeminal nuclei in the
medulla are transferred to the vagus and give rise to vomiting. In
tumors of the cerebellum the vomiting may be brought about through
the affection of the centres of equilibration and the concurrent
vertiginous sensations (Ferrier), or it may be due to direct irritation by
contiguity of the floor of the fourth ventricle. In general, the tumors
situated farthest forward in the brain appeared to be the least likely
to give rise to vomiting.
12 Brain, July, 1879.
Vertigo was noted in 31 out of 100 cases. Under this general

designation dizziness, giddiness, reeling, insecurity in the erect
posture, etc. have been included. The vertigo can be explained in
several ways besides by the view which refers it to an affection of
centres of equilibration in the cerebellum. Like headache and
vomiting, it seems sometimes to be the outcome of pure irritation of
the cerebral membranes. Alterations in the intracranial circulation
produced by the growth of the tumor is another probable cause.
Experiments have demonstrated the existence of a communication
between the arachnoid cavity and the labyrinth, and consequently
the increased intracranial tension present may result in pressure on
the labyrinthine fibres of the auditory nerve, and thus occasion
vertigo.
The importance of ophthalmoscopic examinations in suspected

cases of brain tumor can scarcely be overestimated. They will often
serve to clinch the diagnosis in favor of tumor. Of the 100 tabulated
cases, choked discs were recorded in 8; optic neuritis or neuro-
retinitis in 18. These results serve to show the importance of the
examination of the eyes. It will be seen that with Allbutt, Norris, and
others we make a distinction between choked disc, papillitis,
congestion papilla, or ischæmia of the discs, and descending or
interstitial neuritis. The differences between these two varieties of
inflammation of the interocular ends of the optic nerve are well
presented by Norris in a previous volume of this work,13 which will
make it unnecessary for us to describe the conditions present in
these cases. An examination of the tabulated cases will show that
true choked discs were present in tumors situated in all portions of
the encephalon. They were not infrequently present in tumors of the
convexity. Descending neuritis would seem most likely to occur when
the tumors are so situated that inflammation set up by them can
readily extend by anatomical continuity along the membranes to the
optic nerves. The lymph-space theory best accounts for the
occurrence of choked discs in cases of tumor situated remotely from
the base. In choked disc the appearance is one of intense swelling
and engorgement of the optic papilla. In descending neuritis, as
described by Graefe and Norris, there is rather a dull-red suffusion of
the disc. Some of the cases reported as neuritis may have been
choked discs, and the reverse, as physicians often do not make any
distinction.
13 Vol. IV. p. 771 et seq.
Several practical matters should be borne in mind in connection with

this subject of the condition of the eye-ground. In the first place, sight
is not always impaired in cases of even somewhat advanced choking
of the disc, so that when other symptoms and indications lead to the
suspicion of a brain tumor, unexpected confirmation may be obtained
by ophthalmoscopic examination. Some remarkable cases of this
kind have been reported, and doubtless have been observed by all
ophthalmologists and neurologists of large practice. In some cases
of growths of large dimensions also careful ophthalmoscopic
examination has shown neither choked disc nor neuro-retinitis to be
present. In two of Seguin's cases, for instance (Cases 28 and 29),
these appearances were absent. In one he reports no neuro-retinitis,
but only some fulness of the veins. In the other, a large sarcoma of
the centrum ovale, ophthalmoscopic changes were absent. The
absence of disturbance of vision, therefore, should not lead the
physician to overlook making a thorough ophthalmoscopic
examination; nor should the absence of ophthalmoscopic
appearances lead him to make up his mind that serious intracranial
disease was not present. The presence of double choked discs is in
the highest degree significant of a brain tumor.
Observations on the temperature of the head have been made in a
few cases of tumor of the brain. Full accounts of such observations
in two cases (1 and 3 of Table) have been published by one of us.14
It is not within the scope of the present paper to review the general
subject of cranial or cerebral thermometry. We will simply, in passing,
recall the labors of E. Seguin,15 Broca,16 Gray,17 Lombard,18
Maragliano and Seppilli,19 and Amidon.20
14 Philadelphia Medical Times, Jan. 18, 1879, and New York Medical Record, Aug. 9,
1879.
15 Medical Thermometry and Human Temperature, by E. Seguin, M.D., New York,

1876.
16 Progrès médical, 1877.
17 New York Medical Journal, Aug., 1878.
18 Experimental Researches on the Temperature of the Head, London, 1881.
19 Quoted in Archives of Medicine, 1879.
20 Archives of Medicine, April, 1880.
L. C. Gray21 has recorded some observations in cerebral

thermometry in one case of tumor of the brain. The tumor, a soft
jelly-like mass the size of a hazelnut, was found between the
horizontal branch of the Sylvian fissure and the first temporal fissure,
while the whole of the right occipital lobe was converted into a
colloid, extremely vascular mass, which gave way under
examination, this degeneration also extending anteriorly to the tumor
as far as the fissure of Sylvius. Microscopical examination showed it
to be a typical glioma.
21 N. Y. Medical Journal, August, 1878.
The temperatures at different stations were as follows:

Left. Right.
Frontal 96.75° 98.33°
Parietal 95° 99.75°
Occipital 96.75° 100.50°
The average of the left side was 96.16°; of the right, 99.52°; of the
whole head, 97.84°.
In a case of frontal tumor (Case 1 of Table) the average

temperatures of the different stations taken were as follows:
Middle frontal station 96.5°

Middle occipital station 95.5°
Right frontal station 95°
Left frontal station 94.7°
Right parietal station 94.7°
Left parietal station 94.4°
In another case, reported in full by one of us22 (Case 94), a gumma

involved the basal termination of the corpus callosum, the peduncles
of the corpus callosum, the lamina cinerea, and anterior perforated
spaces; and the average temperatures at the different stations were
as follows:
Right frontal station 97.1°

Left parietal station 94°
Right occipital station 97°
Left occipital station 94.5°
Right anterior vertical station 97°
Left anterior vertical station 94°
Right posterior vertical station 96.6°
Left posterior vertical station 94.3°
22 New York Medical Record, Aug. 9, 1879.

In a gumma in the cortical motor zone of the right side the head-
temperatures, taken once, were found to be for the right parietal
region, 97.2°; for the left, 96°. In another tumor of the right motor
zone the right frontal region gave a temperature of 98°; the left, of
96°. In a tumor of the left occipito-parietal region the temperatures
were for the right parietal region, 98°; for the left, 97.8°. Although the
temperature of the head was only taken once in each of these three
cases, the observations were carefully made with tested
thermometers.
J. T. Eskridge, in a case of a tumor of the cerebellum with monocular

hemianopia (Case 76), made the following temperature
observations:
Axillary R. 98.6°; L. 98.6°

Head:
Anterior frontal station R. 98.4°; L. 98.4°
Posterior frontal station R. 98.5°; L. 98.6°
Superior frontal station R. 98.4°; L. 98.4°
Parietal frontal station R. 99.2°; L. 98.6°
Rolandic frontal station R. 98.8°; L. 99.1°
Occipital frontal station R. 99.4°; L. 99.1°
Posterior central station 99°.
Anterior central station 99°.
The normal average temperatures, as determined by Gray, were as

follows:

Right frontal station 93.71°
Left parietal station 94.44°
Left occipital station 92.66°
Right occipital station 91.94°
Left side of the head 93.83°
Right side of the head 92.92°
The whole head, exclusive of the vertex 93.51°
Motor region of the vertex 91.67°
The whole head, inclusive of the vertex 92.66°
We conclude that in brain tumors 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.
Mental disturbance of some description was present in about one-

third of all the cases studied. Doubtless they were not recorded in a
large number of cases. Obernier says: “If the psychical qualities of a
patient suffering from cerebral tumor be analyzed, and a careful
comparison made of the former with the existing mental condition,
certain symptoms of mental disturbance will be discovered in most
cases where the tumor is a growing one.” The disturbances may be
in any sphere of the mind—in intellection, volition, emotion, or
perception. Mental slowness and uncertainty, inability to fix the
attention, impossibility of continuous mental action, apathy, or
stupidity, with hesitation or slowness of speech, were strikingly
exhibited in cases of tumor of the antero-frontal region. In Case 1 the
patient's mental condition was studied with great care, and in the
detailed report of the case23 the following facts were noted: The
psychical manifestations were among the most important features of
the case. Although comparatively uneducated, he had been when in
health intelligent and energetic. He had never during his illness had
the gay humor or delirium of grandeur seen in the general paralysis
of the insane. His condition, on the whole, was one of intellectual
slowness and uncertainty. He seemed to have great difficulty in
receiving mental impressions and in directing the movements of his
body. His faculty of attention was, in great measure, destroyed. It
could only be fixed, and then but partially, by distinctly and
vehemently repeating a question or command. He could hear, but it
was necessary to make a tremendous external impression on his
sense of hearing in order to call out a mental response. He
sometimes appeared to me like a man dazed by a great catastrophe
which he could not understand. He was not aphasic, although he
manifested certain striking peculiarities of speech, or, rather, of the
manner of speaking. What he said, either spontaneously or in
answer to questions, was spoken clearly and distinctly and in a firm,
loud voice. His sentences were short, but complete; neither words
nor syllables were omitted; and he made no mistakes in articulation,
enunciation, or pronunciation. In answering he did not seem to be
able to retain for any length of time a hold upon the same idea or to
follow a particular train of thought. He did not wander from one
subject to another, but he would suddenly stop speaking, as if unable
to go farther. Often on being questioned he would try to reply, and
after a sentence or two would sob and burst into tears like a violently
hysterical woman. He would at times have what might be termed
volcanic outbursts of speech. When all was perfectly quiet in the
ward he would suddenly explode with a sentence or two, and then
again subside into stillness. Exclamations of this kind might be
repeated at intervals of a few minutes for hours together, or they
might recur only at intervals of hours. Sometimes what he said would
be connected with some past events of which he seemed to have a
vague recollection; often it would be a demand for something to eat
or drink; and often, again, it would be a paroxysm of profanity.
23 Philadelphia Medical Times, Jan. 18, 1879.
Impairment of will is not uncommon in antero-frontal and other

cerebral tumors, and failure of memory, depression of spirits, and
even acute mania, occur. Many of the patients are emotional,
excitable, and irritable; they often sob and cry, apparently from the
great pain. In some cases, however, emotional conditions are
present which seem to be dependent on some special localization of
the tumor. Hallucinations were noted in two of our tabulated cases.
In one case, a tumor of the motor zone, the patient had delusions
that some one was about to take him away. There were also illusions
of fear or persecution. In another the patient had visual
hallucinations.
Speech-defects of various kinds occur in connection with intracranial

growths. Ladame, quoted by Rosenthal, has cited forty-five cases of
disturbances of speech in which the tumor occupied the most varied
regions of the brain. Peculiar disorders of speech from special
localizations will be treated of under Local Diagnosis.
Local spasms, which go under various names, as cramps,

twitchings, epileptoid attacks, athetosis or athetoid movements, are
common symptoms, particularly of growths which involve the cortical
motor area. They are of great diagnostic value. They are commonly,
although not invariably, accompanied by paresis, which is usually
most marked in the part most affected by the spasm. These local
spasms, beginning in one extremity, in a finger or toe it may be, often
spread toward the centre, until they involve to a greater or less
extent the whole limb, the side of the face, or one-half of the body.
Sometimes instead of this they recur with the same definite
movements over a long period. They are the expression of irritation
of cerebral centres or tracts connected with the muscles or groups of
muscles affected by the abnormal movement. They should always
lead the physician to carefully consider the great probability of a
lesion in some way involving the motor area.
Tumors of the cerebellum, pons, and medulla oblongata sometimes

give rise to general convulsions which closely simulate attacks of
grave epilepsy. These convulsions or general spasms are among the
most important symptoms of intracranial neoplasms. More than
paralysis, they may be regarded as general symptoms, as they are
more likely to occur from tumors situated in different and distant
regions of the brain than paralysis. They are by no means confined
to cases in which the lesion is situated in the so-called motor area of
the brain or in the cerebellum or pons-medulla region. Both
physiological and pathological experiments have shown that
convulsions violent in character, but having certain special
characteristics, may originate from severe irritation of the dura mater.
According to Duret,24 irritation of the sensory nerves of the dura
mater cause reflex spasms or contractures of the muscles of organic
life. These spasms or contractures may occur in the face, eyeballs,
neck, trunk, or limbs, and sometimes on one side and sometimes on
the other. They tend to diffuse and invade neighboring groups of
muscles. “They have never the localization, the measured and
purposed character, of the contractions which belong to the lesions
of the cortex. They frequently become transformed into permanent
contractures.” The application of these facts and conclusions to brain
tumors is evident. As neoplasms are so frequently connected, either
directly with the dura mater or with the fused membranes, it is
evident that the convulsive attacks from which the patient suffers
may occur from tumors located anywhere within the cavity of the
skull.
24 Sur les Traumatismes cérébraux, par H. Duret, chapter iii., summarized in Brain.
vol. i., 1878, p. 47.
General convulsions, as well as local or unilateral spasms, are

present in many tumors of the motor cortex; but if their method of
origin and their progress are closely watched they will usually be
seen to begin with local twitchings.
A glance at the table will show examples of convulsion in almost

every region of the brain.
Contractures—conditions of tonic spasm which continue more or

less persistently—may be either early or late symptoms. They may
occur in one or several limbs, in the face, or rarely in the neck. They
are probably due in some cases to persistent irritation of the dura
mater, in others to comparatively slight but continuous irritation of
motor centres, and in still others to advanced degeneration of the
motor tracts.
Choreas and choreic movements are not frequent, unless some of

the forms of local spasm are regarded as local choreas. In one of
Petrina's cases, a glioma involving the substance of both frontal
lobes, choreic movements of the right arm were present, and in this
same case tremor in both arms was also a symptom. Tremor
simulating that of paralysis agitans or multiple cerebral sclerosis is
occasionally observed, and sometimes a tremor which is nervous or
hysteroidal in character is one of the results of the great suffering of
the patient.
Paralysis or paresis is of course one of the most frequent evidences
of the existence of an intracranial tumor. The palsies of cerebral
tumors are chiefly unilateral, but the loss of power may be in one or
both limbs, in one side of the face, or in the entire one-half of the
body, according to location and extent. Tumors of the cortical motor
zone usually begin their paralytic manifestations with paresis of one
member or one side of the face, which goes on, as the growth
increases in size, to more or less complete hemiplegia.
The paralysis which results from brain tumor is due either to

pressure or to absolute destruction of tissue. In the latter case the
destruction is brought about not only by the simple displacement of
brain-substance, but also through the obliteration of blood-vessels
and the consequent softening.
Peculiar forms of paralysis occur as the result of neoplasm growing

in special locations, as will be more clearly shown under Local
Diagnosis. Thus we have the alternating paralyses from tumors of
the crus cerebri or of the lower part of the pons, and paraplegia, or
perhaps what might be better called double hemiplegia, from multiple
tumors which affect both sides of the brain. In rare cases paralysis of
all four extremities has resulted from a growth in the middle line of
the base of the brain. Some form of paralysis is recorded to have
been present in 20 cases out of 100.
Apoplectiform attacks sometimes take place suddenly during the

progress of cases of brain tumor. A patient who has been suffering
for months with the general symptoms of tumor, and who may or
may not have had some paresis of the limbs or face, has an attack of
unconsciousness, from which he arouses after a time, and is then
found to be almost completely hemiplegic. After such attacks, in
some cases, the symptoms of brain-irritation, particularly the
headache and vomiting, subside or greatly improve. Such attacks
may be explained in several ways—from the occurrence of
congestion with œdema, of intercurrent hemorrhage, or of softening
from obliteration of blood-vessels by the advancing growth; and the
temporary subsidence or more permanent disappearance of the
headache and other symptoms is probably, in some cases at least,
owing to the diminution of tension because of the breakdown of
tissue in the neighborhood of the growth. Sometimes the seizures
which occur during the progress of the case are both epileptiform
and apoplectiform in character.
Sometimes in cases of intracranial tumor there are present in the

cranial nerve-trunks and the muscles supplied by them the changes
known as the reactions of degeneration. These changes are
characteristic of the peripheral palsies, and indeed sharply
distinguish them from paralyses of central origin. The exception to
this rule in cases of intracranial growths is, of course, only apparent
and not real, because these palsies, when caused by the pressure of
a tumor on a nerve-trunk, even within the cavity of the skull, and not
upon their proper centres or intracerebral tracts, are as much
peripheral as though the injury was caused by compression of these
nerve-trunks outside of the skull. These reactions of degeneration
are briefly as follows: The nerve-trunk gradually, sometimes rapidly,
loses its response to both the galvanic and faradic currents. The
muscle loses its response to faradism coincidently with the nerve-
trunk, but to galvanism it is apt to exhibit first increased excitability,
then gradually lessening excitability: and with this lessening
response it puts on the so-called qualitative changes. These consist
of the serial alterations—i.e. the negative pole, instead of exciting the
more active reaction at closure, gives a less response than the
positive pole at closure, and also calls forth a response at opening
which may be greater than the opening contraction of the positive
pole, which may be abolished. In health the positive pole causes
often an active response, and the negative pole none, or almost
none, at opening. Finally, occur modal alterations in the affected
muscles, which consist of a slow, lazy contraction instead of a quick,
lively one as in health, and a tendency in the muscle to remain
contracted (tetany) while the current is passing. The many
modifications—or, better, the partial exhibitions of these changes and
the conditions underlying them—are to be sought in detail in special
treatises. It is sufficient to say that they have been reported in a
number of cases of brain tumor, and that the nerves in whose
distributions they would be especially seen are the motor oculi, or
third, the abducens, or sixth, and the facial, or seventh. It is doubtful
if a very exact electrical examination could be made of many
muscles supplied by these nerves, except in the case of the facial,
and possibly the elevator of the upper eyelid. It is in the case of the
seventh nerve that the recorded observations have been made. It
will be noticed, by reference to the table, that the third, sixth, and
seventh nerves are frequently involved in tumors of the crus and
pons-medulla region, and that the paralysis is usually on the side of
the lesion. These are the cases which would exhibit the reactions of
degeneration. It has been said that in ordinary hemiplegia, and also
in paralyses from tumors of the brain high in the motor region, the
affected side exhibits simply a qualitative increase to electrical
excitation; and this may be explained by the increased excitability to
all stimuli of the lower or spinal-cord centres when cut off from the
brain. The statement, however, which has been made, that in tumors
of the cerebellum the sound side exhibits a quantitative decrease,
sounds like a paradox, and requires further tests before being
accepted as a fact in electro-diagnosis.
Ataxia has been observed in cases of brain tumor situated in various

locations. The symptom described as ataxia, staggering, or
staggering backward, is more particularly observed in cases of tumor
of the cerebellum, pons, and corpora quadrigemina.
Changes in the state of the reflexes are somewhat frequent. Usually

the skin and tendon reflexes will be increased on the side opposite
the lesion, although some striking exceptions, probably due to the
positions of the growth, occur.
Atrophy of the limbs is sometimes present, but usually in brain tumor,

as the lesions are above the nutritive connection of the nerve, true
atrophies do not occur.
True neuralgias are frequent, particularly in the distribution of the

trigeminal. Trigeminal neuritis also undoubtedly occurs in lesions
involving this nerve at its origin, in its course, or in the Gasserian
ganglion.
Anæsthesia, either in the form of local or hemianæsthesia, was
observed in about 20 per cent. of the cases. It is rarely present as an
isolated symptom, but frequently accompanies unilateral paresis. In
a partial or variable form it most frequently is seen in connection with
tumors of the Rolandic region. It is a marked symptom in postero-
parietal growths and those involving the posterior part of the internal
capsule. It may take the form of loss of sensation to pain, touch,
pressure, temperature, etc.
Hyperæsthesia occurs so commonly as to be almost regarded as a

general symptom of brain tumor. Sometimes it is confined to the
head; sometimes it is generally diffused; more frequently it is present
in the limb or limbs affected with the paralysis. With hyperæsthesia
the patients often complain of spontaneous pain in the limbs.
Diplopia or double vision is a somewhat frequent symptom, occurring

most commonly, of course, when the ocular nerves are involved
directly or indirectly by the tumor; hence tumors of the floor of the
skull, of the crus cerebri, of the pons, or of the cerebellum are most
likely to give rise to this symptom. A close study of the character of
diplopia and of other symptoms which go with it will usually enable a
local diagnosis to be made. Diplopia, however, does sometimes
occur in tumors situated remotely from the base, either because of
pressure, because of general nervous weakness, or possibly
because of involvement of cortical oculo-motor centres.
Ptosis is another symptom, generally unilateral, and most frequently

present in connection with strabismus, diplopia, and dilatation of the
pupil from involvement of the third nerve. Dilatation of the pupil and
contraction of the pupil may be present as general symptoms of
tumors. The latter is most probably due to meningeal irritation.
Hemianopsia is another ocular symptom sometimes present in cases

of brain tumor, as it may also be in other forms of encephalic lesion.
It was present in 5 of 100 cases. Norris25 gives a full description,
brought well up to the present time, of this symptom, and a
discussion of the lesions upon which it depends. Seguin26 also
discusses this subject. Starr27 has collected a large number of cases

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In the third or terminal stage paralysis, anæsthesia, convulsions, etc.

Cases have been reported in which intracranial tumors of

The position taken by Obernier, that individuality has much to do with

When the subject of local diagnosis is considered farther on, those

The possibility of the existence of multiple tumors should never be

In another case reported by one of us3 three gummata were found in

The following are other illustrations of multiple tumors and of tumors

M. 44.—Several severe falls on the head. Recent chancre with

M. 5.—Convulsions, beginning either in right foot or in right face; not

(1) Enormous tubercular tumor of left cerebral hemisphere,

M. 2.—Screaming fits. Vomiting. Paralysis of left side of face,

(1) Small glioma in left hemisphere of cerebellum, and (2) a similar

F. 45.—Epileptiform attacks for fourteen years. Vertigo, occipital

(1) Glioma in right hemisphere of cerebellum 1¾ inches in diameter.

M. 65.—Sudden attack of spasm of left arm, with paresis and

(1) Tumor in ascending parietal convolution at junction of upper and

Vomiting is of frequent occurrence, although it does not usually come

A case reported by one of us (Case 70) was a remarkable example

We incline to agree with Ferrier12 that the majority of cases of

Vertigo was noted in 31 out of 100 cases. Under this general

The importance of ophthalmoscopic examinations in suspected

Several practical matters should be borne in mind in connection with

15 Medical Thermometry and Human Temperature, by E. Seguin, M.D., New York,

16 Progrès médical, 1877.

17 New York Medical Journal, Aug., 1878.

18 Experimental Researches on the Temperature of the Head, London, 1881.

19 Quoted in Archives of Medicine, 1879.

20 Archives of Medicine, April, 1880.

L. C. Gray21 has recorded some observations in cerebral

The temperatures at different stations were as follows:

In a case of frontal tumor (Case 1 of Table) the average

Middle frontal station 96.5°

In another case, reported in full by one of us22 (Case 94), a gumma

Right frontal station 97.1°

22 New York Medical Record, Aug. 9, 1879.

J. T. Eskridge, in a case of a tumor of the cerebellum with monocular

Axillary R. 98.6°; L. 98.6°

The normal average temperatures, as determined by Gray, were as

Left frontal station 94.36°

We conclude that in brain tumors the average temperature of the

Mental disturbance of some description was present in about one-

Impairment of will is not uncommon in antero-frontal and other

Speech-defects of various kinds occur in connection with intracranial

Local spasms, which go under various names, as cramps,

Tumors of the cerebellum, pons, and medulla oblongata sometimes

General convulsions, as well as local or unilateral spasms, are

A glance at the table will show examples of convulsion in almost

Contractures—conditions of tonic spasm which continue more or

Choreas and choreic movements are not frequent, unless some of

The paralysis which results from brain tumor is due either to

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