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Progr ammi n g T h e

W orld W ide W eb

Ei ghth Edi ti on

RO B E R T W. S E B E S TA
University of Colorado at Colorado Springs

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Library of Congress Cataloging-in-Publication Data

Sebesta, Robert W., author.
Programming the World Wide Web / Robert W. Sebesta, University of Colorado at Colorado Springs. --
Eighth edition.
pages cm
Includes index.
ISBN 978-0-13-377598-3 (alk. paper)
1. Internet programming. 2. World Wide Web. I. Title.
QA76.625.S42 2014
006.7’6--dc 3
2014000161

10 9 8 7 6 5 4 3 2 1

ISBN-10: 0-13-377598-4
ISBN-13: 978-0-13-377598-3
To Aidan
This page intentionally left blank
Preface

It is difficult to overestimate the effect the World Wide Web has had on
the day-to-day lives of people, at least those in the developed countries.
In just 20 years, we have learned to use the Web for a myriad of disparate
tasks, ranging from the mundane task of shopping for airline tickets to the
crucial early-morning gathering of business news for a high-stakes day trader.
The speed at which millions of Web sites appeared in the last two decades
would seem to indicate that the technologies used to build them were sitting
on the shelf, fully developed and ready to use, even before the Web appeared.
Also, one might guess that the tens of thousands of people who built those
sites were sitting around unemployed, waiting for an opportunity and already
possessing the knowledge and abilities required to carry out this mammoth
construction task when it appeared. Neither of these was true. The need for
new technologies was quickly filled by a large number of entrepreneurs, some
at existing companies and some who started new companies. A large part of
the programmer need was filled, at least to the extent to which it was filled,
by new programmers, some straight from high school. Many, however, were
previously employed by other sectors of the software development industry.
All of them had to learn to use new languages and technologies.
A visit to a bookstore, either a bricks-and-mortar store or a Web site,
will turn up a variety of books on Web technologies aimed at the practic-
ing professional. One difficulty encountered by those teaching courses in
Web programming technologies in colleges is the lack of textbooks that are
targeted to their needs. Most of the books that discuss Web programming
were written for professionals, rather than college students. Such books are
written to fulfill the needs of professionals, which are quite different from
those of college students. One major difference between an academic book
and a professional book lies in the assumptions made by the author about
the prior knowledge and experience of the audience. On the one hand, the
backgrounds of professionals vary widely, making it difficult to assume much
of anything. On the other hand, a book written for junior computer science
majors can make some definite assumptions about the background of the
reader.

v
vi    Preface

This book is aimed at college students, not necessarily only computer science
majors, but anyone who has taken at least two courses in programming. Although
students are the primary target, the book is also useful for professional program-
mers who wish to learn Web programming.
The goal of the book is to provide the reader with a comprehensive introduc-
tion to the programming tools and skills required to build and maintain server
sites on the Web. A wide variety of technologies are used in the construction
of a Web site. There are now many books available for professionals that focus
on these technologies. For example, there are dozens of books that specifically
address only HTML. The same is true for at least a half-dozen other Web tech-
nologies. This book provides descriptions of many of the most widely used Web
technologies, as well as an overview of how the Web works.
The first seven editions of the book were used to teach a junior-level Web
programming course at the University of Colorado at Colorado Springs. The
challenge for students in the course is to learn to use several different program-
ming languages and technologies in one semester. A heavy load of programming
exercises is essential to the success of the course. Students in the course build a
basic, static Web site, using only HTML as the first assignment. Throughout the
remainder of the semester, they add features to their site as the new technologies
are introduced in the course. Our students’ prior course work in Java and data
structures, as well as C and assembly language, is helpful, as is the fact that many
of them have learned some HTML on their own before taking the course.
The most important prerequisite to the material of this book is a solid background
in programming in some language that supports object-oriented programming. It
is helpful to have some knowledge of a second programming language and a bit of
UNIX, particularly if a UNIX-based Web server is used for the course. Familiarity
with a second language makes learning the new languages easier.

New to the Eighth Edition

• Chapter 2 Added descriptions of three new type attribute values for the
input element, url, email, and range to Section 2.9.2.
• Chapter 3 Added descriptions of four new selectors, first-child ,
­last-child, only-child, and empty, to Section 3.4.5.
• Chapter 5 Expanded Section 5.9, titled The canvas Element, from thirteen
lines to three and one-half pages, adding three new figures.
• Chapter 7 Added the new section, 7.2, titled Uses of XML, which briefly
describes some of the many areas in which XML has been used.
Deleted Section 7.4, titled Document Type Definitions, in its
entirety.
• Chapter 12 Added Section 12.2.7, titled Attributes.
• Chapter 14 Added a completely new chapter, now Chapter 14, titled
Android Software Development.
 Preface    vii

Table of Contents
Chapter 1 lays the groundwork for the rest of the book. A few fundamentals are
introduced, including the history and nature of the Internet, the World Wide
Web, browsers, servers, URLs, MIME types, and HTTP. Also included in Chap-
ter 1 are brief overviews of the most important topics of the rest of the book.
Chapter 2 provides an introduction to HTML, including images, links, lists,
tables, forms, the audio and video elements, the organizational elements, and the
time element. Small examples are used to illustrate many of the HTML elements
that are discussed in this chapter.
The topic of Chapter 3 is cascading style sheets, which provide the standard
way of imposing style on the content specified in HTML tags. Because of the
size and complexity of the topic, the chapter does not cover all of the aspects of
style sheets. The topics discussed are levels of style sheets, style specification for-
mats, selector formats, property values, and color. Among the properties covered
are those for fonts, lists, and margins. Small examples are used to illustrate the
subjects that are discussed.
Chapter 4 introduces the core of JavaScript, a powerful language that could
be used for a variety of different applications. Our interest, of course, is its use
in Web programming. Although JavaScript has become a large and complex
language, we use the student’s knowledge of programming in other languages to
leverage the discussion, thereby providing a useful introduction to the language
in a manageably small number of pages. Topics covered are the object model of
JavaScript, its control statements, objects, arrays, functions, constructors, and
pattern matching.
Chapter 5 discusses some of the features of JavaScript that are related to
HTML documents. Included is the use of the basic and DOM 2 event and event-
handling model, which can be used in conjunction with some of the elements of
HTML documents. The HTML canvas element also is described.
One of the interesting applications of JavaScript is building dynamic HTML
documents with the Document Object Model (DOM). Chapter 6 provides
descriptions of a collection of some of the changes that can be made to documents
with the use of JavaScript and the DOM. Included are positioning elements;
moving elements; changing the visibility of elements; changing the color, style, and
size of text; changing the content of tags; changing the stacking order of overlapped
elements; moving elements slowly; and dragging and dropping elements.
Chapter 7 presents an introduction to XML, which provides the means to
design topic-specific markup languages that can be shared among users with
common interests. Included are the syntax and document structure used by XML,
namespaces, XML schemas, and the display of XML documents with both cascad-
ing style sheets and XML transformations. Also included is an introduction to
Web services and XML processors.
Chapter 8 introduces the Flash authoring environment, which is used to
create a wide variety of visual and audio presentations—in particular, those that
include animation. A series of examples is used to illustrate the development
processes, including drawing figures, creating text, using color, creating motion
viii    Preface

and shape animations, adding sound tracks to presentations, and designing com-
ponents that allow the user to control the Flash movie.
Chapter 9 introduces PHP, a server-side scripting language that enjoys wide
popularity, especially as a database access language for Web applications. The
basics of the language are discussed, as well as the use of cookies and session track-
ing. The use of PHP as a Web database access language is covered in Chapter 13.
Chapter 10 introduces Ajax, the relatively recent technology that is used to
build Web applications with extensive user interactions that are more efficient
than those same applications if they do not use Ajax. In addition to a thorough
introduction to the concept and implementation of Ajax interactions, the chapter
includes discussions of return document forms, Ajax toolkits, and Ajax security.
Several examples are used to illustrate approaches to using Ajax.
Java Web software is discussed in Chapter 11. The chapter introduces the
mechanisms for building Java servlets and gives several examples of how servlets
can be used to present interactive Web documents. The NetBeans framework
is introduced and used throughout the chapter. Support for cookies in servlets
is presented and illustrated with an example. Then JSP is introduced through a
series of examples, including the use of code-behind files. This discussion is fol-
lowed by an examination of JavaBeans and JavaServer Faces, along with examples
to illustrate their use.
Chapter 12 is an introduction to ASP.NET, although it begins with a brief
introduction to the .NET Framework and C#. ASP.NET Web controls and some
of the events they can raise and how those events can be handled are among the
topics discussed in this chapter. ASP.NET AJAX is also discussed. Finally, con-
structing Web services with ASP.NET is introduced. Visual Studio is introduced
and used to develop all ASP.NET examples.
Chapter 13 provides an introduction to database access through the Web. This
chapter includes a brief discussion of the nature of relational databases, architectures
for database access, the structured query language (SQL), and the free database
system MySQL. Then, three approaches to Web access to databases are discussed:
using PHP, using Java JDBC, and using ASP.NET. All three are illustrated with
complete examples. All of the program examples in the chapter use MySQL.
Chapter 14 introduces the development of Android applications. The basics
of view documents, which are written in an XML-based markup language, and
activities, which are written in a form of Java, are introduced. Several relatively
simple examples are used to illustrate this new approach to building Web applica-
tions for mobile devices.
Chapter 15 introduces the Ruby programming language. Included are the
scalar types and their operations, control statements, arrays, hashes, methods,
classes, code blocks and iterators, and pattern matching. There is, of course, much
more to Ruby, but the chapter includes sufficient material to allow the student to
use Ruby for building simple programs and Rails applications.
Chapter 16 introduces the Rails framework, designed to make the construc-
tion of Web applications relatively quick and easy. Covered are simple document
requests, both static and dynamic, and applications that use databases, including
the use of scaffolding.
 Preface    ix

Appendix A introduces Java to those who have experience with C++ and
object-oriented programming, but who do not know Java. Such students can learn
enough of the language from this appendix to allow them to understand the Java
applets, servlets, JSP, and JDBC that appear in this book.
Appendix B is a list of 140 named colors, along with their hexadecimal
codings.

Support Materials
Supplements for the book are available at the Pearson Web site
www.pearsonhighered.com/sebesta. Support materials available to all readers
of this book include
• A set of lecture notes in the form of PowerPoint files. The notes were
developed to be the basis for class lectures on the book material.
• Source code for examples
Additional support material, including solutions to selected exercises
and figures from the book, are available only to instructors adopting this
textbook for classroom use. Contact your school’s Pearson Education
representative for information on obtaining access to this material, or visit
pearsonhighered.com.

Software Availability
Most of the software systems described in this book are available free to students.
These systems include browsers that provide interpreters for JavaScript and parsers
for XML. Also, PHP, Ruby, and Java language processors, the Rails framework, the
Java class libraries to support servlets, the Java JDBC, and the Android Development
system, are available and free. ASP.NET is supported by the .NET software
available from Microsoft. The Visual Web Developer 2013, a noncommercial
version of Visual Studio, is available free from Microsoft. A free 30-day trial version
of the Flash development environment is available from Adobe.

Differences between the Seventh Edition

and the Eighth Edition
The eighth edition of this book differs from the seventh in the following ways:
Descriptions of the url, email, and range attributes of the input element
were added to Chapter 2.
Descriptions of four new selectors, first-child, last-child, only-
child, and empty, were added to Chapter 3.
The description of the canvas element was increased from a paragraph to
three and one-half pages and three new figures were added to Chapter 5.
x    Preface

A new section was added to Chapter 7, titled Uses of XML, which briefly
describes some of the many areas in which XML has been used. Section 7.4, titled
Document Type Definitions, was deleted in its entirety.
A new section, titled Attributes, which describes the attributes of C# was
added to Chapter 12.
A completely new chapter was added to the book, Chapter 14, titled Android
Software Development, which introduces the structure of Android applications
and the process of developing them. The use of intents to call other activities and
data persistence are also discussed.
Throughout the book, numerous small revisions, additions, and deletions
were made to improve the correctness and clarity of the material.
 Preface    xi

Acknowledgments
The quality of this book was significantly improved as a result of the extensive
suggestions, corrections, and comments provided by its reviewers. It was reviewed
by the following individuals:

Lynn Beighley Peter S. Kimble

University of Illinois
R. Blank
CTO, Almer/Blank; Training Director, Mark Llewellyn
The Rich Media Institute; Faculty, University of Central Florida
USC Viterbi School of Engineering
Chris Love
Stephen Brinton ProfessionalASPNET.com
Gordon College
Gabriele Meiselwitz
David Brown Towson University
Pellissippi State Technical Community
College Eugene A. “Mojo” Modjeski
Rose State College
Barry Burd
Drew University Najib Nadi
Villanova University
William Cantor
Pennsylvania State University Russ Olsen

Dunren Che Jamel Schiller

Southern Illinois University Carbondale University of Wisconsin—Green Bay

Brian Chess Stephanie Smullen

Fortify Software University of Tennessee at
Chattanooga
Randy Connolly
Mount Royal University Marjan Trutschl
Louisiana State
Mark DeLuca University—Shreveport
Pennsylvania State University
J. Reuben Wetherbee
Sanjay Dhamankar University of Pennsylvania
President, OMNIMA Systems, Inc.
Christopher C. Whitehead
Marty Hall Columbus State University

Matt Goldstein, Executive Editor; Kelsey Loanes, Editorial Assistant, and Kayla
Smith-Tarbox, Program Manager, all deserve my gratitude for their encouragement
and help in completing the manuscript.
 Brief Contents
1 Fundamentals 1

2 Introduction to HTML/XHTML 33

3 Cascading Style Sheets 95

4 The Basics of JavaScript 137

5 JavaScript and HTML Documents 193

6 Dynamic Documents with JavaScript 239

7 Introduction to XML 277

8 Introduction to Flash 315

9 Introduction to PHP 357

10 Introduction to Ajax 401

11 Java Web Software 431

12 Introduction to ASP.NET 493

13 Database Access through the Web 559

14 Android Software Development 599

15 Introduction to Ruby 647

16 Introduction to Rails 691

Appendix A Introduction to Java 721

Appendix B Named Colors and Their Hexadecimal Values 737

Index 741
xii
Contents
1 Fundamentals 1
1.1 A Brief Introduction to the Internet   2
1.2 The World Wide Web   6
1.3 Web Browsers   7
1.4 Web Servers   8
1.5 Uniform Resource Locators   11
1.6 Multipurpose Internet Mail Extensions   13
1.7 The Hypertext Transfer Protocol   15
1.8 Security   18
1.9 The Web Programmer’s Toolbox   20
Summary   27
Review Questions   29
Exercises   31

2 Introduction to HTML/XHTML 33
2.1 Origins and Evolution of HTML and XHTML   34
2.2 Basic Syntax   38
2.3 Standard HTML Document Structure   39
2.4 Basic Text Markup   40
2.5 Images   49
2.6 Hypertext Links   55
2.7 Lists   58
2.8 Tables   63
2.9 Forms   69
2.10 The audio Element   83
2.11 The video Element   84
2.12 Organization Elements   86
2.13 The time Element   88
2.14 Syntactic Differences between HTML and XHTML   89
xiii
xiv    Contents   

Summary   90
Review Questions   91
Exercises   93

3 Cascading Style Sheets 95

3.1 Introduction    96
3.2 Levels of Style Sheets   97
3.3 Style Specification Formats   98
3.4 Selector Forms   99
3.5 Property-Value Forms   103
3.6 Font Properties   105
3.7 List Properties   113
3.8 Alignment of Text   117
3.9 Color   119
3.10 The Box Model   121
3.11 Background Images   126
3.12 The <span> and <div> Tags   128
3.13 Conflict Resolution   129
Summary   132
Review Questions   133
Exercises   135

4 The Basics of JavaScript 137

4.1 Overview of JavaScript   138
4.2 Object Orientation and JavaScript   141
4.3 General Syntactic Characteristics   142
4.4 Primitives, Operations, and Expressions   145
4.5 Screen Output and Keyboard Input   154
4.6 Control Statements   158
4.7 Object Creation and Modification   165
4.8 Arrays   166
4.9 Functions   171
4.10 An Example   175
4.11 Constructors   177
4.12 Pattern Matching Using Regular Expressions   178
4.13 Another Example   182
4.14 Errors in Scripts   184
Summary   186
Review Questions   188
Exercises   190
 Contents    xv


5 JavaScript and HTML Documents 193

5.1 The JavaScript Execution Environment   194
5.2 The Document Object Model   195
5.3 Element Access in JavaScript   199
5.4 Events and Event Handling   201
5.5 Handling Events from Body Elements   205
5.6 Handling Events from Button Elements   207
5.7 Handling Events from Text Box and Password Elements   212
5.8 The DOM 2 Event Model   222
5.9 The canvas Element   228
5.10 The navigator Object   232
5.11 DOM Tree Traversal and Modification   234
Summary   235
Review Questions   236
Exercises   237

6 Dynamic Documents with JavaScript 239

6.1 Introduction   240
6.2 Positioning Elements   240
6.3 Moving Elements   246
6.4 Element Visibility   249
6.5 Changing Colors and Fonts   250
6.6 Dynamic Content   254
6.7 Stacking Elements   257
6.8 Locating the Mouse Cursor   261
6.9 Reacting to a Mouse Click   263
6.10 Slow Movement of Elements   265
6.11 Dragging and Dropping Elements   268
Summary   273
Review Questions   273
Exercises   274

7 Introduction to XML 277

7.1 Introduction   278
7.2 Uses of XML   280
7.3 The Syntax of XML   281
7.4 XML Document Structure   283
7.5 Namespaces   285
xvi    Contents   

7.6 XML Schemas   286

7.7 Displaying Raw XML Documents   294
7.8 Displaying XML Documents with CSS   296
7.9 XSLT Style Sheets   298
7.10 XML Processors   307
7.11 Web Services   309
Summary   311
Review Questions   312
Exercises   313

8 Introduction to Flash 315

8.1 Origins and Uses of Flash   316
8.2 A First Look at the Flash Authoring Environment   316
8.3 Drawing Tools   322
8.4 Static Graphics   331
8.5 Animation and Sound   336
8.6 User Interactions   347
Summary   352
Review Questions   353
Exercises   355

9 Introduction to PHP 357

9.1 Origins and Uses of PHP   358
9.2 Overview of PHP   358
9.3 General Syntactic Characteristics   359
9.4 Primitives, Operations, and Expressions   360
9.5 Output   365
9.6 Control Statements   367
9.7 Arrays   371
9.8 Functions   379
9.9 Pattern Matching   383
9.10 Form Handling   386
9.11 Cookies   392
9.12 Session Tracking   394
Summary   395
Review Questions   396
Exercises   398
 Contents    xvii

10 Introduction to Ajax 401

10.1 Overview of Ajax   402
10.2 The Basics of Ajax   405
10.3 Return Document Forms   415
10.4 Ajax Toolkits   419
10.5 Security and Ajax   427
Summary   428
Review Questions   428
Exercises   429

11 Java Web Software 431

11.1 Introduction to Servlets   432
11.2 The NetBeans Integrated Development Environment   437
11.3 A Survey Example   445
11.4 Storing Information on Clients   453
11.5 JavaServer Pages   462
11.6 JavaBeans   474
11.7 Model-View-Controller Application Architecture   479
11.8 JavaServer Faces   480
Summary   488
Review Questions   489
Exercises   491

12 Introduction to ASP.NET 493

12.1 Overview of the .NET Framework   494
12.2 A Bit of C#   497
12.3 Introduction to ASP.NET   502
12.4 ASP.NET Controls   508
12.5 ASP.NET AJAX   539
12.6 Web Services   544
Summary   553
Review Questions   555
Exercises   556
xviii    Contents   

13 Database Access through the Web 559

13.1 Relational Databases   560
13.2 An Introduction to the Structured Query Language   562
13.3 Architectures for Database Access   567
13.4 The MySQL Database System   569
13.5 Database Access with PHP and MySQL   572
13.6 Database Access with JDBC and MySQL   581
13.7 Database Access with ASP.NET and MySQL   588
Summary   595
Review Questions   596
Exercises   598

14 Android Software Development 599

14.1 Overview   600
14.2 The Tools   602
14.3 The Architecture of Android Applications   602
14.4 The Execution Model for Android Applications   603
14.5 View Groups   605
14.6 Simple Views   606
14.7 An Example Application   609
14.8 Running an Application on an Android Device   618
14.9 Using the Intent Class to Call Other Activities   619
14.10 An Example Application: A Second Activity   620
14.11 More Widgets   628
14.12 Dealing with Lists   632
14.13 Data Persistence   637
14.14 Debugging Applications   641
Summary   643
Review Questions   644
Exercises   645
 Contents    xix

15 Introduction to Ruby 647

15.1 Origins and Uses of Ruby   648
15.2 Scalar Types and Their Operations   648
15.3 Simple Input and Output   656
15.4 Control Statements   659
15.5 Fundamentals of Arrays   664
15.6 Hashes   669
15.7 Methods   671
15.8 Classes   676
15.9 Blocks and Iterators   681
15.10 Pattern Matching   684
Summary   687
Review Questions   687
Exercises   688

16 Introduction to Rails 691

16.1 Overview of Rails   692
16.2 Document Requests   694
16.3 Rails Applications with Databases   700
Summary   718
Review Questions   719
Exercises   720

Appendix A Introduction to Java   721

A.1 Overview of Java   722
A.2 Data Types and Structures   724
A.3 Classes, Objects, and Methods   726
A.4 Interfaces  730
A.5 Exception Handling  730
Summary   735

Appendix B Named Colors and Their Hexadecimal Values   737

Index   741
 Credits
Figures 2.10, 2.14, and 3.7 Courtesy of Robert W. Sebesta
Figures 2.11 and 2.12 © Total Validator
Figures 3.12, 6.9, and 6.12 © Colin Underhill / Alamy
Figures 4.13, 5.1, 12.5–12.8, 12.21–12.23 © Microsoft Corporation
Figures 4.14 and 5.2 © Mozilla
Figure 4.15 © Google, Inc.
Figure 6.10 © Chris Mattison / Alamy
Figure 6.11 © Charles Polidano / Touch The Skies / Alamy
Figures 8.1–8.5, 8.8, 8.10, 8.13, 8.14, 8.16, 8.19, 8.20 8.23, 8.26–8.33 © Adobe Systems
Inc. All rights reserved. Adobe and Flash is/are either [a] registered trademark[s] or a
trademark[s] of Adobe Systems Incorporated in the United States and/or other countries.
Figures 11.4–11.9, 11.1711.18 © Oracle and/or its affiliates. All rights reserved.

xx
Another random document with
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is less likely to be localized, and, on the whole, it is not so severe as
the terrible torture of the neoplasm. Irregular but very decided febrile
phenomena are more likely to be present in meningitis than in tumor.
Like brain tumor, tubercular meningitis of the convexity may give
psychical disturbances, palsies, local spasms, general convulsions,
sensory disturbances, peculiar disorders of the special senses, etc.;
but these symptoms in the former usually come on more irregularly
and are accompanied less frequently with paroxysmal exacerbations
of headache, vomiting, vertigo, etc. Tubercular meningitis of the base
can be more readily distinguished from cases of tumor by the fact
that one cranial nerve after another is likely to become involved in
the diffusing inflammatory process. Tubercular meningitis is of
shorter duration than the majority of cases of brain tumor, and in it
delirium and mental confusion come on more frequently and earlier.
A history and physical evidences of more or less generalized
tuberculosis favor the diagnosis of tubercular meningitis. In both
affections the ophthalmoscope may reveal choked disc or
descending neuritis. It will be seen that the differentiation between
the affections is not always very clear, although in some cases the
decision may be quickly reached from a study of the points here
suggested.

Some of the forms of chronic hydrocephalus are difficult to

distinguish from tumors, especially gliomata. In hydrocephalus, when
not the result of, or not accompanied by, tubercular meningitis, the
disease advances more slowly and with less irritative symptoms than
in cases of tumor. Headache, vertigo, vomiting, and the other
symptoms of meningeal irritation are not so frequently present,
although the ophthalmoscopic appearances are often the same.

Rosenthal speaks of the necessity of diagnosticating brain tumor

from the chronic cerebral softening of Durand-Fardel, from acquired
cerebral atrophy, and the cerebral hypertrophy of children. An
elementary knowledge of the general symptomatology of intracranial
tumors will, however, be sufficient to prevent mistakes of
differentiation in these cases. Neither of these affections presents
the violent paroxysmal symptoms, the affections of the special
senses, or the severe motor and sensory phenomena of intracranial
growths.

Acute mania and paretic dementia are sometimes confounded with

intracranial growths. A case of brain tumor is more likely to be
regarded as one of acute mania than the reverse. In some
comparatively rare instances in the course of their sufferings the
cases of tumor become maniacal, but even a superficial study of
general symptomatology in such a case will be sufficient to clear up
the doubt.

Paretic dements are occasionally supposed to be cases of brain

tumor, because of the epileptiform attacks and isolated pareses
which occur as the disorder progresses. It is only necessary to refer
to this matter, as the mistake would not be likely to be made by one
having any familiarity with dementia paralytica.

L. J. Lautenbach, in a recent communication to the Philadelphia

Neurological Society, which embodied a large number of
ophthalmoscopic examinations of the insane at the State Insane
Hospital, Norristown, Pennsylvania, and the Insane Department of
the Philadelphia Hospital, and also the results of the investigations of
the fundus of the eye in cases of insanity by other observers,
showed that about 16 per cent. of cases of acute mania presented
well-defined papillitis—a condition which he described as one of
swelling and suffusion of the disc, corresponding to cases reported
as choked disc, descending neuritis, and severe congestion of the
optic nerve. No reports of post-mortem examinations were made of
these cases, but they did not present the clinical history of meningitis
or brain tumor. It therefore follows that the existence of papillitis in a
case of acute mania does not necessarily point to a gross lesion,
such as tumor or meningitis.

In the early stage of posterior spinal sclerosis some of the symptoms

of the initial or middle stage of intracranial growths in certain
positions are likely to be present; more particularly, such eye
symptoms as diplopia from deficiency or paresis of the ocular
muscles and disorders of the bladder may mislead. In posterior
spinal sclerosis, however, some at least of the pathognomonic
symptoms of locomotor ataxia, such as lancinating pains, absent
knee-jerk, or Argyle-Robertson pupil, will almost invariably be
present. Those tumors of the cerebellum, pons, tubercular
quadrigemina, etc. which give rise to ataxic manifestations are
usually readily discriminated from posterior spinal sclerosis by the
headache, vomiting, and other general symptoms of brain tumor,
which rarely occur in ataxia. It is far more difficult to separate non-
irritative lesions of certain cerebellar and adjoining regions from the
spinal disorder.

Strange to say, one of the most frequent mistakes of diagnosis is

that which arises from confounding brain tumor with grave hysteria.
In several of our tabulated cases the patients at different periods of
the disease and by various physicians had been set down as
suffering from hysteria. One of Hughes-Bennett's cases (Case 30), a
wayward, hysterical girl of neurotic family, had had her case
diagnosticated as hysteria by one of the highest medical authorities
of Europe, and yet after death a tumor the size of a hen's egg was
found in the cerebrum. In a case reported by Eskridge (Case 76)
hysterical excitement and special hysterical manifestations were of
frequent occurrence, and misled her physicians for a time. Eskridge
remarks, in the detailed report of this case, that to such a degree
was the emotional faculty manifest that had no ocular lesion been
present there would have been great danger of mistaking the case
for one of pure hysteria; and, indeed, a careful physician of many
years' experience, not knowing the condition of the eyes,
pronounced the woman's condition to be pregnancy complicated by
hysteria. A close study of such objective phenomena as choked
discs and paralysis will usually be of the most value.

Even malaria has been confounded in diagnosis with brain tumor.

Holt37 reports a case which presented the history of a fever, at first
periodical, with marked splenic enlargement, great muscular
soreness, and incomplete paralysis, which was diagnosticated to be
chronic malarial poison. The patient for a time improved under
quinine, but eventually grew worse, and on an autopsy a glioma-
sarcoma was found on the inferior surface of the cerebellum. Several
years since a physician about fifty years of age was brought to one
of us for consultation, and in his case a similar mistake had been
made. The case was a clear one of tumor, probably cerebellar, with
headache, neuritis, vertigo, and other general symptoms, which
pointed to an organic lesion. This patient, who came from a malarial
district in the West, had doctored himself, and had been treated by
others with enormous doses of quinine and arsenic.
37 Med. Record, March 1, 1883.

LOCAL DIAGNOSIS.—Niemeyer would hardly say to-day that the

brilliant diagnoses where the precise location of a tumor is fully
confirmed by autopsy are not usually due to the acumen of the
observer, but are cases of lucky diagnosis. It can be asserted with
confidence that the exact situation of a tumor can be indicated during
life in at least two or three locations. Great caution should be
exercised, as insisted upon by Nothnagel,38 in the localization of
tumors of the brain, because, among other reasons, of the frequent
polypus-like extension of such tumors.
38 Wien. Med. Bl., 1, 1882.

The subject of local diagnosis can be approached in several ways,

according to the method of subdividing the brain into regions. Thus,
Rosenthal discusses, in the first place, tumors of the convexity of the
brain, but as this is a very general term, covering portions of several
lobes, we can see no advantage in making such a subdivision.

A few general remarks might be made in the first place, however,

with regard to the general symptoms presented by surface or cortical
growths as compared with those which are produced by deep-seated
neoplasms. The direct or indirect involvement of the membranes in
nearly all cortical tumors makes the symptoms of irritation referable
to these envelopes very numerous and important.

The various centres so called, motor, sensory, and of the special

senses, which have their highest differentiation in the cerebral
cortex, are each and all represented by well-defined tracts of white
matter in the centrum ovale and capsules which connect these
centres with the lower brain, the spinal cord, and the periphery of the
organism. It therefore follows that symptoms produced by localized
lesions of the cortex will be reproduced in other cases by those of
the tracts which go to or come from these centres. We may thus
have a monoplegia or a hemiplegia, a partial anæsthesia or a
hemianæsthesia, a hemianopsia, a word-blindness or word-
deafness, a loss of power to perceive odors or to appreciate
gustatory sensations, from a peculiarly limited tumor or other lesions
of either the gray centres of the cortex or of the white matter of the
central area of the brain; but these specialized symptoms are more
likely to arise from cortical lesions in the case of intracranial
neoplasms, because of the much greater frequency with which these
adventitious products arise from membranes and therefore involve
the cortex.

Peculiar symptoms arise in the case of lesions of the centrum ovale

from the fact that it contains not only projection-fibres which more or
less directly connect cerebral centres with the outer world; but also a
system of commissural fibres which unite corresponding regions of
the two cerebral hemispheres by way of the corpus callosum and
commissures, and a system of association-fibres which connect
different convolutions together, in special cases even those which
are situated remotely from each other, but are associated in function.

It is evident, therefore, as asserted by Starr,39 that a peculiar set of

additional symptoms will be referable to the destruction or irritation of
these commissural and association fibres. For example, failure to
perform easily corresponding bilateral motions in face, hands, or feet
would indicate some obstruction to conduction in the commissural
fibres joining the motor convolutions. “Integrity of both occipital
lobes, and simultaneous, connected, and harmonious action in both,
are necessary to the perfect perception of the whole of any object
when the eyes are fixed upon one point of that object.” Starr gives
the following examples of the methods of detecting a lesion of such
fibres: “In the case of the fibres associating the auditory with the
motor speech-area the symptoms to be elicited seem to be very
simple. Can the patient talk correctly? Can he repeat at once a word
spoken to him? These are the questions which any one will ask who
examines a case of aphasia. But this is not all. The patient must be
further questioned. Can he read understandingly to himself, and tell
what he has read? This will test the occipito-temporal tract. Can he
read aloud? This will test the occipito-temporo-frontal tract. Can he
write what he sees? This will test his occipito-central tract. Can he
write what he hears? This will test the temporo-central tract. Can he
write what he says, speaking to himself in a whisper? This will test
his fronto-central tract. Can he name an odor or a color? Brill has
recorded40 a case of lesion of the cuneus associated with color-
blindness to green, and he states that the patient had difficulty in
naming various colors on account of the presence of a slight degree
of amnesic aphasia.... Can the patient write the name of an odor?
Can he tell how a surface feels—smooth, or warm, or heavy? Such
questions as these will suggest themselves at once to any one who
studies the association of ideas subjectively.

“Take as an example a lesion in the centrum ovale of the occipito-

temporal region. Such a lesion will produce hemianopsia, because it
involves the visual tract of the projection system. It may also produce
a peculiar mental condition known as word-blindness, in which the
patient is no longer able to associate a word or letter seen with its
corresponding sound or with the motion necessary to write it.
Charcot has reported a case of this kind.... The man, who was a very
intelligent merchant, was suddenly seized with right hemianopsia
while playing billiards, and was surprised to find that he saw but one-
half of the ball and of the table. Soon after he had occasion to write a
letter, and after writing it was surprised to find that he could not read
what he had just written. He found, however, that on tracing
individual letters with the pen or fingers he became conscious of the
letters—a few letters (r, s, t, x, y, z), however, being an exception to
this rule. When a book was given him to read he would trace out the
forms of the letters with some rapidity, and thus manage to make out
the words. If his hands were put behind him and he was asked to
read, he would still be observed to put his fingers in motion and trace
the letters in the air. Speech was in no way interfered with, but
reading aloud was only accomplished, like reading to himself, by the
aid of muscular sense. Here, then, was an example of a lesion which
had separated entirely the tract associating sight with speech—viz.
the occipito-temporal tract—but had left intact the tract associating
sight with muscular sense—viz. the occipito-central tract.”
39 Med. Record, vol. xxix. No. 7, Feb. 13, 1886.

40 Amer. Journ. of Neurology, Feb., 1883.

Our tabulated cases, although collected for the purpose of studying

inductively the phenomena of intracranial tumors from all points of
view, have been arranged to indicate, so far as is possible, the
special symptoms which are produced by growths in special
localities. Thus we have made thirteen subdivisions:

I. Superior antero-frontal region (5 cases).—The lateral and

median aspects of the hemisphere from the anterior tip
backward to the posterior thirds of the first three frontal
convolutions, the region roughly bounded by the coronal suture.

II. Inferior antero-frontal or orbital region (5 cases).—From the

anterior tip of hemisphere at the base backward to the optic
chiasm and Sylvian fissures.

III. Rolandic region or motor cortex (15 cases).—From antero-

frontal region backward nearly to mid-parietal lobe, including
posterior thirds of superior middle and inferior frontal
convolutions, ascending frontal and ascending parietal
convolutions, and anterior extremities of superior and inferior
parietal convolutions—lateral and median aspects.

IV. Centrum ovale, fronto-parietal region (5 cases).

V. Postero-parietal region (5 cases).—From Rolandic region to

parieto-occipital fissure, including posterior two-thirds of the
superior and inferior parietal convolutions and the præcuneus.
 VI. Occipital region (9 cases).—Occipital lobe—cortex and
centrum ovale.

VII. Temporo-sphenoidal region (4 cases).—Temporo-

sphenoidal lobe.

VIII. Basal ganglia and adjoining regions (19 cases).—Caudate

nucleus, lenticular nucleus, optic thalamus, internal capsule,
corpora quadrigemina, and ventricles except the fourth.

IX. Cerebellum (9 cases).

X. Floor of fourth ventricle (6 cases).—(Directly or indirectly

involved.)

XI. Pons varolii and medulla oblongata (8 cases).

XII. Crura cerebri (3 cases).

XIII. Middle region of base of brain and floor of skull (7 cases).—

In the main, from optic chiasm backward to pons, in the middle
basilar region, in some instances extending beyond this area in
special directions.

Tumors of the antero-frontal regions can be diagnosticated with

considerable certainty, partly by a study of the actual symptoms
observed and partly by a process of exclusion. Headache of the
usual type, vertigo, choked discs, inflammatory and trophic affections
of the eyes, widely varying body-temperature, and high head-
temperature are among the most positive manifestations. Mental
slowness and uncertainty seem to be greater in these cases than in
others. Mental disturbance of a peculiar character unquestionably
occurs in cases of tumor, as of other lesions, in this region. This
disturbance is exhibited chiefly in some peculiarity of character,
showing want of control or want of attention. The speech-defects
present in a number of cases were rather due to the change in
mental condition than to any involvement of speech-centres. Under
Symptomatology has been given in some detail a study of the
psychical condition in one case of antero-frontal tumor. The absence
of true paralysis and of anæsthesia is characteristic. Nystagmus and
spasm in the muscles of the neck and forearm were present in one
instance, but usually marked spasm is not to be expected. Vomiting
is less frequent than in tumors situated farther back. Facial and other
forms of paresis occasionally are present, but are not marked, and
are probably due to involvement by pressure or destruction of
surrounding tissue of neighboring motor areas. Hemianopsia, such
as was observed in Case 10, showed involvement of the orbital
region. Tumors of the inferior antero-frontal lobe give the same
positive and negative characteristics as those of the superior frontal
region, with the involvement in addition of smell and certain special
ocular symptoms, such as hemianopsia.

Tumors of the motor zone of the cerebral cortex, the region

surrounding and extending for some distance on each side of the
fissure of Rolando, can be diagnosticated with great positiveness: 15
of the 100 cases are examples of tumors of this region, and in many
of these the diagnosis of the location of the growth was accurately
made during life. Localized spasm in peripheral muscles; localized
peripheral paralysis; neuro-retinitis or choked discs; headache; pain
elicited or increased by percussion of the head near the seat of the
tumor; and elevated temperature of the head, particularly in the
region corresponding to the position of the growth,—are the
prominent indications. The spasmodic symptoms usually precede
the paralysis in these cases. The spasm is often local, and generally
begins in the same part in different attacks—in the fingers or toes or
face of one side.

A study of cases of tumor localized to the cortical motor area will

show that in almost any case a local twitching convulsion preceded
the development of paresis or paralysis. Hughlings-Jackson41 reports
a case of sarcoma, a hard osseous mass on the right side of the
head, of eighteen years' standing, subjacent to which was a tumor
the size of a small orange growing from the dura mater. The patient
was a woman aged forty-nine, whose symptoms were very severe
headache and double optic neuritis, with paresis in left leg, followed
by slighter paresis in left arm and left face. A very slow, gradual
hemiplegia came on by pressure on the cortex without any fit.
Jackson says this is the only case which he has seen in which the
hemiplegia has not followed a convulsion where the lesion has been
on the surface. In all very slowly oncoming hemiplegias which he has
seen, except this one, the tumor was in the motor tract.
41 Medical Times and Gazette, London, 1874, vol. i. 152.

As the white matter of the centrum ovale and capsules represents

simply tracts connecting cerebral centres with lower levels of the
nervous system, with each other, or with the opposite hemisphere,
lesions of this portion of the cerebrum will closely resemble those
cortical lesions to which the tracts are related. We have already
referred to the peculiar symptoms referable to involvement of
commissural and association fibres. Tumors of the centrum ovale of
the fronto-parietal region, of which five examples are reported in the
table, vary in symptomatology according to their exact location.
Those situated in the white matter in close proximity to the
ascending convolutions give symptoms closely resembling those
which result from lesions of the adjoining cortical motor centres. In
the cases of Osler, Seguin, and Pick (Cases 26, 27, 28, 29) spastic
symptoms in the limbs of one side of the body, with or without loss of
consciousness, were marked symptoms. In two of these cases some
paresis preceded the occurrence of the spasms. They did not,
however, fully bear out the idea of Jackson that the hemiparesis or
hemiplegia in tumors of the motor tract comes on slowly before the
appearance of spasm.

Tumors of the postero-parietal region present some characteristic

peculiarities. In several cases tumors were located in this region, and
in several others the white matter of the parietal lobe was softened
as the result of the obliteration of blood-vessels by the tumors. In
general terms, we might say that hemianæsthesia, partial or
complete, and impairment of sight and hearing on the side opposite
to the lesions, seemed to be the most constant peculiarities.
Tumors and other lesions of the occipital lobes have in the last few
years received extended attention, and, where possible, exact study,
because of the opportunities which they furnish for corroborating the
work of the experimental physiologists. It is unfortunate that the
records of older cases do not furnish the exact detail which would
render these tumors among the most important and interesting to be
met with in the brain: some cases have, however, been observed
with great care, and a few such are included in the table. To
understand the special significance of the symptoms of such tumors,
it will be well briefly to state some of the well-established facts about
the function of the occipital cortex. The investigations of Gratiolet
and Wernicke especially have proved that this surface of the brain is
in direct connection with the fibres (1) which are continued upward
from the posterior or sensory columns of the cord through the
posterior portion of the internal capsule, and (2) with the expansion
of the optic nerve, or the tract which passes, according to Wernicke,
from the thalamus to the occipital lobe. There is but a partial
decussation of the optic nerves at the chiasm, so that each half of
the brain receives fibres from both eyes. This arrangement is best
stated by Munk (quoted by Starr) as follows: “Each occipital lobe is in
functional relation with both eyes in such a manner that
corresponding halves of both retinal areas are projected upon the
cortex of the lobe of the like-named side; e.g. destruction of the left
lobe produces loss of function of the left halves of both retinæ.” This,
of course, causes the right halves of both fields of vision to appear
black. This condition is known as lateral homonymous hemianopsia,
and was exhibited in several of the tabulated cases (Cases 40, 41,
42, and 43). It is probable that the dimness of the right eye recorded
in Case 38 was really right lateral hemianopsia, as patients mistake
this condition for blindness of that eye alone which is on the side
upon which the visual fields are blank. It follows that this condition of
the eyes will be caused by a destructive unilateral lesion at any point
upon the optic tract behind the chiasm; and its exact nature and
location are to be inferred from other corroborating symptoms.
Among these corroborating symptoms, as will be inferred from the
other functions of the occipital cortex, is especially to be considered
partial hemiplegia and partial hemianæsthesia. This was observed in
Cases 38, 40. These most characteristic localizing symptoms of
occipital tumor have usually others, which, if not of such special
importance, yet help to form a special complexus. Among these
diffused headache is referred to by some writers as characteristic,
but it seems to us that a localized headache, with pain on percussion
over the affected region, is the only kind in this as in other regions
which could have special diagnostic importance. Affections of
hearing are recorded by some. It is not at all uncommon to have an
incomplete hemiplegia and local paralysis. In Case 41 complete
hemiplegia with facial paralysis is recorded. Local palsies, ocular and
facial, are recorded in Cases 36, 37, 38, and 39. It is doubtless by
transmitted pressure, or by extension of the tumor, or the softening
caused by it, toward the motor fibres, that these more or less
incomplete paralyses are caused. The general symptoms, such as
vertigo, vomiting, and convulsions, are frequently present with
tumors of the occipital lobes. We are at a loss to know upon what
data of theory or experience Rosenthal bases his statement that
psychic disorders are more common in occipital tumors than in those
of the anterior and middle lobes, unless he refers simply to the
hebetude and late coma which seem to come generally in these
cases.

Tumors of the temporo-sphenoidal region, so far as we have been

able to study them, present few characteristic features. Physiology
seems to point to the upper temporal convolutions as the cerebral
centres for hearing; thus, according to Starr,42 “disturbances of
hearing, either actual deafness in one ear or hallucinations of sound
on one side (voices, music, etc.), may indicate disease in the first
temporal convolution of the opposite side. Failure to recognize or
remember spoken language is characteristic of disease in the first
temporal convolution of the left side in right-handed persons, and of
the right side in left-handed persons. Failure to recognize written or
printed language has accompanied the disease of the angular gyrus
at the junction of the temporal and occipital regions of the left side in
three foreign and one American case.” In two of our four cases of
tumor in the temporo-sphenoidal region disturbances of hearing
were noted, but in none was the sense studied with sufficient care to
throw any light upon the actual character of the disorder. The case of
Allan McLane Hamilton (Case 47), already referred to under
Symptomatology, was interesting because of the presence of a
peculiar aura connected with the sense of smell. Stupidity, want of
energy, drowsiness, and general mental failure were marked in
tumors of this region.
42 American Med. Sci., N. S. vol. lxxxviii., July, 1884.

Tumors of the motor ganglia of the brain are seldom strictly localized
to one or the other of these bodies. Growths occurring in this region
usually involve one or more of the ganglia and adjacent tracts, and
can only be localized by a process of careful exclusion, assisted
perhaps by a few special symptoms. Paralysis or paresis on the side
opposite to the lesion usually occurs in cases of tumor of either the
caudate nucleus or lenticular nucleus; but whether this symptom is
due to the destruction of the ganglia themselves, or to destruction of
or pressure upon the adjoining capsule, has not yet been clearly
determined. In a case of long-standing osteoma of the left corpus
striatum (Case 49) the patient exhibited the appearance of an
atrophic hemiplegia: his arm and leg, which had been contractured
since childhood, were atrophied and shortened, marked bone-
changes having occurred. Another case showed only paresis of the
face of the opposite side. Clonic spasms were present in two cases,
in one being chiefly confined to the upper extremities of the face. In
this case paralysis was absent. Disturbances of intellect and speech
have been observed in tumors of this region. According to
Rosenthal, aphasic disturbances of speech must be due to lesions of
those fibres which enter the lenticular nucleus from the cortex of the
island of Reil.

Tumors of the optic thalamus usually cause anæsthesia or other

disturbances of sensation in the extremities of the opposite side.
They sometimes show third-nerve palsies of the same side in
association with hemiplegia on the opposite side, these symptoms
being probably due to pressure owing to the proximity of the
neighboring cerebral crus. Speech and gait in such tumors are also
often affected.

Tumors of the corpora quadrigemina give rise to disturbances of

sight and special ocular symptoms, such as difficulty in the lateral
movement of the eyes. Spasms were usually present. Automatic
repetition of words was observed in one case, nystagmus in another,
and diminished sexual inclinations in a third. In other cases peculiar
ataxic movements or a tendency to move backward were noted;
other symptoms, such as spasm, vomiting, headache, were general
phenomena of intracranial tumors; still others, such as hemiplegia,
hemiparesis, or anæsthesia, were probably simply due to the
position of the growth in the neighborhood of motor ganglia and
tracts.

Tumors of the cerebellum have some special symptoms, which also

derive importance from their characteristic grouping. The symptoms
which depend upon the lesion in the organ must be distinguished
from those which are caused by pressure upon adjacent parts,
although these latter symptoms are very important as corroborative
evidence of the location. Among the special symptoms is occipital
headache (often not present), especially when the pain is increased
by percussion about the occiput or by pressure upon the upper part
of the neck. In these cases weakness of the gait (Case 75) and other
motor phenomena, which are usually described as inco-ordination,
are of comparatively frequent occurrence. They are not so much true
inco-ordination as tremor of the limbs, rotation (which is usually only
partial), and the so-called movements of manége. These movements
were present in one-third of the cases collected by Leven and Oliver
(quoted by Rosenthal). Staggering gait is also present, and may be
dependent upon the vertigo, which is apt to be unusually intense in
this kind of intracranial tumor (Cases 69 and 71). The symptoms
caused by pressure of cerebellar tumors upon adjacent organs are
of importance, because in conjunction with the special symptoms
they acquire unusual significance. Sight and hearing are the two
special senses apt to be affected, because of pressure upon the
geniculate bodies and upon the auditory nerve or its nucleus.
Descending optic neuritis, progressing to total blindness, and varied
forms of oculo-motor paralysis may be present. Strabismus
convergens has been said to be a symptom, caused by the paralysis
of the sixth nerve. A hemiplegia and hemianæsthesia result
sometimes from pressure upon the tracts in the pons or medulla.
Continued pressure upon the medulla may eventually, toward the
termination of the case, according to Rosenthal, cause disorders of
the pulse and of respiration and deglutition. This author gives
absence of psychical symptoms as negative evidence which counts
for tumors of the cerebellum, but our table shows several instances
(Cases 70, 71, 74, and 76) in which were present hebetude,
incoherence, or hysteroidal symptoms. It is probable, however, that
such symptoms are not as common and distinct as in tumors of the
cerebrum.

Certain symptoms—or, better, groups of symptoms—characterize

tumors of the pons varolii, and serve to render the local diagnosis
comparatively certain. These depend upon the fact that the pons
combines in itself, or has on its immediate borders, nerve-tracts,
both motor and sensory, in great complexity, from or to almost every
special or general region of the body. Among these symptoms may
especially be mentioned alternating and crossed hemiplegia,
paralysis of eye-muscles (strabismus), paresis of tongue, dysphagia,
anæsthesia (sometimes of the crossed type), and painful affections
of the trigeminus. Vaso-motor disturbances have also been noted. In
one case persistent and uncontrollable epistaxis hastened the fatal
termination of the case.

Conjugate deviation of the eyes, with rotation of the head, as stated

under Symptomatology, is a condition often present in tumors of the
pons varolii as well as in the early stages of apoplectic attacks. A
paper43 has been published by one of us on a case of tumor of the
pons, and from it we will give some discussion of this subject.
43 Journal of Nervous and Mental Disease, July, 1881; Case 84 of Table.

Vulpian was probably the first to study thoroughly conjugate

deviation. The sign, when associated with disease of the pons, was
supposed by him and by others to be connected in some way with
the rotatory manifestations exhibited by animals after certain injuries
to the pons. Transverse section across the longitudinal fibres of the
anterior portions of the pons produces, according to Schiff, deviation
of the anterior limbs (as in section of a cerebral peduncle), with
extreme flexion of the body in a horizontal plane toward the opposite
side, and very imperfect movements of the posterior limbs on the
other side. Rotation in a very small circle develops in consequence
of this paralysis.44 The movements of partial rotation are caused,
according to Schiff, by a partial lesion of the most posterior of the
transverse fibres of the pons, which is followed in animals by rotation
of the cervical vertebræ (with the lateral part of the head directed
downward, the snout directed obliquely upward and to the side).
44 Rosenthal's Diseases of the Nervous System, vol. i. p. 125.

This deviation, both of head and eyes, occurs, however, not only
from lesions of the pons and cerebellar peduncles, but also from
disease or injury of various parts of the cerebrum—of the cortex,
centrum ovale, ganglia, capsules, and cerebral peduncles. It is
always a matter of interest, and sometimes of importance, with
reference especially to prognosis, to determine what is the probable
seat of lesion as indicated by the deviation and rotation.

Lockhart Clarke, Prevost, Brown-Séquard, and Bastian, among

others, have devoted considerable attention to this subject. To
Prevost we owe an interesting memoir. Bastian, in his work on
Paralysis from Brain Disease, summarizes the subject up to the date
of publication (1875). Ferrier, Priestly Smith, and Hughlings-Jackson
have investigated the relations which cortical lesions bear to the
deviation of the eyes and head.

It has been pointed out by several of the observers alluded to that

when the lesion is of the cerebrum the deviation is usually toward the
side of the brain affected, and therefore away from the side of the
body which is paralyzed. In a case of ordinary left hemiplegia it is
toward the right; in one of right hemiplegia, toward the left. In several
cases of limited disease of the pons, however, it has been observed
that the deviation has been away from the side of the lesion. In our
case (Case 84) the conjugate deviation was to the right, while the
tumor was entirely to the left of the median line, thus carrying out
what appears to be the usual rule with reference to lesions of the
pons.

During the life of the patient it was a question whether the case was
not one of oculo-motor monoplegia or monospasm from lesion of
cortical centres. It is probable, as Hughlings-Jackson believes, that
ocular and indeed all other movements are in some way represented
in the cerebral convolutions. In the British Medical Journal for June
2, 1877, Jackson discusses the subject of disorders of ocular
movements from disease of nerve-centres. The right corpus striatum
is damaged, left hemiplegia results, and the eyes and head often
turn to the right for some hours or days. The healthy nervous
arrangement for this lateral movement has been likened by Foville to
the arrangement of reins for driving two horses. What occurs in
lateral deviation is analogous to dropping one rein; the other pulls
the heads of both horses to one side. The lateral deviation shows,
according to Jackson, that after the nerve-fibres of the ocular nerve-
trunks have entered the central nervous system they are probably
redistributed into several centres. The nerve-fibres of the ocular
muscles are rearranged in each cerebral hemisphere in complete
ways for particular movements of both eyeballs. There is no such
thing as paralysis of the muscles supplied by the third nerve or sixth
nerve from disease above the crus cerebri, but the movement for
turning the two eyes is represented still higher than the corpus
striatum.

It would seem a plausible theory that we have in this conjugate

deviation of the eyes and head a distinct motor analogue to the
hemianopsia which results from certain lesions high in the optic
tracts. The fact that we never have a distinct oculo-motor
monoplegia from high lesions, but always a lateral deviation of both
eyes in the same direction, suggests that only a partial decussation
of the fibres of the motor nerves of the eyes occurs, and that each
hemisphere does not control the whole motor apparatus of the
opposite eye, but half of this apparatus in each eye.

Alternating hemiplegia, or paralysis of one side of the body followed

by a paralysis of the other side, is observed in tumors of the pons,
and is readily accounted for by the close proximity of the motor
tracts, a lesion which affects one tract first being very likely, sooner
or later, to involve, partially at least, the other, as in Case 84. Cross-
paralysis of the face and body may be seen, and like crossed
anæsthesia (seen also in Case 84) depends upon the fact that both
motor and sensory fibres to the limbs do not decussate at the same
level as these fibres to the face. Trigeminal neuralgia, from
involvement of the nerve by pressure or otherwise, is recorded in this
characteristic group of symptoms. The association of the general
with the local paralytic symptoms in the manner stated, the
involvement of sensory functions, and the deviation of the eyes and
head serve to distinguish tumors of the pons from cortical or high
cerebral local lesions. Cases 81, 84, 89, and 90 illustrate these facts
in various ways. Case 82, involving the floor of the fourth ventricle,
appears to be an exception, as the deviation is toward the side of the
lesion.

The special localizing symptoms which indicate a tumor of the crus

cerebri are paralysis of the oculo-motor nerve upon the same side as
the tumor, and especially the tendency of this paralysis to pass to the
other side later in the case; disturbance of the innervation of the
bladder; and involvement of the vaso-motor functions. In considering
these symptoms in detail it becomes very evident why we have the
alternating paralysis of the two oculo-motor nerves. As this trunk
arises from the crus, it is in direct risk of injury by the neoplasm, and
the extension of the new growth even slightly must later in the case
involve its fellow. Therefore a ptosis, followed by a similar symptom
on the other side, or other third-nerve symptoms passing from one
side to the other, with other characteristic and corroborating
symptoms, furnish strong evidence of this lesion, as in Case 93.
Rosenthal refers especially to involvement of the bladder, as
difficulty of micturition, but the three cases in the table do not present
such a symptom. He says that experiments prove that irritation of the
peduncle is followed by contraction of the bladder, and that it has
been shown that lesions of the crus abolish the influence of the will
upon micturition. As this occurs at all levels of the cord, its
occurrence with lesions of the crus is not to be considered a very
distinctive symptom. The involvement of the vaso-motor functions is
one of much interest. Its occurrence is not recorded in the cases of
tumors of the crus included in the table, but in Case 94 of twin
tumors in front of the optic chiasm it is recorded that profuse
perspiration occurred. We believe that the centres for the vaso-
motors are not well determined: they seem to be affected by various
lesions, especially about the base of the brain. Among other
corroborating symptoms may be mentioned rotatory movements and
deviation of the head: these rotatory movements are probably
caused by the action of the sound side not antagonized by the
muscles of the paralyzed side. Lateral deviation of the head is
referred to by some. Partial or complete hemiplegia, with facial
paralysis on the side opposite to the lesion, may occur; whereas the
oculo-motor palsy is seen on the same side as the lesion. Diminution
of sensibility happens on the opposite side, or occasionally pain in
the legs, as recorded in Case 92. It is of interest to note, with
Rosenthal, that the reactions of degeneration are not likely to appear
in the facial muscles in this lesion, as it occurs above the nucleus of
that nerve, and thus causes a true centric paralysis. The absence of
psychic symptoms is usually to be noted.

Tumors anywhere in the middle portion of the base of the brain and
floor of the skull, the region of the origin of the various cranial
nerves, can of course be diagnosticated with comparative ease by a
study of the various forms of paralysis and spasms in the distribution
of these nerves, in connection with other special and general
symptoms. Varieties of alternate hemiplegia are to be looked for, and
also isolated or associated palsies of the oculo-motor, pathetic,
facial, trigeminal, and other cranial nerves. In studying these palsies
it must be borne in mind that although the lesions producing them
are intracranial, the paralyses themselves are peripheral.
In most cases apparent exceptions to the ordinary rules as to
localization are capable of easy explanation; thus, for instance, in a
case of tumor of the occipital lobe (Case 44) numbness and pain
were present in the right arm, although the tumor was situated in the
right hemisphere. The tumor was of considerable size, and may
have affected by pressure the adjoining sensory tracts.

Hughlings-Jackson45 reports a case of tubercular tumor, half the size

of a filbert, in the pons under the floor of the fourth ventricle, in the
upper third of the left side. A much smaller nodule was found in the
right half of the pons. This patient, a man thirty-three years old, had
inconstant headache, a gradual incomplete hemiplegia of the right
side, with also paresis of the left masseter and right lower face.
Sensation was diminished in the right arm, leg, and trunk. The optic
discs were normal; the left pupil was smaller than the right. There
was lateral deviation of the eyes to the right. Diplopia was present in
some positions, and one image was always above the other. Aphasic
symptoms were also present. Especial interest attaches to the fact
that the facial paralysis in this case was on the same side as the
hemiplegia, opposite that of the lesion; whereas usually in lesions of
the pons facial paralysis is on the side opposite the hemiplegia. This
is explained by the fact that the tracts of the facial nerve decussate
in the pons below its upper third, and therefore in this case the lesion
caught the nerve-tracts above their decussation.
45 Med. Times and Gazette, London, 1874, p. 6.

PROGNOSIS.—The prognosis in intracranial tumors is of course

usually in the highest degree unfavorable. The early recognition of
the existence of a tumor syphilitic in origin will enable a
comparatively favorable prognosis to be made. It is far from correct,
however, to suppose that all or a majority of the cases of known
syphilitic origin are likely to have a favorable termination. Amidon46
puts this matter very correctly as follows: “Has a destructive lesion
occurred? and if so, where is it located, and what is its extent?
Indications of a destructive lesion should lead one to a cautious
prognosis as regards perfect recovery, while the prognosis for life