of remission may be interspersed with exacerbations of the symptoms. After
months of such alternation the terminal period begins; here the symptoms are
those of the acute type of rapid course and are quickly followed by death in
coma. This rapid termination is due to rupture of the abscess or haemorrhage
into it. Cases of abscess of the frontal lobe have gone to autopsy without
the lesion having been suspected.
Complications such as phlebitis of the superior petrosal and lateral sinuses
are frequent in abscess due to middle ear disease; meningitis is more likely
to complicate cases due to trauma. In the former the symptoms of the com-
plication are oedema of the tissues about the ear and of the neck, with hardness
TUMORS OF THE BEAIN AND ITS MEMBRANES. 729
of the jugular veins; meningitis is evidenced by stiffness of the neck and
cranial nerve involvement.
The prognosis is uniformly bad unless the seat of the, disease can be reached
by surgical means.
Treatment. Prophylaxis consists in the proper management of nasal and
aural lesions and attention to the cleanliness of all cranial injuries. Further
than this the treatment is purely surgical and consists in trephining the skull
and evacuating the abscess. For the technique of this procedure the reader
is referred to works upon surgery.
TUMORS OF THE BRAIN AND ITS MEMBRANES.
Among the neoplasms affecting the brain alone are classed also all tumors
within the cranium and those external to the cranial cavity which subse-
quently, by extension, affect the brain, such as those of the orbit, of the nasal
cavity and of the neighboring fossae.
Varieties. Of these the most common is the tuberculoma or tuberculous
tumor, next in order of frequency is the glioma and following these in order
of frequency are the sarcomata, carcinomata, cystic tumors, including those
due to the echinococcus and the cysticercus cellulosae, and gummata. All
the other varieties of neoplasm occur in the brain, such as lipomata, m}ocomata,
fibromata, osteomata, cholesteatomata, psammomata, etc., but those
mentioned above are most commonly met. Of these only gliomata and
psammomata occur nowhere but in nerve tissue.
.Etiology. Brain tumors seem to be more common in the male sex and
are seen at all ages. Tuberculous tumor is more frequent in children, while
late in life carcinoma is the usual type of neoplasm. During adolescence and
early adult life we meet gummata, sarcomata, gliomata and parasitic tumors.
Metastatic tumors are rare and are chiefly carcinomata. In the production
of new growths of the brain heredity has little influence. As an exciting
cause trauma may occasionally be a factor.
The portions of the brain most frequently involved are the base of the
cerebrum and the cerebellum (tuberculoma); the hemispheres and pons
(gumma); the cerebral substance near its surface and the ventricles (cystic
tumors), the pineal gland (psammoma). Glioma is seen in the retina spread-
ing to the cerebrum or may develop primarily in this site; sarcoma, carcinoma,
myxoma and fibroma affect the meninges; sarcoma, mucous and fibrous
tumors occur in the sheaths of the vessels while carcinoma at times is
found in the substance of the hemispheres.
Symptoms. These are chiefly due to presstu-e and vary with the situation
of the tumor. Of general symptoms, one of the earliest and most prominent
is headache, usually constant but with intensely severe exacerbations; at
73© DISEASES OE THE NERVOUS SYSTEM.
times it may intermit. Vomiting, often without nausea, may accompany
the headache or occur independently; it may be of projectile type. Vertigo
is frequent and varies in degree; it may be slight or so marked as to interfere
with walking or standing.
Mental symptoms such as irritability, loss of memory, absent-mindedness,
dulness, drowsiness and, at times, coma, may be present or conditions of
excitemeAt or delirium may be manifest.
Speech defects, most commonly a running together of the syllables, may
occur.
Epileptiform or apoplectiform attacks (see Jacksonian epilepsy, p. 804)
are characteristic symptoms. Choreiform twitchings may be observed.
True apoplexy may take place from rupture of a blood-vessel in or near the
tumor.
Optic neuritis is one of the most important symptoms from a diagnostic
point of view. It occurs in a large majority (80 percent.) of the cases, its
course is progressive and it terminates in optic atrophy; it is usually bilateral
but the nerve of one side may be involved before that of the other. Choked
disc is not infrequent.
Sensory disorders such as pruritus, derangements of tactile sensation
and neuralgic pains as well as disturbances of the special senses may occur.
Urinary abnormalities (polyuria or glycosuria) may be observed if the
tumor involves the floor of the fourth ventricle.
As the disease goes on the appetite and the nutrition suffer, though more
rarely these manifestations are absent, and as the patient nears death the
pulse may become slow, the breathing irregular and the temperature
elevated.
The observance of symptoms referable to the situation of the neoplasm is
important particularly from a standpoint of diagnosis. In order to systemat-
ize the different symptoms which may occur as a result of tumor occurring
in different localizations, the brain has been divided (Dana) as in Fig. 11.
a. The prefrontal area may be considered as that portion of the brain
anterior to a line drawn at right angles to another drawn through the frontal
and occipital extremities of the brain and beginning at the upper end of the
ascending branch of the Sylvian fissure.
h. The central region includes that portion of the cerebrum between the
line described above and another, limiting the posterior central convolution
prolonged downward to the fissure of Sylvius.
c. The parietal lobe.
d. The occipital lobe.
e. The temporal or temporosphenoidal area.
/. The pons and medulla.
g. The cerebellum.
TUMORS OF THE BRAIN AND ITS MEMBRANES.
731
Other situations not included below are:
h. The corpus callosum.
i. The basal ganglia and capsules.
/. The corpora quadrigemina and pineal gland. „
k. The crura cerebri.
/. The base of the cerebrum.
Tumors situated in the prefrontal area may cause no localizing symptoms,
particularly if on the right side, and even general symptoms may be lacking.
In other instances the latter may be plainly evident, emotional disturbances,
2. Localized spasms and epilepsy, with
sensory aurae; local palsies, slight an-
esthesia, motor aphasia, agraphia.
I. No symp-
toms or men-
tal dulness,ir-
ri t a b i li ty ,
childishness,
lack of power
of attention;
later, motor
spasms or pa-
ralysis, anos-
m i a , eye
symptoms.
Pe re u s sion
tenderness.
Ascending
limb of fis-
s u r e of
Sylvius.
3. No symptoms or mus-
ctilar anaesthesia, aprax-
oculomotor (third
nerve) symptoms,
word blindness.
With deep lesions,
anaesthesia; if the
lesion penetrates
sufficiently
deep, hemian-
opsia.
5.
Word
deaf-
ness,
no
symp-
toms.
Crossed paral-
ysis of III, IV
and limbs.
6. Crossed paraly
sis of Vand limbs.
7. Cerebellar
ataxia, vertigo,
vomiting, forced
TT . / movements, occi-
°"' pital headache; later
zontal L. ^ bulbar symptoms.
F.of S.
6. Crossed paralysis
of tongue and limbs;
bulbar palsy.
Fig. II. — Showing focal symptoms of brain tumor— {after Dana).
mental stupidity and irritability being present in affections of either hemis-
phere. Aphasia may occur if the lesion involves the inferior frontal convo-
lution and spasm or destructive paralysis may result if the tumor extends
posteriorly. Hemianopsia and optic neuritis may be caused by involvement
of the optic tract; disturbance of the sense of smell by involvement of the
olfactory centers. Invasion of the orbit results in oculomotor palsy and
exophthalmos. There may be tenderness on percussion over the neoplasm.
Tumors of the central region may cause spastic symptoms. If in the upper
part of this region spasm of the toes, ankles or legs; if in the middle third the
spasm begins in the fingers, forearm or shoulder; if in the anterior third the
732 DISEASES OF THE NERVOUS SYSTEM.
facial muscles or tongue are affected. With the spasmodic symptoms there
may be numbness or tingling, beginning in a certain group of muscles. Mus-
cular sense may be disturbed.
Tumors of the parietal lobe may be accompanied by no symptoms but stereag-
nostic perception may be affected; word and mind blindness may be associated
with involvement of the angular gyrus and inferior parietal lobule. Third
nerve psftralysis has been observed in tumors near the angular gyrus, though
this symptom is difficult of explanation.
If the tumor extends to the central region motor symptoms may occur.
Tumors of the occipital lobe involving the cuneus may cause homonymous
hemianopsia if unilateral, complete blindness if bilateral. In other portions
of the left lobe mind blindness may result, while if the angular gyrus is involved
the hemianopsia may be associated with word blindness. Accompanying
extension forward into the parietal lobe there may be hemataxia, hemianaes-
thesia and possibly partial hemiplegia.
Tumors of the temp or o sphenoidal lobe may, when in the posterior part of
the first and in the posterior superior part of the second gyrus, be evidenced
by word deafness; if on the right side they usually are without symptoms.
In involvement of the hippocampal convolution there may be disorders, of
smell and taste.
Tumors of the pons and medulla cause either irritation or destruction of the
fibres of these structures or symptoms due to pressure. At times both these
consequences result. Neoplasms in this vicinity are likely to produce symp-
toms involving the face on one side and the body upon the other.
Accompanying lesions of the peduncle of the cerebrum there may be third
nerve paralysis on the side of the lesion and hemiplegia of the other side.
In lesions below this point and involving the pons, paralysis of the fifth nerve
of the same side and hemiplegia of the opposite side may result. Sixth nerve
involvement with internal strabismus may be associated with tumors still
lower down and also facial palsy and deafness due to involvement of the
seventh and eighth nerves may occur. In tumors of large size, hemianaesthesia
and forced movements of the body and conjugate deviation of the eyes away
from the affected side may be present.
In neoplasms of the medulla there may be hemiplegia; hemianaesthesia
and bulbar symptoms may occur. Irritation of the origins of the ninth,
tenth, eleventh and twelfth nerves which have their origin in this structure may
also result, being evidenced by dysphagia, irregular cardiac action and res-
piration, and vomiting. Retraction of the head, numbness, tingling, and
even convulsions may be present. Pressure on the cerebellum causes dis-
orded coordination and a staggering gait.
Tumors of the cerebellum are evidenced by very typical symptoms which
are described in detail on p. 735.
TUMORS OF THE BRAIN AND ITS MEMBRANES. 733
Tumors of the corpus callosum cause symptoms analogous to those due to
involvement of the third and lateral ventricles. There are no symptoms refer-
able to the cranial nerves, but mental hebetude and stupor, hemiplegia of
gradual development and finally paraplegia are likely to be present.
Tumors of the basal ganglia and internal capsule cause symptoms resem-
bling those of lesions of the corpus callosum, such as gradually increasing
hemiplegia with accompanying hemianesthesia and, if the tumor involves
the optic thalamus and neighboring portions of the internal capsule, athetoid
and choreiform movements may be present. Tumors involving the anterior
portions of the optic thalamus may also be evidenced by these movements
while those of the lenticular or caudate nuclei alone are usually without symp-
toms. If very large, however, tumors of the thalamus may produce hemi-
anopsia or hemianaesthesia, and neuritis of the optic nerve is often an early
symptom.
Tumors of the corpora qiiadrigemina alone are rare, there being usually
associated involvement of the crura. They are evidenced by disturbance
of coordination, forced movements and oculomotor paralyses, with nystag-
mus and loss of pupillary reflexes; hemianopsia or complete blindness may
also be present. Tumors of the crura are rarely met. They may cause
oculomotor palsy on the same side, due to third nerve involvement, and
hemiplegia of the opposite side.
Tumors of the base of the brain, when in the anterior fossa, are accompanied
by symptoms very similar to those caused by tumors of the prefrontal area
with the addition of loss of the sense of smell resulting from involvement
of the olfactory lobe. Disturbance of the second and third nerves may also be
present. Neoplasms of the middle fossa and interpeduncular space press
upon the optic chiasm and are consequently accompanied by optic neuritis
and bitemporal hemianopsia.
The presence of a tumor may be suspected from the general symptoms,
its situation from the focal manifestations. The Rontgen ray has been
employed in the diagnosis of the condition and at times has given brilliant
results although the failures have been in the majority. Possibly further
perfection of this means of diagnosis may produce successes with greater
uniformity.
The prognosis. Tumors of the brain due to syphilis may be benefited by
medical treatment. Gliomata and fibromata may continue to grow slowly for a
number of years and tuberculous neoplasms at times cease increasing in size
and undergo calcareous degeneration. Malignant tumors may cause death in
a year or two, death either being sudden due to involvement of the fourth ven-
tricle or preceded by gradually increasing coma due to progressively augment-
ing intracranial pressure.
Treatment consists in regulating the patient's mode of life within strict
734 DISEASES OF THE NERVOUS SYSTEM.
hygienic limitations. The use of alcohol, sexual over-indulgence and all
causes of excitement should be avoided since any influence tending to cause
cerebral hyperaemia may result fatally. These considerations should be kept
in mind in dealing with all varieties of cerebral neoplasm, as well as the fact
that the exhibition of general tonic treatment is indicated.
In gro^i^ths of suspiciously syphilitic character, as well as in all others in
which the type of the lesion is uncertain, antisyphilitic treatment should be
administered. Cerebral gummata are readily and rapidly absorbed by this
means. This treatment may be prescribed in the form of mercurial inunc-
tions and the internal administration of potassium iodide in increasing doses
or the syrup of hydriodic acid in doses of i drachm (4.0) three times a day.
Both the mercury and the iodide should be given to the limit of the patient's
tolerance. The mercury may also be given in the form of the bichloride, -Y2
of a grain (0.005) three times a day or hypodermatically (the salicylate i
grain — 0.065 — dissolved in benzoinol). When the tumor appears to have
ceased increasing in size the mercury may be stopped but the iodide should
be continued in sufficient dosage to control the growth.
Tuberculous tumors necessitate the employment of the usual means indi-
cated in tuberculous conditions, such as iron, codliver oil, etc., and here partic-
ularly, proper diet, out-door life and attention to the patient's general hygiene
should be insisted upon.
For the headache the bromides, antipyrine, antipyrine salicylate (salipy-
rine) or acetphenetidine (phenacetine) may be employed. The ice cap or
the application of leeches is also useful in this connection and if occipital,
the pain may be relieved by the application of the actual cautery to the nape.
In the light of the advances which surgery and cerebral localization have
made of late years operative procedures may be employed with comparatively
slight danger. Success is most likely to be attained in sarcomata and fibro-
mata involving the dura and in neoplasms of the cerebellum. Even if the
growth is not found, or proves to be impossible of removal, the operation, since
it relieves the intra-cranial pressure may result in material benefit to the
patient.
CEREBELLAR DISEASE.
While the cerebellum may be the seat of disease of considerable extent
without symptoms to suggest the lesion, affections of certain portions of this
structure, namely its central lobe and vermiform process, are characterized
by very typical manifestations.
Tumor is the most common cerebellar lesion, neoplasms of various character,
such as sarcoma, tuberculoma, glioma, cystic tumors, gumma, etc., having
been observed. Abscess and haemorrhage may occur but these conditions
are very much rarer.
ACUTE AND CHRONIC MYELITIS. 735
The principal symptoms of cerebellar disease are disordered gait, vertigo
and headache.
The gait is uncertain, the patient reels and stumbles to one side or the other,
forward or backward, very much after the manner of a drunken man. He
is likely to walk with the feet wide apart, for this diminishes the tendency to
stagger. Muscular sense remains normal, consequently there is no Romberg
symptom. The arms and body are seldom affected.
The vertigo varies in degree, is not constant and may occur independently
of the gait disturbance. It is most marked when the patient is standing
or walking and is very greatly diminished or absent entirely when he is sitting
or lying. If of severe type it is a most distressing symptom.
Headache is frequent; in most cases it is occipital, while less frequently
the pain may be in the temporal or frontal regions.
Other symptoms suggestive of cerebellar disease are vomiting, spasmodic
movements of the eyes, optic neuritis which may go on to atrophy and blind-
ness, and neuralgic pains at the back of the head and neck. The knee jerks
are often exaggerated but may be entirely absent. More rarely effusion
into the ventricles resulting from obstruction of the venae Galeni, symptoms
referable to pressure upon the medulla and the origins of the cranial nerves,
glycosuria, rigidity of both sides of the body from pressure interference with
the paths of the motor nerves and sudden death from involvement of the
medullary centers may occur.
Forced positions may accompany lesions of the middle peduncles of the
cerebellum. When these are present the patient assumes a position in bed
and, when moved, unconsciously reassumes this posture; constant positions
of the head and eyes may be associated with this symptom.
Forced movements may be present; these consist of a turning of the body
about its longitudinal axis or a tendency to walk in circles.
DISEASES INVOLVING CHIEFLY THE SPINAL CORD OR ITS
MEMBRANES.
ACUTE AND CHRONIC MYELITIS.
Definition. An acute inflammation of the spinal cord. Acute myelitis
differs from the subacute and chronic forms of the inflammation merely in
rapidity of development of symptoms, consequently as far as aetiology and path-
ology are concerned the different types will be discussed as one. As the inflam-
mation involves different extents of the cord, to it different terms are applied;
transverse myelitis, when an entire cross section of the cord is affected; diffuse
when a large extent vertically is diseased; focal when but one small area is
736 DISEASES OF THE NERVOUS SYSTEM.
involved; disseminated when the disease affects a number of small areas;
central when the gray substance about the central canal is inflamed.
Etiology. The disease is met at all ages but more frequently in males.
It may occiir as a result of exposiire to the inclemencies of the weather, follow-
ing injuries, such as contusions, strains or fractures of the spinal column,
secondary to sepsis and the infectious diseases, as a result of syphilis or of
disease of the vertebrae. Many of these factors cause, first, a mechanical in-
jiury which is followed by inflammation as a secondary manifestation.
The most common site is the upper dorsal, the most infrequent the lumbar
region.
Pathology. The spinal cord is at first intensely congested, reddish-brown
in color, softer in consistency than normal, and the distinction between white
and red matter is less marked; tiny haemorrhages may be visible, their sites
later becoming cavities; later in the acute type, the color changes to yellowish
or white, the affected area is infiltrated with serous fluid and becomes softened
and degenerated. The meninges also are the seat of morbid change.
The microscope reveals the presence of extra vasated red cells and leucocytes,
of the latter, however, but a few; in places the nerve tissue has wholly disap-
peared, in others degenerated axis-cylinders without medullary sheaths may
remain; the ganglion cells may be entirely destroyed or are of rounder outline
and without processes. As the nerve tissue is destroyed its place is taken
by neuroglia, the cells of which increase in number. Deiter's cells may be
present, as also may granular fatty cells, and the walls of the enlarged blood-
vessels are the seat of hyaline degeneration. Where the normal cord sub-
stance has been replaced by neuroglia tissue, no regeneration is possible, the
change being permanent.
Symptoms. The onset of myelitis may be sudden with a chill, followed
by a rise in temperature, io3°-io4° F. (39.5°-4o.° C.) or even higher, rapid
pulse, headache and prostration, or there may be prodromal symptoms
such as numbness or other paraesthesiae in the back and extremities. More
rarely is the disease ushered in by convulsions.
The typical symptoms differ so markedly with the portion of the spinal cord
affected that it is considered best to discuss those likely to be met in most
cases and later those which are characteristic of the various areas of the cord
usually involved.
a. The symptoms of motor irritation. These are seen both at the onset
and during the progress of the disease and consist of convulsive movements,
either quick or slow, of the muscles of the legs.
h. The symptoms of the motor paralysis. These appear early and are the
first symptoms to suggest the diagnosis; they consist of a weakness and loss
of power in the legs, progressing until total paraplegia is present. If one
leg is less affected than the other, the inflammation is less general in the corre-
ACUTE AND CHRONIC MYELITIS. 737
spending half of the cord. In lumbar or dorsal myelitis only the lower limbs
are paralyzed; in myelitis of the cervical region all four extremities are paral-
yzed.
c. Sensory disturbances are late symptoms. Early in the course of the
disease there is rarely pain, but numbness and tingling of the extremities,
and at times the girdle sensation may be present. The sense of touch remains
normal except at very late stages of the affection when anaesthesia is the rule,
although hyperaesthesia. or paraesthesiae may be present. Sensory disturbances
aid us in diagnosticating the level of the lesion since their upper limit corre-
sponds in fair degree to the site of the inflammation.
d. Reflex disturbances. These differ with the site of the lesion and with
the extent of cord involved. In lumbar myelitis the skin reflexes are dimin-
ished over the legs; in dorsal or cervical myelitis when the lumbar cord is
intact, the cutaneous reflexes of the legs may be normal or increased, owing
to the fact that the lumbar reflex arc is unaffected and the possibihty of inter-
ference with the inhibition. At times, however, these reflexes may be dimin-
ished even in dorsal or cervical lesions.
The patellar reflex and ankle clonus are absent when the lumbar cord is
extensively diseased and the former is lost when the inflammation involves
the lateral posterior columns and the anterior horns in this region. When
the cord above the lumbar region is affected, the tendon reflexes of the legs
are increased owing to the interference with the passage of inhibitory impulses.
A lesion involving the entire cord in the dorsal or cervical region may be
accompanied by a loss of the reflexes in the lower extremities. When the
inflammation is confined to the cervical region, the tendon reflexes of the
arms may be exaggerated.
e. Bladder and rectal disturbances. Early in the disease both micturition
and defascation are delayed, later there is retention of urine and ultimately
the bladder and rectum become incontinent.
/. Trophic and vasomotor disturbances. When the lesion is in the dorsal
or cervical cord there is no wasting of the paralyzed muscles of the legs, but
when the lumbar cord is involved, atrophy takes place and, if the anterior