TUMORS OF THE BRAIN

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spoken of by the patient as half-blindness. We also note flashes of light on one side and hallucinations of vision.

Left temporal lobe, first and second convolutions. A tumor here gives rise to sensory aphasia (word deafness).

Left lower parietal lobe and angular gyrus or occipitotemporal tract involvement gives rise to sensory aphasia (word blindness).

At the base of the brain a tumor causes symptoms according to its situation.

In the anterior fossa it may cause loss of the sense of smell.

In the middle fossa it occasions hemianopsia and paralysis of the ocular muscles through the third, fourth, and sixth cranial nerves; neuralgia of the face and anæsthesia, by involvement of the fifth nerve; opposite hemiplegia, neuroparalytic ophthalmia, nystagmus, bilateral spastic paralysis, and deafness.

In the posterior fossa it may cause paralysis of the seventh, ninth, tenth, eleventh, and twelfth nerves; vertigo and ear symptoms; and cerebellar ataxia, a tendency to incline or fall to one side.

The medulla, if involved, may cause widespread paralysis, either paralysis of the cranial nerves alone or hemiplegia with convulsions.

Involvement of the cerebellum causes vertigo, vomiting, headache (which may be frontal or occipital), and early optic neuritis. If the middle lobe is involved, we observe the peculiar cerebellar ataxia and a pitching or reeling gait.

Differential Diagnosis.—We determine the existence of a brain tumor from the general symptoms alone, or the local symptoms alone, or both the general and local symptoms. We have to distinguish tumors from chronic nephritis by examining the urine and noting the condition of the heart, arteries, and blood pressure; by an examination of the fundus of the eye; by the character of the headache, which is more severe in tumors; and by the age of the patient. Tumor is more frequent in young persons. There are no local spasms in uramia. By means of an eye examination, prescribing glasses, and counteracting anæmia by medication, we can exclude hypermetropia and astigmatism. The headache is not severe in these cases. By studying the patient, and by the condition of the optic disc, we may exclude hysteria.

ABSCESS of the brain usually involves a history of injury or otitis media. There is often fever, the early symptoms are severe, and optic neuritis is rare.

The situation of the tumor is indicated by the study of the symptoms. The "signal symptom " is a term applied to a beginning spasm or paralysis, such as numbness and twitching of the thumb, which gradually extends to the hand and then the arm. The order of appearance of the local symptoms is an aid, such as first thumb, then hand, arm, and face. may compare the local symptoms, such as paralysis with aphasia and paralysis with hemianopsia.

Then we

The variety of tumor can sometimes be determined. According to the age of the patient and the rapidity of growth, we may surmise the nature of the growth. The history may help in syphilis, tuberculosis, cancer, or sarcoma. The rapidity of the onset may guide us, as tubercle and cancer

advance rapidly. The signs of irritation are more frequent in glioma and meningeal tumors. The degree of variety in symptoms may guide us; there is more variation in the symptoms caused by glioma. Gummata, tubercles, and sarcomata are more likely to involve the base of the brain. Intracerebral tumors are often gliomata or sarcomata. Sarcomata of the pituitary body or aneurysm may cause early optic neuritis or a peculiar form of hemiopia.

Course. Usually we see general symptoms, but there may be first a local spasm or a general convulsion, with a "signal symptom." The number and severity of the symptoms gradually increase, and finally death occurs in stupor, in general convulsions, or suddenly from heart failure. Recovery may take place after specific treatment or from an operation if the tumor is accessible.

The duration is from one to three years.

The prognosis is bad, except where syphilis is the cause, and where the situation permits of removal.

Treatment. To exclude gumma, give inunctions of mercury, with potassium iodide up to 300 grains or more daily. Tuberculous tumors have been reported to have undergone encapsulation and calcareous change in consequence of appropriate tonic treatment.

Surgical treatment is effectual when the tumor has caused the symptoms leading to its exact localization. Unfortunately, less than 5 per cent (Dana) are "operable." An exploratory trephining is many times indicated when doubt exists. There is likelihood of a return after removal.

THROMBOSIS OF THE VENOUS SINUSES

Etiology.-Primary or marantic thrombosis may take place in cachectic. patients or in the aged, and cause death. Exhausting diarrhoea in children under six months may rarely lead to thrombosis.

Secondary septic thrombosis occurs as a complication of inflammatory conditions of contiguous parts or disease of the middle ear, fracture, or suppurative conditions outside the skull, particularly erysipelas, carbuncle, and parotitis. These cases are much more frequent than the primary cases. Secondary non-septic thrombosis may complicate embolism or pressure on a sinus by cerebral tumors.

Pathology. The obstruction to the circulation of that part of the brain affected by the lodgement of the clot in a sinus results in intense congestion and oedema of that part. Softening of this area of brain tissue may ultimately take place. The septic thrombi soften, disintegrate, and may give rise to purulent meningitis and embolic abscesses, which often take place in the lungs.

Symptoms. For general cerebral symptoms, there are usually apathy, stupor, delirium, convulsions, muscular rigidity, vomiting, optic neuritis, and coma. It is seldom that localizing cerebral symptoms occur, and the condition is found only at autopsies, sometimes, where no exciting symptoms had existed. The involvement of the superior longitudinal sinus gives rise to the most marked cerebral symptoms, although they are never characteristic. The symptoms of the most diagnostic importance are cedema.

ABSCESS OF THE BRAIN (SUPPURATIVE ENCEPHALITIS)

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and distention of the veins outside the skull, in the parts where the veins pass through the bones to join the internal sinuses. If the superior longitudinal sinus is thrombosed, we observe congestion and oedema of the sides of the head and forehead, prominence of the anterior fontanelle in children, and epistaxis. Thrombosis of the cavernous sinus causes œdema and congestion of the eyelid and prominence of the eyeball. Thrombosis of the lateral sinus causes oedema and congestion over the mastoid.

If we have to deal with a septic thrombosis, we observe chills, intermittent or remittent pyrexia, and the typhoid state. Meningitis and abscess of the brain, as complications, will give rise to their symptoms.

The duration of the disease is from a few days to several weeks. The prognosis is bad, unless the thrombus is small and non-septic. Treatment.-Potassium iodide and calomel have been recommended for the cachectic form. Operative treatment has given some brilliant results.

ABSCESS OF THE BRAIN (SUPPURATIVE ENCEPHALITIS)

Etiology.-1. It occurs from continuity through the cranial bones. In about 35 per cent of cases abscess arises from injury to the scalp or skull; in about 10 per cent from caries of the cranial bones; in about 40 per cent from diseases of the middle ear; and in about 10 per cent from chronic suppurative rhinitis. There is often an associated meningitis.

2. Through the blood vessels. During the course of pyæmia, malignant endocarditis, gangrene or suppuration of the lung, empyema, or an infectious disease, septic emboli may lodge in the brain.

Pathology. The abscess results from an acute encephalitis with the formation of pus. The collection of pus may not be encapsulated, and then it extends rapidly with fatal results. Or it may be encapsulated and develop slowly. Sometimes it may remain stationary for a number of years, causing no symptoms, but ultimately enlarge or break. Multiple abscesses may form, secondary to pyæmia, which add cerebral symptoms to those of the pyæmia. The abscess may break through into a ventricle or through the cortex, causing meningitis. The course of abscesses of the brain may be acute or chronic.

Symptoms in Acute Cases.-1. SYMPTOMS OF PRESSURE.-There is headache, severe, constant, possibly localized; then follow vomiting of a cerebral nature, usually optic neuritis, generally irregularity of the pupils, slowness of the pulse, 60 to 70, alternating drowsiness, restlessness, and delirium, and finally coma.

2. SYMPTOMS DUE TO PYÆMIA.-There is a chill with the onset, often repeated during the disease. There is irregular fever, but as a rule we see periods of normal or subnormal temperature. The typhoid condition finally supervenes.

3. LOCALIZING SYMPTOMS.-Irritation or destruction of some portions of the brain, as in brain tumors, gives rise to special symptoms. Convulsions may be confined to certain groups of muscles. There is paralyses, hemiplegic or monoplegic, also aphasia. Phlebitis causes oedema behind the ear and a sensation of fulness over the jugular vein. Meningitis causes rigidity of the neck and cranial nerve paralysis. If the abscess is located in the frontal

lobes, it is usually caused by disease of the nose or ethmoid cells. Mental dulness may be the only symptom. In the temporosphenoidal lobe an abscess may cause no symptoms; if it is in the parietooccipital lobe hemianopia may result. Vomiting, vertigo, and a staggering gait usually accom

pany a cerebellar abscess.

A CHRONIC ABSCESS, developing in a part of the brain not specialized ("silent region"), may become encapsulated without causing symptoms. The patient may be subject to headache and vertigo. Sooner or later the abscess ruptures into a ventricle or on to the cortex, and sudden coma or convulsions ensue.

The diagnosis is made from the history, showing a cause of infection; from septic symptoms; and from localizing symptoms.

The prognosis is grave unless the pus can be evacuated.

In non-purulent hæmorrhagic encephalitis following grippe, pneumonia, malarial disease, and typhoid fever the prognosis is not bad.

The treatment is surgical. With improved knowledge in diagnosis, in the treatment of middle ear and sinus suppurations, and in surgical technique, the mortality is decreasing.

PARASITES OF THE BRAIN

These are very rare in this country, but we occasionally find tumors due to the echinococcus and the Cysticercus cellulosa. The former produces hydatid cysts, such as are found in the liver. These cysts may be large or small, few or many, and are almost always on the surface of the brain.

The cysticerci also form cysts, usually on the surface or in the ventricles, commonly multiple and generally encapsulated. As a rule, they give rise to no symptoms, but there may be persistent headache, convulsions (limited

INJURIES OF THE SPINAL CORD

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or general), and gradually developing blindness-the same symptoms as those of tumors.

The treatment is surgical.

INJURIES OF THE SPINAL CORD

Concussion. Under this head we usually speak of such slight lesions as very small lacerations, hæmorrhages, or contusions. It has been described under Railway Spine.

Laceration and contusion of the spinal cord may be extensive. They are usually associated with severe fractures or dislocations of the vertebral column. There is paralysis, which corresponds to the portion of the cord injured. It is possible for a complete, although slow, recovery to take place.

Compression of the cord, either from a displaced bone, blood clot, or foreign body, such as a bullet, may take place. A blood clot from a hæmorrhage into the meninges or cord gives rise to intense pain in the back, hyperæsthesia, muscular spasm, rigidity, the sensation as if a cord were tied around the waist, and rapidly developing paralysis.

Compression due to bone causes symptoms immediately after the injury. These symptoms are likely to be more serious, and although the bone may be removed, the damage may be permanent.

Wounds of the Spinal Cord.-There may be a complete division of the cord by fractured or dislocated bones, by a knife, or by gunshot or other injury. There may be an escape of the cerebrospinal fluid. We may observe clear symptoms, indicating the situation of the injury. Sometimes, however, a less severe injury will cause symptoms of complete division of the cord. These may be due to the hæmorrhage and oedema. More often there is a considerable portion of the cord injured, and the symptoms are extensive and not well defined. Cysts and abscess may form. Sepsis is not the rule. The paralysis is usually permanent.

The TREATMENT is surgical or symptomatic.

Tumors, cysts, abscess, and parasites of the spinal cord cause symptoms of irritation and compression which point to the affected locality. The TREATMENT is symptomatic, antisyphilitic, or surgical.

HÆMORRHAGE INTO THE SPINAL MEMBRANES

Synonyms: Extramedullary hæmorrhage, spinal apoplexy.

Etiology. This is a rare condition. It may be caused by blows and concussions; chronic pachymeningitis hæmorrhagica; rupture of an aortic aneurysm into the spinal canal after erosion of the vertebral bones; rupture of an aneurysm of the vertebral or basilar artery; hæmorrhagic diseases, such as purpura hæmorrhagica and scurvy; and convulsions or tetanus; or it may be a lesion in caisson disease. Blood from the cranium may make its way downward between the membranes.

Pathology. The hæmorrhage may be extrameningeal, between the bones and the dura, or intrameningeal, between the membranes. It is most frequent in the cervical region. It is quite rare for a sufficient amount of blood to escape to compress the cord.