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Mental disorder increases; headache becomes more violent, and sometimes more localized; amblyopia tends to advance to complete blindness, with marked swelling of the papilla, or special disorders of vision, such as hemianopsia, occur; palsies, ataxia, convulsions, contractures, rigidity of limbs, altered reflexes, local spasms, anæsthesia, hyperæsthesia, paræsthesiæ, neuralgias, appear according to the extent and location of the growth. Certain special phenomena, according largely to the seat of the tumor, may also appear, such as disorders of hearing, taste, or smell, polyuria, diabetes, albuminuria, polyphagia, or dysphagia.
In the third or terminal stage paralysis, anæsthesia, convulsions, etc. become more profound; mentality sometimes decreases to nearly complete imbecility, although in many cases a fair amount of mental power is preserved almost to dissolution. Involvement of the bowels and bladder becomes a distressing symptom, involuntary evacuations adding to the torments of the patient. Bed-sores, acquired or trophic, appear; the patient's limbs are painfully contractured; great emaciation is usually present. With agonized head, often blind or deaf, with torturing pains in anæsthetic, paralyzed, and wasted limbs, covered with painful sores, filthy involuntarily, imbecile or demented, death comes as a thrice-happy relief.
Cases have been reported in which intracranial tumors of considerable size were discovered on autopsy, and had evidently been present for years without their presence having been discovered or even suspected; but these are extremely rare. In general terms, however, it may be said that every case of brain tumor must give rise to symptoms. These symptoms may be few or many, slight or severe, brief or protracted, constant or paroxysmal, according to circumstances. Our experience and study of the literature of the subject lead us to the conclusion that the pathological character of the growth would have some influence as to the severity and prominence of symptoms. Gliomata—which are sometimes hard to distinguish from the brain-substance, particularly the soft gliomata, producing comparatively little pressure—when
located in certain so-called latent areas of the brain might escape detection during life; so might also very small tumors of any kind situated deeply in the substance of the brain.
The position taken by Obernier, that individuality has much to do with the activity of symptoms of brain tumor, has some strength. He refers particularly to the psychical response to the irritation caused by brain tumors, which differs very much in different individuals. The fact, which has been pointed out in the article on Hysteria, that hysterical symptoms are often present in cases of brain tumor as well as in other forms of organic disease, is also sometimes the cause of mistake by the diagnostician. The cases of Hughes Bennett and Eskridge will be referred to in this connection under Diagnosis.
When the subject of local diagnosis is considered farther on, those regions which are most active and those which hold an intermediate position in the production of particular and distinctive symptoms will be more particularly discussed.
The possibility of the existence of multiple tumors should never be overlooked. These are of comparatively frequent occurrence, and sometimes give rise to a puzzling symptomatology. In our search through the literature of the subject for cases we met with many examples of multiple tumors. In preparing our table multiple tumors were usually omitted. They give sometimes symptoms and signs so conflicting as to make a local diagnosis impossible, and even to confuse the expert as to general diagnosis. In other cases, however, one growth of larger size or in an active region takes command of the situation, and leads clearly to its diagnosis in spite of other less significant tumors. This was shown, for example, in one of our cases (Case 14). From the symptoms not only was the presence of the larger tumor diagnosticated, but its exact location was indicated during life. Post-mortem examination, however, showed a smaller tumor at the inferior angle of the right lobe of the cerebellum, and also some basal meningitis with effusion which had not been suspected. The first tumor was one of the ascending frontal
convolution, extending into the fissure of Rolando. Its presence and location had been diagnosticated by the right brachial monoplegia and paresis of the leg, which later increased to paralysis of the limb, with right facial paresis, ptosis, partial anæsthesia of right side of face, and slight clonic spasms of the right arm. At the present time, when the question of operating for the removal of brain tumors is so prominently before the profession, and is now generally regarded as justifiable for growths in this one location, the cortical motor area, the possibility of the coexistence of another tumor should be carefully weighed. In this case, owing to the clear diagnostic indications, the question of operation was considered at the time of consultation, but fortunately—in large part because the patient was almost in extremis —it was decided not to operate. The operation would have been futile, the autopsy showing that the probable immediate cause of death was the basilar effusion which accompanied the cerebellar growth.
In another case reported by one of us3 three gummata were found in three different locations: one in the prefrontal region, another in the retro-central fissure, and a third in the supramarginal convolution. The general symptoms of brain tumor were present in this case, but no localization was possible.
3 Arch. Med., viii. No. 1, August, 1882.
The following are other illustrations of multiple tumors and of tumors with other lesions out of a large number which we have collected:
M. 44.—Several severe falls on the head. Recent chancre with secondary symptoms. Six months before death headache which grew worse; most severe in right supraorbital region, and also obstinate vomiting, vertigo, hiccough, insomnia. Some loss of power on both sides. Slow in answering and indisposed to talk. Choked discs. Involuntary evacuations. Some improvement under treatment, and then relapse. Complete blindness. Polyuria. Specific gravity of urine as low as 1003 and 1005. Appetite at times ravenous. During last few weeks of illness head inclined to the right side, probably from spasm. Intense thirst throughout the illness.
(1) Large sarcoma in the white substance of the right parietal and frontal lobes, involving ascending parietal convolutions. (2) Softening and abscess of the right temporo-sphenoidal lobe and posterior base of the right anterior lobe. Softened mass size of a hickory-nut in the upper portion of the right ascending frontal convolution. (3) Small cystic tumors of the choroid plexuses.4
4 J. T. Eskridge, Trans. of Philada. Path. Society, for 1878-79, vol. ix. p. 119.
M. 5.—Convulsions, beginning either in right foot or in right face; not unconscious during fits. Right-sided hemiplegia. Double optic neuritis, followed by atrophy. Gradual increase in size of head, with gaping sutures. Later, rigidity of right arm and leg. Shortly before death the following symptoms suddenly set in: headache, convulsions of right side with unconsciousness and retraction of head, rigidity of right arm, and tremor of right leg. Later, both arms flexed, with constant tremors of left arm, spreading over whole body. Right sterno-cleido-mastoid was stiff; almost opisthotonos.
(1) Enormous tubercular tumor of left cerebral hemisphere, extending from depth of Sylvian fissure and eroding skull. Corpus striatum soft and diffluent. Weight, over eleven ounces. (2) Tumor, double size of pea, in lower part of middle lobe of cerebellum.5 This case was especially interesting for the onset of the cerebellar symptoms late in the case, caused probably by a late appearance of the cerebellar tumor
5 Hughlings-Jackson, Med. Times and Gaz., London, 1872-73 (2), p. 34.
M. 2.—Screaming fits. Vomiting. Paralysis of left side of face, including corrugator and orbicularis palpebrarum. Winking in both eyes suspended. Paralysis of external rectus muscle. Agitation and contractures of right arm and leg. Later, unsteady movement of head and right arm and jerking of right leg.
(1) Small glioma in left hemisphere of cerebellum, and (2) a similar tumor projecting from left lateral half of floor of fourth ventricle at common nucleus of the abducens and facial nerves.6
6 W. H. Broadbent, Proc. Clin. Soc. Lond., v. 66-68.
F. 45.—Epileptiform attacks for fourteen years. Vertigo, occipital headache, disordered vision, intolerance of light, sleeplessness, excitability, constipation, with paræsthesia of left side. Retraction of head, vomiting. Very late, convulsive movements of right eye and right side of mouth; then general clonic spasms, coma, and death. No paralysis. For twenty-six years there had been an induration of one breast, which toward end of life had a somewhat scirrhous appearance.
(1) Glioma in right hemisphere of cerebellum 1¾ inches in diameter. (2) Glioma in centre of middle lobe of left hemisphere of the cerebrum ¾ inch in diameter. Surrounding nervous tissue softened and broken down.7
7 William L. Bradley, Tr. Conn. Med. Soc., 1880, p. 39.
M. 65.—Sudden attack of spasm of left arm, with paresis and coldness and numbness. Headache and staggering. Wandering in mind. Not unconscious. Twitching in eye. Two days later violent convulsion in entire left half of body, with vomiting; not unconscious. After convulsion left hemiplegia, with left deviation of tongue. Head and eyes turned to right; vertigo. Partial anæsthesia of left face, body, and limbs. Paræsthesia; painful nervous shocks through affected limbs. Sounds in back of head. Later, mind cleared up and many symptoms ameliorated. Very late, convulsion and coma. Cheyne-Stokes respiration, involuntary evacuations. Duration, seven weeks.
(1) Tumor in ascending parietal convolution at junction of upper and middle thirds. (2) Large tumor occupied entire occipital lobe, but did not present on surface, reaching to convexity of descending cornu of lateral ventricle.8
8 W. H. Broadbent, Tr. Clin. Soc. Lond., v. 233-236.
It is rarely absent; in most cases it has peculiar characteristics. Its usual type might be described as continuous pain, sometimes of persistent severity, but generally with exacerbations or paroxysms of great violence. No suffering can surpass that which some of the victims of intracranial neoplasms are compelled for months or years to endure. It is only equalled by the torture produced by malignant growths in the vertebral axis, the throat, or the bones of the pelvis. The pain is not, however, always of this character. In a comparatively few cases it is described by the patient as dull or moderate, or he simply complains of distressing sensations of weight, pressure, or constriction. Usually in these cases, however, the pain increases and becomes less and less endurable. In 100 cases the headache is described as agonizing, violent, severe, or torturing 20 times; as moderate or dull, 26 times. It is simply mentioned 20 times, but here presumably it was of the ordinary severe type. Thus in 66 cases, or 66 per cent., headache of some type was recorded. No mention was made of headache at all in 29 cases, in some of which, however, it was doubtless present. In only 5 cases was it stated not to have been present: 3 out of these 5 were said to be gliomata, and of the other 2, one was probably gliomatous, and the other a cyst in the brain-substance. Tumors of this kind, which exert comparatively little pressure and which are not connected with the membranes, are probably those which are least likely to cause pain. In several instances the patients complained spontaneously of the pain being greatest in the region of the head nearest the seat of growth. With reference to cerebellar tumors, it somewhat generally supposed that occipital pain is usually present. It sometimes is and sometimes is not. In 15 cases of tumor of the cerebellum and of the fourth ventricle the pain was described as occipital twice, as fronto-occipital three times, and as cervico-occipital once. Callender has noticed that cortical lesions are more frequently accompanied by localized pains than lesions of deeper parts.9 Some of our cases would seem to bear out this view, although the data are not numerous or complete.
9 St. Bartholomew's Hospital Reports, 1869, and Ferrier's Localization of Cerebral Disease, p. 99.
In a few cases percussion of the head elicited or intensified pain in the region corresponding to the location of the tumors. We believe that percussion of the skull may afford valuable aid in localizing encephalic tumors, particularly when they are meningeal or cortical. Ferrier10 holds that percussion often elicits pain over the cranial region beneath which a lesion is localized, and Alex. Robertson of Glasgow11 has also directed attention to the value of percussion of the skull in the localization of disease on the surface of the brain.
10 Brain, January, 1879.
11 Abstr Internat. Med Congress, 1881, p. 85, and Journal of Nervous and Mental Disease, April, 1882.
Vomiting is of frequent occurrence, although it does not usually come on as early or remain as persistently as headache. It is more likely to be paroxysmal, with longer or shorter intervals of relief. It frequently occurs at the time of the exacerbations of the headache, and between the paroxysms of vomiting, nausea, slight or great, is often present. It probably occurs in about 50 per cent. of all cases of brain tumor. It is recorded as having been present in 34 out of 100 cases. It was comparatively infrequent in antero-frontal growths, occurring only twice out of 10 cases.
A case reported by one of us (Case 70) was a remarkable example of persistent cerebral vomiting. For four weeks before her death the patient vomited almost incessantly. The tumor in this case involved the middle cerebellar peduncle and the adjacent region of the right cerebellar hemisphere, and had grazed and superficially softened the floor of the fourth ventricle.
We incline to agree with Ferrier12 that the majority of cases of cerebral vomiting can be ascribed to irradiation of irritation by the nerves of the cerebral membranes or to the physical effects of acute pain. The nuclei of the trigeminus and of the vagus are in close anatomical relationship in the medulla oblongata. Irritative impressions conveyed from the cerebral membranes, and particularly from the dura mater, to the trigeminal nuclei in the
medulla are transferred to the vagus and give rise to vomiting. In tumors of the cerebellum the vomiting may be brought about through the affection of the centres of equilibration and the concurrent vertiginous sensations (Ferrier), or it may be due to direct irritation by contiguity of the floor of the fourth ventricle. In general, the tumors situated farthest forward in the brain appeared to be the least likely to give rise to vomiting.
12 Brain, July, 1879.
Vertigo was noted in 31 out of 100 cases. Under this general designation dizziness, giddiness, reeling, insecurity in the erect posture, etc. have been included. The vertigo can be explained in several ways besides by the view which refers it to an affection of centres of equilibration in the cerebellum. Like headache and vomiting, it seems sometimes to be the outcome of pure irritation of the cerebral membranes. Alterations in the intracranial circulation produced by the growth of the tumor is another probable cause. Experiments have demonstrated the existence of a communication between the arachnoid cavity and the labyrinth, and consequently the increased intracranial tension present may result in pressure on the labyrinthine fibres of the auditory nerve, and thus occasion vertigo.
The importance of ophthalmoscopic examinations in suspected cases of brain tumor can scarcely be overestimated. They will often serve to clinch the diagnosis in favor of tumor. Of the 100 tabulated cases, choked discs were recorded in 8; optic neuritis or neuroretinitis in 18. These results serve to show the importance of the examination of the eyes. It will be seen that with Allbutt, Norris, and others we make a distinction between choked disc, papillitis, congestion papilla, or ischæmia of the discs, and descending or interstitial neuritis. The differences between these two varieties of inflammation of the interocular ends of the optic nerve are well presented by Norris in a previous volume of this work,13 which will make it unnecessary for us to describe the conditions present in these cases. An examination of the tabulated cases will show that
true choked discs were present in tumors situated in all portions of the encephalon. They were not infrequently present in tumors of the convexity. Descending neuritis would seem most likely to occur when the tumors are so situated that inflammation set up by them can readily extend by anatomical continuity along the membranes to the optic nerves. The lymph-space theory best accounts for the occurrence of choked discs in cases of tumor situated remotely from the base. In choked disc the appearance is one of intense swelling and engorgement of the optic papilla. In descending neuritis, as described by Graefe and Norris, there is rather a dull-red suffusion of the disc. Some of the cases reported as neuritis may have been choked discs, and the reverse, as physicians often do not make any distinction.
13 Vol. IV. p. 771 et seq.
Several practical matters should be borne in mind in connection with this subject of the condition of the eye-ground. In the first place, sight is not always impaired in cases of even somewhat advanced choking of the disc, so that when other symptoms and indications lead to the suspicion of a brain tumor, unexpected confirmation may be obtained by ophthalmoscopic examination. Some remarkable cases of this kind have been reported, and doubtless have been observed by all ophthalmologists and neurologists of large practice. In some cases of growths of large dimensions also careful ophthalmoscopic examination has shown neither choked disc nor neuro-retinitis to be present. In two of Seguin's cases, for instance (Cases 28 and 29), these appearances were absent. In one he reports no neuro-retinitis, but only some fulness of the veins. In the other, a large sarcoma of the centrum ovale, ophthalmoscopic changes were absent. The absence of disturbance of vision, therefore, should not lead the physician to overlook making a thorough ophthalmoscopic examination; nor should the absence of ophthalmoscopic appearances lead him to make up his mind that serious intracranial disease was not present. The presence of double choked discs is in the highest degree significant of a brain tumor.
Observations on the temperature of the head have been made in a few cases of tumor of the brain. Full accounts of such observations in two cases (1 and 3 of Table) have been published by one of us.14 It is not within the scope of the present paper to review the general subject of cranial or cerebral thermometry. We will simply, in passing, recall the labors of E. Seguin,15 Broca,16 Gray,17 Lombard,18 Maragliano and Seppilli,19 and Amidon.20
14 Philadelphia Medical Times, Jan. 18, 1879, and New York Medical Record, Aug. 9, 1879.
15 Medical Thermometry and Human Temperature, by E. Seguin, M.D., New York, 1876.
16 Progrès médical, 1877.
17 New York Medical Journal, Aug., 1878.
18 Experimental Researches on the Temperature of the Head, London, 1881.
19 Quoted in Archives of Medicine, 1879.
20 Archives of Medicine, April, 1880.
L. C. Gray21 has recorded some observations in cerebral thermometry in one case of tumor of the brain. The tumor, a soft jelly-like mass the size of a hazelnut, was found between the horizontal branch of the Sylvian fissure and the first temporal fissure, while the whole of the right occipital lobe was converted into a colloid, extremely vascular mass, which gave way under examination, this degeneration also extending anteriorly to the tumor as far as the fissure of Sylvius. Microscopical examination showed it to be a typical glioma.
21 N. Y. Medical Journal, August, 1878.
The temperatures at different stations were as follows: