Brain tumor

“ 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. ”

“ The great frequency with which injuries of all kinds occur must of course not be overlooked in this connection. It is said by those who oppose the idea of the direct causal relations of injury that almost every one could trace such disease to falls or blows which few escape. In some of the cases of brain tumor, however, the history of injury bears a direct relation in time to the initial symptoms of the tumor. Certain tumors, as the fibromata, osteomata, angiomata, would appear to be of more frequent occurrence as the direct result of traumatism. ”

“ In the medication of tumors of the brain we can unfortunately do but little more than treat the symptoms and ameliorate the various conditions as they arise. There is no specific for these growths, unless the syphilomata be an exception; and experience shows that specific treatment is usually disappointing even when applied to a syphilitic brain tumor. The dietetic and hygienic rules laid down by some are only such as are invariably recommended as routine practice in all kinds of disease ”

“ As [p. 1046] intracranial tumors almost invariably terminate fatally, strictly speaking we have no sequelæ.
PATHOLOGY.—We present in tabular form the various classes of tumors found in the one hundred cases of brain tumor in the table appended to this article:
The histology of tumors of the brain does not in the main differ from that of the same growths as found in other parts of the body, so that a detailed description of their structures, even though founded upon original research, could not offer many novel facts in a field which has been so thoroughly cultivated. ”

“ Trophic disturbances of decided character are sometimes present in cases of brain tumor. Their presence, character, and extent depend upon the position of the tumor and the cranial nerves involved. Trophic disorders of the eye have been noted in cases of tumor of the antero-frontal region, and also of various positions at the base, especially those so situated as to involve the trigeminal nerve. In a fibroma of the superior antero-frontal region (Case 1) conjunctivitis and corneitis of the left eye, with anæsthesia of the conjunctiva, were present, and were very marked symptoms. ”

“ It is not difficult to understand why a tumor not destructive to important brain-centres, nor growing sufficiently rapid to produce brain-pressure, yet rapidly enough to compress the blood-channels, may produce symptoms like those of simple cerebral anæmia. It is claimed that with such a tumor the symptoms are aggravated on the patient's lying down, while in simple anæmia they are ameliorated.34 The latter proposition holds good as a general rule ”

“ 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. ”

“ The tumor gradually increases in front and laterally, until it produces great deformity, and often interferes with respiration and the act of swallowing. From its pressure on the great blood-vessels running to and from the head, there is a constant liability to engorgement of blood in the brain, and to apoplexy, epilepsy, etc. When the enlargement once makes its appearance, it continues to increase in size as long as the person lives, unless appropriate treatment be resorted to. It never disappears spontaneously. ”

“ 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. ”

“ Vertigo from coarse organic lesion of brain, such as a tumor, is common, and is, indeed, rarely absent in such cases. The cases in which it is lacking or least remarkable are, I think, to be found in the anterior and middle cerebral lobes, while it is almost sure to exist at some time when the tumor is in or near the cerebellum. ”

“ Unlike headache in intracranial tumors, it is not a constant symptom. The headache of brain tumors is due in part at least to the conditions of tension which are produced by the growth interfering with the balance of pressure within the skull. Headache is also, as has been pointed out in the article on Brain Tumors, frequently due to the irritation of the membranes; but in this case the one great nerve through which pain expresses itself is the trigeminal, which has its distribution both within the skull and outside of it to all parts of the head. ”

“ Human serum albumin labeled with 131I is sometimes used for location of brain tumors. It appears that tumors 23 alter a normal “barrier” between the brain and blood in such a manner that the labeled albumin can penetrate tumorous tissues although it would be excluded from healthy brain tissue.
The brain behaves almost uniquely among body tissues in that a “blood-brain barrier” exists, so that substances injected into the blood stream will not pass into brain cells although they will pass readily into muscular tissue. This blood-brain barrier does not exist in brain tumors. ”

“ The location having been fixed and other portions of the brain having been examined, if it is not possible or desirable to retain the entire brain as a specimen, a block should be removed embracing a considerable portion of healthy brain-tissue on all sides of the tumor. In order to study the gross internal appearance of the tumor, it is a good plan to make a clean section through the middle of the tumor. ”

“ They tend to diffuse and invade neighboring groups of muscles. “They have never the localization, the measured and purposed character, of the contractions which belong to the lesions of the cortex. They frequently become transformed into permanent contractures.” The application of these facts and conclusions to brain tumors is evident. As neoplasms are so frequently connected, either directly with the dura mater or with the fused membranes, it is evident that the convulsive attacks from which the patient suffers may occur from tumors located anywhere within the cavity of the skull. ”

“ It is everywhere admitted that a cerebral tumor may exist for a long time without causing papillitis, and also that inflammation of the discs may exist for months or years, until they have become entirely atrophic, before the brain disease shall have caused death. ”

“ It is proper, however, for the sake of convenience and thoroughness, to make brief mention of the structure of brain tumors, and especially to dwell upon certain features of these morbid growths which may be considered characteristic of their encephalic location, and hence have not only pathological but also clinical interest. It is hardly worth while to refer to speculations which aim to elucidate the very foundations of the science, except that in a few of these theories we gain an additional insight into both the structure and conduct of some very characteristic brain tumors. ”

“ Errors of diagnosis, however, may here be avoided by taking into consideration the special symptoms which generally accompany the presence of tumors of the brain, such as vertigo, headache, vomiting or even hemiplegia, and local paralysis. The sensory nerves also may become affected by the pressure of the tumor upon them. Thus, pressure upon the trifacial nerve may give rise to neuralgic pains, feelings of tingling and numbness, or even anæsthesia ”

“ Occasionally a more or less diffused and violent meningitis hastens the fatal issue.
COMPLICATIONS AND SEQUELÆ.—Tumors of the brain may be complicated with other affections due to the same cause. Thus, for example, in a case of gumma other evidences of syphilis may be present in the form of nodes, eruptions, etc. A sarcoma or carcinoma of the brain may be associated with similar disease in other organs. Such affections as cystitis, pyelitis, keratitis, etc., which have been discussed under Symptomatology, are secondary complications of cases of tumor. ”

“ 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 ”

“ With the growth of the tumour the symptoms become aggravated, the optic neuritis is followed by optic atrophy and blindness, the patient gradually becomes stuporous, and finally dies in a state of coma. The severity of the symptoms depends to a large extent on the rapidity of growth of the tumour; thus an osteoma growing slowly from the inner table of the skull and implicating the brain may reach a considerable size without producing cerebral symptoms, while a comparatively small sarcoma or syphilitic gumma of rapid growth may endanger life. ”

“ Impairment of will is not uncommon in antero-frontal and other cerebral tumors, and failure of memory, depression of spirits, and even acute mania, occur. Many of the patients are emotional, excitable, and irritable; they often sob and cry, apparently from the great pain. In some cases, however, emotional conditions are present which seem to be dependent on some special localization of the tumor. Hallucinations were noted in two of our tabulated cases. In one case, a tumor of the motor zone, the patient had delusions that some one was about to take him away. ”

“ So long, however, as surgeons will persist in burrowing into the brain substance for a supposed subcortical tumour, so long will the mortality remain high. The great secret in operating on a brain tumour lies in knowing when to terminate the attempt at removal of the tumour and when to rest content with a pure ‘decompression’.
It is obvious, therefore, that cortical tumours—more especially such as give rise to early localizing symptoms, e.g. Rolandic tumours—offer a better prognosis than when the surgeon has to deal with subcortical, central, and basal tumour formation. ”

“ A sudden and serious aggravation of symptoms may result from hæmorrhage into a soft tumour, such as glioma.
The diagnosis of the pathological nature of a cerebral tumour is generally “hardly more than a guess” (Gowers) . At the same time it may be borne in mind that syphilitic gummata occur in adults, from forty to sixty years of age, who have suffered from acquired syphilis, and who may present other evidence of the disease. They tend to increase somewhat rapidly. A negative Wassermann reaction does not necessarily exclude a diagnosis of brain syphilis. ”

“ The diagnosis of cerebral tumours is very difficult, particularly when attempts are made to indicate their exact seat, but that of other cerebral lesions is somewhat easier.
The prognosis is very grave, and in the case of domestic animals nothing can be done. In the ox intra-cranial operations are difficult, by reason of the presence of the sinuses which obstruct the approach to the brain cavity; economically surgical treatment is seldom advisable. ”

“ Too often when a cancer is suspected or discovered it is taken as a foregone conclusion that the malady is hopeless, except as the results of the disease, that is the new growth, may be removed by the knife, X-ray, radium, caustics, etc. And after a surgical operation, as far as my observation goes, the patients are invariably left entirely to their own resources, with the hope, alas, too often futile, that the tumor will not regrow, but with no attempt to so guide the life that there shall not be the same tendency to a recurrent malignant new-formation. ”

“ Whether dependent on injury or not, the symptoms associated with sarcoma of the skull vary according to whether the tumour is extrinsic or intrinsic—whether, for instance, the growth develops in the inward direction and presses on the brain, or grows from the pericranium and is directed externally. Intrinsic tumours, with the exception of some local pain, œdema of tissues, and dilatation of superficial veins, give rise to symptoms closely resembling those observed in intracranial tumour formation. ”

“ CEREBRAL TUMOURS. The brain may be injured and compressed by various tumours of other than parasitic origin. Such tumours may originate in the bones, the meninges or the choroid plexus, or they may simply be due to generalisation of a previously existing tumour. Whilst of very varied origin and nature, all tumours of the cranial cavity have one common effect, viz., to compress the brain. This continuous compression causes progressive atrophy of the brain, but its existence is not always suspected, because the lesions may not give rise to any marked symptoms. ”