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Atlas of Surgical Approaches to Soft Tissue and
Oncologic Diseases in the Dog and Cat
Atlas of Surgical Approaches to Soft Tissue and
Oncologic Diseases in the Dog and Cat

Marije Risselada, DVM, PhD, DECVS, DACVS-SA

Department of Veterinary Clinical Sciences
Purdue University College of Veterinary Medicine
West Lafayette
IN, USA

Illustrations by Alice MacGregor Harvey

This edition first published 2020
© 2020 John Wiley & Sons, Inc.

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from this title is available at http://www.wiley.com/go/permissions.

The right of Marije Risselada to be identified as the author of this work has been asserted in accordance with law.

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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and
should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient.
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Library of Congress Cataloging-in-Publication Data

Names: Risselada, Marije, 1973- author.
Title: Atlas of surgical approaches to soft tissue and oncologic diseases
in the dog and cat / Marije Risselada ; illustrations by Alice MacGregor
Harvey.
Description: Hoboken, NJ : Wiley-Blackwell, 2020.
Identifiers: LCCN 2020017962 (print) | LCCN 2020017963 (ebook) |
ISBN 9781119370130 (cloth) | ISBN 9781119370178 (adobe pdf) |
ISBN 9781119370192 (epub)
Subjects: MESH: Dog Diseases–surgery | Cat Diseases–surgery | Surgical
Procedures, Operative–veterinary | Neoplasms–veterinary |
Neoplasms–surgery | Atlas
Classification: LCC SF992.C35 (print) | LCC SF992.C35 (ebook) | NLM SF
992.C35 | DDC 636.089/6994–dc23
LC record available at https://lccn.loc.gov/2020017962
LC ebook record available at https://lccn.loc.gov/2020017963

Cover Design: Wiley

Cover Images: Illustration credit – Alice MacGregor Harvey

Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
Contents

Preface ix

Section 1 Oromaxillofacial 1

Approach to the Rostral Mandible 2

Ventral Approach to the Ramus of the Mandible 6
Intraoral Approach to the Ramus of the Mandible 8
Lateral Approach to the Mandible 12
Nasal Planectomy and Premaxillectomy in the Dog 16
Nasal Planectomy in the Cat 20
Approach to the Rostral Maxilla 22
Intraoral Approach to the Maxilla 26
Combined Dorsolateral and Intraoral Approach to the Caudal Maxilla 30
Approach to the Zygomatic Arch 36
Approach to the Temporomandibular Joint 40
Dorsal Rhinotomy in the Dog 44
Dorsal Rhinotomy in the Cat 46
Dorsal Approach to the Sinuses in the Dog 48
Dorsal Approach to the Sinuses in the Cat 50

Section 2 Cervical Area and Ear 53

Approach to the Lateral Ear Canal 54

Approach to the Horizontal Ear Canal and Tympanic Bulla 58
Ventral Approach to the Tympanic Bulla in the Dog 62
Ventral Approach to the Tympanic Bulla in the Cat 66
Lateral Approach to the Mandibular and Sublingual Salivary Glands 70
Ventral Approach to the Mandibular and Sublingual Salivary Glands 74

v
vi ◾ Contents

Lateral Approach to the Mandibular and Retropharyngeal Lymph Nodes 76

Ventral Approach to the Mandibular and Retropharyngeal Lymph Nodes 78
Lateral Approach to the Larynx 82
Ventral Approach to the Larynx 86
Ventral Approach to the Trachea, Esophagus, Carotid Sheath 90
Ventral Approach to the (Para)Thyroid Glands 94
Approach to the Superficial Cervical Lymph Node 96

Section 3 Forelimb 101

Lateral Approach to the Scapula 102

Dorsal Approach to the Spinous Processes and Scapula 106
Forequarter Amputation: Lateral Approach 108
Ventral Approach to the Brachial Plexus and Axillary Artery 114
Craniolateral Approach to the Brachial Plexus 118

Section 4 Hindlimb 123

Partial/Middle Hemipelvectomy (Acetabulectomy) 124

Total Hemipelvectomy 132
Coxofemoral Disarticulation 140
Mid-Femoral Amputation 144
Approach to the Popliteal Lymph Node 150
Approach to the Femoral Artery 152

Section 5 Thorax 155

Right Lateral Approach to the Cranial Thorax 156

Left Lateral Approach to the Cranial Thorax 160
Right Lateral Approach to the Caudal Thorax 164
Left Lateral Approach to the Caudal Thorax 168
Closure of a Rib Wall Resection without Diaphragmatic Advancement 170
Closure of a Rib Wall Resection with Diaphragmatic Advancement 174
Median Sternotomy 178
Transdiaphragmatic Approach to the Thorax 182
 Contents ◾ vii

Section 6 Abdomen 189

Midline Approach to the Abdomen (Female Dog, Cats) 190

Midline Approach to the Abdomen (Male Dog) 194
Grid Approach to the Abdomen 198
Lateral Approach to the Dorsal Abdomen 200
Paramedian Approach to the Inguinal Canal and Lymph Node 204
Paracostal Approach to the Abdomen 208
Combined Paracostal and Midline Approach to the Abdomen 210
Closure of a Caudal Abdominal Defect with Mesh 214
Approach to the Prescrotal Urethra 218
Approach to the Scrotal Urethra 222

Section 7 Perineal Area and Pelvic Canal 227

Dorsal Perineal Approach 228

Lateral Perineal Approach for Perineal Hernia 232
Approach for Anal Sacculectomy 236
Episiotomy 238
Approach for Feline Perineal Urethrostomy 242
Ventral Approach to the Pelvic Canal 248

Section 8 Digits and Tail 253

Lateral Approach to Digit 1 254

Lateral Approach to Digit 2 258
Dorsal Approach to Digits 3 and 4 262
Dorsal Approach to Digit 5 266
Dorsal Approach to the Sacrococcygeal Joint 270

References 275
Index 277
Preface

My goal in creating this book was to generate a go-to atlas that any starting surgeon or surgeon-in-training could use as a
guide in preparing for soft tissue and oncologic cases or as a resource in the operating room to complement existing atlases.
Several novel approaches and new procedures have been published in the veterinary scientific literature in the last several
years; although most have been described in textbooks, no specific illustrated atlas incorporating these updated approaches
and procedures has existed until now.
Included are chapters on oromaxillofacial approaches as well as the cervical area and ear, forelimb, hindlimb, thorax, and
abdomen. The book finishes with approaches to the perineal area, pelvic canal, and digits and tail. Its thoroughness makes
this atlas an excellent guide for planning and executing approaches to soft tissue and oncologic diseases.
It is my hope that this book will serve future veterinarians, surgeons, and surgeons-in-training to facilitate learning new
procedures or quickly brushing up prior to surgery.
Marije Risselada
West-Lafayette, IN, USA

ix
Section 1
Oromaxillofacial

◾◾ Approach to the Rostral Mandible 2

◾◾ Ventral Approach to the Ramus of the Mandible 6
◾◾ Intraoral Approach to the Ramus of the Mandible 8
◾◾ Lateral Approach to the Mandible 12
◾◾ Nasal Planectomy and Premaxillectomy in the Dog 16
◾◾ Nasal Planectomy in the Cat 20
◾◾ Approach to the Rostral Maxilla 22
◾◾ Intraoral Approach to the Maxilla 26
◾◾ Combined Dorsolateral and Intraoral Approach to the Caudal Maxilla 30
◾◾ Approach to the Zygomatic Arch 36
◾◾ Approach to the Temporomandibular Joint 40
◾◾ Dorsal Rhinotomy in the Dog 44
◾◾ Dorsal Rhinotomy in the Cat 46
◾◾ Dorsal Approach to the Sinuses in the Dog 48
◾◾ Dorsal Approach to the Sinuses in the Cat 50
Approach to the Rostral Mandible1

­I NDICATIONS

●● Partial mandibulectomy
●● Rostral mandibulectomy
●● Lip avulsion repair

PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE

I) The lips are clipped and the skin is aseptically prepped and the oral cavity prepared for surgery. The patient is placed
in ventral/sternal recumbency with the maxilla suspended by surgical tape, allowing the mandible to hang down in a
natural position with the entire mandible draped in.
II) The margins around the neoplastic lesion are measured and marked with a sterile marker. The labial and oral mucosa
are incised along the preplanned line using a blade. Stay sutures, skin hooks, or retractors can be used to elevate the
lip away from the surgical field. A periosteal elevator is used to free the bone from muscular and fibrous
attachments.
A stab incision is made caudal to the symphysis. The defect is enlarged by blunt elevation and sharp dissection with
a periosteal elevator and/or scissors to allow the caudal osteotomies to be made without soft tissue trauma.
Bone wax or a hemoclip can be used to stop the bleeding from the mandibular alveolar artery after completing the
caudal cut.

Atlas of Surgical Approaches to Soft Tissue and Oncologic Diseases in the Dog and Cat, First Edition. Marije Risselada.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.

2
 Approach to the Rostral Mandible ◾ 3

Approach to the Rostral Mandible

I)

II)
4 ◾ Section 1 Oromaxillofacial

PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE continued

III) The excess rostral lip is trimmed in a triangle with the base oriented rostrally. The edges of the lip are moved towards
the dorsal midline (A to A and B to B) to start the closure.

­C LOSURE

The closure is started by assessing if excess lip needs to be trimmed; it is continued by approximating the deeper layers if
possible and performing a simple interrupted or simple continuous closure of the mucosa (labial mucosa to the gingiva on
each side of midline). The lip (the defect left from the triangle removed at the rostral aspect) is closed in three layers:
mucosa, muscle/connective tissue, skin.
If the cut was through the symphysis, bone tunnels can be drilled to anchor the soft tissues of the lip to the bone with
suture.

­A LTERNATE POSITIONING AND APPROACHES

●● An alternative to a hanging drape is to place the dog in dorsal recumbency with the head and neck elevated on a sandbag/
towel with the entire mandible draped in.
 Approach to the Rostral Mandible ◾ 5

Approach to the Rostral Mandible continued

III)
Ventral Approach to the Ramus of the Mandible2

­I NDICATIONS

●● Ventral approach to the mandibular bone

­PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE

I) The patient is placed in dorsal recumbency with the neck extended. The mandibular area, extending as needed into
the cervical area, is clipped and prepped. A sandbag or towel can be placed under the neck of the patient to stabilize
the head. The legs are pulled backwards. The maxilla can be taped down to the table, increasing the stability of
­positioning. The mouth can be positioned open during preparation, allowing the entire mandible to be draped into the
surgical field if needed.
II) The skin incision is centered over the mandibular ramus, running parallel to the horizontal ramus of the mandible.
The subcutaneous tissues are bluntly dissected to expose the digastricus muscle. The digastricus muscle is either
­transected at a point away from the bone (for margins) or dissected off the bone with a periosteal elevator if no
­margins are required.

­C LOSURE

The incision is closed by approximating the deeper tissues, subcutaneous layer, and skin in an appositional fashion.

­A LTERNATE POSITIONING AND APPROACHES

●● A midline incision centered between the mandibular rami allows access to the tongue base without entering the oral
cavity.

Atlas of Surgical Approaches to Soft Tissue and Oncologic Diseases in the Dog and Cat, First Edition. Marije Risselada.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.

6
 Ventral Approach to the Ramus of the Mandible ◾ 7

Ventral Approach to the Ramus of the Mandible

I)

II)
Intraoral Approach to the Ramus of the Mandible2,3

­I NDICATIONS

●● Segmental mandibulectomy

­PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE

I) The patient is placed in lateral recumbency with the upper and lower lips clipped, prepped, and draped in. The lateral
cervical area can be draped in as well to allow for access to the mandibular lymph node or for an advancement flap
for closure of the defect if needed. A sterile mouth gag can be placed on the down side to maintain access to the oral
cavity without the need for manual retraction of the mandible.
The margins around the neoplastic lesion are measured and marked with a sterile marker. The labial and oral
mucosa are incised along the preplanned line using a blade. Stay sutures, a skin hook, or retractors can be used to
elevate the lip away from the surgical field.
II) On the oral surface, the mylohyoideus muscle caudally and the geniohyoideus muscle rostrally are elevated from the
bone using a periosteal elevator, taking care not to damage the salivary gland and duct.

Atlas of Surgical Approaches to Soft Tissue and Oncologic Diseases in the Dog and Cat, First Edition. Marije Risselada.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.

8
 Intraoral Approach to the Ramus of the Mandible ◾ 9

Intraoral Approach to the Ramus of the Mandible

I)

II)
10 ◾ Section 1 Oromaxillofacial

PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE continued

III) Labially, the digastricus muscle is elevated away from the bone, allowing access to the preplanned osteotomy site. The
osteotomies can be performed with a high speed drill, an osteotome and mallet, or an oscillating saw.
IV) Depending on the size and location of the lesion, the rostral cut can be at the symphysis, caudal to the ipsilateral
canine or across the midline. Bone wax or a hemoclip can be used to stop the bleeding from the mandibular alveolar
artery after completing the caudal cut.

­C LOSURE

This is performed by approximating the deeper layers first and performing a simple interrupted or simple continuous
­closure of the mucosa.

­A LTERNATE POSITIONING AND APPROACHES

●● For a full mandibulectomy the incision is extended caudally, with a full thickness commissurotomy to allow access to the
vertical ramus of the mandible (see Lateral Approach to the Mandible).
 Intraoral Approach to the Ramus of the Mandible ◾ 11

Intraoral Approach to the Ramus of the Mandible continued

III)

IV)
Lateral Approach to the Mandible1,3

­I NDICATIONS

●● Mandibular rim excision

●● Segmental mandibulectomy
●● Mandibulectomy

­PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE

I) The patient is placed in lateral recumbency with the upper and lower lips clipped, prepped, and draped in. The lateral
cervical area can be draped in as well to allow commissurotomy and for access to the mandibular lymph node or for
an advancement flap for closure of the defect if needed. A sterile mouth gag can be placed on the down side to
­maintain access to the oral cavity without the need for manual retraction.
The margins around the neoplastic lesion are measured and marked with a sterile marker.
II) A full thickness incision is made at the commissure to allow exposure of the vertical ramus of the mandible. The labial
and oral mucosa are incised along the preplanned line using a blade. Stay sutures or retractors can be used to elevate
the lip away from the surgical field.
On the oral surface, the mylohyoideus muscle caudally and the geniohyoideus muscle rostrally are elevated from
the bone using a periosteal elevator, taking care not to damage the salivary gland and duct. Labially, the digastricus
muscle is elevated away from the bone. The masseter muscle overlies the vertical ramus of the mandible and is cut
at its ventral attachment and elevated dorsally to expose the dorsal extent of the mandible and the approach to the
temporomandibular joint.

Atlas of Surgical Approaches to Soft Tissue and Oncologic Diseases in the Dog and Cat, First Edition. Marije Risselada.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.

12
 Lateral Approach to the Mandible ◾ 13

Lateral Approach to the Mandible

I)

II)
14 ◾ Section 1 Oromaxillofacial

PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE continued

III) The osteotomies can be performed with a high speed drill, an osteotome and mallet, or an oscillating saw. For a full
mandibulectomy, the rostral cut is typically at the symphysis (but can be altered depending on the location of the
lesion) and is performed first to allow lateral retraction of the mandible. The pterygoid muscle, located medial to the
vertical ramus, is severed last to allow removal of the left or right mandible.

­C LOSURE

This is performed by approximating the deeper layers first in an interrupted or continuous suture pattern, followed by
performing a simple interrupted or simple continuous closure of the mucosa.
The commissure is closed in three layers: mucosa, muscle, skin. The commissure can be advanced cranially to decrease
deviation of the tongue and/or drooling. The closure can be reinforced by placing a button or stent on the dorsal and ventral
side at the commissure to avoid the incision lines pulling apart by opening the mouth.
 Lateral Approach to the Mandible ◾ 15

Lateral Approach to the Mandible continued

III)
Nasal Planectomy and Premaxillectomy in the Dog4–7

­I NDICATIONS

●● Nasal planum tumors with bony involvement

●● Rostral maxillary tumors

­PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE

I, II) The entire maxilla is clipped and prepped and the patient is placed in ventral recumbency with the head and neck
elevated on a sandbag/towel with the maxilla draped in. A drape can be placed in the oral cavity or the mandible can
be draped in. Margins are planned around the tumor and can be outlined with a sterile marker.

Atlas of Surgical Approaches to Soft Tissue and Oncologic Diseases in the Dog and Cat, First Edition. Marije Risselada.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.

16
 Nasal Planectomy and Premaxillectomy in the Dog ◾ 17

Nasal Planectomy and Premaxillectomy in the Dog

I)

II)
18 ◾ Section 1 Oromaxillofacial

PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE continued

III) An external skin incision is made along the planned excision line and is extended full thickness through the upper lip
bilaterally to connect to the intraoral part of the resection.
Internally, an incision is made through the mucosa and the soft tissues are elevated off the bone with a periosteal
elevator, exposing the bone along the preplanned osteotomy line. The osteotomy can be performed with an osteotome
and mallet, oscillating saw, high speed air drill, or a combination.
Turbinates are broken down by blunt and sharp dissection and the rostral maxilla removed. Bleeding can be stopped
by direct pressure, gauze soaked in cold saline, or hemostatic agents. If bleeding persists from the palatine artery, liga-
tion might be necessary.

­C LOSURE

IV) The labial submucosa + mucosa are attached to the gingival and palatine bone, periosteum, and mucosa in a single
layer appositional suture pattern. Bone tunnels can be used to secure the submucosal layer to the bone. The left and
right lip are brought together (arrows) to allow reconstruction of the lip.
V) The free edges of the rostral edges of the lip are closed in a three layer pattern (mucosa, submucosa, skin) to close the
oral cavity. The knots of the mucosal sutures can be buried within the closure if absorbable suture is used, allowing for
easier visualization of the suture line. Lastly the skin is reattached to the nasal passages (to periosteum, bone, or ­cartilage)
to create a new nasal orifice. This can be done in a simple interrupted or a simple continuous suture pattern.

­A LTERNATE POSITIONING AND APPROACHES

●● This approach can involve a nasal planectomy only or can involve a combination of a nasal planectomy with a rostral
maxillectomy.
●● If only a nasal planectomy is performed, reconstruction is similar, and follows V.
●● An alternate approach, if the nasal planum or skin are not included in the resection, is to position the patient in dorsal
recumbency with the lips falling away from the maxilla.
 Nasal Planectomy and Premaxillectomy in the Dog ◾ 19

Nasal Planectomy and Premaxillectomy in the Dog continued

III)

IV)

V)
Nasal Planectomy in the Cat4–6

­I NDICATIONS

●● Nasal planum tumors

­PATIENT POSITIONING AND DESCRIPTION OF THE PROCEDURE

I) The patient is placed in ventral recumbency with the head and neck elevated on a sandbag/towel with the maxilla
draped in. A drape can be placed in the oral cavity or the mandible can be draped in. Margins are planned around the
tumor and can be outlined with a sterile marker.
II) An external skin incision is made along the planned excision line and is extended full thickness. The soft tissues are
elevated off the bone with a periosteal elevator, exposing the bone. Bleeding can be stopped by direct pressure, gauze
soaked in cold saline, or hemostatic agents.

­C LOSURE

This is achieved by suturing the skin to the nasal passages (to periosteum, bone, or cartilage) to create a new nasal orifice.
This can be done in a simple interrupted or a simple continuous suture pattern.

Atlas of Surgical Approaches to Soft Tissue and Oncologic Diseases in the Dog and Cat, First Edition. Marije Risselada.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.

20
 Nasal Planectomy in the Cat ◾ 21

Nasal Planectomy in the Cat

I)

II)
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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