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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.
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.
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.
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.
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.