FOCAL SYMPTOMS may be direct and result from the invasion of a portion of the brain by the growth, or indirect and due to its interfering with the function of structures more or less distant from the tumor. Both sets of symptoms are frequently present and prominent at the same time, requiring great care to sep arate the one from the other.
Incomplete hemiplegia, monoplegia, limited convulsive movements (Jackso nian epilepsy), paralysis or spasm of sin gle muscles or groups of muscles, and contraction are the local disturbances in motility that may result from tumor of the brain. There may be, also, various perversions of the sensory phenomena, hemianopsia and aphasia, depending upon the seat of the growth.
The counsE and DURATION of intra cranial growths are variable, depending upon the character of the tumor, its loca tion, and the complications. The symp toms are usually gradual in their devel opment, in a few rapid, and in others they are arrested for several months. Some tubercular growths may apparently run their course in a few weeks on ac count of the presence of meningitis, while others extend over a period of years. In a few cases, after a growth has gradually progressed several months or a year with out any very alarming symptoms, death may suddenly occur with symptoms of a vascular lesion. The average duration of tumor of the brain is about fifteen months, but the variation is from a few months to two or three years, or even a greater length of time.
Diagnosis.—The first problem for the diagnostician to solve in a case is: Are the symptoms due to organic intracranial disease? When an organic lesion devel ops in a nervous subject, symptoms, functional in character, will be added to those of organic disease. Hysteria and organic disease are not infrequently found in the same subject at the same time. A nrultiplicity of symptoms point ing to hysteria is of less importance in enabling one to make a diagnosis than the presence of one symptom organic in origin. As a rule, symptoms that are usually regarded as organic when caused by functional disturbance are temporary and fleeting in character, and the op posite, while true in the vast majority of cases, finds a notable exception in multiple sclerosis of the central nervous system. Marked muscular wasting in the distal portion of a paralyzed limb of cerebral origin, associated with flexor contracture and decided increase of the deep reflexes over those of the corre sponding limb of the opposite side; most cases of crossed paralysis or pronounced trophic disturbance in one or both eyes, of cerebral origin; more than transient lateral homonymous hemianopsia or sen sory aphasia, may be regarded, in the vast majority of cases, of organic origin, although only one of these conditions ex ists. There are other and more frequent
symptoms which are always very strong evidence of organic brain disease, but not positive proof of it. Among these the first in importance is optic neuritis, or choked disk. The latter may be due to tumor, renal disease, lead encephalop athy, or pronounced anmmia. The first condition named produces much more swelling of the disks than is found re sulting from any of the last three; be sides, in the latter, there are evidences of either renal disease, lead poisoning, or anmmia. Intraventricular effusion or abscess of the brain may cause choked disk, but these diseases have their dis tinct symptoms. It must be borne in mind that organic brain disease may be present in a person suffering from dis ease of the kidneys, lead poisoning, or anemia. Under such circumstances a careful analysis of the symptoms and a study of the case will enable the phy sician to determine the nature of the ease. Persistent headache, obstinate vomiting, and vertigo are frequent symp toms of intracranial growths, but they rarely continue long nnassociated with eye-changes, except possibly in tumors of the medulla. Paralysis or spasm of the ocular muscles, rapid in its develop ment, and facial paralysis, not extra cranial in origin, are usually due to or ganic brain disease. In hemiplegia of organic origin the deep reflexes of the paralyzed side are greatly in excess of those on the non-affected side. This is not so in hysteria. Hemianmsthesia, in cluding the special senses, as observed by Gowers, "is one of the rarest effects of cerebral tumors, and is absolutely un known from this cause unless associated with loss of motor power." Whether it occurs from tumor or other forms of or ganic brain disease, affecting the poste rior portion of the internal capsule, the lateral hemianopsia homonymous in char acter, will differ from the "crossed am blyopia" sometimes seen in hysteria. Persistent sensory aphasia is probably almost always due to an organic brain lesion. Convulsions, general or local, must be seen and carefully observed by an intelligent nurse before the true nature can be determined by the phy sician. It is well to bear in mind that a febrile condition, simulating—by its periodicity—malaria, may occur in the course of organic disease of the brain, especially in connection with abscess, tumor attended by rapid softening of the surrounding substance, tuberculosis, and possibly syphilis.