CUBA
WHAT EVERYONE NEEDS TO KNOW®
JULIA E. SWEIG THIRD EDITION
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The Cuban Revolution and the Cold War, 1959–91
Why did Fidel, Che, and the other revolutionaries think they would succeed in spreading revolution in the third world?
What were the basic objectives of the Cuban Revolution’s foreign policy?
Where was Cuba’s foreign policy focused during the early years of the revolution and how did Che Guevara fit into the mix?
How did Latin American governments react to Cuba’s armed internationalism?
How did Cuba’s presence in southern Africa evolve?
What was Cuba’s role in the Horn of Africa and the Ethiopia/Somalia conflict?
How did Cuba’s foreign policy in the Middle East evolve?
How did world events shape Cuba’s relationship with the Soviet Union?
What were the key features of Cuba’s involvement in Central America and the Caribbean in the 1980s?
How did the collapse of the Berlin Wall and dissolution of the Soviet bloc affect Cuba?
How did Cuba adapt at home to the loss of Soviet subsidies and global realignment brought by the Cold War’s end?
What were the regime’s economic reforms and why were they so limited?
What kind of foreign investment began in Cuba, what consequences did this investment bring to the island, and how did authorities respond?
Did Cuba attempt to emulate any other economic models in this period?
How did artists manage to pull off such a cultural boom in the 1990s?
What caused the 1994 balsero refugee crisis?
How did the Cuban health care system fare in this period?
How did Cuba cope with HIV/AIDS?
How did human rights fare more generally during this period?
What was the Varela Project and what is its significance?
What kind of space did the regime permit for intellectuals, especially those involved in debates over economic reform?
How did space for organized religion evolve during this period?
Who was Elián González and what was his significance to Cuba and U.S.-Cuban relations?
How did the Elián González affair influence Cuba’s domestic politics?
Does Cuban art and music provide an arena and space for critical expression?
How did the United States react to the end of the Soviet era in Cuba?
What was the Cuban Democracy Act, who was behind it, and what did the law intend to accomplish?
How did the United States and Cuba resolve the 1994 refugee crisis?
How did Cuban American activists and members of Congress react to these agreements?
Was a broader U.S. opening toward Cuba in the cards?
What was Brothers to the Rescue, and why did Cuba shoot down two of its planes?
How did the United States respond?
How did Cuba respond to Helms-Burton?
After the dust settled from the shoot-down and Helms-Burton, how did Cuba policy take shape during Bill Clinton’s second term? 174
How did the death of Jorge Mas Canosa affect the Cuban American community?
How did the Elián González episode affect the end of the Clinton presidency, the 2000 presidential election, and the Cuban American community? 178
How did the September 11, 2001, attacks affect U.S.-Cuban relations? 180
Why did Cuba remain on the State Department’s list of state sponsors of terrorism during the George W. Bush administration? 182
Who were the “Cuban Five”? 183
Was Castro a target of assassination attempts during this period, and what efforts were made to prosecute their authors? 185
What were the main features of U.S. policy toward Cuba under George W. Bush and how did Cuba respond? 187
How did Cuba adapt its foreign policy to the end of the Cold War? 191
How did relations with Europe and Canada help Cuba survive after the Soviet collapse? 192
How did Cuba use its long-cultivated clout at the United Nations? 194
How did Cuba relate to Latin America in a newly democratic environment? 195
What did Cuba have to do with the election of Left/Populist governments in the region, especially in the Andes? 198
What was the scope of Cuba’s relationship with Venezuela and Hugo Chávez in these years? 200
What were the main features of Cuba’s integration into the world economy after the Cold War? 203
How did Cuba react to the war in Iraq? 205
How did the Cuban government deal with Fidel Castro’s illness in 2006? 207
What happened in the immediate aftermath of the announcement of Fidel’s illness? 208
Who is Raúl Castro and why was he chosen to succeed Fidel?
How did Cuba’s provisional leadership respond as the reality of Fidel’s absence took hold?
How was Raúl Castro elected president of Cuba?
After becoming president, what did Raúl do and how did Cubans react?
How did public discourse and debate evolve under the early presidency of Raúl Castro?
there political reforms?
Was Cuba’s successor government able to begin opening up economically without promoting unmanageable political strife?
How did the United States react to the news of Fidel turning over provisional power?
Did Raúl Castro initially take a different approach to the United States than his brother Fidel?
Once a stable succession was evident, how did the U.S. government adjust its view of Cuba?
How did the Cuban American community react to Fidel’s illness and Raúl’s assumption of the presidency?
Cuba play in the 2008 presidential
Did the succession arouse any changes in Cuba’s
What were the principal features of Cuba’s ties with Latin America during Raúl Castro’s early rule?
How did Cuba expand its ties with Russia, China, and Iran?
What is the status of Cuba’s deep-water oil exploration and what foreign governments and companies became involved?
Did the European Union move closer to Cuba since Fidel stepped aside?
How extensive is Cuba’s cultural projection—music, art, film, literature—on the global stage?
A Changing Cuba Under Raúl Castro’s Presidency
What are the principal elements on the landscape of Raúl Castro’s presidency?
How did Cuba reform its migration laws and why was this significant?
What has been the role of the Catholic Church in Cuba during Raúl Castro’s presidency?
What is the status of gay rights in Cuba?
What’s the story with the release of political prisoners?
How did the Obama administration’s early policy toward Cuba distinguish itself from its predecessors?
Who is Alan Gross and why did he become a factor in U.S.-Cuba relations?
Why did Cuba remain on the State Department’s list of countries supporting terrorism throughout Obama’s first term? 282
What happened to Luis Posada Carriles? 284
Since the death of Hugo Chávez in 2013, what are the enduring features of Cuba’s relationship with Venezuela? 285
December 17, 2014, and Beyond
What transpired on December 17, 2014? How did historic announcements by Presidents Barack Obama and Raúl Castro come to pass? 289
What factors motivated both governments to come to these historic accords? 293
What was the reaction to “17-D” in the United States? In Cuba? In Miami? Around Latin America and the world? 296
How did the United States and Cuba implement Obama and Castro’s “17-D” policy goals? 299
What are the next steps, challenges, and opportunities facing U.S.-Cuban relations moving toward the completion of Barack Obama’s second term in January 2017? 303
What is the future of the Cuban Adjustment Act in this new bilateral context? 306
In addition to the formalization of restored diplomatic ties with the United States, what other events of significance in Cuba’s international relations took place in late 2015? 309
Looking ahead to 2018, what dynamics will characterize Cuba’s reform process moving forward? 310
ACKNOWLEDGMENTS
For this third edition, my thanks again to Michael Bustamante for his superb editorial and research assistance. My thanks also to Valerie Wirtschafter for her superb assistance during the final production and editorial stage. My mentor and friend Saul Landau died just a few months before Barack Obama and Raúl Castro made their historic, groundbreaking announcements of prisoner swaps and a process for normalization of relations on December 17, 2014. Victory indeed has a thousand architects, but Saul’s instigation, creativity, and energy over the decades of apparently intractable enmity animated that day: other than his fine children and grandchildren, I can think of no more lasting legacy. February 2016
FOREWORD
December 17, 2014, or You Live Long Enough
By early December of 2014, I could read the tea leaves: the Obama White House was poised to announce something important on Cuba, a prisoner swap, maybe some new regulations to make it easier for more Americans to travel there. A prisoner exchange alone would make national news. So on December 16, when I received the White House press office invite for a “listen-only” briefing, I cleared my schedule, anticipating calls from network bookers for possible television spots to help the anchors analyze the breaking news.
Early the next morning, much earlier than the White House briefing, the phone rang. It was Jeffrey Goldberg, or “Golber” [pronounced goalbear], as Fidel Castro called him during our 2010 visit to Havana for Jeff’s Atlantic interviews. Given Fidel’s continued retreat from the political stage since that time (see the Introduction that follows for the story of our week with Fidel and the inadvertent news he made) it was more than fitting that the call came from Jeff. Long my barometer of the fourth column’s appetite for international news worthy of attention other than Iran or the Middle East, Jeff had apparently been privy to the pre-briefing briefing the White House offered to the journalists it regards as leading shapers of American public opinion.
“Hey—so do you know what they are about to announce?” I told him more or less what I had pieced together.
“Yeah, but they’re doing all of it,” he replied.
“All of it?” my skepticism kicked in.
Jeff started ticking off the list that Obama and Raúl would reveal to their publics live later that day. Some 18 months of leak-free secret talks, itself an accomplishment, had achieved a deal on normalization, diplomatic relations, removing Cuba from the terrorist list, business opportunities for the American private sector; oh, and yes, vastly expanded travel rights for Americans to Cuba. The key to making these bigger moves possible? A prisoner exchange involving Alan Gross (the development contractor jailed in Havana since 2009 over his involvement in covert USAID programs), a previously unknown American spy, and the remaining three of the “Cuban Five” agents also serving lengthy sentences in American jails, plus the intercession of Pope Francis.
Flabbergasted, my first reaction was to laugh, incredulous that the moment so many of us had worked toward was finally here. I’ll admit, I also shed a tear or two, of pure joy to be a witness to such history, and of having the experience of shaping and advocating a policy idea once scorned, then regarded as conventional wisdom but unimportant in the grand foreign policy scheme of things, and now, finally, the policy of the president of the United States.
About a month earlier, some two hundred journalists, policy wonks, academics, activists, and former government officials gathered for a book party in a luxurious home in Washington, D.C. Book parties are the lifeblood of nightlife in Washington: the gathering might not have been especially remarkable, but for the title of the book: Back Channel to Cuba Celebrating the launch of a book laying out the history of secret negotiations between Washington and Havana, the Cuba “in” crowd thought it knew something might be coming on Cuba, but no one in attendance had a read on the scope of President Obama’s plans to normalize diplomatic and commercial relations with Cuba.
And such is work life in Washington: many of us can spend years working on some big policy issue, with doses of enough satisfaction from half-steps and compromises to outweigh the frustration of, well, the half-steps and compromises. But seldom do we see the president of the United States go as big as President Obama has on Cuba. Gay marriage and immigration required the monumental effort of thousands of people working all of the angles, some for more than a decade. By comparison, the D.C. Cuba crowd (plus some academics from around the country) is much tinier—three or four dozen diehards who have collectively churned out hundreds of policy reports, articles, op-eds, memos, and 10-point plans, not just for one decade, but for several.
But when President Obama made his historic announcement at the White House the following month, most of these same colleagues found themselves in Havana for a conference on U.S.-Cuban relations. Crammed into an auditorium near Havana’s Malecón, panelists and audience members on the morning of December 17th looked up to see that a large video screen had been wheeled in. Just a few minutes after Obama made the announcement from the White House, Raúl Castro began his own, from his office. Between news of the return of the last three of the “Cuban Five” and the establishment of normal diplomatic relations, the packed auditorium erupted in riotous applause, cheers, tears, the national anthem, and a celebration that lasted for days.
Back in Washington, I also spent the next few days trying to explain what had just happened to a lot of journalists. “Will it work?” CNN’s Jake Tapper posed that very eye-of-the-beholder question when “Golber” and I appeared together on his show that afternoon. What is the “it,” and what is the meaning of “work?” This third edition of Cuba: What Everyone Needs to Know endeavors to answer those, and a few less Washington-centric questions raised by December 17, 2014, and its aftermath in Cuba and in U.S.-Cuban relations.
Since that day, I’ve kept a running “you-live-long-enoughyou-see-everything” list. It starts with Obama and Raúl shaking hands for the world to see at Nelson Mandela’s funeral,
continues with the American president calling for the embargo to be lifted during his State of the Union Address, continues with Obama and Raúl sitting together with their staffs, expressions of satisfaction and ease on their faces, at the Summit of the Americas, follows with Hillary Clinton tweeting her approval and calling for the end of the embargo in the heart of Cuban Miami, includes flag-raising ceremonies at the embassies in Washington and Havana, includes a parade of American senior government officials—ranging from the Secretary of Commerce, Secretary of Agriculture, Deputy Security of Homeland Security, the Climate Change Envoy, and even the Head of the Treasury Department office that enforces sanctions against Cuba—visiting the island. It even includes the case of the missile crisis that wasn’t: the quiet return to the United States in early 2016 of a hellfire training missile that wound up in Havana after Lockheed Martin lost it in Europe in 2014. Finally, my list culminates with President Obama making the first presidential visit to Cuba since 1928 just as this edition went to press. The jacket cover for this third edition could have included a number of historic photographs that tell this remarkable, and still very much unfolding story: the photograph we selected speaks for itself.
Takoma Park, Maryland February 2016
INTRODUCTION
In Washington, D.C., August masquerades as a sleepy summer month. Beltway insiders habitually head out of town, trying to escape the mid-Atlantic swelter. Yet surprise conflicts, refugee crises, and budget showdowns always seem to up-end family plans to unplug. At least that is the running joke.
For as long as I can remember, rumors of Fidel Castro’s death have tended to surface in August as well. But in the summer of 2010, as if to preempt the news cycle, the aging Cuban revolutionary leader seized the stage of a national conference in Havana to make a six-minute speech warning of a potential nuclear crisis involving Iran. It was Fidel’s first public appearance since falling gravely ill in 2006. Save for a steady stream of published reflexiones or the occasional video clip, Fidel’s legendary ubiquity in Cuban private and public discourse had notably faded. On this occasion, Fidel once again grabbed the soapbox, attempting to alert Cubans and global public opinion to a looming catastrophe in the Middle East. The next week, Atlantic magazine journalist Jeffrey Goldberg published a cover story called “The Coming War with Iran.” I remember thinking that if Fidel saw the piece, he might take it as confirmation of his anxieties and validation of his seriousness as a student (if no longer protagonist) of international relations. Later that month, I was not too surprised to receive a phone call from Ambassador Jorge Bolaños, Cuba’s lead diplomat
in Washington. Though on vacation, I was planning to go to Cuba a few weeks later and assumed his call was about my trip. Instead, Bolaños got right to the point. “Julia,” he asked, “can you put me in touch with Jeffrey Goldberg?” Washington is a small town, so while perhaps comically presumptuous, it was not really a stretch for the ambassador to think that one writer who happens to be Jewish might be able to track down another prominent writer who recently had been named one of the “Forward 50” Jews in the United States by the Jewish Daily Forward. As it turns out, Jeff and I have been friends for years.
“Fidel can see you this weekend,” Bolaños briskly told an also-vacationing Goldberg. Evidently, Castro wanted to compare notes about the brewing standoff over Iran’s nuclear program. Given Fidel’s notorious media savvy, I suspect he also viewed Jeff as a vehicle to send several messages—to Washington, Tel Aviv, Tehran, and to the left-leaning American and Latin American publics for whom his words still hold substantial cachet.
Three days later, Jeff and I sat in disbelief in the Miami airport waiting to board a sold-out flight to Havana. Because of the loosening of U.S. government restrictions on travel to Cuba, over the past several years Cuban-American families have filled more than 30 flights a week to the island, weighed down with everything from toiletries to flat screen TVs to multiple layers of clothing (thus avoiding steep taxes on excess luggage). More and more Cuban-Americans, as well as those who identify as diaspora Cubans, are traveling to their homeland, whether to visit, vacation, or, under the guise of remittances, invest in their families’ emerging small businesses. But most Americans who are not of Cuban descent are still banned from the 30-minute puddle jump, unless licensed by the Treasury Department.
During his tenure in power, the usually loquacious Fidel relished interviews with visiting reporters and editors. Over the years, he had met with hundreds, maybe even thousands, of Americans—members of Congress, cabinet secretaries, Nobel
Prize winners, religious leaders, intellectuals, Wall Street CEOs, even rock stars and fashion models. Yet ever since contracting a severe intestinal infection four summers earlier, the aging comandante had not spoken to one major American journalist. Although we understood Fidel wanted to talk about the Middle East, we had no idea what to expect.
Our first meeting took place in an office Fidel keeps at the Palacio de Convenciones, an imposing conference center. Fidel’s wife Dalia, son Tony, and personal doctor joined us for the nearly three-hour discussion, together with a translator and a small security detail. An avid and careful reader, Fidel showed Jeff the blue journal of notes he had taken on the Atlantic piece, and the two spoke at length about the Obama administration’s limited policy choices with respect to the Iranian nuclear program. Fidel also discussed a number of unexpected themes: his experience of anti-Semitism as a boy, his respect for the suffering Jews experienced historically (especially during the Holocaust), and his distaste for Ahmadinejad’s knee-jerk anti-Israel hostility.
This was the first time I had seen Fidel Castro in nine years, let alone since his illness and retirement. Notorious for his stamina as a talker, Fidel in the past seldom left me with the impression that he was a good listener. But during our substantive conversation, and later, over lunch in an adjacent dining room, he seemed relaxed, peppering Jeff and me with questions about our kids and their education. He also spoke repeatedly about living out of office in an entirely different way than he had for most of his life.
As if to prove the point, Fidel invited us to join him for an outing at the national aquarium the following day. Originally we had plans to see Adela Dwornin, the president of the Comunidad Hebrea (i.e., the Jewish Community) in Cuba. Fidel asked us to bring her along. Che Guevara’s daughter, Alina (a marine biologist), was there too, along with Guillermo Garcia, a leading conservationist whose father was a guerrilla fighter from Fidel’s days in the Sierra Maestra.
Seated together in the bluish light of the underground observation room, we watched mesmerized as three dolphins gracefully played and danced under water, accompanied by three young handlers, no oxygen. Between acts, the divers gestured for us to approach the glass—Fidel first. They taught him how to communicate with the animals, and for about 10 minutes he stood alone with his nose and hands pressed against the glass tank, bobbing up and down, following the divers’ cues. We took our turn too.
During a lull in the ethereal Cirque de Soleil–type performance, Fidel leaned over and asked about my plans for the rest of the week. I told him I had a number of meetings scheduled and then popped a question I had been waiting to ask for ten years. For my first book, Inside the Cuban Revolution, I interviewed dozens of Cuban participants in the 1950s underground insurgency. But while in office, Fidel had several times rebuffed, or more likely ignored, my efforts to interview him. With a little more time on his hands, Fidel now agreed to speak with me about that fateful chapter in Cuban history. At his suburban Havana home the next day for a final good-bye chat with Jeff on his way to the airport, we decided I would return two days later.
I developed ten questions, assuming I would be lucky if we got through two or three. We sat in a room evocative of the American “Florida rooms” of the mid-20th century: wicker furniture painted lavender, rocking chairs, a television and VCR, stained glass, plants. Adjacent to Fidel, a table held the props of most people in their late 80s: several pairs of glasses, TV remotes, a glass of water, a stack of papers and books (including my own).
But before addressing my historical inquiries, Fidel had something else to share. “I’m going to give a speech tomorrow at the University of Havana to mark the beginning of the new school year, and I have been working on the text.” The speech would mark his first open-air appearance since just before falling ill in 2006. He recited some of the first lines in a dry tone— nothing of the legendary orator. For the most part, his remarks
focused on developments in the Middle East, perhaps a subject far removed from the daily routines of his prospective audience of Cuban students. Having grown up in the wake of the materially and ideologically trying “Special Period” following the Soviet collapse, Cuban youth today are not nearly as politicized as when Fidel’s own generation entered student life. It clearly bothers the now former head of state that the next generation appears less interested in ideas and more interested in stuff. Fidel thus sought to energize their collective political and international consciousness. Yet he also seemed intent on proving that after facing mortality and a long, difficult recovery, he could still regale the crowd with a real stem-winder.
I spent six hours with Fidel that day. After rehearsing his speech, he answered each of my questions and encouraged me to keep them coming even when I was sure fatigue or boredom would have set in. At the time of our conversation, he was preparing to release a new volume of memoirs and thus proved to be particularly attuned to the period of time covered in my first book. At one point I made reference to a shipment of weapons from Costa Rica to the Sierra Maestra in 1958. Annoyed that I had used a different and quite possibly better source to describe this event, Fidel asked his wife to get the editor of his memoirs on the phone. I shuddered at the prospect of Fidel’s editor having to answer to the dictates of such a notoriously punctilious man. Friendly competition between historians over the provenance of a source is one thing; kibitzing with a living world historical figure about whose sources are more accurate was quite another.
By late afternoon, Fidel offered to answer any historical question I could muster. I asked if his definition of “historical questions” included discussing the transformations taking place in Cuba since he stepped down from power—recent history, but fair game, I hoped. His answer—a firm and definitive no—confirmed what I had observed and what his passionate detractors still find hard to accept: Fidel was not governing, neither from behind the scenes nor in any other way. The
current leadership certainly consults him about the strategic direction of the country. But since 2008, it appears Fidel has agreed to stay out of Raúl’s way and quietly back his decisions. Both Fidel’s columns about contemporary international affairs and his memoirs are conspicuous for what they lack: commentary on Raúl’s rather substantial agenda for revamping sin prisa, pero sin pausa (not in a hurry, but without delay) the political, economic, and social modus operandi that had prevailed for most of the previous half century.
The now digitally savvy Cuban state media has grappled with how to portray this new division of labor. When Fidel was in power, every utterance, public appearance, or meeting with a foreign dignitary claimed front-page coverage. In contrast, during the acute stage of his illness, very little information about his condition surfaced. As his recovery became more secure, Cubans adjusted to the once omnipresent head of state in retirement mode, donning an Adidas track suit instead of the olive drab of an active military commander. At least in 2010, Fidel still sought the occasional public appearance and today maintains a political base among party old-timers and revolutionary diehards. Granma’s coverage of our visit gave an idea of the media’s struggle to convey the new rules of the game. Two photos above the fold: one with Fidel in a plaid shirt, slacks, and sneakers playing host at the aquarium; the other, a picture of President Raúl Castro in a suit and tie, seated in a stiff protocol meeting during a state visit. The message in these images seems quite clear: Raúl is running the country, including foreign affairs, and Fidel is definitively retired, with enough time on his hands to spend a couple of days talking Middle East politics, playing with dolphins, or revisiting his own history.
Back during lunch on the first day of meetings with Fidel— the day before the dolphin show—I had tried to get us away from the Middle East and change the geographic focus of the conversation to our own neck of the woods. These days, Latin America is neither Washington’s complacent imperial backyard nor Fidel’s proving ground for revolutionary insurgencies.
Still, many of Fidel’s political children—whether because they spent substantial time in revolutionary Cuba, were at one point inspired by its example, or participated in revolutionary movements that Cuba cultivated and helped arm—now lead everything from labor and social movements to foreign ministries and governments throughout the region. Even though market economies and multiparty democracies prevail over anything resembling the Cuban Revolution’s model of one-party state socialism, Latin America’s ideological diversity, gradual leftward turn, and ever-growing diplomatic independence from the United States represent a long-term foreign policy victory for Fidel of literally continental proportions.
But when I failed to draw from him a Latin American geopolitical tour d’horizon, Jeff tried another, more direct approach. “So, are you still exporting the Cuban model?” Fidel did not miss a beat, but his response, once Jeff reported it the following week, made headlines around the world: “The Cuban model? It doesn’t even work for us anymore.”
Ten words out of ten hours of talks that week brought Fidel the kind of spotlight I suspect he was after by inviting Goldberg to interview him, but on the wrong subject—not the Middle East, but Cuba itself. Around the world and in the United States, the media blizzard conveyed shock, and a bit of disbelief, that the architect of the Cuban Revolution was ready to admit “the Cuban model” had run its course. But in a sense the foreign media were the last in on the news. By 2010, the failure of the Cuban economy and government to generate productive jobs and an open society—coupled with the thousand other outmoded, expensive, and corruption-inducing elements of this “model”—had become the primary topic all Cubans talked about, starting with the sitting president Raúl Castro himself. “¿Cómo va la cosa?” (How is the thing going?), Cubans jokingly ask each other these days, referring to ongoing internal debates about reform. International reporting, however, at times still focuses on whether a recovered Fidel is really in charge and whether his known allergy to capitalism will ever yield to the
pragmatic changes his brother has long regarded as essential in order for the Revolution to leave any meaningful legacy.
Publishing this line compelled the retired commander-inchief of the Revolution to comment on politics at home for the first time in four years. A few days after Goldberg’s blog post, Fidel made an indoor appearance at the University of Havana to release the latest volume of his memoirs. Taking a short detour from his historical remarks, he admitted the quote was accurate but insisted Jeff’s published interpretation was incorrect. Both Jeff and I took the quote to be a recognition that Fidel had absorbed and endorsed Raúl’s case for a substantial (if gradual and still rhetorically “socialist”) overhaul of the terms of Cuba’s social contract. In fact, Fidel now claimed rather cryptically, he had meant “exactly the opposite.” “My idea, as the whole world knows, is that the capitalist system no longer works for the United States or the world… . How could such a system work for a socialist country like Cuba?”
Of course, in reporting the remark Jeff had implied nothing of the kind. But the purpose of Castro’s demarche was to reassure his revolutionary base that Cuba could withstand changes his brother would soon introduce without importing the orthodox capitalism Fidel had decried for decades and against which he had defined the Cuban Revolution itself. In other words, Fidel sought to assure his political followers that change would not mean abandoning Cuba’s ability to make decisions for itself or reneging on the state’s commitment to social welfare and education via some kind of shock therapy. Thus, in a roundabout way, and without commenting directly on his own achievements or failures in domestic economic matters (likely the subject of more intractable debate than his accomplishments in foreign affairs), Fidel had given his implicit endorsement to Raúl’s leadership and the changes now occurring under his watch.
Indeed, within a matter of weeks, Raúl went on to launch a series of measures first hinted at when he formally assumed the presidency in 2008—namely, massive layoffs from state jobs and more space for small-scale (for now) private enterprise.
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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 nonirritative 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 worddeafness, 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 colorblindness 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 occipitotemporal 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 onehalf 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 anterofrontal 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).—Temporosphenoidal 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 headtemperature 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 bonechanges 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 nervetrunks 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. Crossparalysis 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 vasomotors 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
