NEOPLASMS OF THE CENTRAL NERVOUS SYSTEM (MULTIPLE CEREBRAL AND SPINAL SCLEROSIS) The study of neoplasms of the central nervous system has taught us that the symptomatology is determined more by the seat of the tumor than by the nature of the neoplasm. Text hooks, therefore, with few exceptions (Henoch's Lehrbuch) discuss genuine neoplasms and the granulation tumors together.
The same plan will be adopted in this work although it cannot be denied that the signs of brain tubercle in children are sufficiently char acteristic to justify a separate classification.
Brain tumors are very frequent in childhood. Gowers calculates that one-third of all the cases that have been analyzed occurred during the first two decades of life. Brain tubercle greatly preponderates over other tumors (out of 62 cases of brain tumors, examined post mortem in the Karolinen-Kinderspital in Vienna, 53 were tuberculous). The accompanying table by Allen Starr gives a good idea of the character, frequency and localization of brain tumors in childhood and renders a detailed discussion of the subject superfluous. The frequency of cere bellar tumors in childhood may however be emphasized.
Even infants are subject to the disease (Demme's case in an infant three days old; infant five months old in the Karplinen-Kinderspital with brain tubercle). Aside from congenital tumors (angiomata), the most common are tubercles, but sarcomata also occur during the first year of life (ten-months-old infant in the Karolinen-Kinderspital). The greatest tendency to tuberculosis of the brain exists during the first years of fife. The male sex furnishes the largest contingent of brain tumors (according to Gowers 440 men and 220 women). This dispropor tion is attributed to the fact that men are more exposed to head injuries, which are supposed to play an etiolog,ic rule in many forms of tumor.
Pathologic the majority of cases brain tubercle is multiple (in 35 out of 53 cases in the Karolinen-Kinderspital). The seats of predilection are the cerebellum (24 out of 53 in the Kinderspital), the basal ganglia, the pons, the corpora quadrigemina, the cerebral hemi spheres and, rarely, the medulla oblongata. The tumors are spherical, with a poor blood supply, necrotic at the centre, caseous, and surrounded by a layer of vascular granulation tissue which contains giant cells and tubercle bacilli. Children who die of brain tuberculosis frequently have a terminal tuberculous meningitis and always present other signs of tuberculosis, particularly in the glandular system. Cholla is a tumor consisting of neurogEar tissue which occurs only in the central nervous system and is usually quite different from sarcoma (Strube), Gliomata are found qttite as often in the cerebrum as in the cerebellum, and frequently in the pons. In contradistinction to tubercle, glioma is apt
to present itself in the form of a flat proliferation extending laterally rather than as a spherical tumor; in fact the infiltrating tumor may be so intimately mingled with the brain substance as to produce an apparent hypertrophy of certain portions of the brain. In color and general appearance glioma resembles the tissues of the brain, but the neoplasni is hard, more vascular and more reddish. The composition is sometimes more fibrous (fibroglioma), or mucoid (myxoglionia). Iltemorrhagic and cystic softening is not infrequently seen in glioma. Sarcoma shows a preclilection for the cerebellum, but also occurs quite frequently in the cerebral hemispheres, especially- when the growth starts in the cal varium or tbe dura mater ancl the brain is involved secondarily. When a sarcoma of the dura mater breaks through it is sometimes called a fungus dam, matris. Sarcoma is a typical malignant neoplasm and grows rapidly, compressing the cerebral mass and producing necrosis; it also breaks through from one tissue to another without respecting tissue boundaries. According to the nature of the supporting tissue, we distin gitish fibro- myxo- and, particularly, vascular angio-sarcoma. Necrosis also occurs in the interior of sarcomatous tumors. Cavernous angiomata, which are congenital and grow rapidly after birth, may involve not only the surface of the brain but also the meninges. tbe bones of the skull and even the external coverings (Kalischer). Carcinoma, usually soft and vascular, sometimes occurring fiS a primary cerebral or dural tumor, psammoma (fibrous neoplasms of the pineal gland mixed with brain sand), eholesteatoma pearly gray epithelial tumor) and adenoma of the hypophysis are rare forms of tumor in childhood. Parasitic cysts (cysticercus, echinocoecuS) are more important because they are as frequent in children as in adults. Cystieercus usually forms small multiple vesicles cm the surfaee of the brain and in the ventricles. Within the vesicles the head of the worm is seen as a black point (with a microscope the sucking organs can be recognized). As sequelle localized inflammations of the brain and of the meninges are observed. Echino coccus of the brain is much more rare and leads to the formation of a much smaller number of vesieles, which are larger in size than those of eysticercus. Parasytic cysts may undergo calcification with complete recovery.