Cerebral Tumour

rigid, tubercular, temperature, substance, left, softened, growth, examination and meningitis

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On November 29th he became very drowsy and would answer no ques tions. Both arms were rigid and flexed, with the thumbs twisted inwards. The legs also had become stiff and the toes extended. The back was rigid with inclination to opisthotonus. He could swallow, but apparently with difficulty. The respiration was jerking, and appeared to be chiefly dia phragmatic. The abdomen was rather retracted. The eyeballs twitched. The child was alternately flushed and pale, with profuse perspiration. He had several .convulsive attacks during which the left corner of his mouth was drawn up. Temperature at 9 A.M., 108°. The boy had no more fits after 2 P.M., but lay unconscious with his eyes fixed and turned to the right. There was oscillation of the eyeballs, and the pupils were dilated and immovable. He winked when the right eye was touched, but the left conjunctiva was insensible. The joints were rigid and flexed. The belly was retracted. The pulse was excessively rapid and very irregular in force and rhythm. Respiration 36, with occasional deep sighs. The child died the same night in convulsions. The temperature shortly before death was 108.8°.

On examination of the body the brain weighed fifty ounces. The con volutions were flattened, especially over the right hemisphere. On remov ing a thin layer of brain-substance at the posterior part of this hemisphere a large cavity was found of between two and three inches in diameter. This was empty and was lined by a species of false membrane. The brain-sub stance composing its roof seemed rather firmer than natural, and was from one-sixth to one fourth of an inch in thickness. The floor of the cavity was formed by a firm lobulated tumour as large as a good-sized orange. This reached to the base of the skull, where it was firmly attached to the dura matey. It lay external to the pops, occupying the posterior part of the middle lobe and the adjacent part of the posterior lobe. Its boundaries were not distinctly defined, for it passed insensibly into the cerebral sub stance around. On section the mass showed a uniform surface of a yel lowish-white colour. It was generally very firm to the touch, but spots were found here and there where the substance was softer, as if from fatty de generation. - Some of these softened spots had become hollowed out into cavities of about the size of a marble, with irregular walls. On microscopi cal examination the tumour was found to consist of small round cells, with many spindle-shaped cells and a fibrous matrix. There were also many fat globules. The lateral ventricles contained about eight ounces of fluid. The crura cerebri were softened, flattened, and rather twisted. The cor pora quadrigemina also softened. Optic nerves small and soft. There was

no appearance of recent meningitis.

This case illustrates fairly well the course of the disease. The severe paroxysms of headache with Which the illness began, the vomiting, the affection of sight, the gradually increasing paralysis, and the muscular con tractions and spasms which succeeded, together with the chronic progress of the case, all pointed to compression of the cerebral substance. It is probable that the effusion into the ventricles was a late symptom, only oc curring when the retraction of the head and dorsal rigidity became marked. The accumulation of fluid compressed the cerebral substance, and was a cause of the drowsiness and stupor which marked the last hours of the boy's illness. The complete clearness of mind which continued until a late period in the course of the disease is worthy of note in the case of so large a growth. A curious point in the case is the continuous elevation of temperature ; for pyrexia is not a usual symptom in gliomatous tumours of the brain until quite the close of the illness, unless the growth be compli cated with meningitis, and in this case no recent signs of inflammation could be discovered. On account of this pyrexia the tumour was thought to be a tubercular one, although no evidence of tubercle could be obtained during life by examination of the other organs of the body.

In the case of children it is exceptional to find any other variety of tu mour than the tubercular form. This, in the majority of cases, becomes sooner or later complicated with tubercular meningitis, the symptoms of which will then mix with and obscure the more special phenomena con nected with the cerebral growth. Anomalous cases of tubercular menin gitis are often, as Dr. Hennis Green pointed out in his admirable paper, instances of this combination.

A little girl, twelve months old, was noticed towards the beginning of March to squint outwards with the left eye, and shortly afterwards the eyelid of that side began to droop. Much about the same time she suf fered from sickness, and was restless and agitated, often screaming out as if in pain. The face used to flush, often on one side only. She took her bottle well. The bowels were confined. At the beginnineof April the restlessness from which she had suffered increased, and she cried greatly, rolling her head from side to side on the pillow. She then had a fit in which both arms and legs were rigid and convulsed ; her head was re tracted and her back arched. After this she did not completely recover consciousness, and, either from dulness of intelligence or from impaired vision, ceased to recognise her mother. She still, however, took her bottle well when the teat was put into her mouth.

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