When seen, on April 23d; the child lay in her cot apparently uncon scious. The head was retracted and the back rigid ; the arms were stiff and semiflexed, with the thumbs inverted ; the on each side were rigid and extended ; but while the left lower limb lay stiff and straight the right was slightly flexed, and the leg from the knee downwards was in constant movement, alternately flexed and extended. There was ptosis of the left eye, but no squint. The pupils were unequal and insensible to light, the left the more dilated. The breathing was irregular, with sighs and pauses. Temperature at 6 P.M., 99°. The child took her bottle well, but lay as if unconscious, although the pupils contracted when the con junctivae were touched. After this the rigidity continued with occasional remissions, and an external squint became again developed in the left eye. The temperature varied between 99° and 100.5°.
At the beginning of May the patient began to cough, and a pneumonic consolidation was discovered in the right lung. After this she became rapidly worse ; the coma became deeper ; the temperature rose to 103° ; and she died on May 11th.
On examination of the body there was found a consolidation breaking down in the right lung with many gray granulations. The convolutions of the brain were flattened and congested. Its substance was excessively soft, so that the brain did not preserve its shape when removed. The lateral ventricles contained eight ounces of clear fluid. Attached to the under surface of the left emus cerebri was a nodulated tumour of the size of a walnut, feeling soft to the touch like a bag of pus. It was irregular on the surface, and was attached to the crux by a slender stalk of soft, yellow cheesy matter, and covered with pia mater. No gray granulations could be detected about the membranes, but the dura mater was reddened and thickened.
In this case the occurrence of signs of paralysis of the left third nerve (ptosis and external strabismus), accompanied by headache and vomiting, pointed to localised pressure, such as that of a growth ; and as this nerve and no other was affected at the first, the position of the growth in or upon the left crus cerebri (which is pierced by the oculo-motor nerve) could be positively indicated. The other symptoms—convulsions, rigidity, and stupor—which followed after an interval are such as are common in cases of cerebral tubercle, and almost invariably attend the close of the ill ness. In fact, such symptoms, preceded during several months by head ache, vomiting, and paralysis of a cerebral nerve on one side, are very characteristic of tubercle of the brain. The disease might, indeed, be
often divided into two stages—an early chronic stage, in which headache, vomiting, optic neuritis, tremors and convulsive movements, and more or less marked muscular weakness succeed one another irregularly and at various intervals of time, and into an acute second stage, in which con vulsions, paralysis, rigidity of limbs, retraction of head, and stupor usher in the end of the illness. We must not, however, always expect to meet with a division of the disease into two well-defined stages. Sometimes the earlier cdurse of the malady is accompanied by few symptoms, and these, on account of the tender age of the child and the character of the symptoms themselves, may have little importance attached to them.
Thus a little girl, aged six months, had vomited more or less since birth, and was said to moan frequently and " fret " as if in pain. She had wasted considerably but had never had convulsions. The family history was a healthy one.
In so young a child vomiting, pain, and restlessness, combined with loss of flesh, are familiar symptoms, and do not point in any way to infra cranial disease. But on examining the baby carefully it was noticed that when the child cried the mouth was drawn up to the left, side, and that the left eyebrow contracted better than the right. When the face was at rest the right eye was more open than the left, and the nasal line skirting the angle of the mouth was less deep on the right side of the face. The pupils were equal and there was no squint..
In a few days other symptoms began to be observed. The head became retracted, there were tremulous movements in the right arm, the child seemed heavy and stupid, and often appeared to be quite unconscious. Rigidity of the limbs then came on, the drowsiness deepened into coma, and the child died. After death patches of meningitis were found at the base of the brain. A small cheesy mass, the size of a cherry-stone, was imbedded in the substance of the pons—the left posterior half—and a second, pedunculated, growth of the size of a marble was attached to the upper part of the medulla oblongata and lay underneath the right crus cerebri. There was a considerable amount of fluid in the ventricles, and a mass of caseous glands in various stages of softening lay about the roots of the lungs.