A Post-graduate Lecture ON INTRA-CRANIAL TUMOURS.

JANUARY 20, 1894.

A Post-graduate Lecture ON

INTRA-CRANIAL

TUMOURS.

Delivered in connexion, with the London Post-graduate Course at the National Hospital for the Paralysed and Epileptic,

Queen-square,

on

Nov. 23rd, 1893,

BY JAMES TAYLOR, M.A., M.R.C.P. LOND., SENIOR ASSISTANT

M.D.

EDIN.,

PHYSICIAN TO THE HOSPITAL.

the onset of the weakness was clear and unmistakable. If, on the other hand, a tumour was thought of as the most likely cause, it would have to be supposed to be one of excessively slow growth, and there were absent all three of the symptoms commonly regarded as more or less essential-viz., headache, vomiting, and optic neuritis. For several weeks he was kept under observation. The fits, which occurred almost daily, were of the character of the slighter ones which I have already described, and there was no loss of consciousness. No change was observed in the discs until Sept. 19tb, when it was noted that there was slight but distinct optic neuritis in both eyes, an observation confirmed by Mr. Marcus Gunn. It was now evident that we had to deal with a tumour, and, being then in charge of Dr. Jackson’s beds, I asked Mr. Horsley He agreed to see the patient with a view to operation. that the tumour was in or near the cortex and advised its removal. I need not recount to you the details of the operation. It will be sufficient if I tell you that a tumour was found at the upper part of the fissure of Rolando penetrating into the white matter of the brain, and that it The immediate effect was inwas successfully removed. creased weakness of the left side. The arm has remained weak, but is gradually recovering ; the leg is now as strong as before the operation. There have been no fits, and the optic neuritis has almost disappeared.1 I now show a patient whom I have had under observation for several years. She was admitted as an in-patient under Dr. Gowers’ care four years ago, with distinct left-sided weakness, a history of fits of somewhat indefinite characterthese had only been very few-and she suffered from headache and occasional sickness. There was well-marked optic neuritis. There was nothing obtainable in the history to indicate the nature of the growth, which was undoubtedly present, but she was treated with iodide of potassium. Her recovery was not rapid, but she did improve so as to be able to go out in a few months, and she has remained well ever since. She is now, as you see, able to walk well; her neuritis disappeared before she left the hospital and has remained absent ever since, and there has been no recurrence of the symptoms. Where the tumour was it is not easy to say. It was evidently in the right hemisphere, and it was probably near the surface. What its nature was is also uncertain, although the disappearance of the symptoms under treatment with iodide of potassium is suggestive. But I do not think that this is conclusive, for undoubtedly certain tumours do subside in the brain or at least become quiescent both with drugs and without them, and I should hesitate to say that the disappearance of all the symptoms in a case of cerebral tumour under the influence of iodide of potassium is conclusive proof of the nature of the tumour. I have another case here to which I would direct your attention. The patient is at present under the care of Dr. Hughlings Jackson, who has kindly allowed me to show him. This boy, thirteen years of age, was suddenly seized with an attack of vomiting fourteen months ago. Since that time he has been subject to similar attacks about three times a week. About two months after the onset of the vomiting he began to suffer from intense paroxysms of headache, usually in the frontal region, and these have also continued up till now. During the pain he usually vomits, although he is frequently sick without headache. In July of this year he had a fit in which he turned completely round and fell on his back. He has had similar attacks repeatedly since. In these he usually turns to the right, although latterly he has fallen directly backwards. He began to complain at this time of pain in his left thigh and to have incontinence of urine, which is still present. He is now very drowsy. Six months ago his sight began to fail and has become gradually worse. His family and personal history are free from any suggestion. Now as he lies in bed all the movements of the arm can be fairly carried out, although there is some tremor in the left hand in bringing it to his face. Both grasps are weak, but there is no wasting or rigidity. Leg movements also, as he lies in bed, can be carried out but feebly ; still there is no wasting or rigidity. He is able to sit up a little, although there is a tendency to fall backward. He is quite unable to stand, fallii)g back at once on attempting to do so and saying he is giddy. There is no sensory impairment. His knee-jerks are present. His sight is much impaired, and there is well-marked optic neuritis, which is

case to which I wish to draw your of is that the patient before you. He is a to-day jman thirty-five years of age, who was sent to me on June 30th ,ast by Dr. Gibson of Launceston, Cornwall, and he was .admitted to the hospital under the care of Dr. Hughlings Jackson, who was kind enough to entrust the case to me. ’The man complained of epileptic seizures which affected the ’left side and to which he had been subject for years. More (recently there had been superadded definite weakness of the ’same side, more especially of the leg. His history was that at - the age of fifteen-i e., twenty years before admission-one ’day after rolling down a bank he had a fit commencing with of power in the left leg. He then felt his head go round ,and lost his senses. On coming to he could not use the ,’eg. For several years after this he remained quite well. He ’then had a fit of the following character : he experienced a cramping feeling in the left calf of the leg, after which the ’knee was flexed ; the hip was next affected, and then the ’Rngers of the left hand, which felt as if splitting ; the .arm was moved from the side, the head and face were turned, the trunk was jerked, and he lost his senses. He remembers no loss of power on recovering, which he did (n a few minutes. Such were the fits which he continued eto have at intervals of months or years until four years .ago, when he had either one severe fit or a series of them, after which the left leg was paralysed. It gradually improved, but has never regained its power completely. During the last four years the fits have not been attended with loss of consciousness. They commenced with .a I I pop " in the right side of the head, followed by a feeling .of tearing in the left iliac region, and this was succeeded by -a drawing up of the leg and a similar affection of the corresponding arm and face ; after a fit the arm and leg were .completely but temporarily paralysed. But there have also -been much slighter fits, confined only to the leg, and others c:n which the arm only was moved ; this last variety, however, On admission was always preceded by a sensation in the leg. fûe was found to present a certain amount of rigidity of the left - leg and to walk with a slight but characteristic hemiplegic t’5’ait. The weakness was chiefly manifested in trying to dorsifiex the foot. There was also a slight clumsiness in carrying out fine movements with the corresponding hand. The .face was not affected, and there was no tenderness of the - scalp, although shooting pain on the left side just above the -superficial auditory meatus was complained of immediately ’before the attacks. The lightest touches were felt everywhere, as well on the left as on the right side, but there was ’definite impairment ix the power of localising these all over ’the left side. The left knee-jerk was exaggerated, ankledonus was present on that side, but not on the other, and the wrist-jerk and e’lbow-jerk on the left side were more marked than on the right. The optic discs were normal. There was no history of epilepsy or accident, and, indeed, othing in the family or personal history of the patient to throw light on the nature of the malady. Such is the -description of the patient’s condition on admission to the hospital. As you will have seen, however strong suspicion -might be that there was some actual organic brain lesion underlying the symptoms, there could not be said to be in the symptoms any actual proof of its nature. Definitely localised 3ts—6t.s of sj-caHed Jacksonian epilepsy associated with the onset of, or more usually subsequent to, hemiplegia in ,children-are common enough as a result of actual organic brain disease, vascular or inflammatory. In adults they 1 Since the may also occur if the hemiplegia dates from infancy, but Cn this case the historf of the occurrence ofmany fitsbefore appeared. No. 3673.

GrEXTLBME,—The first

uttention

above

was

written the

optic neuritis

has

entirely dis-

134 progressing to atrophy. The other special senses are normal. you to-day, in which the tumour was in the cortex itself. The head, as you will observe, is large and square. He has Tumour in the white matter of the cerebrum may have the incontinence of urine, and he passes his motions in the bed. general symptoms already referred to. Its special charac. For some days past he has behaved peculiarly, shouting out teristic is’a slowly increasing paralysis commencing in on& at imaginary people in the ward. He says they are talking limb. There may be no fits and little or no headache. If loudly and that he feels he must shout. Of the diagnosis of the growth encroaches on the posterior part of the internal intra-cranial tumour in this case there can be no reasonable capsule there may be anaesthesia and even hemianopia. doubt. There are headache, vomiting, optic neuritis, and The part of the body paralysed will of course depend also fits. There is no local paralysis such as was present in upon the position of the tumour. It is in such tumonrs thepreceding two cases, and nothing indeed to suggest that that not infrequently all the three usual symptoms the tumour is in the hemispheres. The facts that he is of tumour-headache, vomiting, and optic neuritis-are unable to stand, that there is a tendency to fall backward absent, especially if the tumour is a slowly growing one. with giddiness, together with the absence of localised The distinctive symptom of tumours of the pons and medulla paralysis, all point to the cerebellum as the locality of the is the involvement of one or more of the cranial nerves, growth. In what part of it it lies it would be difficult to and it should be remembered that often marked evidences oi say; all that one would venture to surmise is that it is paralysis may be present before any of the classical symptoms almost certainly encroaching on the middle lobe. The of tumour declare themselves. Especially is this true when of fits does not us. are not of the the growth is an infiltrating one, and when, so to speak, the They presence help peculiar character associated with cortical disease, but structures are slowly strangled and their functions gradually rather of the nature of indefinite twitchings with marked abolished. In such cases it is not uncommon to have little cyanosis, characters usually present with tumour at the base or no headache, and optic neuritis is probably as frequently absent as present. As regards the cerebellum, there are twe, or in the cerebellum. I should now like to say a few words as to the general distinct classes of tumour in regard to their symptomssymptomatology of intra-cranial tumours. As you are no doubt viz., those in which reeling is present and those in which it is aware, the trilogy of symptoms which are supposed to be abso- not. In the former class the symptoms are, as a rule, though lutely pathognomonic of that affection is represented by head- not invariably, much more severe and are believed to depend ache, vomiting, and optic neuritis. If you have those three upon an involvement of the middle lobe. In the latter class. present the existence of a tumour is almost certain. The only of cases the symptoms may not be obtrusive. Occasionally condition I can imagine which might cause all of them and headache and sickness, but nearly always optic neuritis, will Lot be tumour is meningitis, usually tuberculous; but, the con- be present, but often in such a way as not to excite suspicion, verse is by no means true, for you may undoubtedly have a and this is a class of cases in which the diagnosis is apt to be, cerebral tumour with not one of those three symptoms pre- missed. One point of interest, perhaps of importance, is the sent. To this I shall again refer presently, but in the mean- state of the knee-jerk in cerebellar cases. In some cases it time let us consider for a moment the character of those is unusually brisk, chiefly in those, I believe, in which there three symptoms. The headache of intra-cranial tumour is not are reeling and unsteadiness ; in others it is absent, either absolutely characteristic. It is, so far at least as our present constantly or at times, and always difficult to elicit. In knowledge goes, in no way localising-e g., it is notorious two cases with such symptoms which I have examined that the headache in cerebellar tumour is very frequently post mortem the tumour was in the lateral lobe, not frontal, sometimes occipital, often both. Its chief charac- affecting the middle lobe at all. Smell also is not teristic is that it is paroxysmal, and another distinguishing uncommonly abolished in cerebellar cases. Whether this point is that it is frequently accompanied by vomiting with- is a result of the intra-cranial pressure on the olfactory

nausea. The local tenderness in the scalp which is lobes or whether it is due to a condition of these nerves sometimes present in cases of tumour is not to be con- analogous to that which abolishes the function of the optic founded with the headache, and, whereas the former in nerves it is not easy to say. That it is due to any involvemany cases is significant, the latter is as yet without localis- ment of the actual centre is very unlikely. The question of treatment of these various growths ma ing ii3fluence. The vomiting of optic neuritis may also be described as sudden and paroxysmal, as occurring with- be briefly dismissed. Unless it is certain that the tumour out nausea, but as being frequently associated with head- is tuberculous, iodide of potassium will of course be ache. It is to be carefully regarded and treated, for a given. I have known this drug to markedly influence the symptoms of a growth which afterwards proved to be severe attack of vomiting i2 often the immediate precursor of death. The last of the three-optic neuritis- malignant. In tuberculous tumours cod-liver oil and iron are is the most important. Optic neuritis may be present, for indicated. A certain, if small, proportion of patients will example, in albuminuria and lead poisoning, and also, it probably recover, perhaps temporarily, even without drugs. is said, in anasmia without tumour ; but in the great The most marvellous case of recovery from cerebral tumour majority of cases there is no doubt that it is indica- I have ever seen could not be ascribed to drugs, as the patient tive of intra-cranial tumour. It also is not localising, took none. The growth was probably tuberculous. Of coune although I believe that the optic neuritis of cerebellar I have seen the symptoms disappear in numerous cases which tumour is in its characters frequently at least suggestive. presented unmistakable symptoms of tumour under the iw There is no doubt that in many cases of cerebellar tumour fluence of iodide of potassium and mercury. The operative the neuritis is particularly intense, being accompanied treatment of these growths is too large a question to discuss by numerous haemorrhages and by the peculiar fan-like at this time. That it is clearly indicated and is, moreover, arrangement of glistening white spots radiating from the hopeful in certain cases must be evident from the case 0/ macula which is common in albuminuric retinitis. This form the first patient I showed. of neuritis I have seen much more frequently associated with cerebellar tumour than with any other variety, although, as I have said, it is not pathognomonic, only suggestive. So NEUROLOGICAL FRAGMENTS. much for the general symptoms of tumour. I shall now BY J. HUGHLINGS JACKSON, M.D. ST. AND., F.R.S., briefly consider the symptoms associated with growth in different parts of the brain or cerebellum. Growths in PHYSICIAN TO THE HOSPITAL FOR THE PARALYSED AND EPILEPTIC: or encroaching on the cortex are characterised more than others by localised pain on pressure over the scalp at No. V. the place corresponding to the underlying tumour. The more DR. RISIEN RUSSELL’S RESEARCHES ON THE KNEE-JERKS

out

the tumour the more marked is this symptom. Localised convulsion-i. e., convulsion starting in some particular segment of a limb-although not present in all cortical tumours, is also present only in a tumour in which the cortex is involved. This convulsion may be only slight twitching and nothing more ; it may also be local cramp, which ceases before it has extended ; but, on the other hand, it may begin as either of these and gradually go on to a convulsion which affects the whole body and abolishes consciousness. After snch a fit there is usually local paralysis, most marked in the part in which the convulsion started. All these statements have been illustrated in the history of the first case I showed

superficial

DURING ARTIFICIALLY INDUCED ASPHYXIA IN DOGS AND RABBITS. -’

IN a former paper, also entitled ’’ Neurological Fragments, " I have adverted to the loss of the knee-jerks in some cases of great supervenosity. I there refer to certain experiment.made by Dr. Risien Russell on dogs and rabbits. He has nor published his researches on Some Circumstances under wbieb the Normal State of the Knee-jerk is altered.In that paper .

1

THE LANCET, March 5th, 1892. 2 Proceedings of the Royal Society, vol. liii.