Brain tumors in childhood

BRAIN

TUMORS

IN

CHILDttOOD

REVIEW OF THIRTY-EIGKT CASES CARL W. RAND, M.D., Los ANGELES, CALIF., AND R. J. VAN WAGENEST,M.D., FRESNO, CALI~'. the standpoint of the pediatrician the diagnosis of intracranial F RO~r t u m o r s has a practical clinical application. I t is not necessary to h a v e a highly specialized neurologic t r a i n i n g in o r d e r to arrive at a t e n t a t i v e diagnosis of b r a i n tumor. Too f r e q u e n t l y , however, in deali.ng w i t h children, the possibility of such a lesion is not given sufficient regard. In r e v i e w i n g our charts we f o u n d evidence t h a t not infreq u e n t l y b r a i n t u m o r was a late, r a t h e r t h a n an early, consideration. I n this p r e s e n t a t i o n the a u t h o r s m a k e no effort t o w a r d fine neurologie distinctions. Emphdsis will be placed on the m o r e obvious signs and s y m p t o m s e n c o u n t e r e d in children suffering f r o m i n t r a c r a n i a l tumors. This r e p o r t is based on a series of verified a n d suspected brain t u m o r s in children who were a d m i t t e d to the C h i l d r e n ' s Hospital of Los Angeles f r o m Jan. 1, 1924, to ~V~ay 1, 1934. D u r i n g this decade t h e r e were 1].,340 admissions to the medical service. Our g r o u p comprises t h i r t y - e i g h t cases, giving a r a t i o of 0.335 per cent, or one b r a i n t u m o r in e v e r y 298.6 medical admissions. None of these children h a d r e a c h e d the t h i r t e e n t h b i r t h d a y . I t has been estimated b y W i l l i a m s ' t h a t b r a i n t u m o r s in general r e p r e s e n t a b o u t 1.8 per cent of all t u m o r s of the body. B r a i n tumors are said to be r e l a t i v e l y less f r e q u e n t in children t h a n in adults; Cushing ~ giving the ratio of a p p r o x i m a t e l y one t u m o r :in childhood to six in adult life. Certain types of t u m o r s f r e q u e n t l y seen in adults, i.e., meningiomas, acoustic neuromas, and p i t u i t a r y adenomas, seldom if ever occur in children u n d e r twelve y e a r s of ag'e. The p r o p o r t i o n of gliomas in children is t h e r e f o r e increased a n d is a p p r o x i m a t e l y 75 p e r cent of all i n t r a c r a n i a l tumors, while in adults the p e r c e n t a g e would r a n g e f r o m 37 per cent to 42 p e r cent. Cushing raises the question w h e t h e r or not m a n y more b r a i n t u m o r s go u n r e c o g n i z e d in child r e n t h a n in adults. The m a j o r i t y o f these are various types of gliomas with an occasional t u b e r c u l o m a a n d r a r e l y a congenital cystic tumor. The cerebellum is the seat of predilection for' gliomas in children. Cushing gives the ratio of eerebellar to c e r e b r a l t u m o r s as 2 to 1 in children; as c o m p a r e d to 1 to 5 in adults. I n this s t u d y we have considered t u b e r e u l o m a s in the c a t e g o r y of t u m o r s because it is difficult to distinguish b e t w e e n the two types of lesions clinically. Tubereulomas are said b y Bailey 3 to be " f o u r times

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as f r e q u e n t in children as in a d u l t s . " They are, however, relatively i n f r e q u e n t as c o m p a r e d to gliomas even in children (ratio 1 to 10) and r a r e l y occur in adults. W h e n present in children, t u b e r c u l o m a s are said to occur m o r e f r e q u e n t l y in the cerebellum. This was also our experience, as out of three eases two were in the cerebellmn and one in the r i g h t p a r i e t a l lobe. The t u b e r c u l o m a s r e p r e s e n t e d 7.8 per cent of the entire series. All w e r e in Mexican children. Of this g r o u p of t h i r t y - e i g h t t u m o r s (Table I), eighteen have been verified as some t y p e of glioma either b y operation or autopsy, three as tuberculomas, a n d one as a R a t h k e ' s pouch cyst, a n d one as a eholesteatoma. In fifteen not verified b y tissue study, the diagnosis TABL~ I

TYPES o r TuMolcs Gliomas (verified) Gl~omas ( p r o b a b l e b u t n o t verified)* T u b e r c u l o m a s (verified) R a t h k e ' s p o u c h cyst (verified) C h o l e s t e a t o m a (verified) Gummas Total *These fifteen of some type.

cases

not

verifi,ed

by

tissue

study

18 15 3 1 1 0 38 were

in

all probability

giiomas

of b r a i n t u m o r :is considered a s . h i g h l y probable. There was no gumma in this series, and in only one instance was there a positive blood W a s s e r m a n n r e a c t i o n in which a verified glioma (probable medulloblastoma of the f o u r t h ventricle) existed. The eerebrospinal fluid W a s s e r m a n n r e a c t i o n in this ease was negative. This bears out the well-known fact that cerebral g u m m a s are v e r y rare and t h a t gliomas m a y develop in syphilitic patients. The cases of both verified (Table I I ) and unverified b u t p r o b a b l e t u m o r s (Table I I I ) h a v e been g r o u p e d according' to the general location of the growth. A p p r o x i m a t e l y two-thirds of the verified tmnors, 69.5 per cent, and a m a j o r i t y of the unverified tumorG 60 per cent, T A B L E II LOCATION OF ~EEIPIEE, TUI~IOI~S*

R a t h k e ' s p o u c h cyst T h i r d ventricle R i g h t cerebral h e m i s p h e r e L e f t cerebral h e m i s p h e r e Midbrain F o u r t h ventricle R i g h t cerebel]ar lobe L e f t cerebellar lobe Cerebellum ( b i l a t e r a l ) Medulla Vermis UnlocMized Total *Of these, 69.5 per cent were subtentorial.

1 2 4 0 0 8 2 1 2 1 2 0 9,3

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were subtentorial. The m a j o r i t y of these posterior fossa lesions were either in the f o u r t h ventricle or in some portion of the cerebellum. The ratio of s u b t e n t o r i a l to s u p r a t e n t o r i a l tumors in the verified group was a p p r o x i m a t e l y 7 to 3, while in the unverified g r o u p the ratio was 3 to 2 m a k i n g the p r o p o r t i o n of cerebellar, as c o m p a r e d to cerebral, lesions in our series s o m e w h a t g r e a t e r t h a n the established figures. TABLE CLINICAL

LOCATION

Ill

OV

UNVERIFIED

TUMORS*

R a t h k e ' s pouch cyst Third ventricle Right cerebral hemisphere L e f t cerebral hemisphere Midbrain :Fourth ~r R i g h t cerebe]lar lobe L e f t c e r e b e l l a r lobe Cerebellum (bilateral) 3/[edulla Vermis Unlocalized Total

1 2 1 0 2 2 2 1 2 0 0 2 15

*Of these, 6,0 per cent w,ere s-abtentorial.

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AGE

IN

LO

6

ii

12

YEARS

C h a r t 1 . - - G r a p h s h o w i n g the r e l a t i v e f r e q u e n c y of t u m o r s a t va ri ous ages. The g r e a t e s t n u m b e r occurred at eight y e a r s of age. The others show,ed no predilection for a n y p a r t i c u l a r age. AGE OF INCIDENCE (CHART

1)

I n considering the age incidence, one is i m m e d i a t e l y impressed by the f a c t t h a t e a r l y age is not an a r g u m e n t against the possibility of the presence of a b r a i n tumor. The y o u n g e s t p a t i e n t was an i n f a n t of ten months on w h o m a diagnosis of encephalitis h a d been made. The spinal fluid contained t h i r t y - t h r e e cells and increased globulin and was u n d e r increased pressure. An i n t r a e r a n i a l t u m o r was not suspected, b u t upon a u t o p s y multiple gliomas of the cerebellum with spontaneous h e m o r r h a g e s were found. The n e x t y o u n g e s t child,

RAND

AND

VAN

WA(]ENEN:

BRAIN

325

TU2CIOIgS

eleven months old, had a f o u r t h ventricle tumor, p r o b a b l y a medulloblastoma. The discs were not choked. The spinal fluid in this instance was u n d e r increased pressure, contained no eel[s, and gave a negative globulin test. There was paralysis of the r i g h t t h i r d and sixth crania[ nerves, accompanied by hydrocephalus and conwflsions. The greatest numbe~ of tumors, five in all, occurred in an eight-yearold child. The remaining thirty-one cases showed no predileetion for a n y age but were scattered over an age period from one to t ~ e l v e years. 14

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11

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1

r DURATION

IN

MONTHS

Chart 2.--Graph showing" d,uration of symptoms in months before admission. All patients had symptoms one month or more before being seen. ThPee patients not included in this graph had symptoms five, eight, and five years, respectively, before being seen. One of these was a cystic glioma; the other two, cystic congenital tumors.

DUgATION

0F SYMPTOMS

IN MONTHS

BEFORE

ADMISSION

(CIIART 2)

If one is confronted with a child who has been sick only a few hours, or possibly days, the probability of a brain tumor is remote. This is well brought out in Chart 2. Fourteen of the children had symptoms for at least from one to three months before admission. F o u r t e e n additional cases showed s y m p t o m s from six months to a year previous to hospitalization. Two patients had symptoms f o r eighteen m o n t h s ; one, for two y e a r s ; three, for two and one-half y e a r s ; and one, for four years before admission. Three additional cases were not included

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in this g r a p h because their s y m p t o m s had covered a period of y e a r s r a t h e r t h a n months, being five, eight, a n d five years, respectively. One of these was a cystic t u m o r of tile vermis ( p r o b a b l y an astrocyt o m a ) ; the second was a s u p r a s e l l a r ( R a t h k e ' s pouch) eyst; the t h i r d was a cho]esteatoma in the neig;hborhood of the optic chiasm, invading' the t h i r d ventricle. I n o t h e r words, tile first of these last three eases was cystic; the other two were both cystic and congenital. All Of these conditions would i m p l y slow g r o w t h and b e s p e a k a r e l a t i v e l y long p r o d r o m a l period. RELATIVE FREQUENCY OF PRESENTING SY3/IPTOMS (CtKART 3 )

The time element does not preclude the possibility t h a t the physician m a y be c o n f r o n t e d w i t h an acute e m e r g e n c y in a child suffering f r o m a b r a i n tumor. The p a r e n t s m a y give a history which on the surface

BY~PTO~S OF 0VER TWO Y E ~ '

P~SISTE~T

DURATION

PERIODIC VOMITING

HEADACHE

DISTURBANCE OF GAIT

OONVGI~ IONS

NYSTAGE,"JS

MORNING V01,1ITING

OCULARI,IOTOR PALSIER FAILING VISION

NAUSEA C h a r t 3 . - - G r a p h showing r e l a t i v e frequency of principal p r e s e n t i n g symptoms.

would seem to point to a short illness overlooking s y m p t o m s which go b a c k over a period of time. These s y m p t o m s m a y have seemed to t h e m to be of little significance b u t in r e a l i t y are of u t m o s t importance. Morning' v o m i t i n g m a y be given as an example. One is more a p t to be misled in a child who has been ill f r o m t h r e e to six months t h a n in a child who presents an emergency. Of these eases, 94.7 per cent give a h i s t o r y of over two w e e k s ' duration. Persistent Periodic Vomiting (Chart 3).--In general it seems t h a t v o m i t i n g which is of central origin, w h e t h e r it be f r o m a b r a i n tumor, meningitis, or eranioeerebral injury, is sudden a n d not p r e c e d e d b y a n y period of nausea. This has been called, sometimes erroneously, projectile vomiting. Some of the eases p r e s e n t i n g difficulty in diagnosis were of children who were considered to h a v e gastrointestinal

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disturbances. I n most instances careful studies w e r e made of the gastrointestinal system before i n t r a e r a n i a l t u m o r was considered. I t would seem the p a r t of wisdom t h a t all p a t i e n t s b e i n g t r e a t e d for r e g u l a t i o n of diet should h a v e ophthalmoscopic e x a m i n a t i o n s if vomiting persists over ohe week. This is i l l u s t r a t e d b y our series, in which 73.6 p e r cent p r e s e n t e d the complaint of persistent periodic vomiting, while 21 p e r cent complained only of m o r n i n g vomiting. An a t t e m p t was made to analyze the s y m p t o m of vomiting. This was done f o r two reasons. I n the first place vomiting, while not always associated w i t h serious consequences, is a v e r y common complaint of childhood, and in the second place, it was the o u t s t a n d i n g s y m p t o m in this group. Two types of v o m i t i n g were encountered. The first was persistent periodic vomiting which failed to be e x p l a i n e d b y the physical examination. I t occurred at any time d u r i n g the d a y but seldom, if ever, awoke a child f r o m his steep. This is. in contr.adistinetion to v o m i t i n g due to appendicitis, intussusception and other gastrointestinal disorders in which the child m a y be a w a k e n e d w i t h vomiting. I f the m o t h e r says the ehild is a w a k e n e d b y vomiting, it usually signifies some intestinal disorder. The second t y p e o c c u r r e d only in the m o r n i n g and will be discussed later. A n y o n e who observes large, groups of ehildren in hospitals m u s t be impressed b y the f a c t t h a t it is a r a r e t h i n g for a child, regardless of his social status or home training, to vomit w i t h o u t m a k i n g some att e m p t to reach f o r a basin or show other instinctive methods to protect himself and his surroundings. On the other hand, the child with a b r a i n t u m o r has little or no warning. One m a y find him with the bedelothing soiled, or, if v o m i t i n g is projeetile in type, the v o m i t u s m a y be on the floor or wall. U s u a l l y the child is as s u r p r i s e d as the a t t e n d a n t who discovers him. Headache (Chart 3 ) . - - P e d i a t r i c i a n s generally agree t h a t it is relatively infrequent f o r a child to complain v o l u n t a r i l y of headache. I f a child complains of headache, a p e d i a t r i c i a n should carefully inquire into the cause. A t the same time one must learn to. differentiate between the headaeltes described b y nervous, interested p a r e n t s a n d the headache t h a t a child will m e n t i o n of his own volition. All will a g r e e t h a t headache in a child is a serious complaint if it is .frequent or persistent. The t y p e of headache does not necessarily indicate the location of the tumor. However, it is we)l k n o w n t h a t occipital or suboccipital pain is more common in p o s t e r i o r fossa lesions. This m a y be associated with stiffness of the neck or suboccipita] tenderness. The fact t h a t cerebellar t u m o r s sooner 'or l a t e r will cause a block of the a q u e d u c t of Sylvius with r e s u l t a n t h y d r o c e p h a l u s would indicate t h a t in time the headache m a y become general. P a i n in the forehead, temples, or v e r t e x m a y occur with a t m n o r in almost a n y location. Suboceipital tenderness, however, should be emphasized in view of the

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fact that approximately two-thirds of the brain tumors in childhood arc below the tentorium. Tile headache may, or may not, be associated with vomiting. In this series headache was complained of in 63.1 per cent of the cases. If a child is old enough to answer questions, there is little difficulty in getting the history of headache, lie may greet you with the words, "Don't touch my head,"' even before the question is asked. Younger children will put their hands to their heads or rub their heads on the pillow. When headache is pronounced, the child is usually lethargic and may become comatose. I n adults b r a d y e a r d i a is often associated with headache when intracranial t u m o r s are present. This is usually not the ease in children. I t was not f o u n d in our series.

DG'turl)a,nce of Gait (Ch(~rt 3 ) . ~ o s t of the disturbances of gait have been in the n a t u r e of ataxia. Stumbling and falling', especially in y o u n g e r children, have been prominent. On the other hand, staggering is i n f r e q u e n t in children with early fourth ventricle tmnors. F o r a considerable period of t i m e t h e y m a y be even agile on their' feet, being able to climb trees, roller skate, or r u n like their playmates. Occasionally incoordination was first noticed w h e n the child eould not ride his bicycle or use roller skates p r o p e r l y . As the t u m o r grows and begins to impinge upon or invade the eerebellar hemispheres, gait dist u r b a n c e s become more evident. On the other hand, a tumor' beginning in one cerebellar lobe m a y evidence itself b y early gait disturbance. I n our series 55.2 p e r cent complained of gait disturbance. P r a c t i c a l l y all of these patients h a d p o s t e r i o r fossa lesions of one t y p e or another. Not all of the cerebellar patients, especially with the f o u r t h ventricle tumors, h a d ataxia. Loss of balance sense and stumbling in a child is often looked upon as a w k w a r d n e s s by the parents, a n d l~ttle significance is a t t a c h e d to it. I t is difficult, often impossible, in a child of two or three y e a r s to get v a l u a b l e i n f o r m a t i o n f r o m the gait. I t is well k n o w n t h a t these children have their good days and t h e i r b a d days. On one d a y the e x a m i n e r m a y elicit no disturbances in g a i t ; on a n o t h e r the a t a x i a is only too evident. The mother often ealls this to the p h y s i c i a n ' s attention. I n e o o r d i n a t i o n of the u p p e r extremities, while less f r e q u e n t t h a n of the lower, m a y occur. The child m a y be a w k w a r d in feeding or dressing himself, t i e cannot perf o r m fine m o v e m e n t s with his hands, I f the t u m o r is in the vermis, t h e r e is usually incoordination of the t r u n k a l muscles. Such a child, if pushed b a c k w a r d f r o m the standing position, cannot save himself f r o m falling b y shifting' his eenter of g r a v i t y , l i e falls like a tenpin because he cannot t h r o w his pelvis f o r w a r d . A g a i n crawling' or creeping in y o u n g ehildren m a y be impossible beeause t h e y cannot synergize the action of t h e i r t r u n k a l muscles with those of their extremities.

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t I e m i p l e g i e gaits m a y be seen if the lesion is n e a r either m o t o r strip, b u t these are less f r e q u e n t in ehildren t h a n in adults.

Convulsions (Chart 3).--Convulsions during childhood are, generally speaking, r a t h e r frequent. T h e y m a y at times be the first elinieal manifestation of almost any acute infection. I n general it m a y be said convulsions are most f r e q u e n t l y assoeiated with febrile states. One valuable aid in the diagnosis of convulsions due to b r a i n t u m o r is t h a t t h e y are not associated with a n y m a r k e d elevation of t e m p e r a t u r e . While epilepsy is not u n c o m m o n in children, it was r a t h e r s t r i k i n g t h a t not once was this diagnosis m a d e in this series of b r a i n tmnors. The eharaeteristies of the typical epileptic fit are well known. The t y p e of convulsion assoeiated with d e c e r e b r a t e r i g i d i t y is not i n f r e q u e n t in cerebellar t u m o r s or those a b o u t the b r a i n stem b u t is p r a c t i c a l l y n e v e r seen in the t r u e epileptie. While convulsions do not eonstitute a v e r y p r o m i n e n t s y m p t o m in this series, 31.5 p e r cent, their presenee was almost a l w a y s of serious import. Convulsions were m o r e f r e q u e n t in children u n d e r t w o y e a r s of age t h a n in the older ones. T h e y were seldom of any loealizing value. No instance of j a e k s o n i a n epilepsy was r e c o r d e d in this series. In only one instance did a child with a b r a i n t u m o r survive m o r e than three weeks a f t e r the onset of convulsions. This was the ease of a five-and-one-half-year-old girl p r e s m n a b l y with a f o u r t h ventricle t u m o r who died three months a f t e r admission. Children with t u m o r s who h a v e convulsions are p e r h a p s less likely to have assoeiated loss of sphincter control t h a n epileptics. Nystagmus (Chart 3 ) . - - N y s t a g m u s was present in a p p r o x i m a t e l y ka]f of the cases of eerebellar tumor. It was not constant, often coming on r e l a t i v e l y late. I t should be emphasized t h a t n y s t a g m u s is seldom p r e s e n t e a r l y in f o u r t h v e n t r i c l e or even in vermis tumors. A b o u t h a l f of the cerebellar t u m o r s w e r e in the midline and c o n s e q u e n t l y did not cause n y s t a g m u s . W h e n present, however, especially if assoeiated with headache or vomiting, n y s t a g m u s shouhl be considered as v e r y significant. N y s t a g m u s was :found in this series in the same proportion as convulsions, namely, 31.5 p e r cent. The two, however, h a d no relationship. No a t t e m p t will be made to analyze the various f o r m s of spontaneous n y s t a g m u s . Suffice it to s a y t h a t horizontal n y s t a g m u s is b y far' the most frequent. Morning Vomiting (Chart 3).--In a relatively large percentage of early fourth ventricle tumors m o r n i n g v o m i t i n g m a y be the only presenting s y m p t o m . This m a y continue for weeks or months before other s y m p t o m s appear. A n y child with p e r s i s t e n t r e p e a t e d m o r n i n g v o m i t i n g should be looked u p o n with suspicion f r o m the s t a n d p o i n t of a. possible f o u r t h ventricle tumor. Not i n f r e q u e n t l y these ehildren h a v e been considered as p r e s e n t i n g b e h a v i o r problems or of being of a n e u r o p a t h i e constitution. The v o m i t i n g m a y have been considered

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as a s u b t e r f u g e on the p a r t of the child to p r e v e n t him f r o m going to school or f r o m being obliged to p e r f o r m some other distasteful duty. I t is a significant f a c t t h a t m o r n i n g v o m i t i n g m a y a p p e a r alone for a long time, the child not v o m i t i n g at a n y o t h e r time in the t w e n t y f o u r hours. I n observing these cases we w e r e impressed with the f a c t t h a t not i n f r e q u e n t l y a child was sent into the hospital f o r v o m i t i n g but while in the hospital the p a t i e n t did not vomit. This w o u l d seem to be misleading. I n an analysis of this, it would seem t h a t we did not b e a r in m i n d the difference in routine b e t w e e n the hospital and the home, the m a i n point being t h a t while a child .is in the hospital, he is not allowed to be up and about. One is t h e r e f o r e led to believe t h a t morning Vomiting m a y be induced b y sudden change of posture associated with arising in the morning. Consequently, these hospitalized children, being k e p t in bed, are less. likely to vomit. I t has been said t h a t a child w i t h m o r n i n g vomiting, e n l a r g e m e n t of the head, and headache gives p r e s u m p t i v e evidence of a. f o u r t h ventricle tumor. Ocular Motor Palsies (Chart 3 ) . - - S t r a b i s m u s of one sort or another is relatively frequent among otherwise healthy children. One can always find cross-eyed children in a hospital. Not infr'equent]y operations are p e r f o r m e d in children's hospitals f o r imbalance of ocular muscles. t t o w e v e r , there m a y be a significant nenrologic b a c k g r o u n d f o r these conditions. I n seven of our children, 18.4 p e r cent of the series, bilateral i n t e r n a l strabismus occurred twice, u n i l a t e r a l ptosis and bilateral ptosis once each, and unilateral i n t e r n a l s t r a b i s m u s three times. I t is well k n o w n t h a t paralysis of the abdueens n e r v e is a notoriously unreliable sign. I t is f r e q u e n t l y seen in internal h y d r o c e p h a l u s f r o m a n y cause, the sixth n e r v e being tile longest a n d consequently most liable to t r a u m a . Fc~iling Vision (Ch(~rts 3 and 4 ) . ~ A special g r a p h has been made showing the relative frequency of choked discs as compared with the i n f r e q u e n t subjective complaint of failing vision (Chart 4). I n only 18 p e r cent of the eases were visual disturbances m e n t i o n e d in the history, while ophthalmoscopic e x a m i n a t i o n r e v e a l e d the presence of choked discs in 73.6 per cent of the series. In several instances the diagnosis of t u m o r was either missed, or c o n s i d e r a b l y delayed, because the e y e g r o u n d s were not examined. In view of the f a c t t h a t tile discs are choked in 73 p e r cent or more of eases of b r a i n tumor, one cannot r e f r a i n f r o m emphasizing again the i m p o r t a n c e of this examination. E v e r y p e d i a t r i c i a n should be able to recognize w h e t h e r or not the eyegrounds are normal. O r d i n a r y choking of the discs is a characteristic picture a n d should occasion little difficulty of recognition. One should not wait, espeeially in children, f o r a h i s t o r y of' f a i l i n g vision before

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TUMORS

examination of the fnndi. A child should never be fitted for glasses without first h a v i n g an ophthalmoscopic examination.

Nausea (Chart 3 ) . ~ N a u s e a is difficult to define, i t is p u r e l y a subjective symptom. It not enly implies being' " s i c k to the s t o m a c h " ' but a loathing" for food. Patients who are n a u s e a t e d will not eat. This holds true in children as in adults. W h e n present it occurred relatively late and comprised only ].5.7 per cent of the cases. I t was not n e a r l y as f r e q u e n t as vomiting (73.6 per cent). The child with a brain t u m o r m a y vomit f r e q u e n t l y but in the interim will usually take food readily. W e know of no other, condition in which this. is true except perhaps in pyloric stenosis. In this respect only, do these two conditions resemble one another.

Spirted Fluid Fib,dings (Chart 5 ) . - - S p i n a l fluid examinations were made in 70.2 per cent of the cases.

Chart

4.--Graph

showing

:---

I Chart 5.--Graph

relative frequency frequent complaint

I t is generally considered that ium-

of choked discs as contrasted of failing" vision.

mmmmmmm m mszmm mm-

to the

in-

mmmnmmmm m-

I showing spinal

fluid f i n d i n g s in 70.2 p e r c e n t

of th,e e a s e s .

bar puncture is attended with considerable risk in eases of brain tumor'. This is especially so if a t u m o r is suspected in the posterior fossa. The d a n g e r lies in the risk of herniation of; the cerebellar tonsils into the f o r a m e n m a g n u m with consequent embarrassment of the m e d u l l a r y centers. In view of the fact that a large p e r c e n t a g e of the tumors were in the cerebellar region, we admit freely that a considerable h a z a r d was entailed in c a r r y i n g out these studies. F o r t u n a t e l y no h a r m f u l results occurred. I n spite of the fact that no ~11 effects followed l u m b a r puncture, we do n o t wish to leave the impression that we advocate its promiscuous use. W h e n it is employed, it should be. p e r f o r m e d carefully in the horizontal position with the use of a manometer. I n this w a y the outflow of fluid can be kept u n d e r control and the pressure more a c c u r a t e l y measured. The measurement of spinal fluid pressure is one of the most accurate indices of the existing degree of intraeranial

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pressure and in this respect is of value. Struggling, which f r e q u e n t l y occurs in children, during lumbar p u n c t u r e must be taken into account in estimating pressure readings. Seventy-three per cent of oar spinal fluid examinations showed inereased pressure. The pressure, u n f o r t u n a t e l y , was not a c c u r a t e l y measured with a m a n o m e t e r and depended upon the estimation of the observer. I n 3 1 9 e r cent the g]obnlin was increased. This was seldom the ease if the t u m o r chanced to lie in the f o u r t h ventrieIe. This was c o n t r a r y to our expectations. The cell count was increased in only 4 per cent of the eases. I n this hospital a cell c o u n t up to ten is considered within normal limits. I n only three cases did the count rise above this, being respectively, nineteen, thirty-three, and one h u n d r e d t w e n t y cells. I n the three eases of tubereuloma, the first had no spinal fluid examination ; the second contained seven cells and no increase in globulin; and tile t h i r d resulted in a bloody tap and was not repeated.

Errors in Diagnosis (Table IV).--Errors in diagnosis are excusable at some stage in ahnost every disease. Symptoms are kMeidoseo.pie; they seldom follow the definite chronologic sequence as described in textbooks. The impression gained at the first examination is often changed after f u r t h e r study. Consequently, there is f r e q u e n t l y a wide divergence of opinion between the admitting diagnosis and the final diagnosis in any group of eases. I n the series u n d e r consideration a correct elinicM diagnosis was arrived at in 70.9 p e r cent of the eases. W i t h a relatively large g r o u p of unverified t m n o r s one cannot be sure r e g a r d i n g the series as a whole. Table IV, " E r r o r s in D i a g n o s i s , " has been p r e p a r e d to bring out tile differences between the admitting diagnosis and the final diagnosis. The principal sourer of error in each instance has been ]isted. In the eleven cases cited the constant sour're of error which existed was failure to examine the eyegrounds. W h e n this was done, the physician was put on the right track. I t demonstrates v e r y clearly the fact t h a t mistakes often happen not because of lack of general knowledge but because of incomplete examination. Three eases t e n t a t i v e l y diagnosed as encephalitis have been cited. These all p r o v e d at a u t o p s y to be t u m o r s of some part of the cerebellum. The existence of encephalitis, especially soon after the influenza epidemic of 1918, was very frequent. D u r i n g the latter years it has been seen with diminishing frequency. P ostinfluenzal and possibly postvaeeina] encephalitis are among the most common forms in children. The encephalitis fo.rm of poliomyelitis should always be borne in mind. These conditions are usually associated with a rise in t e m p e r a t u r e ant1 often witch signs of meningeal irritation. Such would ~mt be the case in a ~;umor. Choking o:f the discs, while rare, m a y be present in acute encephalitis.

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D i e t a r y disturbances are v e r y common a m o n g y o u n g children. I t is, therefore, not surprising t h a t a ease of brain t u m o r with v o m i t i n g should be a d m i t t e d u n d e r this heading. The same m a y be said of acidosis. Two cases have been listed as behavior problems or neuropathic constitution. ) I o r n i n g vomiting was a p r e s e n t i n g s y m p t o m in both. They had been followed a n u m b e r of months in a child% guidance elinie, where it was considered that vomiting was a s u b t e r f u g e on the p a r t of the child to p r e v e n t his going to school. T h e y were t r e a t e d f o r some time as behavior problems. F i n a l I y f u n d u s exanainations, made because of headaches, clarified the diagnosis. One ease of TABLE I V ERR01% IN DIAGNOSIS ADMITTING DIAGNOSIS Encephalitis Encephalitis Encephalitis Diet regulation Diet regulation

SOU~CE O~ ERRORS Eyegrounds not examined. Eyegrounds not examined. Misinterpretation of history. Tumor, right cerebra] hem- Eyegronnds not examined. isphere No x-ray study. Tumor, third ventricle Eyegrounds not examined. Glioma Eyegrounds not examined. No x-ray study. No spinal :fluid. study. Tumor, s ventrlcle Eyegrounds not examined. FINAL DIAGNOSIS Tumor, left cerebellum Tumor, third ventricle

Diet regulatlon; Acidosls; Allergy Acidosis; Sinuslgls

Tumo% mldline eerebellar

Behavior problem Rickets

Tumor, cerebellum Tnmor, left cerebellum

Swollen arm;

Convulsions Tuberculoma, cerebellum

Neuropathie constltut~on

Tumor, fom'th ventricle

Fitted for glasses without fundus examination. Eyegrounds not examine& Eyegrounds not exmnined. Misinterpretation of history. Eyegrounds not examined. No x-ray study. Spinal fluid not properly examined. Eyegrounds not examined. No x-ray study.

riekets which resulted in death from a tumor of the left cerebellum was incorrectly diagnosed beeause of lack of eyeground examination and misinterpretation of the history. In reviewing the history in the light of poshnortem findings, w e find one should have been at least suspicious of a brain tumor. The diagnosis of rickets was eorreet but had nothing' to do with the cause of d e a t h ; a u t o p s y showed an unsuspected tumor. One child was admitted with swelling of the arm and draining cervical adenitis. Both were tuberculous. While u n d e r t r e a t m e n t he had a convulsion, whieh was disregarded, and the child was discharged. Upon readmission tuberculous meningitis was suspected, and a. spinal fluid examination was made. A bloody' t a p resulted and the usual tests could not be made. I t was not repeated as should

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have been done. No r o e n t g e n r a y s t u d y of the skull was carried out. The fundi were never examined. A u t o p s y revealed a tuberculoma of tile cerebellum. ROENTGI~;NOLOG1C S T U D I E S

Stereoscopic roentgenologic examinations of the skull are highly i m p o r t a n t in any case of suspected brain tumor. It is realized that in y o u n g children this is difficult, and sometimes impossible, to accomplish. However, the effort should be made. I n the m a j o r i t y of cases the findings will consist of increased convolutional pressure a t r o p h y and separation of the sutures. I n this series these changes were present ~n 52.7 per cent of the cases. Convolutional markings alone are perhaps of no great significance, for it has been shown by E a t o n ~ that they occur f r e q u e n t l y in n o r m a l children u n d e r the age of twelve. lie thinks general nutritional changes m a y be a f a c t o r in their production. W h e n f o u n d in conjunction with separation of the sutures, convolutional a t r o p h y has definite significance. This is especially true if accompanied b y measurable enlargement of the head. The t e n d e n c y for the i n f a n t to decompress himself by widening of the sutures and fontanels must be kept in mind. W h e n this occurs, signs of increased pressure as manifested by headaches and choking of the discs m a y be delayed. I n certain cases of p i t u i t a r y disorder' alteration in the sella tureiea may be present. This would constitute a very small proportion. Since the use of air as a diagnostic measure was introduced by D a n d y 5 v e n t r i e u l o g r a p h y has been employed with increasing frequency. I t is a valuable asset. We have setdom used air when a cerebellar lesion is suspected: first, because internal hydrocephalus, which accompanies these tumors, can be easily recognized in children from o r d i n a r y r o e n t g e n o g r a p h i e studies and a c c u r a t e l y confirmed by Maeewen"s sign (cracked-pot note elicited by percussion of the ealvarium) ; second, there is considerable risk following v e n t r i c u l o g r a p h y in obstructive hydrocephalus, a high t e m p e r a t u r e reaction often resulting unless the air is immediately r e m o v e d ; and third, ventrieular estimation can be easily done b y simply t a p p i n g the ventricles prep a r a t o r y to a eerebellar exploration. I n supratentorial lesions vent r i e u l o g r a p h y has greater value. E n c e p h a l o g r a p h y , the introduction of air by spinal route, should p r o b a b l y seldom, if ever, be used in eases of suspected brain t u m o r accompanied b y clinical signs os increased intraeranial pressure. Cysts in the region of the sella tureica m a y be shown by roentgenologic examination. A ease in point will be discussed. g. ~., male, aged nine years~ was admitted on June 20, 1928~ and dismissed July 15, 1928. He was seen by a number of men on the staff, including one of the writers. Several men felt that he had a brain tumor, probably ia the cerebellar region. Vestibular studies pointed to a lesion of the right cerebe]lopontile angle. A visual field examination, even roughly made, was not recorded, l~oent~

RAND AND VAN WAGENEN:

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335

genologic studies were conducted,, fiat plates being used. These consisted of roentgenographs of the head, long bones, chest, a~d sinuses. No adventitious shadows were seen in the head. This child was taken to the Mayo Clinic where on Aug. 6~ 1928, we learned6 that bitemporal hemianopsia was demonstrated and " a calcification above the sella turciea was revealed by x-ray examination." lie was considered to have a cyst near the optic ehiasm. At operation it proved to be a calcaxeocholesteatoma containing a large amount of fluid rich in cholesterol crystals. lie was discharged from that institution as improved. I t is well pointed out by Bailey7 that certain tumors about the pituitary region give symptoms simulating cerebellar disease, ttowever, our error in diagnosis lay in the fact that visual field examinations were not laade~ and sufficiently careful roentgenologic studies were not conducted. Had we found the bitemporal hemianopsia and the suprasellar shadow, both of which were undoubtedly present, the ease would have been clarified. A second case (26-294, Feb. 15, ]926; 26-758, h~Iay 31, 1926; and 28-958, May 14, 1928) is called to attention. This case, that of a little girl, nine and a half years old, who had fairly typical signs of hypopituitary disease presenting a picture of FrShlich's syndrome, first came under observation in lPebruary, 1926. Roentgen ray studies of her head showed marked eonvolutional impressions, some enlargement of the sella turcica, and narrowing of the posterior elinoid processes. A supposed pituitary adenoma was diagnosed~ and the child was operated upon. Fragments of what appeared to be a somewhat enlarged pituitary gland were removed. Microscopic sections showed these to be made up of squamous epithelium. The significance of this was not apparent at the time. There was gratifyb~g improvemerit which lasted for a period of years. Finally her symptoms of headache and visual disturbance recurred, and she was reoperated upon Apr. 19, 19331 when a very large suprasellar, or Rathke's pouch, cyst was encountered. During the intervening eight years, she had developed supraseliar shadows which were plainly seen in subsequent plates and wt~ich in themselves were enough to make a diagnosis. She died on Dec. 23, 1933, almost eight years after first being seen; this is the longest survival period of any case. During our period of observation we were permitted to see the laying down of calcium in this craniopha~yngeal pouch cyst as evidenced by repeated roentgen ray examinations. NEUl~OOTOLOGIC STUDIES (TABLE V) N e u r o o t o l o g i c s t u d i e s h a v e b e e n of g r e a t v a l u e . Examination of t h e e i g h t h c r a n i a ] n e r v e i n s o m e r e s p e c t s is a n a l o g o u s t o t h e e x a m i n a t i o n of t h e s e c o n d a n d f r e q u e n t l y a s s u m e s p r i o r i t y o v e r t h e o p t i c nerve in disclosing the location of an intraerania] lesion. Whether or n o t t r u e c h o k i n g of t h e e i g h t h n e r v e e x i s t s in b r a i n t u m o r c a s e s is a question. However, abnormalities in the function of both auditory a n d v e s t i b u l a r c o m p o n e n t s of t h i s n e r v e m a y b e of d i s t i n c t v a l u e . T h i s is p a r t i c u l a r l y t r u e of t h e i n t r a c l ~ a n i a l v e s t i b u l a r p a t h w a y s . T h e e x a m i n a t i o n of t h e s e p a t h w a y s i n c h i l d r e n is m o r e d i f f i c u l t t h a n i n adults, owing to the children's inability to cooperate. However, cert a i n r a t h e r d e f i n i t e c o n c l u s i o n s m a y b e d r a w n in t h e m a j o r i t y o f cases. Differential diagnosis between a subtentorial or a supratentorial lesion can be made with considerable certainty. T h i s i n i t s e l f is o f g r e a t v a l u e , e s p e c i a l l y i f t h e l e s i o n b e s u b t e n t o r i a l , as t h e u s u a l c e r e b e l l a r e x p l o r a t i o n g i v e s a d e q u a t e e x p o s u r e to h a n d l e a n y l e s i o n w h i c h m a y be encountered

in the posterior fossa.

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I n t h i r t e e n eases n e u r o o t o l o g i c s t u d i e s were c a r r i e d out ( T a b l e V ) . I n n i n e i n s t a n c e s i n w h i c h the d i a g n o s i s of a p o s t e r i o r ' fossa l e s i o n was s u g g e s t e d b y m e a n s of s t u d i e s of' the v e s t i b u l a r m e c h a n i s m , e i g h t w e r e correct. I n one of t h e s e a l e s i o n was p r e d i c a t e d i n the r i g h t eereb, e l l o p o n t i l e a n g l e . T h i s p r o v e d to be a c h o l e s t e a t o m a i n t h e r e g i o n of t h e e h i a s m i n v a d i n g t h e t h i r d v e n t r i c l e . I n a n o t h e r i n s t a n c e t h e v e s t i b u l a r r e a c t i o n s w e r e c o n s i d e r e d as n o r m a l , b u t a e r a n i o p h a r y n g e a l p o u c h cyst was f o u n d at o p e r a t i o n . I n s t i l l a n o t h e r i n s t a n c e , TABLE V -A_NALYSIS OF NEUROOTOLOGI~ ~h[PRESSIONS COMFAt~,ED, W I T ' t t TUIVlOg LOCATION NEUP~OOTO,LOGIC' IMPRESSIONS

LOCATION 0F TUIV[Og

TYPE OF TUMOP~

Spongioblastoma multiforme Right cerebellar lesion--pressure on Right eerebellar tu- Gliom~ (type not given) mor extending into brain stem eerebellopontine angle Medulloblastoma :Fourth ventricle tuSuggest lesion--fourth ventricle (.~) mor Medulloblastoma Suggest cerebellar involvement Left cerebellar lobe Suggest posterior fossa lesion--not defi- :Fourth ventricle--ex- Medulloblastoma tending to left ecrnite ebellar lobe Suggest posterior fossa lesionlprobably ~ourth ventricle tu- Medulloblastoma mot brain stem involved. (A frontal lobe tumor will sometimes simulate this.) Medulloblastoma Suggest left eerebellar lesion Cystic tumor from vermis involving left eerebellar lobe u Medulloblastoma Probably posterior fossa lesion Cholesteatoma Cerebellopontine angle (left), or eerebel- Postehiasmal and third ventricle Iar tumor (left) extending into the angle Picture suggests posterior fossa ]esion~ Medulla Spongioblastoma probably ]eft eerebellar multiforme Posterior fossa intact Suprasellar Rathke's pouch cyst Intraeranial tumor--coma prevents lo- Right temporal lobe Spongioblastoma multiforme (.~) calization Right ecdpital lobe Midline supratentoriaI lesion Spongioblastoma multiferme Postfossa lesion--probably brain stem

Fourth ventricle

i n a n a l r e a d y c o m a t o s e child, t h e tests c o u l d n o t be c o m p l e t e d , a n d n o c o n c l u s i o n s c o u l d be d r a w n . A t a t t t o p s y a f o u r t h v e n t r i c l e t u m o r w a s f o u n d . F o l l o w i n g one n e u r o o t o l o g i e s t u d y a m i d d l e s u p r a t e n t o r i a l lesio~ was p r e d i c a t e d . A t auto,psy a s p o n g i o b l a s t o m a m u l t i f o r m e of t h e r i g h t o c c i p i t a l lobe was f o u n d . P e r i m e t r i c . fields a n d v e n t r i c u l o g r a p h y w o u l d h a v e m a d e tile l o c a t i o n of the l e s i o n m o r e precise.

ea'r~oLoc~Y (~aBLE VI) E n d - r e s u l t s i n verified b r a i n t u m o r eases are s e l d o m t a b u l a t e d or p u b l i s h e d . V a n W a g e n e n s r e c e n t l y has s m m n a r i z e d the e n d - r e s u l t s of 169 eases of v e r i f i e d b r a i n t u m o r s f r o m C u s h i n g ' s clinic e i g h t y e a r s

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l e x p e c t a n c y of the children with gliomas, t a k e n a f t e r operation. rp'~e as a whole, was 38.8 too. The survival period of children with midline eerebellar medulloblastomas was 14.5 too. The patients with eereTABLE VI TYPE AND LOCATION 01v PROVE]) LESIONS W I T H ~UI~VIVAL PER[O])S

SEX

OPERATION

TYPE

OP LESION

LOCATION

Female

None

Female Female

Partial removal Medulloblastoma None iVfultiple gliomas

Female

None

Female

Exposed--not Medulloblastoma removed Exposed by Ad- Cholesteatoma son. Partial

Male

Medulloblastoma

removal Partially removed

Male

Not removed

Female

Partially removed None

Male Male

Left eerebellar lobe Righ~ and left cerebral hemispheres Fourth ventricle, 16 days growing forward Fourth ventricle 3 yr.

Vermis--eerebellum

Spongioblastoma multiforme Medulloblastoma

Right occipital lobe

4 yr.

Fourth ventricle

1 yr.

Glioma (spong%blastoma multiforme.~) Spongioblastoma multiforme Medulloblastoma

Right temporal lobe

8 mo.

Medulla

3 wk.

Left cerebellar lobe

9 ln0.

Male

Partial removal Medulloblastoma

Male

4 yr. 6 me. 5 mo. ] mo.

Medulloblastoma

Female Male

Female

SURVIVAL PERIOD

5 yr.+ (may be living) 10 me.

Fragment removed Partially removed Partial removal on two occasions Partially removed None None

Male

LESION

Left eerebellar lobe

Mgdulloblastoma

Male

OF

Postehiasma] and third ventricle

Ratbkc's pouch cyst Supra sellar

(~)

8 yr. 6 mo.

Spongioblastoma multiforme Cystic (colloid ? ) Medulloblastoma

Fourth ventricle Third ventricle Fourth ventricle, ! growing forward :Fourth ventricle

6 too.

4 toO. 13 mo.

Living, over 7 yr. Right eerebellar lobe 4 yr.

I

Female

Ventricle tap

Female

None

Male Female

Glioma (unclassified) Tubereuloma

3 too. Multiple (1) left temporal lobe; (2) right eerebel]ar .lobe; (3) left eerebellar lobe Partial remowtl Tubereuloma; tuber- Right eerebellar lobe 2 yr, culous meningitis 10~ too. Tuberculoma ; tuber- Right parietal lobe None eulous meningitis

bellar astroeytomas,

however,

did much

better, the average

survival

period being nine years. Our group of children in whom lesions were verified showed an unu s u a l l y high p e r c e n t a g e

of m a l i g n a n t

tumors.

The o p e r a t i v e

results

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were discouraging. Indeed, only one child of this entire g r o u p is k n o w n to be living today. The pathologic records in the earlier cases were incomplete. T w e n t y - o n e cases in which the p a t h o l o g y was definite h a v e been listed. T h e r e were nine medulloblastomas, five of which originated in the f o u r t h ventricle, one in the vermis, two in the left cerebellar lobe, and one in the r i g h t cerebellar lobe. The longest s u r v i v a l period for these t u m o r s was over seven years, in a lad who has had intensive postoperative high voltage therapy. The shortest survival period of this g r o u p was sixteen days, in an elevenm o n t h - o l d infant. There w e r e two cases of s p o n g i o b l a s t o m a multiforme, one occurring in the r i g h t occipital lobe a n d the second, an a t y p i c a l f o r m of this tumor, i n v a d i n g the medulla. The first was explored, but the t u m o r was not r e m o v e d at operation. The child lived f o u r months. A t h i r d ( p r o b a b l y a s p o n g i o b l a s t o m a m u l t i f o r m e ) occ u r r e d in the r i g h t t e m p o r a l lobe. These t u m o r s w e r e all supratentoriM as compared with the subtentorial medulloblastomas mentioned above. There were two unclassified gliomas, the seeo.nd of which was multiple occurring in a ten-month-old infant. No cystic tumors were encountered, and no astrocytomas were identified. There was one cystic t u m o r of the third ventricle in a two-year-old child. This case occurred early in the series, and the specimen has been lost. One wonders if it m a y not have been the relatively benign colloid t y p e of cyst occurring in the t h i r d ventricle, which has recently been so. well described by D a n d y 2 A second unusual congenital t u m o r was a eholesteatoma in the. region of the postehiasm and t h i r d ventricle. There was one typical l~athke's pouch cyst with a survival period of eight and one-hMf y e a r s f r o m the earliest s y m p t o m . D u r i n g this little girl's life the. t u m o r was twice o p e r a t e d u p o n and p a r t i a l l y removed. Suprasellar' calcification was seen to develop during this interval. There were three tubereu]omas, one p a r t i a l l y removed f r o m the r i g h t eerebellar lobe and a second in the right parietal lobe, which was not explored, and a third presenting multiple tubereulomas in the left temporal, right cerebral, and left cerebral lobes, respeetively. All of these ehi]dren died of tuberculous meningitis. The longest s u r v i v a l period was two y e a r s ; the. shortest s u r v i v a l period three months. S U M M A R Y AND C O N C L U S I O N S

A r6sum~ of thirty-eight cases of verified and highly probable intracranial t u m o r s in children has been a t t e m p t e d . None of the children h a d r e a c h e d his thirteent!l b i r t h d a y , and the m a j o r i t y of t h e m were u n d e r ten y e a r s of age. The group, as a whole w a s y o u n g e r t h a n is usual in preadolescents, in w h o m the age os p u b e r t y is approaching. More e x a c t diagnoses should have been m a d e a n d b e t t e r results obtained. H o w e v e r , the same could p r o b a b l y be said in the m a j o r i t y of

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children's hospitals in this c o u n t r y so f a r as the diagnosis and treatm e n t of such lesions is concerned. ~ u c h more could be accomplished by g r e a t e r a t t e n t i o n to the common presenting' symptoms, i.e., persistent periodic vomiting, headache, d i s t u r b a n c e in gait, ocular m o t o r palsies of various types, e n l a r g e m e n t of the head, failing vision, nausea, convulsions, m o r n i n g vomiting, and n y s t a g m u s . These are of common occurrence. They have been recorded in the relative f r e q u e n c y of their appearance. Doubtless m a n y cases of cerebral t u m o r in small children are not recognized. Histories should be more c a r e f u l l y taken. One can l e a r n m u c h f r o m mothers. The pitfalls in diagnosis, as we h a v e f o u n d t h e m in r e v i e w i n g o u r cases, h a v e been p o i n t e d out. W i t h o u t exception the lack of use of the ophthalmoscope has been most evident. W e ha~e seen children t r e a t e d as b e h a v i o r problems because they vomited their b r e a k f a s t s - - c h i l d r e n in w h o m b r a i n t u m o r s w e r e later diagnosed. I n other children extensive gastrointestinal investigations, which could h a v e been obviated b y the use of the ophthalmoscope, were carried out because of vomiting. W e have seen children with failing vision f r o m brain t u m o r s fitted to glasses w i t h o u t f u n d u s examination. W e be]ie-ze t h a t if e v e r y p e d i a t r i c i a n would use his ophthalmoscope diligently m a n y cases, otherwise overlooked, w o u l d be e o r r e e t l y diagnosed. Little t h a t is new has been p r e s e n t e d in this report. W e trust, however, t h a t the more i m p o r t a n t s y m p t o m s have been sufficiently emphasized to aid in earlier diagnoses of brain t u m o r in children. REFERENCES 1. Williams, W. I~. : The Initial of Tumors and Their Relativc Frequency, Nat. Hist. of Cancer, New u 1908, William Wood 8~ Co., chap. 18, pp. 375399. 2. Cushing, Jc[.: Am. J. Dis. Child. 33: 551, 1927. 3. Bailey, i~ I n t r a c r a n i a l Tumors, Springfield, II1., 1933, Charles C. Thomas, pp. 403, 404. 4. Eaton, }I. D.: CaliL & West. ~Ied. 23: 862, 1925. 5. Dandy, W. E.: Surg. Gynec. Obst. 30: 329, 1920. 6. Idem: Personal communication. 7. Bailey, P.: Arch. Neurol. & Psychiat. 11: 137, 1924. 8. Van Wagenen, W . P . : J . A . 1Y[. A. 102: 1454, 1934. 9. Da~dy, W . E . : Benign Tumors in the Third Ventricle of the B r a i n : Diagnosis and Treatment~ Springfield, Ill., 1933, Charles C. Thomas.