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A CASE OF MULTIPLE (TUBERCULOUS) CEREBRAL
By R. T. WILLIAMSON, M.D. (London), F.R.C.P., Assistant Physician,
Royal Infirmary, Manchester. JAMES L., aged 34, was admitted as an in-patient at the Ancoats Hospital, September 22nd, 1903, on account of severe headache.
History.-In January, 1903, the patient had an epileptic fit, which commenced with twitching in the right hand. The duration of the fit was short (about two minutes). Afterwards there was slight loss of power in the right arm and leg for a few days. Four severe fits occurred during the summer of 1903. Also since January, 1903, there had been many attacks of very slight twitching (of short duration) in the right hand. In July he began to suffer from severe headache. The headache had been so intense that he had been obliged to remain in bed for seven weeks before admission.
There was no history of injury to the head, of previous illness, or of syphilis. Examination revealed also no signs of syphilitic infection, and though the patient was often carefully questioned he always denied having had syphilis. There was no history of ear disease.
On admission to the hospital, examination revealed no objective signs of disease and no optic neuritis. There was one prominent symptom-intense headache, which was worse when the patient was in the vertical position. The headache was chiefly frontal : it was severe both during the day and the night, and was not specially worse at night.
Although no history and no evidence of syphilitic infection could be obtained, iodide of potash, gr. 7), with 7!m. of aromatic spirits of ammonia, was given three times a day on September 24th, and continued until he left the hospital on October 14th.
The headache diminished decidedly, and the patient was discharged from the hospital on October 14th greatly relieved. He afterwards attended the out-patient room; the iodide was continued for several weeks; the patient improved markedly, and the headache almost disappeared. The iodide was then discontinued, and an expectorant mixture given on account of a slight attack of bronchitis which occurred about this time. The headache soon became severe again, and the patient was obliged to return to the hospital as an in-patient, on November 26th, 1903.
On the second admission the condition was practically the same as on the first. He complained of intense headache. It was severe both during the day and night, and was not worse at night. The pain was all over the head, but was most severe in the frontal region. There was no optic neuritis. Vision was not affected. There was no hemianopsia. The pupils reacted both to light and accommodation. There was no paralysis of the facial, ocular, or tongue muscles—and no affection of the motor or sensory branch of the fifth cranial nerve.
The sense of smell and hearing were unaffected. There was no paralysis or paresis of the limbs. The knee jerks were present. Ankleclonus was absent; and the plantar reflexes were of the normal type. All forms of sensation in the limbs, face, and trunk were unaffected. (There was no affection of the stereognostic sense.)
The heart, lungs, and abdominal organs were normal. The urine had a sp. gr. of 1018: albumen and sugar were absent.
On Dec. 14th, slight, but definite optic neuritis was first detected. (A few days previously the optic discs were normal.)
The margins of the right disc were blurred : the colour was greyish red, and the disc was slightly swollen. The retinal vessels were tortuous and two small hæmorrhages were present, one at the upper and the other at the lower margin of the disc. The upper margin of the left disc was blurred and swollen: the colour of the disc was greyish red. There was no hemianopsia. The mental condition was unaffected. Two days after the optic neuritis was first detected (i.e., on Dec. 16th), the patient vomited in the morning and soon afterwards, about 10-30 a.m., he became drowsy, and rapidly passed into a comatose state. There were no signs of paralysis or paresis of the limbs. The pulse was 76 : the respirations were irregular. He remained comatose and death occurred about 12-15.
During the whole of the period the patient was in the hospital the severe headache had continued : on many occasions it was so intense that he rolled about in his bed in great agony. On four occasions hypodermic injections of morphia had to be given to relieve the pain. Antipyrin, gr. 10, was given very frequently when the headache was specially severe. An ice bag applied to the head appeared to relieve the pain a little.
In spite of the patient's denial of syphilitic infection, and in spite of the absence of any objective signs of past or present syphilitic lesions, it was thought advisable to try the action of iodide of potash and mercury. On November 11th, 10 grains of iodide of potassium, with m 15 of liquor hydrargyri perchloridi, were prescribed, three times a day. On November 30th the mercury was omitted from the mixture and potassium iodide given four times a day. But mercurial inunctions were commenced on this date and continued until Dec. 9th.
During the period the patient was in the hospital the temperature was never above normal. Vomiting occurred on eighteen occasions during the last three weeks of life. There was no cough and no expectoration. The patient was not wasted. There were no night sweats, and no symptoms or signs of tuberculous disease in the chest.
The autopsy revealed no signs of organic disease in the heart, lungs, liver, kidneys, or other organs of the thorax and abdomen. The convolutions of the brain were slightly flattened. There was no fluid in the cerebral ventricles.
Vertical frontal transverse sections of the brain were made, and four subcortical tumours" were found in the white matter of the cerebral hemispheres. Two were present in the right and two in the left hemisphere. The position of the “tumours ” is shown in the diagrams. All were roughly spherical in shape. The diameter of the largest was about an inch ; the diameter of the other three “tumours was about of an inch. The largest "tumour” was situated in the centre of the white matter of the left cerebral hemisphere in the posterior parietal region (see fig. 3). Another smaller “tumour” was present in the white matter of the right cerebral hemisphere in the same section at this region of the brain, but it was nearer the convex cortex than the one in the left hemisphere (see fig. 3).
A third tumour was seen in the white matter just under the cortex of the median part of the left cerebral hemisphere in a section through the anterior part of the ascending frontal convolution (see fig. 1). In the right cerebral hemisphere one "tumour” was situated in the white matter beneath the cortex at the upper part of the ascending parietal convolution (see fig. 2).
All of the tumours were very firm at the periphery, and bounded by a thick capsule of fibrous tissue. The central part of each was
The largest was quite soft in the centre, and on section a small quantity of creamy pus-like fluid escaped leaving a small cavity about of an inch in diameter.
Fig. 3. Figs. 1, 2, and 3. Three vertical transverse sections of cerebral hemispheres, showing position of tuberculous tumours which are indicated in deep black.
From the naked eye appearances it seemed probable that the "tumours were either gummata or tuberculous masses (conglomerate tubercules).
No signs of syphilitic disease were detected in any other part of the body. The patient had denied syphilis, and there had been no signs of past syphilis on clinical examination. Also there had been no symptoms or signs of tuberculous disease. The diagnosis therefore had to be decided from the pathological examination of the “tumours," and at first it was not very easy to say whether they were tuberculous or syphilitic. The very thick and firm fibrous capsule was in favour of the gummatous nature of the tumours; also there were no small tubercles around the four tumours, and no tubercles were found in any other part of the body (but probably some tuberculous focus had been overlooked at the autopsy).
In favour of the tuberculous nature of the tumours was the fact that one was situated in the central part of the cerebral white matter (the other three were in the white matter also, but were near the cortex).
Gummata are very rarely situated in the centre of the cerebral white matter. The fact that one tumour contained a small quantity of puslike fluid in its centre, was in favour of tubercle and against gumma. Central purulent softening is much more common in tuberculous tumours than in gummata.
Microscopical examination revealed a caseous degeneration of the centre of the “ tumours,” and a very thick fibro-cellular peripheral zone. Between these two portions was a zone of cellular tissue, containing a few scattered giant cells, which had a structure consistent with, but not clearly conclusive of, its tuberculous nature.
Fig. 4. Fig. 4. Transverse section of the largest tuberculous mass, stained with logwood. (Actual size of tumour.)
The small blood vessels did not present signs of endarteritis. The proof that the “tumours were really tuberculous masses-conglomerate tubercles--was furnished by the presence of large numbers of tubercle bacilli in sections of the tumours stained for these organisms in the usual manner.
The case was of interest on account of the few symptoms which were present during the course of the illness. The prominent symptom was the intense headache. Optic neuritis only appeared a few days before death-only during the last week of life. There were no paralytic or definite localising symptoms of the tuberculous tumours.