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sister alive and in good health, patient and this sister comprising the whole family no history of phthisis in the family could be obtained. About a year ago he says he had "low fever," but he was in bed and away from his work only ten days: he has never felt strong. Ten days ago he began to suffer from headache which affected the whole of his head, and he then began to feel weak; four or five days ago he commenced to stagger when walking, and had to give up his work two days ago. Patient is a fairly well nourished lad; face pale; seems a little stupid; lies on his right side curled up in bed but is very restless; there is a little photophobia; complains of pain in lumbar region on stooping; skin hot and dry.

Alimentary System.-Sordes on lips; tongue moist, coated with fur; appetite poor; breath foul, smells like a typhoid patient. Bowels open, no diarrhoea; abdomen retracted; there is a little tenderness on pressure in the right iliac fossa, with gurgling. Absolute liver dulness commences above in nipple line at fifth rib, and extends downwards to half-an-inch below costal arch. Spleen cannot be palpated.

Circulatory System.-Heart's apex-beat best felt in fourth. interspace one inch internal to nipple line. Area of cardiac dulness commences above at third intercostal space, is not enlarged to right of sternum. A faint systolic bruit is heard in third left intercostal space, not conducted in any particular direction. Pulse 88, regular, fair tension.

Respiratory System.-Nothing abnormal detected in lungs. beyond a few rhonchi.

Nervous System.-Patient says his left arm sometimes feels numb for five or ten minutes at a time. There is no loss of

He says he sees

He is a little

sensation. Pupils equal and react to light. double, though examination failed to prove this. deaf, and says he has a little difficulty in swallowing. Patellar reflexes easily obtained. No ankle clonus. Urine 1025 sp. gr., alkaline; when boiled with acetic acid gives a faint trace of albumen; under microscope a few leucocytes seen, also bladder epithelium. Evening temperature 101.8°.

July 26th. Very restless; complains of feeling low and miserable, also of headache. Vomited this morning. Right pupil is larger than left. Evening temperature 101.2°, pulse 78.

July 27th. Was very restless until three this morning, since then he has slept, but now, 9 a.m., is restless again. Bowels have not been open since admission; no typhoid spots; foul smell continues; tache cerebrale present; no diplopia now; no obvious deafness. The temperature keeps above 101° F. Pulse in morning 96, evening 108.

July 28th. Had urethran gr. xv. at 11 p.m. last night, and later half that quantity, but only slept about an hour; very restless all night, shouting out; is complaining of some pain in right hypochondrium; ? friction on deep respiration. Temperature keeps high to-night, 102° F., pulse 114.

July 29th. Bad night; very restless and noisy. Had two doses of urethran, but only slept about two hours. Passed his urine in bed during night. Had an enema, which brought away many brown masses of fæces. Evening temperature 101°, pulse rising in frequency-to-night 132.

July 30th. Slept well last night after an opium draught. Passes urine under him, tongue coated, abdomen still retracted, no spots; resents any movement of head. There seems to be some tenderness on left side of spine in cervical region; does not speak when spoken to; appears in pain when pulled up by the arms; systolic bruit heard over aortic area. Temperature above 100° F., pulse less frequent.

July 31st. Is much quieter to-day, passing urine in bed; now lies on his left side; does not talk or shout out; no vomiting, bowels not open, is not swallowing milk well. Temperature this morning 98.4°, evening temperature 100°, pulse 120. A blister was applied to nape of neck, and afterwards dressed with ung. hydrarg. Calomel gr. iij. ordered.

August 1st. Lies on his back, moving his extremities a little. There is great difficulty in deglutition, special senses do not seem impaired, does not talk, urine passed in bed. Evening temperature 100'2°, pulse 140.

7 a.m.

August 2nd. Remained in about the same condition till The difficulty in swallowing increased, so that when milk was put in his mouth it curdled at once, and patient ejected it on his tongue. Has wasted very much; does not speak; no paralysis, although patient only moves a little, and then it is mostly his arms. At 7 a.m. began to have difficulty with respiration. When seen at 8 a.m. was a little cyanosed; respiration almost entirely abdominal; pulse small, frequent. He improved a little with an injection of ether; but gradually respiration became more and more impaired till he died at 2-30 p.m. Before death there seemed to be some twitching of the left eye to the right.

Necroposy-August 3rd. On removing skullcap, lines and streaks of exudation of lymph were seen laterally on both sides extending upwards from the sylvian fissures. There was also very extensive basal meningitis, accompanied with abundant exudation of yellowish gelatinous lymph around optic chiasma and over cerebral peduncles, pons, and medulla. Membranes highly infected, and the seat of an eruption of miliary tubercles: in some of the tubercles, after staining with fuchsin, tubercle bacilli were found. Lateral ventricles dilated, and contained an excess of turbid serum. On slicing cerebellum, a yellow caseating mass was found in the left lobe near inner margin of anterior superior lobe, about the size of a filbert nut. Fresh sections, stained with fuchsin, showed tubercle bacilli amongst the amorphous débris of the caseating portion.

At the apex of the left lung there were some firm yellow caseous masses - 1⁄2 inch in diameter, the larger ones caseating the remainder of lung showed early infiltration with mostly discrete grey translucent miliary tubercle. At the apex of the right lung there was a large cheesy mass surrounded with smaller secondary tubercular infiltrations; the remainder of lung shows early infiltration with grey miliary tubercle. Some of bronchial glands caseous and calcareous.

Heart normal. Spleen, no tubercles found. Kidneys, one or two grey tubercles on the surface and here and there in the

No

centre. Liver 40 oz.; two small calcareous masses were found imbedded in the left lobe just above the under surface. other tubercles found with naked eye. There was an eruption of miliary tubercles all over the peritoneum-there had, in addition, been previous peritonitis of some standing, and the exudation had organised into a loose areolar tissue which bound together here and there intestinal coils, and caused adhesion of the liver and spleen to the diaphragm.

Large intestine: Mucous surface superficially though extensively ulcerated in places; the surface of some of these ulcers presented a “seared" appearance, as if intersected with cicatricial bands tending to pucker the gut. Mucous surface of section similarly ulcerated, as also were the cæcum and also cæcal valve; mucous membrane of upper part of ileum being hyperæmic and much ulcerated: there were met with irregular ulcers transverse in direction with hard infiltrated base, but exhibiting puckering, as if the base were cicatrizing : the induration of base was due to infiltration of serous coat corresponding to ulcer with a group of firm fibrous grey tubercles which were often pigmented and nearly a slate grey or black colour.

Remarks. This case is a remarkable instance of the latency of tubercular disease. The boy's failure of health dated from the attack of low fever a year before his death, but he was able to do his work until ten days before admission, and then gave it up only on account of the headache and rapidly increasing weakness.

It was noticed in the out-patient room that he stood with his legs rather wide apart, and waddled in walking. He had never fallen down or had uncontrollable giddiness. No accurate diagnosis was made at the time of admission, but his aspect and the elevation of temperature suggested the possibility of typhoid. This idea was abandoned immediately he had been thoroughly examined, as, beyond the facts above noted and a little gurgling in the right iliac fossa, there was nothing to support it. Moreover, the retraction of the abdomen negatived the idea, and encouraged the already considered diagnosis of tubercular

meningitis. The rigidity of the neck and retraction of the head suggested a cerebellar tumour. These symptoms have been noted by Gowers and Ross, among other observers, as occurring occasionally in cases of cerebellar tumour; but according to Gowers it is as yet uncertain whether they are due to the irritation of structures in the cerebellum or to pressure on the pons or medulla oblongata. It is probable that the disease began in the chest, and that the acute and fatal symptoms were due to a very recent development of tubercular meningitis.

For the very full and interesting notes of the case and postmortem I am indebted to the Resident Medical Assistant, Mr. Crump, and to Dr. Crooke, the Pathologist to the General Hospital.

NOTES OF A CASE OF CEREBRAL TUMOUR.

BY EDGAR HOGBEN, B.A., M.D., M.R.C.P.,

PHYSICIAN FOR OUT-PATIENTS AT THE QUEEN'S HOSPITAL,
AND MEDICAL TUTOR, QUEEN'S COLLEGE.

THE following case of Cerebral Tumour, which occurred in my practice at the Queen's Hospital, proves of interest by reason of the rapid progress of the new growth from the earliest manifestation of symptoms to the fatal issue, and also on account of the large extent of brain substance involved.

W. S. S. (44), a type-setter employed on the staff of the "Belfast Morning News" came to the Queen's Hospital Feb. 14, 1888, complaining of impaired vision, headache, and loss of memory. He was accompanied by his wife, who gave the following history. The patient's father died of rheumatism, his mother of apoplexy, all his uncles (on father's side) have died in fits, one sister is alive now suffering from some head trouble. He was a man of temperate habits, married at the age of 24 years, never contracted syphilis, and has two healthy daughters now grown up. His hair became gray at the age of 25 years. He always enjoyed robust health, never having been confined to bed by illness save for one attack of sore throat. He had been

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