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Case of Lardaceous Cancer of the CraniumAuthor(s): Alfred BakerSource: Provincial Medical Journal and Retrospect of the Medical Sciences, Vol. 4, No. 15 (Jul.16, 1842), pp. 283-285Published by: BMJStable URL: http://www.jstor.org/stable/25491324 .

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PROVINCIAL MEDICAL JOURNAL

An IRtvooptt? of 1e etiR?iaI Sft"nce

No. 15.VOL. II.] LONDON, SATURDAY, JULY 16, 1842. [sPRICE SIXPENCE. No.~~~~~~~ ~ ~ ~ 1.VL[SapdEiinSevne

c A s E

OF

LARDACEOUS CANCER OF THE, CRANIUM.

By ALFRED BAKER, Esq.

(Read before the Patbological Society of Birmingham.)

Joseph Rollason, aged thirty-one, a glasscutter, re

siding at Nineveh, whose habits have for some years

been rather intemperate, states that, about three years

ago, being intoxicated, he fell, and cut the forehead

on the left side. This wound soon healed, and he

never experienced any ill effects from it. Some nine

months back he went to St. Helen's, Lancashire,

where he resided in a damp house during an inlclement

season. In two months after he arrived there he was

attacked with violent pain in the head, occasional gid

diness, and dimness of sight. He also felt dull and

heavy pain in the left arm, with numbness and loss of

power in the middle finger, and in a few days afterwards

pains in the lower extremities, especially in the joints.

He took medicine with slight relief, but in another

week the pain in the head became more severe, and

was accompanied with a small and soft swelling over

the part formerly cut. As he grew worse, he returned

home about six weeks after the attack commenced, at

which period the pain over the head was diminished,

whilst that in the legs continued. In a fortnight after

his return he complained of pain within the head, and

stated that his previous pains appeared to be in the

scalp and on the surface; he had also pain and stiff

ness in the articulations of the lower jaw, and was

only able to openi his mouth to a small extent; when

asked to show his tongue, he could protrude the tip

only, and he seemed to be incapable of introducing

food into his mouth, from the closure of the jaws. In

the course of a few days, numbness and tingling down

the left side of the face and left arm came on, and the

sight, especially with the left eye, became worse. The

swelling referred to, situated a little above the left

frontal eminence, began to enlarge without pain, and

acquired considerable hardness.

He remained much in the same state for about four

months, having occasional remissions and exacerba

tions of his symptoms, when suddenly the pain in the

head was aggravated, and the tumor, which had been

slowly enlarging, became tender to the touch. The

tingling sensations were worse, and affected the right

side of the face more severely than the left, where

they were first felt. He had also a puriform discharge

from the nostrils, occasionally mixed with blood, whilst

all his other symptoms had attained greater severity.

I saw him on the 10th April, 1842, and found him

in the following state:-There was a large ovoid tumor

on the left side of the frontal bone, running backwards

from and a little to the left of the tuber frontale, equal

in size to two-thirds of a duck-egg cut lengthnise. It

was hard, and superficially lobular, and appeared to

be intimately connected with, if not arising from, the

bone. The integument covering it is not discolored; it is free from tenderness and pain. Another smaller

swelling, which is soft, though still firm, has been

to-day discovered on the back of the right side of the

skull, near the lambdoidal suture. The patient's face

is inexpressive; the left eye is more prominent than

the right, and the superciliary fossa is obliterated; no

orbital tumor detectible; both eyes somewhat con

gested; the pupils are rather contracted and insensible

to light, but he is quite unable to discover even a

lighted candle placed before him. The two sides of

the face are not quite symmetrical, the left cheek

being slightly drawn. He can, however, retain air in

his mouth, by forcibly closing his lips and blowing. He states that his powels of smelling and tasting are

weaker than formerly, but his hearing is not much

impaired. He occasionally feels the tingling sensation

before spoken of, in his left cheek, and it is pretty constant in the right eyelids and side of the face. Ordinary sensation does not appear to have been at any time lost in any part of the body; but the motory power of the left arm is enfeebled, and he cannot grasp anything firmly with the left hand. The whole

limb is wasted from muscular atrophy. He has for

the most part been quite intelligent, but lately has

become rather obtuse; always had control over the

sphincters, but is obliged to obey the desire for urinary evacuations immediately. The breathing is slow anld easy; pulse 112, weak, and small; skin cool; bowels open. He is taking the bichloride of mercury, anid the gums are just beginning to look tumid. On April 14th the left eye became injected, and the cornea

subsequently opaque. By the 4th of May the right eye underwent similar changes in its vasculality and transparency, and the cornea in each became subse quently ulcerated.

May 19. The patient has been progressively getting

worAd. He is now much emaciated; has the Hippo cratic face, with slight contraction of the corrugatores superciliorum. He lies in a state of semicoma, re gardless of objects around him unless roused, when he replies to questions, articulating his words imperfectly, and speedily talks unconnectedly. The tumors upoIl the head have each enlarged, and the posterior has

become firmer; the upper eyelids' are half closed, and he is unable to raise them voluntarily; the left

eyeball is still more prominent, being on a plane much anterior to the right, and this globe is more covered by the lid; the conjunctiva in each is the seat of serous infiltration, with slight congestion (sub-con junctival cadema), and each cornea is impaired by opacity and ulceration in its lower half. A transverse line, much indented, traverses the left cornea hori zontally, as though the globe had been protruded against the margin of the lower lid, which, by pressure, had induced ulceration; whilst in the right cornea a

No. 94.

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284 CASE OF LARDACROUS CANCER OF THE CRANIUM.

roundish ulcer seems to have removed all.. the laminae,

and to have merely escaped perforation tl4rpugh the integrity of the aqueous membrane, thus forming a

curiously transparent spot completely surrounded by a zone of opacity; both cornea were slightly vascular.

He is quite blind, and no effect is produced, upon the

pupils, which are rather small, by bright light; the

left malar bone is the seat of hard swellingith4uudue projection, but attended with little pain; his breath is exceedingly fetid, although he has taken no mercury for three weeks; the respiration is stertorous,. and his

wife tells me that he feels difficulty of deglutition, and

occasional choking in the throat; he continues. to

discharge a bloody matter from the nose, aud the nares

seem obstructed by it, and air thus excluded; the

pulse is 90, small, and soft; the surface and extremi

ties warm; his appetite is poor, and his tongue, which

he protrudes better, is white; bowels regular, and

urine rather scanty; both evacuations have been

passed voluntarily, excepting during an attack of de

lirious excitement two days ago, when his urine and

feces escaped unconsciously. Ammonia, wine and

water, beef-tea. 27. After last report he became delirious at night,

and occasionally in the day. Another tumor was

discovered over the right ascending ramus of the lower

jaw, which was said to have existed from the com

mencement of his illness, andto have steadily enlarged,

but which had been concealed by a bushy whisker.

It was hard, ovoid, elevated, free from tenderness, and

connected with the bone. On the 22nd he had twitch.

ings of all his limbs. Two nights ago he aga,4 became

delirious, muttered unintelligibly, and seemed uncon scious of the presence of any one. He could take no

food, and the increased pressure on the brain was

marked by a proportionate coma, with stertor in

bireathing. He died about eleven o'clock this morning.

Sectio Cadaveris Twenty-eight Hou-rs qfter Death.

The body was extremely emaciated, and the left

limbs thinner than the right. The tumor on the fore

head was as large as two-thirds of a duck-egg, and

that behind as big as a shilling, and little raised. The

left malar bone was still swollen, firm and projecting.

Head.-The scalp over the large tumor was so ad

herent as to require a patient dissection fQr its sepa

ration. It lay beneath the occipito-frontal aponeurosis and pericrfinium, and was lobulated on its 'irface,

the grooves being shallow, and of a blueish tn ge.

The smaller and softer swelling behind wss cut into

in reflecting the scalp, and was fou7d to consist of a

white medullary substance contaitng numerous red

dots, lines, and patches, as though from torn vessels

and ecchymosis. The bone was seen at the _?ttom eroded and cellular, as in necrosis. WJs& the cal

varium was removed, the large anterior t"kr was

found to project inwards upon the brain, its inner

portion not being so prominent as the external. It

was enclosed in a dense, whitish membrane, somewhat

patchy, as though from old deposits of lymph in flat.

tened granules. There were no signs of adhesion to

the dura mater, no torn or ragged projectons being

observed upon its surface. When the calvifum was

separated, the tumor was seen clearly to be a growth

within the proper tissues of the bone. The small

posterior substance exhibited the same characters

within as withoi4t the cra1Aiunm-yiz., v dplicate hrexq

brane, enclosing a soft, medullary, white matter, with

red points and spots and a honeycomb bone at the

bottom; its site was near to the posterior superior

tngle of the parietal bone. The large tumor, when

divided through the middle, was found to consist of

white, lardaceous matter deposited within the peri

cranium. It was divided into two portions by the

bone, which traversed it nearly across the centre. The

portion of cranium thus ineluded seemed at first sight

to be thicker than natural; but, upon examination,

this appearance was ascertained to depend upon the

deposition of the cancerous matter into the cells of the

diploe, and upon a separation of the denser parts of the

bone into lamint, which were divided from each other

by white lines of the same material. Besides these dis

junctions of the bone in its proper axis, its continuity

was destroyed by lines running vertically from the

diploe to the exterior and inner surface of the skull,

which established continuity between all the sections

of adventitious matter. The osseous structure seemed

also changed, being more transparent than natural,

and having a blueish tinge. The surfaces of the bone

were spicular and redder than the rest of the mass.

Both of these growths had compressed the brain, the

larger one making a deep and extensive indentation

on the upper and back part of the left anterior lobe,

the smaller faintly hollowing the back part of the

right middle lobe. The dura mater seemed whiter and somewhat

thicker than common, and its sinuses contained little blood. The arachnoid was slightly opaque over the

brain generally, and its cavity contained about three

ounces of clear serum. The pia mater was slightly

injected. The brain itself was uniformly pale and

bloodless, the cineritious structure being of faint yel lowish grey color. Each lateral ventricle con4ined about a teaspoonful of sanguinolent sertun, which occu

pied from gravitation the posterior corner. The cen

tral parts of the cerebrum were healthy, and the velum

interpositum and choroid plexuses were remarkably deficient of blood. Upon examining the base of the

cranium, the sella tursica was found to be occupied

by a tumor, which projected over the smaller wings of

the sphenoid and fore part of the petrous bone, in

volving and compressing the contents of the cavernous

sinuses and the fifth nerves with the Casserian ganglia.

This growth had the same characters as those already

described, and the bones beneath it were similarly

diseased. On the left side the bones of the orbit

seemed to be more changed than on the right, and by

their tumefaction on the facial l.spect to have pro

truded the globe of the eye.

Chest.-The heart was large and flaccid, and its

cavities slightly and uniformly dilated. The lungs were much collapsed and healthy. There was no

effusion in the pleural cavities. Abdomen.-The liver was large, aid the right lobe

elongated. It was dark in colour, and contained some

three or four masses of medullary orlardaceous cancer,

of pulpy consistence and white color, with spots of

deep red and softer quality, as though from the process

of ramolliseement and effusin of blood in consequence

of ruptured vessels. One of these, oocupying the acute

edge of the right lobe, was as large as the palm of the

hand. Its circumference was a little raised above the

urrowdiug parts, whilst it eentie w i4ttted. Its

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DEFORMED LEG CURED - OPERATION. 285

appearance corresponded with that described, except ing that posteriorly it was more diffluent, and from this part a reddish white opaque fluid exuded upon division, resembling thick strawberry-cream. The spleen was rather large and congested; the pancreas healthy and congested; the other viscera exhibited no morbid chauges.

REFLECTIONS.

The numbness and tingling in the left arm occurred before any external swelling was perceived. This

would lead to the opinion that the disease first pro truded in the interior of the cranium, and probably compressed more immediately the optic thalamus. After the existence of this symptom we saw the deve lopment of the 6xternal tumor. The limb became atrophied, and loss of power was felt, from the simul. taneous extension of growth within and without the skull.

The numbness and tingling, in the first place of the left cheek, and subsequently of the right, show the early commencement of that medullary growth which

was found in the base of the cranium, the extent and connections of which explain satisfactorily the altered sensations in the soft parts, the amaurosis, the dis charge of blood and matter from the nose, the protru sion of the left eye, and the ptosis of the left upper lid, for it involved the optic nerves, the third, fourth, fifth, and sixth, as they pass through the cavernous sinus to enter the orbit, the pituitary body, and the sphenoidal and ethmoidal cells, as well as the bones of the orbit. The proptosis especially is worthy of notice, since the globe was not protruded by any tumor within the orbit, but by a general diminution of its size from the encroachment on the bony walls. The occurrence of opacity and ulceration of the cornee indicated destruction of the functions of the fifth nerve, and was accompanied by a pale chemosis.

The difficulty of opening the mouth was not perhaps dependent upon any nervous lesion, but rather upon the mechanical impediment to the motions of the jaw, caused by the tumor on the ascending plate of the lower maxilla of the right side, to which mustbe added An indisposition arising from the state of the gums, produced by mercury. The limited protrusion of the tongue may also be referred to this latter cause.

,Effusion is a common mode of termination in such diseases. It was shown in this instance before death, by the delirium succeeded by coma and stertor. But

the serous fluid is not always poured into the cavities formed witllin ti#e cranium, when tumors of this cka racter affect the skull. On the contrary, it is fre

quently deposited in the chest or belly, according to the direction in which the malignant growtths are pro. pagated.

The white condition of the brain was remarkable. It was not the ansemial bram from loss of blood, bul a peculiar ,qarly whiteness ulike anything I have before seen.

The tuniors in the liver were unsuspected, but did not excite surprise. The frequency of such deposit in internal organs, when diseases of this characte, attack the external parts, is already sufficiently esta

blished; and it is only an additional proof, if one be necessary, of the inexpediency and impropriety o

removing by operative measures heterologous growth, of this kind from the surface of the body.

Lastly, with reference to the nature of the disease,

I regird it' is as white medullary, or lardaceous cancer

of thWbones of the cranium, and the characters of the

tubera in the liver in some measure strengthen this

view. - [believe it to have originated in the diploe of

the bone, to have separated the plates of the skiill

more widely, to have eventually effected a solution of

continkiity I them by small ulcerated apertures, .to

have Aen extended itself between the lamina of the

cranium, until at length it had completely perforated

it, when it became placed between the bone and peri

cranium. Having gained this point, less resistance wag oiered to its growth under the elastic investment

of the b6ne, and it now diffused itself more widely,

so as to form a tumor upon, as well as within, the

cranial cavity.

CASE OF DEFORMED LEG.

FROM

UNSUCCESSFULLY TREATED FRACTURE, CURED BY AN OPERATION.

By THOMAS D. MUTTER, M.D.,

Professor of Surgery in Jefferson Med. Coil., Philadelphia.

About the last of August 1840, I was requested by

Dr. Franklin to visit in consultation, George S., of

Maryland, a young man of fine constitution, and

twenty-three years of age. From the history of the

case, it appears that some ten months prior to the

perio&ht which we saw him, he was engaged with

others in blasting rocks, and that while so occupied,

a large fragment of stone struck him on the right leg,

producing a most severe compound fracture of both

bone-' He was immediately placed under treatment,

but from some cause or other, profuse- suppuration in

the wound took place, with ulceration of the in

teglments on the back of the limb; and after having

renlained under the management of the gentlemen

who first saw him, for three months, he "got up"

with the leg shortened three inches and a half, from

the lower fragments overlapping the upper, and the

foot so much turned in, that it was impossible for him

to bring the heel to the floor. The limb is also

diminished in its diameter in consequence of the state

of 1Ibkction in which it has remained since the occur

ren&e of the accident, the patient having used crutches ever since his " getting up." There is no pain even

when the limb is roughly handled, and no motion

between the fragments, they having become firmly a4iched to each other by ledges or bridges of bone

att ed from one to the other, and also by

m bf callus thrown out in the interossial space.

TMe integument on the batk of the leg presented

nearly throughout the characteristics of a cicatrix, and

near the centre there was a small ulcer. As in this

condition the limb was worse than useless, he came

to Philadelphia, for the purpose of hvying it ampu

tated. After a careful examination of the case, and

w0ing the hazards of amputation and resection of

the bones, both Dr. Franklin and myself came to the

conclusion that the latter operation, as it gave us a

prospect of saving the leg, was most advisable; anid

i. accordingly, after subjecting our patient to a few

days of preparatory treatment, I undertook its per

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