No. 659.

LONDON, SATURDAY, APRIL 16, 1836. [1835-36

LECTURES

ON

DISEASES OF THE BRAIN ANDNERVOUS SYSTEM,

DELIVERED IN THE UNIVERSITY OF PARIS.

BY M. ANDRAL,Physician in Chief to the Hôpital de la Pitie, andProfessor, and Lecturer on the Principles andPractice of Medicine, in the Faculté de Médecineof Paris.

LECTURE XX,CANCER OF THE NERVOUS CENTRES.CALCULOUS DEPOSITS ETC. IN THE IBRAIN.

GENTLEMEN: In our last lecture, we com-pleted the history of tubercles of the nervouscentres. We shall now commence that ofcancer when seated in the same parts.Cancer of the nervous centres does not

present any special difference of anatomicalcharacters or disposition from the same le-sion in any other part or organ of the body;we shall, therefore, pass by the anatomicalpathology, and turn at once to considera-tions of another nature. Cancer of the licerebro-spinal axis is a disease still morerare than tubercles of the brain and spinalmarrow; however, this lesion certainly ex-ists ; we possess a certain nu mber of casesobserved by men fully capable of distinguish-ing the disease, and on whose authority wemay place full reliance. But these cases, aswe have just now said, are rare-; the num-ber of authentic cases is very limited, andcan only serve to furnish a few observa-tions, from which we cannot hpe to formanything like a complete or gene ral descrip-tion ; it is always, however, good to makean effort at reducing the knowledge we pos-sess upon any lesion into a syster natic form ;we thus lay a foundation upon which othersmay work, and as time and further re-

searches enlarge the circle of our facts, wemay hope that others will be enabled to de-duce certain general conclusions which, inthe actual state of the science, toe cannotventure to aim at.

We are acquainted with only forty-fivecases of cancer of the nervous centres, pub-lished up to the present day; of these Ihad examined forty-three, when the lastedition (1833) of our Clinique Medicale cameout; since that time I have found only twoadditional cases; one of these has been pub-lished by Mr. BELL; the second was ob-served by M. DECHAMBRE, interne at Sal-petriere, and is to be found in the first num-ber of the Bulletin Clinique, published byMM. PIORRY, LHERISTIER, &c On addingthese two latter cases to the forty.-threewith which we were previously acquainted,we obtain a sum total of forty-five cases ofcancer of the nervous centres. Let us nowmake an analysis of these forty-five cases,and see whether we can obtain sufficientmaterials for anything like a general his-tory of this lesion ; and first to determine,as we have already done for cerebral he-morrhage, ramollissement, tubercle, andother lesions, whether-Is Cancer found more frequently in one part

of the Nervous Centres than in another.Now, in our forty-five cases, we findthirty-two in which this accidental productoccupied one of the cerebral hemispheres ; ;in five cases it was seated in the cerebellum.Thus you see, at a single glance, that thecerebellum is much less subject to cancer-ous deposit than the anterior portions ofthe brain; five to thirty-two is a very largeproportion on the side of the latter. In twocases only the cancerous mass occupied thesubstance of the mesocephale; we find threecases for the pituitary gland, and, finally,three more examples of cancer, in the spinalmarrow.* If, instead of cancer confined to

* A third case, detailed in the most pre-cise manner, may be found in the Arch.General. for 1834, p. 239, by M. CA:R.RE.-REP. L.t The case of M. CARRE, above noticed,

was one of cancer of the mesocephale orpons ; added to the two of M. ANDRA.L itmakes three.—REP. L.t There is also a case of cancerous tn.

mour in the left pyramidal body, reportedin the Gaz. Med. of London, June 1834.-REP. L.

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the nervous pulp, we were to take cases inwhich the morbid product existed withinthe cavity of the vertebral canal, we mightincrease our number by two or three morecases; however, we cannot strictly includethese latter, for the cancerous mass i3 de-.

veloped in the membranes of the chord, andnot in the nervous substance itself ; it is tothe latter species that we now direct ourattention, and we are acquainted with onlythree examples of it.

Volume and Number of CancerousFormations.

Cancer of the nervous centres presentsitself with a great variety of volume. Insome cases the accidental product acquiresa very great mass ; the cancer may occupyone-fourth, one-third, of the whole hemi-sphere of the cerebrum ; in other cases thecancerous tumour is small, and is dissemi-nated throughout various parts of the brain.The number of these cancerous formationsis also variable; thus we often find not morethan one or two cancerous tumours in the

hemisphere, whilst in other cases we find agreat number of moderate volume, but scat-tered throughout different points of the cere-bro-spinal axis.

The Nervous Substance around

the cancerous production is far from pre-senting itself in all cases under the same

aspect, or in similar conditions. In a cer-tain number of cases, we find the nervous

pulp immediately surrounding the cancer,in its.normal state, and perfectly intact. Inother cases the nervous pulp is more or lesschangcd. Sometimes we simply find tracesof congestion, either slightly or deeply co-loured : in others, the substance of the

hemisphere around the cancer is hardened,or inflamed, or presenting divers degrees oframollissement. In a word, we may find allkinds of lesions in the nervous substance,produced by the presence of cancerous as

well as tubercular deposits in the brain.When the cancerous mass has reached sucha degree of development as to arrive at thesurface of the brain and its meninges, it

may give rise to various diseases in theselatter parts ; in some cases the membranes,as well as the cerebral pulp, are intact; butin others, they are more or less injected, in-filtrated with serum, thickened, &c. Thel:ard parietes of the skull may also be im-plicated in the disease. Thus, after havingmade its wav to the dura mater, the cancerfirst destroys this membrane, and then thebones of the cranium. In some cases ithas penetrated through the cribriform plateof the ethmoid bone, filling the nasal fossa,and all the sinuses that communicate with

them. In others, the cancerous mass hasbeen found protruding through the differentforamina at the base of the cranium, andembracing in its ramifications all the parts

lying beneath the base. The nerves them.selves may also be attacked, by the exten.sion of the disease from the cerebral tissueto their trunks or roots. The lesion of thenerve is not always the same ; sometimesthe nervous filaments are merely compressed.and their functions not completely de.

stroyed ; the portion of the nervous trunklying close to the cancerous mass is flat-

tened ; at other times the trunk of thenerve is not only flattened, but destroyed by

I the effect of the compression which has beenexercised on it. Finally, the nerves maypartake oaf, the cancerous degeneration, andbecome comprised in the morbid growthwhich has embraced all the neighbouringparts.

Cerebral Functions deranged by Cancer.You must see, at once, how important it

is to be acquainted beforehand with thelesions that may be produced in come-

quence of the development of an accidentalproduct within the cavity of the cranium.It is unnecessary to call to mind what avariety of parts, each directing a differentfunction, is contained within that cavity,and as the cancer may extend to any of thoseparts, and compress or irritate them by itsvicinity, we must have a great variety ofsymptoms, according as different organs jmay be injured. Thus, you can conceivethat in cases of cancer developed at thebase of the brain, or about the medulla ob-longata, in proportion as the tumour ac.quires magnitude and implicates the eighth,the seventh, the fifth, or other nerves, weshall have different symptoms produced oneafter another, apparently without any con-nection, but depending on the extension ofthe original disease to the parts above men-tioned, and only to be explained in thismanner: thus, suppose the fifth pair to hefirst engaged, we have a modification ofsensibility in all the parts with which thatwidely-distributed nerve is connected ; themotions of the cheek, lips, &c., become de-

ranged as the portio dura is pressed upon.Finally, when the malady has reached theeighth pair, we have still graver symptomsmanifested ; the motions of the tongue be-come embarrassed ; the speech is lost, re-

spiration and deglutition get difficult, anddeath soon ensues.

Cancerous Diathesis.—Causes of Cancer.You must be aware that the morbid loo-

duct called " cancer," is frequently metwith in different organs of the body at thesame time. This repetition of the diseaseis commonly attributed to a constitutional

peculiarity, which we denominate the "can’cerous diathesis;" hence, if we have can-cerous deposit in any part of the frame, wemay expect to find it in the brain also. Let

us examine our forty-five cases in order tosee how far this latter assertion may be con-

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foimable with facts. Now, in the forty-fivecases which we have analyzed we find onlyten where cancerous deposit existed inother parts of the body, at the same timethat it was found in the brain, and more-over it would appear that in the whole of Ithese ten cases, the brain was the last organattacked.In speaking during our last lecture on the

causes which produce tubercles of the ner-vous centres, we said that no special causeof their development in the brain could bediscovered. They are deposited within thecavity of the cranium under the same cir-cumstances as in the cavities of the chest orabdomen: the same remark applies to thedevelopment of cancer in the brain; it is Iproduced in the nervous centres under theinfluence of the same occasional causes thatgive rise to its formation in other tissues ;but it is not always easy to appreciate ordiscover the occasional cause of cancer.

Thus in our forty-five cases we have sought Ito find if we could determine the cause thatgave origin to the commencement of can-cerous deposit. In only ten cases have webeen able to discover any thing like a cause,viz., external violence inflicted on the cra-nium ; in all the other cases the diseaseoriginated, as it is said, spontaneously, i. e.. Iwithout any cause appreciable to us.Authors have been in the habit of attributinga certain influence to the

Period of Lifem the production of cancerous deposit inthe nervous centres; all that we can affirmhowever is, that cancer of the brain is most ,,

frequently found at that age or period of life Iin which cancer in general exists with mostfrequency: thus cancer exists more fre-quently from the age of 2 to 17 years, andit is precisely at this same period that wefind cancer of the brain most common. Letus make a rapid analysis of onr cases in thispoint of view. Before the age of 20 we findnine cases of cancer of the nervous centres;of these nine cases two existed in children2 years of age ; one at 3 years; one at 4 ;and then we find the remaining five casesthus distributed, 7 years, 11, 12, 14, and 17years of age. Between 20 and 30 we know ofonly three cases ; one at 21 years ; the secondat 26; the third at the age of 29. From 30to 40 we find the cases become much morenumerous; in that period we find comprisedno less than eight; viz., two at 33 years;one at 34 ; one at 36 ; two at 37 years ; and,finally, two more at the age of 38. Herethen you see a sudden increase of from threeto eight cases : at the period of life compris-ed between 30 and 40 year?, we have nearlythree times more cases of cancer than be-tween 20 and ;;0. From the age of 40 tothat of 50, the number of cases increasestill more ; thus we find in this period notless than eleven, distributed in the following

manner:-one at the age of 40 ; one at 41 ;three at 45 ; three at 47 ; two at 48 ; and,finally, only one at the age of 50. Now atfrom 50 to 60 years, the number beginsto descend: we find now only nine casesat that period of life, viz., one at 51; threeat 52 ; one at 55; one at 57; and the threelast cases at 58. As we advance in the agesof our patients, we perceive a marked di-minution in the number of cases. Thus, atfrom 60 to 80 we find orily five cases, dis-tributed as follows, viz., one at 62 ; one at61; the third at 66; one at 71 ; and the fifthor last at the age of 77. Let us now hastento examine the

Symptoms of Cancer of the Nervous Centres;and here we have to make the same obser-vation which has already been suggested byother accidental productions in the brain,viz., that cancer does not reveal its presenceby any peculiar or special phenomena.According to its seat and volume, accordingto the condition of the surrounding nervouspulp, and very frequently according to thesympathetic effect it may produce on distantparts of the brain, cancer may cause differ-ent functional derangements, and our diag-nosis must often be founded much less onthe nature of the symptoms, than on themanner in which they march and are con-nected together, or on the previous andpresent history of the patient. We shallstudy, according to custom, cancer as it maybe seated in the cerebral hemispheres of thebrain, in the cerebellum, or, finally, in thespinal marrow; and first for the symptomsof cancer

! In the Cerebral Hemispheres.The accidents produced may, in the first

place, manifest themselves in connection

with the intellectual faculties, but here theyare far from being constant; thus in a greatmajority of cases of cancer we find the in-telligence remains intact. This was the

case even in one example where an immensecancerous mass filled the right cerebral be-

misphere. At other times the intelligenceis modified, but the disorder is not very! marked, and comes oit only towards the ter-mination of the disease: there are other! cases where the trouble of intelligence isintermitting. The mental power is dis-turbed at uncertain periods, while during

’ the intervals the patient possesses the fullcrijoytijent of his reasoning faculties.! Finally, certain cases of cerebral cancer arerecorded, ia which the lesion of the intel- ligence was carried to such a degree as toteririipate in mental alienation.

, The Lesiuns of Movement’ ! next demand our attention; these may pre.)! sent themselves with the same variety as le- sions of intelligence ; like the latter, they aret absent in several cases; thus, when the can- cercous production is developed in n. slow and

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gradual manner, the brain becomes, as itwere, habituated to the presence of the fo-reigu body, and does not betray any symp-toms of irritation, or. give any sign what-ever of functional disturbance. In othercases, we observe more or less trouble ofthe moving power: most ordinarily, thistrouble consists in paralysis; the loss of mo-tion is then developed in a gradual manner;the paralysis is formed slowly, and not withthe sudden attack that characterises apo-plexy. The limbs at first feel dull, heavy,numbed, the fingers become weak, the handis unable to grasp an’object with firmness, orthe gait becomes uncertain, the toe oftenstrikes against the ground; this feeblenessof the voluntary muscles is more and morepronounced, and, finally, terminates in com-plete paralysis. After what we have said inthe lecture on cerebral hemorrhage, it is

unnecessary to mention that the paralysistakes place invariably on the side of the

body opposite the lesion in the brain; how-ever, when it has continued any length oftime, the hemiplegia is often converted intogeneral paralysis. In a very remarkablecase, the knowledge of which we owe to M.ESQUIROL, paraplegia was the result of a dou-ble cancer of the brain: the anterior extre-mity of both hemispheres was occupied by acancerous mass, which gave rise to paralysisof the superior extremities, while, contraryto what usually happens, the inferior limbsremained intact.

Instead of partial- or general paralysis,cancer of the cerebral hemispheres mayproduce convulsive movements that attackeither one or more limbs, or the whole body;thus, in several individuals, the existence ofepilepsy has coincided with the developmentof a cancerous deposit in the brain. Re-

member, then, that amongst the variouscauses of epilepsy, we must enumerate can-cer of the cerebral hemispheres. Havingthus disposed of motility, let us next examine

The Lesions of Sensibilitythat accompany cancer of the brain. Theseare at least as variable as the troubles ob-servedin connection with movement and theintellectual faculties. One of the most

striking is headache. This is a prominentsymptom, which presents itself in nearly allcases of cerebral cancer; it is an intense Ipain, persisting generally with severity, and ’’

forming a grave phenomenon in the ensem-ble of signs which we observe ; however, insome cases, this cephalalgia is either absent,or exists under so mild a form, as nearly toescape the notice of the patient himself.Here a question of some interest presents

itself: Has this headache a particular na-ture ? Can we recognise it as the lancinat-ing pain of cancerous affections ? You knowthe peculiar pain which is attributed by mostwriters to affections of a cancerous nature. i

Now this special pain is far from being men- I

tioned in all the published cases of cancer;on the contrary, we only find it described asI existing now and then; thus, in a majorityof examples, where headache is describedas one of the prominent symptoms, we find

that it did not differ in any respect from theordinary pain observed in ramollissement,tubercle, or other cerebral affections. How-ever, in a few cases, the existence of a lan.cinating pain similar to that of cancer inother parts of the body, has been placed be.yond the possibility of doubt. We call tomind especially one case, where, for a longperiod of time preceding any other symptom,the patient suffered under a violent head-ache, sometimes of a lancinating character,at other times burning, and giving rise toexcruciating tortures ; hence, whenever thislancinating pain of the head exists with anyconstancy, we may seize on it as a symptomcalculated to lend some considerable aid inclearing up our diagnosis of cerebral cancer;but, on the other hand, we must be on ourguard, and avoid the error of supposingthat when a lancinating pain is absent, nodanger of cerebral cancer exists. In can.cerous affections of various other organs ofthe body, we frequently observe the absenceof this lancinating pain, that is to say, thespecial character " lancinating " does not

always attend the pain produced by the dis.ease. Thus how many cases do we possess,where cancer of the stomach of some one ofthe abdominal viscera &c. has been accom.

panied with any peculiar pain, which mighthave revealed the nature of the organic af-fection. The pain which attends cancer ingeneral, is, in fact, of various kinds, depend-ing more on the sensibility of the patientthan the nature of his affection; and wecannot help thinking, that the term lanci-nating" has been applied in much too

general a manner as a diagnostic mark ofcancerous disease.The pain is often situated at the side of

the head, near which the cancerous productexists, and then throws some light, if not onthe exact nature of the disease, at least onthe probability of a foreign body being pre-sent ; however, in many other cases it isgeneral, and does not in any way indicatethe point of the brain that is the seat ofinjury. The cephalalgia accompanyingcerebral cancer, is sometimes constant, atother times intermitting ; in the latter caseit may resemble neuralgia, radiating from aconstant point of the cranium to other parts.The pain, of which the cerebrum is theprincipal seat, may manifest itself with moreor less intensity in other parts of the body;thus, in some individuals attacked withcerebral cancer, the limbs, or different partsof the body, become the prey of certain

pains, which may bear a close resem-

blance to rheumatismal or neuralgic affec-tions ; other patients present a remarkableexaggeration of the cutaneous sensibility; it,

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is impossible to touch any part of the skin,without producing the most painful anddistressing sensations. On the contrary incertain other cases we find the cutaneoussensibility lessened, or perhaps altogetherabolished. Thus you see how the samelesion may, by acting differently on dif-ferent brains, betray this individual differ-ence by the variety of functional phenomenawhich it determines.

Cancer, though bounded exactly by thecerebral hemispheres, without having in anyway compromised the nerves, may exercisea certain influence on the oryans of sense.Thus the very remarkable case of a younggirl, seventeen years of age, has been pub-lished, affected with large cancer of thecerebral hemispheres; this patient graduallylost the power of movement in the wholebody, and as the motility became extin-guished, the different senses were at thesame time slowly modified, and at length Icompletely lost ; yet, strange to say, in themidst of this general destruction, the intel-lectual faculties remained quite intact; thechild could reason well; her memory, judg-ment, &c. were sound, although, towards thetermination of her disease, she was incapa-ble of moving, and without the power ofseeing, and was deprived of smell, taste,and sensation in general. If we now ex-amine what

Accidents of Nutritive Life

may accompany cancer of the cerebral

hemispheres, we shall find that the latterlesion, like tubercle, often gives rise to cer-tain derangements of the digestive organs.Thus vomiting has frequently been noted asone of the symptoms attending cancer ofthe brain; remember, however, that this

symptom is produced by a great variety ofcerebral lesions, and certainly depends noton this or that particular organic disease,but on a lesion of the nervous pulp sur-rounding the foreign body, which lesionpropagates its influence to the stomach, andgives rise to nausea, vomiting, and otherfunctional irritations of that organ.The circulation and respiration are not

troubled in any notable manner; in somecases wa find palpitation of the heart men-tioned as a symptom; in others the patientis described as being subject to attacks ofdyspncea. However, we look in vain afterdeath for the cause of these phenomena;we are quite unable to discover anything inthe seat or extent of the lesion, that willexplain why the heart should suffer in some,the lungs in others ; indeed it is probablethey are sympathetic affections, dependingmore on the way certain parts of the brainare disposed to be affected by an irritatingcause, than on any particular organic lesionCancerous deposit has much more influenceon the functions o( circulation and respira-

tion, when seated in the spinal marrow,than when it exists in any part of the brain.

Lancinating Pain and Cancerous Tint.A while ago we spoke of the value of

" lancinating pain " as a symptom of cancer,and how far we might depend upon thatsign. Here nearly a similar question pre.sents itself. In endeavouring to determineour diagnosis, when we find that an indivi-dual presents most of the signs that indi-cate an accidental product in the brain, arewe to look for the pale-yellow leaden sallowhue generally given by writers, as charac-terizing the visage of persons labouring un-der cancerous disease ? VII have here tomake the same observation that we appliedto " lancinating " pain. The sallow tint ofcancer is rarely seen when the disease hasits seat in the cerebro-spinal axis. If youexamine the cases on record, you will findonly a few in which this symptom is men-tioned ; however, whenever it does exist, itis certainly calculated to throw some -lighton the nature of the organic lesion presentin the brain. You must not place, then, toomuch reliance on this phenomenon. Thiscancerous tint of the integuments may beabsent, and, moreover, it does not presentitself before a very advanced period of thmalady.

Nothing is more variable than the

Duration of Cerebral Cancer.In general we may regard cancer of thecerebral hemispheres as slow ; as one of

long formation. In a few cases, death mayarrive in some months after the first ap-pearance of the symptoms, but in a far

greater number the disease runs on foryears. The patient having suffered for a con-siderable period under the symptoms al-ready indicated, either dies gradually in astate of extreme exhaustion, or another dis-ease intervenes and terminates existence.Thus it is not rare to find cancer terminatein producing meningitis, congestion of thebrain, encephalitis, &c., coma, and death,as we see in cases of tubercles; or, duringthe chronic stage, secondary inflammation

may attack the thoracic or abdominal vis-cera, and hasten the fatal result.

Cancerous Tumours in the Pituitary Gland.Cancerous tumours have been found oc-

cupying the pituitary gland, in three casespublished by M. ROGER. What were the

symptoms in these three cases ? In all, theauthor observed a sensation of weight inthe anterior part of the head. In the first

case, the individuals affected were dull andapathetic, and soon became blind; however,the latter symptom most probably depended; on the pressure which the tumour exercisedon the decussation of the optic nerves. Thispatient died in a state of coma. In the se-cond case, the loss of sight was the very

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first symptom observed. Soon after the ap-pearance of this phenomenon, the individualwas seized with headache, which perseveredwith little intermission for the space of threeyears. He presented nothing very remark-able, except this constant cephalalgia andweakness of vision. The subject of this se-cond case fell gradually into a state of gene.ral feebleness, which terminated in comaand death. In the third case, we again findamaurosis mentioned. Thus you see that thepower of vision was lost in our three cases.In the last, the intellectual faculties becamemodified towards the end of the disease ; thememory was much injured, but the patientdid not eventually sinlc into a state of coma,like tfie rest: on the contrary, he was seizedwith convulsive movements, in the midst ofwhich he died. Such is a brief analysis ofthe only three cases we possess, where thepituitary gland was the seat of cancerousdeposit. Yon see that you cannot hope todraw many general conclusions from so in-significant a number of facts; indeed wehave not attempted the task. From thecerebral hemispheres, let us turn to the ce-rebellum. We are not acquainted with morethan five cases of

Cancerous Productions in the Cerebellum.

However, few as they are, we must endea-vour to make some use of them, and seewhat functional derangements were pro-duced by the existence of the lesion in thispart of the cerebro-spinal axis. We mustcommence, therefore, by reducing the num-ber of our cases from five to three; we arecompelled to set aside two, because theyhave been observed with carelessness, or

imperfectly, or described in so general a

manner, that we cannot place sufficient re-liance on their accuracy. One of these casesis old; it is mentioned by MOPGAGNI inhis " De Sedibus," but he merely speaks ofparalysis, attended with a scirrhous kind ofinduration in the cerebellum. It is impos-sible, you see, to decide if this were truecancer or not, and this case is altogether toovague to serve for our history of this dis-ease. Thus we must try and build some-thing like a description upon three cases;do not then expect it will he complete. Inthe three cases we find headache ; the pain,moreover, always corresponded with the in-jured portion of the brain, and was seatedin the occipital region ; it was generally in-tense and constant; or sometimes it re-

mitted, and came on from time to time naccesses more or less violent. It is naturalto expect some considerable modifications ofthe motility in case of cancer, as well as

any other foreign body in the cerebellum.What are these lesions ? They vary in dif-ferent individuals. Thus, in one, we find ageneral agitation of the muscles of the trunkand limbs; in another, the convulsive move-rnent was accompanied by loss of conscious-.

ness, and gave rise to true epilepsy; in an.other case the motility was not disturbed inso remarkable a manner ; the only indica-tion of the presence of a foreign body in thenervous centres, was a tottering and nucer-I tain gait. Finally, in one case was observeda momentary retroflection of the head andtrunk. On examining our three cases ofcancer of the cerebellum with attention, wedo not find a single one in which a perma-nent lesion of motility, such as paralysis orcontraction, is described to have existed.

The lesions of intelligence do not presentanything very particular, or worthy of de.tailed notice. In one case only do we findthe intellectual faculties injured ; the pa-tient’s memory was lost, not his general me-

mory, but the power of recalling to mindthe names of things; this was at first mo-

mentary, and then became constant; theindividual, however, preserved fill along thememory of ideas, he evidently recollected,but was unable to give utterance to his re-collections. In one case were observed sen.sations of giddiness and dazzling in the eyes;these were accompanied by pain, and pre.ceded by vomiting, or excessive nausea.

Such is a resacmc of the symptoms that haveattended cancer of the cerebellum.

Cancerous Growths in tlae Mesocephale.next follow in order, and here we findonly two cases of the disease.* What arethe symptoms to which cancer of the meso- ,

cephale gives rise ? The symptoms are not !detailed at any great length in either of ourtwo cases; however, the last seems to havebeen observed with some care, and is muchmore perfectly given than the first. Youwill find it in the Bulletin Clinique of M.PioRrY, where it was published about a

month ago by M. DECHAMBRE, interne atSalpetriêre (B2cll. Clinique, No. 1, May 1st).The subject of this case was a female,twenty-six years of age; the first symptomsof disease in. the brain were preceded by aprodrome ; two years before her admissioninto the hospital she was seized with dizzi-ness, vertigo, and palpitations ; at the ex-

piration of a year, violent headache, giddi-ness, and sense of creeping in the left arm;this gradually terminated in loss of motionof the member, and three months later thelower extremity on the left side graduallylost the power of moving. When admittedinto the hospital, two years after the ap-pearance of the premonitory symptoms, thehemiplegia of the left side was still incom·plete; the cutaneous sensibility of the faceremained intact on both sides, but the leftnares seemed insensible to the touch of afeather, or the contact of tobacco. The mo-

* We have already noticed a third casein the Archives Generales, June 1834, wherethe symptoms and history are describedwith great accuracy.—REP. L.

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tions of the tongue were performed with alittle difficulty, and it often became engagedbetween the teeth. These lesions of mo-

tility were soon joined by others of a differ-eut nature, the principal amongst whichwas an automatic, and almost constant, ele-vation and depression of the globes of theeye. We have already mentioned some

phenomena connected with alterations ofthe sensibility; thus, at one period of thedisease, the patient assured the author thatthe right side of the face was completely in-sensible ; this however passed away, and Ithe lesion shifted to the left side of the face;the left conjunctiva then became little sen-sible to the touch ; the nares on that sidealso were incapable of distinguishing odours ;finally, towards the end of the disease, therewere pains in the heels, soles of the feet, icalves, and knees. We shall read tex- Itually for you a certain number of symp-toms. "Thus," says M. DEC HAMBRE,’* " afterthe patient’s admission, and up to the ter-mination of her disease, we witnessed amultitude of attacks, in which the pupilsremained contracted ; the patient did not Ifoam at the mouth, nor was she convulsed; Ishe cried out from time to time, heard every-thing, but was unable to speak; these at-tacks became more and more frequent, andwere repeated several times [in the courseof the same day; they were followed by themost violent headache, which diminishedafter vomiting, accompanied by severe

pains in the joints. These symptoms werenot the only ones; the patient was some-times delirious, and towards the month ofOctober was seized with a creeping sensa-tion in the right hand, which gradually ex-tended to the lower extremity on the sameside; finally, for some time before herdeath, the patient presented the followingassemblage of symptoms :-The eyes redand brilliant; complete amaurosis on theleft side; incomplete at the right. The pa-tient complained, when eating, of not beingable to taste the food in her mouth; the leftnares was completely insensible; the tongue i,deviated strongly towards the left side."These symptoms continued without anychange until death. On examining the

body, the brain in general was foundhealthy; however, the mesocephale (ponsvarolii) was evidently enlarged, and in thecentre was found a small cancerous mass,enveloped in a brownish-blue, gelatinous,but dense substance, which extended for-wards as far as the deepest of the transversefibres of the pons, and backwards as far asthe anterior surface of the fourth ventricle;the tubercula quadrigemina were thus en-gaged ; the aqueduct of Sylvius was oblite-rated, and the surface of the ventricle itselfpresented an irregular and brownish appear-ance. Tnere was no trace of cancerous

production in any other part of the body.The phenomena which presented them-

selves during life in the present case, were,as you see, very various, How are we toexplain their production ? On reading overthe account of the anatomical appearancesobserved after death (and this shows thegreat utility of a minute and accurate de.scription of all morbid appearances), we findthe different functional derangements fullyexplained by the extension of the diseasefrom the pons varolii to the origins of thefifth and second pairs of nerves ; thus thesenses of taste and smelling were diminishedor partially lost, and you see how the fifthpair of nerves were diseased; moreover, thelesion in the pons extended more to the leftthan to the right side of the pons, and weaccordingly find that the senses were modi-fied in a much greater degree on the leftside of the body. The sight was nearlygone, and the tubercula quadrigemina werefound implicated in the disease.We have next to examine

Cancer of the Spinal Marrow.Here also the disease is very rarely ob-served ; we have not been able to collectmore than three cases ; of these three ob-servations, that published by M. VELPEAU,in 1825, is certainly the most remarkable,and most worthy of attention. The subjectof M. VELPEAU’S case was a female, thirty-five years of age, who, for some time, suffer-ed under pains in the limbs and convulsiveattacks; these were followed by a gradualparalysis of the sensibility and motility;such were the principal symptoms accom-panying cancer of the spinal chord in thisexample; pains along the members, con-vulsive movements, and, finally, paralysis.We have now laid before you a brief his-

tory of cancer when affecting the nervouscentres. Our description is, perhaps, veryimperfect, but, considering the limited mate-rials we possess, it seemed to us preferableto describe the phenomena observed in cer-tain groups of cases, rather than to attempta general description of the disease. We

have now disposed of tubercle and cancer,the most important amongst the foreign oraccidental productions which have theirseat in the cerebro-spinaI axis. But thereare certain others which we should examine.Thus, true calculous formations have beenoccasionally discovered in the brain ; wehave collected seven cases of

Calculi of the IVe2-vo?ts Centres.

They do not occupy in equal proportion thecerebrum, cerebellum, and spinal marrow;thus, of our seven cases, six times the cal-culi were found in the cerebral hemispheres ;one in the cerebellum; while the spinalchord does not furnish a single example.In the three first of our cases we find thecalculous matter was small, and dissemi

,

nated in the nervous pulp rather than col-lected into a single mass, as in tubercles or

104

cancer; in one case the calcareous depositwas attended with tubercle in another partof the brain. One of the three cases justnow alluded to, was observed by me atthe Hopital des Enfans, and is noticed inthe Clinique Medicale, t. 5, p. 720. Thesecond has been described by Dr. AVISARD,in the 75th volume of the BibliothèqueMedicale. The third observation belongs toDr. LEGUILLOU: You will find it in theJournal Hebdomadaire for 1835, No. 15, April,p. 33.*

In these three cases of calculous depositin the brain what were the symptoms ob-served ? In mine, the only symptom worthyof notice was a curious movement of thehead, alternately from right to left, and vicever8d,. Here the calculi, in great numbers,were contained in a cyst which occupiedthe iight lobe of the cerebellum ; in thesecond case the corpora striata were theseat of about thirty calculi, differing in sizefrom a millet grain to that of a pea ; theonly symptom in this case was a modifi-cation of the motility; the patient for twoyears had suffered under violent cramps ofa painful nature in the calves of both legs ;he was then seized with severe spasmodicmovements and convulsions of the four ex-tremities ; these accidents continued onlyfor a few days, when the respiration be-came stertorous, and the patient died in astate of coma.The case described by M. LEGUILLOu

occurred in a young girl, nineteen years ofage. She had been subject to frequentheadache, generally coming on at the men-strual periods; about two months beforeher death the headache became constant,and about six or eight days before death shewas seized with convulsions, which termi-nated in loss of consciousness, foaming atthe mouth, &c.; in a word, in true epi-lepsy. This state lasted only for one or twodays, after which the girl died. Several

encysted tubercles and calculi were foundin different parts of the cerebral hemi-

spheres. In the other cases, instead ofsmall calculi disseminated throughout thenervous pulp, we find the calculous depositcollected into one mass of various magni-tudes.

* We regret that M. Andral did not quotethe sources whence he derived his otherfour cases. We may, however, indicate thefollowing additional cases. In the cerebel-lum three cases; one by LIETAUD, " Hist.Anat. Med." I. 3, obs. 179 ; the other byLITTRE, in the Memoirs of the Academy,1705, p. 55 ; the third is mentioned in ABER -CROMBIE on

" Diseases of the Brain," p. 426.One in the pons varolii, by METZGER, " Ob.Anat. Reg.," 1792, p. 3; and by HoME,Philosophical Transactions, 1814. And one inthe cerebellum by HOOPER, " Morbid Ana-tomy of the Brain," p. 13.—Rep. L.

t It is unnecessary for us to dwell upon thet symptoms observed in these cases : theyt did not present anything particular, beiigt exactly similar to those produced by acci- dental formations in general; we shall,therefore, refer you to what has been said, upon cancer and tubercle of the nervouse centres.) The ages of the patients comprised in ourfour last cases, were as follows :-One was, 16 years of age; one 17; one 51, and the

last 57. This is the place to say a word ont the

Transformation of a large Portion of theBrain into a kind of Stony Matter,

which has sometimes been observed in ani., mals; a case of this kind was seen in a cow1 buy M. THiou of Orleans. Cysts of various; kinds, containing different accidental pro.(luctions, have also been discovered inthe nervous centres. We may cite one inparticular, which has been recorded by M.JOBERT ; in this case the author found a, cyst fil:ed with a yellowish matter, occupyingthe left side of the mesocephale (pons).; The cyst in its development had exercisedconsiderable pressure on the origin of the5th pair of nerves, and also implicated the3rd, 4th, and 5th pairs. The neighbour.ing parts of the brain were also evidently

compressed by the tumour. Here is a casethat must have given rise to a variety ofsymptoms not alone depending on the pre-

’ sence of an accidental body in the pons, butinfinitely more on the various parts of thenervous system that were implicated in thedisease. Thus in the case just mentioned,the disease commenced with pains in theface, running along the nervous branches;this lesion finally terminated in destructionof the cutaneous sensibility of the face:other parts supplied by the fifth pair ofnerves were also more or less affected.Thus the sense of taste was lost, and wemight in fact describe with accuracy thehistory of the symptoms from the anatomicalpathology of the lesion in the brain.

A Substance resembling in appearanceColesterine

has been found in some parts of the

cerebro-spinal axis; in these cases theforeign body presents itself under the ap-pearance of grains of pearls, and on chemi-cal analysis is found to resemble closelythe pearl in composition; there are fourcases of this kind extant: in two the foreignproduction occupied the cerebral hemi-

spheres ; in one, published by M. RAYRR, itwas found in the pituitary body; in thefourth or last case, the accidental productwas discovered in the substance of the ponsvarolii ; we have nothing particular to sayon the symptoms to which this morbid de.posit gives rise. They are the same as forthe other foreign bodies already noticed.

105

The last accidental productions we shallnotice are

.

Entozoa, which have sometimes been found inthe Nervous Centres.

They are of two kinds, the acephalocyst orheadless hydatid; and the cysticercus, or

bladder-tailed hydatid ; the latter species, beit remarked, is always found in the convo-lutions of the hemispheres. We know offour cases of this kind, and in one only dowe find any very remarkable lesion of theintellectual or motile powers. It was thecase of an individual in whom mental alien-ation coincided with the presence of an

hydatid in the brain. The ages of our fourindividuals are very various, and it is im-

possible to draw any conclusion upon thispoint. Some occurred in children; the restin persons far advanced in life.

We have now terminated this grand divi-sion of diseases of the nervous centres, viz.,diseases accompanied by an appreciablechange of organic structure. In every othercase if a lesion does exist, it escapes all ourresearches, and in the midst of the most pro-found and general functional derangements,we cannot discover the slightest modificationof the normal structure of the brain or spinalmarrow.

NORTH-LONDON HOSPITAL.

CLINICAL REMARKS

ON CASES OF

ERYSIPELAS, SECONDARY HEMORRHAGE,AND RECTO-VAGINAL FISTULA.

DELIVERED IN APRIL 1836.

BY MR. LISTON.

I THINK it as well to say nothing aboutthe case in which the upper jaw was re-moved, at present, but rather wait a little,that you may see how the patient goes on.Not that I am in the least apprehensiveof any unfavourable change taking place,but merely for your satisfaction. Manypractitioners say that no good can be doneby operating in the generality of cases ofthis description ; but I am convinced thatin many instances great good can be done,and when I speak of Ann Struther’s case,*I will mention others in which the opera-tion has been attended with permanentbenefit. 1 shall now proceed to speak of acase of

Erysipelas occurring in the UpperExtremity,

in a man who was admitted on the 17th of

* See Lancet, March 5 & 26, 1836, pp. 917 & 32.

December, in consequence of this diseasefollowing a slight wound of the thumb,which he received ten days before his ad-mission. Leeches and poultices had beenapplied to the inflamed part before his ad-mission, and several punctures had beenmade in it. On his admission, there wasswelling and redness of the hand, extend.ing as high up as the elbow. I did notconsider the incisions which had been made,deep enough, I therefore made severalothers, deeper and more extensive, both inthe hand and fore-arm. There was a free dis-charge of blood, serum, and ill-digested pus,and he was considerably relieved. The dis-ease, however, did not abate rapidly, theswelling of the hand, particularly the ring-finger, seemed to increase; it became evi-dent that the articulation between the first

phalanx and the metacarpal bone was dis-eased, and I therefore determined on remov-ing the finger, with a portion of the meta-carpal bone, as no doubt the irritation waskept up by their presence. I shall not enter

upon the treatment of erysipelas at present,my opinions on that subject you have heardbefore. It would seem, however, that noconstitutional treatment will, in some ad-vanced stages of the disease, do away withthe necessity of puncturing or incising theinflamed part. If you neglect such a pro-ceeding, destruction of the soft part takesplace, and the bones themselves frequentlybecome involved in the mischief. Since Ilast spoke on the subject of erysipelas, wehave succeeded in subduing the action ofthe vascular system, without either the useof the lancet or tartarized antimony, bygiving small doses of the aconitum napel-lus, and afterwards of belladonna. Twocases in which this treatment has been most

successfully employed, have been accuratelydetailed in some late numbers of THE LAN-CET. You have no doubt read them, aswell as watched the cases themselves in thehospital. The first case was that of a womanwho the first time she was in the hospitalwas treated for erysipelas by antimony,punctures, and fomentations. It was sometime before she recovered, and her conva-lescence was exceedingly tedious. In thesecond attack, after subduing the inflamma-tory fever in some measure by antimonials,we administered extract of belladonna in

very minute doses, and in two or three daysshe was quite well. The second case was

that of a woman who had been much sub-ject to the affection, having had successiveattacks of it at intervals, seldom recoveringfrom them under a fortnight. Small dosesof the aconite, followed by belladonna, weregiven her, and in the course of three daysshe also was convalescent. There has beenanother case lately here of a man who hadsmall ulcerations of the leg from the toes upto the knee, aggravated by a scald, and whowalked about until the leg became exceed-.