CHAPTER XXVI DIAGNOSIS OF DISEASES OF THE HEAD (Part 1)

CHAPTER XXVI DIAGNOSIS OF DISEASES OF THE HEAD Chapter VII., in which the diagnosis of injuries of the head and of their sequela3 is discussed, should be read in connexion with this chapter. In it will be found information on cerebral localization, and on such affections as ha^matoma, hernia cerebri, and pulsating collections of fluid beneath the scalp. In this chapter are considered those affections of the scalp, vault of the skull, and cranial contents as are not traumatic in origin. The intracranial com- plications of middle-ear disease are dealt with in its concluding section. ' Tumours of the Head The first step in the diagnosis of a tumour of the head is to place it in one of three groups : (1) tumours of the scalp, (2) tumours of the skull, (3) intracranial tumours. With the head fixed, gently grasp the swelling and notice whether it can be moved over the bone : if so, it is extracranial — a tumour of the scalp. Further proof will be afforded by a good skiagram, in which, in such a case, the dense shadow of the calvaria will be seen uninterrupted and distinct from the less opaque shadow of the tumour. It is less easy to distinguish witli certainty be- tween cranial and intracranial swellings. Feci care- fully for pulsiilion in the swelling; thou determine TUMOURS Oi^' THE SCALP 361 whether it yields under gentle continuous pressure, and whether a strong expiratory effort, as in crying or cougliing, causes it to fill out ; examine for cerebral symptoms — irritative or paralytic — and, above all, examine carefully a good skiagram. Tumours of the skull are irreducible, incompressible, do not expand or give an impulse during a forced expiration, and are rarely pulsating ; if they grow inwards as well as externally they may cause symptoms due to irritation or compression of the brain. In a skia- gram the special features of the shadow of a cranial tumour are either that it is all superficial to the inner table of the skull, or that its deep margin is well defined and distinct from the brain. Intra- cranial tumours often protrude between growing centres of ossification, and their situation in the middle line or at a fontanelle is noteworthy. The pulsation of the cerebral contents is to be felt in them ; when formed largely of the cerebro-spinal fluid they are more or less reducible on gentle pres- sure, and their tension is increased by forced expira- tion. There may or may not be cerebral symptoms, which vary as the tumour irritates, compresses, or destroys the cerebral tissues. The skiagram will show a deficiency in the cranium involving both tables of the skull. Tumours of the Scalp Having determined that a given swelling is in the tissues superficial to the bone and perios- teum, its precise diagnosis may be arrived at as follows : 1. The colour will at once distinguish cutaneous naevus. When a soft tumour beneath healthy or na5voi(l skin is found to be compressible and to become fuller and tenser on the nalient cryiiiij or 366 SURGICAL DIAGNOSIS [chap. straining, it is a subcutaneous venous naevus. The patient is generally a child, and the swelling was noticed at or soon after birth. 2. If the tumour pulsates forcibly, is uneven on the surface, evidently consisting of convoluted vessels, through which the firm bone of the skull can be felt, and if large arteries can be traced in the scalp to the edge of the tumour, compression of which stops or lessens the pulse in the tumour, it is a cirsoid aneurysm. The skin over these tumours is usually hot. (See also p. 281.) 3. If the tumour is globular, tense, smooth, and fluctuating, irreducible and devoid of pulsation, it is a cyst. Four forms of cyst are known, only three of which.can be diagnosed. If the tumoiu- is acquired, adherent to the skin, and freely movable over the bone, it is a sebaceous cyst. This kind is often mul- tiple, is commoner in middle and late life, and may attain a large size, and become inflamed and ulcerate. If the cyst has developed after an injury to the scalp it will probq,bly prove to be an implantation cyst, and the bone may be found to be slightly indented beneath the cyst. If the scalp moves over the tumour, and if the latter is partially fixed to the bone, not freely movable over it, it is a dermoid cyst. Such cysts may be noticed at birth or may be only observed later on. They are most often found near the outer angle of the orbit. They are generally single. The bone beneath them may be thinned or even perforated. A meningocele, the pedicle of wjiich has become occluded, could not be diagnosed with certainty from the above, unless it were tajipcd and found to contain clear serous fluid. If the tumour was of large size at birtli, the surgeon should suspect meningocele and tap the tumour to clear up tiio din-ffuosis. XX vt] ulcers of the SCALP 367 4. If the tumour is solid, movable over the crauium and under the scalp, and slightly lobulated in outline, it is a subaponeurotic lipoma. These tumours are usually of small size, and rather flattened in shape ; they may become large and globular, and are then liable to be mistaken for tense sebaceous cysts. They are to be distinguished from cysts by the abseiice of fluctuation, by the shght lobulation of the sur- face, and by non-adhesion to the scalp. They are commonest in the frontal region, but may occur under any part of the scalp. 5. When the side of the head alcove the ear is swollen, hot, reddened, oidematous, acutely painful and tender, and tight closure of the jaws or wide opening of the mouth is painful, abscess beneath the temporal fascia is to be diagnosed. If the surgeon detects fluctuation the diagnosis is certain. A high temperature and polymorphonuclear leucocytosis will confirm the suspicion of abscess. The swelling is tense and boggy, and . has the limits of the temporal fascia, not extending down on to the face or neck, but there may be osdema of the eyelids on the same side. It is convenient to consider here the diagnosis of — Ulcers of the Scalp 1. If at the base of the ulcer hard, dry, rough bone is felt and seen, the case is one of' necrosis. When spontaneous the disease is syphilitic or tuber- culous, and care must be taken to distinguish between these forms. If there are other signs of tertiary syphilis, especially gummata or deep ulcerations, or the scars of such, and there is a positive Wasscrmann reaction, it is syphilitic osteo-myelitis. The syphilitic form begins with headache, apparent thickening of the bone and scalp, and slow ulceration, and the dead 368 SURGICAL DIAGNOSIS [chap. I tone ha.s a womi-eaten appearance; I ho ulceration is ainuous and often multiple. If, however, the ulcer has thin undermined edges, and discharges thin glairy pus in which tubercle bacilli can be found, it is tuberculous osteo-myelitis. This disease begins in a swelling which forms an abscess and bursts, discliarging pus. The patient is usually young, thin, and delicate-looking ; the Wassermann reaction is negative, and there are often other tuberculous foci. The surgeon must be careful to distinguish mere exposure of the cranium from its necrosis. By wounds or cellulitis portions of bone are often exposed, but after a time the bone becomes pink in colour, and then gradually granulations sprout through its surface and the wound heals over. It is only when this does not take place, or the surgeon has evi- dence of the separation of a sequestrum in llie formation of a groove around the exposed bone, that he must diagnose it as dead. 2. An ulcer of the scalp witli thick everted edges and a dirty fungating or sloughy base, with a foul- smelling discharge, is either an ulcerated sebaceous cyst or an epithelioma. If on inquiring into the lustory of the case one finds that it began as a chronic globular lump which later on became in- flamed and burst, and if the base of tlie ulcer moves over the bone and the associated lymphatic glands are not enlarged, it is an ulcerated sebaceous cyst. 3. But if, even with this history, the base of the ulcer has become adherent to the bone, or the glan':ls at the angle of the jaw or behind the mastoid pro- cess or sterno-mastoid muscle are enlarged, it has developed into an epithelioma. In a doubtful case a portion of the edge of the ulcer should be excised and submitted to microscopic examination. -.\vij Tl^MOURS OF THE SKCLL 300 ■J. WiieiT the ulco]- hegHij in .-i wait or crack or iu ii very chronic patch oi liijju.s, lias gradually extended, and its edge and Ijase are adherent to the pericranium or bone, it is an epithelioma. The asso- ciated lymph-glands may be fpund enlarged. 5. A very chronic slowly-progressing ulcer with a thin rolled edge and smooth clean base, without enlargement of lymphatic glands, is a rodent ulcer. (See also p. 297.) Tumours of the Skull 1. If, in an infant, low, rounded, firm swellings of the bone are found grouped around the anterior fontanelle but not extending quite up to it, they are the " natiform swellings" of Parrot, and are due to congenital syphilis; the surgeon should ex- amme carefully for other manifestations of inherited syphdis. If any part of the skull (not a fontanelle or suture) is found to yield under the finger, having the resistance of parchment rather than of bone, the condition is known as craniotabes. Such softened spots are usually found m the parietal bone behind the parietal eminence; they are generally associ- ated with congenital syphiUs, but may be due to rickets. 2. When, in later life, low, smooth, or imeven swclhngs of tlie bone are found, which are painful and tender, firm or fluctuating, they are to be diag- nosed as syphilitic nodes. These vary much in their condition. In some the pam and tenderness are extreme. Some are hard and bony, others softer and others again fluid. They may be single or multiple. Little pits in the bone may be felt be tween elevated ridges ; in other cases the skin is ulcerated, and gummatous material or sequestra are exposed. They are associated with otlier evidence 370 SURGICAL DIAGNOSIS [chap. of syphilis and are favourably influenced by anti- syphilitic treatment. 3. If the head is found flattened behind, with the forehead prominent, and the fontanelle widely open or open too late, and the bones are thickened along the sutures, it may he described as a rickety skull. The anterior fontanelle should not be palpable after the first year of life. 4. A prominent, clearly circumscribed tumour fixed to the bone, of absolute hardness, of very slow growth, and opaque to X-rays, its shadow in a skiagram being continuous with and as dense as that of the skull, is an osteoma, or ivory exostosis. If also intracranial, it may be accompanied by cere- bral symptoms. Very rarely, after a period of many years such a tumour has become separated from the normal bone and cast off as a sequestrum. 5. A circumscribed tumour fixed to the skull, solid, firm, irreducible by pressure, and of steady growth, is to be diagnosed as a malignant tumour of the bone. The appearance of the tumour may be preceded by severe local pain ; it grows with varying rapidity, and may exhibit pulsation either universally or in places only. Such tumours, which may be multiple, are usually secondary to carcinoma of the breast, prostate, or thyroid gland ; examina- tion will reveal the primary growth or evidence of au operation performed for its removal. 6. If an adult finds that he constantly has to get a larger hat, or by other signs a general increase in the size of the skull is verified, the affection will be recognized as hypertrophy of the skull. If at the same time, or subsequently, the long bones of the extremities become enlarged and curved, aud the stature diminished, the disease is osteitis deformans, or Paget's disi5a,sc. If, however, the mandible luis xxvi] INTRACRANIAL TUMOURS 371 become prominent, and the hands and feet have en- larged, the " hypertrophy " of the skull is a part of acromegaly. 7. When the head of an infant or young child is found to be disproportionately large and continually mcreasmg ni size, with wide separation of the cranial bones and perhaps distinct fluctuation perceptible from suture to suture, it is a case of hydrocephalus. Intracranial Tumours 1. If the tumour was noticed at or soon after birth, IS soft, fluctuating, translucent, and yields under gentle pressure, and then becomes fuller and tense when the patient cries or strains, it is a meningo- cele The bone may be seen or felt to be deficient at Its base. These tumours are usually globular in shape ; they are most often met with over the occip- 1 al protuberance, at the root of the nose, or aloifg the middle line of the vertex. If they are tapped cerebro-spinal fluid escapes. Meningocele is often associated with hydrocephalus. 2. If a congenital tumour with the general char- acters of a meningocele is found to pulsate synchron- ously with the temporal artery, it is kmown to con- InZlTr'r f '^"'i *° ^ »eningo- encephalocele. In these cases pulsation may only be detected wlien the tumour is partially reduced The movements of the brain with respiration may be detected, as well as arterial pulsation. " Cerebral Tumours When a patient sufiers from severe persistent headache, associated with irregular causeleis von ng, optic neuritis, and the gradual developnJnt of the signs oi compression of the lu'ain-a sin p subnormal tennperature, and loss of mental owe^ 372 SURGICAL DIAGNOSIS [chap. and the symptoms have come on spontaneously, have developed gradually, and have resisted medicinal and dietetic treatment, the presence of a cerebral tumour may be diagnosed. The patient must be examined for evidence of local destructive effects indicative of the exact position of the tumour. At present there are parts of the brain, especially the precentral convolutions, the functions of which are not clearly determined, and in these parts tumours may grow without gi^^ng rise to symptoms by which their exact seat can be determined. Tliis " silent area " of the brain will no 'doubt soon be better understood, and then tumours will be localized there as certainly as in other parts. Advances are continually being made in our knowledge of cerebral localization, and the reader must refer to works on neurology for full information on this subject. The following state- ments we believe to be in accordance with present knowledge ; they may be useful to students in local- izing a cerebral tumour. The seat of pain does not correspond with the position of the tumour ; vomit- ing is more severe in tumours below the tentorium ; if optic neuritis is observed to come on earlier on one side, or is found more severe on one side, in the absence of definite paralysis, the tumour is to be regarded as on that side. Compression signs come on more rapidly in tumours of the cerebellum and base of the brain than in those in the cerebral hemi- spheres. The function of each of the cranial nerves must be carefully and systematically examined, ai\d then the voluntary muscular power and the sensation of the whole body tested. If paralyses are found, a careful consideration of their distribution will guide to the localization of tlin tumour. 1. Motor paralysis of one limb or of one side of xxvi] CEREBRAL TUMOURS 373 tlie lace, with convulsive attacks comixieucing in the paralysed part— Jacksonian epilepsy— and lessened acuteness of tactile sensibility ni the paralysed member, pomt to the tumour being in the motor cortical area of the opposite side, i.e. the ascending frontal convolution, and the seat of the paralysis will in- dicate more precisely what part of this convolution IS diseased. The centre for the leg is close to the ongitudinal fissure (mcisura iuterhemispherica), next below IS that for the trunk, then lower down is placed the centre for the upper limb, and lowest down, reaching to the Sylvian fissure (sulcus lateralis), is the centre for the face. 2. If there is hemiplegia, together with hemianajs- thesia and hemianopia, it pomts to the tumour in- yolvmg tbe internal capsule of the side opposite to the para ysis. The loss of vision is m the temporal field of the eye of the same side as the tumour and m the nasal field ,n the eye opposite to the tumour. ... 11, m addition to hemiplegia, hemianassthesia, and hemianopia, tliere is special loss of control of he movements expressive of the emotions, and athetoid movements are observed, the tumour will in-obably be found to involve the optic thalamus. I the anaesthesia was noticed quite early in the course of the case It would confirm the diagnosis 4^ Heimplegia and hemianaesthesia, with paralysis of the muscles supplied by the third nerve of the opposite side indicate that the tumour involves the "^j^"'-'- ''-'^-^^ - of^ s: 5. Hemiplegia and hemian^esthesia, mth facial palsy and deafness on the opposite side and coniugate deviation 0 the eyes towards the hemiplegS sfl! indicate that the tumour is in the pons «. Paralysis of both sides of the b;dy, with difH- 374- SURGICAL DIAGNOSIS [cuAr. culty ill speech aud deglutition, points to the tumour involving the medulla oblongata. 7. Blindness in the nasal part of each retina producing bitemporal hemianopia indicates that the tumour is pressing upon the optic chiasma, and that it is in the pituitary gland (hypophysis). 8. When the symptoms commence with deafness and noises in one ear, quickly followed by paralysis of the external