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administered. The ophthalmoplegia is now plainly decreasing. She can elevate the lid to about one-third the usual height and can move the eye slightly in all directions-most upwards, and least outwards. The left pupil is smaller than the right, but responds to light. She remains, however, blind in the left eye. The area of impairment of sensation has further contracted, and is now confined to the forehead, upper eyelid and conjunctiva, and on the forehead spots where sensation is returning are to be found.]

AN ACCOUNT OF A CASE OF TUMOR OF THE CERE-
BELLUM COMPLICATED BY DROPSY OF THE VEN-

TRICLES. EXPLORATORY OPERATION, TAP-
PING OF VENTRICLES. DEATH ON

THE FIFTH DAY.*

BY F. X. DERCUM, M.D., AND W. JOSEPH HEARN, M.D.

DISCUSSION OF THE CASE BY DRS. MILLS, SINKLER, DE SCHWEINITZ, DEAVER AND BALL, WITH A NOTE BY DR. KEEN.

HISTORY AND SYMPTOMS BY DR. DERĊUM.

G. M., æt. 28, was admitted to the nervous wards of the hospital under my care on November 12, 1890. He had been for some time previous in the German Hospital, and Dr. Frese, chief resident physician of the same, gave me very kindly the following account of the patient :

He had been admitted to the German Hospital five months ago complaining of headache (which was general) and pain in the back of the neck. He was also subject to epileptiform attacks, during which consciousness was lost, while his arms and legs became very stiff. An ophthalmascopic examination disclosed a well marked, choked disc on each side, with much impairment of vision; marked deafness also was noted. His symptoms gradually increased in intensity, until, finally, blindness and deafness were absolute. He was also subject to spells of great excitement, during which he would scream at the top of his voice. His actions were for a time so violent that he had to be for a short period confined in the cell of the hospital.

Dr. Ball, under whose immediate care he was, says that the man did not impress him as being actually insane during these attacks, but that he screamed at the top of his voice as though making a vain attempt to make himself hear. During the intervals nothing unusual was noted about his movements or about his gait. His walk was neither spastic nor ataxic, but simply like that of a man who was generally weak. His urine was free from albumen or sugar.

When admitted to my wards his condition was as follows: marked general weakness, most marked in the legs; absolute loss of sight and hearing; and, also, as far as we could determine, absolute loss of smell and taste. Cutaneous sensibility

*Paper read and discussion held before the Philadelphia Pathological Society, December 11, 1890.

seemed to be everywhere well preserved. No paralysis of sphincters. Slightly diminished knee-jerks.

The patient was a German, and communication with him was only possible by writing with the index finger upon the palm of one of his hands in German script. Under these difficulties we learned again of his headache, that it was agonizing, and, if possible, steadily growing worse; and, further, that it was most intense upon the left side and anteriorly. When his head was gently percussed no pain was elicited anywhere except in the left frontal region. When his grip was tested it was found that the right hand was markedly weaker than the left. The epileptiform attacks were also repeatedly observed. In these his arms and legs would become very rigid, and to the rigidity would be added a rapid clonic movement of small extent. The head was thrown backward and held in fixed position, and in one of the attacks in which I saw him it was slightly turned to the left, while the eyeballs rotated outward and to the left.

After an ophthalmoscopic examination, Dr. de Schweinitz reported marked, double optic neuritis, dilated and immovable pupils and nystagmus, also slight divergent strabismus, due to loss of fixation.

At the German Hospital, Dr. Frese had made a very thorough trial of antisyphilitic remedies, and had indeed, noted some improvement during their use. This improvement, however, proved to be transient. Notwithstanding when admitted to the nervous wards mercurial inunction was again resorted to, but without noticeable result.

The patient's condition growing steadily worse, I called my colleague, Dr. Mills, into consultation. After reviewing the facts, we deemed it probable either that the man was suffering from a tumor in one of the silent regions of the brain or from some more general disturbance, such as an internal hydrocephalus. Various facts pointed to the left frontal region as the seat of the disturbing cause. In the first place, the headache was most marked in this region; secondly, this region was decidedly painful to percussion, while the remaining surface of the skull was not ; thirdly,—a fact not mentioned above—the right side was most involved during the epileptiform attacks, and lastly, the right arm was notably weaker than the left. An absolute diagnosis was not possible, nor was any attempted. Dr. Mills inclined towards the theory of tumor, the writer towards that of hydrocephalus, either primary or secondary to some other cause.

The propriety of an exploratory operation was discussed, together with Dr. W. Joseph Hearn of the surgical staff, and finally, when marked mental failure had begun to make itself noticeable, decided upon. When admitted the man had been as intelligent as could, under the circumstances, have been expected. To questions written upon his hand in his native language he gave intelligent answers, and frequently volunteered information regarding his condition. After the lapse of some ten days, however, it began to be more difficult to communicate with him. Words and sentences would have to be written again and again before he would comprehend their meaning, and his replies were made less readily and were less satisfactory than before. Evidently he was losing ground.

Finally, on November 26, two weeks after admission, an exploratory operation was undertaken in the presence of the neurological and surgical stafis of the hospital, Dr. Hearn operating. The details of the operation I leave, of course, to Dr. Hearn. Suffice it for me to say that the exploration was directed to the left frontal region, a large oblong opening being made in the skull slightly in advance of the hand centre and extending well forwards. In addition to great vascularity of the brain, no

noteworthy feature presented itself until the dura was opened. Here it was found that the brain bulged greatly, and further, that it fluctuated markedly upon palpation. Exploratory puncture was, after a brief consultation, decided upon, with the result that between five and six ounces of fluid escaped from the left lateral ventricle. The previously protruding brain now sank within the cranial cavity, so that its surface was half a finger's breadth from the surface of the skull. The operation was terminated at this point.

In a few hours the patient rallied and recognized those about him as before through the sense of touch. On the following day I carefully examined him and found that the power of smell and taste had undoubtedly returned, and the resident in charge maintained that there had been a distinct return in the sense of hearing; this I failed to confirm. There was absolutely no change in the blindness, though the pupil reacted distinctly to light. These symptoms of improvement were, however, maintained but a short time. On the third day a hernia cerebri began to make its appearance, and concomitantly there set in progressive mental failure, coma, and finally death on the fifth day.

Autopsy. --December 2, 1890, the dressing being removed, a small amount of bloody and watery discharge escaped from the wound, which was free from odor; but little attempt had been made at union, and under the flap some effused blood was found. Through the trephine opening a large soft mass extruded, flecked here and there with dark green masses, looking like altered extravasated blood. The hernia itself projected an inch or more beyond the opening, and for an inch or more over its edges; it was reddish in color and thoroughly disorganized. The calvarium was removed, the hernia readily slipping back through the trephine opening. Its inner surface was found very irregular, being studded with minute osteophytes, especially in the left parietal region; it was not especially adherent to the dura. To either side of the attachment of the longitudinal sinus were found marked and numerous depressions, the bone being in these areas quite translucent.

[graphic][merged small][merged small]

The dura was everywhere tense, except in the left temporal region and in the immediate neighborhood of the wound. Veins of dura in neighborhood of longitudinal sinus, full and prominent. Pacchionian bodies quite large and numerous, and corresponding to areas of thinning in the calvarium. During manipulation of dura in removal, escape of cerebro-spinal fluid was noted from the wound. Inner surface of dura smooth, but showing numerous thickenings corresponding to the roughness on the inner surface of the calvarium.

The hemispheres exhibited no peculiarity other than a change of consistence in the left hemisphere in the neighborhood of the wound. No where was any induration. On removing the brain and inspecting the base, the basi-temporal surfaces, and especially the lips of the temporal lobes, were soft and oedematous. The cerebellum showed no appreciable change of consistence in either hemisphere or in its middle lobe. The pia-arachnoid showed some infiltration along veins and fissures. On opening the left lateral ventricle it was found excessively dilated. At the highest point of its anterior branch, involving neither the inner nor the outer wall, was found a small reddish wound, the inner end of the puncture made by the trocar. The right lateral ventricle was also found very much dilated, though less than the left. Foramen of monroe also large and dilated. Velum interpositum infiltrated and whitish. Chorid plexuses not excessively cystic. Walls of third ventricle unusually pale. No noticeable change in quadrigeminal bodies, pons or crura. On carefully separating the quadrigeminal bodies from the cerebellum a large jelly-like mass the size of a pigeon's egg was revealed, occupying the central lobe of the cerebellum. Peripheral portion of the tumor was excessively soft; centrally and to the right it felt much firmer. It was firmly attached to and merged with the white substance of the right hemisphere, and appeared to have originally sprung from this region. It was simply in contact with the white substance of the central lobe and with that of the left hemisphere, having hollowed out a space for itself in these structures by pressure and absorption. Below and anteriorly the roof of the fourth ventricle had been partially destroyed by the same process.

In reviewing the symtoms, it is remarkable that no ataxia was at any time present. Even the nystagmus was not decisive as it is known to occur in disease of the second frontal convalution. Again, it would have been impossible to explain the total loss of hearing, smell and taste through cerebellar symptoms alone. Evidently these symptoms must be referred to a great general increase of intra-cranial pressure. Such increase of pressure was afforded by the excessive internal hydrocephalus, the latter itself having its cause apparently in the occlusion through pressure by the tumor of the aqueduct of Sylvius. It can, perhaps, be readily understood how an increase of intra-cranial pressure, associated also with œdema, as noted in the autopsy, could lead to a loss of taste and smell. Whether the blindness is to be attributed to a like cause or to descending neuritis I will leave to Dr. de Schweinitz

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