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J. A. (Joel Asaph) Allen.

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forwards, showing great pressure behind. No pulsation was seen.
A small puncture was made through the dura, through which a
fine stream of old blackish blood spurted several feet in the air.
The dura was, therefore, freely opened, and a large amount of
similar blood, estimated at three ounces, evacuated. A large
bloodclot now appeared, covering an area of about three square
inches and being about one-quarter inch thick. It extended
upward and backward, was firmly adherent, and was removed
with difficulty, partly by aid of forceps, partly by sharp spoon.
Pulsation of the brain was thereafter plainly seen. The brain
seemed excavated and pressed inward where the clot had been
removed. The wound was thereafter thoroughly irrigated with
warm sterilized water, the dura sutured with fine catgut, the but-
ton replaced, the wound closed without drainage, and antiseptic
dressings applied.

The further course was very favorable. The wound healed by
first intention. Two days afterward, he could say yes and no and
count to four; two days later the aphasia had disappeared and
the patient was able to talk freely, although pronouncing some
words with hesitation and difficulty. The paresis of the arm and
leg disappeared completely in a week, and the patient got up. On
his discharge, four weeks later, it was noted that vocal fremitua
over the left side of the head was normal, the pupils normal in
size and reaction. Paralysis of the face had entirely disappeared^
and the condition of the facial nerve was normal. He was able to
draw the face to either side and raise the nostril. The tongue
could be protruded without deviation to either side. His right
hand was somewhat weaker, registering 10 to left *90. Knee
reflexes normal ; muscular power and sensibility perfect. Apha-
sia had completely disappeared ; memory was perfect, and be left
the hospital mentally and physically coi^pletely restored.

His assailant was discharged from jail a wiser, and, I hope, a
more peaceable man, a week after the operation.

This case is of interest on account of the correct diagnosis
verified by prompt operation, the replacement and successful



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CLINICAL BBFOBTS. 535

implantation of the large button, by which adhesions of dura to
the skin and possible future troubles were avoided, the rapid dis-
appearance of all the serious symptoms, and the complete restora-
tion of the patient to health, and of his assailant to liberty. I wish
here to call attention to the dangers of using strong antiseptics in
operations on the brain. Physiological investigations have shown,
as published in Deutsche Medicinische Wbchenachri/ty that the brain
is extremely sensitive to chemical irritants, and it was found that
carbolic acid, in strength above 1 to 200, speedily produced death,
and that corrosive sublimate, even as weak as 1 to 10,000, inflicted
severe injury upon the brain tissue. I believe that nothing but
sterilized water ought to be used in brain injuries or operations.

TREPHINING FOR ABSCESS OF BRAIN — RECOVERr.

Case XIII. — G. B., 4 years of age. entered the Sisters' hospital oik
November 22. 1893. Eight weeks previously, he had been injured on
the top of his head by a " rasp/' which some other boys were throw-
ing up in the air. The injury consisted of a punctured wound of scalp
and skull. No physician was called, the wound was bandaged at home,
and the little boy continued playing. The next day the head was
swollen and the boy remained in bed all day, but thereafter he appar-
ently got well, and continued healthy for six weeks. Two weeks ago
he began to get easily fatigued, looked pale, had slight fever at night,
attacks of vomiting, and increasing drowsiness and stupor. One week
ago. the family physician was called, found the boy with a fever of
103. rapid pulse, mental dullness, and stupor. He advised his removal
to the hospital, but the parents first consented one week later, as he
was rapidly growing worse and the stupor was increasing.

On examination, he looked pale, with heavily-coated tongue,
slight facial paralysis on left side, otherwise no symptoms of
paresis. He was in a state of stupor, fretful and peevish, and
could not, or would not, answer any questions. A small scar was
seen on the top of his head, to the right of the median line and
just behind the coronal suture. Temperature 103 ; pulse 130.
The symptoms indicated a brain abscess, and, after consultation
with Dr. Crego, exploratory trephining was advised and performed
immediately.

A downward convex incision was made, circumscribing the
scar. After the periosteum had been removed, a small opening,
filled with granulations, was seen in the skull. A half-inch button
was removed with the trephine, outside the hole, and a rim of bone
removed around the hole with cutting forceps (Keen's). The dura



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63G CLINICAL REPORTS.

mater thereafter bulged into the openiog, was not pulsating, and
a granulating mass found, corresponding to the hole in the
skull. The dura was opened, and just beneath the granulations a
stream of pus gushed out from an abscess cavity beneath the cor-
tical substance. The opening was enlarged with dressing-forceps
and about two ounces of pus evacuated. The cavity seemed, by
exploration with the finger, to be about the size of a large egg. It
was irrigated with sterilized water, loosely packed with iodoform-
sauze, let out through an opening in the flap corresponding to the
deeper opening. The wound was thereafter sutured and antiseptic
dressing applied.

November 23d. He rested quietly during the night and seems
much brighter, says he feels " first rate," and wishes to get up.
Pulse, 120 ; temperature, 101.

November 24th. Wound dressed, irrigated and iodoform again
introduced.

November 26th. Temperature, 99. The wound was thereafter
irrigated and dressed every other day, a small strip of iodoform
gauze being introduced for drainage ; the pus discharge dimin-
ished rapidly, and he left the hospital, convalescent, on December
10th.

From a letter from his physician, of January 16, 1894,1 quote:
<< Mentally and physically the child seems to be perfectly well
has gained in weight, and is as active as ever. The discharge of
pus ceased shortly after his leaving the hospital, and the wound is
nearly healed."

The interest in this case is the entire absence of paralysis,
although the abscess, evidently, was near the motor center and
must have exerted considerable pressure on this point.

The diagnosis was made on the symptoms of mental dullness
and elevation of temperature.

For the history of the following case I am indebted to Dr. W.
C. Krauss, of Buffalo :

TREPHINING FOR EPILEPSY. — RECOVERY.

Case XIV.— W. T., of Attica, N. Y.; age, 24; height, five feet
eight inches ; weight, 165 pounds ; constitution strong and healthy.
Nothing in his antecedents and early life is worthy of special consider-
ation. When twelve years of age an accident befell him, on a Fourth
of July, which proved to be the cause of his later misfortune. Some
boys having procured the barrel of an old gun, were engaged in dis-
charging it to help celebrate our national holiday. The gun flew into



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CLINICAL BBP0BT8. 537

the air and, on descending, struck the patient on the left frontal re^on
of the head. He was carried unconscious to a physician^s office, who
removed several small bone particles of the skull and sewed up the
wound. Suppuration set in, which continued for a few weeks, and the
boy seemed to have recovered fully from the efifects of the injury.
About six years ago, six years after the accident, he began to notice
that he felt unusually drowsy, dull, and stupid on awakening in the
morning. This condition lasted for some time, the cause undiscovered,
until he was discovered in an epileptic attack by his room-mate.

He consulted several physicians without obtaining any relief. In
the Fall of 1890, he consulted Dr. Krauss, who, without any success,
prescribed bromides. He made a thorough examination and found a
large deep depression over the left frontal bone, the posterior edge
extending through the coronary suture. Up to this time he had been
able to work hard on a farm, but would have the nocturnal attacks.

On May 2, 1891> Dr. Krauss was called to Attica to see him, and
found him in one of the attacks. He was sitting in a chair, his eyes
wide open, glassy, staring, his head drawn to the left, speechless, but
not exhibiting any signs of convulsions.

These attacks were growing more frequent, had become diur-
nal as well nooturnal, and some radical procedure was demanded.
Two days later, Dr. Krauss was again called to Attica, and I was
requested to accompany him and operate. On our arrival, we
found the patient in the status epilepticas, the attacks being no
longer intermittent but continuous, without longer intervals than
41 couple of minutes. He had heeix in this condition for thirty
hours, one attack of convulsions following the other without the
patient regaining consciousness. The pulse was weak and rapid,
face cyanotic. A large depression, covered with a tight, whitish,
adherent scar, was seen, as described. A large curved incision,
convex backwards, was made, the scalp loosened with difficulty
from the bone, and an irregular defect of bone found under the
scar. The surrounding edges of the bone were much hypertro-
phied, strongly adherent to the dura and pressing it inwards. The
dura was loosened all around from the hypertrophied bone, which
thereafter was removed all around the defect with cutting forceps.

During the following day he had six attacks, but thereafter he
improved rapidly, and he soon returned to his work a well man.
No attacks occurred for seventeen months, he got married and felt
well, but continued the treatment with bromides. On October 7,
1892, he consulted Dr. Krauss again, and stated that the attacks
were returning and were becoming daily more frequent. Dr.



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538 CLINICAL BEPOBT8.

Krauss advised him to enter the Sisters' hospital, .in Buffalo, in
order that he could be under observation and treatment. The
attacks, similar to the ones he had at first, grew daily more
frequent and intense, and after three days he veas in the same con-
dition of status epilepticns. An operation, similar to the firsts
but convex forwards, where the bone could not be reached during
the first operation, was performed, hypertrophied bony edges,,
strongly adherent to dura mater, found and removed and the dura
again widely loosened from the bone with Horsley's spatula. He
recovered rapidly, having some attacks only during the following^
twenty-four hours, and was discharged from the hospital on
November 6, 1892, apparently cured. He was again treated by
Dr. Krauss with bromides, his food restricted, and all work pro-
hibited for six months. Thereafter he resumed his former work.
He has since had no more attacks or peculiar feelings, his physical
and mental condition, Dr. Krauss states, are excellent, and we
hope for no further trouble. The depression is covered by his^
hair and gives him no concern whatever.

The interest in this case is the late appearance after the injury,,
the apparent recovery after the first operation, relapse, and a still
further remission and a possible cure after a second operation. It
is the belief of Dr. Krauss and Dr. Crego, who saw him the second
time, that death promptly would have occurred if he had not been
operated on.

A DOUBLE LESION OF THE BRAIN— CEREBRAL CYST—
CEREBELLAR TUMOR.*

Bt EDWARD B. ANGELL, M. D., Rochester, N. Y.

Some months ago, a case of obscure brain trouble came under my
care, the symptomatology of which readily enough determined a.
diagnosis of cerebellar tumor. Had this been the only morbid
condition, the case would hardly have been of more than clinical
value. But an earlier lesion, resulting in the destruction of certain
important convolutions of the cerebrum, has some scientific bear-
ing upon cerebral pathology, and the functional correlation
between the two hemispheres. For this reason I desire to place
the case upon record before this association.

Mary C. aged 32 years, single, a shoemaker by occupation, of good
social status, family history negative ; the personal history unimportant

1. Read at the meeting of the Neurological Section of the American Medical Associa^
tion, Milwaukee, June, 6, 7 and 8, 189a



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CLINICAL BBPOBTS. 58^

with one exception. At the age of five years, daring convalescenoe
from a severe attack of scarlatina, sudden right hemiplegia developed,
due doubtless to a thrombosis of a branch of the left mid-cerebral
artery. It was attended with loss of speech, but without loss of con-
sciousness. Of this early palsy the details will be given later.

Aside from defective development of the right arm and hand, it left
little trace upon the constitution. She enjoyed good health till two and
one-half years before her death, when the symptoms, due to the
cerebellar tumor, gradually developed. Briefly noted in the order of
their appearance they were, physical and mental languor, slight vertigo
and later uncontrollable vomiting, unstable equilibrium, occasional
occipital headache, some parasthesia in the right arm and leg, deaf-
ness of the right ear, later becoming complete. The cerebellar ataxia
gradually increased, the tendency to fall being toward the right side
and backward. About a year before death vision in the right eye
failed and ultimately there was almost obliteration of special sensa-
tion. The intellect, however, was very little impaired, and that only
on account of the pressure exerted by the encroaching tumor. There
was no involvement of the third, fourth or sixth pair of nerves. Right
optic neuritis was pronounced. The knee jerk was equally exaggerated
on either side and increased by reinforcement. Occasionally the urine
showed traces of sugar, but no albumin. Sensory response to pain,
touch and temperature was well preserved to the end. Operative
measures were not advised on account of the probably inaccessible loca-
tion of the growth.

The autopsy revealed a nodular, encapsulated tumor — a glio-
sarcoma. It was the size of a small egg, spherical in shape, and
weighed two oanoes. It lay between the right cerebellar hem-
isphere and the inferior margin of the right temporo-sphenoidal
lobe, with the occipital lobe above, and pressed directly upon the
corpora quadrigemina. The growth was bounded on its inner side
by the right eras cerebri, the pons and upper portion of the
medulla. These last two structures had been crowded inward by
the tumor, and thns several of the cranial nerves springing from
them had been subjected to pressure. The growth was almost
entirely free from the surroanding organs, althoagh it involved
some of the cerebellar tissue. It sprang from the middle pedancle
and was partly covered by the cerebellar convolutions. It was
detached enough for ready removal, bat its position anterior to
the cerebellam and adjacent to the most vital structures of the
brain rendered it inaccessible. Of the cranial nerves only the
auditory and glosso-pharyngeal were subject to much pressure,,
althoagh tbe trigeminal was somewhat involved.



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540 CLINICAL BKPOBTS.

Upon removing the calvariam, the membranes were found
unaltered and the blood-vessels uncongested. The cerebral con-
volutions, though flattened, seemed normal, and there was no
superabundance of serous fluid. But just above the junction of
the fissures of Sylvius and Rolando was a cyst, grayish in color
and filled with serous fluid. This cavity, the remnant of the
destructive thrombosis of early childhood, was limited below by
the ascending and horizontal limbs of the Sylvian fissure, and
reached down to the sheath of the left ventricle — the external
capsule and claustrum. It replaced the lower precentral convolu-
tion, the upper part of the operculum, a narrow strip of the ascend-
ing parietal along the Rolandic fissure and nearly the posterior
half of the island of Reil, practically almost the whole of the speech
<^enter. Not only had specific convolutions been destroyed, but
the whole hemisphere suffered arrest of development. The left
cerebrum weighed sixteen ounces, four ounces less than the right,
and its convolutions were less prominent, its sulci shallower and
the cortical gray matter thinner.

Section of the brain showed a similar atrophy of the basal
neuclei. The left striate body was only three-fourths the size of
the right, while the left optic thalamus was a third smaller than
its fellow. The atrophy of the left crus cerebri was marked and
extended into the pyramidal tract.

The right cerebellar hemisphere was a fifth smaller than the
left, weighing two ounces, while the left weighed two and one-
half ounces. The variation in size unquestionably was not due to
the cerebellar tumor, as might be supposed, but rather- to the
earlier defect ; since in atrophy of one cerebral hemisphere, the
alternate cerebellar hemisphere, especially its middle lobe, is retarded
in development. This proportional loss in the right cerebellar hemi-
sphere was exactly identical with that of the left cerebral — in either
case the weight being twenty per cent, less than that of its fellow.

Curiously the cerebral convolutions of the right side, corres-
ponding to the ones destroyed in the left, were strikingly promi-
nent in comparison with the other convolutions of the same side,
or with similar convolutions in other brains. The Rolandic con-
volutions were in reality hypertrophied, and anatomically sug-
gested unusual functional activity.

Outside the brain, as was to be expected, there was more or
less unilateral atrophy of the tissues. The lesion had nearly
destroyed the right arm area, as well as those of thj face and



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CLINICAL BEPOBTS. 541

tongue. The leg area had not been invaded, consequently its
growth was but little retarded. But the right arm and hand were
very small and almost useless, while the right side of the face was
more petite than the left, and that half of the tongue materially
thinner and less promment.

Careful questioning established these facts. Before the paraly-
sis she was right-handed ; after recovery she slowly became left-
handed, learning to write with that hand, though poorly and always
from right to left. The paralysis lasted about three month s»
There was complete loss of speech for four or five weeks ; then it
was gradually restored, though two months more were required
before she could talk well. Her mother volunteered the remark
that '< she seemed to learn to talk over again." There was no
noticeable mental impairment subsequently, though she was not
an apt scholar and cared little for study. Memory was always
good, her temperament cheerful and contented. She possessed a
strong will power.

In her movements she was rather awkward ; could not learn to
dance, found it difficult to run, and in other ways showed evidence
of defective muscular action.

This case of acquired porencephaly possesses two features of
some importance. We know that a lesion of the left third frontal
convolution with consequent loss of speech, is soon compensated
in early life by the development of a speech function which
apparently lies dormant in the corresponding convolutions of the
opposite hemisphere. But in the present instance, in addition to
the clinical facts, is the anatomical one of undue development of
the right motor convolutions corresponding to the ones destroyed
on the left side. Again, this decided hypertrophy of certain
cerebral convolutions, due to increased functional need, exemplifies
the effect muscular activity exercises upon the growth of the con-
trolling nervous centers. Is it not fair to assume that we may
thus explain, in part, the value of passive muscular exercise^
whether by electricity, massage or other means, in the treatment
of paralysis ? Mechanical stimulation of the affected muscles not
alone benefits by improving local nutrition. It has central
influence as well. I believe that persistent exercise of any muscle
distinctly influences the growth of its cortical center. It would
be a matter of great value to determine whether physical trainings
influencing as it must the motor area of the brain, stimulates in
any way intellectual development.

295 Alexandeb Stbeet.



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^42 SSLECTIOKS.



SUPPURATING MYOMA OF THE UTERINE WALL FOL-
LOWED BY TWIN PREGNANCY.

Bt JAMES F. W. ROSS, M. D.

Lecturer in Gynecology in the Woman's Medical College ; Gynecologist to St. John*s

Hospital, Toronto General Hospital, and St. Michaers Hospital.

The following notes are taken from my case book : Mrs. J., »t.
28, kindly referred to me by Dr. Stevenson, of Trenton, admitted
July 22, 1891. Nothing unasaal about menstrual history ; was
married two years ago ; had a child born in May, 1891, good
delivery. Four years ago she had a sickness that was attended by
much vomiting ; had a good deal of pain in the region of the
bladder and pain in passing water — only a few drops of water
would pass at a time, and there was a frequent desire to micturate.
On the 2'7th of May her child was born ; four days after she
noticed a pain in the right iliac region, that shot across the abdo-
men and across the back ; the pain was severe. At first it was
constant ; it gradually became diminished ; and now, July 22d,
only occurs for a few hours every day or night. Since her con-
finement she has noticed -an enlargement on the right side, low
down in the abdomen. After the confinement thelochial discharge
lasted for six weeks.

Two weeks ago — that is, during the first week in July, and
about ^Ye weeks after her confinement — a greenish-yellow, thick
foul-smelling discharge commenced to flow freely from the vagina.
At present the discharge is thinner, not so offensive, and has every
appearance of laudable pus. The discharge has gradually been
increasing in quantity. Patient looks very ill ; she lies on her
left side, as it hurts her to turn on her back. There is pain on
pressure over the abdomen, chiefly in the left iliac region ;
tympanites present ; she has an aching pain in the right iliac
region. Has been troubled with painful micturition for the last
week or two. The urine is found normal.

On inspecting the genitals, I found a large abscess in the left
labia majora, and a very offensive discharge of pus from the
vagina ; the parts were all reddened and inflamed as a consequence
of the irritation of the discharge of this pus. The os uteri was
enlarged, and the cervical canal patulous. One finger was passed
in, and a large fibroid, about the size of a child's head, was dis-



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SELBCTIONS. 543

covered pressing into the cavity of the uterus. The patient was
placed under chloroform, and on exploring the interior of the
uterus the fingers burst into a horrible sloughing mass, evidently a
sloughing intramural fibroid. The cervix was still further dilated,
and by means of gallstone forceps and fingers the tumor was
scooped out until the surface towards the peritoneal cavity was as
much diminished in thickness as was consistent with safety. The
hemorrhage was free, but the uterine cavity, and the cavity of the
tumor, were tamponed tightly with iodoform gauze tied into knots,
together with vaginal packing, and a pad and bandage to com-
press the genitals.

The abscess in the left labia majora was freely incised, and a
large quantity of pus evacuated. The uterine cavity was douched
out twice daily for a few days, and the uterine cavity repacked
with iodoform gauze. The patient made an uninterrupted recovery.
One would have thought that the uterus of such a case would be
so much weakened by such a large growth in its wall that
pregnancy would scarcely be carried through at any subsequent
period with safety. ^The tumor had a very broad attachment, and
was not one of those intra-uterine fibroids with a pedicle, but
bulged out into the abdominal cavity, so that the junction of the
uterine muscular tissue could be distinctly felt above and below it
by a depression. The uterine wall was implicated from the fundus
to the internal os.

The reason I relate the history of the case at this late date after
her recovery is owing to the factr that I have just received a letter
from her medical attendant, who states : '' Mrs. J., the patient of
mine on whom you operated, has since been safely delivered of



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 54 of 78)