sight. Very irritable. Psychic pain and complaints. Incoherence of
ideas. In three to four years some anæsthesia of left leg; the left
hand became rebellious to the will. Paralysis progressed; symptoms
increased very slowly. Intense coryza, with running from the nose,
accompanied with a feeling as if a strange body filled up this cavity.
Great appetite. Had an attack of unconsciousness, preceded by violent
pains and creepings in the left hand, and presenting the following
conditions: Dorsal decubitus; flushed face; head strongly retracted;
{1084} frowning; respiration difficult, but not stertorous; pupils
large and insensible to light; the left eye widely opened, the right
shut; very marked contraction in the orbicular muscle; stringy mucus
in large quantities from right nostril; the left commissure of the lip
strongly carried downward and backward. Tongue white, not deviated.
Limbs of the right side not anæsthetic or paralyzed; the hand strongly
shut. On the left arm painful pricking; the elbow flexed at a right
angle, hand completely paralyzed. Motion diminished in left leg;
sensibility not altered; intelligence obtuse, but the patient responds
to questions. Nausea; hiccough. Finally, diaphragmatic breathing;
asphyxia by strangulation.
Pathology and Location: Tumor size of hen's egg lodged between the
superior surface of the cerebellum and cerebrum.
Remarks: M. Boullet, _Gaz. méd. de Par._, 1834, 2d S., vol. ii. p.
264.
75. Sex and Age: F. 64.
Clinical History: History of a fall down stairs. Headache. Frequent
vomiting. Stupor, and when admitted to the hospital three weeks before
death could not give any account of herself or of her complaint.
Semi-comatose. No definite paralysis. She could move both arms and
legs, but could not stand. Involuntary evacuations. No deviations of
the eyes; apparently saw well. Pupils equal and moderately contracted;
right disc a little redder than the left, but no swelling of the disc.
Died in a convulsion, the right side being most affected.
Pathology and Location: Tumor size of a greengage plum, sprang from
the dura mater just under the tentorium cerebelli on the left side. It
had caused the deep depression of the left lobe of the cerebellum.
Also a small clot, partly decolorized, just outside the right corpus
striatum.
Remarks: B. Bramwell, quoted in _Med. and Surg. Rep._, vol. xxxiv.,
Mar. 11, 1876.
76. Sex and Age: F. 32.
Clinical History: Headache first. Then pain in right eye and numbness
in right arm and leg; vision poor in right eye, with improvement. The
left soon similarly affected, without improvement. Vomiting (patient
was pregnant); vertigo. Ataxia marked. Patellar reflexes diminished.
Tongue protruded to left. Right pupil dilated. Taste abolished on
right side. The left field of vision showed hemianopia of the temporal
side. Both eyes showed optic neuritis. Later, shooting pains in legs
and left arm. Mind clear, but hysteroidal excitement frequent.
Surface-temperature of head elevated. Toward end mental aberration,
then unconsciousness. Died during labor.
Pathology and Location: Sarcoma.
A nodular tumor, size large horse-chestnut, on upper surface of right
lateral hemisphere of cerebellum.
Remarks: J. T. Eskridge, M.D., _Journ. of Nerv. and Ment. Dis._, vol.
xii. No. 1, Jan., 1885.
_Floor of Fourth Ventricle._
Directly or indirectly involved.
77. Sex and Age: F. —.
Clinical History: Vertigo only on standing. Sensibility normal.
Walking and standing impossible. Ataxia of legs. No paralysis. Facial
and trigeminus intact. Dysphagia. Double amaurosis. Eyeballs fixed,
directed forward. Symmetrically dilated pupils. Hearing, smell, and
taste normal. Consciousness clear.
Pathology and Location: Tumor of whole anterior part of vermiform
process of the cerebellum, lying on floor of fourth ventricle. Corpora
quadrigemina compressed to thinness of paper.
Remarks: Curschmann, _Berlin. klin. Wochenschrift_, 1877, p. 237,
quoted by Bernhardt, 227.
78. Sex and Age: M. 6½.
Clinical History: Fell from a bench, striking the occiput. Headache
for a day or two afterward. Slight irregularity in gait. For weeks
restlessness, headache, and motor ataxia the chief symptoms. In three
months speech became indistinct. “He screamed his words.” Defective
memory. Apparent exophthalmus; ataxic movements of the head, and a
look of profound stupidity; epistaxis; bulbar conjunctiva anæsthetic;
left pupil dilated; vomiting. Ophthalmoscopic examination showed
congestion of right optic nerve and left descending neuritis, going on
to progressive atrophy.
Pathology and Location: Glioma.
Anterior portion of the fourth ventricle occupied by a rounded
swelling of the pons; from under surface of the pons enlargement about
equal on both sides. The anterior pyramids at entrance of pons seemed
abnormally elevated, with the point of entrance also deeper than
normal. Corpora quadrigemina much smaller than usual, and seemed
pushed upward and flattened.
Remarks: V. P. Gibney, _Am. Journ. of the Med. Sci._, N. S. vol. lxx.,
July, 1875, p. 142.
{1085} 79. Sex and Age: M. 11.
Clinical History: Fronto-occipital headache. Vertigo. Staggering gait.
Falls often, and to right. No paralysis. Diminution of sight.
Irregularity of movements of eyes. Right strabismus (?). Vomiting.
Pathology and Location: Tubercle.
Size of hazelnut, in middle of vermiform process, above fourth
ventricle. Some softening of surrounding tissue.
Remarks: Capozzi, quoted by Bernhardt, p. 224.
80. Sex and Age: M. 25.
Clinical History: Fronto-occipital headache. No anæsthesia. No
paralysis; staggering gait. Loss of consciousness, with trembling of
upper extremities. Vertigo. Falls to right. Double optic neuritis;
amaurosis; nystagmus. Dementia; moroseness. Vomiting. Sudden death.
Pathology and Location: Between the amygdalæ of cerebellum; in front
of cerebellum, bulging into fourth ventricle, merging with floor of
fourth ventricle. Medulla oblongata pushed forward to right.
Remarks: Annusk, _V. Graefe's Arch._, Bd. xix., 1873, quoted by
Bernhardt, 223.
81. Sex and Age: M. 58.
Clinical History: Headache, vertigo, diplopia; vomiting. Left facial
paralysis. Ptosis of both eyes, worse in left. Contracture of left
masseter. Speech nasal. Sense of pharyngeal obstruction. Both eyes
diverted to right; on looking toward left the right eye turns to
middle line, and left eye does not follow. Pupils contracted, left
more than right. Anæsthesia of right face. Left ear slightly deaf.
Smell and taste normal. Head movable, with deviation. Trunk and
extremities not anæsthetic or paralytic. Later, smell of left side
diminished. Reactions of degeneration in left face.
Pathology and Location: Floor of fourth ventricle to left of median
line, involving motor root of fifth and nuclei of sixth, seventh,
eighth, and ninth nerves on that side.
Remarks: C. Wernicke, _Arch. für Psychiatrie und Nervenkrankh._, vii.
Bd. 5, iii. Heft., 1877, p. 513.
82. Sex and Age: F. 6½.
Clinical History: Symptoms of tubercular meningitis with a few
irregular symptoms; conjugate deviation of the eyes to the left and
upward. Cheyne-Stokes breathing.
Pathology and Location: Tubercular granulation about the size of a
large pea springing from the left side of the fourth ventricle, just
inside the posterior pyramid, midway between the cerebellar peduncle
and calamus scriptorius; touched the under surface of the middle lobe
of cerebellum. Head hydrocephalic. Miliary tubercles along Sylvian
fissure, and a few elsewhere.
Remarks: Morris J. Lewis, _Trans. of Phil. Path. Soc._, 1879-81, vol.
x. p. 172.
_Pons Varolii and Medulla Oblongata._
83. Sex and Age: F. 8.
Clinical History: Right external strabismus, with contraction of the
right corner of the mouth; contraction disappeared, but squint
remained. Persistent cough, with stringy mucous expectoration.
Staggering. Left hemiparesis, with left partial hemianæsthesia. Severe
constipation. Bowels opened only about once in five days. Water passed
voluntarily once every two days. Difficulty of articulation. Squint
had almost disappeared, but later returned for a few days, and then
disappeared entirely. Became unable to walk, or even to sit,
unsupported. Also became unable to speak, but produced strange
inarticulate sounds. Difficulty in swallowing. A marked feature in
this case was the absence of headache. The only pain suffered was the
pain of dull character referred to the left ear, but which lasted only
two days.
Pathology and Location: Occupied the lower half of the pons and the
upper half of the medulla oblongata, bulging most at the lower border
of the pons at the right side, and extending a little lower and higher
at the right side than on the left. Floor of fourth ventricle bulged
slightly, and appeared to be expanded in all directions, so that the
median fissure was pushed decidedly to the left. Incision revealed the
tumor to be a large cyst filled with bloody fluid and detritus. The
lower part of the ventricular floor not involved.
Remarks: C. K. Mills, not before published.
84. Sex and Age: M. 32.
Clinical History: Thrown from a horse and kicked on the head. History
of syphilis; headache, severe at first, always came on at night;
became less severe later. Vertigo. {1086} Defective memory; apathy.
Right hemiparesis; helplessness of all the limbs before death; partial
ptosis of the right side. Sensation diminished in the left side of the
face and in the right limbs. Pupils small before death. Descending
optic neuritis. Conjugate deviations of the eyes and rotation of the
head to the right. Persistent epistaxis; tendency to hemorrhage from
mucous membranes. Constipation.
Pathology and Location: Gumma and fibroma.
(1) Gumma, half an inch in diameter, distinctly limited to the left
upper quarter of the pons. (2) Fibroma, no larger than a pea, between
the dura and pia mater, causing a slight depression in the first
temporal convolution about the junction of its middle and posterior
thirds, and halfway between the parallel fissure and the horizontal
branch of the Sylvian fissure. Microscopical examination of the optic
nerves showed a descending neuritis of subacute character.
Remarks: C. K. Mills, reported at the meeting of the Amer. Neurol.
Assoc., June, 1881, and published in the _Journ. of Nerv. and Mental
Dis._, July, 1881; and _Arch. Med._, vol. viii. No. 1, Aug., 1882.
85. Sex and Age: M. 35.
Clinical History: History of syphilis. Wounded in head by glancing
bullet. Headache of great severity at intervals. Vomiting at time of
headache. Vertigo. Failure of memory and depressed spirits.
Epileptiform attacks. In the spasms lifted up the right side of his
body and worked over toward the left. Occasional cramps in stomach and
legs. Temporal and orbital neuralgias. Descending neuritis, and
eventual atrophy of both optic nerves. Constipation. Died at the close
of a series of convulsions, death being preceded by general paralysis.
Pathology and Location: Gumma.
A rounded mass, quarter of an inch in diameter, attached to the pia
mater, just to the left of the centre of the anterior surface of the
pons. The entire anterior central portion of the pons was softer and
more doughy than usual. At the junction of the pons with the medulla
oblongata was a recent hemorrhage, which had spread downward to about
the middle of the latter.
Remarks: C. K. Mills, _Brain_, Jan., 1880, and _Arch. Med._, vol.
viii. No. 1, Aug., 1882.
86. Sex and Age: M. 5.
Clinical History: At first left internal squint and nightly paroxysms
of excessively silly laughter. Slight paralysis of right arm, with
rigidity. Paresis of right leg, increasing to paralysis, with
rigidity. During sleep arm and leg became relaxed. Difficulty in
swallowing. Paralysis of left orbicularis palpebrarum and left
external rectus muscles. Sensibility not impaired. Electro-muscular
contractility present in all the paralyzed muscles (?). Speech lost,
apparently from difficulty in articulation. Intelligence preserved
till near the close. Sight, smell, and taste good. Later, suffered
from intense headaches and frequent attacks of palpitation of the
heart, with flushing of face and injection of left conjunctiva, and
with increased rigidity of right arm and leg. Death from paralysis of
the pneumogastric.
Pathology and Location: Glioma.
Gliomatous transformation of the pons, but no distinct separable
neoplasm. Had encroached somewhat on cerebellum, particularly in
region of left pneumogastric lobule.
Remarks: W. Pepper, _Trans. Phila. Path. Soc._, 1878-79, vol. ix. p.
136.
87. Sex and Age: M. 2.
Clinical History: Dysphagia; paresis of left arm and ptosis of left
eye, which improved, followed by same symptoms on right side. “Legs
affected.” Head very large. Dribbling. Paralysis of articulation.
Contraction of orbicular muscle, causing ptosis (?). Clonic spasm of
right side of mouth, and rhythmical jactitation of right arm on
attempted movement. Unable to stand or sit. Optic discs normal.
Evacuations involuntary. Left side of face paralyzed. Tonic spasms of
right sterno-mastoid. Later, left arm jerked like right, and rigid
contractions of legs. Retraction of head and occasional spasm of left
sterno-mastoid. Impossible to gauge sensation.
Pathology and Location: Tubercle.
Tumor of left side of lower part of pons and central and posterior
part of upper half of medulla. Cerebral fluid increased. Medulla
oblongata was twice the normal size.
Remarks: J. M. Hobson, M.D., _Brain_, vol. iv. p. 531.
88. Sex and Age: M. 12.
Clinical History: Slight paresis of right side (arm and leg). He spoke
thickly and swallowed badly. Slight headache. Was depressed. Delirious
at night. Slight paresis of left face. {1087} Irregularity of pulse.
Choked discs. Later, paralysis of sixth nerve. Sudden death, probably
in a fit.
Pathology and Location: Glioma.
Membranes of base congested. Tumor, which appeared to occupy the whole
left half of pons varolii. No trace of fifth nerve on left side.
Remarks: Hughlings-Jackson, _Med. Times and Gaz._, Lond., 1874, i.
151.
89. Sex and Age: F. 60.
Clinical History: Headache frontal, severe and almost constant.
Paresis of right arm and leg. Painful spasm of right arm. Paresis
gradually extended to left half of body. Persistent pain in right arm,
with tremor; later, same symptom, less marked, in left arm, simulating
paralysis agitans. Atheromatous arteries. Melancholic; talks to
herself; very hard of hearing. Head directed constantly to right.
Tremor increased on voluntary motion. Atrophy of muscles of arms.
Flexors of legs contractured. Electro-muscular contractility reduced,
especially on right side. Later, pain on touch in right arm. Febrile
intermitting symptoms, simulating malaria. Still later, distinct
contracture of neck. Conjunctivitis of left eye, with corneal dulness,
followed by kerato-iritis, with ulceration of cornea. Dysphagia;
swelling of submaxillary glands. Œdema of lungs.
Pathology and Location: Sarcoma.
Tumor of left side of pons and left cerebellar crus, extending toward
transverse sinus.
Remarks: Petrina, _op. cit._
90. Sex and Age: M. 54.
Clinical History: Severe continuous headache. Eyes constantly turned
to the right. No diplopia. Eyes, moved together, could not turn beyond
the median line of the left, though the right eye alone could be
turned for some distance to the left beyond the median line. Pupils
equal and mobile. No paralysis or loss of sensation. Some dizziness
and stagger in walking. Died of pneumonia.
After the autopsy the position of the head was regarded not as
compensatory for the position of the eyes, but as due to a severing of
fibres joining the rotatory muscles of the head with their reflex
centres.
Pathology and Location: In the pons at a level one centimeter below
the apparent origin of the fifth nerve on the left side. It was so
situated in front of the eminentia teres that it involved the course
of the fibres of the left abducens, and by a little prolongation
across the raphé toward the right side interrupted the fibres of
communication between the centres for the sixth and third nerves. It
did not involve the common nucleus of the sixth and seventh. It
interrupted the posterior-interior longitudinal bundle and the
adjacent part of the raphé. No other lesion was found. The tumor was
the size of a small nut.
Remarks: Quioc, _Lyon Méd._, 1881, July, Nos. 19 and 20, quoted by M.
Allen Starr, _Journ. of Nerv. and Mental Dis._, vol. xi., July, 1884,
p. 377.
_Crura Cerebri._
91. Sex and Age: M. 25.
Clinical History: No headache. Staggering some days before death.
Apoplectic seizure, with right-sided hemiplegia. Ptosis of left side
(some days before death). Loss of consciousness for three or four
days. No vomiting.
Pathology and Location: Glioma.
In left crus cerebri, including also portion of right.
Remarks: Sutton, _Brit. Med. Journ._, Feb., 1870, quoted by Bernhardt,
p. 163.
92. Sex and Age: M. 9.
Clinical History: Awkwardness in using right hand; soon almost
complete paralysis in the right arm. Headache; nausea; vomiting;
double vision, followed by strabismus, due to paralysis of the left
abducens. Occasional twitchings in right hand, but no convulsions.
Paralysis extended to the right leg; staggering gait. Ataxia and
rigidity in the fingers of the paralyzed hand. Pain in the legs. Optic
neuritis.
Pathology and Location: Sarcoma.
Pressing upon the left crus cerebri and the pons.
Remarks: E. C. Seguin, _Journ. of Nerv. and Ment. Dis._, Jan, 1882.
93. Sex and Age: M. 3.
Clinical History: Headache; unnatural drowsiness. Ptosis of right eye,
with very marked divergent strabismus and fully-dilated pupil; similar
paralysis in left eye, not quite so {1088} marked. Paresis of left
leg. Very late, unconsciousness, constant motion of tongue and lips,
and clonic spasms of left arm and leg. Twitching of right face.
Convulsions, death. Duration, about one year.
Pathology and Location: Tubercle.
Size of a walnut in right crus, almost destroying the crus just at its
junction with pons; making pressure on left crus. Third pair of nerves
diminished in size and softened. Recent inflammatory changes at base.
Increased cerebral fluid.
Remarks: S. Browne, _Dublin Q. J. Med. Sci._, 1849, vii. 496-499.
_Middle Region of Base of Brain and Floor of Skull._
94. Sex and Age: F. 35.
Clinical History: History of syphilis. Headache severe, at first with
long intermissions; later, continuous, and often agonizing. Vomiting
with paroxysmal headache, coming on late in illness. Vertigo, usually
with headache. Excitable and irritable. Slight twitching of mouth,
hands, and forearms. Left hemiplegia; upper as well as lower fibres of
facial nerve paralyzed. Left internal strabismus.
Electro-contractility diminished. Difficulty in enunciation.
Sensibility diminished in left leg. Later, hyperæsthesia and great
pain in paralyzed limbs. Conjunctivitis and necrosis of cornea of left
eye; conjunctiva and cornea insensitive. Sight impaired. Descending
optic neuritis. Hearing impaired on left side. Smell defective.
Profuse perspiration, more marked on right side than on left.
Constipation. Temperature, taken in right and left axilla for eleven
weeks before death, gave the following averages: Right axilla, 99.1°,
M.; 100°, E. Left axilla, 99.4°, M.; 101.4°, E. On some days
remarkable falls in temperature to 96°, 95°, and even 94° and 93°.
Average head-temperatures above the normal: for stations on right side
of head averaging about 97°; on left side, about 94.3° F.
Pathology and Location: Gumma.
A twin-tumor, each mass about two-thirds of an inch in diameter, in
front of the optic chiasm. The growths involved the basal termination
of the corpus callosum, the peduncles of the corpus callosum, the
lamina cinerea, and anterior perforated spaces. They also probably
encroached upon the roots of the olfactory nerves, the optic nerves
and commissure, and the anterior portions of the circle of Willis,
which seemed to have been broken in front. The base of the brain, from
the posterior line of the tumor backward to the pons, was markedly
softened. Microscopical sections of optic nerves showed the
appearances peculiar to descending neuritis in a somewhat advanced
stage.
Remarks: C. K. Mills, _Philadelphia Medical Times_, March 23, 1879, in
“Proceedings of the Pathological Society of Philadelphia;” also, _New
York Medical Record_, Aug. 9, 1879, and _Arch. Med._, vol. viii. No.
1, Aug., 1882.
95. Sex and Age: F. 21.
Clinical History: Suffered for three years from excessive thirst and
polyuria, with occasional vague pains in the head. A constant relation
existed between the amount of fluid imbibed and of urine passed.
Specific gravity of urine, 1002. No albumen nor sugar. Eight liters of
urine passed in the twenty-four hours on an average. Slight headache
and dimness of vision shortly before death; no other nervous symptoms.
No ophthalmoscopic examination was made.
Pathology and Location: Sarcoma.
About the size of a chestnut at the base of the brain, at a spot
corresponding to the sella turcica. It had caused complete
degeneration of the optic chiasm, and had encroached considerably on
the circle of Willis.
Remarks: F. Fazio, _Il Morgagni_, quoted in _Med. and Surg. Rep._,
vol. xlii., May 8, 1880, p. 415.
96. Sex and Age: F. 73.
Clinical History: Suffered for several years from post-nasal catarrh,
with enlargement of tonsils and granular pharyngitis. Fulness in right
side of throat; muco-sanguinolent discharge from post-nasal space;
bulging of soft palate. Severe pain through the right side of the
head. Deafness of right ear and dimness of right eye. Mental failure.
Paresis of levator palpebræ superioris and orbicularis; complete
paralysis of external rectus; possibly slight paresis of the muscles
supplied by the third nerve of the right side. Diminished sensibility
of right half of face and cornea, and conjunctiva of right eye. Cornea
opaque; conjunctival catarrh; vision almost nothing; ophthalmoscopic
examination could not be made. Left {1089} eye showed some diminution
in acuity of vision, with concentric narrowing of visual field;
pigmentation.
Pathology and Location: Lobulated epithelioma.
Involved the cribriform plate of the ethmoid bone, the whole of the
body of the sphenoid, and the anterior part of the basilar process of
the occipital bone. These were softened to the consistency of cheese.
Membranes and cerebral substance firmly adherent to the base of the
skull at the inner portion of the bottom of the right cerebral fossa.
Blood-clot in one of the large arteries of the optic papilla.
Sclerosed blood-vessels. Atrophy of optic nerve and retina.
Remarks: W. Pepper, _Trans. of Philada. Path. Soc._ for 1878-79, vol.
ix. p. 138.
97. Sex and Age: F. 25.
Clinical History: Headache (for six years), with vomiting. For three
years had dimness of vision. For a year had blindness. Exophthalmus,
with dilated pupils and fixation of eyeballs. Painful spasm of right
face occasionally. Occasional paresis of left arm and leg, with pain.
Severe vertical headache. Anosmia. Involuntary discharge of urine and
feces. Convulsions. Stupor. No local paralysis of face or extremities.
Death happened unexpectedly.
Pathology and Location: Cancer.
Tumor apparently springing from pituitary body, passing through
infundibulum into right lateral ventricle. Tumor was “almost the shape
and size of goose-egg.” It occupied anterior half of ventricle, and
flattened out thalamus and corpus striatum. By pressure it had
flattened the olfactory and optic nerves. The growth extended into the
sphenoidal fissure, causing absorption of bone.
Remarks: Habershon, _Med. Times and Gaz._, 1864 (2), pp. 463, 464.
98. Sex and Age: M. 44.
Clinical History: No symptoms during life indicating any brain
disease. The patient had died of phthisis.
Pathology and Location: Osteoma.
Consisting of true bone with Haversian canals, occupying position of
infundibulum and corpora albicantia, which were totally absent. Not
connected at all with dura mater. The pituitary body was apparently
healthy.
Remarks: Bristowe, _Tr. Path. Soc. Lond._, vi. 25.
99. Sex and Age: F. —.