% Pii[i[oi| of iospitat jpraqtiije. CASE OF SUPPOSED CEREBRAL
TUMOUR,
TREPHINING. By Suugx.-Lieut.-Col. W. K. Hatch, m.b., f.r.c.s.
The patient, a man of 40 years, was admitted under the care of Surgeon-Major Lyons in Januaiy, 1897. He had been a paiuter and lately a butler by occupation, but owing to the occurrence of fits which caused him to fall suddenly and to break whatever he had in his hands, he sought admission into hospital. He had suffered from small-pox and malarial fever, and for the last nine or tenj-ears from fits, which he said came on suddenly on alternate days, and sometimes three or four times in the day; no syphilitic history could be ascertained. The fits were preceded by giddiness and headache for half an hour, after which he would fall suddenly to the ground and become unconscious. The family history was quite satisfactory. He was emaciated and had an anxious look, and appeared to be in pain, pain was complained of in the head and also in left shoulder. The left eyeball seem ed rather more prominent than the right. His pulse was slow and incompressible, 56 per minute. There was a small wound in the scalp, four inches behind the left ear, another on left shoulder, and a scar over left orbit, all said to be due to falls. The heart and lungs were normal, also the abdominal viscera, and the urine shewed no signs of phosphates, albumen or sugar. As to the duration of fits, no statement could be obtained; but there was no foaming at the mouth or biting of the tongue. Vision was weak; no signs of anaesthesia or hypersesthesia were present. The patient walked with a little difficult}7 owing to giddiness, but paralysis was not present. Further examination of the eyes showed doubts of his neuritis. The bowels were confined. On the 16th January, that is,on the 3rd day after admission, he had a fit which lasted a minute only, it began with shaking of the left upper extremity, twitchings of the facial muscles and convulsive movements of the whole body followed, the teeth chattered and saliva dribbled from the mouth, pain was felt in the occipital region. He became quite unconscious, the temperature was normal; next day he had another fit, and he appeared very dull afterwards and answered questions slowly. An enema was given,and the bowels were opened; but next day the patient did not know anything about it, and complained of feeling very giddy. After this he gradually improved and became more intelligent until the 27th, when his temperature rose to 1026? in the evening; there were no fits observed in the interval, though it is possible he may have had one, at all events the headache was less, some blood was noticed in the stools, and two haemorrhoids came down. On the 29th another tit came on when he was lying on ?
.
d
214
INDIAN MEDICAL GAZETTE.
fingers of the left hand were then the fingers of the right and flexed, forcibly
his left side ; the
hand in a similar way; the left leg was then flexed and subsequently the right, saliva dribbling from the mouth. The patient then attempted to rise from the bed, but could not do so, he began to mutter and to make movements with his hands as if he were sewing. The eyes remained wide open, and the patient was quite unconscious, but recovered partially in five minutes, and was since conscious for three hours, after which lie said he was better, and had less headache, but did not remember anything. There was slight shivering, and the pulse rose to 88 per minute. On the 5th February the right optic disc was found to be less inflamed, the left was worse, and there was a recent hemorrhage below it. Another fit was observed on lltli February, on the 23rd, 27th, and again on March 16th, 17th and 29th, and several attacks of a similar nature in April and June. Treatment by iodides and bromides did not do an}7 good, and Dr. Lyons therefore transferred him to my wards on 8th July in order that he might be trephined. Examination at that time did not elicit anything further; the left eyeball was just as prominent, but not more so than before, and no signs or history of any injury to the head could be made out. On the 13th of July the patient was thoroughly prepared for operation, and chloroformed, a point over the lower end of the left motor area was marked on the bone, and a horse-shoe incision having been made, a skin flap was raised, the large-sized trephine was applied, and the dura mater exposed ; it appeared normal and pulsation could be felt, the disc of bone was not replaced, but the skin flap was sutured and dressings applied. He had a very bad night, was restless and vomited, for the next few days he complained of headache; the temperature was normal until the 20th when it rose to 100?, the bowels were constipated and purgatives were given. On the 24th he had the first fit after operation, and bit his tongue slightly, the fit lasted 15 minutes, much longer than usual. On the 28th he was again put under chloroform, the former flap was raised, and the trephine applied behind the site of the first operation ; the bone was removed, the dura mater had an cedematous appearance, and was opened carefully; another circle of bone was removed above the second opening, its upper margin being close to the longitudinal sinus, the bridge of bone between the two openings was snipped through, the area of brain exposed was carefully examined ; but nothing abnormal could be detected, though a fine trocar and canula was introduced twice. The scalp dura mater was then sutured and scalp replaced. For several days pain, nausea and giddiness were complained of, the temperature did not rise. On the 3rd August he had a slight fit, and the
[.Tone
1898.
all was well; lie until the 15th, when he had a fit of very short duration, and another on 17th, after this lie was much better until 27th when he had another fit. On September 12th, he again had a fit, but remained free from fits until 18th of October, during this time his condition was much improved, headache became less, and his mental state was also better. No difference in the condition of the eyes or prominence The trephine of the eyeball was detected. openings could be easily felt through the scalp He now said and became gradually depressed. he felt well enough to go to work, and was discharged with orders to shew himself once a fortnight, but he never returned to hospital. In the absence of any history of syphilis, injury or tubercle Dr. Lyons was of opinion that there was a growth pressing on the lower part of the left motor area. The improvement of the patient after operation and the absence of any bulging of the dura mater and brain was however against this, I am inclined myself to think the fits were epileptic ; the condition of the eyes and prominence of the eyeball would not, however, be accounted for.
dressings
were
removed,
gradually improved
?
TUMOUR,
TREPHINING. By Suugx.-Lieut.-Col. W. K. Hatch, m.b., f.r.c.s.
The patient, a man of 40 years, was admitted under the care of Surgeon-Major Lyons in Januaiy, 1897. He had been a paiuter and lately a butler by occupation, but owing to the occurrence of fits which caused him to fall suddenly and to break whatever he had in his hands, he sought admission into hospital. He had suffered from small-pox and malarial fever, and for the last nine or tenj-ears from fits, which he said came on suddenly on alternate days, and sometimes three or four times in the day; no syphilitic history could be ascertained. The fits were preceded by giddiness and headache for half an hour, after which he would fall suddenly to the ground and become unconscious. The family history was quite satisfactory. He was emaciated and had an anxious look, and appeared to be in pain, pain was complained of in the head and also in left shoulder. The left eyeball seem ed rather more prominent than the right. His pulse was slow and incompressible, 56 per minute. There was a small wound in the scalp, four inches behind the left ear, another on left shoulder, and a scar over left orbit, all said to be due to falls. The heart and lungs were normal, also the abdominal viscera, and the urine shewed no signs of phosphates, albumen or sugar. As to the duration of fits, no statement could be obtained; but there was no foaming at the mouth or biting of the tongue. Vision was weak; no signs of anaesthesia or hypersesthesia were present. The patient walked with a little difficult}7 owing to giddiness, but paralysis was not present. Further examination of the eyes showed doubts of his neuritis. The bowels were confined. On the 16th January, that is,on the 3rd day after admission, he had a fit which lasted a minute only, it began with shaking of the left upper extremity, twitchings of the facial muscles and convulsive movements of the whole body followed, the teeth chattered and saliva dribbled from the mouth, pain was felt in the occipital region. He became quite unconscious, the temperature was normal; next day he had another fit, and he appeared very dull afterwards and answered questions slowly. An enema was given,and the bowels were opened; but next day the patient did not know anything about it, and complained of feeling very giddy. After this he gradually improved and became more intelligent until the 27th, when his temperature rose to 1026? in the evening; there were no fits observed in the interval, though it is possible he may have had one, at all events the headache was less, some blood was noticed in the stools, and two haemorrhoids came down. On the 29th another tit came on when he was lying on ?
.
d
214
INDIAN MEDICAL GAZETTE.
fingers of the left hand were then the fingers of the right and flexed, forcibly
his left side ; the
hand in a similar way; the left leg was then flexed and subsequently the right, saliva dribbling from the mouth. The patient then attempted to rise from the bed, but could not do so, he began to mutter and to make movements with his hands as if he were sewing. The eyes remained wide open, and the patient was quite unconscious, but recovered partially in five minutes, and was since conscious for three hours, after which lie said he was better, and had less headache, but did not remember anything. There was slight shivering, and the pulse rose to 88 per minute. On the 5th February the right optic disc was found to be less inflamed, the left was worse, and there was a recent hemorrhage below it. Another fit was observed on lltli February, on the 23rd, 27th, and again on March 16th, 17th and 29th, and several attacks of a similar nature in April and June. Treatment by iodides and bromides did not do an}7 good, and Dr. Lyons therefore transferred him to my wards on 8th July in order that he might be trephined. Examination at that time did not elicit anything further; the left eyeball was just as prominent, but not more so than before, and no signs or history of any injury to the head could be made out. On the 13th of July the patient was thoroughly prepared for operation, and chloroformed, a point over the lower end of the left motor area was marked on the bone, and a horse-shoe incision having been made, a skin flap was raised, the large-sized trephine was applied, and the dura mater exposed ; it appeared normal and pulsation could be felt, the disc of bone was not replaced, but the skin flap was sutured and dressings applied. He had a very bad night, was restless and vomited, for the next few days he complained of headache; the temperature was normal until the 20th when it rose to 100?, the bowels were constipated and purgatives were given. On the 24th he had the first fit after operation, and bit his tongue slightly, the fit lasted 15 minutes, much longer than usual. On the 28th he was again put under chloroform, the former flap was raised, and the trephine applied behind the site of the first operation ; the bone was removed, the dura mater had an cedematous appearance, and was opened carefully; another circle of bone was removed above the second opening, its upper margin being close to the longitudinal sinus, the bridge of bone between the two openings was snipped through, the area of brain exposed was carefully examined ; but nothing abnormal could be detected, though a fine trocar and canula was introduced twice. The scalp dura mater was then sutured and scalp replaced. For several days pain, nausea and giddiness were complained of, the temperature did not rise. On the 3rd August he had a slight fit, and the
[.Tone
1898.
all was well; lie until the 15th, when he had a fit of very short duration, and another on 17th, after this lie was much better until 27th when he had another fit. On September 12th, he again had a fit, but remained free from fits until 18th of October, during this time his condition was much improved, headache became less, and his mental state was also better. No difference in the condition of the eyes or prominence The trephine of the eyeball was detected. openings could be easily felt through the scalp He now said and became gradually depressed. he felt well enough to go to work, and was discharged with orders to shew himself once a fortnight, but he never returned to hospital. In the absence of any history of syphilis, injury or tubercle Dr. Lyons was of opinion that there was a growth pressing on the lower part of the left motor area. The improvement of the patient after operation and the absence of any bulging of the dura mater and brain was however against this, I am inclined myself to think the fits were epileptic ; the condition of the eyes and prominence of the eyeball would not, however, be accounted for.
dressings
were
removed,
gradually improved
?
