Chapter L: J. Lautenbach, in a recent communication to the Philadelphia (2)

Clinical History: Vomiting. Loss of sight and hearing; inability to speak. Somnolence. Pupils widely dilated. Later, all special senses involved. Tongue protrudes to right. Pulse irregular. Right face anæsthetic. Neuro-retinitis in both eyes, worse in right; left eye retained some vision. Hearing and taste perfect; smell impaired. No paralysis. Pain constant over eyes. No convulsions.

Pathology and Location: Under left anterior lobe and extending from falx cerebri, to which it was adherent, over the cribriform plate of the ethmoid, involving left olfactory nerve, backward and diagonally across the sella turcica to right petrous bone, where the end of it pressed on fifth nerve of right side at its point of exit. Pressed upon optic chiasm.

Remarks: E. Williams, _Med. Record_, 1868, pp. 29-31.

9. Sex and Age: M. 49.

Clinical History: Vertigo. Always excessively stupid, allowing himself to be made a fool of. Violent bleeding from the mouth and nose ten years before death, followed by nasal discharge. Frontal headache, especially on left side. Failure of sight. Small tumor in inner upper angle of left orbit, which dislocates left eye outward; right eye also deviated outward without any apparent mechanical reason. Pupils dilated and sluggish. Sight much diminished. Mouth slightly drawn to one side. Speech slow, but not hesitating. Gave replies to questions slowly, and did not usually keep to the point, but clothed his answers in general remarks. A certain amount of self-esteem pervaded his conversation. Continuous headache. Very late, had convulsions which began on the left side and extended to the right.

Pathology and Location: Tumor the size of a large walnut to the right of the middle line, external to the dura mater at a point corresponding to position of right olfactory bulb. Vitreous table of the frontal bone and crista galli of the ethmoid completely destroyed. On the inner side of dura mater another tumor fills the right anterior fossa and a large portion of the left.

Remarks: Obernier, _Virch. Arch._, vol. xxxvi. p. 155, and _Ziemssen's Cycl. Pract. of Medicine_, Am. ed., vol. xii. p. 268.

10. Sex and Age: M. —.

Clinical History: Diminution of vision. At first much reduced, without any ophthalmoscopic changes. Slight headache; loss of appetite; restless sleep; rapid pulse. Vision sank rapidly until completely extinguished. Remained thus for nineteen days; then sight began to return, first in the right eye, and then in the left. Increased, so that an examination of the eccentric fields could be undertaken; this showed absence of the external halves of the fields of {1071} vision—hemianopsia. “The transition of the existing portions of the fields of vision to the lost portions was effected by a region which, by a low light, should be reckoned to the latter, so that then the boundary-line of the defect fell somewhat to the outside of the fixation-point running in the right eye in a vertical direction, and in the left diagonally from the inside and above downward and outward. Within the next four weeks the central vision increased in the right to V = 1/2, and in the left to V = 1/20, while the defect in the eccentric vision continued in the way described.”

Patient died of symptoms of acute meningitis.

Pathology and Location: Sarcomata.

Two tumors: one about the size of a pigeon's egg between the optic trunks in front of the chiasm, surrounded by the optic nerve in a forked manner, the nerve-fibres being parted by it. A second tumor situated beneath the pons, raising the dura mater. It had probably originated in cavernous sinus.

Remarks: Saemisch, _Klin. Monatsblätter_, 1865, p. 51, quoted by Obernier, _Ziemssen's Cycl. of the Pract. of Medicine_, Am. tr., vol. xii. p. 269.

_Rolandic Region—Motor Cortex._

11. Sex and Age: F. 38.

Clinical History: History of syphilis. Blows on the head. Headache, with agonizing paroxysms. Top and right side of head sensitive to percussion and headache severest in these regions. Vomiting; vertigo. Great mental irritability. Severe left-sided spasms, beginning with twitchings in left toes and foot. Partial paralysis of right leg and arm, most marked in leg. Hyperæsthesia. Impaired sight. Choked discs. Head-temperature taken once: right parietal region, 97.2° F.; left parietal region, 96° F.

Pathology and Location: Gumma.

Attached to the fused membranes of the right convexity. Involved the upper fourth of the ascending frontal and a smaller segment of the ascending parietal convolution, crossing Rolandic fissure at its upper extremity. A good example of strictly cortical lesion.

Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, August, 1882.

12. Sex and Age: F. 30.

Clinical History: No history of causation. Headache continuous, sometimes agonizing. Percussion of head caused most pain in right parietal region. Vomiting when headache was most severe. Vertigo. Mind clear, but acted slowly: emotional. Spasm, beginning with twitching of fingers of left hand: most severe on left side, and especially in left arm. Upper as well as lower fibres of left facial nerve partially paralyzed; nearly complete paralysis of left arm; slight paralysis of left leg. Bowels and bladder partially paralyzed. Impaired sensibility in limbs of left side. Left patellar reflex diminished. Sight very imperfect. Choked discs. Hearing defective in right ear.

Pathology and Location: Carcinoma.

The tumor involved the middle portion of the ascending parietal convolution and the upper part of the inferior parietal lobule, pushing aside the interparietal fissure. The anterior extremity of the tumor was about one-fifth of an inch back of the centre of the fissure of Rolando. On the inner side of the tumor the white matter of the brain was broken down. Adherent to the pia mater; the pia and dura mater were united by strong adhesions.

Remarks: C. K. Mills, reported at the meeting of the American Neurological Association, June, 1881, _Arch. Med._, vol. viii. No. 1, Aug., 1882.

13. Sex and Age: M. 31.

Clinical History: Evidences of tuberculosis. Headache continuous, with severe exacerbations; most severe at vertex. Vertigo. Some irritability and emotionality; hallucination that some one was going to come and take him away. Spasm confined to left arm. Partial paralysis of left arm and leg, and, late in his illness, of left side of face. Left hemianæsthesia, at first partial, but later complete and persistent. Sight impaired; right pupil dilated and left contracted before death. No ophthalmoscopic examination. Hearing defective in left ear; tinnitus aurium. Head-temperature taken once: right frontal region, 98° F.; left frontal region, 96.3° F. Cheyne-Stokes breathing on day of death.

Pathology and Location: Tubercular tumor.

Dura and pia mater adherent over the tumor, which involved the posterior extremities of first and second frontal and upper thirds of both ascending convolutions of right hemisphere. Interior of hemisphere broken down; the parts destroyed included white matter of the parietal lobe, the posterior third of lenticular nucleus, and the adjacent portion of internal capsule. Miliary tubercles in pia mater around and near the tumor.

Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, Aug., 1882.

{1072} 14. Sex and Age: M. 19.

Clinical History: First symptom, headache; then vertigo. Sudden right brachial monoplegia; possibly some paresis of leg. Recovered use of arm; went to work; was kicked by a mule, and became worse. Headache and right-sided paresis returned. Increasing stupor; paralysis of right arm complete; of leg almost; right facial paresis; ptosis of right side. Partial anæsthesia on right side of face; pain on right side. Slight clonic spasms of right arm. Paralysis of bowels and bladder in last week. Tendency to Cheyne-Stokes respiration. No vomiting. Eyes not examined.

Pathology and Location: Gumma.

A large tumor in the ascending frontal convolution, at junction of middle and upper thirds: one-third of mass on convexity of convolution, the remainder in fissure of Rolando. Smaller tumor at inferior angle of right lobe of cerebellum. Some basal meningitis with effusion.

Remarks: C. K. Mills, _Med. and Surg. Rep._, vol. li., Aug. 2, 1884, p. 119.

15. Sex and Age: M. 56.

Clinical History: Sickness began with an epileptiform seizure lasting about ten minutes; flexing movements of right arm. Next day dragged his right leg slightly. Partial convulsions, without loss of consciousness, followed, and became very frequent. Two months before death convulsions ceased, but absolute paralysis of the arm and paresis of the leg remained. One month later complete palsy of right half of face occurred. Mind became impaired. Complete aphasia. Right-sided anæsthesia. Reflexes of right foot less marked than those of the left. Rectal temperature, 100.4° F. At times deviation of the head and eyes to the left. Left frontal and temporal regions tender to pressure. Very late nystagmus. No headache.

Pathology and Location: Glioma.

In the left ascending frontal convolution, occupying the upper third of this convolution. The tumor extended backward to the fissure of Rolando, and in front was bounded by a vertical line which would meet the upper extremity of the vertical frontal fissure. The inferior boundary was distant about one and three-quarter inches from the longitudinal fissure. Surrounding convolutions flattened and widened.

Remarks: Samt, _Arch. gén. de Méd._, Jan., 1876, from _Berlin. klin. Wochenschr._, Nos. 40, 87.

16. Sex and Age: M. 49.

Clinical History: Irritability and loss of memory. Paresis, passing to paralysis, of left arm; paresis of left leg. Slight left-sided paralysis of tongue. No facial paralysis; no optic neuritis. Ankle-clonus and exaggerated knee-jerk on left side. No wasting of muscles or abnormal electrical reactions. Toward end paroxysmal twitchings of left side, including side of face, with left-sided paresis of face. Hebetude. Visual hallucinations. Complete left hemiplegia. Paralysis of sphincter. Vomiting. Strong contraction of pupils. Duration about two months.

Pathology and Location: Glioma.

Involving the middle portion of the right ascending frontal convolution and posterior end of middle frontal convolution, extending as a spheroidal mass downward to roof of lateral ventricle.

Remarks: A. Hughes Bennett, _Brain_, vol. v., 1882, p. 550.

17. Sex and Age: M. 30.

Clinical History: Convulsions for twelve years prior to death. Character of fit: first, cramping of right big toe, then twitching of calf-muscles and drawing up of leg and knee. Most of the fits stop here, without loss of consciousness. In some fits the arm is convulsed after the leg, beginning in fingers, and consciousness is lost. Paralysis of right leg. Slight convulsive action of left leg. Sensation of right leg unimpaired. Temporary aphasia at beginning of attack; on one occasion the aphasia was present without fit. The right arm probably paretic after each seizure. No facial palsy. Has as many as thirty fits daily. Marked cessation of seizures at one time. Three days before death became hemiplegic, with exaggerated deep reflexes on paralyzed side; also ankle-clonus. During later years fit sometimes began in hand. No optic neuritis while under observation.

Pathology and Location: Glioma.

Left hemisphere, including posterior half of superior frontal convolution and upper half of ascending frontal convolution, except the extreme end. The superficial area was defined by fissure of Rolando posteriorly, superior frontal fissure externally, and longitudinal fissure internally. Anteriorly, the tumor gradually merged into normal brain. In the longitudinal fissure the growth extended to calloso-marginal fissure.

Remarks: J. Hughlings-Jackson, _Brain_, vol. v., 1882, p. 364.

18. Sex and Age: F. 58.

Clinical History: General headache, most marked in the occipital region, and always worse at night. Sore, stiff feeling in neck; at times nausea and vomiting. Trembling {1073} of left hand; later, paresis. Two sorts of movements of left arm—one, a fine tremor; the other, attacks of jerking. Paresis of left arm increasing, with some contracture; slight paresis of left leg. Sight failing; later, semi-stupor; pupils small and fixed, the right larger. Right internal rectus weak. Left lower face paretic. Strong contractures of left arm and hand. Good knee-jerk. Choked discs. Some days bright, others almost moribund. Case advanced to complete paralysis of left arm and leg; involuntary evacuations; divergent strabismus and ptosis; indistinct speech; delirium and coma.

Pathology and Location: Alveolar carcinoma.

An ovoid tumor in the upper part of the ascending frontal convolution and in its subjacent white matter. It extended well across the fissure of Rolando.

Remarks: E. C. Seguin, _Opera Minora_, p. 495, and _Journal of Nervous and Mental Disease_, vol. viii. No. 3, July, 1881.

19. Sex and Age: M. 50.

Clinical History: History of syphilis and severe fall on the head. Vertigo. Prickling sensation in left foot, extending to thigh, finally to arm and head, followed by unconsciousness and convulsion. Stupor after convulsion. After this, convulsive attacks at intervals. Eighteen months before death an apoplectic attack, in which was unconscious for several hours. Spasmodic attacks, preceded by a peculiar twisting of the fingers of the left hand. Paresis of the right hand and arm. Some diminution of sensation, not well made out. Slight want of use of the left leg.

Pathology and Location: Gumma.

One-third of an inch in thickness at the middle of the ascending frontal convolution. Membranes fused; tumor adherent to them. Œdema of the brain. Gumma in the lungs.

Remarks: H. C. Wood, “Proceedings of the Philada. Neurological Society,” _Medical News_, vol. xlviii. No. 9, Feb. 27, 1886, p. 248.

20. Sex and Age: M. 59.

Clinical History: Gradual loss of speech—aphasia. Gradual paralysis of right side. No headache prior to this. No anæsthesia. Taste, smell, hearing, and sight intact. Apathetic face. Middle branch of facial nerve paralyzed, especially the muscles of the right corner of the mouth. Wrinkles of forehead less strongly marked. Right upper and right lower extremity in strong contracture. Leg swollen. Increasing torpor of bladder. Normal electrical reactions, except speedier and increased reaction of the right facial nerve. Reactions of convulsibility in the right arm with ten to twenty cells. Very late, unconsciousness and paralysis of bowels and bladder.

Pathology and Location: Myxo-glioma.

In front of the left ascending frontal convolution, bounded below by the Sylvian fissure and the upper convolution of the island of Reil; seems to immediately enter into the structure of the island. Left optic thalamus and corpus striatum moist, but completely separated from the tumor. Convolutions flattened.

Remarks: Petrina, _op. cit._

21. Sex and Age: M. 35.

Clinical History: Had epileptic fits for two years before his death. Occasionally the spasms began in the left half of the face and extended to the arm and leg, but did not become general. After such attacks sensation was lost in the left arm, and the arm was paretic for some hours. Toward the close of life the paresis became permanent, and extended from the arm to the leg, and sensibility was somewhat impaired in these limbs. The temperature was 2.5° F. higher over the right parietal eminence than over the left.

Pathology and Location: Gumma.

Arising from the membranes, two inches in diameter, but very thin, involved the gray matter of the posterior extremities of the first and second frontal convolutions, the upper and middle thirds of the ascending frontal convolution, and the adjacent border of the ascending parietal convolution of right hemisphere.

Remarks: F. H. Martin, _Chicago Med. Journ. and Exam._, vol. xlvi. 21.

22. Sex and Age: F. 57.

Clinical History: After excitement lost consciousness. Paresis and heaviness of the right upper extremity. Aphasia; used words inaccurately; short of words and enunciation impaired. Second attack of loss of consciousness. Twitching in right half of body and face. Paralysis of right upper extremity. Severe pains in right arm and leg. Another attack of loss of consciousness, with spasms of right half of body. Right lower extremity and right lower face paretic. Slight trismus; right masseter contracted. Dull headache. Organs of sense not affected. Understands all that is said to her, although aphasic. {1074} Sensibility good. Right-sided pneumonia; œdema of lung.

Pathology and Location: Fibro-glioma.

Tumor size of fist occupied the whole of the lower and middle portion of the parietal lobe, imbedded in both ascending convolutions. Ascending frontal convolution pushed aside; the annectant gyrus and island of Reil compressed and flattened. Fissure of Sylvius arched over by tumor. White substance also pushed toward the corpus striatum. Meninges congested. Left parietal bone somewhat excavated.

Remarks: Petrina, _op. cit._

23. Sex and Age: F. 39.

Clinical History: Began to suffer with epilepsy two weeks after a blow on the left parietal region. The fits were preceded by formication in the right hand and tongue, and began with spasm in the right hand, which was weak for some hours afterward. A permanent right facial paresis developed one month after the blow, and two months later the tongue, arm, and hand were also paretic on the right side. Disturbance of vision due to choked discs had developed, and temporary attacks of aphasia occurred after the frequent convulsions. She sank into a condition of stupor and aphasia four months after the first symptoms. The skull was then trephined at the seat of the old injury in hopes of evacuating a chronic abscess, but no pus was found. One week after this she died.

Pathology and Location: Gumma.

A gumma one inch in diameter was found on the surface of the left hemisphere, at the junction of the middle and lower thirds of the ascending parietal convolution, and involving also the convolution posterior to this. The membranes were adherent to the gumma.

Remarks: H. B. Sands, _Med. News_, April 28, 1883.

24. Sex and Age: M. 25.

Clinical History: Four years previous to death had received a blow on the left side of the head. A year later, twitching in the tongue and the left side of the face. Twitching of the left arm. Twitching increased. Paroxysmal spasm and general convulsions, with loss of consciousness. Paresis, and then slowly-developed paralysis, of the forearm and hand. Some paresis of left leg. Double optic neuritis. Violent headache.

This patient was in charge of Hughes-Bennett at the Hospital for Epilepsy and Paralysis, London. He diagnosticated brain tumor, and suggested its removal. Rickman Godlee trephined over suspected region, and removed a glioma of the size of a walnut. The operation was performed November 25th. The patient did well until December 16th, when he was seized with a rigor, followed by fever, sickness, and pain in the head. A hernia cerebri of large dimensions supervening, he died December 23d.

Pathology and Location: Glioma.

Meningitis was found at the lower border of the wound, spreading downward toward the base of the brain.

Remarks: Hughes-Bennett and Rickman Godlee, _British Medical Journal_, Nov. 29, 1885.

25. Sex and Age: F. —.

Clinical History: Syphilitic history. Tingling sensation and numbness of the left arm and leg, which increased until it ended within six weeks from its commencement in complete motor paralysis, with a deficiency in the perception of touch. Left side of the face also slightly paretic. Mental confusion and loss of memory.

Pathology and Location: After antisyphilitic treatment and counter-irritation, trephining was performed over the middle of the ascending parietal and frontal convolutions. Internal table of the disc removed was found softened and thicker than usual, having on its internal surface projections or roughnesses. A second opening was made over the occipital region, and a similar thickening was found. Opposite first opening the dura mater pale and thickened. It was elevated, and a false membrane of yellow color was removed. An incision was made in the direction of the {1075} paracentral lobule, when a gush of grumous, red-colored fluid escaped.

Day after the operation much better; on third day moved her toes; within a week lifted her leg; fingers moved within a week. Mind greatly changed for the better.

Remarks: Macewen, “Proceedings of Path. and Clin. Soc. of Glasgow,” _Glasgow Med. Journ._, vol. xxi., 1884, p. 142.

_Centrum Ovale—Fronto-parietal Region._

26. Sex and Age: F. 16.

Clinical History: Fell when sixteen months old from the table on her head. Left hand, five months later, noticed at times to be stiff and firmly closed. Three months later the leg became similarly affected, and two months later general paroxysms. Many seizures for periods of weeks or months, then intervals of freedom. Spasm began by contraction of the left hand: she would lie down and jerk for a half minute or minute, laughing or talking all through it, never losing consciousness. In about six years left leg became paretic. Seizures became much worse and more frequent; unconscious for six weeks, and fifty to eighty spasms in twenty-four hours. Ten months without spasms until a week before death, when they returned with great violence. Spasms always began in the left hand; appeared to extend to the leg first, and then to the face. Intellect clear.

Pathology and Location: Fibro-glioma.

In the white matter, but touching upon the gray at several spots at the position of the upper end of the ascending frontal convolution of the right hemisphere. The tumor occupied largely the anterior portion of the paracentral lobule.

Remarks: Osler, _Medical News_, vol. xliii., Jan. 19, 1884, in “Proceedings of Medico-Chirurgical Society of Montreal;” also, _Am. Journ. Med. Sci._, N. S. vol. lxxxix., Jan., 1883, p. 31.

27. Sex and Age: M. —.

Clinical History: Severe fall, followed by insensibility. Paralysis of the left side followed injury, but improved. Three years later, epileptic convulsions: sudden fall, general spasm, biting tongue. These attacks replaced by partial or localized epilepsy without loss of consciousness: tonico-clonic spasm of muscles of left side of face and neck and of left upper extremity, especially of the thumb and index finger. Left pupil a trifle larger than right; left cheek paretic, left arm and forearm absolutely paralyzed; left leg weak. Marked tactile anæsthesia on left side. Ophthalmoscope showed fulness of veins, but no neuro-retinitis. Late, some opisthotonos. Deafness in right ear; axillary temperature, 36.4° C. Pain in right arm and leg and in posterior part of head on right side. Conjugate deviation of head and eyes from palsied side. No neuro-retinitis. Localized and general convulsions recurred from time to time.

Pathology and Location: Sarcoma.

Larger than a hen's egg in white substance of right hemisphere, occupying the whole thickness of the hemisphere above the opto-striate bodies. Exerted much pressure upon these bodies, on convolutions near, and even upon the inner surface of the left hemisphere. Adherent to the dura mater. Right half of the brain much enlarged, and lateral ventricle and septum lucidum forced over to the left. Two depressions on the top of the skull; dura mater depressed and adherent to convolutions. Some pachymeningitis.

Remarks: E. C. Seguin, _Opera Minora_, p. 215; reprinted from the _Transactions of the Amer. Neurol. Ass._, vol. ii., 1877.

28. Sex and Age: M. 34.

Clinical History: Attacks of right-sided epilepsy every four or six weeks; later, every week or oftener. Spasms wholly restricted to the right arm or leg; the slightest attacks only momentary shocks on the right side of the body. No spasm in the face. Only very rarely lost consciousness. Never frothed at the mouth, bit his tongue, or micturated in the attacks. In intervals had good use of his right hand and leg up to a late period. Paresis of right limbs came on with indefinite numbness of right leg. Diffused headache, mostly frontal. No facial palsy; no anæsthesia. Knee-jerk absent on left side and strong on right. {1076} Later, complete paralysis of right arm and leg, with œdema. Violent headaches, more to the left of the median line at the vertex; photophobia, nausea, and vomiting. No neuro-retinitis. Still later, paresis, and then paralysis of right face. Atrophy; contractures; bed-sores; semi-coma; profuse sweating; high temperature; conjugate deviation of the eyes to the right; head straight.

Pathology and Location: Sarcoma.

In centrum ovale, underneath the left cortical motor area, and completely undermining it, was a large cavity which contained a large amount of coffee-red serum, and also a tumor lying on its inner side near the paracentral lobule. The tumor was connected behind with the falx cerebri in the region of the paracentral lobule.

Remarks: E. C. Seguin, _Opera Minora_, p. 499, and _Journ. of Nerv. and Mental Dis._, July, 1881.

29. Sex and Age: M. 22.

Clinical History: First symptom was a fit, which was followed by a rigor. After this fit paresis of right arm and leg, with inability to articulate properly. Could not raise the affected arm, but could grip objects weakly. Paralysis of right side of face and tongue. Was quite rational. No loss of sensation. Later, violent headache, followed by vomiting. Slight amelioration of many symptoms, soon followed by second attack of violent headache, which could not be localized; complete right hemiplegia and aphasia. Later, dysphagia. Death rather sudden.

Patient had had amputation of thigh about six months before for sarcomatous enchondroma of head of the tibia. Had also had chancre four years before.

Pathology and Location: Enchondroma.

In left hemisphere, between anterior part of corpus striatum and “surface of frontal lobe.” The cortex over tumor and the outer and anterior portion of corpus striatum were softened and broken down.

Remarks: T. P. Pick, _St. George Hosp. Rep._, vol. ix. p. 663.

30. Sex and Age: F. 16.

Clinical History: Patient was a wayward, hysterical girl of neurotic family, precocious, and with abnormal sexual instincts and indulgences. Had a sudden attack of total blindness, then sudden recovery; sudden blindness again, and deafness; then restoration of hearing; loss of power in lower limbs, ending with total blindness, deafness, and paraplegia. Had dilated pupils and some hyperæsthesia; also marked hysteroidal attacks, becoming at last maniacal.

Negatively, no constant headache or affection of ocular, facial, or lingual muscles, no convulsions or vomiting; no abnormal ophthalmoscopic appearances (except slight choked disc).

The case had been diagnosticated by many doctors and one of the “first authorities in Europe” to be hysteria.

Pathology and Location: Tumor in right hemisphere, size of hen's egg, translucent, and nodulated, soft, highly vascular, with small extravasations of blood on its surface, occupied medullary substance of middle lobe superior to lateral ventricle causing bulging of roof of ventricle.

Remarks: A. Hughes-Bennett, _Brain_, 1878, vol. i. p. 114.

_Postero-parietal Region._

31. Sex and Age: M. 25.

Clinical History: Kicked on the head. Headache, nearly continuous, with violent paroxysms. Vomiting at intervals, most when headache was most violent. Vertigo. Mental confusion; sometimes maniacal. Left convergent strabismus. Partial right hemianæsthesia. Patellar reflexes slightly exaggerated; slight ankle-clonus on the right side. Blind in both eyes; sight of right eye lost first. Choked discs, and eventually optic atrophy. Hearing defective in right ear. Constipation. Head-temperatures taken once; right parietal region, 98° F.; left parietal, 97.8° F.

Pathology and Location: Fibroma.

Adherent to membranes, and involving the left postero-parietal and occipital region to within half an inch of longitudinal fissure. The brain-tissue around softened and broken down, the parts disintegrated being chiefly the white matter of the postero-parietal and occipital lobes.

Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, August, 1882.

32. Sex and Age: M. 49.

Clinical History: Dropping of left hand at intervals, with power regained in about an hour. Brief attacks of loss of speech, and numbness in lips and tongue on both sides. Numbness in tips of his fingers and the left hand. Slight paroxysms of general rigidity. Severe frontal headache. No vomiting. Loss of sight, gradually increasing to total blindness. Involuntary micturition. Increasing hebetude. Slow but probably correct intellection. Left upper extremity, toward last, paretic. Was able to stand, but could scarcely walk. Hearing and taste preserved. {1077} Some doubt as to smell. Later, imbecile. After a severe fit of general convulsions he died. Duration, about four months.

Pathology and Location: Carcinoma.

It occupied nearly exactly the site of the right “poster-parietal lobule” (superior parietal). It was clear of the ascending parietal convolution in front, and behind did not quite touch the external parieto-occipital fissure; below it extended just short of the intraparietal fissure, and on inner face of hemisphere reached for half an inch into quadrilateral lobe. Below tumor toward ventricle brain-substance softened.

Remarks: James Russell, _Brit. Med. Journ._, 1876, ii. p. 709.

33. Sex and Age: F. 36.

Clinical History: Right-sided temporal and orbital neuralgia. Anæsthesia of left arm. Epileptic attacks. Slighter attacks of spasm, without unconsciousness, in left face, left arm, and hand. Paresis of left arm. Blindness. Optic neuritis. Pupils dilated and immobile. Later, loss of smell and taste. Mental depression.

Pathology and Location: Gummata.

In right supramarginal lobule two tumors size of pea, lying superficially.

Remarks: Broadbent, _Lancet_, Jan., Feb., 1874, quoted by Bernhardt, p. 68.

_Beitrage zur Symptomatologie und Diagnostik der Herngeschwülste_, von Dr. M. Bernhardt, Berlin, 1881.

34. Sex and Age: ——

Clinical History: Left hemiplegia with some anæsthesia. Deafness developed in the left ear, with a total inability to localize the origin of sounds.

Pathology and Location: Tumor size of an apple in middle of ascending parietal convolution and backward. Around the tumor white softening, which extended forward as far as the fissure of Rolando, and backward throughout the right parietal lobe, and beneath almost into the central ganglia.

Remarks: Strümpell, _Neurolog. Centralb._, Aug. 15, 1882.

35. Sex and Age: M. 54.

Clinical History: Middle finger of the right hand began to jerk violently, also some of the flexor tendons. Twenty minutes after this he had a fit, in which he became unconscious and beat himself violently on the chest with the right arm. Had three of these fits. Aphasic after this for two weeks. Had high fever at the time of the seizures; was rubbed all over the body with ice. The fingers became paretic, not the forearm or arm. Arm became numb at times, especially after exertion. With dynamometer, left hand, 75; right hand, 55. Headache, which ceased after some months. Right optic disc abnormally red, but not choked; left disc normal. Had a convulsive attack in the Philadelphia Hospital, in which the four fingers of the right hand rapidly vibrated, contracting and extending without pain; no loss of consciousness or other disturbance. The tongue was also affected, so that speech was impossible. Later, the patient had a general convulsion, preceded by a drawing sensation in the face; convulsive movements began in right hand. Tongue bitten. Attack preceded by severe headache. Had another attack without loss of consciousness or convulsion, preceded by a sensation as of a knife cutting through the flesh, which travelled up from the left hand to the shoulder, and then to the head. Increasing loss of sensation in the fingers of the right hand. Increasing difficulty of speech, with spells of melancholia and crying. Right side of face markedly paralyzed. Right arm almost entirely paralyzed and much swollen. Speech much affected; difficulty in swallowing. Paralysis involves the right leg.

Pathology and Location: Gliomata.

A small tumor occupies the lower end of the left supramarginal convolution, just where it joins the foot of the ascending parietal convolution. The latter convolution was not involved in the tumor, but was distinctly pressed upon in its lower third. The ascending frontal convolution was entirely healthy.

In right hemisphere a similar gliomatous growth in the foot of the angular convolution where it runs into the middle temporo-sphenoidal convolution, involving also the upper part of this convolution, and to a slight extent the deepest portions of the superior temporo-sphenoidal convolution.

Remarks: H. C. Wood. Not before published.

{1078} _Occipital Region._

Occipital lobe—cortex and centrum ovale.

36. Sex and Age: M. 57.

Clinical History: Headache. Vertigo. Paresis of left side. Left facial paralysis, especially middle branch. Vomiting. Right pupil dilated. Tongue not involved. Uvula directed to left. Left velum palati relaxed. Taste, smell, sight, and hearing normal; sensibility of whole body normal. Reaction of degeneration on left side of face. Left side of body shows reaction of convulsibility. Slight quantity of albumen. Paresis declined with exception of facial nerve. Apathetic. Œdema of lung.

Pathology and Location: Glioma.

In middle of right occipital lobe; lobe softened. Right lateral ventricle narrowed and left dilated. Right posterior horn and right thalamus opticus compressed.

Remarks: Petrina, _op. cit._

37. Sex and Age: M. 27.

Clinical History: Dysphagia, most marked with liquids, caused by paresis of pharynx, more marked on left. Left hemiparesis for three years. Headache (frontal and temporal), which is of a boring, tearing character. Failure of memory. Speech guttural and monotonous. Puriform expectoration. Later, feeble voice, hiccough, yawning, somnolence.

Pathology and Location: Fibroma.

On posterior face of left petrous bone and inferior occipital fossa, extending behind occipital foramen and to right of cerebellar falx. A prolongation involving the pneumogastric and glosso-pharyngeal, and spinal accessory. Also cerebellar abscess.

Remarks: Cruveilhier, _Bull. de la Soc. Anat._, 1855, xxx. 475-479.

38. Sex and Age: F. 20.

Clinical History: Headache. Dimness in right eye, then in left; finally, blindness in both. Convulsions. External strabismus; right pupil dilated, left contracted. Coma, alternating with consciousness. Vertigo. Optic discs congested, presenting small hemorrhages; exophthalmus. Paresis of right arm and leg; partial anæsthesiæ on same side. Earache. Vomiting, not frequent. Coma and death.

Duration, about three months.

Pathology and Location: Sarcoma?

Occupied all the posterior part of right hemisphere of cerebrum, pressing upon and indenting opposite hemisphere and right half of the cerebellum.

Remarks: S. O. Habershon, _Guy's Hosp. Rep._, 3d S., xx. 330-334.

39. Sex and Age: M. 18.

Clinical History: Periodical headaches. Pains in the neck and vertebral column. Points of exit of trigeminal nerve sensitive. Staggering gait. Diplopia. Confused sounds in right ear. Tetanoid contractions of neck.

Pathology and Location: Echinococcus.

In right occipital lobe.

Remarks: Visconti, _Annal. Univer._, Oct., 1869, quoted by Bernhardt, p. 98.

40. Sex and Age: F. 21.

Clinical History: Right hemianopsia. Central vision good. Other symptoms: headache, dysarthria, anæsthesia of the right half of the face. No paralysis, no mental symptoms. Choked discs.

Duration seven months.

Pathology and Location: Cystic glioma.

In the left occipital lobe; had reached and destroyed the cortex of the lobe at its apex, and had extended inward, nearly reaching the inferior cornu of the lateral ventricle. The entire inner half of the occipital lobe was thus destroyed.

Remarks: Jany, _Knapp's Archiv f. Augenheilk._, vol. xi. p. 190, quoted by Starr, _Am. Journ. Med. Sci._, N. S., lxxxvii., Jan., 1884, p. 72.

41. Sex and Age: M. 42.

Clinical History: Right hemianopsia. Central vision good. Other symptoms: aphasia, right complete hemiplegia, with facial paralysis.

Pathology and Location: In left occipital lobe, surrounded by a zone of softening, reaching inward to and involving the pulvinar of the left optic thalamus. Optic tracts normal.

Remarks: Hirschberg, _Deut. Zeitsch. f. Prakt. Med._, 1878, No. 4, quoted by M. Allen Starr, _Am. Journ. Med. Sci._, N. S., lxxxvii., Jan., 1884, p. 69.

42. Sex and Age: M. 42.

Clinical History: Right hemianopsia, not quite reaching the point of fixation. Central vision good in both eyes. Ophthalmoscopic examination negative. Other symptoms: vertigo, loss of memory, aphasia, and partial agraphia, with temporary right hemiplegia.

Pathology and Location: Gelatinous sarcoma.

In the left occipital lobe, involving all three of its convolutions, as well as the præcuncus. Softening extended inward through the white substance to the posterior cornu of the lateral ventricle. Thalamus and optic tracts normal.

Remarks: Jastrowitz, _Arch. f. Augenheilk._, 1877, p. 254, quoted by Starr, _Am. Journ. Med. Sci._, N. S., lxxxvii., Jan., 1884, p. 71.

{1079} 43. Sex and Age: M. 40.

Clinical History: For seven years epileptic seizure, beginning with spasm of left leg and going on to general convulsions; motions more violent on left side. An aura consisting of a darkness, coming gradually over the field of vision from the left side, always preceded the attack. During the intervals left-sided headache was the chief symptom. It seems probable that a temporary left hemianopsia preceded the attack.

Pathology and Location: Cyst filled with serum.

In white matter of the right occipital lobe, surrounded by a zone of softening which did not involve either the cortex or the wall of the lateral ventricle.

Remarks: Traube, _Gesammt Beitrage zu Pathologie_, ii. 1083, quoted by Starr, _Am. Journ. Med. Sci._, N. S., vol. lxxxvii., Jan., 1884, p. 73.

44. Sex and Age: M. 52.

Clinical History: Headache. Numbness down right arm. Later, paroxysms of headache lasting twenty to forty minutes, generally preceded by pain and numbness in right hand and arm, ascending to head, and so intense as to produce profuse perspiration. Delirium (lasting two days) during these attacks. No paralysis or previous fit, nor vomiting. Few hours before death had convulsions.

The pain and numbness were in right arm, although tumor was in right hemisphere.

Pathology and Location: Malignant tumor.

Size of pullet's egg at inferior portion of posterior lobe on right side in substance of cerebrum, approaching within a few lines of surface.

Remarks: J. C. Langmore, _Trans. Path. Soc. Lond._, iii. pp. 246-248.

_Temporo-sphenoidal Region._

Temporo-sphenoidal lobe.

45. Sex and Age: M. 33.

Clinical History: History of syphilis. Blows on the head. Headache, continuous, usually dull, occasionally severe. Occasional vomiting. Stupidity, want of energy, drowsiness. One general convulsion a few hours before death. Partial anæsthesia on the right side. Hyperæsthesia of left side. Sight impaired. No ophthalmoscopic examination. Hearing defective in right ear. Constipation.

Pathology and Location: Gumma.

One and a quarter inches in diameter, attached to adherent membranes, and involved the middle portions of the first and second temporal convolutions of left hemisphere. A layer of brain-substance both anterior and posterior to the tumor was softened. The tumor grazed the ascending parietal and inferior parietal convolutions. A large foyer of greenish-yellow pus was found to the inner side of the tumor.

Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, August, 1882.

46. Sex and Age: M. 42.

Clinical History: At first an attack of vertigo which lasted over twenty-four hours: some unconsciousness for a time. Continued headache; loss of memory; giddiness and vomiting, the latter occurring without connection with the state of the stomach as to food. Partial bilateral deafness, which the patient stated was of long duration. No paralysis, but right hand a little weaker than left. Distinct mental failure during last two weeks of life; incoherence and faulty memory.

Pathology and Location: Epithelioma.

Ovoid tumor about one and a half inches in diameter in the central portion of the temporo-occipital region. Hippocampal convolution grazed. Some surrounding softening and meningitis. One corner of tumor had produced a small spot of softening in the cerebellum.

Remarks: H. C. Wood, “Trans. of Path. Soc. of Philada.,” 1880, _Med. Times_, vol. xi., Jan. 29, 1881.

47. Sex and Age: F. 40.

Clinical History: Suffered from a light form of epilepsy dating from tenth year, which resulted, it was believed, from a fall. Rarely bit her tongue, but usually frothed at the mouth. No history of one-sided spasms. Always had an aura of a peculiar character. She suddenly perceived a disagreeable odor, sometimes of smoke, sometimes of a fetid character, and quite uncomplicated by other sensory warning. Developed phthisis, her attacks occurring from time to time until her death.

Pathology and Location: At lower part of right temporo-sphenoidal lobe a shrinking and induration involving the uncinate gyrus and parts of the adjacent convolution. The olfactory nerves were not involved. A form of low-grade hemorrhagic pachymeningitis present.

Remarks: Allan McLane Hamilton, _New York Med. Journ. and Obstet. Review_, vol. xxxv., June, 1882, p. 575.

{1080} 48. Sex and Age: F. 39.

Clinical History: Attacks of convulsion seven weeks before her death. In two weeks mind affected; drowsy and stupid; condition of dementia. Passed into a state of semi-consciousness. No eye symptoms. No paralysis. Percussion on left side of head painful.

Pathology and Location: Sarcoma.

Occupied the posterior part of the fourth and fifth temporal convolutions, and the third convolution was atrophied. Did not involve the lateral ventricle. Under surface flattened and resting partly upon the left lobe of the cerebellum.

Remarks: W. H. Draper, _New York Hosp. Histories_, N. S. vol. x. p. 445, quoted by M. Allen Starr, _Am. Journ. Med. Sci._, N. S. vol. lxxxvii., April, 1884, p. 383.

_Basal Ganglia and Adjoining Regions._

49. Sex and Age: M. 59.

Clinical History: Contractures of right arm and leg since childhood. Death from accident. The arm was atrophied and shortened, flexed at elbow and wrist; disappearance of some cartilages at wrist and wasting of joint-surface of radius. Femur flexed at hip; knee-joint flexed; ankle-joint in position of equinus. Other bone-changes. Right leg shortened.

Pathology and Location: Osteoma.

Tumor in left corpus striatum on “surface of anterior thick half,” projecting outward into white substance of brain, and inward into anterior portion of optic thalamus.

Remarks: A. Bidder, _Arch. f. Path. Anat. und Physiologie, und f. Klinische Med._ Virchow, 1882, p. 91.

50. Sex and Age: M. 30.

Clinical History: Right frontal and occipital headache. Vertigo. Paræsthesia of the toes, particularly the right. Face drawn to the right. Left face paretic. Right eye smaller than left. Weakness and fatigue of limbs. Convulsions. Vomiting. Slow pulse.

Pathology and Location: Myxo-sarcoma.

In right corpus striatum protruding into right lateral ventricle and cortex.

Remarks: Schüppel, _Arch. d. Heilk._, p. 357, 1867.

51. Sex and Age: M. 34.

Clinical History: Walked a mile to an infirmary, and in less than one hour went into a series of severe epileptic attacks, which continued for four hours. The spasms were clonic, and chiefly in upper extremities, with violent contortions of face; the latter most marked on left side and in zygomatici. Between the fits there was deep coma, especially three hours before death, when, after another violent fit, he died, seven hours after first seizure. No paralysis, and report says nothing about any previous fits.

Pathology and Location: Myxomatous glioma.

It exactly occupied the place of right nucleus caudatus, extending outward as far as white fibres, but not involving them. Brain-tissue in proximity normal.

Remarks: Dowson, _Med. S. and Gaz._, London, 1878, p. 333.

52. Sex and Age: ——

Clinical History: Partial anæsthesia of right half of trunk. Hyperæmia of retina, and capillary hyperæmia of left optic disc. Left pupil dilated; left ptosis; left diverging strabismus. Paralysis of right side and extremities. Paralysis of muscles around right corner of mouth. Incontinence of feces and urine. Redness of face. Variations in temperature.

Pathology and Location: Tubercle.

In left optic thalamus. Partial destruction of left peduncle of cerebrum.

Remarks: Fleischmann, _Wien. med. Wochenschrift_, 6, 7, 8, 9, 1871, quoted by Petrina.

53. Sex and Age: F. 44.

Clinical History: Severe headache on left side. Sensibility lessened in left extremities, at same time frequent pain. Intelligence diminished. Speech retarded. Strabismus of left eye. Amblyopia. Left pupil alternately dilated and contracted. Left lagophthalmos. Chattering of the teeth. Twitchings on the left paralyzed half of the face. Tongue and uvula tending toward the left.

Pathology and Location: Sarcoma.

Right optic thalamus. Corpora quadrigemina compressed.

Remarks: Friedreich, quoted by Petrina, _op. cit._

54. Sex and Age: F. 38.

Clinical History: Headache. Creeping sensations in right arm and leg. Right facial paresis. Paresis of left extremities. Convulsions. Dimness and confusion of sight. Diplopia. Hardness of hearing. Failure of memory. Difficulty in speaking and swallowing. Improvement under iodide of potassium.

Pathology and Location: Glioma.

Left optic thalamus.

Remarks: Bruzelius and Blix, 1870, quoted by Bernhardt, 153.

55. Sex and Age: F. 14.

Clinical History: Headache, vertigo. Epileptic attack. Right hemiplegia. No anæsthesia. Slight dilatation of pupils.

Pathology and Location: Sarcoma.

In left optic thalamus. The right optic thalamus also affected. Corpora quadrigemina enlarged and pushed backward.

Remarks: Rusconi, _Gaz. Med. Ital._, 1874, No. 11.

{1081} 56. Sex and Age: M. 30.

Clinical History: Headache. Left ptosis; fixation of left eyeball. Drowsiness. Retarded speech. Gait unsteady. Paresis of right hand and foot. Emaciation; incontinence of urine.

Pathology and Location: Serous tumor.

Large as a nut, in posterior half of right optic thalamus.

Remarks: Troschel, _Med. das ver. für Heilk. in Preussen_, xliii., 1839, quoted by Petrina.

57. Sex and Age: F. 36.

Clinical History: Imbecile. Speech inarticulate. Pupils contracted. Spasms in arms, but light in limbs.

Pathology and Location: Cancer.

Left optic thalamus and corpus striatum without definite boundary, extending into brain-mass.

Remarks: Brenner, quoted by Petrina, _op. cit._

58. Sex and Age: F. 33.

Clinical History: Headache and vomiting for three weeks: for one week had been maniacal. Convulsions. Apoplectiform attack, marked by unconsciousness, general muscular flaccidity, and stertorous breathing. Paralysis of left face; twitching of right face.

Pathology and Location: Glioma.

Between left optic thalamus and hippocampus minor, extending from the ventricle to the under surface of the brain. Corpus striatum and optic thalamus unaffected. Hemorrhage on under surface.

Remarks: Owen, _St. George's Hosp. Rep._, ix., 1877-78, p. 150.

59. Sex and Age: M. 45.

Clinical History: Vertigo, headache, and tinnitus. Five years before attack had fallen and struck the back of his head. Much exposed to the sun. One day in August a general feeling of numbness came over him. This was followed by vertigo, etc., as above. Staggered and stumbled in walking as if intoxicated. Unable to maintain his balance in the dark or with his eyes closed. Some numbness in legs and arms, but no actual loss of sensibility. No neuro-retinitis; no paralysis. When erect had a constantly increasing tendency to stagger backward. Divergent squint and diplopia appeared. Potassium, iodide blisters, and seton were used. Noises and headaches disappeared. During last two or three weeks some difficulty in swallowing. Involuntary evacuations. Occasional hallucinations.

Pathology and Location: Glio-sarcoma.

Tumor size of walnut in third ventricle, moulded to the interior. Extending to base of brain just above corpora albicantia, and forward as far as anterior commissure. A caudate prolongation completely blocked up the Sylvian aqueduct. Owing to this obstruction, a large quantity of serum had been imprisoned, enormously distending the fourth and lateral ventricle. The growth invaded left optic thalamus. Superior surface of cerebellum softened from median line to middle of right hemisphere.

Remarks: F. Woodbury, _Am. Journ. of the Med. Sci._, N. S. lxxvi., July 1, 1878.

60. Sex and Age: M. 15.

Clinical History: Epileptic from childhood: had had no fits for last three years. Had tremors and was dull. Short-sighted, and had a habit of absurdly frequent winking. Nothing else wrong with eyes. Suddenly, after a mental disturbance, had intermitting pulse. Cold surface, dulness, head and face swollen and flushed. Then tonic spasms, loss of consciousness, involuntary micturition. General tremors, dilated pupils, stupor. Next diffused dusky-red flush of both cheeks, also over back of hands and forearms. Temperature depressed to 92° in axilla. Automatic repetition of words. Taste and smell normal. He recognized himself in looking-glass on the day he died.

Pathology and Location: Sarcoma.

In third ventricle, lying between corpora striata and optic thalami of opposite sides. It completely enveloped optic commissure, and partially involved track of optic nerves issuing from front. The sole organic connection of tumor was with the commissure. The tuber cinereum was distinct from its tissue.

Remarks: Russell, _Med. Times and Gaz._, 1873 (1), p. 522.

61. Sex and Age: M. 19.

Clinical History: Periodical headaches. Unsteady gait. Left hemiparesis. Peculiar swelling of face. Delirium. Convulsions and sudden death. Bad-smelling discharge of the nose.

Pathology and Location: Echinococcus.

In left lateral ventricle; the whole of the ventricle a sac.

Remarks: Yates, _Med. Times and Gazette_, Aug., 1870.

62. Sex and Age: M. 14.

Clinical History: Convulsions; vomiting; internal strabismus of right eye; gradually increasing paresis of left leg and arm. Reeling toward left side. Occipital headache. Pain and numbness in left arm. {1082} Lateral movements of eyes lost; paralysis of accommodation; nystagmus. Oscillation of left hand. Left leg ataxic. Patellar reflex exaggerated, and ankle-clonus present on left side. Superficial reflexes increased on right side. Partial anæsthesia on left side. Sight good; double optic neuritis. Left-sided hearing impaired. Taste and smell normal. Toward end, increasing torpor; left hemiplegia, except slight power retained in face, with anæsthesia and analgesia. Tonic fits. Right pupil dilated, and external strabismus in right eye. Slow respiration. Ankle-clonus and increased knee-jerk in right.

Pathology and Location: Glioma.

Involved right anterior tubercle of corpora quadrigemina; also right optic thalamus, posterior part of internal capsule, and tegmentum of crus cerebri. The enlarged optic thalamus pressed back upon right anterior portion of cerebellum and middle peduncle, and exerted some transmitted pressure upon medulla oblongata.

Remarks: David Ferrier, _Brain_, vol. v. p. 123.

63. Sex and Age: F. 29.

Clinical History: Cervico-occipital headache. Vertigo. Convulsions. Right facial paresis. Tendency to fall backward. Uncertain gait. Optic neuritis. Double amblyopia. Difficulty in moving both eyes toward the left. Diminished intelligence. Vomiting.

Pathology and Location: Glioma.

In corpora quadrigemina. Cerebellum not involved. Tumor lay upward and outward from the left cerebellar crus ad pontem.

Remarks: Annuske, _Von Graefe's Arch._, 1873, Bd. xix., quoted by Bernhardt, 167.

64. Sex and Age: M. 21.

Clinical History: Right temporo-frontal headache. Vertigo. Pains in right leg. No anæsthesia. Right leg paretic. Tinnitus. Atrophy of the right optic nerve. Abnormal somnolence. Sexual inclination diminished. Vomiting. Blindness, first of the right and then of the left. Right divergent strabismus. Pupils dilated.

Pathology and Location: Lipoma.

Tumor compressed corpora quadrigemina and geniculate bodies.

Remarks: Hirtz, _Bull. de Société Anat._, Mars and April, 1875, quoted by Bernhardt, 168.

65. Sex and Age: F. 3.

Clinical History: Right hemiparesis. Right-sided tremor. Contraction of the right elbow. Late, loss of sight in left eye. Ptosis, dilatation of the left pupil. Stupidity. Peculiar movements when seated from right backward to the left.

Pathology and Location: Tubercle.

At site of corpora quadrigemina, springing into the third ventricle. Left cerebral peduncle compressed.

Remarks: Pilz, _Jahrbuch. für Kinderkrankh._, iii., 1870, 2, 133, quoted by Bernhardt, 168.

66. Sex and Age: M. 25.

Clinical History: Cervico-cephalic pains. Vertigo. Uncertain gait. No paralysis. Tension of muscles of neck. Optic neuritis. Double amaurosis. Tinnitus. Diminution of hearing. Intelligence clear until within fourteen days of death. Insensibility, delirium, coma. Small irregular pulse.

Pathology and Location: Glioma.

Tumor displaced corpora quadrigemina and pineal gland. Projected into the third ventricle through aqueduct of Sylvius and into fourth ventricle.

Remarks: Duffin, _Lancet_, June 17, 1876.

67. Sex and Age: M. 7.

Clinical History: Occipital pains. Staggering gait toward right and backward. Hydrocephalic cries. Tendency of head forward. Alternating diverging strabismus. Double optic neuritis. Sudden death in paroxysm of pain. Paresis of bladder. Vomiting.

Pathology and Location: Tumor took the place of posterior part of corpora quadrigemina and velum. Cyst in the midst of the cerebellum, reaching the fourth ventricle.

Remarks: Kohts, _Virch. Arch._, Bd. lxvii., 1876, quoted by Bernhardt, 168.

_Cerebellum._

68. Sex and Age: M. 1.

Clinical History: Frontal headache. Slight control over arms and legs. Stiff neck. Dilated pupils. Sopor. Vomiting. Duration, one year.

Pathology and Location: Glioma.

Size of an orange in the middle of cerebellum. Chronic hydrocephalus.

Remarks: H. Green, _Trans. Path. Soc._, vol. xx., 1870.

69. Sex and Age: F. 21.

Clinical History: Fall from a swing upon the head, followed by loss of consciousness for a few minutes. Occasional headache during eleven years, always located at the occipital region. Eight months before death severe paroxysmal headaches, increased to one every five or six days, and lasting three to four days. Great hyperæsthesia of the head. Choked discs in both eyes. Complete blindness. Slight paresis of left side of body; twitching of muscles of left side of face. Staggering gait; sometimes complained of a momentary swinging or rotary sensation. Intellect clear. During last few days of life loss of power of deglutition, and also of taste, smell, and hearing.

Pathology and Location: Tubercle.

In left and middle lobe of cerebellum, involving the pia mater. Over the tumefaction leptomeningitis.

Remarks: H. F. Formad, _Tr. of Philada. Path. Soc._, 1879-81, vol. x. p. 178.

{1083} 70. Sex and Age: F. 27.

Clinical History: History of syphilis. Headache, with paroxysmal exacerbations. Vomiting, frequently recurring; for four weeks before death vomited almost incessantly. Vertigo; impossible to sit or stand because of vertigo late in illness. Slowness of mind and hebetude. General muscular weakness. Right partial hemiplegia and hemianæsthesia. Trigeminal neuralgia. No ophthalmoscopic examination, but sight impaired. Marked slowness of respiration; respirations ran down as low as four and five per minute two weeks before death.

Pathology and Location: A nodulated mass involved the right middle cerebellar peduncle and the adjacent region of the right cerebellar hemisphere. The right upper half of the floor of the fourth ventricle superficially softened. A small area of softening was also found involving the under outer surface of the left optic thalamus, the breadth of the internal capsule, and a small segment of the lenticular nucleus.

Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, August, 1882.

71. Sex and Age: F. 13.

Clinical History: Tubercular history. Headache, with severe paroxysms; most marked in frontal and occipital regions. Vomiting; vertigo; attacks of reeling and falling. Mental dulness. Weakness of limbs, but no distinct paralysis. Hyperæsthesia; severe pains in limbs. Gradually went blind, first in left eye, and then in right. Descending neuritis determined nearly a year before death; marked optic atrophy observed a month before death. Constipation.

Pathology and Location: Tubercle.

A large nodulated mass occupied the lower two-thirds of the right cerebellar hemisphere; one small nodule extended across the posterior extremity of the superior vermiform process, destroying altogether about one-third to one-half of a cubic inch of its substance. Internal hydrocephalus.

Remarks: C. K. Mills, _Arch. Med._, vol. viii. No. 1, Aug., 1882.

72. Sex and Age: F. 20.

Clinical History: Headache. Occasional vomiting, but only upon a full stomach and at the beginning of a paroxysm of headache. No impairment of intellect; no paralysis; no convulsion; no inco-ordination. During last few days, when in paroxysms of headache, her face would be drawn toward left side, accompanied by a rigid drawing backward of the head, by pain in left shoulder and arm, and by a marked diminution of sensation in the same shoulder and arm. Head-pain excruciating, at first involving the whole cranium, afterward only the forehead and temples, but finally only the back of the head and nape of the neck. Died of sheer exhaustion. Symptoms and physical signs of phthisis.

Pathology and Location: Tubercle.

In right lobe of cerebellum. Tubercular disease of both lungs with pleuritic adhesion. Fatty liver.

Remarks: L. S. Clark for A. S. Gerhardt, _Tr. of Philada. Path. Soc._, 1878-79, vol. ix. p. 144.

73. Sex and Age: M. 45.