A ^ ) A CASE OF ABSCESS IN THE CEREBELLUM. THE BOSTON MEDICAL AND SURGICAL JOURNAL. Vol. LXV. Thursday, December 12, 1861. No. 19. A CASE OF ABSCESS IN THE CEREBELLUM AND MENINGEAL DISEASE OF THE SPINAL CORD. [Head before the Boston Society for Meilical Improvement, November 25th, 1861, by B. E. Cutting, M.D., of Roxbury, Associate Member.] .. As affections of the cerebellum, to say nothing of its proper func- tions, are involved in so much obscurity, the notes of a single case, rendered complete by a faithful autopsy, may not be unworthy of record. Eliza A. L. Aged 5 years. Born in St. Johns, N. B. At 1% months fell from a chair, and struck the head. Backward in speech and walking; in consequence, it was supposed, of the fall. Walked at l£ years. At 2 years, had dysentery, with vomiting. Was long in regain- ing strength. At 3£ years, had severe inflammation of the throat. Recovered very slowly. Speech thick and indistinct ever afterwards. Wry- neck for eight or nine weeks. At 4| years, in Boston, attacked with scarlet fever, which culmi- nated in the first^week of July last. About the middle of July appeared very stupid, taking no no- tice of what was passing about her, not even of the death and funejparT'of a younger child in the same room. However, when questioned, she returned sensible answers. This stupor had lasted ten or fifteen days, when abscesses broke and discharged from both cars. From this time she seemed brighter, and continued to im- prove ; began to sit up, and to gain flesh. August 17th, removed to Roxbury. At this time she walked like a beginner. When placed upon the feet, she complained that they were sore. Was carried out in a chair every day, and enjoy- ed the exercise and airing. Appetite ravenous lor bread and meat, but would not eat anything else. Slept all night, quietly. At times complained of pains in the limbs, and desired to have them rubbed. Constant and very offensive discharge from the cars. August 24th.—Vomited. This was followed by purging, which ceased on the following day. Vol. Lxv.—No. \d 382 Abscess of the Cerebellum. August 25th and 26th.—Vomited often. Thirsty. Asked for bread. Had no dejection. Complained of pain in head and body. Running from ears profuse. August 27th.—I saw her for the first time, and obtained the foregoing account. Now, lying on back ; eyes rolled up, squinting occasionally; pupils rather large, and slightly variable. Now and then a slight spasmodic twitching about the mouth and face; occa- sional grinding of the teeth; once an outcry as if in acute pain; consciousness seemingly feeble; no decided loss of sensibility; general unwillingness to move, or to be moved; a foul, purulent discharge pouring out of both ears; skin hot and dry; pulse 110, feeble; no dejection; vomiting frequent and distressing; nothing thrown off except a little white, feathery froth. August 28th and 29th.—Vomiting continued, very frequent and painful—so much so that on account of it she refused food, and even water, although thirsty; bowels constipated; spasmodic actions ceased; strabismus gone; other symptoms same as before. August 30th (one week from attack).—Head began to be drawn backward; and, other symptoms remaining the same as before, this tendency increased daily and steadily until, September 3d, the occiput rested upon the scapulse—the crown of the head being upon the pillow, and the eyes turned directly to the headboard of the bed. The pelvis was at this time bent back- ward as far as possible, but the spinal column remained in other respects in normal shape. There were no indications of spasm, palsy, or loss of sensibility. Pulse 100. Costiveness conti- nued; dejection, by enema, "small, but as in health." Vomiting frequent—particularly distressing whenever attempts arc made to take nourishment or drink. Has taken only a few drops of li- quid, through a quill, since August 29th. Marked difficulty in swallowing—seeming to arise from loss of power in the throat. Troubled in nights with an occasional cough, said by attendants to " perfectly resemble croup cough." September 6th.—Took, to-day, about a teaspoonful of rice-water, which caused so much distress that she absolutely refused further trial. Asks for nothing. Moans occasionally. Pulse 100. Con- scious and takes notice. Memory unmistakable. Unwilling to be touched. Restive, turning occasionally from side to side. Ap- pears to suffer but little when undistarbed. Got out of bed in the night, and was found standing nearly upright, holding on to the foot-post of the bed. Head immovably fixed back upon the scapula). Pelvis less firmly bent than heretofore. Expression ghastly. Emaciation extreme. Has not taken a fluid ounce of food or drink for eight days. Had dejection, spontaneously, " small, but as from one taking food." Has complete control over the bladder, and insists upon being taken up and placed upon the chair. hi the night of September Gtli to 7th suffered greatly, but was Disease of the Spinal Cord. 383 partially quieted by ether, and thirty drops of liquid acetate of opium, which the attendants managed to get down in divided portions. Showed almost incredible voluntary muscular strength in the paroxysms of distress. Towards morning of Sept. 7th, the pulse became rapid and intermittent; the breathing, which up to this time had been in no wise remarkable, became irregular and interrupted. The extremities soon after began to be motionless and cold—till, sinking very gradually and quietly, she— September 7th, died, at 1 P.M. The following outline, from a rough drawing by one of the gen- tlemen who saw the patient in the last days of her illness, will give a tolerable idea of her appearance. The extraordinary position of the head and pelvis are well in- dicated, as also the strained prominence of the anterior portion of the neck. The limbs are represented as the patient often placed them, though she frequently changed their positions. The usual posture of the foot and toes is correctly shown. The expres- sion of the face, distressful for the most part, with open mouth and half-closed eyes, has not been attempted, as this varied from smiles to tears, according to her emotions. Such a state of things differs essentially from opisthotonos, which the position at first sight suggested to several visitors, but in which all the muscles are rigidly contracted—the more powerful flexors prevailing over the extensors. This may be seen in the subjoined outline of Sir Charles Bell's sketch taken from soldiers wounded in the head at Corunna. The original is believed to be the only exact portrait of the affection ever taken from niture. As such, although the parts of 384 Abscess of the Cerebellum. the brain injured are not mentioned, a comparison of its outline with that before given may not prove uninteresting. In our pa- tient there were no strong spasms or violent contractions. It is true, the head could not be moved from the position assumed, but then this fixed position was the gradual work of several days. Neither were there indications of palsy or loss of sensibility in any part. During all the last sickness (excepting, perhaps, the first few days), the patient was undoubtedly conscious, and, though not always seeming to notice, observed whatever took place about her. She would repeat remarks, and give her mother descriptions of what was done in her absence. She could hear tolerably well, though her ears were greatly diseased, and discharged very freely. Her eyes lost much of their natural expression, and a mucous film covered the lower portion of the eyeball exposed to the air by the imperfect closing of the lids, yet she could see quite well. Even the last night of her life she recognized her mother, and dis- tinguished her, by sight, from others standing near. From time to time, she made choice of her attendants. She would not allow the door of her room to be closed at any time. She always insisted upon having the gas lighted at early nightfall. She remembered things long past, as well as of a few days or hours. She compar- ed the appearance of one of the physicians who came to see her, to that of her "old doctor " who attended her for sore throat a year and a half previously. The day before she died she told her mother that she was very sick, and could not recover. In many, various, and unmistakable ways she showed that her mental powers, such as they were, were not materially impaired by the disease which finally proved fatal. Autopsy, by Dr. C. Ellis, twenty-four hours after death. Present, Drs. Ellis, Gould, Dean, C. Homaus, Arnold, and Cotting. The petrous portion of the right temporal bone was extensively carious, the cancelli being filled with pus. The corresponding part of the left side was still more diseased, a small sequestrum of the inner surface and parts below having nearly separated. The dura mater covering the latter part had been destroyed, and the cerebellum was adherent. On separating it, there was a gush of pus from an abscess, which occupied two thirds of the left lobe, but. according to Dr. Dean, who examined the parts carefully after hardening them in alcohol, did not involve the pons, or any other part. He also found a small, circumscribed cavity (abscess ?) in projecting part of the middle lobe of the cerebellum, extending from a point about on a level with the origin of the 7th nerve, and reaching as high as the top of the 5th. There was some opa- city of the membranes at the base, but no pus, and nothing which showed absolutely the extension of the disease from the ear. Up- wards of two ounces of serum in the lateral ventricles, with soft- ening of the cerebral substance around, and of the septum lucidum. The blood in the left lateral sinuses was firmly coagulated. Abscess of the C^ebellum. 385 The interval between the arachnoid and pia mater of the spinal cord was filled with a dense deposit of pus, extending the whole length of the cord, but especially noticeable in the dorsal and lumbar region. The inner membranes were much thickened. The cord was of about the normal size, and healthy, both to the naked eye and under the microscope. The organs of the chest and abdo- men were healthy. h -\ ■N •^