Roprlntod from the Journal of Nervous and Mental Disease, February, 1892. 
A CASE OF TUMOR OF THE CEREBELLUM, 
IN WHICH TREPHINING WAS DONE FOR THE 
RELIEF OF INCREASED INTRA-CRANIA L 
PRESSURE.1 
By PHILIP COOMBS KNAPP, A.M., M.D., 
Clinical Instructor in Diseases of the Nervous System, Harvard Medical School. 
I NASMUCH as the indications for surgical interference 
with intra-cranial growths are not yet absolutely 
determined, it has seemed worth while to report the 
following case, as one of the first where operation was un- 
dertaken primarily to relieve symptoms, rather than to 
effect a cure. 
The temporary relief afforded by opening the skull and 
thus diminishing the intra-cranial pressure has been made 
evident by the results following certain operations, where 
either the new growth was not found or it was too large or too 
deeply seated to be removed. At the first Congress of Ameri- 
can Physicians and Surgeons, in 1888,Weir suggested the pro- 
priety of trephining to relieve symptoms in cases where the 
new growth was inaccessible or where its seat could not be 
determined. At the Tenth International Congress in Ber- 
lin, in 1890, Horsley urged the advantages of such a pro- 
cedure, and mentioned six cases where he had trephined, 
simply to relieve pressure, with beneficial results. In some 
of the other cases of operative interference, reliefofpressure 
seems to have been one indication for the operation, but it 
was not the primary object. Horsley’s six cases and the 
case about to be reported are, as far as I can learn, the only 
cases where relief of pressure was the primary object. In a 
recent contribution on the subject I unfortunately over- 
looked Weir’s suggestion made in 1888, but the credit of the 
suggestion belongs to him and not to Horsley. 
1 Read before the American Neurological Association September 22, 
23, 24, 1891. 2 
PHILIP COOMBS KNAPP. 
On the 30th of October, 1890,1 was asked to see R. W., 
a lawyer, unmarried, aged 28; born in this country of Ger- 
man-Jewish parents. The family history was negative. 
His own previous history was good, except that at the age 
of seventeen months he had acute anterior poliomyelitis, 
and the left leg was left paralyzed and atrophied. Ve- 
nereal disease and the excessive use of alcohol were denied, 
but he had smoked freely. 
For several years he had had constipation and some indi- 
gestion ; this was attended with occasional dull headache, 
but he considered himself well until the spring of 1889. 
About this time he began to have severe headache in the 
right occipital region. He grew irritable, left his home 
and lived by himself for some time, refusing to have any- 
thing to do with his family, and seldom seeing his friends. 
The headache increased during the summer, until early in 
October it was so severe that he went to bed and stayed 
there a week, when it ceased. On getting up he began to 
notice an occasional black cloud before the eyes, dimness 
of vision and diplopia ; at times he saw three or even six 
objects. On the 24th of October, 1889, he consulted Dr. O. 
F. Wadsworth, who found no external abnormality about 
the eyes. The pupils were rather large, but they reacted 
normally. The field of vision was unimpaired and the 
movements of the eyes were well performed. The tension 
was moderate, v. o. d. c. + 0. 5. — ff, v. o. s. c. -|- 1. o. cyl. 
= ff. Accommodation diminished ; o.d. read 5 Snellen 
at 15 inches; o.s. c. T~ 1.0. cyl,. read 5 Snellen at 12 inches. 
There was pronounced pupillitis in both eyes, extending 
farther and being more prominent in the right. There 
were many fine vessels but no haemorrhages. The fundus 
elsewhere was normal. 
About this time he had one or two attacks in which he 
cried out. He was never seen at the onset of any of them, 
but he frothed somewhat at the mouth and fell on the floor. 
The face was red and looked drawn. He stated himself that 
in these attacks there was merely a faint feeling about the 
heart when he had indigestion, at which time his heart felt un- 
comfortable. The headaches continued and became more 
severe, being situated for the most part in the occiput, but at 
times affecting the frontal or temporal regions. He com - 
plained of a feeling of pressure, as if a bar were being crowded 
through his temples. About the same time he had spells of 
nausea and vomiting, immediately after which the pain in the 
head became excruciating. This pain in the head has periods 
of exacerbation, in which it becomes so intense as to render A CASE OF TUMOR OF THE CEREBELLUM. 
3 
him slightly delirious. With the beginning of the trouble 
he lost the sense of smell. The eyesight failed slowly, 
until in August, 1890, the last perception of light was lost. 
Vision was retained longer in the left eye than in the right. 
One day after a severe attack of nausea, the vision returned 
temporarily. 
He consulted Dr. G. F. Jelly, who gave him iodide of 
potassium in forty-grain doses, which he took for nearly a 
year, but somewhat irregularly. This had produced well- 
marked iodism when I saw him. Phenacetine, in twenty- 
grain doses, had, during this time, kept the headache 
endurable, but within a few weeks he had required small 
doses of morphine. 
For three weeks before I saw him he had noticed a dis- 
tinct failure of hearing in the left ear. For some time he 
had complained of peculiar sensations in the mouth. It felt 
distorted, the upper lip felt swollen and as if something 
were clinging to the roof of the mouth, the tongue, the 
gums, and the soft palate. The cheeks felt numb. Swal- 
lowing was fairly well performed, but he made complaint of 
difficulty in swallowing. He found food hard to chew, 
and thought the teeth made no impression on it. He 
could swallow hot substances better than cold, being 
able to drink hotter liquids than ordinary people. He 
complained much of thickness of speech, due, as he said, to 
the distortion of his mouth and to the peculiar feeling in the 
roof of the mouth. The hands also for six weeks had felt 
as if they were asleep, and the nose felt numb. For a week 
he complained of profuse salivation, and found it hard to 
swallow the saliva. 
There had also been pain in the eyes, and he had had 
occasional flashes before them. Of late he slept poorly. 
He was at times rather querulous, but no failure of mental 
power could be detected. He was quick and ready in con- 
versation, was fond of listening to reading, and kept thor- 
oughly informed on all the questions of the day. The 
speech was somewhat thick and the articulation was not 
very distinct, but there was no more disturbance than is 
often noted with healthy people, no stumbling over sylla- 
bles, no incorrect use of words, nor any difficulty in com- 
prehending what was said. 
Except for the faint feelings at the beginning of the 
trouble there had been no disturbance of the thoracic 
organs. His appetite had been good until a short time 
before I saw him, and, except for constipation and the 
attacks of nausea, he had had no indigestion. He had 4 
PHILIP COOMBS KNAPP. 
gained in weight during the summer. At times he had an 
urgent desire to urinate, but when he attempted it he could 
not perform the act for some time. He passed water fre- 
quently and in large amounts. With the failure of vision 
and his lameness, he had had some uncertainty in walking, 
but nothing like a staggering gait. There had been but 
little vertigo, For a week or more his family had noticed a 
little swelling of the face, most marked on the left side, but 
there was no distortion; within a few days the swelling had 
seemed greater on the right. 
The patient was well developed and well nourished. 
The left leg and thigh were much wasted, cold to the touch, 
and the foot presented the characteristic deformity of polio- 
myelitis—talipes equino-varus. There was a pustular iodide 
acne over the nose and forehead. The eyes were kept 
partly closed, but he could open them fairly well, the lev- 
ator muscles seeming a trifle weak. The right eye was not 
moved outwards quite so far as the left. The right side of 
the upper lip and of the tongue was a little swollen, and 
the right naso-labial fold was a trifle less pronounced. 
Otherwise the movements of the eyes, face and tongue 
were normal, but the masseters were not very strong. The 
pupils were dilated, equal, and reacted to convergence 
though not to light. Vision and smell were lost. Hearing 
in the left ear was much diminished ; he could understand 
only when I spoke in a loud tone. Sensibility to temper- 
ature was good, except that it was very slightly dimin- 
ished in the left cheek ; sensibility to touch was everywhere 
normal. .Dynamometer: right, 50 kg.; left, 35 kg. He 
grasped the dynamometer somewhat clumsily with the left 
hand. Otherwise no ataxia was noted. The pulse was 
100. Examination of the thoracic organs was negative. 
The muscles of the face and jaws reacted normally to 
fafadism. The membrana tympani showed nothing re- 
markable. There was double optic neuritis. The re- 
flexes were normal, except that there was no knee-jerk 
in the left leg. The gait was natural, and there was no 
uncertainty of station on closing the eyes. There was no 
tenderness on percussing the skull. 
On the 6th of November he was still suffering from severe 
pain in the head, usually of a shooting character, and involv- 
ing the right eye and right side of the face. Although the 
iodide had been discontinued, the numbness in the face, 
the peculiar sensations in the mouth, the stiffness of the 
jaws and the trouble in chewing, and the subjective diffi- 
culty of speech had increased. The numbness of the hands A CASE OF IUMOR OF THE CEREBELLUM. 
5 
was greater and most marked on the ulnar side. The 
tactile sensibility of the left side of the face was perhaps a 
trifle diminished. The tactile and muscular sensibility of 
the hands was good. The masseters were weak. The 
tongue protruded to the right, but he could protrude 
it to the left. Of late he had been restless and slept poorly, 
and he twisted his hands as if the numbness were uncom- 
fortable. Salivation was increased, and he would spit fre- 
quently, but he could swallow well. There was a tender 
spot on the right temple, and pressure or percussion caused 
a deep-seated pain. He had considerable itching of the 
nose and face. Pulse, 104. 
I advised an operation, and the family took it under con- 
sideration. For several weeks, however, he had a distinct 
remission of the severe pain, so that nothing was done; but 
the pain returned, and I was called in again on the 8th of 
January, 1891. The headache had then become more 
severe. The unpleasant par.'esthesiae about the mouth per- 
sisted. He had a sensation in the left ear as of bubbling. 
For a time that night his right arm felt as if it were paral- 
yzed. The numbness of the hands persisted. He made up 
his mind to an operation, viewed the prospect cheerfully 
and courageously, and was the only one of the family to 
keep in good spirits. He was admitted to the Boston City 
Hospital the 12th of January, 1891. 
On the 13th his ears were examined by Dr. J. Orne 
Green, who made the following report : 
“ Deafness first noticed in left ear six months ago. A 
buzzing was noticed before this. The deafness,was con- 
tinual, now is intermittent. Right ear, no trouble till three 
months ago. The pain commenced on the left side and 
now is sharp, shooting like the beating of the pulse. No 
dizziness at any time. Does not talk of any high-pitched 
noises. Both drum membranes a little dull and very slightly 
contracted. They are both free from any signs of conges- 
tion, as also is the meatus. 
W. v. 1. ■■ — o. 
V. v. 1. moderate only through speaking tube. 
Weber, F. C. on teeth, r. > 1., on forehead, not head. 
Rinne, F. C. r. be 1-=tV- 
Both ears show defective hearing ; right slight; left 
extreme. Both show defective bone conduction, nothing 
abnormal visible. Left ear gradual loss of hearing, coming 
on only after gradual loss of smell, sight, and many other 
symptoms, would lead me to suppose that the disease did 
not directly affect the auditory apparatus, but that it was 
possibly involved from gradual pressure from a distance. 6 
PHILIP COOMBS KNAPP. 
14- W. r. U'- 1- w"=0- 
V. v. 1. only through tube. 
F- c. v. n" i- 
F. C. v. > 1. 
In left perception of F. C. and F. A. through diagnostic 
tube. 
14 January. No distinct loss of muscular sense in 
either arm, yet he seemed a trifle uncertain in his move- 
ments. The tactile sensibility was normal. The knee-jerk 
was absent in both legs. His gait seemed a little uncer- 
tain, perhaps more uncertainty than ought to be attributed 
to his blindness and lameness, yet nothing very material. 
15. Since entering the hospital he has been compara- 
tively comfortable, having a good appetite, sleeping well, 
and having no severe pain. He required cathartics and 
phenacetine. 
17. The knee-jerk was present in the right leg. He 
complained much of numbness and prickling in the right 
hand, but there was objectively no disturbance of sensi- 
bility. He had rather more headache, which was relieved 
by a cathartic. Urine high colored ; acid, 1028 ; no albu- 
men or sugar. Sediment, a few crystals of calcic oxalate 
and uric acid. 
18. He has had one or two periods of severe pain, 
although less severe than usual. Once he required mor- 
phine. He detected the odor of cologne used about him, 
and noted a shadow passing before his eyes. Examination 
of the chest was negative. The head was shaved, the 
fissure of Rolando marked by the Thane-Horsley method, 
and the fissure of Sylvius by the rule given by Dana ; and 
observations were made of the surface temperature. 
Just below the beginning of the fissure of 
Sylvius, R. 98 1-40 L. 98 1-2 
6 cm. above external angular process, 96 1-4 96 1-20 
Parietal eminence, ' 97 97 
4 cm. back of the upper end of the fissure 
of Rolando, and 3 cm. from the 
median line, 95 1-2 95 3-4 
8 cm. back of the upper end of the fis- 
sure of Rolando, and 3 cm. from the 
median line, 96 1-2 96 3-4 
The tender spot in the right temporal region still 
persisted. 
19. Ether was given and Dr. E. H. Bradford operated. 
The operation was done with the patient in a sitting position. 
A curved incision seven or eight inches long was made in A CASE OF TUMOR OF THE CEREBELLUM. 
7 
the right parietal region, two or three inches above the ear. 
The flap was turned down and the periosteum scraped off. 
A trephine button an inch in diameter was removed just 
posterior to the anterior end of the fissure of Sylvius. Upon 
removal of this button the dura was found pulsating, and it 
bulged distinctly through the opening. Another button 
was removed just posterior to this, and the bridge of bone 
between was broken away and the opening somewhat 
enlarged with rongeur forceps. The dura was then opened 
and the brain substance palpitated with the finger, which 
was carried under the edge of the opening for an inch or an 
inch and a half in every direction. No increase of resistance 
was detected. The brain substance felt somewhat fluc- 
tuating, and it was incised, and a probe was inserted for 
three-quarters of an inch. No new growth was detected. 
The wound was irrigated with warm solution of corrosive 
sublimate, 1-10,000 ; the dura was replaced, but it was not 
sutured ; the flaps were sutured with cat-gut, and a steril- 
ized dressing and a gauze bandage were applied. 
He recovered from the ether without nausea or vomiting. 
The pulse was regular and of good strength, and the gen- 
eral condition was favorable. There was some discomfort 
in the head, but no great pain. 
20. A comfortable day. No rise of temperature. Pulse 
still regular and of good strength. He is somewhat restless 
at times, and complains of soreness of the head, especially 
on moving it. Slept well and took some food. 
21. Condition unchanged. He dozes a good part of the 
time. He has no severe pain and takes a fair amount of 
food. Bowels moved by enema. He lies quiet and is not 
inclined to talk. His friends think that his hearing has 
become much more acute since the operation, but Dr. Green 
fails to find any difference. 
22. Dressing changed. Wound healing well without 
suppuration. New dressing applied. 
23. He talks more but was a very little delirious. The 
dressing was found moistened with a clear fluid. He com- 
plains of slight pain in the wound. 
24. He is more comfortable and he has less soreness, 
The appetite is good and he sleeps fairly. He has phen- 
acetine and sulfonal as required. 
25. He talked strangely this morning as if wandering, 
but he was perfectly rational in the afternoon. He com- 
plained of pain in the occipital region. 
Dr. Green reports: “The patient thinks that he can hear 
better, but on testing with the watch and fork no marked 
changes can be discovered.” 8 
PHILIP COOMBS KNAPP. 
26. Wound dressed. Flaps firmly united. There is a 
bulging at the seat of operation the size of half an orange, 
over which the cerebral pulsation may be seen and felt. 
Considerable pain this afternoon, controlled by phenace- 
tine. He had a sensation as of smoke in the throat, and a 
taste of smoke, and he asked where it came from. He com- 
plains still of thickness of the tongue. 
27. Dressing removed and wound dressed with absorb- 
ent cotton and collodion. The tongue is protruded to the 
left and the left side of the mouth is drawn up. The grip of 
the hands is equal. He still has pain in the wound. 
28. The same symptoms of paralysis persist. He had 
a comfortable night and the appetite is fair. The bowels 
move only by the aid of cathartics. He is perfectly ra- 
tional, but since the operation he has been irritable and fault- 
finding. He is very much disappointed that he has not 
regained his sight. He was anxious to return home, and 
therefore was discharged. 
On his return the hernia was the size of half an orange, 
and the extreme posterior end of the incision was still 
ununited. He complained a good deal of soreness of the 
wound, but he was free from the old pain. There was com- 
plete left hemiplegia and hemianaesthesia. He was querulous 
and hard to get on with. Most of the time he was som- 
nolent, yet he perceived what was going on, although his 
memory of events was not good. The somnolence per- 
sisted and increased. He complained much of soreness. 
There had been more or less oozing of blood from the pos- 
terior end of the incision, and about the 7th of February 
some fragments of brain substance appeared. The incision 
was gradually opening, and a slightly offensive odor came 
from it. 
On the 14th, having become very nearly comatose, he 
began to have a profuse watery discharge from the wound, 
and on the 16th he began to improve. After this he was 
free from pain, he was mentally clear and bright, he sat up, 
enjoyed seeing his friends and listening to reading, and felt 
very well. There was no irritability or querulousness, but 
he was somewhat despondent because his vision did not 
return, as he had hoped. The hemiplegia and anaesthesia 
persisted. 
He remained in this condition of comfort and freedom 
from pain, with the hernia gradually sloughing, and the dis- 
charge of fluid persisting until March 7th, when he was 
suddenly seized with most intense pain. He soon became 
comatose ; the pulse and temperature rose rapidly ; he could 
not be roused, and he died on the 9th. A CASE OF TUMOR OF THE CEREBELLUM. 
9 
An autopsy was made twenty hours after death, only the 
head being opened. There was a large sloughing hernia 
projecting through the skull, and the skin and the brain 
membranes were adherent to the edges of the opening. 
Extending upwards from the opening was a large ecchy- 
mosis in the external periosteum of the skull. The hernia 
was sliced off and the brain removed. Except for the 
hernia and the adherent meningitis nothing was noticed 
about the external surface of the brain, except some con- 
gestion. The blood-vessels of the base were normal. The 
calvaria was of good thickness, and showed no sign of 
absorption. The left half of the cerebellum seemed larger 
than the right. The brain was hardened as a whole in 
chloride of zinc for further examination. 
After the hardening, during which the shape of the 
brain was unfortunately not so well preserved as might 
have been desired, the striking feature was a marked curv- 
ing of the longitudinal tissue, the convexity pointing to the 
right. Owing to this the upper end of the right fissure of 
Rolands was over two centimetres in front of the left. 
The base of the hernia was of considerable size. It extended 
from the transverse retro-central sulcus posteriorly to the 
middle of the triangular part of the third frontal convolution 
anteriorly, and from the middle of the first temporal convo- 
lution inferiorly to the lower end of the superior precen- 
tral sulcus superiorly ; involving the lower parts of the 
ascending parietal and ascending frontal convolutions, the 
posterior end of the third frontal, and a little of the second 
frontal, the superior temporal, and a little of the inferior 
parietal lobule. The ventricle, which was considerably 
enlarged, communicated with the opening in the hernia. 
The convolutions about the upper end of the right fissure of 
Rolando were as large, and apparently as well developed 
as those on the other side. 
The cerebrum and the basal ganglia were normal. The 
left lobe of the cerebellum was enlarged, and was found to 
contain a large neoplasm, measuring about three centi- 
metres antero-posteriorly and transversely,and about acenti- 
metre and a half in thickness. It had a dense capsule, and 10 
PHILIP COOMBS KNAPP. 
the interior was of a semi-solid consistency. On micro- 
scopic examination it proved to be a tubercle. Its posterior 
end was within six or eight millimetres of the posterior tip 
of the cerebellar hemisphere, it lay close up to, but not 
involving, the vermis cerebelli, and was close to the upper 
surface of the cerebellum. 
The case presented no distinctive focal symptoms. By 
exclusion, therefore, I decided that it was probably in one 
of three places—in the right temporal lobe or in one of the 
lateral lobes of the cerebellum. The uncertainty was too 
great to warrant undertaking its removal, but I felt that we 
were justified in trephining to relieve the increased intra- 
cranial pressure. Such being the case I advised trephining 
over the right temporal lobe, being influenced by the local 
tenderness, the increased surface temperature in that 
region, the early loss of smell, and the deafness. The event 
showed that these indications were fallacious. 
The operation was in part successful. It undoubtedly 
shortened the patient’s life, but, for a time, it gave him 
relief from pain. In subsequent operations I should advise 
in the first place making a larger opening ; and, in the 
second, tapping the lateral ventricles. In a similar case 
recently reported by Duncan1 this was done with some re- 
lief.- The abundant fluid discharge was probably from the 
ventricles, and contributed much more to the patient’s relief 
than did the mere removal of the buttons of bone. 
i Philadelphia Hospital Reports. Vol. I.