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12b. Readmission Summary, January 13 to February 17, 1933

The patient was readmitted to Peter Bent Brigham Hospital on Jan. 13, 1933 with a diagnosis of:

951-8454 Cerebral Tumor: Verified Glioblastoma Multiforme
A Ventriculography was performed on Jan. 17, 1933 by Dr. Light and a Right Transfrontal Re-Exploration was performed on Jan. 24, 1933 by Dr. Cutler. General histories upon readmission were consistent with previous findings with the chief finding of marked diminution of vision.

OPERTIVE NOTE Ventricular Tap thru Old Parietal Burr

Jan. 17, 1933. Hole with Lumbar Puncture Needle - Removal

OPERATOR Dr. Light. Of 30 cc. of Clear Fluid and Replacement with Air - X-ray Study.

ANAESTHESIA None.

  • This woman returns to the hospital for the 3rd time with essentially the same complaint. She was a patient of Dr. Cushing's service in July of last year and was thought to have a tumor above the sella pushing the 3rd ventricle backward. She had experienced some 3rd ventricle symptoms, notably sudden attacks of flushing and sweating and feeling of warmth. There was also a beginning bitemporal hemianopsia. Ventriculography was carried out and the location of the tumor determined. A right transfrontal flap was made and Dr. Cushing searched the suprasellar region by going under the frontal lobe. Nothing was found and he thereupon made a large subtemporal decompression and incised the dura to permit the lateral ventricle to dilate in case of obstruction to the foramen of Munro and made a 2nd stage operation easier. She returned to the hospital in October and ventriculography was again performed. In the meantime, however, she had been given x-ray treatment to the supposed side of tumor and there was at this examination no evidence of the growth. She was thereupon sent out without treatment and returns now because she has been growing rapidly blind, is developing an extraordinary thirst, and has been having attacks of queer odors and has had some numbness in the right arm and leg. Examination shows little in the way of neurological findings except for greatly impaired vision of 2/200 in each eye with a bitemporal defect and greatly constricted fields of vision. Reflexes are normal and there is no evidence of pyramidal tract irritation. She is consuming and abnormal amount of water but she is not overly sleepy. She still has occasional hot flashes. Impression - Tumor of the 3rd ventricle, suprasellar location, increasing in size during the past 6 mos. Deserves ventriculography.

  • Without anaesthesia and 18 gage lumbar puncture needle was inserted thru the old parietal burr hole and into the right lateral ventricle. There was a free flow of fluid and about 30 cc. were secured and this was replaced by air while turning the head from side to side. Little headache was experienced. She was sent to the x-ray laboratory for plates. In the discussion which followed it developed that while there is definite evidence of a suprasellar tumor which is elevating the floor of the 3rd ventricle, there is little hope of reaching this through ventricles which are but little dilated and she will benefit more by x-ray treatment than by operative exploration.

(Dr. Light.)

VENTRICULOGRAM REPORT

Dr. Sosman

  • Third ventriculogram now shows slight herniation of the right ventricle toward the bone flap and decompression, this ventricle being about one third larger than the left ventricle. The third ventricle is again displaced upward and backward but the formina is Munro are still open.

  • Impression - Findings indicate tumor between the third ventricle and sella.

(M.C.Sosman)

SPECIAL NOTE

Jan. 17, 1933.

Dr. Cutler.

  • This patient has been in the hospital twice for operation and observation. She has been stated to have a supra-chiasmal lesion, possibly in the 3rd ventricle or at least just above and perhaps posterior to the ciasm (sic). At the original entry a large right transfrontal approach was carried out but no tumor could be found. The flap was made very large and a good sized decompression left in the right temporal region with the idea that if it was a 3rd ventricle tumor and the right ventricle was enlarged that a tumor could be approached across the right lateral ventricle. At the 2nd period of study when ventriculograms were again carried out in September and October, ventricles were not enlarged and were not displaced and it seemed unwise or justifiable to go ahead with any surgical procedure. From the very beginning the most classical and important neurological manifestation has been a bitemporal hemianopsia which has steadily increased until the present time vision is confined to a very small and almost totally nasal field. It would seem as if this lesion could only be produced by a post-chiasmal pressure from above, either a pharyngioma without calcification of its wall or a glioma at the base of the 3rd ventricle. None of the ventriculograms have hinted that it might be an intra-ventricular tumor, though, of course, meningiomata grow in the 3rd ventricle as I have had the ill fortune to experience myself. She now comes back with practically total loss of vision.

  • Ventriculography was performed by Dr. Light this morning. I think the best we can say is that there seems to be a solid tumor post-chiasmal and above the posterior to the sellar region which may be pushing the 3rc ventricle upwards and backwards. If this is true this lesion has not even interfered with the flow of fluid from the lateral ventricle and the 3rd ventricle. The ventricular field has not greatly changed from normal and certainly one foramen of Munro is no more obstructed than the other. A tumor in this position would seem unapproachable and I think it perhaps foolhardy to attempt something which beforehand I do not have much confidence in. The air was, therefore, removed from the ventricles in part and the patient is to be carried on with x-ray therapy to await further developments.

SPECIAL NOTE

Jan. 24, 1933.

  • This patient is now in the hospital for the third time. She is 43 years old and first admitted to Dr. Cushing's service last July. There was a complaint of failing vision, the loss occurring in the temporal fields; and positive third ventricle symptoms. Ventriculography was performed but no definite finding made. A right frontal approach was carried out and nothing abnormal found.

  • She has been in the hospital twice since for further study and has had one course of x-ray treatment. Perhaps with some benefit to her fields of vision. Recently, ventriculogram showed the ventricles about the same size, the third ventricle pushed upward and backward by a mass. The fact that the patient is going blind makes me favor re-operation.

OPERATIVE NOTE Re-elevation Right Frontal Flap for

Jan 24, 1933. Glioma Posterior to Chiasm.

OPERATOR Dr. Cutler

  • Local anaesthesia plus morphine - satisfactory.

  • Old flap re-elevated by Dr. Light most satisfactorily. Usual incision in dura, at anterior limits of the frontal lobe. Frontal lobe pushed backward, upwards and an extraordinarily complete view of chiasm and optic nerve obtained. Bulging down behind the ciasm (sic) - certainly not originating in the sella itself - was a gray translucent tumor. Considerable fragments of this removed and report histologically by Dr. Wolback to be a rapidly growing glioma.

  • In view of the fact that the tumor presented by the histological diagnosis is just as satisfactorily treated by x-ray as by surgery, and perhaps more so, and because of the impossibility of removing the tumor even if the right optic nerve was sacrificed, or the right chiasm, operations stopped in favor of x-ray treatment. Would closed in layers with silk. (Dr. Cutler)

POSTOPERATIVE NOTES

Jan. 25, 1933.

Dr. Gaiser.

  • This is the 1st p.o. day. Yesterday Dr. Cutler re-elevated the right frontal flap, found a glioma posterior to the chiasm, which could not be removed and it was further felt that x-ray treatment could offer as much as surgery. The operation was well tolerated. However, she responds rather poorly at the present time. Her blood pressure is subnormal, running around 80/60 and 70/50. Pulse rate 120. Temperature 101.8. Respirations 20.

Jan. 27, 1933.

Dr. Light.

  • A few hours after operation she became drowsy, and pulse began to rise. She was placed on the operating table again and the dressing removed. A few c.c. (about 25) of red fluid were removed by a blunt needle from the anterior end of the wound. Dressing reapplied, and she soon improved.

  • Yesterday she was restless, and last night irrational. Today it is difficult to rouse her, altho painful stimuli still result in response.

  • Dressing: Removal of all sutures. Grooved dissector under ant. End of incision, and I expressed probably 30-40 c.c. blood fluid, reducing somewhat the tension of the decompression, which was quite tense. Crinoline dressing.

Jan. 27, 1933.

Dr. Gaiser

  • This is the 3rd p.o. day. Temperature 100.2; pulse rate 90; respirations normal. Blood pressure 80/60. Because the patient appeared to be becoming more drowsy and less responsive, altho at times restless, and even on several occasions attempting to get out of bed, she was taken to the operating room today by Dr. Light, who removed about 25 cc. of red fluid from beneath the flap. The flap was not pushed out particularly and the wound appears to be in good condition. The skin silks were removed. Thus far there has been no definite change in her condition. She is taking a fair amount of fluid by mouth, ranging between 1300 and 1800 cc. Today she is incontinent of urine. She also had an involuntary bowel movement.

Jan. 29, 1933.

Dr. Gaiser

This is the 5th p.o. day. Since the last note was dictated there has been very marked improvement. Yesterday she was able to recognize me, and remembered by name, and today she has been talking with her family, altho doing so rather sleepily and very slowly. She thinks a long while before answering questions. Fundi which were rather indistinctly seen show about 2 D of choking. Temperature is 99.6. Pulse rate 95. Respirations 20. There was some edema of the face on both sides two days ago, which has disappeared at the present time. Jan. 31, 1933.

Dr. Gaiser.

    This is the 7th p.o. day. Patient's vital signs have come down to normal. She responds normally, eats well and shows very marked improvement since the dictation of the last note. She has, however, a complete ptosis of the left eye lid and appears to be almost totally blind in the right eye. Vision is fair in the left eye. She has about 1-D of choking at the present time. Skin has healed beautifully without separation of the edges or signs of infection.

Feb. 4, 1933.

Dr. Bennett.

    This is the patient's 11th p.o. day. Vital signs remain normal and she continues to do very well. There has been slight improvement in the ptosis since the last note. Vision remains about the same.

Feb. 8, 1933.

Dr. Bennett.

    This is the patient's 15th p.o. day. Vital signs remain normal. She has again improved slightly. Yesterday she was up in a chair and today she has walked to the bathroom with the nurse's support. Wound continues to do perfectly.

Feb. 11, 1933.

Dr. Bennett.

    This is the patient's 18th p.o. day. Vital signs are normal. Visual fields were done today tho it is doubtful if she has enough vision to make them very instructive. Condition otherwise is unchanged. Monday she will be started on deep x-ray treatment.

Feb. 15, 1933.

Dr. Bennett.

    This is the patient's 22nd p.o. day. For the past few days she has been having deep x-ray therapy and today developed chronic spasm of the right leg. The twitching lasted for about 10 minutes and caused the patient considerable distress. She was seen by Dr. Patterson and given .15 of luminal which quieted her and relieved her. No other change.

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