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13. Post Mortem Report, March 31, 1933

POST MORTEM

Mar. 31, 1933

Hours post mortem 4 hrs. P.M.

Autopsy performed by Dr. George M. Hass. March 31, 1933. 2 A.M.

Dr. Richard Light.

DIAGNOSES

Glioblastoma, rapidly growing

BODY:

  • Inasmuch as the undertaker was in considerably hurry, the usual description of the body was largely dispensed with, inasmuch as I was assured by Dr. Light that there was nothing of unusual interest. However, the patient is a middle-aged woman, measuring approximately 150 cm. in length. She is well developed and quite well nourished. There is no unusual degree of obesity. There is no abnormal distribution of fat or hirsutes. The skin is of fine texture and quite smooth without blemishes. The hair of the head is dark brown in color, tinged with gray and closely cropped. Extending upward from the midline of the forehead, from the region of the glabella, is a thin, white, healed surgical scar. This extends back to about the region of the coronal suture and then is continued to the right and downwards. There is also a scar which begins in the region of the glabella and is continued over the superior ridge of the orbit in the region of the right eyebrow. The hair is scanty over the right temporal region. There is definite bulging of the scalp and a large bony defect in the skull in the posterior temporal region. The eyes, ears, nose and mouth are essentially negative. There are no superficially enlarged lymph nodes. There is no edema.

BRAIN:

  • Will be weighed after fixation in formalin. The scalp is reflected anteriorly and posteriorly, after the usual mastoid to mastoid incision. Over the right fronto-parietal region there is a considerable degree of adherence of the scalp to the underlying epicranium and to the margins of the bone flap which has been fairly well healed. There is practically no over-riding of the bone flaps and there is but slight bulging of the brain through the area of decompression. The calvarium is removed. The dura is thickened and adherent to the undersurface of the calvarium of the bone flap and to the margins of the intact calvarium around the bone flap. Finally, the dura is freed and the area of operative approach exposed. The dura is not usually tense. It is reflected medially. There are a few adhesions between the dura and the pia arachnoid. Several small pia arachnoidal cysts containing yellowish fluid are encountered in the region of the decompression. The arachnoid is moderately adherent to the brain in several areas in the right frontal region. The brain is also lightly adherent to the dura overlying the right orbital plate. These adhesions pass between the pia arachnoid and the dura. There is no blood clot. Several areas of gray matter are slightly discolored yellowish. It is particularly true backwards in the region anterior to the chiasm and near the tip of the frontal lobe. These areas of yellowish discoloration are presumably secondary to degeneration of the cortical substance following operative manipulation and are not evidence of tumor tissue. The convolutions of the brain in general are slightly flattened. The right hemisphere is somewhat larger than the left and there is definite diminution of consistency of the brain, presumably due to dilation of the lateral ventricles. This semi-fluctuation which can be obtained is greater on the right. As the optic chiasm is approached, the following features are observed. The chiasm is thrust forward and thinned out by a tumor which is situated posterior to the chiasm in the region of the pituitary fossa. The optic nerves as they pass forward in their usual positions, can not be definitely distinguished because of the anterior angulation of the chiasm. During the removal of the brain the major pathology is found in the hypothalamic region extending downwards in the position of the infundibulum of the pituitary and into the sella trusica compressing the anterior lobe of the pituitary forward and replacing a large portion of the posterior lobe. There is an apparent slight expansion of the sella tursica and definite erosion of the posterior clinoid processes, and the superior margin of the dorsum sellae. No other important findings are noted during removal of the brain with the exception of a very slight pressure cone at the base. The inferior surface of the pons and medulla appear to be essentially normal. The venous sinuses of the skull contain no thrombi of ante mortem origin. The middle ears and mastoid cells are not examined. The appearance of the tumor and its relations to adjacent structures may best be considered together with a description of the brain after formalin fixation.

BRAIN: (After formalin fixation)

  • Weighs 1520 grams. A review of the external surface reveals nothing of additional importance. A single sweeping sagittal incision is made so as to divide the hypothalamic third ventricle tumor into two equal halves. The large tumor measures 4 cm. in coronal diameter, 2 cm. in its antero-posterior diameter and so far as can be determined, approximately 3 cm. in diameter at its greatest breadth. It is largely located posterior to the optic chiasm and anterior to the corpora quadragemina and posterior commissure. It has either filled or compressed the entire third ventricle upwards so that the superior surface of the tumor lies at approximately the same level as the rostrum of the corpus callosum. Lying on the superior surface of the tumor and displaced upward and somewhat flattened, is the massa intermedia. Anterior to and above this mass of gray and white matter is the flattened choroid plexus of the third ventricle which is continued towards the foramen of Munro on each side. The septum pellucidum is apparently intact. The fornix is thrust upwards and compressed against the corpus callosum by the expanding tumor. Along the anterior margin the tumor appears to be fused with the optic chiasm and apparently there is infiltration of the chiasm by the tumor growth. The posterior limits of the tumor so far as the boundaries of the third ventricle are concerned, lie in the region of the corpora mammillare but there appears to be an extension backward of the growth along the floor of the aqueduct of Sylvius. This expansion backward is presented as an apparent, slightly irregular, narrow band which measures somewhat less than 2 mm. in thickness. This band, however, can be followed entirely to the fourth ventricle and there is a mass of tumor which is situated in the fourth ventricle and largely filling this space. This tumor mass is grayish in color, less firm than the remainder of the brain and is approximately 10 x 12 mm in its greatest dimensions. On cross section this tumor tissue is triangular in shape, being molded to conform to the shape of the ventricle. The pineal body is situated in its usual position and is not involved by the tumor. The aqueduct of Sylvius, so far as can be determined, is not obstructed by the growth. Returning to the main tumor again, it shows that as the tumor is continued downward in the general course of the infundibulum of the epituitary it narrows somewhat and at its narrowest portion just above the pituitary gland, it measures only 9 mm. in diameter. The stalk of the pituitary can not be visualized and is presumably included in the mass of tumor which extends downward into the land posterior to the anterior lobe and replacing the entire posterior lobe region. The pituitary gland with the included tumor measures 22 mm. in its lateral diameter, 15 mm anterio-posteriorly and 10 mm in its perpendicular diameter. The diaphragma sella of course, has been entirely destroyed. All of the pituitary except a small anteriorly displaced portion of the anterior lobe consists of tumor tissue. This narrow rim of anterior lobe measures 3 mm at its greatest point of thickness. The tumor itself varies from pale gray to white in color. It is coarse in textures and although fairly firm, presents many soft areas, some of which have undergone cystic degeneration. These small cysts vary from 1-3 mm in diameter. This is obviously the structure of the glioma which, according to our previous histological examination, is a glioblastoma. Although there is apparent extension into the cerebral penducles one cannot judge by this single section the degree of involvement.

Hass.

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