A Case of Successful Operation 
for Brain Tumor. 
BT 
CHARLES L. DANA, M. D., 
and J. E. CONWAY, M. D. 
REPRINT EX) FROM TUB 
Wcto UTorft J&efctcal Journal 
for June 22, 1895. Reprinted from the New York Medical Journal 
for June 22, 1895. 
A CASE OF SUCCESSFUL 
OPERATION FOR BRAIN TUMOR. 
By CHARLES L. DANA, M. D., 
and J. R. CONWAY, M. D. 
The following case was so satisfactory from a thera- 
peutic point of view and adds so distinctly to the achieve- 
ments of cerebral surgery that no excuse is needed for 
placing it on record. Aside from its importance in giving 
renewed confidence to the surgeon and neurologist, it has 
much clinical interest on account of its hearing on the ques- 
tion of the sensory functions of the motor area of the brain 
cortex. 
History, by Dr. Dana 
History of the Case.—Jacksonian Epilepsy ; Paralysis of 
Left Arm, with Sensory Troubles; Headache; Optic Neuritis; 
Operation, with Improvement of Symptoms.—Charles T., aged 
sixteen years, was born in Germany. The family history is nega- 
tive. There is no history of any specific infection or of alcoholic 
habits. About three years before admission the patient had re- 
ceived a blow on the left side of the head, just over the squamous 
suture. He was somewhat stunned, but speedily recovered and 
apparently suffered from no after-effects. About six months later 
he began to suffer from headache and epileptic convulsions, 
Copyright, 1895, by D. Appleton and Company. 2 
SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
which latter, so far as I can learn, were general in character. 
He had two or three every month for a year. At the end of 
this time—that is, about a year and a half altogether—he no- 
ticed that the attacks began with sensations of tingling and 
numbness in the left fingers, and that the convulsive movements 
affected the fingers and arm first. They were followed by uni- 
lateral convulsions and unconsciousness. These attacks in- 
creased in frequency until he had sometimes one or two a 
week. About a year ago he noticed that his left arm was be- 
coming weaker and smaller. Five or six months before admis- 
sion he again suffered from severe pains in the head, and occa- 
sionally had attacks of vomiting. He had no trouble with the 
legs or with the face. The symptoms increased, and he began 
to suffer from pains in the left arm as well as weakness and 
stiffness, and sensations of numbness and pricking. When the 
convulsive attacks came on, he experienced intense pain in the 
arm before unconsciousness set in. He was first seen by me, 
May 29, 1894, at my clinic at the Post-graduate School, and at 
about that time he had had four consecutive fits in one day. 
Physical Examination.—The hoy seemed to possess a fair 
degree of intelligence. His gait was normal, and he apparently 
had no weakness or disturbance of the leg. There was a slight 
amount of weakness of the muscles of the lower half of the 
face on the left side. The left arm was very weak, so that he 
could raise it but a little way from the side, and the grasp of 
the hand was only about ten on the dynamometer, the normal 
being forty-five. Detailed examination of the left arm showed 
weakness of the deltoid, and of the flexors and extensors of the 
forearm. Supination was nearly impossible, pronation moder- 
ately good. Flexion of the fingers and wrist very weak; un- 
able to grasp a pencil or hold a tumbler. There was total pa- 
ralysis of the adductors and abductors of the fingers and of the 
extensors of the wrist and fingers. Circumference of the left 
forearm, three inches below the olecranon process, eight inches; 
right forearm, nine inches. There was exaggeration of the ten- 
don reflexes of the arm, and every now and then clonic move- 
ments of the flexors and extensors of the fingers and also of the 
flexors of the forearm took place. Slight irritation of the finger- SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
3 
tips would cause a sharp, painful contraction of the forearm and 
hand. The left arm was colder and redder than the right. 
Sensation.—The sense of contact over the left hand and arm 
is slightly diminished ; he is unable to locate the point of con- 
tact within two or three inches. Two points, two centime- 
tres apart, on the finger-tips are felt as one. Localization by 
placing the fingers of the normal hand on a definite point on 
the paralyzed hand is defective; but he localizes better an ob- 
ject on the right hand with his left finger than on the left hand 
with his right finger. Pain sense, if anything, slightly over- 
acute; a pinch or a prick of the left hand causes more pain 
than on the corresponding part on the right hand. He suffers 
from neuralgic pains in the left arm. Temperature sense normal 
to both heat and cold. Muscular senseis defective ;he does not 
recognize the position of the fingers or hand or arm well, and 
he does not recognize weights well. The most striking defects, 
therefore, are the impaired muscular sense and the impaired 
localization sense, together with a little hyperalgesia and ex- 
cessive reflex excitability. The left leg shows slight increase in 
the knee-jerk, but no ankle-clonus and no particular motor 
weakness, nor is there any sensory trouble. There is very little 
motor trouble in the face and no sensory disturbance. The right 
half of the body is normal. 
The patient complains a great deal of intense frontal head- 
aches, which, he says, are worse at night and in the early morn- 
ing. Examination of the eye shows a well-marked optic neuritis 
on both sides; the visual acuity, however, is still good, though 
there is some limitation of the visual field. Hearing, smell, and 
taste are normal. The bodily functions, aside from those de- 
scribed, are normal; the appetite is good; the bowels are regular. 
The patient, as may he seen, presented in a typical 
manner the general symptoms of a brain tumor and also 
well-marked localizing symptoms. Owing to the fact that 
the left arm was paralyzed and that sensory disturbances 
were present here, and that the face and leg were hut little 
affected, it was easy to say that the lesion was affecting the 4 
SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
arm centre of the right cerebral hemisphere. The fact that 
the pain and paresthesia and initial convulsive movements 
began in the fingers indicated that the finger and hand 
centres were more particularly involved. The diagnosis of 
a tumor involving the hand and arm centres was therefore 
made. Owing to the fact that the boy had had convulsions 
and headache before any localized symptoms appeared, it 
seemed possible that the tumor might be anterior to the 
motor centres and might be invading them secondarily. 
The age of the boy, the absence of syphilis and of any signs 
of tuberculosis, together with the rather rapid growth, led 
me to think that the tumor was probably a glioma or glio- 
sarcoma. The case was turned over to Dr. Conway, assist- 
ant surgeon to the Fourth Medical Division at Bellevue 
Hospital, who kindly consented to operate. The patient 
was also seen by Dr. Herman M, Biggs, who confirmed the 
local diagnosis and suggested the probability that it was a 
glio-sarcomatous tumor. Dr. Conway operated on the pa- 
tient June 4th. The details of the operation Ido not pur- 
pose to give here, but leave them to he described by him. 
The Operation, by Dr. Conway. 
On the day previous to the operation the scalp was thor- 
oughly shaved and cleansed, the bowels were purged, and the 
patient was carefully nourished. At this time Dr. Dana 
mapped out the hand and arm centres, leaving an indelible 
mark with the silver-nitrate pencil. 
Two hours before beginning proceedings five minims each 
of tincture of strophanthus and tincture of digitalis with a for- 
tieth of a grain of strychnine sulphate were administered, be- 
cause the pulse was somewhat feeble and the operation likely 
to be severe and prolonged. 
June —The patient being etherized and the usual anti- 
septic precautions taken, a horseshoe-shaped incision was made, 
including an area about three inches in diameter, the base of SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
5 
the semicircle being below upon the right side of the head, 
and the centre of the flap corresponding to the motor area pre- 
viously marked out. The scalpel was carried firmly to the 
hone, incising the periosteum at the same time, the latter being 
turned down adherent to the scalp, thus exposing the hone at 
once. A conical trephine three quarters of an inch in diameter 
was applied to the skull over the arm centre, and after a great 
deal of difficulty, because of the extreme thickness ot the bone, 
an opening was made. In removing the button of bone it was 
found that the dura was adherent, causing it to be slightly torn. 
The trephine was again applied above and a little posteriorly to 
the first opening and all the bone between and around was cut 
away with the rongeur forceps until the aperture in the skull 
measured nearly two inches in diameter. This was done be- 
cause it was evident from the appearance of the dura that the 
tumor was extensive and would require a large opening. AT- 
shaped incision was then made in the dura over the centre of 
the tumor, which was found closely adherent to it, the pia and 
brain tissue being somewhat torn in separating the two from 
the dura. The tumor, which was found to be a flat, tough, and 
fibrous mass in appearance, about an eighth of an inch in thick- 
ness, was then separated from the pia and brain substance by 
means of the handle of a silver teaspoon. The new growth 
was so incorporated with the gray matter of the brain substance 
at about the centre of the first trephine opening that a small 
portion of brain substance was removed with it, and for a short 
space around this centre small deposits of the same substance, 
in a number of minute spots, were noticed, but not interfered 
with. 
By exploration anteriorly, it was found that the growth ex- 
tended probably some distance beyond the opening in the bone 
already made, but, as the portion already removed was two 
and a quarter by two inches and the patient was rapidly grow- 
ing weak, it was thought advisable to allow any remnant to re- 
main and be removed by a later operation. 
All portions of the main growth posteriorly, above, and be- 
low having been thoroughly taken away, the edges of the in- 
cised dura were brought together with catgut and the scalp 6 
SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
was stitched with interrupted silk sutures, drainage being pro- 
vided for by means of very small rubber tubes. 
It was immediately found necessary to stimulate him freely 
with the customary heart tonics, used hypodermically, until the 
heart became safely strong. 
Three hours after the operation he had a general convul- 
sion, and during the same night three more followed, but none 
of them were of a very severe type. 
The wound remained aseptic and rapidly healed, all sutures 
and drainage-tubes having been removed within five days. The 
temperature was elevated two degrees during the first week, 
but gradually became normal. 
History continued, by Dr. Dana. 
The arm and hand centres were mapped out upon the shaved 
scalp by myself, the skull was trephined, the dura opened, and a 
tumor found immediately under the point of the first trephine 
opening. The opening was enlarged extensively, and it was found 
that the growth lay directly beneath the dura mater, from which 
it had apparently started, and extended forward a considerable 
distance, being bounded anteriorly by about the middle of the 
frontal lobe, posteriorly it reached as far as the posterior edge 
of the first central convolution, and below it extended down to 
near the lower edge of the central convolutions. The tumor 
was in its posterior part, where it covered the central convolu- 
tions, easily stripped off from the pia mater; but beneath this 
area—that is to say, directly over the middle portion of the 
central convolutions—the cortex was seen to be congested, 
dark, and infiltrated with grayish spots. While not entirely 
destroyed, its functional activity was evidently impaired, for it 
did not respond to strong irritation of the faradaic current ap- 
plied directly upon the convolution. On stripping the tumor 
up anteriorly it was found that about the base of the second 
frontal convolution the tumor had become attached to and in- 
filtrated into the cortex so that this was torn in removing parts 
of it. As much as possible of the tumor was removed, but a 
considerable portion of the anterior part had to be left, although 
the opening in the skull was enlarged as much as was thought SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
safe. The patient made a good recovery, the wound healing by 
first intention; but in the first day he had two convulsions and 
during the following fortnight he suffered intensely from head- 
aches, pain in the arm, and he was at times actively delirious.. 
The situation of the trephine opening and of the tumor (from a photograph 
taken a year after the operation). The dotted line indicates the outline of 
the trephined area ; the dotted area indicates the position of the tumor. 
The symptoms gradually abated, and by June 27th his mind 
was clear, his head was free from pain, and he felt thoroughly 
convalescent. 
Physical examination at that time showed the following con- 
ditions: The paresis of the face was unchanged and the condi- 8 
SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
tion of the leg seemed the same. The left arm could be moved 
more freely; the patient raised it from his side, flexed and ex- 
tended it with greater, readiness; there was less rigidity, and 
the reflex excitability and tendency to twitching had entirely 
gone. There was still considerable weakness in extension and 
flexion, and pronation was very feeble. The fingers were held 
most of the time in extension, but they could be flexed feebly ; 
they could also be slightly adducted and abducted, so that on 
the whole the movements of the arm were better than before 
the operation. 
Sensation.—The pain in the arm had disappeared, and there 
was hardly any of the hyperalgesia which he had before ex- 
perienced. Still hyperalgesia did exist, as shown by simultane- 
ous pricks of the two sides or by pinches of the two forefingers, 
the boy always saying that he felt more pain when the skin of 
the left hand was pinched than when that of the right was so 
treated. 
Light contact by touch of the finger or the head of a pin 
was appreciated normally, or almost so. There was a slight 
delay in contact sensation, however. Localization was slightly 
more defective than previous to the operation. A point on the 
thumb would be felt on the forefinger; two points, two centi- 
metres apart, would be felt as one. Motor touch, so called, 
as shown by his attempts to describe an object placed in his 
hand, was defective, though not much so; he thought that a quar- 
ter of a dollar was a half dollar, and was rather doubtful of the 
nature of the coin altogether. Temperature sense was normal. 
The muscular sense, as shown by appreciation of movements 
of the fingers and position of the fingers, hand, and forearm, 
was quite defective. The fingers when held out straight were 
said to be flexed, and attempts to place the right arm in the 
same position as that in which the left was placed were unsuc- 
cessful. Appreciation of weights was also defective, and at- 
tempts to use the hand in any way were extremely awkward, 
though this was largely due to the stiffness and weakness of the 
limb. 
April 2, 1895 (eleven months after the operation).—The pa- 
tient went until July, 1894, without further convulsions. Since SUCCESSFUL OPERATION FOR BRAIN TUMOR. 
9 
that time he has had about one convulsion a month. The seiz- 
ures, however, are now unilateral only, and not accompanied 
with loss of consciousness, as was the case before the operation. 
They are preceded by an aura of tingling and slight pain begin- 
ning in the fingers and running up the arm. The hand and 
arm go through clonic movements, the face and leg twitch 
slightly, the eyes turn to the left, the leg is very slightly 
moved. 
The paralysis is now less than before the operation. The 
boy can raise the arm straight above the head, flex and extend 
it, flex the fingers, especially in the ulnar distribution, and ex- 
tend the fingers slightly, but not the wrist. He can pronate 
but not supinate. The fingers are kept in rather rigid flexion, 
and they are straightened with some difficulty. There is clonus 
on forced extension of the arm and hand. The left leg is a 
trifle weak, and drags a little on walking; the knee-jerk on the 
left side is exaggerated. The left side of the face shows slight 
paresis. 
There is no pain or tenderness now in the affected side, nor 
is there any sensory disturbance in the face or leg. 
The hand shows defective localizing sense. When a point 
on the finger is touched, he in the majority of cases refers it to 
the wrong finger, and he can not touch a given point on the 
affected hand with the fingers of the normal hand. 
The sense of position of the fingers and hand, the tactile, 
pain, and temperature senses are normal or nearly so. He has 
no headaches; his eyesight is good, and there are only slight 
traces of the optic neuritis. His general health is good. 
The piece of tumor removed was found to be from a spindle- 
celled sarcoma. The New York Medical Journal. 
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