JP.l-i iPRINTED FROM (T UNIVERSITY Medical Magazine. EDITED UNDER THE AUSPICES OF THE ALUMNI AND FACULTY OF MEDICINE OF THE UNIVERSITY OF PENNSYLVANIA EDITORIAL STAFF Advitory Committo*: > u.'u" L«. uwVTU?■*,* Editor!*! CommittM : u<oihh,u CONTENTS. JANUARY, 1895 Subcortical Glioma of the Cerebrum Affecting Principally the Arm Centre; Removal; Recurrence of the Growth ; Second Operation ; Recovery. CASE OF PROFESSORS H. C. WOOD AND J. WILLIAM WHITE REPORTED BY ALFRED C. WOOD, M.D., Instructor in Clinical Surgery in the University of Pennsylvania; Assistant Surgeon to the University Hospital. TJTBRARY. SURGEON GENERAL'S OFFICE JUL 2 0 1909 SUBCORTICAL GLIOMA OF THE CEREBRUM AFFECTING PRINCIPALLY THE ARM CENTRE ; REMOVAL ; RE- CURRENCE OF THE GROWTH; SECOND OPERATION; RECOVERY.1 Alfred C. Wood, M.D Instructor in Clinical Surgery in the University of Pennsylvania ; Assistant Surgeon to the University Hospital. For the privilege of reporting the following case I am indebted to Dr. H. C. Wood, in whose service at the University Hospital the patient first came under observation, and Dr. J. William White, to whom he was referred by Dr. Wood for surgical intervention. Briefly, the history is as follows :2 " W. B., aged 28 years, of Irish descent, whose occupation is that of a bar-tender, states that he has always enjoyed good health until the beginning of the present trouble. Careful inquiry failed to elicit any family predisposition which would have a bearing on the present condition. According to his account of himself, he first noticed, in August, 1892, occasional twitchings in the left hand. These have recurred at irregular intervals up to the present time, until now they sometimes happen several times a day. They begin with a tearing sensation in the hand, movement and sensory dis- turbances, however, coming on almost simultaneously. The arm is commonly flexed at the elbow by tonic contractions, though the hand is clonically and furiously moved. Sometimes the attacks are not attended by loss of consciousness. Usually, however, of late, the first movements are followed almost at once by unconsciousness and a fall to the ground, there being general muscular relaxation, excepting in that the mouth is commonly drawn towards the left side. On two occasions there have been violent general epileptiform convulsions. When he first came under observation there was no distinct paralysis of the arm, but a slowly progressive loss of power not yet amounting to complete paralysis has developed. There have been occasional attacks of vomit- ing. In the early history of the trouble he was free from headaches, but lately these have been more and more frequent and severe. The pain is located in the region of the right temple, and has been at times so severe as to preclude sleep for a whole week. There is also at present a rapidly-progressive and severe double optic neuritis, with retinal hemorrhages and large, tortuous, retinal veins. Thirteen years ago, he says, he was struck on the top of the head with steel knuckles, 1 Read before the Philadelphia County Medical Society, 1894. 1 Abstracted from a clinical lecture delivered at the University Hospital upon the patient by Dr. H. C. Wood, in January, 1894. 2 Alfred C. Wood. possibly a little to the right of the middle line. The blow caused him to reel, and he was dazed for a few moments, but did not lose conscious- ness. No further trouble was experienced from this accident. The reflexes are normal. The urine is free from albumin and sugar, specific gravity 1033, acid in reaction. There are no disturbances of the special senses other than diplopia and some contraction of the field of vision, which latter is evidently the result of the optic neuritis. The symptoms point to the presence of an organic disease, affecting especially the motor arm centres in the cerebral cortex, and spreading upward to those of the face ; possibly, also, affecting slowly the leg centres, as there seems to be some weakness of the left leg. " I do not think it possible to make an absolutely positive diagnosis as to the nature of the organic disease, but I have no doubt from the way in which the case has progressed that there is some form of tumor present. The possibility of syphilis has been carefully considered and put to one side by a very active antispecific treatment, which failed to produce any improvement whatever. The important practical question is whether the tumor springs from the meninges or arises within the brain. Here again the diagnosis is simply one of probabilities, not certainties. It is, to my thinking, improbable that the tumor springs from the meninges. Early in the case pain was wanting, so that the headache from which he now suffers is almost certainly a pressure symptom, and not the result of any localized meningitis or meningeal irritation. In the second place, the occurrence of an optic neuritis along with a cortical lesion, situated as high up in the vault as the present must be, would indicate great increase in the brain pressure. A tumor springing from the membranes and so located that in its first inception it would evince its presence by symptoms of irritation of the cortical centres, would, I opine, of necessity have produced by pressure and secondary changes complete destruction of the cortical centres by the time it had grown sufficiently to cause the violent pressure symp- toms present in this patient. I believe, therefore, that the tumor is of intracranial origin. It is probably not tubercular on account of the general good health of the patient, and it must therefore be in all prob- ability sarcomatous or gliomatous. After a very careful consideration I have come to the conclusion to recommend surgical interference, for the following reasons : The case is progressively going from bad to worse, and must soon end in death if surgery be of no avail; second, it is possible that I may be mistaken in supposing that the tumor arises from within the brain, and if a meningeal tumor should be found, the result of surgical interference would, of course, be most brilliant; third, even if a glioma or sarcoma of the brain substance exists, it seems to me possible to remove sufficient of the mass to relieve the intense Subcortical Glioma of the Cerebrum. 3 pressure symptoms, and probably to increase the comfort and protract the life of the patient. I shall, therefore, send the case to Professor White for operation." With such a history, in addition to the careful study already made of the case by Dr. Wood, it is needless to say that in the advisability of an operation, Dr. White was fully in accord. The consent of the patient having been readily secured, the day previous to that set for the operation the entire scalp was shaved and well scrubbed with soap and warm water, then washed with alcohol, and finally douched with a solution of bichloride of mercury 1 : 1000 and carbolic acid 1 : 50, after which the head was covered with an antiseptic dressing wrung out of a solution of corrosive sublimate 1 : 2000 and carbolic acid 1 : 100. The usual preparatory treatment for a patient about to undergo an operation of this magnitude was carefully carried out. Operation, 1.30 p.m., January 24, 1894. After the administration of ether the cleansing of the scalp was repeated in the same manner as before. As the symptoms, detailed above, clearly pointed to implica- tion of the arm centre of the right cerebral hemisphere, the position of the fissure of Rolando on the right side was marked upon the scalp, having been determined by the method of Mr. John Chiene, of Edin- burgh, which is as follows:1 A moderately heavy piece of paper, at least five inches square, is folded upon itself by bringing two diagonal corners into apposition, forming a triangle (/4 B C, Fig. I). The angle A B C, being one-half of a right angle, is equal to forty-five degrees. One free margin, coinciding with B C, is then folded over so that it lies upon the line A B, forming the angle E B D (Fig. II), whose value is one-half of forty-five degrees, or 22.5 degrees. Now, by retaining the last fold and unfolding the first, the sum of these two angles is obtained, which equals 67.5 degrees (E> B C, Fig. III). As pointed out by Thane, the fissure of Rolando starts on the line from the glabella to the inion at a point 55.7 per cent, of the distance, 1 An American Text-book of Surgery. 4 Alfred C. Wood. measured from the former, and runs downward and forward at an angle of sixty-seven degrees for a distance of about three and one-half inches, the lower extremity of the fissure running slightly more perpendicularly than indicated by the line. For practical purposes it is sufficient to measure half an inch behind the middle point between the glabella and inion as the upper extremity of the fissure. If now the angle B of the folded paper, which represents sixty-seven and a half degrees, be placed at this point with the straight edge B C along the middle line of the head anteriorly, the folded margin of the paper (B Z?) will rep- resent the position of the desired fissure, which stops at three and a half inches from the upper extremity. It is now well known that the convolutions at the upper end of this fissure control the movements of the opposite leg, while those at the lower extremity control the muscles of the opposite side of the face ; between these the centre which governs the arm is located. Having fixed these points on the scalp with an aniline pencil, it remained to indicate their positions on the skull, which was done by forcing a fine drill through the scalp and rotating it two or three times to make an impression on the bone. A large horse- shoe-shaped flap with the base anteriorly, and consisting of all the layers of the scalp, was raised so as to expose the motor area, and the hemorrhage controlled by means of hemostatic forceps. An inch-and- a-half trephine was applied over the arm centre as indicated by the mark on the skull, and the button of bone removed. The exposed dura was of a deep purple color and tense and bulging, but was not adherent. The opening was then enlarged above and below with the rongeur forceps, to the extent of from two to two and a half inches. Before the operation was begun it was decided to proceed after the method recommended by Mr. Horsley, which consists in making an appropriate flap and removing the necessary portion of bone. After the hemorrhage is arrested, sterilized gauze is laid in the wound and an antiseptic dressing applied ; the removal of the tumor being deferred until the patient has recovered from the shock of this pro- cedure. After the dura was exposed, however, the amount of tension indicated so high a degree of intradural pressure that it was thought advisable to proceed further. The dura was very carefully divided and turned aside. The convolutions exposed were deeply congested and bulged into the wound, showing unmistakably that the seat of trouble had been exposed. Palpation did not throw any additional light on the condition, as there did not seem to be either distinct resistance or undue softening. An incision into the most prominent portion of the swelling revealed what at first seemed to be a cyst, with a wide zone of altered brain substance surrounding it. The tissue around the cyst was dark in color, and contained a few small extravasations of blood, Subcortical- Glioma of the Cerebrum. 5 and upon closer examination was thought to be a new growth with secondary central softening, giving the appearance of a cyst. This mass was found to merge into healthy brain substance on its different aspects without any attempt whatever at encapsulation, or of sharp demarcation. The removal of this tissue was effected by the cautious use of the knife, scissors, and curette. It was impossible to remove it as a whole, on account of its soft consistence, and it was, therefore, taken away piecemeal. There was no way of judging when the tumor had been entirely eradicated, but the operation was discontinued'as soon as healthy brain tissue appeared to have been reached on all sides. The cavity left in the brain was about the size of a large walnut. Bleeding-points were ligated where possible, a drainage-tube inserted, the wound packed with iodoform gauze to arrest the bleeding which still continued, the wound in the dura was closed by catgut sutures except at the point where the tube and gauze came out, the flap stitched in place with silkworm gut, and an antiseptic dressing applied. The op- eration was well borne, and the patient came up from the ether nicely, suffering only moderately from shock. As the effects of the anesthetic wore off it was discovered that the left side of the face was flattened and expressionless, and when voluntary motion returned it was found that there was complete paralysis of the left arm and leg. At 10.30 p.m. of the same day, motion began to return in the paralyzed leg, and by 12 o'clock, midnight, the patient was able to flex the limb and move it about. Sensation was not impaired. The course of the wound was satisfactory throughout, the iodoform gauze was removed on the sec- ond day, and the drainage-tube two days later ; there was no discharge of pus at any time, and healing was prompt except at the point occu- pied by the tube, which closed by granulation. The paralyzed side of the face soon began to improve and went on to complete recovery. Motion in the arm began to reappear two weeks after the operation, but has made little improvement. It was soon found that the scalp overlying the trephine opening in the skull was becoming elevated. This condition increased rapidly until a tumor the size of an egg had formed, in spite of continuous firm bandaging. The swelling was at first thought to be due to what is known as fungus cerebri, but it later became apparent that it was a recurrence of the neoplasm. There were no subjective symptoms of intracranial growth. In May, having made the same preparations as before, a flap was dissected back from the swelling, the opening in the skull enlarged, and a considerable quantity of substance, similar in character to that removed at the first operation, was taken away. The distinction between the healthy brain substance and the new growth was more pro- nounced, so that the removal of all of the tumor could be made more 6 Alfred C. Wood. complete and certain. There was very free hemorrhage, which, how- ever, yielded to pressure, the wound was closed w'ithout drainage, and the usual dressings were applied. The operation was immediately more serious than the first. There was more hemorrhage and more shock, but the patient rallied well, and was up and about again in a few days. Since the moment of the first operation there has been absolutely no headache, no recurrence of the spasms, not even an abnormal sensa- tion, and the vision, which was very imperfect before, now seems as good as it was previous to the beginning of the trouble. He walks about with the assistance of a cane moderately well, but he has little use of. the left arm. Microscopic examination of the tissue removed showed the appear- ances of a glioma. The patient left the hospital and passed from observation until about six weeks ago, when he stated that he had been entirely free from all symptoms during the interval. He walks well without a cane, although the left leg is somewhat spastic. The functions of the arm have not improved much. Since leaving the hospital, however, there has been no attempt to improve the condition of the limbs by massage and electricity, so that failure to make greater progress towards the restoration of the muscular tone of the left arm and leg may be due in part to this neglect. There is now some increase in the knee-jerk on the left side, indicating descending degeneration in the cord. The scalp over the seat of the former operation is depressed, as is always observed in these cases if the bone has not been replaced nor substi- tuted by a portion from another source. The part seems entirely healthy ; there is no evidence of a return of the growth. The patient states that he eats well, sleeps well, and is up to his usual health and weight. The features of especial interest in this case are,- (1) The accurate location of the growth clinically. (2) The precision with which the tumor was exposed by the tre- phine opening. (3) The immediate and complete left-sided paralysis, followed by perfect restoration of the normal condition in the face, and the return of a very fair degree of function in the leg, while motion in the arm has failed to improve markedly, showing that the arm centre has probably been almost entirely removed, while the face and leg centres were but slightly encroached upon at the operation, and, although suffering tem- porarily from the traumatism, have preserved their integrity. (4) The recurrence of the growth, followed by its successful re- moval ; the patient remaining well until the present time, now seven months after the last operation and eleven months after the first. Subcortical Glioma of the Cerebrum. 7 (5) The assertion of Seguin, Mills, and others that in subcortical lesions of the brain hemiparesis precedes the spasms, and which con- dition was noted in a case recorded by Diller and Buchanan, was not borne out, as the reverse was true in the case just reported. Myotonia, which is also said by Mills, Lloyd, and Seguin to be a symptom of a subcortical lesion, was absent. The present position of cerebral surgery marks one of the great achievements of the healing art, and has been made possible entirely through the agency of modern aseptic technique. We do not now con- sider it a more serious matter to expose and explore the brain than the peritoneum. Unfortunately, the affections of the brain are not so frequently suitable for surgical attack as are those of the perito- neal cavity. However, with the seat of numerous important functions of the brain already determined, with the constantly increasing cer- tainty with which the neurologist is able definitely to locate the exact seat of numerous pathological processes, with the ability to cut down and expose these points with precision, through a knowledge of cranio- cerebral topography, and with the present Unproved operative tech- nique, the legitimate field of surgical interference must grow broader. It is evident that in order successfully to remove a tumor of the brain, without taking the life of the patient, it must be situated upon or near the convexity. From a careful study of the post-mortem records of 600 cases of brain tumor, by Starr,1 there were found forty-six in which an operation was indicated by the general and local symptoms, and in thirty-seven (6 per cent, of the total number) the conditions were such that the tumor could have been easily removed. The aver- age proportion of brain tumors that are favorably situated for removal, as given by various authorities from a study of post-mortem records, is 7 per cent. It is especially interesting to note that in the cases anal- yzed by Starr the tumor could have been removed easily, and with safety to the patient, in at least 78.7 per cent, of the cases in which the symptoms pointed to a growth in an accessible region. There is no doubt, however, that the number will be much greater in the future, for the reasons already mentioned. In regard to the mortality of these operations, the same author, from a study of the operations so far reported, finds that in a series of eighty-one cerebral tumors the growth was successfully removed fifty- four times. Of these thirty-nine patients recovered and fifteen died, the percentage of final recoveries being therefore 48.14. Brb reports a case (quoted by Starr) which in many particulars is so similar to the one just detailed that it is here reproduced. 1 Brain Surgery, 1893. 8 Alfred C. Wood. The patient was a man who had suffered from the general symp- toms of brain tumor-viz., headache, vertigo, vomiting, and optic neu- ritis-for some months. The development of occasional spasms fol- lowed by paralysis in the left arm and leg indicated the central convo- lutions of the right hemisphere as the probable position of the tumor. Czerny operated in November, 1890, and found the tumor to be an infiltrated glio-sarcoma, and removed a part of it, its complete extir- pation being impossible. The patient recovered from the operation, was very much improved for eight months, and then began to suffer again from the old symptoms. In November, 1891, his condition had become so bad that it was thought best to repeat the operation. The tumor was found to have grown again, and again a large part of it was removed. Again improvement was very striking, but at the date of the report, July, 1892, a third operation upon this man was in contempla- tion, the symptoms having again appeared. As a result of his studies, Starr states that the large majority of the gliomata and the glio-sarcomata were infiltrated, into the brain sub- stance to such an extent as either to have escaped detection at an oper- ation, or to have been impossible of excision. When it is considered that this statement is based upon a study of 600 cases, the one here reported must be considered as having terminated unusually successfully. The cause of these tumors is as obscure as is that of those situated upon other parts of the body. In a large number of the cases a history of traumatism will be obtained, but whether or not this has any etio- logical bearing it is impossible to say. The patient whose case is detailed above reports having received a blow on the head thirteen years ago. At the time of operation there was no evidence of injury either of the scalp or in the skull.