Reprinted from the 
University Medical Magazine. 
April, 1889. 
THE SURGICAL ASPECTS OF DR. WOOD’S CASE OF 
BRAIN TUMOR. 
By J. William White, M.D., 
Demonstrator of Surgery, University of Pennsylvania, Assistant Surgeon to the 
University Hospital. 
The surgical problem in this very interesting case was to expose the occi- 
pital lobe, and especially the cuneate portion of that lobe in such a manner as 
to permit of its inspection, its palpation, and the exploration by the finger of 
its under and internal surfaces, and of the corresponding portions of the ten- 
torium and falx cerebri. As there was also an evident possibility that the 
disease affected the angular gyrus, it was necessary to bear in mind the relation 
of that portion of the cortex to the original trephine opening. 
It was also apparent that, thoroughly to investigate the region of the 
cuneus, it would be necessary to remove the skull not only on the horizontal 
level of the tentorium, which it must be remembered is convex upward, its 
centre being higher than its circumference, but also almost to the middle line, 
so that the posterior portion of the longitudinal fissure could be entered with 
the finger. Of course this involved very close proximity to both the lateral 
sinus, inclosed in the convex border of the tentorium, where it is attached to 
the transverse ridges upon the inner surface of the occipital bone, and to the 
posterior portion of the superior longitudinal sinus contained within the broad 
convex margin of the falx. 
The points necessary to outline on the scalp were therefore as follows : 
inferiorly, the level of the attachment of the tentorium, i. e., the line of the 
lateral sinus ; superiorly, the line of the external parieto-occipital fissure and 
the region of the angular gyrus ; internally, the line of the attachment of the 
falx, i. e., the line of the longitudinal sinus. 2 
WHITE, SURGICAL ASPECTS OF BRAIN TUMOR. 
These were easily determined in the following well-known manner : Reid’s 
base line, running from the lower border of the orbit through the centre of the 
bony meatus of the ear, was first drawn. ’The line of the great longitudinal 
fissure was indicated by a line drawn from the glabella to the external occipital 
protuberance. The fissure of Sylvius was located by a line drawn from a point an 
inch-and-a-quarter behind the external angular process of the frontal bone to a 
point three-quarters of an inch below the most prominent part of the parietal emi- 
nence. Continuing this line backward, so that it would unite with the line of the 
longitudinal fissure, the posterior inch-and-a-half of the former indicated the ex- 
ternal parieto-occipital fissure. The region between the anterior end of this line, 
and the posterior end of the fissure of Sylvius, including a portion of the 
cortex slightly above and below that level, is the region of the angular gyrus. 
Or that region may be said to lie on that level and behind a line passing through 
the posterior border of the mastoid process and perpendicular to the base line. 
The line of the lateral sinus was one extending from the external occipital pro- 
tuberance to a point an inch behind the external meatus. The correctness of 
this line was verified by Dr. Osler and myself the day before the operation. 
The obvious surgical difficulties peculiar to this case were : i. The neces- 
sity for so closely approaching the two great venous sinuses ; 2. the very great 
inequality in the thickness of the skull at this region, rendering the trephining 
itself somewhat more dangerous than usual; 3. the need for affording room 
for such displacement of the occipital lobe in a direction superiorly and exter- 
nally as would admit of palpation of the cuneus, falx, and tentorium. 
The operation was performed by Dr. Agnew, assisted by me. The first 
trephine opening was made at the lower internal angle of the right occipital 
lobe, the instrument being placed so that the teeth would clear the lines of the 
lateral and longitudinal sinuses by from a quarter to a half inch, the variations 
constantly occurring in the width, and the attachments of those venous chan- 
nels being carefully considered. It was proposed to cut away subsequently 
with the rongeur any portion of bone remaining which might interfere with the 
examination of the suspected regions. 
At about the completion of the trephining a jet of blood, from the lower 
and outer third of the circumference of the wound, showed that a large vessel 
was opened. The circle of bone was instantly pried up with a lever and 
removed, when it was found that a trephine tooth had torn a slight nick in the 
extreme upper margin of the lateral sinus, which was congested and swollen 
beyond its natural limits. A pledget of gauze instantly and completely arrested 
the bleeding. A second trephine opening was then made over the region of the 
gyrus, and the openings made to communicate by means of the rongeur. The 
brain protruded abnormally. The secondary cystic deposit was recognized 
and removed, and further search for a tumor was abandoned, no definite symp- 
toms having pointed, so far as my knowledge of cerebral localization goes, to the 
main growth in the temporo-sphenoidal lobe. 
At the conclusion of the operation, which lasted for one hour and ten min- 
utes, and during* which twelve ounces of ether were administered, and perhaps 
ten to fifteen ounces of blood lost, the patient’s condition was one of extreme WHITE, SURGICAL ASPECTS OE BRAIN TUMOR. 
3 
shock. He recovered consciousness, recognized his wife, spoke to me ration- 
ally, complaining bitterly of pain in his right eye and in his right arm, but died 
some hours later in collapse. 
The cause of death was multiple—shock, ether, and hemorrhage doubtless 
each exerting its influence. It is impossible to be quite sure as to their relative 
importance, but I am of the opinion that the first two were chiefly concerned, 
for the reason that there was no leakiness of the skin, no profound or persistent 
depression of temperature, no blanching of the lips or cheeks, no constitutional 
symptoms of hemorrhage. On the other hand, the degree of handling and 
interference with brain structure was of necessity exceptionally great, and the 
portion removed was quite considerable. I am inclined, too, to agree with Dr. 
Wood in the belief that in brain tumors a relatively small quantity of ether 
produces alarming symptoms, and I would include in this statement most 
operative cases of disease or injury of the cranial contents, associated with the 
removal of a portion of the skull. The only possible explanation which has 
occurred to me is that, under these circumstances, the lessening of external resist- 
ance, as shown in the occasional protrusion of portions of even healthy brains 
through a trephine opening, may favor the rapid absorption and expansion of 
the ether vapor in that region, so that, with the same amount given, a relatively 
large proportion reaches the great nerve centres. This is a mere suggestion, 
however, possibly faulty in its very premises, and relating to a question which 
must be solved by the experimental therapeutist rather than by the surgeon. 
As to the hemorrhage from the sinus, there is nothing in that per sc neces- 
sarily fatal, or even alarming. Many instances of recovery after such wounds 
have been reported, and Pott is even said to have successfully performed vene- 
section from the longitudinal sinus. The bleeding is always easily arrested, if 
the wound of the sinus can be exposed, the lightest pressure serving, as in 
most other forms of venous bleeding, to control it. This is so well known that 
surgeons do not hesitate, in the presence of proper indications, to trephine 
directly over the course of either the lateral or the longitudinal sinus. The 
fatal cases have been those in which a sinus was wounded either by trephine or 
by bony spiculae before the portion of cranium could be elevated so as to expose 
the wound. In one of the earliest cases of so-called “ brain surgery” which 
occurred in Philadelphia, I trephined a patient of Dr. C. K. Mills over the 
course of the longitudinal sinus and removed from beneath the dura a fragment 
of bone and a small pistol ball, together with some surrounding sclerosed and 
adherent brain tissue, with the result of curing the patient of an inveterate epi- 
lepsy.