[Reprinted from The Medical News, February 8, 1890.] 
A FAILURE IN BRAIN SURGERY. 
By HAL C. WYMAN, M.D., 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY IN THE 
MICHIGAN COLLEGE OF MEDICINE AND SURGERY, DETROIT. 
James H., a rugged and robust young farmer; 
father of one child. About a year ago, while 
digging in the field, he was suddenly attacked 
with pain in the back of the head. At first 
supposing it to be merely an ordinary headache, 
he went to the house and bathed his head with 
cold water, but the pain continuing severe, he 
consulted a physician four miles distant, returned 
home, took the medicine as directed, and was con- 
siderably relieved of his suffering. The following 
day he did not feel strong enough to work, and sent 
for the physician, who diagnosed malarial fever. 
The attack lasted about six weeks, during which 
time he suffered more or less from pain in the head. 
Becoming dissatisfied with his medical attendant, 
he sought other advice, which confirmed the orig 
inal diagnosis of malaria. He took many drugs, 
but experienced no marked relief from the pain. 
About four months after the beginning of the 
attack, he found that his eyesight was failing. He 
also suffered from nausea and his sleep was dis- 
turbed. He vomited a great deal, although the 
attacks of vomiting would not come on until some 
time after taking food, so that he did not lose flesh rapidly. Pain in the frontal region continued per- 
sistently. He was then placed upon potassium 
iodide. This drug for a time seemed to make some 
impression on his sufferings, and under its influence 
he was able to secure a few hours’ sleep. However, 
after a few days its effects passed entirely away, and 
the pain returned with renewed vigor and intensity. 
He became still more restless and sleepless, vomited 
more frequently, the symptoms finally culminating 
in an epileptic seizure. Following this attack of 
epilepsy, he had divergent squint and additional 
convulsions, with marked muscular weakness and 
some fever. 
Drugs of every sort were tried in vain, the pain 
continuing. 
Dr. Mere, at my request, made an ophthalmo- 
scopic examination of the eyes and found the con- 
dition of the retina indicating pressure upon the 
optic tract. 
Operation.—The man became blind or partially 
blind within a few weeks after the attack of head- 
ache. He had had almost no unilateral symptoms, 
and had but slight movements of rotation, and at 
times great muscular weakness. These facts led me 
to locate the disease in the neighborhood of the 
, sella Turcica and in the cerebral ventricle. There- 
fore, I trephined the frontal bone just above the 
supra-orbital ridge on the right side. One button 
of bone was removed, and through the opening the 
membranes were incised. First, however, the dura 
mater was raised and a probe pushed along the 
orbital plate of the frontal bone in the direction of 
the optic commissure. Then the finger was intro- 
2 
WYMAN, A FAILURE IN BRAIN SURGERY. 
3 
duced and the parts carefully explored, but no tumor 
or abnormality being detected, a small director was 
pushed cautiously through the anterior lobe of the 
right cerebrum in the direction of the anterior horn 
of the rmht lateral ventricle. But little fluid was 
evacuated, owing to the brain substance choking up 
the instrument. No sensation as of the point of the 
director free in a cavity was observed. During the 
administration of the anaesthetic the patient nearly 
died from failure of respiration. His respiration 
resembled the Cheyne-Stokes respiration in that his 
breathing was at times very rapid and then slow. 
The opening was made at the position designated 
because the symptoms pointed to disease in the 
neighborhood of the optic commissure and crura 
cerebri, and to effusion into the ventricles. A brief 
recapitulation of the morbid phenomena presented 
by the case may serve to make clearer my reasons 
for operating. Pain, quite uniform in quantity and 
character; fever, of several weeks’ duration, imme- 
diately after the attack of pain ; impairment of sight 
in both eyes, varying at times in degree; nausea; 
movements of rotation quite indistinct in the his- 
tory; general impairment of strength not unilateral. 
No incoordination; disturbance of sleep variable; 
copious nasal discharge and impairment of sense of 
smell. These led me to think that there was effusion 
into the ventricles, with disease near the optic com- 
missure and crura cerebri which might be removed 
by an operation of the kind described. The opera- 
tion was made in the amphitheatre of the Detroit 
Emergency Hospital in the presence of the students 4 
WYMAN, 
of the Michigan College of Medicine. Thorough 
cleanliness was observed in every detail of the work, 
and the autopsy revealed no evidences of wound 
infection. 
Autopsy.—Body moderately emaciated. Wound 
crescent-shaped on right forehead beginning near 
the external angle of the orbit, ranging upward and 
toward the median line of the face until the root 
of the scalp is reached, then descending to a point 
midway between the eyebrows. It was closed with 
nine interrupted sutures and had a plastic exudate 
between its surfaces. 
The general appearance of the body suggested a 
man of moderately strong physique. His head was 
well shaped. On removing the calvarium the dura 
mater was adherent by numerous Pacchionian bodies 
which had in several places almost perforated the 
bone. A wound about three-fourths of an inch in 
length was found in the dura mater over the anterior 
lobe of the right hemisphere, which corresponded 
to a hole in the right frontal bone made by the 
crown of a trephine. Incising the dura and the 
attachment of the falx cerebri to the crista galli, they 
were turned back so that the arachnoid and pia 
mater were exposed. Much fluid was present in the 
subarachnoid space. There was some ecchymosis 
of the arachnoid and pia mater near where the dura 
mater had been divided at the time the bone was 
trephined. There were also present on the surface 
of the pia some particles of brain-tissue about the 
size of grains of wheat. 
The membranes were entirely removed, and with A FAILURE IN BRAIN SURGERY. 
5 
a sharp knife a section was made through the right 
cerebrum on a level with the corpus callosum. This 
opened the right cerebral ventricle and allowed 
several ounces of fluid to escape. The left ventricle 
was opened in the same way, and was found dis- 
tended with fluid. The third ventricle was then 
opened by cutting through the corpus callosum and 
fornix, and was found distended with fluid. The 
iter e tertio ad quartum ventriculum was distended 
with fluid, so that it easily admitted a lead-pencil 
into the fourth ventricle. No other changes in the 
cerebrum were observed, except the shallowness of 
the spaces between the convolutions. The mem- 
branes were now removed and the cerebrum turned 
back to expose the optic commissure and the 
tentorium cerebelli, which was divided so that the 
crura cerebri, pons Varolii, and medulla oblongata 
could be easily examined. Nothing abnormal was 
noticed, except the excess of cerebro-spinal fluid. 
The optic nerves and commissure were normal. The 
spinal cord was divided after cutting the cranial 
nerves, and the entire brain was turned out of the 
skull. The cerebellum, pons, and medulla appeared 
normal at first, but looking more carefully at the 
cerebellum that organ was found to differ markedly 
in the appearance of its right and left hemispheres. 
The left hemisphere had a swollen appearance and 
a peculiar elastic feel which did not exist in the 
right hemisphere. A cut was made into it to 
demonstrate the arbor vitae, when about an ounce 
of fluid ran out. Separating the cut surfaces, a 
cavity was found to have been divided which 6 
A FAILURE IN BRAIN SURGERY. 
measured one-half inch in one diameter and one 
inch in another. Within this cavity, which was 
walled entirely with medullary matter, not a point 
or streak of gray showing at any point, a tumor 
oval in shape was found. It was about three-fourths 
of an inch in its long diameter, and was attached to 
one side of the .cavity by a thick, short pedicle.