Report of a Case of Cerebral Tumor, Diagnosed 
by Focal Symptoms, with Operation, Suc- 
cessful Removal of Tumor and 
Exhibition of Specimen. 
Read before the Chicago Medical Society, Dec. 18, 1893. 
BY D. A. K. STEELE, M.D. 
CHICAGO. 
REPRINTED EROM THE 
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
JANUARY 27, 1891,. 
CHICAGO: 
Office of the Journal of the American Medical Association. 
1894. REPORT OF A CASE OF CEREBRAL TUMOR, 
DIAGNOSED BY FOCAL SYMPTOMS, WITH 
OPERATION, SUCCESSFUL REMOVAL 
OF TUMOR AND EXHIBITION 
OF SPECIMEN. 
BY D. A. K. STEELE, M.D. 
CHICAGO. 
In reporting to you a case of cerebral tumor diag- 
nosed by focal symptoms and successfully removed, 
I desire to express my obligations to Drs. R. H. 
Isbester, 0. A. King and W. E. Quine for a careful 
history, thorough examination and accurate diagno- 
sis of the case before it was referred to me for ope- 
ration, and to Dr. T. A. Davis for valuable assistance 
during and after the operation. 
The subject of cerebral tumors became interesting 
to surgeons in 1879 through the reports of cases by 
Macewen of Glasgow, and again especially in 1884, 
when Bennett and Godlee of London, arrested the 
attention of the surgical world by their narration of 
the diagnosis and removal of a subcortical tumor of 
the brain. Since then, many cerebral tumors have 
been diagnosed by focal symptoms and a few success- 
fully removed. Horsley, Keen, Hirshfelder, Morse, 
Deaver, Nancrede and others have reported cases. 
I desire to submit the following case as an addi- 
tion to the literature of the subject: 
The patient was referred from the Dispensary 
clinic of the College of Physicians and Surgeons to 
my regular Saturday clinic for operation in the early 
part of October. When I first saw the case I made 
a thorough examination, and placed the patient on 
large doses of iodid of potassium for the purpose of 
clearing up the question as to whether or not there 
might be syphilitic brain disease, although no his- 
tory of any was elicited. Specific treatment pro- Lndotkeliafearl.sareomatous 
Fibrous tissue.. 
Dounc/ sarcomatous ee//s 
Drain, sand. 
Arteriole 
ENDOTHELIAL FI BRO-SARCOMA OF BRAIN. 
'A/veo/ar fibrous structure 
^incite st apedsarcomatous cdF 
Approbation ofsarcomatous cells. 
fndot/iehal pear/.. 3 
duced no effect on his symptoms. November 18 the 
patient was operated upon. The history was as fol- 
lows : 
The patient, John Pierson, was born in Sweden, Jan. 18, 
1852; he is 41 years old. He is the eldest of nine children, 
four boys and five girls. His family was always very healthy. 
His mother, brothers and sisters are living. His father died 
of old age at 77. He is a laboring man ; married and has six 
children, four girls and two boys, all of whom are living. 
Upon arriving in this country, May 15,1881, he went direct 
to Batavia, Ill., where he remained six years. He then went 
to St. Charles, Hl., and lived there until he came here for 
treatment. 
About five years ago the patient while asleep in bed was 
aroused by a sharp pain of a cramping character, in the calf 
of the right limb, which lasted from two to five minutes. It 
was very severe. This pain and the following plantar con- 
traction of the toes, constituted the first attack. About one 
week later he had a second cramp, which was in severity 
the equal of the first. It occurred in the same region and 
was about the same duration. The cramps appeared at an 
interval of seven or ten days and were about as severe as 
the first. Just preceding a spasm there was a prickly, par- 
esthetic feeling in the locality of the expected monospasm. 
Two things characterized these spasms: 1, that they ex- 
tended up the right limb gradually until they reached the 
right groin ; they then passed into and extended in the lower 
part of the trunk, when they became more painful; 2, after 
each spasm the limb was weaker, so that as the spasms be- 
came more frequent they caused a general weakening of 
the muscles and therefore lameness. The spasms continued 
to extend upward until the right arm and the face were 
affected. It took about one year for the whole right side 
to become affected. The spasm would always start in the 
same place, creep upward to the trunk, and then die away 
before the arm and face were affected. After the right side 
was affected the patient sometimes had a prickling sensa- 
tion in the left leg, but at no time were there any spasms. 
During the whole period of five years the patient never had 
an attack of unconsciousness. He often had very severe 
headaches, starting in the occipital region and extending to 
the frontal. 
Examination showed motor paralysis and sensory blunt- 
ing of the right leg; the right patella tendon reHex was 
much increased; hearing was much reduced in the right 
ear; there was no choke disc or optic neuritis; none of the 
orbital muscles were involved. Speech was slow. A diag- 
nosis of cerebral tumor originating in the leg center of the 
cortical area of the left hemisphere of the brain, and ex- 
tending downward and forward to the arm and face centers 
was made, and operation advised, after specific treatment 
was tried without avail. 4 
The patient was prepared and I was ably assisted during 
the operation by Dr. T. A. Davis. The toilet of the operat- 
ing field was thoroughly made 'the previous day; shaving 
and cleansing, and a wet 1-2000 bichlorid dressing applied to 
be worn until time of operation. 
After the patient was thoroughly under chloroform a small 
solid cylindrical rubber band was passed around the head to 
render bloodless the field of operation in the scalp. Four 
stitches, as recommended by Dr. F. Shafer of this city, were 
introduced equidistant apart, binding the rubber con- 
strictor to the scalp so as to prevent slipping. Owing to the 
extent of the symptoms, showing that the convolutions of 
the upper half on either side of the Rolandic fissure were in- 
volved, the nicety of delicate cerebral localization technique 
was; dispensed with and a horse-shoe shaped flap of three 
Endothelial fibro-sarcoma of brain; weight GO grams; base of tumor 
showing depression at point of attachment. 
inches width was turned down and fixed with one stitch to 
the integument beneath, to keep it out of the way of the 
operator. A large button of bone was then removed and 
the opening enlarged by the rougeur to a size correspond- 
ing to nearly that of the scalp flap, a little over three inches 
in diameter and heart-shaped. Palpation through the 
meninges showed great resistance over the region corre- 
sponding to an inch each side over the upper third of the 
Rolandic fissure. Below this region the resistance was nor- 
mal. On opening through the meninges there was found 
absence of pulsation over the region corresponding to the 
part offering great resistance to palpation, and slight pul- 
sation below that region. 5 
Faradization with a double brain electrode over the dense 
tissue was followed by no muscular response, but at the lower 
margin of this tissue, and on down the Rolandic marginal 
convolutions there was responsive contraction of arm mus- 
cles, increasing as it distanced the dense tissue. Macro- 
scopically the dense tissue presented a yellowish color and 
bulged into the wound. On digital exploration a tumor of 
considerable dimensions was found extending down into the 
brain and readily separable from it, a few slight adhesions 
of the tumor capsule alone offering any barrier. After out- 
lining the free borders of the growth, a firm pedicle was 
found attached to the skull, or falx-cerebri at the region of 
the superior longitudinal sinus. The tumor was "shelled 
out" quite readily with the fingers leaving the firmer por- 
tion, the pedicle, which was removed with a strong curette, 
after cutting the skull away up to it with the rougeur forceps. 
A large rent in the superior longitudinal sinus was neces- 
sarily made on removing the pedicle, which necessitated 
firm packing with iodoform gauze of the whole intra-cranial 
wound. This readily controlled the hemorrhage, which was 
enormous for a few seconds ; bnt it prevented the satisfac- 
tory closure of the wound with the return of the bone chips. 
The regular antiseptic dressing was applied and was not 
disturbed for three days, when the bulk of the gauze dress- 
ing was removed, leaving only one small piece over the rent 
into the sinus. At the second dressing, four days later the 
remaining piece of gauze was removed. 
Slight constitutional disturbances followed the operation ; 
temperature 101 degrees; operation fever for thirty-six 
hours followed by a decline to normal on third day. There 
Endothelial flbro-sarcoma of brain, side view. 6 
was complete motor paralysis of arm and leg for twenty- 
four hours following the operation, at the end of which time 
slight motion returned to leg, and nineteen days later some 
motion was observed in the arm. Slight but steady improve- 
ment has occurred since that time. Although we expected 
from the origin of the tumor that sensation and motion 
would return in the arm first, as a matter of fact they 
returned promptly in the leg, and later in the arm. Sensa- 
tion was first felt in the shoulder muscles, the next day he 
could move the arm and on the third day he could draw up 
the forearm ; and now he has good control of the whole arm 
except the fingers. He has no power and but little sensa- 
tion in the fingers. He tells me that he is capable of exer- 
cising some muscle or making some new movement each 
day. The patient is now able to sit up, is permitted to 
walk a little and is anxious to return to his home in time 
for Christmas. 
The packing prevented the accurate suturing of 
the scalp; there was an opening of perhaps two 
inches through which the ends of the strips of gauze 
were drawn out. At the end of a week these edges 
were freshened and re-sutured. Now we have a small 
opening of half an inch through which I keep a minute 
strip of gauze for capillary drainage. There is gran- 
ulation tissue covering the wound, and the patient 
has practically recovered. One week later the wound 
had firmly cicatrized and the patient returned home. 
Endothelial flbro-sarcoma of brain, convex surface. 7 
In regard to the character of the tumor, the speci- 
men was submitted to the Pathological Laboratory 
of the College of Physicians and Surgeons. The ex- 
amination was made by S. J. Sornberger and Prof. 
Evans. Under microscopical examination,both of the 
longitudinal sinus, that is,the pedicle of the tumor, 
and the tumor itself, the following characteristics 
are presented: 
Appearance of operation-wound at time of report. 
1. An abundant fibrous stroma, alveolar in ap- 
pearance. 
2. An abundance of endothelial cells, both large 
and small. These cells are in places crowded together 
in dense concentric masses, while others are scattered 
profusely among the fibers of connective tissue. 8 
3. Calcareous granules, quite abundant, distrib- 
uted throughout, but rather more abundant in the 
small tumor from the sinus, and near its upper 
margin. 
Diagnosis.-Endothelial fibro-sarcoma. 
Remarks.-As you examine the tumor which I sub- 
mit to you for inspection, you will observe that it is 
cone-shaped, bearing a striking resemblance to a 
small pine cone, although somewhat more irregular 
in outline. It weighs exactly two ounces. Its verti- 
cal diameter is two and a half inches and the trans- 
verse diameter two inches. The base is smooth and 
slightly depressed in the center where it was plucked 
from the stem or pedicle. The surface presents a 
papillomatous appearance, small finger-like or tuber- 
ous processes extending downward and outward in 
all directions but more marked around the apex of the 
tumor. If we invert it and place it in the same 
position it occupied in the brain, you will observe 
that it grows downward and forward from its point 
of origin in the wall of the longitudinal sinus into 
the Rolandic fissure, displacing the paracentral lob- 
ules, and the surface irregularities are probably due to 
the varying amount of brain resistance to the out- 
growth of the tumor. Some portions of it lying in 
the great fissure and the smaller projections pushing 
between the convolutions. 
The reaction under the double brain electrode may 
be explained in part by the atrophy of the adjacent 
portion of th^ brain, or motor cells from pressure, 
and in part by mechanical displacement. 
We would infer that the failure to elicit reflex spasm 
by electric stimulation of the leg center was due to 
mechanical displacement of the center upward and 
backward by the tumor, when we find that the re- 
moval of the tumor was followed by a prompt return 
of sensation and motion in the leg. While the slower 
return of the same function in the arm speaks for 
pressure atrophy of the motor cells of the arm 
center. 
240 Wabash Avenue.