Reprinted from the Journal of Nervous and Mental Disease, February, 1893. 
Tumor of the Cortex. 
BY • 
By FRANK W MADDEN,'M.D., 
Plattsburgh. N. Y. TUMOR OF THE CORTEX PRODUCING HEMI- 
PLEGIA, WITH LOSS OF TACTILE, PAIN, 
AND MUSCULAR SENSE. 
By FRANK S. MADDEN, M.D., 
Plattsburgh, N. Y. 
I ^HE localization of motor centres in certain well- 
defined areas of the brain is a scientific fact of 
fairly accurate exactness. The centres for certain 
of the special senses-vision, hearing, smell, etc.-have 
been localized with equally practical accuracy. Common 
sensation, with its subdivisions of tact, pain, temperature, 
and muscular perception, has not yet been positively 
shown to be in constant relation to any definite area of 
the brain, though much clinical and experimental data 
has accumulated tending to show that the sensory centres 
mentioned are quite closely related, if not identical, with 
the corresponding motor areas. Heusner,1 Wernicke," 
Jastrowitz,3 Gray,4 and Daskchewitsch6 have each reported 
clinical examples of loss of common sensation in associ- 
ation with paralysis of motion, the lesion being in the 
cortical motor region or in the white matter immediately 
subjacent. That the anatomico-physiological relation- 
ship between motor and sensory centres is a close one, 
is generally, if not universally, admitted, and especially 
is this true of the muscular sense. 
The case herewith reported is worthy of record in 
this relation. The history is as follows: 
i Heusner: Deutsche med. Wochenschr. October 18, 1888. 
2 Wernicke : Archiv f. Psychiat. und Nervenk. Bd. 20, H. 1. 1888. 
3 Jastrowitz: Deutsche med. Wochenschr. February 23, 1888. 
4 Gray, L. C. : N. Y. Medical Journal. February 19, 1891 
5 Daskschewitsch : Centralblatt f. klin. Medicin (Leipzig). No. 27, 
1891. 
6 Seguin and Weir : American Journal Med. Sciences. July, August, 
and September, 1888 2 
FRANK S. MADDEN. 
R. K. B., aged fifty-one; married; merchant and 
speculator. Family history good. 
Personal History.-Denies syphilis; was always fairly 
healthy; very temperate in the use of tobacco and alco- 
hol, and not given to sexual excesses. Thirty years ago 
he received an injury to the back of his head by falling 
on the ice. In 1888 he was struck over the left occipito- 
mastoid region with a heavy cane; suffered much pain 
for two weeks afterward. In the summer of 1890 he had 
an attack of extreme dyspnoea, nausea, vomiting, and 
diarrhoea, the result of a run of fifty yards to catch an 
outgoing steamer. 
On October 8, 1890, he had a convulsion, epileptiform 
in character, preceded by a sensation of severe tension 
with inco-ordination of movement in the left arm and 
forearm, followed by loss of power in the arm, which 
extended to the leg, with, finally, total loss of conscious- 
ness and convulsive movements affecting both sides of 
the body, but particularly the left. Vomiting of the 
cerebral type occurred two hours after a return to con- 
sciousness. Under sodii bromid. he remained well after 
this attack, until October 23d, when he had a succession 
of epileptic seizures of the Jacksonian type, affecting 
the left arm, preceded by loss of power and paraesthesise 
in the limb affected. Vomiting again occurred about 
four hours after the attacks had ceased. 
About this time the patient complained of slight 
occasional headache; was much depressed mentally, and 
at times irritable and quite nervous. Numbness, ting- 
ling, and various other paraesthesiae of the left hand 
gave him great annoyance. Loss of tactile sense was 
demonstrable in the left hand. and was absolute in the 
ring finger. There was also loss of muscular sense, with 
marked ataxia at times. One or two light attacks of a 
convulsive character occurred during the ne Kt month, 
and but little change was noticeable in the patient's 
condition. 
On November 23d he had a violent epileptic convul- 
sion, preceded by the usual aura and with disturbance 
of vision and ataxic aphasia. Vomited after the seizure 
as before. 
On December 1st he had another attack, involving 
the left upper extremity, neck, and face. 
The patient's condition did not vary materially during 
the ensuing two months, although there was a gradual 
progression of all symptoms; a noticeable drag of the TUMOR OF THE CORTEX. 
3 
left foot became apparent, and the gait became stagger- 
ing. The pain in the head and tenderness (region of 
right parietal eminence) increased in intensity. Im- 
pairment of tact and muscular sense was also more 
conspicuous. 
One or two slight seizures occurred in February, and 
the patient developed a mental condition of exaggerated 
excitability, with attacks of hysterical crying. 
Ophthalmoscopic examination (Buller, of Montreal) 
in March demonstrated a commencing optic neuritis. 
About this time the patient underwent a remarkable 
change mentally. He became lively and cheerful and 
at times hilarious. His paresis in leg, arm, and face 
gradually increased, and the entire left side became 
hyperalgesic paroxysmally. 
Early in April the patient's condition became one of 
bed-ridden helplessness; and, about April 8th, symptoms 
of extreme compression began to develop: Mild, wan- 
dering delirium, difficulty in swallowing, incontinence 
of urine and faeces, thick and incoherent speech, high 
pulse, elevated temperature, and finally coma and death 
on the 16th. 
Drs. Dunham, Kellogg, and Hyde were present and 
assisted at the autopsy, done on the 17th. 
On removing the calvarium, a bulging of the left 
hemisphere was noticed, over which the dura was much 
thinned. This bulging corresponded to a depression in 
the calvarium, into which it had pressed during life, 
causing absorption of the inner and outer plates of the 
left parietal bone, which was so thin as to be translucent. 
This depression was one-half inch to the left of the 
longitudinal sinus and -over the posterior part of the 
post-central convolution. A smaller protuberance, with 
a corresponding (though lessened) thinning of the bone, 
was noticed on the opposite or right side. The dura was 
found to be extensively adherent over both hemispheres, 
but most tenaciously at the bulging point in the left. 
On stripping away the dura, the pia mater over the right 
parietal lobe presented a mottled and granular appear- 
ance, and the entire parietal lobe on this side bulged out 
markedly. At a point where the posterior central, the 
superior frontal, and the supra-sylvian convolutions form 
an angle, there was an irregular spot, about half an inch 
in diameter, which appeared to have undergone fatty or 
waxy degeneration. Fluctuation was detected at this 
point; and a probe, passed directly into this spot, was 4 
FRANK S. MADDEN. 
followed, when withdrawn, by a few drops of a straw- 
colored serous fluid. A second passage of the probe, one 
inch behind this point, reached a hard mass about three- 
quarters of an inch beneath the surface. A longitudinal 
incision, made three-quarters of an inch from the median 
line, revealed a cavity, previously detected by the probe, 
which proved to be the anterior portion of the tumor 
undergoing cystic degeneration. This cavity measured, 
vertically, one inch ; longitudinally, one and three-quarter 
inches; and transversely, one and one-quarter inches. 
Behind and a little to the outer side of this broken-down 
mass, but continuous with it, was found another nodular 
mass, as large as a good-sized walnut, which was firmly 
adherent to the cerebral substance behind it. Both sides 
of this degenerated growth were easily separated from 
the surrounding tissue and also the anterior portion of 
the nodular mass behind; but the posterior portion was 
so firmly adherent to the cerebral substance, that a por- 
tion of the latter was removed with the growth. The 
tumor involved the posterior central, superior parietal, 
supra-syIvian, anterior portion of the angular, and occipi- 
tal convolutions of the right hemisphere. The tissue 
immediately surrounding the tumor was much softened. 
Section of the left hemisphere showed nothing abnormal, 
except the bulging above mentioned, which was pre- 
sumably due to pressure. 
Microscopical examination showed the growth to be 
a melano-sarcoma. 
The patient was seen in consultation at different 
times by Drs. Stewart (of Montreal) and Spitzka and 
Gray (of New York). Operation, which was suggested 
by Dr. Gray, was not done, for the reason that the con- 
sent of the family could not be obtained. It is question- 
able whether an operation would have been beneficial 
if done at any time after a diagnosis could have been 
made. PRESS OF RAFF & CO. 
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