CEREBRAL SURGERY. 
♦ 
OBSERVATIONS 
BY 
H. H. A. BEACH, M. D„ 
Visiting Surgeon, Massachusetts General Hospital. 
I. TRAUMATIC EPILEPSY 
OPERATION, RECOVERY. 
II. TUMOR OF BRAIN 
OPERATION, DEATH. 
Reprinted from the Boston Medical and Surgical Journal 
of April 3 and io, 1890. 
BOSTON, MASS. 
1890. The illustration shows plainly the dark semi-circular cicatrix left by the operation 
and the white crucial cicatrix remaining from the original injury. COMPOUND COMMINUTED FRACTURE OF 
THE SKULL. 
EPILEPSY FOR FIVE YEARS. OPERATION - RECOVERY. 
By H. H. A. BEACH, M.D., 
VISITING SURGEON, MASSACHUSETTS GENERAL HOSPITAL. 
The report of the following unusual case has been purposely delayed, 
that sufficient time might elapse between the date of operation, at the 
Medical Society's Annual Meeting in June, last, and the time of making 
this statement, in order to be reasonably sure that the result had been 
something beyond temporary success or alleviation. More than ten 
months have now passed without a return of symptoms. 
For the early history and examination prior to her admission for sur- 
gical treatment, I am indebted to Dr. James J. Putnam, in charge of the 
Department of Nervous Diseases. It is proper to express here our 
united appreciation of the kindness of Drs. 0. W. Wadsworth, Charles 
F. Folsom, Philip C. Knapp, and George L. Walton, in making special 
examinations of the patient, and contributing their valuable opinions 
upon the significance of the symptoms. 
MEDICAL HISTORY OF THE CASE BY DR. PUTNAM. 
I. C., a girl of twelve, presented herself at the Out-Patient Depart- 
ment of the Massachusetts General Hospital, in April, 1889, and was 
examined by me on the 19th of the same month. Her mother who 
accompanied her, gave the following history : 
The patient was a strong and vigorous child up to four years of age, 
when she was kicked in the head by a horse. She was picked up shortly 
afterwards, senseless, but making a moaning sound, and with blood 
running from the left ear and left side of the nose. She remained 
unconscious for nearly a week, or, at any rate, unable to recognize her 
friends, On the day after the injury, some pieces of bone were re- 2 
moved from the head. During the following days she tried, at times, 
to get out of bed, and would apparently have been able to do so. 
The mother feels sure that there was no paralysis of either arm, leg 
or face. For a month after this there were no special symptoms. Then 
she began to complain of her right hand, which felt heavy, though it 
was not paralyzed. Ou the evening of the following day, she was 
unable to stand, and that night she had a long series of convulsions, 
which were not relieved by bleeding. This attack was followed by a 
lethargic sleep, lasting a number of days. She could be roused, and sat 
up once or twice to vomit, but wished to be let alone, and took no 
food by the stomach. It was then found that an abscess had formed 
at the seat of the injury, and after the evacuation of a large quantity of 
pus, she improved at once. The wound was kept open, and continued 
to discharge for six months, during which time she played about, and 
seemed well, the only nervous symptom being that she would be very 
drowsy for a day or so, about once a month. During the next three or 
four years she had no bad symptoms. 
She learned to read when five years old, and seemed fully intelligent. 
At the age of eight, she had the first of what her friends called " spit- 
ting attacks." This came on while she was sitting at the table, and 
was accompanied by unconsciousness with a staring expression of the 
eyes, the whole lasting for a minute or two. About once a month after 
this she had epileptiform attacks, sometimes of this character, some- 
times not, accompanied with unconsciousness, and often with loss of 
urine. 
When nine years old she had a full epileptic seizure, with rotation of 
the eyes, and convulsive movements of both hands and both feet. 
This was followed by a series of attacks of petit mal of somewhat 
different character from the former ones, and called "stupid spells," 
and once while asleep, she had an attack of "chattering" of the teeth. 
Soon after this a new and interesting symptom showed itself; namely, 
as some of her more serious attacks came on, she would cry out, then 
put her left hand up to her left eye, then have a convulsive twitching 
in both eyes. She declared that she lost sight in the left eye at such 
times. These attacks gradually became more frequent and severe, until 
a course of bromide of potash was begun (October, 1885), after which 
the attacks at once ceased, and did not return for two years (August, 
1887). Her mental condition, also, which had become greatly impaired, 
again became normal under the influence of the bromide. 
In August, 1887, she had a general convulsion, early one morning, but 
she was not at this time taking bromide, and had not done so for six 3 
months. Two months later, and while taking the bromide, she had a 
"chattering spell" at night, with twitching of both hands, and rolling 
of the eyes, but without entire loss of consciousness. Seven weeks later 
she had another similar attack. 
In January, 1888, while at school, she screamed out and fell down, 
and from that time she had the " chattering " and twitching spells at 
night about once in two months. 
In June, 1888, she had an attack preceded by a sensation " as if 
the left eye was going up into the head." It seemed to her that she 
lost vision in that eye, and she clasped her hand instinctively over it. 
Unconsciousness and convulsive movements followed an instant later. 
On recovering consciousness, she was unable to move her right hand or 
arm, and had no feeling in these parts for half an hour. She also com- 
plained of pain in her eyes. 
From this time on, the attacks occurred with great frequency, gen- 
erally followed by loss of power in the right hand, and pain in the 
eyes, and often preceded by loss of sight in the left eye. 
For the last few months she has had a "shadow" constantly over 
the left eye. Of late the "staring spells" have recurred about once 
a week, and the severe attacks every few months. The " staring spells " 
do not seem to be preceded by the ocular aura. 
Her mental condition has again been deteriorating, her behavior being 
rather silly, and suggesting a hysterical condition. 
The physical examination gave the following results: Dynamometer, 
right, 95; left, 180; knee-jerk, normal, and equal on both sides; no 
ankle-clonus. F. V. equal for both eyes; myopia. Otherwise nothing 
abnormal. 
Examination of the head showed on the left side a cicatrix described 
further on. 
Supposing the injury to the brain to exactly correspond with that of 
the skull, it would fall somewhat behind the central convolutions. The 
fact, however, that extensive suppuration had occurred, made it evi- 
dently impossible to localize with accuracy. 
Dr. Wadsworth's report with regard to the limitation of the field of 
vision of the left eye, will also be given further on. 
This case seems to me to need no extended comment. The evident 
origin of the epileptic condition in the injury to the head, would have 
seemed to me to justify an attempt to remove the cicatrices, which the 
wound, and the abscess following it, had left behind, even though no 
"localizing symptoms" had been present. As a matter of fact, the 
parked convulsion and loss of power in the right arm seemed to point 4 
with considerable definiteness to a local irritation, and I believe the 
same to be true of the peculiarly visual symptom% with which many of 
the attacks were ushered in. At the same time I am not able to offer 
a satisfactory explanation of the fact that the lesion noted, which 
affected the cortex of the left hemisphere, a short distance back of the 
central convolutions, should have caused the loss of vision in the eye 
of the same side. 
In spite of cross-questioning, the patient declined to admit that this 
left-sided loss of vision was of the nature of an hemianopsia and, even 
had this admission been made, it would have been no easier to establish 
a relationship between the symptom and the cause. 
1 advised the admission of the patient to the wards of the hospital, 
where she was placed under the care of Dr. H. H. A. Beach, by whom 
the further history of the case will be recounted. 
SURGICAL HISTORY. 
April 25th. Two days after admission she had two slight attacks 
that began with staring; the face grew very red, and the lips became 
cyanotic. She would not answer questions, and remained in a dazed 
condition for a few seconds, then seated herself and went to sleep. 
April 26tb. Had a similar attack to-day, and one during the night. 
April 29th. Last evening gave a cry, had a general convulsion, and 
soon became quiet, intimating that her right side was weak. Her grasp 
proved to be very weak. This attack was repeated one hour later by 
one more violent. She became conscious in a few seconds after. The 
mouth was drawn to the right side at the beginning of the seizure. 
April 30th. She has had four slight attacks, one of which began with 
drawing up of the left corner of her mouth. 
May 13th. No seizures for thirteen days. Reports that she could 
not see with her left eye during the afternoon of yesterday. 
May 16th. Had a slight attack, with staring, loss of consciousness, 
twitching of left hand and drawing down of left corner of mouth. 
Weakness of left hand afterward. 
May 17th. Had three attacks yesterday. One of them was well- 
marked, the patient falling, and striking her head against a board with- 
out being aroused. During the night a most violent bilateral convul- 
sion. 
The seizures continued of varying intensity with not more than a 
day's intermission, up to the day of operation, June 11th. 5 
THE WOUND. 
Aii examination of the head disclosed a crucial cicatrix in the poste- 
rior temporal region admirably shown in the photograph accompanying 
this description, which wras taken by Mr. Storer of the House-staff. 
This cicatrix marked the site of the injury and measured five inches 
in a horizontal direction and four and three-quarter inches vertically. 
A depression that would admit the pulp of the index finger could be 
easily seen and felt at the point where the lines crossed. Upon slight 
pressure at this point the patient complained of tenderness. The centre 
of the depression was three and one-half inches from the longitudinal 
suture and on a vertical line drawn from that suture to the mastoid 
process of the same side. By the cyrtometer the line for the fissure 
of Rolando crossed the anterior portion of the wound area at a point 
midway between an inch and a quarter and a half in front of the sharp 
edge of bone that defined the depression. The lowest point of the 
original wound reached the horizontal line that extends from the glabella 
to the occipital protubrance. Dr. Wadsworth's examination of the eyes 
showed the fundus of both eyes to be normal and the field of vision 
somewhat limited. 
The possibility of there being another source for the epilepsy than 
what could be localized in the vicinity of the wound, was carefully con- 
sidered ; but the persistence and gradually increasing severity of the 
seizures were unmistakable. It became not only justifiable but impera- 
tive in view of the early history of the case, to give her the benefit of 
an exploratory operation with general plan of removing any source of 
irritation and the hope that if the fits were not cured, they might be 
made more amenable to medical treatment. 
OPERATION. 
The scalp having been shaved and made aseptic, the patient was 
removed to the new aseptic ward of the hospital, and the following- 
operation performed in the presence of the hospital staff and other 
medical gentlemen. 
A semi-circular incision of five inches with its convexity downwards 
was made through the scalp, from the anterior end of the horizontal cica- 
trix nearly to the occipital end. This flap having been rapidly reflected 
and all bleeding arrested, an examination was made of the depression. 
Its centre, one-half inch in diameter, was found to pulsate, suggesting 
a close connection with the brain or some large vessel. 6 
An incision was made at this point opening into a web of cicatricial 
tissue, that held in its meshes about one drachm of clear fluid resem- 
bling serum, which trickled slowly from the wound. Upon entering the 
tip of the little finger through the incision, brain pulsation could be felt 
where before the flap had been removed, all seemed as solid and firm 
as one could expect from a consolidated fracture. The opening in the 
skull was nearly circular and about one inch in diameter. The finger 
could not be pushed in any direction owing to the very firm adhesions 
of the cicatrix to the border of bone encircling the opening. Assuming 
that the fluid described was cystic in character, located in the dura, 
whether residual or not from the abscess described in the early history 
of the case; that its shape was flattened, from the great pressure to 
which it had been subjected through cicatricial contraction and that 
either the irritation caused by its presence or that of some spicula of 
bone projecting from the fractured region, had caused the epilepsy, it 
seemed advisable to explore the border of the opening thoroughly. In 
order to do this it became necessary to dissect the collapsed cyst from 
the bone. I then swept the finger completely around the internal sur- 
face of the skull for a distance of one-half of an inch from the border of 
the opening, detaching the adhesion and dura (which could not be sep- 
arated) from the bone. A sharp spicula of bone projected one-third of 
an inch from the anterior border of the opening ; it was removed with 
the bone to which it was attached, by bone-forceps. The brain had now 
retreated from the opening sufficiently to show a mass of firm cicatri- 
cial tissue projecting from its surface. This was carefully dissected 
from the brain and where it had become consolidated with the cortex, 
enough of the latter was removed to leave a soft velvety surface be- 
hind, as nearly like that of healthy brain as possible. The haemor- 
rhage was not troublesome, though considerable. The skin flap was 
then turned down into place, washed and dressed antiseptically ; no 
drainage. 
The patient became slightly cyanotic shortly after the operation, and 
the pulse was, for a time, very weak. There was no vomiting, and she 
became conscious in the course of two hours. 
June 13th. No seizures or twitching. 
June 14th. Dressing changed, wound looking well. 
June 16th. Stitches removed. Has a slight headache. 
June 27th. All dressings removed. Complete union by first inten- 
tion. Has had no attack since the operation. 
October 14th. Never was better. Has had no seizure. 
November 15th. Continues to do well. 7 
Her temperature ranged between 97.8° and 99.2° during convales- 
cence. 
At the date of publication the patient continues in good health with 
no recurrence of the fits. She writes a very good letter informing me 
that she has not missed a day at school and, in addition, is taking music 
lessons and has enjoyed one happy Christmas and New Year. 
REMARKS. 
Since the symptoms for which the operation was done have not 
returned, it may be assumed, at least for the present, that the cause was 
local and consisted of either 
(1) The spicula as a direct irritant. 
(2) The cyst as a direct irritant. 
(3) The firm contraction of the dense cicatrix which had the power of 
drawing the brain directly upon the spicula, or cyst, or both and estab- 
lishing a firm anchorage there. 
The depression of bone and the unquestionable tenderness of one 
spot at the centre of the wound area, that never varied in many ex- 
aminations, furnished strong evidence of some local irritation that could 
reasonably be held accountable for the convulsions. Without those two 
points for diagnosis it is not difficult to suppose a case in which the 
brain anchorage or tumor should be situated at a point designated as 
No. 1, and that certain symptoms should indicate disturbance at a point 
more or less distant, designated as No. 2, through indirect pressure. 
That this false register of the localizing symptoms might be due to 
(1) the varying degrees of intracranial pressure from a tumor; (2) the 
uneven application of pressure or traction from cicatrices or adhesions ; 
(3) the greater sensitiveness of some areas of the cortex to pressure, 
when compared with others. 
In a word, upon direct or indirect irritation or pressure appears to 
hang a doubt that every operator must face until he has opened the skull 
and proved by his exploration that he can eliminate one or the other 
sides of the problem. This possible complication in what are already 
exceedingly difficult cases, 1 have alluded to in the report of an opera- 
tion for the removal of a tumor of the brain from a patient sent to the 
Massachusetts General Hospital by Dr. Putnam in March, 1889.* 
In the event of re-anchorage of the brain by adhesion to a surface that 
might be more or less irritating with or without the complication of a 
cyst, it would be rational to expect symptoms of some kind. Should it 
* See page 9, 8 
become necessary to repeat the operation described, in any case, it has 
occurred to me that a sheet of very thin, aseptic pure gold foil might 
be left between the surface of the brain and the external flap - its duc- 
tility should theoretically adapt it easily to any pressure. Being non- 
corrosive and easily made aseptic, it offers the best and least irritating 
barrier to adhesions, that, through traction, might cause undue irritation 
of the brain. It furnishes a possible solution for a possible difficulty 
and no objection to its use occurs to me. OPERATION IN A CASE OF CEREBRAL TUMOR.* 
By H. H. A. BEACH, M. D., 
Visiting Surgeon, Massachusetts General Hospital. 
The condition of the patient when he entered the Massachusetts 
General Hospital, March 1, 1889, was almost hopeless. Dr. J. J. Put- 
nam, who had been watching him for some months, stated that it was 
only within a few days that he had presented symptoms justifying 
operative measures. He had been rapidly losing strength, and on 
the day of his admission had a convulsion which seriously involved the 
heart. The surgical staff of the hospital were unanimous with Dr. 
Putnam and myself in the belief that every day an operation was 
delayed his chances were materially lessened, and that he was entitled 
to the benefit of an exploratory trephining. 
MEDICAL HISTORY OF THE CASE BY DR. NJTNAM. 
This patient, was seen by me in consultation with his physician, Dr. 
David Choate of Salem, to whom I am indebted for permission to pub- 
lish the case. He was a man fifty-one years of age, married, and of 
temperate habits in all respects. He had always had good health and 
had sustained no injuries, with the important exception that twenty-two 
years ago, he was knocked from a freight car while passing under a 
bridge. He was general agent of a large railroad at the time of his 
illness, and worked hard without much rest, and often late at night. 
The first symptom of his present disease (September, 1888), was a 
trembling of the right hand, which was noticed by the assistant in his 
office. Immediately after this, while he was sitting at his desk and 
talking with his assistant, he found himself, of a sudden, unable to speak, 
though his mind felt perfectly clear. He did not, at this time, attempt 
to write, but from subsequent experience in similar attacks, felt certain 
he could have written as rapidly and as correctly as ever. He was not 
* Read before the Boston Society for Medical Observation, May 6,1889. 10 
paralyzed, and kept at work from two o'clock, when his first seizure 
occurred, until five. During the whole of this period he had some diffi- 
culty in speech, although the complete inability had passed away in the 
course of a few moments. He had also some difficulty in adding long 
columns of figures. 
A little while after the first difficulty in speech, he was seen to rise 
without apparent cause, turn toward the window, and then again seat 
himself, and as he placed his right hand on his desk it seemed to be 
affected with a slight spasmodic, rotating sort of movement. 
On leaving his office at five o'clock, he went directly to Dr. Choate's, 
and while telling him what had occurred, found himself again unable to 
speak, and had to express himself by signs. Both Dr. Choate and the 
patient himself assert there was no loss of consciousness, nor of com- 
prehension of, at least, simple speech. Dr. Choate said to him, among 
other things, " You know what you wish to say, do you?" to which the 
patient gave an emphatic assent. After a few moments he began to 
utter a few simple words, as " yes," and would repeat them over and 
over, as " yes, yes, yes." He would also begin a sentence and then 
break off, unable to finish. There was no convulsion or paralysis, or 
convulsion of the face or limbs. Gradually, the speech returned to a 
great extent, and he went home. 
The same tendency to recurrent utterance of simple words or sen- 
tences was seen on other occasions. 
At bed-time he had a general convulsion with complete loss of con- 
sciousness, but without special aura or localizing symptom. During the 
next two weeks he had frequent returns of difficulty of speech, but 
sometimes several days would pass without any such attacks. 
A second convulsion occurred a few days before 1 saw him, which 
was January 1, 1889. He was making his preparations for coming to 
Boston, and was a little hurried. The attack came on as he sat down 
to take some lunch. It was general in character, like the first. His 
wife noticed, first, a staring look in the eyes, a moment later the eyes 
deviated to one side, and he lost consciousness. During the week pre- 
vious to this, the attacks of speechlessness were said to have been more 
frequent than before. 
The physical examination on his first visit to me was entirely nega- 
tive, except that a slight hesitancy of speech was noticed. There was 
no tremor of hands or tongue ; the pupils were small, but equal and 
quickly responsive. There were no sensory symptoms at all. The 
optic disks were perfectly clear. 
A few weeks later it was found that his memory and capacity for 11 
work were progressively failing. Headache began to come on and 
steadily increased in severity, though at first distinctly intermittent. 
His gait had become unsteady, suggesting that of a drunken man, and 
when 1 saw him again, on January 24th, I found the knee-jerks exag- 
gerated. The pupils were then slightly unequal, the left, that on the 
side of the new growth - being slightly larger than the right. Both 
reacted well to light and with accommodation. No difficulty was no- 
ticed in his comprehension of speech, and the difficulty, on his part, of 
expressing himself, seemed to be wholly from limitation of his vocabu- 
lary, except that words were sometimes misplaced or dropped. 
Dr. Choate wrote to me, that, even early in January, at the time of 
his first visit to me, " there began to be marked difficulty in making- 
out his pay-roll. He would be one or two days behindhand in com- 
pleting it " and by the last of January, at the time of his second visit 
to me, " he was utterly balked in the attempt [to make out the pay- 
roll] and threw down the book with an expression indicative of com- 
plete disgust." The patient's assistant reports that on January 25th 
(while still struggling with his office duties), he "could not write his 
name, nor a message for the telegraph operator." Also, he " would 
begin a remark, and suddenly stopping, would say, ' I have forgotten 
what I was going to say.' " 
The aphasic symptoms in the intervals between the attacks of entire 
speechlessness, consisted, at first, in a sort of hesitancy and a tendency 
to remain silent or to use short sentences. Later " he would certainly 
misspronounce and sometimes try to correct himself. Again he would 
use quite a wrong word." 
Soon after this his increasing headache and weakness obliged him to 
keep his bed, and his general mental dulness obscured the more special 
symptoms. The pain in the head was, as a rule, frontal, though some- 
times occipital, whereas in the beginning it had been mainly occipital. 
On February 18th, Dr. Choate writes that the patient had vomited 
twice during the last few days, and yawned frequently and he would 
speak but seldom and then used but few words and often failed to com- 
plete his sentences. 
I saw him again on February 21st, and found marked optic neuritis. 
The patient was then dull, and slightly wandering in mind, and had 
difficulty in recognizing his sister-in-law, who had just come from Bos- 
ton. No facial paralysis or relative weakness of either hand or leg 
could be made out. The patient's mental condition did not admit of 
tests of sensibility of any value, but not the least indication of either 
parajsthesia, hypersesthesia, or anaesthesia had been complained of or 12 
noticed by others at any time. An attempt to sit up in bed caused, 
alter a moment, a severe paroxysm of headache, attended with marked 
Hushing of the face. The pain was not localized. The knee-jerk was 
increased on both sides. His wife said that in attempting to take a 
cup to drink, he had spilled the contents. This may, however, have 
been due to inattention, for he raised both hands to his head and moved 
all the fingers with apparent ease. 
1 could not make out that hemianopsia was present, but the examina- 
tion was of little value. The pulse at this period was as low as 45, 
47, and 48, at different times. The first symptom that could be called 
localizing, besides the aphasia, occurred on February 26th, and was 
described to Dr. Choate by the patient's wife as follows : The right arm 
was lying on the bed, extended with the palm uppermost, when a de- 
cided convulsive action of the flexors of the hand and fingers was noticed, 
which continued at intervals for about two hours. Part of the time the 
contraction was persistent, the hand being flexed on the wrist and the 
fingers on the hand, and was so strong that his wife was unable to 
overcome it. There was also a convulsive action of the upper eyelids 
and the eyeballs were raised. 
The symptoms recurred occasionally during the following two days, 
but to a less degree. The patient was delirious at times, and made 
attempts to get out of bed. 
In view of the convulsive movement of the right arm, above alluded 
to, it was decided to send the patient to the Massachusetts General 
Hospital with the view of a possible operation, as a last resort, large 
doses of iodide of potassium having failed to cause improvement, and he 
accordingly entered on March 1st, and was placed under the care of Dr. 
H. H. A. Beach. 
Before leaving his home, which was in Salem, the patient had quite 
an alarming turn of faintness, and fearing recurrence of this symptom, 
I asked Dr. Beach to operate at once if he thought it justifiable, and this 
he kindly consented to do. 
During the night before the operation, a number of slight convulsive 
attacks occurred, affecting the right hand and arm at the elbow, as well 
as at the wrist. The patient was dull all the time, but no special 
increase in the dulness was noticed during the attacks. 
On the morning of the operation 1 noticed for the first time, a paresis 
of the extensors of the fingers of the right hand. There was no com- 
plete paralysis, and during occasional movements of the arm toward the 
face, the loss of power was not observable, but when the fingers were 
passively raised they would immediately drop again in quite a different 
manner from those of the left hand. 13 
It may be added that the movements of the right hand, though some- 
times tremulous, were not such as to suggest any impairment of mus- 
cular sensibility or coordination. No change of sensibility seemed to be 
present, although the patient's mental state precluded a thorough exam- 
ination of this point. Optic neuritis, which had been noticed for the 
first time on February 15th, was present, and about equal in the two 
eyes. 
In view of the fact that the patient's first symptom had been a 
marked loss of speech, preceding such general signs as headache; that 
there had been a recurrent spasm of the hand and fingers; and that no 
symptoms had occurred which I was able to interpret confidently, as 
pointing to any lesion of the parts posterior to the central convolutions, 
such as the loss of muscular or cutaneous sensibility, sensory aphasia, 
or special disorders of vision, I concluded that the tumor, which was so 
evidently present, was in the anterior lobe, opposite the lower part of 
the central convolutions, and probably just above the third frontal con- 
volution. I excluded a lesion of the central convolutions and of the 
motor pyramid tract by the fact that marked paralysis was absent in 
spite of the severity of the pressure as indicated by the other symptoms. 
Drs. G. L. Walton and P. C. Knapp were kind enough to see the 
patient with me before the operation, and, on the whole, concurred with 
this opinion, and in the view that operation was justifiable as a matter 
of last resort. 
The operation was performed by Dr. Beach, in accordance with this 
diagnosis, but no tumor was found. 
The patient never recovered from the comatose state in which he was 
left by the operation, and died on the second morning following. At 
the autopsy, which was made on the same day, by Drs. W. F. Whitney 
and R. H. Fitz, the tumor was discovered at the same level where it had 
been sought, but considerably behind the the motor area. 
The exact boundaries were as follows : The posterior edge of the 
growth was limited by the posterior ascending branch of the fissure of 
Sylvius. The anterior boundary was formed by a small sulcus, leaving 
the fissure of Sylvius a little behind the anterior extremity of the inter- 
parietal fissure, which ran down parallel to the fissure of Rolando and 
was continued by a sulcus opening into the Sylvian fissure. 
A frontal cross-section of the brain made between the tumor and 
the central convolutions showed the tissues there to be healthy, although 
highly oedematous. The motor convolutions themselves, and the frontal 
convolutions were perfectly healthy, except as regards the effects of 
pressure and disturbed circulation. The optic tracts were strongly 
compressed. 14 
The tumor, on cross-section, was found to run inwards, as a some- 
what pyramidal body, with its borders not sharply defined, undermining 
three-fourths of the inferior parietal lobule, but leaving a clear space of 
oedematous and yellowish, but, otherwise, healthy tissue between itself and 
the nucleus lenticularis, the posterior edge of which was just visible on 
the section through the middle of the mass. Apparently, the growth 
was not quite far enough back to involve the intra-cerebral optic fibres. 
The pia-mater over the tumor was adherent, and discolored. A space 
of about three-quarters of an inch intervened between the posterior edge 
of the Rolandic convolutions and the nearest point of the tumor. 
The cortical area of the brain which is concerned in the language 
function, is very large, extending from the base of the lower frontal 
convolution back to the occipital lobe and the first and second temporal 
convolutions. A subcortical lesion almost anywhere in this triangle 
may damage the associating tracts or ganglionic centres which subserve 
this delicate function. 
The symptom which generally engrosses most attention in cases of 
aphasia, is the loss or disorder of speech and writing, but the impor- 
tant question from the standpoint of localization is whether this loss of 
expression is due to a paralysis of the motor or " executive " arrange- 
ments (Ross) or is indirectly caused by a loss of the power of under- 
standing language symbols. In other words, an impairment of speech, 
perhaps even a complete loss, does not necessarily indicate a lesion of 
Broca's area but may be due to the fact that a lesion of the auditory 
centres, which stand in such close and necessary relations with the 
speech centres that the two form almost a physiological unit, embar- 
rass the delicate speech function, or, temporarily, inhibit it altogether. 
This may have occurred in this case, where a tumor at the posterior 
extremity of the Sylvian fissure, far removed from Broca's area, caused 
as its first symptom, repeated attacks of complete loss of speech, with 
well-marked hesitancy in the intervals. One of these attacks was fol- 
lowed after a time by a general convulsion, and accompanied by signs 
of transitory mental change, and tremor of the right hand, but others 
were attended neither by convulsion, paralysis, nor loss of conscious- 
ness. Furthermore the patient positively asserted that he was able to 
read and write intelligently during some of the attacks, and his physi- 
cian, confident that he understood accurately what was said to him. 
As regards the first point, Dr. Choate had noted, under the date of 
December 14th, that "under a little excitement in his office he was 
unable to say to his assistant what he wished, but at once sat down 
and wrote, apparently without difficulty, what he had wished to say, but 
could not." 15 
As regards the physiological explanation of the case, we may assume 
either that the speechlessness was due to an irritation or " discharge " 
of the auditory area causing temporary inhibition of the speech func- 
tions, sufficient to prevent expression, yet not enough to wholly destroy 
the comprehension of simple matters, or to circulatory interference with 
the conducting tracts; or to increase in the general cerebral pressure, 
leading to anaemia and oedema, and to loss of the speech functions on 
account of its relative sensitiveness. Of these suppositions the third 
seems the most probable, but whether it be correct or not, the case is 
instructive as showing the danger in assuming a lesion of the lower 
frontal convolution, even where loss of vocabulary seems the prominent 
symptom, and loss of the comprehension of speech relatively slight. 
The position of the tumor makes it probable that the later loss of the 
use of written symbols was due to disturbance of the visual area or 
its connections, but it certainly was not sufficiently pronounced to posi- 
tively justify this diagnosis. A frontal position of the tumor seemed 
further indicated by the localized tremor-like convulsion of the fingers 
and wrist-muscles, with eventual loss of power in the extensors of the 
fingers; but it now seems evident that these symptoms indicated only 
a relatively great mobility or instability on the part of the correspond- 
ing flexor centres, and a greater vulnerability on the part of the ex- 
tensor centres - facts which are quite in accordance with well-known 
principles. 
With regard to the evidences of disturbance of the specific functions 
of the parietal lobe, in which the tumor lay, the only signs of loss 
of muscular sense were that early in January, while the patient was 
still in pretty good condition, his assistant noticed that his hand would 
occasionally slip off from the table or desk without his knowledge; that 
he had some difficulty in forming his letters and holding his pen, and 
that the gait became unsteady; but these symptoms might be attributed, 
perhaps, to general cerebral pressure. 
The movements of the upper eyelids during the convulsive attacks of 
the last few days of life gains in interest from the fact that such move- 
ments have been located by Landouzy and Grasset (quoted by Gowers) 
in the inferior parietal lobule. 
One point is worthy of notice as regards the patient's inability to ex- 
press himself in long sentences (which he would fail to complete, saying 
that he had forgotten what he had meant to say), namely, that this may 
be due to the condition first commented upon by Grashey, in which 
aphasia results from a loss of retentive power of the ganglionic matter, 
probably from impairment of its nutrition. 16 
The aphasic symptoms in Case II* are of interest, partly as support- 
ing the usual opinion as to localization of the functions, partly as 
showing the caution with which it is to be applied. 
In spite of the fact that the new growth, with the subsequent soften- 
ing, had almost destroyed the second left temporal convolution, the loss 
of the power of comprehension of speech was not complete, though, at 
one time, perhaps out of proportion to the limitation of the vocabulary. 
After a time, the general mental failure made the accurate study of 
the less marked symptoms impossible, and the disorder of the circula- 
tion disturbed the action of all the cerebral centres. The most marked 
early symptom referable to the language functions was the alexia. 
The patient's mental condition and unwillingness to submit to closer 
examination, made it very difficult to study this symptom but its pre- 
sence may fairly be attributed mainly to the presence of the tumor in 
the parietal lobe. 
THE OPERATION. 
On the next day the head was shaved and scalp made thoroughly asep- 
tic. Careful attention was paid to instruments and dressings, while the 
surroundings were those of the new aseptic theatre and ward of the hos- 
pital. A semi-lunar flap three and a half inches long was reflected from 
the area covering the second frontal convolution. This was rapidly dis- 
sected up and all bleeding vessels tied. The central point for the trephine 
having been previously marked in the flap by a suture, a trephine of one 
inch diameter was made to perforate the bone which proved to be of 
unusual thickness and density (at least three times that usually found in 
this locality). Upon reaching the dura mater, it was seen projecting 
into the cavity left by the trephine, firm and unyielding, showing great 
intra-cranial pressure. It was evident that the opening would afford 
insufficient room for the examination or removal of what appeared to 
be beneath the surface of the brain. A second opening was trephined 
a little higher and posterior to the first, and the spurs of bone lying 
between them were removed by bone-forceps, making an oval opening 
two inches long by one inch broad. A flap of dura mater was turned 
up, exposing the bulging brain substance which was carefully explored 
with the scalpel to the depth of an inch. There was no undue haemor- 
rhage, no serum, no pus. It was then thought best to explore very 
carefully the four surfaces of the wound with the finger, to determine 
the question of tumor. Nothing unusual could be felt in either direc- 
tion. The only abnormal thing observed was an unusual toughness and 
thickness of the dura. 
* Boston Medical and Surgical Journal, April 10,1890. 17 
Although great care had been taken in his anaesthesia and no unusual 
quantity of blood had been lost, the patient's pulse became very feeble, 
and it was thought prudent not to subject him to further exploration. 
The wound was carefully closed without replacing the bone, for the 
pressure from within the skull was so great as to make it impossible 
to do so. An antiseptic dressing was applied, heaters and stimulants 
used, and he was removed to his bed. He had a good reaction, his tem- 
perature rising to 103° at ten o'clock on the night following, and his 
pulse 110. On the following morning his temperature was 99£°, his 
pulse 85, and respirations 25. There had been no recurrence of con- 
vulsions, nor had he recovered consciousness, but had been comatose 
since the operation. From this time his temperature gradually rose 
until the following day at half-past five, when it reached just 
before death ; the pulse and respiration increasing in frequency and 
diminishing in strength. With the results of the autopsy, you are 
already familiar from Dr. Putnam's description. 
The case has been reported, not alone for its intrinsic interest, but for 
any value it may possess for others in the comparative study of unu- 
sual cases; as, for instance, certain anatomical specimens are only valu- 
able through their classification with others. Investigation and treat- 
ment may be conveniently divided into three sections: 
(1) That connected with the diagnosis and localization of symptoms. 
(2) The operation and its details. 
(3) The after-treatment. 
The first has been thoroughly disposed of by Dr. Putnam, but I will 
add, with his acquiescence, that as far as one case goes, this one is 
interesting in helping to establish the fact that intra-cranial pressure 
from a tumor may cause such symptoms, by the irritation of a more 
sensitive region at a distance, as to mislead the operator in the loca- 
tion of the growth. Other things being equal, such a condition would 
be most likely to occur in large tumors, and, consequently, in those 
least suitable for surgical treatment. 
With regard to operative details, it is probable that the earlier stages 
are likely to be simple in character and confined to the reflection of 
a flap of skin and periosteum of varying size, yet so planned as to permit 
the freest drainage and the arrest of such haemorrhage as may ensue. 
The latter should be easily controlled by a rubber tube applied about 
the head and below the point of incision. In this case the bleeding 
vessels were secured by snap forceps. It may be a useful point in 
practice to mark the centre for the trephine in the flap by a suture 
rather than to depend upon nitrate of silver for the marking, which 18 
might be easily eflfaced during the process of disinfection. It seems 
to me that the first exploration should be made with a trephine of 
at least an inch and a half diameter; for, in many instances it might 
furnish all the opening that would be essential. 
In that way the time required for a second trephining (which might 
be considerable, if the skull were thick as in this instance), would be 
saved. A practical point in replacing the button of bone in the wound 
occurred to me, but unfortunately I could not avail myself of it on 
account of the great pressure from within the cranial cavity. This 
was to notch the bone and the corresponding edge from which it was 
removed with the saw, that when it should be replaced the sawn blood 
channels of the diploe could be properly matched, believing that the 
nutrition of the bone would be better provided for by a continuous 
channel, and a greater chance of its living thus secured. The question 
of how much can be done in the way of exploration after opening the 
dura is an important and practical one, and for the present must be 
left to the discretion of the operator and his advisers at the time. The 
needle, the knife and the finger have their advocates, as shown in pub- 
lished reports, and while my instinct is against exploring the wound 
in the brain with the finger, on account of the contusion that seems 
inevitable, I cannot ignore the contrast between a well - calculated 
manipulation of a competent surgeon and the rough-and-tumble 
bruising and laceration of the soft and hard parts incident to a bad 
fracture of the skull, which are commonly seen in the accident 
rooms of any large hospital. Such cases may do well, as we all know, 
with attention to the removal of loose fragments, the arrest of haemor- 
rhage, and the maintenance of an adequate aseptic condition of the 
wound and its surroundings. The needle or the knife alone would 
hardly be competent to decide some cases; time may give us a better 
substitute. Until it does I suppose we must be content with believing 
that cases dependent upon such explorations are probably so grave in 
their prognosis that they can make little or no difference with the result. 
It may be, as Dr. Putnam suggests, that other openings may furnish a 
way out of the difficulty. The special emergencies of intra-cranial hae- 
morrhage and its complications, the particular resources to be applied 
in cases extraordinary from the position of growths or their attachments 
must depend upon the same skill and readiness of its application that 
have already distinguished many operators in the field of abdominal sur- 
gery where experience has taught so much. The after-treatment, with 
some unusual exceptions, resolves itself into the accepted formula for 
compound fractures of the skull; namely, adequate drainage and asep- 
ticism.