Contribution to the study of cerebral surgery based on an operation for the removal of a tumor / by M.H. Richardson and G.L. Walton.

  • Richardson, Maurice H. (Maurice Howe), 1851-1912.
Date:
1893
Catalogue details

Licence: Public Domain Mark

Credit: Contribution to the study of cerebral surgery based on an operation for the removal of a tumor / by M.H. Richardson and G.L. Walton. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Remarks.—^The pathological findings in the case demonstrate the practical accuracy of the localization—namely, that the bulk of pressure was in the region of the angular gyrus and involving the occipital lobe. The immunity of the speech centre from actual new growth justifies the conclusion that the aphasia was the result of pressure, or of affection of the association fibres and sensory factors necessary to speech, or to both, rather than to implication of the speech centre. The mind-deafness was due to the involvement of the posterior part of the temporal lobes. It will be seen by the accompanying cut that the temporal lobes were some- what twisted by the pressure, so that the fissures became more nearly vertical than horizontal. The fissure of Sylvius was also pressed forward so as to become more vertical than is normal. The motor centres were practically intact, as was to have been expected. The tumor was ap- parently of very rapid growth, and, large as it was at the time of opera- ^tion, it was much larger at the time of death. It had doubtless also pressed toward the surface, partly by natural growth, and partly on ac- count of lessened resistance in that direction. Dr. Whitney states that a piece of the cortex removed at the operation, and given him for exami- nation, showed much the same structure microscopically as the tumor, though less dense. It is possible, therefore, that the tumor proper eluded the touch of the operator partly by the deep situation of the portion directly under the point of operation, and partly on account of the very slight difference in its consistency from that of the protruding brain. In a similar case, on such a marked protrusion of brain, the writers would be inclined to enlarge the opening indefinitely, to explore further, and re- move everything possible, for the absolute hopelessness of expectant treatment being apparent, it would seem wise to give the patient the benefit of an exhaustive search, even in spite of the dangers of the operation. The difficulty in using the rongeur forceps to enlarge the opening in the skull after the dura mater was opened and the brain literally pour- ing out, would lead us in another case, where so great evidence of pressure existed, to enlarge the opening, before cutting the dura mater, to the fullest extent likely to be required. The disadvantage in this procedure is the uncertainty in which direction to extend the opening, a disadvan- tage which is more than counterbalanced by the increased facility in operating, especially as it is a matter of comparatively little moment if the opening proves somewhat larger than necessary—a most improbable situation in any event. The plan of cutting out a semicircle of bone and reflecting skull and skin together, breaking the lower edge for the purpose, certainly offers the advantage of sufficient room for exploration, but has not recommended itself to the writers as necessarily more prac- ticable than the old method of trephining and enlarging. In the first