A CASE OF 
Cerebral Localization, with 
Double Trephining. 
(Acquired Spastic Hemiplegia - Porencephalus.) 
By WILLIAM N. BULLARD, M.D., 
Pisitiny Physician Carney Hospital, Instructor in Boston Polyclinic. 
Reprinted from the Boston Medical and Surgical Journal 
of February 16, /888. 
BOSTON : 
CUPPLES AND HURD, Publishers, 
94 Boylston Street, 
1888. A CASE OF CEREBRAL LOCALIZATION, WITH 
DOUBLE TREPHINING (ACQUIRED SPASTIC 
HEMIPLEGIA - PORENCEPHALUS).1 
BY W. N. BULLARD, M.D. 
Gentlemen : The case which I have the honor to 
report to you to-night derives its chief medical interest 
from the fact that the diagnosis of the lesion, and the 
localization of its seat were correctly made during 
the life of the patient, and that the latter was such as 
could be easily reached by a comparatively simple 
operation. Cases of operative interference in con- 
genital cerebral lesions, or in those occurring in the 
earlier months of life, are very rare, and I, therefore, 
believe it of importance that the possibility of localiz- 
ing these lesions, and the probability that in certain 
cases, even though they be incapable of cure, their 
results can be mitigated, should be strongly empha- 
sized. Until of late years, but little attention has 
been paid to the various forms of congenital or in- 
fantile cerebral lesions, excluding hydrocephalus and 
inflammations of the meninges. Patients suffering 
from congenital or infantile cerebral paralyses are too 
often considered not only absolutely incurable, but in- 
capable, even, of improvement. Some cases unques- 
tionably are so ; but, on the other hand, I believe that 
in many of this class of cases wre can do much to im- 
prove and mitigate those symptoms which we cannot 
remove, and there is no doubt that a broad field lies 
open here for cerebral surgery, provided, only, that 
the neurologist can state with some degree of preci- 
1 Read before the Section for Clinical Medicine.,PSfli'ology, and 
Hygiene of the Sutfolk District Medical Society, 1888,. 2 
sion the condition existing within the cranium, and, 
if the lesion be a localized one, point out its seat. 
The present case occurred in the service of Dr. 
Bradford, at the Children's Hospital, and it is through 
his kindness and at his suggestion that I bring it 
before you to-night. 
The patient was a boy, four and a half years old. 
There was no history of any nervous disease in the 
family, and no history of the patient was obtainable, 
except that he was supposed to have been in his 
present condition since birth. The delivery was by 
forceps, and the child had a scar and depression over 
the right parietal bone, supposed to have been caused 
by them. There was no history of convulsions at 
any time. The child was brought to the Hospital by 
his parents, who insisted upon an operation - trephin- 
ing over the depression - although they were in- 
formed that there was little hope of improvement 
from what they desired, and still less of cure. This op- 
eration had been decided upon before I saw the child. 
I first saw the patient in the Hospital on the 22d 
of June, 1887, when his condition was as follows: 
The child was seated in bed. As a rule, he sits 
quietly all day, doing nothing. Expression vacant. 
Intelligence limited, although he has a certain sense 
of his surroundings, as was shown by his screaming 
one day when he was placed in a bed in another part 
of the ward, and pointing with his finger to the old 
one, and continuing this until he was replaced. He 
understands simple words and sentences, and obeys 
simple directions. He signifies when he is thirsty. 
When told to do so, he will turn his head, and he will 
hand an object to a person, or smell of a rose, when 
it is suggested to him. He can say "yes " and " no," 
and will say "good-bye " when any one is going away, 
but he cannot talk. He drules constantly. 3 
Physical condition: Well nourished, well developed. 
Head large, rather square. On the right side, 5 cm. 
behind, and about 4 cm. above the upper edge of the 
anterior border of the pinna, there is a scar 5 cm. 
long, extending forwards and slightly upwards. This 
scar lies in front of the occipito-parietal depression, 
which is alike on both sides, and seems to cross the 
temporal ridge of the parietal bone, and the 
squamo-parietal suture. On palpation, there is an 
irregular knob or prominence under one portion of the 
scar, and a depression with irregularities on each side, 
that is, anteriorly and posteriorly. There is no de- 
cided tenderness here or elsewhere about the head. 
Nothing else abnormal was detected about the cranium. 
All the special senses appear normal. There is 
right internal strabismus. Eyes not examined ophthal- 
moscopically. 
Nothing abnormal could be detected about the 
trunk or organs of the thoracic or abdominal cavities. 
There was an occasional reduplication of the first 
sound of the heart. 
The spine was straight; no tenderness in the back. 
The patient cannot use any of his extremities, but he 
uses those on the left much better than those on the 
right. 
Upper extremities : The right upper extremity can 
be moved somewhat, but is never used. It is in a 
condition of spastic paralysis. The forearm is held 
semi-flexed upon the arm, and there is considerable 
resistance to passive motion, which can, however, be 
overcome after a time. The hand is firmly flexed on 
the forearm. He will not grasp anything with the 
right hand. He moves the left upper extremity much 
better than the right, and always grasps objects with 
the left hand, and then holds them firmly. 
Lower extremities : The right lower extremity is 4 
smaller, and possibly colder than the left. There is 
a spastic condition of the knee and ankle. The foot 
is held flexed in the equinus position, with the toes 
pointing downwards. Some movement of the limb, 
however, is possible. He can flex at the thigh, knee, 
and ankle when he wishes. The left lower extremity 
is somewhat weak, perhaps from disuse : otherwise, 
nearly normal. 
Knee-jerk exaggerated on both sides. Patient is 
unable to walk or to stand without support. He can 
take a step if supported under the arms, and he can 
hold his weight on the left leg. If the legs become 
locked at the knees, as they tend to do, he can sup- 
port a portion of the weight of his body upon them. 
The sensation is apparently normal everywhere 
throughout the body. Nothing else abnormal detected. 
To resume the case in short, we have here a boy, 
four and a half years old, with much diminished in- 
telligence, inability to speak, inability to use any of 
his limbs well, and with right internal strabismus and 
right spastic hemiplegia. In addition, there is a well- 
marked cicatrix and depression in the right posterior 
parietal region. 
After examination of the case, it was decided, at 
my suggestion, that in addition to the operation 
already proposed, the cranium should be opened over 
the cortical motor area of the left side, as this seemed 
to offer the strongest prospects of relief. 
The operation was, accordingly, performed on the 
27th of June, by Dr. Bradford. The patient being 
etherized, the various points were localized on the 
shaven head, and the position of the fissures of 
Rolando determined as carefully as possible. Dr. 
Bradford trephined first on the right side of the head, 
directly over the cicatrix. A curved incision with its 
convexity downwards, about six inches in length, was 5 
made through the scalp, the periosteum was removed 
intact, and the cranium trephined - the trephine 
used being an inch in diameter. The outer table of 
the portion of bone removed showed a fracture, and 
the inner a slight inequality, due to a fissure. The 
dura mater exposed was thickened, and its vessels 
filled with blood. It (the dura mater) was then in- 
cised, and the brain and pia exposed to view. There 
was no evidence of pressure, nor of anything abnor- 
mal here below the dura. The brain protruded 
slightly through the opening and pulsated. [It is 
important to note here the fact that, in spite of the 
fracture of the cranium, and the accompanying thick- 
ening of the dura mater, the pia and brain were, as 
far as could be told, absolutely normal.) 
It was now decided that it would be wise to trephine 
over the probable seat of the lesion on the left side, 
and, at Dr. Bradford's request, I located the motor 
area on the left side, where it was presumable, fiom 
the symptoms, that the lesion would be found. This 
point was a little higher and slightly further forward 
than that trephined on the right, at the junction, as 
nearly as could be determined, of the middle and 
lower thirds of the fissure of Rolando. There was a 
very small superficial cicatrix in the skin here, not 
involving the deeper tissues of the scalp, and which 
had remained undetected until the position was 
marked. An incision similar to that made on the 
right side was now made here. The cranium, whin 
uncovered, appeared perfectly normal. It was tre- 
phined, and, on the removal of the bone to which the 
dura was attached, a depression in the brain substance 
- porencephalic cavity - was exposed. This not only 
occupied the whole space directly under the opening, 
but also extended somewhat anteriorly. The piaseemtd 
to be adherent. The brain substance in this depression, 6 
which was estimated as about 1| inches long, by J 
inch wide and inch deep at the deepest parr, was 
puckered and shrivelled. Considerable haemorrhage 
from the bone followed the removal of the button on 
this side. This was quickly controlled by plugging. 
As the patient's condition was poor - pulse very 
weak, and respiration slow and labored - nothing 
further was attempted. After replacing the buttons 
of bone on each side, and stitching the dura mater on 
the right, the incisions were sewed up, and bandages 
and dressing applied. 
The patient, however, never rallied thoroughly after 
the operation, although he recovered consciousness in 
the evening, and was conscious until the following 
morning, when he died at 10 a. m., about seventeen 
hours after the operation. The temperature was not 
taken on the evening following the operation, but, the 
next morning, rose to 105°. There was no autopsy. 
This case, it seems to me, illustrates some interest- 
ing points. In the first place, it demonstrates the 
possibility of localizing lesions of this character (po- 
rencephalic) in children in certain cases. This is, of 
course, the first step in any rational attempt for their 
direct alleviation or cure. That these lesions can be 
localized with moderate accuracy, at least, sufficiently 
for all practical purposes in a large proportion of the 
cases of this class, I am convinced, and I believe it to 
be the duty of the neurologist, so far as lies within his 
power, to improve and perfect his knowledge, so that, 
when appealed to by the surgeon, he shall be able to 
point out where the instrument should be directed, 
and to state what sort of lesion is likely to be found. 
Secondly, I believe that this case may be accepted 
as evidence that these lesions - many of them, at 
least - can be reached by surgical interference'with- 
out serious difficulty, since simple trephining can no 7 
longer be regarded as a serious operation in ordinarily 
healthy persons. If this be true, its importance is at 
once manifest. If these lesions can be localized, and 
if surgical interference in them is not a matter of 
serious difficulty, nor of marked risk to the life of the 
patient, we have here, at least, one expedient which 
offers a prospect of alleviation in these cases, however 
remote. 
It is well known to most of us, but I repeat it here 
for the sake of emphasizing it again, that there are no 
cases which, as a class, are regarded by the whole 
medical profession as more utterly hopeless and as 
more entirely beyond any possible medical aid and 
assistance than congenital and infantile brain affec- 
tions. There is no class of cases in which the patients 
are more utterly useless to themselves and to the 
world, or more of a burden to their parents and rela- 
tives. Anything, therefore, which affords the least 
prospect of relief is, in them, of the utmost importance. 
There are two other points in this case which are 
of both neurological and surgical value, which 1 will 
refer to in short. 
The first is the question of the advisability of tre- 
phining in more than one place at the same time in 
children. Whether, in this case, the result might 
have been more favorable had the operations been 
performed separately, it is impossible to decide; but, 
in a similar case, it would certainly seem more safe to 
perform two operations. 
The second point is one which, although theoreti- 
cally well known, cannot be repeated too often, and 
it is well illustrated here. This is, that in spite of a 
fracture or visible injury on one side, the actual cere- 
bral lesion may be upon the opposite, whether pro- 
duced by direct violence or by contrecoup. There- 
fore, in case of cerebral injury, if the symptoms point 8 
to a lesion on the opposite side from the trauma; for 
example, if the hemiplegia is on the same side of the 
body as the fracture of the cranium, we should not 
trephine at the place of fracture, but on the other side. 
In the case of our patient, the probability is that 
the whole trouble was traumatic, and due to the pres- 
sure of forceps. While on the right the parietal bone 
was fractured, on the left, the bone being more yield- 
ing, or the blade being in a slightly different position, 
or for some other reason, a different effect was pro- 
duced. This was probably the rupture of the ascend- 
ing parietal artery or one of its branches. THE BOSTON 
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