J|arc0mii ofj Hie |p«ra Jfjjfter. 
REPORT OF A CASE, WITH ILLUSTRATIONS. 
BY EDWARD N. BRUSH, M. D., 
Assistant Physician, New York State Lunatic Asylum. 
From the American Journal of Insanity for January, 1880. SARCOMA OF THE DURA MATER. 
REPORT OF A CASE, WITH ILLUSTRATIONS. 
BY EDWARD N. BRUSH, M. D., / 
Assistant Physician, New York State Lunatic Asylum. 
The following case is here reported, both on account 
of its clinical and pathological significance. In March, 
1875,1 was invited by my friend, Dr. E. C. W. O’Brien, 
of Buffalo, to see Mr. S , who had sought advice 
concerning a tumor situated just anterior to the junction 
of the saggital and lambdoid sutures. The patient was 
a gentleman aged fifty-six, of clear, ruddy complexion, 
large frame and somewhat inclined to obesity. For 
some years he had been occupied as librarian in a large 
public library, but had recently assumed charge of 
some mining interests. The tumor was about the size 
of a small walnut. It was quite movable under the 
scalp, and pretty firm pressure and free handling gave 
rise to no indications of pain or uneasiness. Its growth 
had been slow and unattended by pain. From these 
facts, and from the presence of what was apparently a 
similar growth, though of several years’ standing at 
the outer and upper margin of the left orbit, an ordin- 
ary sebaceous tumor of the scalp was diagnosed, and its 
removal suggested. Not being able at the time to 
leave his business, the patient preferred to postpone 
the operation until he could take a short vacation 
in the summer. I saw nothing more of him until 
February 13, 1876, when I was requested to assist in 
the removal of the tumor, which I then found had 
increased rapidly in size, and was therefore somewhat 
inconvenient. 1 was quite surprised on carefully ex- 
amining the patient, at the size and shape which the 2 
tumor had attained. It measured about four and one- 
halt inches in one diameter, by about six in the other, 
and projected from the cranium some three inches at 
the most prominent point. The tumor was covered by 
the dense, shining scalp; Avas irregularly nodulated, 
and but slightly movable. The slight mobility was 
accounted for by the extreme tension of the scalp. 
The tumor was not painful on pressure, and the patient 
allowed pretty free manipulation without complaint; it 
did not pulsate, Avas soft and somewhat elastic. Some 
portions of the exterior were red and vascular, and 
attracted attention and comment. 
After due consideration it was decided to attempt 
to remove the tumor, and to proceed as far as pos- 
sible by enucleation, after the first incision. Anaes- 
thesia, with ether, being induced, an incision was 
made from before backwards, over the most prom- 
inent part of the tumor. Attention was at once 
attracted to the unexpected thickness and great vas- 
cularity of the scalp. The tissues through which 
the knife passed were dense, and the vessels much 
enlarged. When exposed, the tumor shoAved what was 
apparently a containing sac or cyst-\vall. I at once 
passed my finger into the Avound, and commenced the 
process of enucleation. The growth was easily sepa- 
rated from the scalp, but I Avas surprised on approach- 
ing its base to find that my finger did not pass under 
it and come in contact with the cranium, but seemed to 
follow out the covering membrane, which apparently 
spread out in all directions upon the skull, and made it 
impossible to raise the tumor from its attachments. 
Thinking that I might possibly have mistaken a layer 
of fascia for the investing membrane of the tumor, 
this was ruptured with the nail, and the finger passed 
immediately down upon the cranium and thence under 3 
the tumor. I at once recognized the fact that the finger 
had passed into the substance of the growth; that it 
was not sebaceous, and that beyond the membrane just 
ruptured, it had no retaining sac. Using the finger as a 
director the incision was enlarged in order that the tumor 
might be more easily examined, and the extent of its 
attachments determined. This done I passed my finger 
through the opening already made in the apparent 
covering of the tumor, down to its base. In doing so 
it came in contact with roughened and denuded bone, 
and in sweeping the finger under the growth to sepa- 
rate it from the skull I was startled by passing it into 
an opening in the cranium. A brief examination satis- 
fied all present that the tumor either had its origin 
from, or passed into the cranial cavity, and it was de- 
cided to discontinue the attempt at removal, Before 
closing the incision, Prof. J. F. Miner was called in 
consultation. After a careful examination he expressed 
the opinion that the growth originated within the 
cranium, that it had eroded its way through the cranial 
walls, and that its removal was impossible. The incis- 
ion was loosely drawm together, warm water dressings 
applied and the patient placed in bed. 
On recovering from the ether the patient’s mind was 
clear and active, pulse one hundred, respiration unim- 
peded, and he complained of but little pain. A por- 
tion of the incision healed by first intention, but the 
extensive separation of the attachments of the tumor, 
which had been made with the finger, destroyed its 
vitality, and in a few days, I was able to lift out a 
large portion of its most prominent part. After the 
removal of a few remaining shreds by suppurative pro- 
cess, a red protuberant mass, about the size of a wal- 
nut, was noticed at the bottom of the cavity; this 
mass bled easily and pulsated regularly. The pulse 4 
never rose above one hundred and twenty, and fre- 
quently was as low as eighty. The discharge from the 
wound was profuse, and at times quite offensive. No 
cbill or febrile stage was at any time observed. For 
four weeks the patient remained in this comfortable 
condition. Motion and sensation were at all times 
normal, and he continued to direct his business affairs 
as clearly as ever, and carefully arranged matters in 
view of his probable death. 
On the morning of March 8th, Mr. S. noticed a loss of 
power and sensation of the right side. This condition 
gradually increased until it reached almost complete 
hemiplegia. The eyes were suffused, pupils contracted, 
face red, pulse rapid and bounding, temperature 103°. 
He complained of intense headache, was easily dis- 
turbed and restless when asleep, but at no time delir- 
ious, motion and sensation gradually returned, and on 
the thirteenth, were nearly normal. The headache 
was relieved by bromide of potassium, and the tem- 
perature controlled by quinia. From the tenth to the 
time of the death, the catheter had to be resorted to, 
to evacuate the bladder. On the twentieth, there was 
nearly complete left hemiplegia. At midnight On 
March 22d, I saw the patient, being hastily summoned 
in the absence of his attending physician, Dr. O’Brien. 
He was in a semi-comatose condition, respiration ster- 
torous—twelve per minute; pulse, rapid and feeble. 
He could only be aroused with considerable effort, but 
would then make intelligent replies to questions. The 
coma increased steadily, and terminated in death in the 
forenoon of the twenty-third. 
Autopsy.—The tumor projected from the upper back 
part of the head in the median line. Its base had a 
diameter of some six inches, and it projected about 5 
three inches above the skull. In its center was a crater- 
like excavation, two inches in diameter, extending down 
to bone. Its edges were ragged, red and granulating, 
the sides grayish and sloughing. The weight of the 
tumor wms estimated at one and one-half pounds. On 
section the pericranium was found to be elevated by 
the tumor. The scalp, though thickened, was separable 
from the morbid growth on all sides. On separating 
the tumor from the skull, the central portion of its 
base was found continuous with an inter cranial por- 
tion, through an irregular, ragged erosion in the cranial 
walls, with a diameter of from one and one-half to two 
inches. The eroding process had affected the border of 
the perforation for a circle of half to three-quarters of 
an inch breadth about it. This erosion is shown in 
Fig. one, representing the outer surface of the calvarium. 
Flg. i. 
Other portions of the bone covered by the tumor were 
more or less roughened. The inner surface of the 
calvarium showed the channels for meningeal vessels deeper than common. The margin of the opening was 
rough and irregular, and its edges bevelled by the 
eroding process, as shown in Fig. two, showing that the 
tumor was originally wholly inter-cranial. 
Fig. II. 
The dura mater was thickened, non adherent; pia 
injected. The tumor arose in the falx cerebri, extend- 
ing between the hemispheres for tlie depth of an inch 
and one-half. The portion internal to the skull weighed 
four ounces. The convolutions on either side of the 
median line were flattened by pressure, and marked 
depression was observed in the lobes of either hemi- 
sphere where the tumor had lain. They were, however, 
not involved in the new growth. On incision, an 
abscess, the size of a pigeon’s egg, was found in the left 
posterior central convolutions. The brain was not sub- 
jected to microscopic examination. Sections of the 
tumor, placed under the microscope, showed it to be 
round celled sarcoma. The interesting features of this 7 
case are the size and origin of the tumor, and the 
absence of all brain disturbance, until a short time 
prior to death, due probably to the early relief of pres- 
sure by perforation of the cranial vault. Growths of 
this character are recorded under various names, as 
fungus hsematodes, fungus durse matris, malignant 
tumor of the dura mater, etc. Gross mentions two 
operations for the removal of similar tumors, and Erich- 
sen and Hamilton mention operative procedure as the 
last resort, ad vising enlargement of the cranial aperture, 
and careful dissection of the tumor from the dura 
mater. It hardly seems to me, that a full knowledge 
of the parts involved, would justify an attempt to re- 
move a tumor of this character. THE 
AMERICAN JOURNAL OF INSANITY. 
The American Journal of Insanity is published quarterly, at the 
State Lunatic Asylum, Utica, N. Y. The first number of each volume 
is issued in July. 
Editor, 
JOHN P. GRAY, M. D., LL. D., Medical Superintendent. 
Associate Editors, 
JUDSON B. ANDREWS, M. D., 
EDWARD N. BRUSH, M. I)., 
SELWYN A. RUSSELL, M. D., 
A ssistan t Physic ian s. 
THEODORE DEECKE, Special Pathologist. 
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Five Dollars per Annum, in Advance. 
Exchanges, Books for Review, and Business Communications 
may be sent to the Editor, directed as follows: “Journal of 
Insanity, State Lunatic Asylum, Utica, N. Y.” 
The Journal is now in its thirty-sixth volume. It was es- 
tablished by the late Dr. Brigham, the first Superintendent of the New 
York State Lunatic Asylnm, and after his death edited by Dr. T. Ro- 
meyn Beck, author of “ Beck’s Medical Jurisprudenceand since 1854, 
by Dr. John P. Gray, and the Medical Staff of the Asylum. It is the 
oldest journal devoted especially to Insanity, its Treatment, Juris- 
prudence, &c., and is particularly valuable to the medical and legal 
professions, and to all interested in the subject of Insanity and Psy- 
chological Science