Were Dr. Walter E. Dandy of Baltimore willing to brag (which he is not), this week he would tell of a brain operation he performed at Johns Hopkins Hospital two weeks ago on 18-year-old Oscar Flicker, freshman of the College of the City of New York and son of Samuel Flicker, realtor.
This operation was to remove a tumor, which proved to be as large as a league baseball,* from Oscar’s brain. It was an operation that taxed all of the surgeon’s knowledge and technique, his accuracy and precision. Few other surgeons are able or willing to do the like.
Before he started to operate, he had to have a vast accumulation of information on the anatomy of the human skull and of the brain, on the cause, development and effect of brain tumors, and on the best operative procedure.
Skull. The skull is the bony framework of the head. It is divided into the bones of the cranium and of the face. The face bones are not to be considered in the discussion of this operation. The bones of the cranium form the brain case. They are the occipital, the two parietals, the frontal, the two temporals, the sphenoid (wedge-formed) and the ethmoid (sieve-formed). At birth these bones are not completely joined, the jointure being fulfilled by membranes, which change into bone as the person grows older.
Brain. Just within the bony brain case are the meninges made up of three separate coverings-the dura mater, the arachnoid and the pia mater. The dura mater (tough mother, protector) lies next to the skull and is closely connected thereto. It resembles fine, wetted parchment. Next and attached to this is the arachnoid (cobweb-formed). This is a thin, fibrous membrane, which one might compare to a slice from a rubber sponge. Through its interstices pass vital fluids. It connects the dura mater to the pia (tender, kind) mater which immediately covers the brain itself, and dips down into the latter’s creases.
The whole brain looks like a dirty, wetted newspaper crumpled up and patted into somewhat the shape of a rounded bun. Another comparison might be to a lobsided mushroom, for the bottom of the brain runs into a sort of stalk, which is the spine.
The outer surface of the brain is grey in color. Here are the nerve cells which function in consciousness. One estimate counts 92,000,000 cells. A stimulus comes to one or more of these, and each affected cell stimulates ten of its neighbors (by this theory). Each of these ten stimulates a neighboring ten, and so on by geometrical proportion, until the influence of the original stimulus fades away. Such stimuli are normally brought to these cells in the grey cortex (bark) by the nerve fibres. These form the white core of the brain. (Naturally there are blood vessels and a variety of other cells in the brain as elsewhere in the human economy.)
Macroscopically (to the naked eye) the whole brain is divided crosswise into two unequal, grossly wrinkled parts. The rear and lower part is the cerebellum, the chief duty of which is to regulate the automatic reflexes and movements, such as walking. The upper and fore part is the cerebrum, where thinking is done. It is by far the larger of the two.
The cerebrum (the tumor operation had nothing to do with the cerebellum) is divided from front to back into two hemispheres, a left and a right, which function almost alike. Each hemisphere is composed of five lobes, termed frontal, parietal, occipital, temporosphenoidal and central. Each is separated to a certain extent from its neighbor by fissures, or depressions, and each is also made up of elevations called convolutions and of lesser depressions.
Sensations, messages from the outer world, are carried by afferent nerves to definite lobes and to definite locations in these lobes. There the grey cells in the cortex mull the influences of these stimuli, play with them, sometimes bury them as memories. If a physical reaction is wanted, consciously or subconsciously, the brain sends out its will by way of efferent nerves to the organs of expression, to the limbs, the viscera, the tongue, the hand.
The locations of the brain functions in each lobe may be roughly placed as follows: At the forward end is the higher psychical centre, just back of the eyebrows and forehead, and running back to about the temples. An injury to an eye or a frontal sinus may puncture this centre, but is not always fatal. Somewhat higher up and a trifle before the temple is the speech centre. Just above that is that of the head. Ahead of the head centre is that of the eyes. Back of these latter two and going in a sort of band from the speech centre to the top of the lobe are successively the centres of the face, the arms, the trunk, the legs, the feet. Then comes a large fissure (or sulcus) immediately back of which are the cutaneous and muscular sensory. Dropping to the ear region one finds the large higher auditory centre. At the top of the lobe and a little back of centre is the stereognostic, whereat the brain recognizes the nature of solid bodies through the widely diffused sense of touch. At the hind end of the cerebrum is the visual centre.
Disease of or accident to any of these centres in the brain affects the part of the body in correspondence. Harm to a part of the right hemisphere influences, in general, the left side of the body; and vice versa. The phenomenon occurs because the bundled nerves which carry messages from the two sides of the body cross each other at the entrance to the skull.**
Tumor. In the case upon which Dr. Dandy operated, the youth began last December to show strange symptoms. He was depressed, erratic, wanted to commit suicide. Hearing, sight and most other functions seemed not affected. But his conduct, his attitude towards life were. There was something wrong with his higher psychical centres (one at the fore end of each hemisphere), perhaps with only one of the two, although they are most intimately related. Physicians diagnosed his ailment as from a tumor which was pressing down upon the fore part of the right hemisphere of the cerebrum. They sent him to Dr. Dandy for confirmation of diagnosis and for operative treatment.
Operation. In the operating room at Johns Hopkins Hospital two weeks ago the youth lay under anesthetic. His scalp had been shaved, scrubbed and treated with antiseptic. The room was hot. Dr. Dandy and his assistants, all in white, hair tied down out of sight and movement, masks over their mouths and noses, moved about. Their every action was smooth, definite, quiet. Instruments-scalpels, hemostats, forceps, needles, saws, chisels, mallet-bandages, medicaments lay in exact, orderly place. There was a contrivance, which the surgeon used later, for pumping air by a special process into the skull cavity to keep the exposed brain from “dying.”
The unconscious boy’s head was twisted so that his right temple lay uppermost. Two quick, accurate, preplanned incisions. A thin-lined six-inch triangle showed faintly. This the surgeon peeled back and let the flap lie out of the way. Then into the skull bone with the saw. Slow, careful rasping. A six-inch triangle lay loose, like a piece of cracker on gelatin. With a blunt instrument Dr. Dandy separated this piece of bone from the underlying, attached dura mater. Into that tough membrane, into the arachnoid tissue, into the pia mater-carefully, very carefully. Some blood. The mass came loose like a slab of stale custard pie.
There now lay the tumor, big as a baseball, looking like a sloppily rounded corn fritter. A few judicious slashes and it was free. Back went the excised meninges. Back the bone. Back the flap or scalp. Sutures there were. The operation was a success, a triumph.
This week the boy was back in his Bronx home convalescing.
*Circumference nine inches.
**This exposition of the brain is for the ‘layman. About the brain there are thousands of facts to know, facts which TIME makes no pretense of expounding. TIME is not a medical journal Ed.