THE ELIMINATION OF THE MIDWIFE
Authors: CHARLES EDWARD ZIEGLER
Journal: JAMA (1913)

All'lll'SY Section of the skull only was permitted.Veins of the Scalp were engorged, exuding on section dark blood.Conges¬ tion of durai sinuses.Nothing else noted in siln.except that the anterior portion of the longitudinal li-sure was curved to the right.On removing (he brain, the lip of Hie lell frontal lobe wa-.found adherent to the dura above the left oibil.The lore part of the right cerebral hemisphere was pushed aside, and encroached on by the corresponding portion of the lell.There was diffuse atheroina of the arteries of the base, and thickening of the meníngea] vessels.(In section of the brain an ovoid tumor was found in the lell frontal lobe the size of a small hen's egg. .1!. encroached on the lower and inner aspects of Ihe surface of the hemisphere, approaching lo within a few millimeters of the cortex in these situations, and producing a distinct depression on the surface Of the opposite hemisphere.It was situated in the white mal 1er, and was of a brownish-gray appearance.The margins were not clearly defined.On the tip of Ihe left frontal lobe wa-a similar growth, adherent to the parietal dura and of a somewhat denser consistency, the size of a small chestnut.The white mailer between tin' larger tumor and the temporal cortex wa-the seat of scattered minute areas of venous stasis or hemorrhage.The entire third frontal convolution from the smaller tumor backward to the sylvian Assure was the seal of an acute softening, Microscopic see! ions were made from (« ) the larger tumor; (6) the smaller tumor; (<•) the white area between the larger tumor and the temporal cortex, and (,/) the softened area of the third frontal convolution.Examination showed that, a and h were similar, being round celled sarcomas, rather rich ill blood-vessels: e showed malignant infiltration, the tumor appearing to arise hy proliferate.fthe adventitial cells of the blood-vessels; both e and ,/ showed hemorrhage and throm¬ bosis, hot h fresh and old (that is. in process of organization).Careful examination failed to reveal any Other al.nialilie.than those described above.Tile points of especial interest, ale: I. Should lite diagnosis have been more definitely mu,le before death?The ease points out thai rapidity of development ol' a clinical picture pointing' to destruc- tive brain lesion is nui of itself an argument againsl the presence of tumor, as the growth may be without symptoms l'or a long lime, ami become suddenly active through rapid ¡nliliralion, metastasis, or the production oí collateral brain disturbance.'.'.Provided thai the diagnosis oí tumor had been made with the data available at the lime, what should have been the attitude as to advising operation in this caser Pressure symptoms were not, present, so that thai justification for opening' ihe skull was absent.The1 only indication was furnished \^y the chance of removing (he tumor.In this ease we know by subsequent develop¬ ments thai operation would have been l'utile, and would have resulted in death.Bui we do not have the data obtained bj autopsy in determining Ihe question of operation.The tendency of the advice generally received by general clinicians from both neurologists and sur¬ geons is in operate in brain tumor unless there are positive contra-indications.Disregarding the personal factor oí criticism for advising and undertaking ill- advised operations, the latter are, ill the eves of the layman, a reflection on both diagnosis and surgery, and operate by their influence to keep suitable eases from receiving the advantages of surgical relief.:>. W'hal was the pathophysiologv ol' the transient hemiplegia associated with (he onset of June 8?I attributed M at the lime to an ischemia ol' (hat side of