Cilass. Book. COPYRIGHT DEPOSIT BEAIISr SURG-EEY ^ BY M. ALLEN STARR, M.D., Ph.D. PEOFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM, COLLEGE OF PHYSICIANS AND SURGEONS, MEDICAL DEPARTMENT OF COLUMBIA COLLEGE, NEW YORK; PRESIDENT OF THE NEW YORK NEUROLOGICAL SOCIETY; CON- SULTING NEUROLOGIST TO THE PRESBYTERIAN, ORTHOPEDIC AND BABIES HOSPITALS WITH FIFTY-NINE ILLUSTRATIONS NEW YORK WILLIAM WOOD & COMPANY 1893 -Yv> Copyright, 1893, by WILLIAM WOOD & COMPANY PREFACE. Brain surgery is at present a subject both novel and interesting. It is within the past five years only that operations for the rehef of epilepsy and of im- becility, for the removal of clots from the brain, for the opening of abscesses, for the excision of tumors, and for the relief of intracranial pressure have been generally attempted. These operations are the prac- tical outcome of the acceptance of the facts of locali- zation of brain function established by the combined labor of physiologists, clinical observers, and pathol- ogists. Brain surgery has as its essential basis the accurate diagnosis of cerebral lesions, which was impossible until the localization of cerebral functions had been determined. And this diagnosis must be made by the physician before the surgeon is called in to remove the disease. It is the object of this book to state clearly those facts regarding the essential features of brain disease which will enable the reader to determine in any case- both the nature and the situation of the pathological process in progress, to settle the question whether the disease can be removed b}" surgical interference, and IV PREFACE. to estimate the safety and probability of success by operation. The facts have been reached by a careful study of the literature of the subject and by a considerable personal experience. The number of articles written upon brain surgery, the number of cases recorded and of operations reported in this country and in Europe during the past ten years is enormous. This litera- ture is accessible to those only who have a large medi- cal library at their command and who have the time for literary research. I have undertaken to bring to- gether and to sift the scattered facts, to arrange them in an orderly sequence, and to deduce such conclusions from their analysis as seem warranted by critical study. While in no way disregarding the work of foreign observers, I have endeavored to utilize Ameri- can observations and to cite American cases in prefer- ence to others. And this has in no way hampered me, for it is to the industry and genius of American surgeons that much of the great advance in this de- partment of surgery is due. To this collection of facts I am able to contribute a considerable number of cases of cerebral disease, oper- ated upon under my direction. My own experience in the clinical study of brain diseases and my observation of the method and results of operations performed by different surgeons have enabled me to estimate the statements of other writers with some degree of criti- cal judgment, and to arrive at certain convictions of my own. PREFACE. V I have to express my deep obligation to Dr. McBur- ne}' for placing at my entire disposal the large number of cases in which he has operated for me, and for a revision of the chapter upon the operation of trephin- ing ; and also my thanks to Drs. Weir, Hartley, Poore, and Briddon for permission to cite the cases which I have seen with them. I am indebted to Dr. Van Gieson for the very careful investigation of patho- logical material placed in his hands and for the draw- ings which illustrate his descriptions. It is my hope that this work may aid the physician to diagnosticate brain diseases with more accuracy, and to select such cases as are properly open to sur- gical treatment by trephining; and also that it may enable the surgeon to perform his delicate task with more precision and with a fuller knowledge of those principles of local diagnosis v/hich should form his constant guide. M. Allen Starr. No. 22 West 48th Street, New York, March 27th, 1893. CONTENTS. CHAPTER I. The Diagnosis of Cerebral Disease. PAGE Diagnosis is Preliminary to Operation and must be Made by the Physician before Surgical Treatment is Attempted. The Diagnosis of the Nature of the Cerebral Lesion. The Diag- nosis of the Situation of the Cerebral Lesion. The Facts of Localization Essential to Diagnosis. Cranio- Cerebral To- pography, . . . 1 CHAPTER II. Trephining for Epilepsy. The Varieties of Epilepsy. Jacksonian Epilepsy. The Motor Form of Attack. The Sensory Form of Attack. The Aphasic Form of Attack. The Psychical Form of Attack. Traumatic Epilepsy. The Operation for Epilepsy. Records of Cases of Epilepsy operated upon, Personal and Selected. The Pathology of Jacksonian and Traumatic Epilepsy. The Re- sults of Trephining for Epilepsy. Conclusion, . . .19 CHAPTER III. Trephining for Imbecility Due to Microcephalus. Clinical Types of Microcephalic Children : (1) Paralytic Cases ; (2) Imbeciles ; (3) Cases of Sensory Defect. The Occur- rence of Epilepsy in these Children. The Pathology of these Clinical Types. The Operation of Craniotomy and its Re- sults. Table of Cases. Report of Personal Cases. Conclu- sions, ........... 114 Vlll CONTENTS. CHAPTER IV. Trephining for Cerebral Hemorrhage. PAGE Records of Cases of Clots Removed from tlie Brain. Report of Personal and Selected Cases. The Symptoms of Traumatic Cerebral Hemorrhage. The Differential Diagnosis Between Intra-Dural and Extra-Dural Hemorrhage. Operations for Non- Traumatic Hemorrhage, 157 CHAPTER V. Trephining for Abscess of the Brain. The Surgical Treatment of Brain Abscess. The Varieties of Brain Abscess. (1) Traumatic Abscesses. Surgical Indica- tions for Trephining, General and Local. Report of Cases. (2) Abscesses Secondary to Ear Disease. Symptoms. Dif- ferential Diagnosis between Abscess, Meningitis, and Sinus Thrombosis. The Situation for Trephining after Ear Dis- ease. Illustrative Cases. Conclusions 179 CHAPTER VI. Trephining for Tumor of the Brain. The Frequency and Varieties of Tumors in the Brain. Analysis of Six Hundred Tumors. Tumors in Children Contrasted with Tumors in Adults. The Diagnosis of the Nature of the Tumor. The Diagnosis of the Situation of the Tumor. The Percentage of Brain Tumors Open to Operation. The Results of Operation for Brain Tumors. Analysis of Ninety- seven Cases. I. Cerebral Tumors. Selected American Cases. Personal Case. Tumor of Frontal Lobes. 11. Cere- bellar Tumors. Diagnosis. Difficulties of Operation. Three Personal Cases. Table of all Brain Tumors Operated upon. Conclusions, .......... 200 CHAPTER VII. Trephining for Hydrocephalus and for the Relief of Intracranial Pressure. Hydrocephalus. Tapping the Lateral Ventricles. Keen's Cases. Robson's Cases. Broca's Cases. General Conclusions. Methods of Operation. Trephining to Relieve Intracranial Pressure, ......... 256 CONTENTS. IX CHAPTER VIII. Trephining for Insanity. PAGE Traumatic Insanity in Relation to Insanity in General. Report of Cases Operated Upon. Trephining in General Paresis. Uselessness of the Operation, 267 CHAPTER IX. Trephining for Headache, and Other Conditions, . 273 CHAPTER X. The Operation of Trephining. The Necessity of Antiseptic Precautions. The Preparation of the Patient. The Choice of an Anaesthetic. Marking the Scalp. The Incision in the Scalp. Methods of Opening the Skull. The Treatment of Hemorrhage. Opening of the Dura. The Exploration of the Brain. The Closure of the Wound 275 LIST OF ILLUSTRATIONS. FIG. PAGE 1. Diagram of the Functional Areas of the Right Hemisphere, 4 2. Diagram of the Functional Areas of the Left Hemisphere, . 5 3. Diagram of the Median Surface of the Right Hemisphere, . 7 4. The Projection Tracts within the Brain, .... 9 5. The Association Tracts within the Brain, . . . .10 6. Photograph of the Head and Brain (Fraser) , ... 12 7. Photograph of a Cast of the Head, 13 8. Diagram of the Cranial Measurements to Locate the Fissures, 14 9. Diagram of the Relations of the Skall and the Brain (Reid) , 15 10. Diagram to Show the Relation of the Skull and the Func- tional Areas of the Right Hemisphere, . . . .16 11. Diagram to Show the Relation of the Skull and the Func- tional Areas of the Left Hemisphere, . . . .17 12. Diagram to Show the Opening in the Skull in Case I. , . 30 13. Diagram to Show the Opening in the Skull in Case II., . 32 14. Diagram to Show the Opening in the Skull in Case III. , . 36 15. Diagram to Show the Opening in the Skull in Case IV. , . 37 16. Diagram to Show the Opening in the Skull in Case V. , .39 17. Diagram to Show the Opening in the Skull in Case VI. , . 42 18. Diagram to Show the Opening in the Skull in Case VII. , . 43 19. Diagram to Show the Opening in the Skull in Case VIII. , . 45 20. Diagram to Show the Opening in the Skull in Case IX. , . 47 21. Diagram to Show the Opening in the Skull in Case X., .48 22. Diagram to Show the Opening in the Skull in Case XL, . 50 23. Diagram to Show the Opening in the Skull in Case XII., . 53 24. Diagram to Show the Opening in the Skull in Case XIII. , . 54 25. Section through Pia and Cortex Showing Meningitis, . . 71 26. Section Showing Spiculum of Bone in the Brain in Case III. , 84 27. Degeneration of Brain Cells in Epilepsy, . . . .87 28. Degeneration of Brain Cells in Epilepsy, . . . .89 29. Degeneration of Brain Cells in Epilepsy, . . . .90 30. Changes in the Neuroglia in Epilepsy, . . . . .98 31. Changes in the Neuroglia in Epilepsy, ..... 99 32. Neuroglia Cells Undergoing Changes in Epilepsy, . . 100 Xll LIST OF ILLUSTRATIONS. FIG. 33. Adhesion of Scalp and Cortex in Case II. , . 34. Section Sliowing Changes in Membranes and Brain in Case II., 35. Clianges in the Cortex in Case II. , 36. The Capillaries and the Neuroglia in Case II. , 37. The Neuroglia in Case II. , . 38. Porencephalic Brain (Shattenberg) , 39. Porencephalic Brain (Ferraro) , . . . 40. Porencephalic Brain (Ferraro) , . . . 41. Hemiatrophy of the Brain, Superior Surface, 42. Hemiatropliy of the Brain, Inferior Surface, 43. Hydrocephalus (Delafield and Prudden) , 44. Diagram to Show the Opening in the Skull in Case XIV. , . 45. Diagram to Show the Opening in the Skull in Case XV. , . 46. Diagram to Show the Opening in the Skull in Case XVI. , . 47. Diagram to Show the Opening in the Skull in Case XVII. , . 48. Diagram to Show the Opening in the Skull in Case XVIII. , . 49. Diagram to Show the Situation of the Clot in Case XVIII. , . 50. Diagram to Show Relation of Skull and Functional Areas of the Left Hemisphere, . . . . . . , , 51. Diagram to Show the Opening in the Skull in Case XIX. , . 52. Diagram to Show the Opening in the Skull in Case XX. , 53. Photograph of the Brain Abscess in Case XX. , . . . 54. Lateral Aspect of the Skull with Trephine Openings (Bal- lance), 55. The Cerebral Axis (Allan Thompson), 56. Photograph of the Skull and Brain (Fraser) , . . . 57. Diagram to Show the Opening in the Skull in Case XXI. , . 58. Photograph of a Tumor Removed from the Brain in Case XXI 59. Hydrocephalus (Delafield and Prudden) , .... 103 105 107 109 110 125 126 127 130 131 132 142 145 147 149 164 165 170 175 186 187 193 210 211 234 235 265 BRAIN SURGERY, CHAPTER I. THE DIAGNOSIS OF CEREBRAL DISEASE. Diagnosis is Preliminary to Operation and must be Made by the Phy- sician before Surgical Treatment is Attempted. The Diagnosis of the Nature of the Cerebral Lesion. The Diagnosis of the Sit- uation of the Cerebral Lesion. The Facts of Localization Essen- tial to Diagnosis. Cranio- Cerebral Topography. There are two essential preliminaries to any opera- tion upon the brain. The first is the diagnosis of the nature of disease which is present, and the second is the diagnosis of its situation. Both are purely medi- cal questions, and until they are decided the surgeon cannot be asked to operate. The diagnosis of the nature of disease in the brain is usually one of no great difficulty. The general cerebral symptoms characteristic of meningitis, either of the dura mater or of the pia mater, of hydrocepha- lus, of cerebral hemorrhage, of cerebral softening from embolism or thrombosis, of cerebral abscess, of cere- bral tumor, and of sclerosis of the brain are in the majority of cases quite evident. The differential diagnosis between these conditions is elaborately dis- 2 BRAIN SURGERY. cussed in every text-book on practice and on neurology. A careful study of the various symptoms, of the order and manner of their development, and of the general history of the case will usually lead with little diffi- culty to a diagnosis of the nature of the lesion present. It is not my purpose to enter upon the discussion of the diagnosis of cerebral disease in general. In the course of the following chapters and in the recital of certain cases the essential facts will be carefully con- sidered. But it should not be forgotten that surgical interference is by no means warranted in any case un- less the nature of the disease is well determined. The second essential preliminary to operation is a knowledge of those facts regarding the localization of brain functions, so far as they are at present deter- mined, which may lead to a correct diagnosis of the situation of the disease. These facts may be stated briefly. The Fads of Localization. There are certain areas upon the cortex of the brain, not necessarily co-extensive with either lobes or con- volutions, whose functions are accurately known. These areas are : (1) the sensori-motor area. (2) The speech areas. (3) The visual area. {-^) The auditory area. (5) The area of sensations of smell and of taste. (1) The sensori-motor area (Figs. 1 and 2) includes the cortex of the anterior and posterior central convo- lutions which border the fissure of Eolando and the adjacent cortex in front and behind these convolutions. - THE DIAGNOSIS OF CEREBRAL DISEASE. 3 Each hemisphere controls movement on the opposite side of the body, but as the right hand is more gener- ally used and is better trained than the left, this area is larger on the left hemisphere than on the right. The cortex of the posterior part of the second fron- tal convolution controls the movements of the eyes and head. Impulses starting from this area produce conjugate movement of these parts toward the opposite side. The eye district is below, the head dis- trict above. The lower third of the anterior and posterior cen- tral convolutions governs the movements of the face, tongue, larynx, and pharynx. The eyebrows and cheeks are controlled by the upper and forward part of this area; the tongue and larynx by the lower and forward part ; the mouth, pharynx, and platysma by the hinder part. The middle third of the anterior and posterior cen- tral convolutions governs the movements of the upper extremity ; the shoulder motions being controlled in the anterior and upper part of this area, the elbow motions in its middle part, and the hand and finger motions in its posterior and lower part. The upper third of the anterior and posterior cen- tral convolutions including their junction in the para- central lobule controls the motions of the lower ex- tremity ; the thigh, knee, foot, and toes being governed by various parts of this area from before backward in the order nam^ed. It will be noticed that the parts susceptible of the 4 BRAIN SURGERY. finest and most delicate movements, those directed by the most acute sensations, the lips, the fingers, and the toes, lie furthest back in the motor area, chiefly in the posterior central convolution. Lesions in this con- volution almost always cause some loss of tactile sensation as well as paralysis, and hence this area is thought to be the seat of tactile sensations as well as of movements, while some cases point to the localiza- FiG. 1.— Diagram (after Eberstaller) of the Fissures and Convolutions of the Con- vexity of the Right Hemisphere of the Brain. The relative depth of the fissures is indicated by the shading. The extent of the fimctional areas is indicated by the dotted lines. tion of muscular sensations in the area just behind that of motion. The median surface of the hemisphere in front of the paracentral lobule is known to be related to movements of the trunk in monkeys, but these movements are rarely affected by disease in man and their cortical representation is still uncertain, though THE DIAGNOSIS OF CEREBRAL DISEASE. a case reported by Horsley ' points to the cortex in front of the leg area on the convexity as the probable location of the trunk area. There are no sharply defined sections of the motor area to be assigned to special motions. Each motion, each part of a limb, has a wide general representation over the cortex and a special representation at a lim- ited area. Horsley says that the areas of representa- FiG. 2.— Diagram of the Fissures and Convolutions of the Convexity of the Left Hemisphere of the Brain. The speech areas are shown on this hemisphere. The motor area is more extensive than on the right hemisphere. tion of different limbs merge into one another ; thus in the representation of the thumb we find that there is a focus, but that the thumb is represented over a great deal of the upper limb region, and that this rep- resentation diminishes in intensity gradually as we pass from the focus upward. This explains the fact that the excision of a small area does not totally para- ^ Amer. Jour. Med. Sci., April, 1887, Case III., Fig. 18. ; 6 BRAIN SURGERY. \ lyze the portion of the limb represented chiefly on I that area. The adjacent areas represent to some ex- f tent that limb and hence can govern it if need be. j (2) TJie speech areas (Fig. 2) are of four kinds and in four locations. They are limited to the left hem- isphere in right-handed persons and to the right hemi- sphere in left-handed persons. There is the motor speech area in the posterior part of the third frontal convolution, in which the movements concerned in the |. act of speaking are controlled. The use of language and the power of talking are affected when this re- gion is destroyed. There is the audit ory speech area in the first and second temporal convolutions, in which the memories of word sounds are stored up. The un- derstanding of language and the powder of recollecting the names of objects are lost when this region is de- stroyed. There is the visual speech area in the lower parietal region, in which the memories of printed words are stored up. The understanding of written language and the power to read are lost when this re- gion is destroyed. The poicer of writing is a part of speech and is usually lost when the motor speech area is destroyed, but its exact location is not fully deter- mined; some cases pointing to the second frontal con- volution, others to the lower parietal convolution near the hand centre as its probable cortical position. (3) The area of sensations of sight (Fig. 3) is lo- cated in the occipital lobe of the brain, including the cuneus on the median surface and the occipital con- volutions on the convexity. The cortex lying in the THE DIAGNOSIS OF CEREBRAL DISEASE. 7 calcarine fissure is the part primarily reached by the visual impulses, ' but the parts named are also concerned in vision. Each occipital lobe receives impressions from one-half of both eyes, hence a lesion in one lobe produces hemianopsia, a half -blindness in both eyes, Fig. 3. —The Median Surface of the Right Hemisphere (after Ecker). The visual centre is in the cortex lying within the calcarine fissure, OC, and in the cuneus, OZ. The sensations of smell and taste are received in the uncinate convolution, [7, and at the tip of the temporo-sphenoidal lobe. AB shows the position of the para- central lobule, which is included in the motor area of the leg. the blind field of vision being on the opposite side to the lesion. (4) The area of sensations of sound (Fig. 2) is lo- cated in the first and second temporal convolutions of the brain. Each ear is connected with, both hemi- spheres ; hence deafness from a unilateral lesion is only partial and is not generally noticed. But if both tem- poral lobes are destroyed the patient becomes totally deaf. ^ Henschen: " Pathologic des Gehirns, " ii. , 358, 1892. 8 BRAIN SURGERY. (5) The area of sensations of smell and taste (Fig. 3) is located at the tip of the temporal lohe on its under and inner surface, which rests on the sphenoid bone. Each lobe is related to sensory organs on both sides, and a unilateral lesion does not often produce noticeable symptoms. There are large areas of the cortex of the brain whose function is undetermined. These are much more extensive on the right hemisphere than on the left. There are no definite symptoms produced, so far as we now know, by lesions in these areas ; but the negative fact is certain, that lesions in them do not cause disturbances of motion, of sensation, or of speech. There appears to be a certain relation between the frontal lobes of the brain and the higher forms of in- tellectual activity, the powers of fixing the attention and of reasoning and of self-control. But disease here does not cause a loss of any one mental fac- ulty, and for the higher powers of the mind a general integrity of the entire brain, not of any one part, is necessary. When it is considered that every concept is made up of numerous memory pictures joined to- gether, each of which has a separate location in the brain cortex, it becomes evident that to the process of thought a healthy state of the entire cortex is necessary and also of the white matter beneath it, through which the associating fibres pass. And it is therefore impossible for a single lesion anywhere to cause a loss of memory or of imagination or of judg- ment. Yet for the co-ordination of facts into orderly THE DIAGNOSIS OF CEREBRAL DISEASE. 9 series, for comparison, and for analysis of knowledge gained through the senses, the healthy state of the frontal lobes appears to be necessary. And lesions in Fig. 4.— The Projection Tracts joining the Cortex with Lower Nerve Centres. Sa- gittal section showing the arrangement of tracts in the internal capsule. A, Tract from the frontal lobe to the pons, thence to the cerebellar hemisphere of the opposite side; ^, motor tract from the central convolutions to the facial nucleus in the pons and to the spinal cord ; its decussation is indicated at K; C, sensory tract from pos- terior columns of the cord, through the posterior part of the medulla, pons, crus, and capsule to the parietal lobe; jD, visual tract from the optic thalamus (OT) to the oc- cipital lobe; E, auditory tract from the inter-geniculate body (to which a tract pass- es from the viii. n. nucleus (J) to the temporal lobe; F, superior cerebellar pe- duncle; (t, middle cerebellar peduncle; H, inferior cerebellar peduncle; CiV, caudate nucleus; CQ, corpora quadrigemina; Fit, fourth ventricle. The numerals refer to the cranial nerves. the frontal region, especially upon the left side, are quite uniformly attended by mental dulness, apathy, lack of power of concentration, and imperfect self- control. 10 BRAIN SURGERY. The cortex of the hemispheres upon the base of the bram lying on the orbital plate, on the sphenoid and temporal bones, and on the tentorium cerebelli has as yet no assignable functions, and lesions in these re- gions do not produce recognizable symptoms. As to the functions of the centrum ovale, it is known Fig. 5.— The Association Fibres in the Centrum Ovale. A, Between adjacent convo- lutions; 5, between frontal and occipital lobes; C, between frontal and temporal lobes, the cingulum; D, between temporal and frontal lobes— lesion of this tract causes paraphasia; E, between occipital and temporal lobes— lesion of this tract causes word-blindness ; CA^, caudate nucleus; OT, optic thalamus. that through this region the great brain tracts pass in various directions (Fig. 4) . Many of these connect the various areas of the cortex with their respective sensory or motor mechanisms in the base of the brain and spinal cord. Others join the different areas of the cortex with each other, this bringing about a com- bination of sensory impressions into a single mental image (Fig. 5). Others again unite the two hemi- THE DIAGNOSIS OF CEREBRAL DISEASE. 11 spheres of the brain with one another, it being certain that symmetrical areas must act in unison on the two sides. The basal gangha, the corpora striata, and optic thalami, lying deep within the hemispheres, are masses of gray matter whose function is undetermined. Le- sions in them frequently affect the various tracts which pass between them in the internal capsule, thus cutting off afferent or efferent impulses to and from the cor- tex and causing sensory and motor symptoms of the nature of hemiansesthesia, hemianopsia, and hemi- plegia (Fig. -1). But if disease in the ganglia does not invade the internal capsule it cannot be detected during life. The crura cerebri, pons, and medulla contain the centres of the various cranial nerve nuclei, and hence cranial nerve palsies are caused by disease in them. They transmit motor and sensory tracts to the spinal cord, hence numerous symptoms appear when they are injured.' The cerebellum, lying in the posterior cranial fossa beneath the tentorium cerebelli, controls the equilibrium of the body; hence disturbances of the nature of staggering and vertigo are produced by lesioDs affecting it, especially if its median lobe is involved. These local symptoms of brain disease must form the chief guides to the physician in his diagnosis and ^ For a fuller statement of these facts of localization the reader is referred to my book, " Familiar Forms of Nervous Disease." 12 BRAIN SURGERY. to the surgeon in operations. When they are present they point to a particular area of the organ which must be involved. When they are absent both neu- FiG. 6.— Photograph (Fraser) Showing the Relations of the Cerebral Hemi- sphere, the Cerebellum, the Cranial Nerves, the Upper Spinal Cord and Cervical Nerves to the Surface of the Head. The figures 1, 2, 3, are placed upon the chief convolutions of the frontal, parietal, occipital, and temporal lobes of the hemi- sphere. THE DIAGNOSIS OF CEREBRAL DISEASE. 13 rologist and surgeon are as helpless as they were before any of these facts of localization were determined. Cases open to Operation. There are many cases in which it is evident that brain disease is present, but in which it cannot be Ftg. 7.— Photo^aphof a Cast of a Head showing the Relation of the Cranial Sutm-es to the Cerebral Fissures and Convolutions. F, Frontal ; P, parietal ; O, occi- pital ; T, temporal lobes ; S, fissiire of Sylvius ; R, fissure of Rolando ; /, inter- parietal fissTu-e ; P O, parieto-occipital fissure ; A P, anterior and posterior central convolutions. located because the necessary symptoms to determine its location are absent. 14 BRAIN SURGERY. There are other cases in which it is evident that the disease is located deep within the hemispheres or on the base of the brain entirely bevond the reach of the surgeon. It is therefore evident that only in a limited number {. distcnz Occiv prctu, Glabella Fig. 8.— Diagram Showing the Measurements Required to Determine the Position of the Fissures of Rolando and Sylvius. of cases of brain disease can any operative interference be considered with favor. Operations may be performed for the relief of epi- lepsy, for the cure of imbecility, for the removal of clots, for the opening of abscesses, for the excision of tumors, for the relief of intracranial pressure— with or without drainage of the lateral ventricles — and for the cure of traumatic insanity. In the following THE DIAGNOSIS OF CEREBRAL DISEASE. 15 chapters each of these conditions will be discussed, the pathology of the disease being especially considered, and the results of operations hitherto done being fully described. Cixuiio- Cerebral Topography. The fact that the brain may be exj^osed for the re- moval of diseased parts in appropriate cases has made Fig. 9.— The Guiding Lines of Reid and the Relation of the Chief Convolutions to them. it necessary to ascertain the relation of its different fissures and convolutions to the cranial sutures, or to certain landmarks upon the surface of the head. These relations are well shown in the figure (Fig. Y), which is a photograph of a cast of a head made immediately after death by Dr. Cunningham, of Dublin.' Numer- 1 See Dublin Journ. Med. So., 1888, p. 157. For an opportunity of photographing this cast I am indebted to Dr. F. Ferguson, Cura- tor of the Museum of the New York Hospital. 16 BRAIN SURGERY. ous rules have been laid down for the determination of the location of various parts of the convex surface of the hemisphere upon the head. The most impor- tant are the following, which may he compared with the diagram (Fig. 8), and with Eeid's figures (Fig. 9). Fig. 10.— The lines indicating the fissures of Rolando and Sylvius laid down on the skull according to the rules given in the text and the relative situation of the func- tional areas of the cortex to these lines : the right hemisphere. To find the fissure of Eolando, lay down a line from the root of the nose to the occipital protuberance over the top of the head, and take a point 0.557 of the distance back upon this line. This point will corre- spond to the upper end of the fissure. The fissure makes an angle of 67° with the median line just THE DIAGNOSIS OF CEREBRAL DISEASE. 17 measured. Hence if two strips of metal fixed to one another at this angle be placed on the head with their junction upon the upper end of the fissure, when one strip is on the median line the other strip, pointing forward and downward, must lie over the fissure of Fig. 11.— The lines indicating the fissures of Rolando and Sylvius laid down on the skull according to the rules given in the text and the relative situation of the functional areas of the cortex to these lines: the left hemisphere. Rolando. In its lower third the fissure becomes a little more vertical than the strip. The fissure is about three and a half inches long. To find the fissure of Sylvius, lay down a base line from the lower margin of the orbit to the auditory mea- tus. Lay down a second line parallel to the base line 18 BRAIN SURGERY. from the external angular process of the frontal bone backward one inch and a quarter and then measure upward one quarter of an inch ; this gives point one. Find the most prominent part of the parietal emin- ence and from it draw a line downward perpendicu- lar to the base line, and on this take a point three- quarters of an inch below the eminence ; this gives point two. Join these two points and the line will lie over the fissure of Sylvius. The anterior limb of the fissure will be two inches behind the external an- gular process. The fissure of Sylvius is about four inches long. To find the parieto-occipital fissure, continue the line of the fissure of Sylvius to the median line. At their junction lies this fissure. Since all areas now open to surgical operation can be located with a definite re- lation to these three fissures, no further rules are nec- essary. Since in opening the skull it is customary to make a fenestra of at least an inch in diameter, and it is frequently necessary to enlarge the opening much more, a procedure in no way dangerous under aseptic conditions, there is no difficulty in recognizing the fissures and convolutions exposed if the rules are closely followed. Prior to the large incision of the scalp it is well to mark certain points upon the skull by the sharp point of a scalpel, so that when the bone is laid bare surface landmarks may still be kept in view. CHAPTER II. TREPHINING FOR EPILEPSY. The Varieties of Epilepsy. Jacksonian Epilepsy. The Motor Form of Attack. The Sensory Form of Attack. The Aphasic Form of At- tack. The Psychical Form of Attack. Traumatic Epilepsy. The Operation for Epilepsy. Records of Cases of Epilepsy operated upon, Personal and Selected. The Pathology of Jacksonian and Traumatic Epilepsy. The Results of Trephining for Epilepsy. Conclusion. The operation of opening the skull for the relief of epilepsy is supposed to be one of the oldest in the his- tory of surgery. That its results were unfavorable is demonstrated by the fact that it fell into disuse and for several hundred years was entirely abandoned. It is within the past decade that it can be said to have become a rational operation, for it is only within that time that a definite guide to the surgeon has been offered by the facts of the localization of brain func- tions. The Varieties of Epilepsy. Hughlings Jackson was the first to point out a radi- cal distinction to be observed between two classes of epileptic patients. In one class the convulsion begins suddenly with little or no v/arning but usually with a cry, and at once the patient loses consciousness and falls in a general convulsion which involves all the 20 BRAIN SURGERY. muscles of the body simultaneously. This lasts sev- eral minutes and is followed by a deep sleep for some hours. This is ordinary idiopathic epilepsy, the origin of which is still unknown. In the second class of cases the attack begins with a conscious sensation in some particular region of the body, either in one-half of the face or in one extremity. The sensation is followed by a twitching of the mus- cles of the part and the sensation and spasm advance gradually from the part originally affected to other parts in a definite order of progress ; thus, from the right half of the face down the right side of the neck to the right arm and lastly to the right leg ; or in the reverse order, from leg to arm and then to face; or from the arm upward to the face or downward to the leg. During such an attack consciousness is not usu- ally lost, though it may be lost when the attack cul- minates in a general convulsion. Such an attack is very often followed by a feeling of great weakness in the part convulsed, which weakness gradually passes away. This form of attack is known as Jacksonian epilepsy. Jacksonian Epilepsy. As far back as lS6i Jackson maintained that this form of ejDilepsy was uniformly due to organic disease of some kind, situated in the convolutions adjacent to the fissure of Rolando. The discoveries of physiolo- gists, made between 1872 and 1880, that electrical irritation of the corresponding convolutions in ani- TREPHINING FOR EPILEPSY. 21 mals would produce spasms of a similar character, af- forded startling confirmation of Jackson's statements. And the subsequent collections of carefully observed cases of disease in man accompanied by records of autopsies made by Charcot/ by Nothnagel/ by Wernicke,' by Ferrier,' by Roland," and by myself" prove conclusively that disease of an organic character located in the motor region of the brain, of a character to produce irritation, will uniformly cause Jacksonian attacks. The character of these attacks, their mode of onset, and the order of their progress depend entirely upon the exact position of the initial irritation in this motor area. If the irritation is slight it may be lim- ited to a small region, if more severe it extends to adjacent regions. This extension may be likened to the ripple on a pond when a stone is thrown into it. The ripple spreads from the centre to the very limits of the pond, but the little waves get lower as they get far- ther away from their point of starting. Irritation in the brain is likewise always more intense at the seat of excitation and grows less severe as the irritation reaches other centres at a distance. The order of progress of the spasm depends entirely upon the rela- ^ Charcot et Pitres : " Localizations Cerebrales, " Eev. de Med. , 1879 and 1883. ^ Nothnagel : " Topische Diagnostik der Gehirnkrankheiten, " 1879. ^ Wernicke: "Gehirnkrankheiten," 1881, '^ Ferrier: " Localization of Brain Disease," 1878. ^ Roland: "De I'Epilepsie Jacksonienne, " Paris, 1887. ^ Starr: "Cortical Lesions of the Brain," Amer. Jour, Med, Sci., 1884, Jan. , April, July. 22 BRAIN SURGERY. tive situation of the motor centres to one another. Thus the fact that the motor centres for the arm lie between those of the face and leg determines the fact that a spasm beginning in the face always extends to the arm before it reaches the leg, or vice versa. It has already been stated that Jacksonian attacks usu- ally begin with a sensation of tingling or numbness in the part convulsed. This tingling is thought to be evidence of an irritation of the centres of tactile sen- sation of the cortex, which coincide in situation with the motor centres. The paralysis which follows the attack and is evidence of exhaustion of the motor cen- tres is often found to be associated with partial loss of sensation, which is evidence of a similar exhaustion of the sensory centres. What is true of these tactile centres has been found to be true also of the sensory centres of sight, and hearing, and taste, and smell. Each of these centres may be irritated by disease, with the result of produc- ing hallucinations, and then be exhausted, with the result of producing loss of the power of perception. It is thus possible to recognize what has been termed a sensory equivalent of a Jacksonian attack, and such a sensory equivalent or sensory epilepsy in any one sense is just as diagnostic of a localized disease in the brain as is a Jacksonian spasm. Sensory epilepsy be- ginning with a sound indicates irritation in the tem- poral region; sensory epilepsy beginning with light before the eyes or an hallucination of sight indicates irritation in the occipital region ; sensory epilepsy be- TREPHINING FOR EPILEPSY. 23 ginning with smells or taste indicates irritation in the temporo-sphenoidal region. These facts are so abun- dantly confirmed by clinical observation followed by autopsies that it is needless at present to cite cases in proof. ' Another form of attack requires mention. It is the aphasic form. It has been frequently observed that when a Jacksonian attack begins v/ith spasm in the right side of the face it is usually associated with an immediate inability to speak. This continues until the attack is over, and even for several hours after- ward. In a number of cases such an inability to speak coming on suddenly is the only symptom of the at- tack. This then may be termed an aphasic form of epilepsy. It is due to irritation followed by arrest of function in the motor speech area, which in right- handed persons is in the third frontal convolution of the left hemisphere of the brain, and in left-handed persons in the right hemisphere. There is probably a form of aphasic attack due to suspension of function of the sensory areas of speech, characterized by a sud- den but temporary inability to understand language and to read. But such attacks have not to my knowl- edge been recorded. The last form to be noticed is the psychical epileptic equivalent, a form of attack consisting of a temporary mental aberration either of the nature of maniacal excitement or of simple bewilderment followed by ^ See Pitres : "Des epilepsies partielles sensitives," Arch. Clin. de Med. de Bordeaux, 1892, Jan. 24 BRAIN SURGERY. stupor and loss of memory of what has happened in the attack. This probably indicates an irritation fol- lowed by suspension of function in the frontal region, but any more definite statement is as yet unwarranted. The facts just stated prove that Jacksonian attacks, either motor or sensory, or aphasic or psychical in na- ture, are to be regarded as symptoms of disease and are very different in their significance from attacks of ordinary epilepsy. Their character denotes the exact position of the disease in the brain, and hence such an attack may be regarded as a guide in the surgical treatment of epilepsy. Cases open to Trephining. It is evident, then, that the surgeon of the present day is no longer in the position of the surgeon in the past centuries, when asked to trephine in a case of epilepsy. For now it is possible to make a rational selection of cases, to choose those which are due to local disease, and to put one's finger on the diseased spot before the knife is used. It is these cases in which such a guide is afforded by our knowledge, which are open to surgical interference. The ordinary idiopathic epilepsy is as far removed from surgical treatment to- day as it was in the past. It is difficult to make any general statement regard- ing the relative number of cases of epilepsy which are open to surgical treatment. I can only state that of 427 consecutive cases of epilepsy of which I have per- sonal records, 26 were considered of organic origin and TREPHINING FOR EPILEPSY. 25 suitable for operation because it was possible to locate the lesion with ai^proximate certainty. The disease in the brain which gives rise to Jackson- ian epilepsy may be of various kinds. Any affection of the meninges, whether pachymeningitis or lepto- meningitis, of traumatic or of syphilitic or of tubercu- lar origin ; or new growths upon or in the cortex of the brain; or cysts formed as the result of small cir- cumscribed hemorrhages, or of spots of softening from embolism or thrombosis of a cerebral artery; or cir- cumscribed encephalitis or sclerotic patches may act as centres of irritation in the cortex of the brain. The majority of these forms of disease when exactly local- ized in a small area appear to be traceable to trauma- tism, either to a blow or fall on the head, or to a frac- ture of the skull with or without depression. In the cases soon to be studied some of these pathological conditions will be described which have been found at the time of operation. The discovery of the fact that such pathological re- sults of traumatism will produce localized spasms when situated in the motor area of the brain has naturally led to the conclusion that similar products anywhere in the brain may give rise to epilepsy. Traumatic Epilepsy. It is well known that many cases of ordinary epi- lepsy are traceable to injuries of the head and that many cases of fracture of the skull have been followed by the development of epilepsy. These cases have 26 BRAIN SURGERY. been grouped together under the term "traumatic epilepsy," and it has been thought that the traumatism could be taken as the guiding indication to the sur- geon for the operation of trephining. That wounds about the head are much more likely to produce epilepsy than wounds in the rest of the body is very well proven by statistics of the Franco-Prussian war. The records of that war show that among S,9S5 individuals wound- ed on the head 46 developed epilepsy; that among 77,461 persons wounded in the body or extremities only 17 became epileptic. The records of our own war do not give any statements that bear upon this sub- ject. There seems to be no doubt among surgeons that epilepsy develops subsequently to injuries of the head more of ten than after injuries of other parts. In these cases the same distinction already considered between general convulsions and localized motor, or sensory or aphasic attacks is frequently observed. If the character of the attack indicates disease in a defi- nite area of the brain, and if the injury of the skull is so located as to coincide with this area, then the sur- geon has a double indication to guide him in the oper- ation. When, however, the injury and the localizing'^ symptoms do not coincide, it is better to follow the localizing symptoms rather than the surgical injury. Thus in two cases operated upon by Dr. McBurney depressed fractures existed, epileptic attacks had de- veloped subsequently to them, but the fit which began in both patients in the arm indicated disease in the middle third of the motor area, while the position of TREPHINING FOR EPILEPSY. 27 the fracture was at least two inches away from this spot. In both cases trephining demonstrated the presence of sph'nters of bone cracked off from the inner table of the skull and embedded in the brain in the motor area for the arm, with the development of cysts at the same place. And the removal of the irritating focus of disease produced a cure. In these cases had the surgical indication — the depressed fracture — been followed the actual cause of the epilepsy would not have been found and removed. It is, therefore, far better when both medical and surgical indications exist, but do not coincide, to follow the medical in- dication. In any case of localizable epilepsy when no remova- ble lesion is discovered at the time of operation, it is. the practice of some surgeons to determine accurately the area in the cortex irritation of which by a mild faradic current will cause a spasm similar to that oc- curring in the disease, and then to excise this area. The resulting paralysis due to excision of a small part of the motor area gradually passes away, and the result of the excision is in some cases to remove the centre of irritation, and thus to cure the attacks. There is, finally, a class of cases following trauma- tism in which the epilepsy is of the general type and in which there are no localizing symptoms. When these are attended by depressed fracture, it is the practice of surgeons to trephine at the area of injury, that being the only guide obtainable. Lesions are sometimes discovered involving the meninges or brain. 28 BRAIN SURGERY. and occasionally the fits are relieved by the operation. More often nothing is found at the place of trephining, and no result is obtained. In this class, where definite symptoms pointing to a focus of disease do not exist, the operation must be regarded as entirely exploratory. The Danger of Trephining. The records of cases of epilepsy in which the opera- tion of trephining has been undertaken are at present very numerous. The operation has been done over 300 times within the past fiYQ years, with very few deaths. Laurient {Jour, cle Med., de Chiriir. et de Pharmac, May 20th, 1891) collected 102 cases of tre- phining for e^Dilepsy, with the result as follows: 5-1 cured; 20 improved; 1 7 not improved ; 2 made worse; 7 died. Agnew (Trans. Amer. Surg. Assoc, Sept., 1891) collected 57 additional cases with result as fol- lows : 4 cured ; 32 improved ; 9 not improved ; 4 un- known result; 1 died. The cases collected here number 12, with result as follows: 13 cured; 11 imjDroved ; 15 not improved; 3 died. Of these cases thirteen are my own. The statistics are chiefiy of value in demonstrating the safety of the oiDcration. The average mortality is 7^. It seems needless to relate very many cases in full. The essential features will be illustrated in the histories of cases which have been under my own observation. For the sake of presenting a sufficient number of cases to secure some credence for the state- ments made, I have appended an account of about 30 TREPHINING FOR EPILEPSY. 29 cases in which the reports are sufficiently exact and sufficiently reliable. These have been selected entirely from American reports. In some of these cases the fits were so exactly localized that a diagnosis could be made without difficulty. In others the existence of a depressed fracture or scar of the scalp was taken as a guide to the surgeon. The majority of the cases were traumatic in their origin. Cases of Epilepstj Trephined. Case I. Trauma — Spasms of right hand — Splinter of hone in motor area — Cyst of the Pia mater — Recovery. A. B., aged 18, was perfectly well until April, 1891, when he was struck by a heavy block of wood falling on his left parietal bone. His skull was fractured and he was taken to a hospital and treated there for several weeks, but not trephined. Three weeks later he began to suffer from peculiar attacks which had continued at frequent intervals until the day of operation, November 9th, 1892. His attacks are all of the same character. They begin with a tingling and numbness in his right hand which extend up the arm to the shoulder, down the trunk and down the leg ; the tingling is never felt in the face. Soon after the tingling begins in the fingers a twitching motion is felt in the hand, and the clonic spasm extends up to the shoulder, involving the entire arm ; it never extends to the leg or face. He does not lose con- sciousness during the attacks; the attacks last about a minute and subsequently he feels a little weak in the arm for a short time; he has no difficulty with his speech. Between the attacks there is neither paralysis nor anaesthesia; he does not suffer from headache; his eyesight is good. Examination of the head showed the existence of a de- 30 BRAIN SURGERY. pression about an inch long parallel to the longitudinal fissure and about an inch to the left of the median line anterior to the vertex. When the fissure of Rolando was laid down upon the head, this depression was found to lie over the first frontal convolution. A second scar was found below the first at a position over the hand area. It was determined to disregard the surgical indication, viz., the fracture, and to trephine over the hand centre of the £>.3r. 12.— The Situation of the Opening made in the Skull in Case T. The position of the fracture is also showu. 'Cortex. This Avas done November 9th, 1892, by Dr. McBurne}'. After the scalp was retracted the attempt to strip up the periosteum revealed the fact of its close adhesion to a fissure in the bone passing directl}' forward from the junc- tion of the middle and lower thirds of the fissure of Ro- lando. It was evident that at this line there had been a fracture of the skull which could not be detected by palpa- tion of the scalp. A trephine opening of one and one- TREPHINING FOR EPILEPSY. 31 quarter inches in diameter was made at the point indicated in the figure over the hand centre (Fig. 12). When the button was removed the dura was found to be close!}' adherent to it, and in the dura was found im- bedded a splinter of bone one inch long and three-fourths of an inch wide. This lay partly outside of and partly in- side of the dura, it having evidently been thrust through the dura at the time of the fracture. The dura about it was thickened to one-sixteenth of an inch. The splinter of bone was cut out and removed. A thickened con- nective-tissue strip which formed the external wall of a cyst was found adherent to its inner surface and removed with it. During the removal about a drachm of clear serous fluid escaped from the cyst, and a vessel of the pia was un- avoidably torn in the removal of the cyst wall, giving rise to considerable hemorrhage. The appearance of the brain as seen through the opening in the dura was normal, though some oedema of pia over it was evident. The bone was not replaced. The wound was closed and healed by first intention within a week. The situation of the splinter of bone was such as to have produced irritation in the hand area of the cortex. The boy had two very slight attacks subsequently to the operation, but after that up to March, 1893, had none whatever and was apparently well. Case II. Trauma — Spasms of right hand — Cyst re- moved — Recovery for six months. Recurrence — Second trephining — Recovei^y. Male, aged 14, at the age of 4 had a severe fall fractur- ing his skull over the left coronal suture. As a result of this he developed right hemiplegia with partial right hemiansesthesia, but without any aphasia. Traces of this hemiplegia still remain. At the age of 12| he had a second fall, hit upon his head, and soon after this he began to suffer from Jacksonian epilepsy. His fits always began with a tingling and spasm in the right hand which extended to the arm and then down the right 32 BRAIN SURGERY. leg, the face being very rarely involved, though oc- casionally the head turned to the right. There was no loss of consciousness during the attack. It lasted about a minute and he felt slightly weaker in the arm and leg after it. He has had as many as six attacks in a day. The boy was mentally very bright and had no headache. Evidence of an old depressed fracture was found in the skull, the depression extending forward over the first Fig. 13.— The Situation of the Opening made in the Skull in Case II. frontal convolution so that its position was decidedly anterior to the motor area of the arm. Medical treatment having failed to relieve these attacks, it was resolved to trephine. The point selected was the arm centre in the middle third of the central convolutions, though its position was an inch and a half posterior to the position of the old fracture (Fig. 13). Dr. McBurney operated at Roosevelt Hospital, January 30th, 1892. On exposing the dura it was found adherent to the bone TREPHINING FOR EPILEPSY. 33 and did not pulsate. When the dura was dissected back it was found adherent to the pia, which was thickened and opaque so that the brain was not visible beneath it. On dividing the pia a cjst was found lying upon the surface of the brain and from this a drachm of clear fluid was evacu- ated. The cyst had lain in. the pia itself . The walls of the cyst were removed. A strand of thickened pia was found running forward toward the old scar. The opening in the bone was, therefore, enlarged in the direction of the old fracture until this was reached and a second cyst was found beneath the old fracture. This cyst was also evac- uated of about two drachms of fluid and its walls taken away. The brain beneath the cysts appeared to be some- what atrophied but pulsated normally. It had an appear- ance of being slightly more yellow than normal brain tissue, and the number of blood-vessels and capillaries- over its surface seemed to be rather increased. The wound was closed and healed well, and from January 30th, 1892,. the date of operation, until April the boy had no fits at all. He then returned to my clinic, complaining of a return of his old attacks. On examination of the head it was found that there was a small collection of pus beneath the scalp over the site of the opening in the bone. This pus was evacuated and the small abscess cavity at once healed. From that date until August, 1892, the boy had no at- tacks. Then his attacks began again, and increased in frequency until in December he was having three or four daily. These attacks began with tingling and twitching in the right hand which extended up the arm and shoulder, then down the side to the leg, arm and leg twitching together for the space of from five to fifteen minutes. Subsequently to the attacks both arm and leg were slightly paretic, the face never being involved, and consciousness not being lost. The use of bromides during this period had no effect upon the increase of the attacks ; he was, therefore, again advised to go into the hospital for opera- tion. On January 7th, 1893, Dr. McBurney operated. On 34 BRAIN SURGERY. exposure of the shaven head the scalp was seen to be thick and tense so that at no place was there any perceptible depression around the old scar or over the defect in the bone. Pulsation of the brain was perceptible by palpation over the area from which the bone had previously been removed, and which corresponded to the arm centre. The tissues were very much thickened and it was thought best to avoid their direct incision. A semilunar incision was therefore made, the summit of which passed somewhat more to the left of the median line than the preceding incision, and by dissecting up its anterior and posterior portions the healthy bone below the old trephine opening was reached, the scalp being carefully dissected away from the old scar tissue. A triangular opening was then chiselled in the bone about one and one-half inches long and three-fourths of an inch wide. The bone was found to be closely adherent to the dura. The dura was seen to be thickened and on being divided and turned back it was closely adherent to the pia. The pia and brain were found to be welded together in a thick connective-tissue rnass. Palpation of this gave the impression of fluid be- neath it. Puncture with a hypodermic syringe brought away a small amount of clear serous fluid from a cavity about half an inch beneath the cortex. Incision was made into this cavity through the brain above it. When the brain tissue was incised it was found to present an abnor- mal appearance. There was no clear line of demarcation between the cortex and the white matter beneath it, but a connective-tissue mass had taken the place of the cortex. This mass of tissue was therefore excised, a piece of a lens shape about an inch long by half au inch wide being re- moved. It appeared to be scar tissue. ^ The second punc- ture with a hypodermic needle at a point an inch further forward revealed the presence of another cyst, and the in- cision in the brain was, therefore, carried forward so as to ^ The microscopical appearances of this tissue are described by Dr. Van Gieson on page 102. TREPHINING FOR EPILEPSY. 35 empty this. Hemorrhage was pretty free, but aftei the scar tissue had been excised the sides of the wound in the brain were seen to consist of fairly normal gray anc^ white substance. The wound was packed with iodoform gauze and dressed antiseptically . The next day the boy was very comfortable, had no paralysis or anaesthesia. Within two weeks the wound had healed. He has had two attacks up to March, 1893. Case III. Trauma — General convulsions beginning in left arm — Splinter of hone in the brain removed — Brain sclerotic — Recoveinj, — Recurrence of fits. A. G., male, aged 24, met with an injury in April, 1888, which produced a fracture of the skull on the right side about at the middle of the coronal suture. After the in- jury he was ill with fever and delirium about six weeks, but gradually recovered. Three j^ears after this injury he began to have convulsions, from which he had suffered at intervals up to April, 1892, when he was first seen. The attacks began with a movement of the left arm and sensa- tion of numbness in the left hand and with a turning of the head to the left; he then lost consciousness and the convulsion became general. He has had as many as two fits in a day, and the longest interval during the year was nine weeks. He had three fits in March, 1892. He was very dull mentally, and had been treated by very large doses of bromide of potassium, which diminished the frequency of but did not arrest the fits. Operation by trephining was performed by Dr. McBur- ney on the 2d of April, 1892. The skull was opened at the point of fracture over the arm centre on the right side (Fig. 14). The external table was found to be fractured but the internal table appeared to be uninjured, but a small splinter of bone was found indenting the dura. The dura was very much thickened and the pia and brain were decidedly oedematous and yellower than normal. The pulsation in the brain was greater around the discolored area than in it. The discolored area pitted 36 BRAIN SURGERY. upon pressure and to the touch gave the impression as if a cyst lay beneath, but puncture in all direc- tions with a hypodermic needle failed to reach any cyst. A portion of the softened area was cut out. It was exam- FiG. 14.— The Situation of the Opening made in the Skull in Case III. ined by Dr. Van Gieson, who reported as follows : " I find that a splinter of bone has been driven down into the dura; the dura is thickened at this place and matted together with the pia. Dura is also sharply indented where the splinter is impacted. I think that the splinter has been much reduced in size by rarefying osteitis (only a few interlacing delicate trabeculse remain of the bone). The splinter was probably originally much larger. Brain substance is much changed, there are too many glia cells. The cortex seems to have come from the motor region : this I gather from the presence of the very large TREPHINING FOR EPILEPSY. 37 ganglion cells in the third layer." ' The wound healed easil}'. He had no paralysis and in three weeks he was discharged from the hospital. At that time he had improved very much mentally, and had had no fits. Soon after leaving the hospital the fits began again, and in the summer they occurred with greater frequency than before the operation, and at the present time they are as severe as ever. Case TV. Trauma — Spasm of right leg — Trephining — Death. A. D., male, aged 30, had been perfectly well until a fall which occurred in 1888. He hit upon his head Fig. 15. —The Situation of the Opening made in the Skull in Case IV. on the left side, near the vertex, but had no scar re- maining as evidence of the fall. Since the fall he had begun to have attacks which consisted of a spasm begin- ^ The microscopical appearances of this tissue are more fully de- scribed on page 83, 38 BRAIN SURGERY. ning in the right leg, with a stamping motion of the foot, after which he would rise from the chair, if seated, and turn to the right, or w^ould turn to the right if the fit came on when he was standing. After turning he lost con- sciousness, and fell in a general fit. These fits had be- come frequent during the past two years, so that he was having as many as six a day when he was first seen by me at Dr. Weir's request. On the 17th of January, 1890, Dr. Weir trephined at the 'New York Hospital. The opening (Fig. 15) was made over the upper third of the motor region, exposing the area corresponding to the leg centre. The skull was found to be unusually thick, but no evidence of fracture was dis- covered. Small white specks resembling miliary tubercles were found scattered over the pia and over the motor area of the leg on the median surface of the brain. The dura was not thick nor adherent. The thickness of the skull made the operation a long one, and the hemorrhage was considerable, and the patient died of shock. Case Y. Traumatic Epilepsij — Hemiplegia tvith athe- tosis—Subcortical cyst emptied — Recovery. H. L. J., aged 12, was weU until the age of 2, when he had a fall upon his head followed by convulsions lasting eleven hours. On recoA^ering from convulsions he was found to be hemiplegic on the right side and aphasic ; he re- covered slowly during the following year, but has never been entirely relieved from the condition of right-sided paralysis, and has always been slow in his speech and men- tally dull. For several years subsequently to the fall he was subject to slight attacks of the nature of petit mal ; two j^ears ago he had his first attack of grand mal, and since that time has had several recurrences. The fits begin by twitch- ing of the eyes and head, the right side being always more affected than the left side in the convulsion; and he loses consciousness. He was examined by me on the 2 2d of November, 1892. A condition of right hemiparesis with athetosis of the TREPHINING FOR EPILEPSY. 39 right hand was found, the paralysis being greater in the hand than in the face or leg. Mentally he was very defi- cient, being able to read but little and being very dull and stupid; his speech was slow but he was not aphasic; there was no affection of sensation in the paralyzed limbs. The diagnosis was made of a traumatic hemorrhage or a cyst in the cortex of the brain in the motor zone affect- ing especially the arm area. Trephining was recom- FiG. 16.— The Situation of the Opening made in the Skull in Case V. mended with a view of removing the clot or the cyst which was considered the cause of the symptoms. On December 2d, 1892, he was trephined by Dr. McBur- ney at Roosevelt Hospital, an opening of one and one-half inches in diameter being made over the arm area (Fig. 16) . The bone and the dura appeared to be normal. On exposing the brain the fissure of Rolando was seen crossing the opening ; the cortex appeared to be normal, but palpation indicated a collection of fluid beneath, and puncture with 40 BRAIN SURGERY. a hypodermic needle resulted in the evacuation of about a drachm of clear serous fluid from a cavity three-fourths of an inch below the cortex. Incision through the summit cf the anterior central convolution gave entrance to this cav- ity, and an attempt to drain it was made by inserting a small bit of rubber tissue. The dura was replaced but not stitched and the scalp was left open over the part of brain exposed. The day after the operation the boy was found to be in about the same condition so far as power went, but the right hand as high as the wrist was decidedly anaesthetic to touch, temperature, and pain, but there was no affection of the muscular sense. The athetosis had ceased. One Aveek after the operation this condition of anaesthesia was much less but still remained. It did not affect his face, or his leg, or his bodj", or his arm, above the wrist. He seemed bright, had no temperature, but had had two attacks of petit mal. The wound healed readily and he went home at Christmas and has had no attacks up to March, 1893. He is said to be much brighter mentally and the athetosis has not returned. Case VI. Trauma — Spasm in face — Temporary aphasia — Trephining — Scar in brain — Recovery — Recurrence of attacks. J. R., aged 40, was struck upon the left temple and sustained a fracture of the skull in August, 1889. When he recovered consciousness he was found to be paralyzed upon the right side and aphasic. In the course of the following six months the hemiplegia gradu- ally subsided and the speech gradually improved so that he was able to go about but was still unfit for work. About a 3'ear after the accident he began to have convul- sions ; some of these were general with loss of conscious- ness, but later they became localized and have remained so for the past two years. They have gradually increased in frequency until, when seen in December, 1892, he was having several attacks every week. The attacks began TREPHINING FOR EPILEPSY. 41 with a twitching of the muscles about the mouth upon the right side ; a drawing of all of these muscles toward the right with a twitching of the eyes, a gradual extension of the spasm to the right side of the neck and to the right arm and hand. During the attack he did not lose con- sciousness but he could not speak, and had a sensation of tingling in the face and mouth. After an attack he ap- peared to be weak and was not able to talk as well as before the attack. Examination on December 10th, 1892, demonstrated a slight paresis of the right side of the face, the tongue not deviating, and some weakness in the right arm, but no affection of the leg ; no disturbance of sensation ; increased reflexes upon the right side. His mental processes seemed to be slow ; he understood perfectly what was said to him, but his replies were slow and his use of language evi- dentlj" imperfect ; he admitted that he could not express himself as he formerly did. He did not suffer from head- ache, but there was tenderness over the left temporal re- gion. A depressed fracture of the skull running backward two inches about over the position of the Sylvian fissure was evident upon palpation. The posterior limit of the fracture was an inch below the location of the motor area of the face. It wa^ thought that beneath the fracture and about it some thickening of the meninges had occurred with the possible formation of a cyst, as the re- mains of an old hemorrhage, and that by an operation some relief could be had. On December 19th, 1892, Dr. Briddon trephined at the Presbyterian Hospital. A small trephine opening was made over the motor centre of the face and a larger one an inch below over Broca's convolu- tion. The intervening bridge of bone was removed and the opening enlarged in all directions by the rongeur, the size of the opening being two and one-half by two inches (Fig. 17) . On removal of the bone a perceptible thickening of the dura, especially over the face centre, was seen. When 42 BRAIN SURGERY. the dura was divided it was found to be three times its ordi- nary thickness and closely adherent to the pia. It was stripped off carefully. The pia was found adherent to the brain and very oedematous. The brain substance at the Fig. 17.— The Situation of tlie Opening made in tlie Skull in Case VI. lower part of the anterior central convolution was appar- ently replaced by a connective-tissue mass. Where the dura was most thickened and its adhesion to the pia and the brain closest the brain exposed in the lower half of the opening ap- peared softer, darker, and abnormal. A hemorrhage had probably taken place, and as the result there remained a mass of . scar tissue, chiefly connective tissue, beneath the pia mater. When the pia was divided it was found to be about a line in thickness. The gray matter of the brain had been reduced in its thickness so that the incision into the pia showed at once the white matter lying beneath it. This condition extended forward beneath the seat of the fracture, occupying a space about half an inch wide by an TREPHINING FOR EPILEPSY. 43 inch long jast above the fissure of Sylvius. The adhesion between the dura and the pia was broken up by the handle of the scalpel, but it was not thought best on account of hemorrhage to attempt the removal of the altered pia and brain. The wound was immediately closed and healed well by primary union within ten days. The patient had two very slight attacks during the fol- lowing two months and complained of some stiffness in the motion of his jaw. The pathological condition found precluded any hope of cure. Case YIL Traumatic epilepsy — Trephining — No re- sult. Male, aged 23, had a fall five years ago, hit upon the vertex to the right of the median line and somewhat, Fig. 18.— The Situation of the Opening made in the Skull in Case VII. anterior to the fissure of Rolando. He soon developed general epileptic convulsions which began with a visual 44 BEAIN SURGERY. aura, consisting of a green light before his eyes. The attack was of the nature of a general convulsion, with a total loss of consciousness; there was no localized move- ment. In addition to the general convulsion he had occa- sional attacks of petit mal. Physical examination failed to show any disturbance of sensation or of motion. He was trephined by Dr. McBurne}', June 10th, 1892, over the seat of the fracture. The depression was found in the external table, not extending to the internal table (Fig. 18). The dura and pia were found to be normal, and the brain presented a normal appearance. The patient re- covered from the operation, was out of the hospital in two weeks. At his last visit, October, 1892, he was still hav- ing his fits, having had five in the past four months. Case YIIL Traumatic epilepsy — Spasm in right hand — Trephining — Improvement — Eelajjse — Death. P. B. C, male, aged 30, was hit in April, 1890, over the left side of the head by a sand-bag and was taken to the Roosevelt Hospital, where he lay for twelve days in a state of unconsciousness. There was no fracture of the skull. He gradually" recovered and was able to return to his home in the South in July, and on July 23d had two fits. Each fit began with tingling and movement in the right hand, extending to the face, which was drav^Q to the right, and the mouth was opened and closed, then the speech was lost. In five minutes the attack had passed off and he felt pretty weU. Such attacks were repeated in August, September, and October ; all of the attacks being of the same character, excepting that on two occasions he lost consciousness for a few minutes. Examination in October, 1890, failed to reveal any deformity of the skull or any evidence of hemiplegia. He was rather slow and deliberate in his speech, with some slight hesitation for words, but this he maintained was his usual manner. His discs were clear, and his pupils equal. He was put upon bromide and belladonna, which he continued until March, 1891, during which time he had no attacks. TREPHINING FOR EPILEPSY. 45 Between March and June, he averaged one severe attack and three slight attacks every month, all of which were similar to the attack first described. After each attack he noticed a decided difficulty in his speech, and the slowness of speech previously noticed still persisted. While there was no apparent clumsiness or anaesthesia in his right side, the power in his right hand was 100 as compared with 110 in his left. His personal equation was about Fig. 19.— The Situation of the Opening made in the Skull in Case VHI. normal, hearing being y^^ of a second, sight yV% of a second, an average of seven tests being taken. It being thought that the injury had probably produced a small hemorrhage upon the surface, the remnants of which might be removed, it was decided to trephine him. The operation was performed in June, 1891, by Dr. McBurney, an opening being made over the arm centre, and extending downward toward the face and motor 46 BRAIN SURGERY. speech centres (Fig. 19). No evidence of fracture was found in the skull, and the dura was not adherent, and the brain appeared to be normal. The wound healed perfectly, and by December the hole in the skull had become filled up by a tense membrane, so it could not be depressed to any extent by the finger. He had two attacks between June and December. These attacks were of the same character as those occurring before the operation. He still talked slowly. During 1892, his attacks became more frequent, he developed severe headaches and optic neuritis, and he finall}^ died in November, 1892. He was not under my observation after December, 1891. It is probable that there was present in this case a small subcor- tical tumor at the time of the operation, which escaped detection and afterward grew until it finally caused his death. Case IX. Trauma — Spasms in left hand — Cyst evac- uated — Recurrence of fits. A child, aged 3, had had a fall, hitting upon the right side of the head, and three months subsequentlj' had developed spasms in the left arm which occurred at first occasionally, and later sometimes as frequently as seven a day. The arm was slightl}' weak. An apparent defect in the bone was felt in the right mid-parietal region. It was decided to make an exploratory operation. This was done by Dr. Poore in October, 1889, at St. Mary's Hospital. On exposing the bone a triangular defect was found in it with a thick connective-tissue membrane filling it (Fig. 20). Beneath this membrane was a cyst which was evacuated. The bone was not trephined on account of evidence of shock following the evacuation of the cyst; the operation was terminated. The child recovered from it, was free from her spasms for a year; recovered in the mean time the power in the arm. At the end of that time, however, the attacks began again. The probability is that this cyst has refilled with fluid and a second oper- ation is contemplated. TREPHINING FOR EPILEPSY. 4? Case X. Trauma — Depressed fracture — Spasm be- ginning ivith turning of the head — Trephining — Recovery — Recurrence of fits. T. M., male, aged 21, had a fall at the age of 7, producing an extensive fracture of the left parietal and frontal bones, which was immediately followed by right hemiplegia and motor aphasia, lasting a year and passing off. At the age of 14 he began to have Fig. 20.— The Situation of the Defect in the Skull in Case IX. general convulsions, which always began with a turning of the head to the right and were followed by a loss of consciousness. For the past seven years he has had such fits at intervals, having had as many as five in one day, but under bromide the rate has been about one in three weeks. He has not developed mentally in a proper way. He has little self-control, is irritable, quar- relsome, and ugly. He has fair intelligence, being able 48 BRAIN SURGERY. to read and write, but is not fit to do any but simple work. Examination October 14th, 1892, showed a trace of the old hemiplegia, the right side being smaller and somewhat weaker than the left. His speech was fair but he talked with some hesitancy. A depressed fracture of the frontal and parietal bones was found over the junction of the third frontal and anterior central region on the left side. Fig. 21.— The Situation of the Opening made in the Skull in Case X. On October 18th, 1892, he was trephined by Dr. Hart- ley, at Roosevelt Hospital. On laying back the scalp two deep depressions in the skull were found with a long angular depression between them (Fig. 21). This lay in front of the fissure of Rolando, about opposite to its lower third. The skull was very much thickened at the site of the old fracture. The bone was cut awav over an area about two and one-half inches square. It had evidently made considerable pressure upon the tissue beneath. The TREPHINING FOR EPILEPSY. 49 bone was adherent to the dura, and when the dura was divided and reflected it was found to be adherent to the pia. The pia was thickened and clouded and formed a cover of thin white connective tissue upon the brain. The cortex beneath the pia looked abnormal. It was rough on the surface, appeared redder than the adjacent cortex, the pia was closely adherent to it and contained an unusual number of capillary vessels. The appearance suggested an increase in the connective-tissue elements of the cortex with a high degree of vascularization. The brain pulsated normally. Puncture through this abnormal tissue failed to reveal any cyst beneath it. The wound was closed and healed readily, the man being up within a week of the time of operation. He had one fit on December 28th, 1892, and none since up to March 1893, though he had five the week before the operation. His mental condition is certainly much better than before the operation. Case XL Trauma — Spasm in the right arm — Tre- phining — Recovery — Return of attacks. E. W., male, aged 11, was perfectly well until January,. 1890, when he fell, striking upon the left parietal region of the skull, cutting the scalp but not fracturing the bone. This area was tender some weeks subsequently to the fall, and he has had pain in it at times ever since. Soon after the fall he began to have attacks, which became frequent, which always occurred at night, and which were always alike. The attacks began with a closing of the fingers and thumb of the right hand and a twitching of the same. The arm was then fiexed and trembled, and the hand was brought to the face by a movement at the shoulder; the face upon the right side then began to twitch, and the head turned slightly toward the right. At this point he wakened from his sleep, perceived a sensation as if his mouth were full on the right side, felt a slight numbness in his cheek, but at the moment of waking the spasm ceased. The spasm never extended to the leg or to the muscles of the other side of the body. The attacks never 4 50 BRAIN SURGERY. occurred when he was awake or in the day-time, but as many as six have occurred in one night. Examination on February 19th, 1892, failed to reveal any evidence whatever of disturbance of sensation or motion. His mental condition was perfect, his eyes were normal, and he had no sj^mptoms to complain of. The condition was, therefore, one of pure Jacksonian epilepsy in the right hand developing subsequently to a Fig. 22.— The Situation of the Opening made in the Skull in Case XI. blow upon the head, but without any permanent defect of power or sensation. The patient was trephined by Dr. McBurne}', on Feb- ruary 25th, 1892, at St. Luke's Hospital. The opening was two by one and one-half inches over the middle third of the fissure of Rolando, and exposing the adjacent cen- tral convolutions (Fig. 22). The bone was found to be normal, the dura was adherent to the bone, and a small, v^hitish plaque of connective tissue was found on the TREPHINING FOR EPILEPSY. 51 dura. The dura was not adherent to the pia, and the brain appeared to be perfectly normal; no cyst and no remnants of a clot were found. The wound was closed and within two weeks the boy was as well as before the operation. During the month of March he had six slight attacks, the face only being affected. During April he had one attack ; during June he had two attacks ; since June he has had no attacks of the former character. During August and between August and October he developed a new kind of attack at night which at first appeared to be of the nature of somnambulism. These were at first occasional, but by October had become as frequent as three or four in a night. They could be brought on by disturbing him in his sleep, either by noise in the room or by shaking him. The attacks consisted of the following motions: he closed his eyes tightly for a moment, then opened them and looked around, but evi- dently saw nothing consciousl}^, as he did not recognize any one present or reply to a question addressed to him. His lips then twitched slightly, as if an attempt were being made to whistle, and the mouth then opened slowly and was held wide open for a few seconds ; he then appar- ently tried to rise up in bed, and sometimes succeeded in getting up upon his knees. There was no convulsive move- ment of the limbs whatever. Usually after a few seconds he lay down again, took a long breath, followed by two or three short breaths, and then the attack was over. Occa- sionally he woke up, and if so he always knew that some- thing had occurred, but was unable to give any account of what the sensation was which enabled him to distinguish such a waking from that from ordinary sleep. He was perfectly well in the day-time, and is a very bright and active boy. I witnessed two of these attacks. The boy's father was for many years a sleep-walker, and the boy is known to have walked in his sleep. He is a restless sleeper, and frequently talks in his sleep. For 52 BRAIN SURGERY. this reason these attacks were thought to be of a somnam- bulistic nature. But during November they become more severe and a decided convulsive movement of the arms and legs developed. The limbs were all rigidly extended and trembled violently, the right hand was flexed, the left hand extended, and after the attack he drooled at the mouth and breathed stertorously for a minute or two. Treatment by gradually increasing doses of tincture of belladonna, from five drops every night up to thirty-five drops every night, had little or no influence upon the at- tacks. On December 20th, 1892, he was put upon bro- mides which immediately reduced their number and sever- ity, and he is upon bromides at the present time, March 1893, and is entirely free from attacks. Case XII. Traumatic epilepsy — Trephining — No result. Male, aged 50, had had a fall several years before the time when he was first seen, March, 1892. Sub- sequently to the fall he had developed fits, beginning in the right hand. He had been trephined in 1891, in Bur- lington, Vt. The hand centre had been exposed, but noth- ing had been found and the fits had continued. On examination an old fracture of the skull was found in the frontal bone anterior to the motor region of the brain. As he was anxious to be operated upon, trephining was done by Dr. McBurney at the seat of this fracture. The frac- ture was found to involve the external table only, the in- ternal table not being affected (Fig. 23). The dura ap- peared to be normal, as did also the pia and brain. The wound healed readily and he was discharged from the hospital in two weeks. At the date of last report, October, 1892, his fits continued as before. Case XIII. Trauma — Epilepsy. — No result. J. F., aged 32, had a severe fall when a boy about nine years of age, leaving a scar over the left parietal bone. When 23 years of age he began to have epileptic attacks, TREPHINING FOR EPILEPSY. 53 consisting of general convulsions with epigastric aura. He had had since that time as many as five fits a day, and was having two or three every week when first seen by me, March 1st, 1890. The attacks did not begin uniformly, in any one set of muscles, but were general. In addition to the convulsions he had attacks of petit mal, daily. His attacks were so frequent as to unfit him absolutely for work of any kind, but had not apparently Fig. 2.3.— The Situation of the Opening made in the Skull in Case XII. affected his intellect to any extent. Examination showed no evidence whatever of disturbance of sensation or of motion. Bromides had failed to control the attacks, though reducing their frequency somewhat. He was trephined on the 8th of March, 1890, at the Roosevelt Hospital, by Dr. McBurney. The old scar was exposed, the fracture in the external table was found (Fig. 24). A section of bone two by three inches in diameter was 54 BRAIN SURGERY. removed. There was no fracture of the internal table. There was no affection of the dura and pia and the brain appeared to be normal. He recovered from the operation and was able to leave the hospital in two weeks. On April 1st his attacks re- FiG. 24.— The Situation of the Opening: made in the Skull in Case Xm, turned, and have been as frequent up to October, 1892, as they were before the operation. The result of these cases may be summarized as follows ; cured 3 ; improved 5 ; not improved 4 ; died 1. To these cases of my own I append short sum- maries of a number of cases of epilepsy which have been operated upon within the past few years in this country. TREPHINING FOR EPILEPSY. 55 (1) D. B. L., m., 25, Keen, Amer. Jour. Med. Set., October, 1888. History. — Fall on right side of head, November, 1886, unconscious for several hours. Some days after found left fingers ansesthetic. Six months after had sadden at- tack of vertigo followed by temporary paralysis of left hand. These attacks continued during following year. Depressed fracture found over middle third right motor area. Bate of operation. — April 18th, 1888. Character of operation. — Trephined over depressed fracture. Adhesion of membranes. Spicula of bone pro- jecting into brain. Cyst found under the fracture. Brain about it altered in color and thickened, was excised. Mi- croscopic examination showed a chronic meningo-enceph- alitis of the excised brain. Result. — Temporary paralysis of hand. No return of the fits up to four months after operation. (2) I. G. W., m., 35, Lloyd and Deaver, Amer. Jour. Med. Sci., November, 1888. History. — Struck on head at age of 16. From age of 21 to 35 had fits beginning with numbness and spasm in left hand and arm extending to left side of face. These be- came frequent and were followed by paresis of left hand and face. Consciousness not often lost in attack. Date of operation. — June 12th, 1888. Character of operation. — Trephined over junction of middle and lower thirds of motor area. Brain normal. Hand centre located by faradism and excised. Result. — Convulsions continued at first, but after three weeks ceased and had not returned at end of three months. Paralysis and ansesthesia in left hand permanent. (3) P. H., m., 39, Frank and Church, Amer. Jour. Med. Sci., July, 1890. History. — For a year had attacks beginning with pain and spasm in right index finger, involving rest of hand, wrist and arm, then loss of consciousness and general con- 56 BRAIN SURGERT. vulsion. Pain in right hand and increasing paralysis with contracture. Right leg slightly weak. Some aphasia. Date of operation. — May 21st, 1889. Character of operation. — Trephined over left motor area middle and lower third. Thick cicatricial mass found on cortex and removed. Brain excised one and one- half inches in diameter, one-fourth of an inch thick. Mass found to be sarcoma. Result. — Some improvement, followed by return of fits in three months, at much longer intervals than before the operation. Paralysis much improved. (4) C. T., f., 39, Keen, Amer. Jour. Med. Sci., Sep- tember, 1891. History. — Fall, on left side of head. Two convulsions in 11 3^ears. Then frequent attacks from age of 13 to 31. Fits began by flexion of right hand followed by spasm of arm and then general convulsion. No paralysis. De- pressed fracture on left side over arm centre and defect in bone. Date of operation. — October 29th, 1890. Character of operation. — Bone and membranes taken away about the depression. Projecting pieces of bone removed. Brain beneath disorganized and depressed. Hand centre located by faradism and excised. Result. — Paralysis of the hand with ansesthesia gradu- ally passing off. N^o attacks at end of eight months. (5) G. H., m., 23, Keen, Amer. Jour. 31 ed. Sci., Sep- tember, 1891. History. — Fracture of skull. Fits two years later from age of 9 to 32. General convulsions. Marked depressed fracture. Date of operation. — November 21st, 1890. Character of operation. — Depressed fracture over lower parietal convolutions on right side found. Bone deficient. Dura absent. Brain adherent to scalp tissue. When this adhesion was divided the brain surface sank away from the skull one-third inch. No effect of faradism on brain. TREPHINING FOR EPILEPSY. 57 Result. — Recovered. Two attacks after operation with- in two weeks. Since then none. Report six months after operation. (G) S.W., f., 27, Mills and Keen, Amer. Jour. Med. Sci., December, 1891. History. — For ten years had attacks of numbness and spasms beginning in the left arm and leg and frequently limited to them, but occasionally becoming general, usually without loss of consciousness. No permanent paralj^sis. Date of operation. — December 10th, 1890. Character of operation. — Trephined over right motor area. Bone thick. Membranes adherent. Small sarcoma found and removed. Also a small portion of cortex which was found to be normal on microscopic examination. Result. — Paralysis, which passed off in a few weeks. Attacks continued as before for six months up to report. (7) G. G., m., 8, Morrison, Trans. Phil. Co. Med. Soc, May 25th, 1892. History. — No traumatism. Convulsions from age of 2 to 8, at first slight, later severe, beginning with face and head turning to right. Date of operation. — August 29th, 1891. Character of Operation. — Trephined over junction of temporal ridge and coronal suture. Dura and brain normal. Result. — Recovery. Fits recurred three weeks after operation and continued. (8) A. C, f., 11, Diller, Pitts. Med. Rev., November, 1892. History. — Fall at six months; convulsions and left hemiplegia. From age of 4 to 11 convulsions beginning in left arm, then face, then leg with unconsciousness. Left hemiplegia worse in arm. Sensation diminished in left arm . Date of operation. — January 9th, 1891. Character of operation. — Trephined over motor area of arm, on right side. Fissure in bone ; cyst found un- der cortex contained three ounces clear fluid. Drained. 58 BRAIN SURGERY. Result. — Recovery. Accumulation of fluid in the cyst when drain was removed. It was replaced and cyst drained for forty days when fluid became purulent. She died on forty-third day. (9) A. :N'., f., 31, A. B. ^hs,w,Ainer.Jour. Med. Sci., December, 1892. History. — General convulsions occurring spontane- ously, alternating with local spasms and always preceded by numbness in right hand and arm. The spasm often ex- tended from arm to leg. Pain and pargesthesise continu- ous in right arm and increasing paralysis in arm and later in leg. Duration two years before operation. Date of operation. — December 14th, 1891. Character of operation. — Trephined over arm area of left side. Bone thick, adherent to dura, veins large in pia. Softened pigmented brain tissue found under dura and partly washed awa}^. No pus found and no cj'st. Result. — Recovery from operation. Relief of pain and paraesthesia. Permanent paralysis of arm. No convul- sions up to seven months after operation. (10) W. H., m., 18, Knapp and Post, Boston Medical and Surgical Journcd, January 7th, 1892. History. — Struck over right temple in 1882. In 1883 convulsions began and have continued until the operation, four or five daily. Fit begins with turning of head to the left, then left side of face and neck and the left arm are convulsed, sometimes general convulsion follows. Date of operation. — May 1st, 1891. Scar over posterior portion of second frontal convolution on right side. Trephined here by Dr. Post. Opening two | inches in diameter through the bone was made. Bone was very thin. Dura normal and pia oedematous and opaque. Brain markedly bluish. Result. — Recovery from the operation. Recurrence of the fits as before during following six months. (11) K. F., f., 16, Knapp and Post, Boston Medical\ and Surgical Journal^ January 'Tth, 1892. TREPHINING FOR EPILEPSY. 59' History. — Was struck on the head in 1885. Since then constant severe headache. In November, 1891, convulsions began, general in character, commencing with turning of head and eyes to the right. Depressed fracture over left second frontal convolution. Operation. — November 24th, 1890. Bone adherent to dura and much thickened. Dura ad- herent to the brain. Dura and a portion of the brain substance excised. Result. — Subsequent history during following four months showed a continuance of convulsions. (12) L. C, m., 6, Sachs and Gerster, Amer. Jour. Med. Sci., November, 1892. History. — Said to have had brain fever at age of 10 months; at age of 5^ years first right-side convulsion, re- peated at interval of one week; right hemiparesis since first attack; athetoid and associated movements. Operation. — December 29th, 1890. Exposure by chiselling of motor area of right arm, de- termined by faradization. Dura tense and adherent; puncture ; no cyst found. Result. — Recovery excellent; no convulsions up to Feb- ruary 2d, 1891, when boy was discharged from hospital; after leaving hospital had one mild attack; not heard from since. (13) W. C. H., m., 20, Sachs and Gerster, I.e. History. — At age of 12 years was pushed back over pole of a wagon; supposed to have struck back of head (?) ; un- conscious for a few minutes, but worked as usual; one week later general epileptic convulsions; has petit mal, and above all Jacksonian epilepsy involving muscles around right half of mouth. Occasionally eyes are involved. No loss of consciousness with majority of attacks. Operation. — February 13th, 1891. Exposed centre for representation of angle of mouth according to Horsley ; adhesions under the button of bone ;. small cysts on dura; on puncture a little bloody fluid. 60 BRAIX SURGERY. Faradization over dura caused contraction only of right angle of mouth. Large opening ; button not replaced. Result. — Attacks returned after operation and have not been diminished, and ej'es are more frequently involved. ^o improvement. (14) M. K., m., 16, Sachs and Gerster, I.e. History. — At age of 18 months fell out of window ; since that time epileptic attacks at varying intervals ; has had tremendous doses of bromides ; ill-tempered and stupid ; stopped bromides ; no attacks for three weeks, then left- sided convulsions becoming general. Operation.— YobvusiTj 23d, 1891. Large trephine opening over motor area for arm and leg, right side of skull. Result. — Good recovery, but no cessation of attacks. ISTo improvement. (15) E. L. M., m., 30, Sachs and Gerster, I.e. History. — Traumatic injury to right side of head; gen- eral epileptic attacks. OjDeration.— July Slth, 1892. Trephining over occipital depression; adhesions over the depression. Result. — Did very well except that he developed delu- sions of persecution. Attacks returned within two weeks; alcoholic excesses. (10) J. D., m., 8, Sachs and Gerster, I.e. History. — Traumatism at seven months; six months previous to operation began to develop auditory and ol- factory aurse and then general epileptic spells ; chronic ear discharge; if ear ceased discharging spells became worse. Operation. — August 14th, 1891. Opening of mastoid and removing two sequestra of bone. Operation. — N'ovember ITth, 1891. Mastoid opened again and silver canula introduced to secure permanent drainage. Facial palsy of left side. September 10th, attack; re- TREPHINING FOR EPILEPSY. 61 peated attacks of convulsion of right side until second operation, but none since; last report August 15th, 1892. Result. — Great improvement after second operation; no attacks up to date. (IT) T. C, m., 26, Sachs and Gerster, I.e. History. — At age of 11| years was severely kicked by a man over the right side of occiput ; six months later epi- leptic attacks which have continued nocturnally about every six weeks since. No hemianopsia. Marked depres- sion in skull ; was eight weeks without any attack ; at- tacks then returned. Operation. — November 20th, 1891. Trephining and chiselling over scar ; tremendous exos- tosis indenting underlying part of brain. November 22d, short spells; none while in hospital; discharged December 15th; has gone out West; has at- tacks every six weeks, but milder ; reports that his mem- ory is better. Result. — Some improvement in severity of attacks eight months after operation. (18) H. L., m., 24, Sachs and Gerster, I.e. History. — Six years ago fell down; thinks he struck on right side of occiput ; one year later first attack, right hand and leg convulsed. At first had attacks six times daily, lately three or four times in two weeks. Operation. — January 29th, 1892. Motor arm centre on left side exposed ; part of dura but no cortical tissue removed. Second operation March 8th, 1892. Removed arm centre as determined by electrical tests, with slight resulting paresis. Result. — Repeated attacks after both operations. No improvement worth mentioning. (19) C. D., f., 9, Sachs and Gerster, I.e. History. — Fell out of bed at six months, striking head against bare floor; at ten months a tedious illness, slow in developm.ent ; at age of five years began to have in- 62 BRAIN SURGERY. numerable convulsions (at least fifty per day). Idiocy. Parents insisting on operation. Operation. — February 15th, 1892. Large trephine opening over left side of head (motor area). Result. — Attacks not quite so frequent as before. Slight improvement. (20) K. A., m., 9, Sachs and Gerster, I.e. History. — At age of five years had a "congestive chill" and spasms ; no paralysis at the time ; two or three years later developed Jacksonian epilepsy beginning in left hand without loss of consciousness ; no evidence of palsy ; boy feels left hand drawn up in cramp. Operation. — April 12th, 1892. Excision of hand centre in right hemisphere ; removed considerable tissue; hand was paretic for a few days. Did very well in hospital for six weeks, but as soon as he left hospital and ran about had severe attack with loss of consciousness and involuntary passage of urine. Result. — Some immediate improvement, but no lasting benefit from operation ; in later attacks right arm was also involved. (21) J. B. G., m., 31, E. D. Fisher; personal commu- nication.^ History. — Habits intemperate ; no history of syphilis; family history negative; a history of injury to the head fourteen years ago; had epileptic seizures for the past twelve years. Following the attacks, he became mania- cal, destructive, and homicidal. On examination, the patient was found to be well nour- ished, intelligent, quiet; he had a slight depression on the left side of the head corresponding to the hand centre of the motor area. Operation. — Maj^, 1892, atBellevue Hospital, by Dr. J. D. Bryant. ^ I am indebted to Prof. Fisher for the five following cases un- published. TREPHINING FOR EPILEPSY. 63 The skull was trephined, the opening enlarged to a diameter of about three inches. There was no evidence of internal fracture or of adhesions of the membranes. The dura was opened, and the hand centre located by the fara- dic current. The patient made a good recovery from the operation, although for two or three days there was a con- siderable elevation of temperature without evidence of any suppuration having occurred in the wound. Result. — The attacks at first increased in frequency, and were not changed in character ; later they decreased somewhat in number, but finally resumed their old fre- quency and nature. The patient was recommitted to the insane asylum on Ward's Island. (22) J. H., m., 22, E. D. Fisher. History. — Family history negative. He gave an indef- inite history of having received an injury on the head. The attacks were characterized by always commencing in the fingers of the left hand with a sensory aura passing toward the face, with resulting loss of consciousness, after which the convulsions became general. Patient's mental condition showed signs of dementia — never violent. Operation. — May, 1892, at Bellevue Hospital, by Dr. George Woolsey. The patient was trephined over the right arm centre, and a considerable portion of the skull removed. Nothing abnormal was found. The dura was opened, and again united. The hand centre was located by the faradic cur- rent, but was not excised. The patient made a good re- covery without elevation of temperature. Result. — The attacks, however, continued to be as fre- quent as before, but no longer commenced on the left side, being general in character. Patient's mental condition was unimproved. Admitted to the Ward's Island insane asylum, December, 1892. (23) A. B., m., 38, E. D. Fisher. History. — Negative family history. He was a moder- ate drinker. He gave a history of injury to the head re- 64 BRAIN SURGERY. ceivecl five years previoush' from a club. About one year after this, he began to have sligiit attacks of an epileptic nature, which finally developed into complete seizures. Severe attacks occurred about once a month, and slight attacks every ds-j. His memory became somewhat im- paired. On examination of the patient a depression over the parietal bone was found behind the motor area. Operation in March, 1892, at the City Hospital, by Dr. J. E. Kelly. The patient was trephined over the site of the depres- sion. The inner table W8.s found depressed and pressing the dura, but there was no evidence of internal fracture. The dura was not opened. The patient made a good re- covery, and leaving the hospital in the summer, continued at work for two months. Result. — Up to date reports that he has had no seiz- ures of any kind unlesss light attacks of dizziness when exposed to the sun may be counted as such. (24) A. D., f., 20, E. D. Fisher. History. — Family history negative. She gave a history of attacks from childhood. The attacks have been almost continuous, and limited usually to the left side. Patient very much demented. The attacks at times, and just previous to the operation, were as frequent as one hundred in a day. Operation at the Citv Hospital in June, by Dr. J. E. Kelly. The patient was trephined over the right motor area, and a considerable portion of the skull removed. Nothing found. The hand centre was located by the faradic cur- rent. A small portion of this centre was excised. Result. — The patient died six hours after the operation, probably from the combined effects of her previous exces- sive seizures and the shock of the operation. (25) A. C, m., 26, E. D. Fisher. History. — Family history negative. The attacks were TREPHINING FOR EPILEPSY. 65 very frequent, general ; patient demented and given to ex- cessive masturbation. He gave a history of an injury received from a fall when 12 years of age. On examina- tion, a considerable depression was found over the left frontal bone, at the margin of the hair. Operation at the City Hospital in May, by Dr. J. E. Kelly. The patient was trephined, and a considerable area over the frontal bone removed, but no sign of fracture nor any adhesion of the dura was found. Result. — The patient made a good recovery without elevation of temperature and for some weeks after the operation seemed much improved in this mental state; the attacks were very much decreased in number, and he ceased masturbating. Later, his condition became about the same as previous to the operation, and he was transferred to the insane asylum. There are many patients suffering from traumatic epilepsy who manifest mental symptoms either asso- ciated with the fits or developing in place of the fits,. C. F. MacDonald reports the following cases : (26) J. M., m., 29, MacDonald, Jour. New. and Ment. Dis., XIII. , August, 1886. A patient in the Auburn asylum, suffering from mania which had developed after a blow on the head with de- pressed fracture of the skull over the right ear, correspond- ing to the superior parietal lobule, was found to be the subject of severe general convulsions. Dr. MacDonald trephined, removing the bone, which was thick, roughened, and adherent to the dura. The patient subsequently re- mained entirely free from his epileptic attacks, and grad- ually recovered from the condition of mania, so that he was discharged cured seven months after the operation. (27) J. C, m., 24, MacDonald, Ic. The patient had been a chronic epileptic with periods of 5 66 BRAIN SURGERY. insanity for eight years, each attack being followed by a period of mania. He was found to have a depressed frac- ture over the right occipital region said to have occurred at the age of six, and he suffered from pain at this loca- tion. He was trephined August 25th, 1885, a button of bone being removed and the dura not opened. A year later he had had no fits at all, and though partly demented, was free from delusions. Park has recently reported two such cases, as fol- low^s : ' (28) The first was in a man of 31, who, on July 20th, 1891, was kicked in the left side of the head by a horse, and who some time later was found unconscious. He was carried into the house, and was aroused. He had no paralysis, but in three days began to act strangely and soon became wilful and almost violent. He developed erotic tendencies, and growing rapidly worse could not be kept at home. On July 28th, he was sent to me by Dr. Krehbiel, of York- shire Centre. At this time the patient was difficult to control and mildly maniacal. July 29th, I found a de- pressed area on the left side near the parietal eminence and a little anteriorly to it ; yet he had absolutely no motor symptoms. At this point there \^ as an H-shaped scar. Immediate operation was done under chloroform . Beneath the scalp I found a depression about the size of a half- dollar, around which I chiselled so as to entirely lift and remove the depressed portion. The bone was well com- minuted; there was a small clot beneath the bone, but none beneath the dura. The bone was not replaced and the wound was closed without drainage. He made a rapid recovery ; returned home in one week with his mind nearly clear and his disposition as it had been before the injury. (29) The second case was in a man of 45, who, when a 1 Roswell Park : Med. News, Dec. 10th, 1892. TREPHINING FOR EPILEPSY. 67 young man, had had an extensive compound fracture of the skull, and who for a while was under the observation of the late Dr. Gray, of Utica, who advised against oper- ation, in accordance with the practice of his day. Of late years the man has developed distinct epileptiform seizures followed by violent maniacal attacks, during which he was positively dangerous, so that his family lived in constant fear ; moreover, his disposition and temper seemed to be gradually changing under this stress, and it got to be a question whether he should submit to an operation or be sent to an asylum. He was placed in my hands for oper- ation by Dr. Putnam. This was made during October, 1891, the depressed bone being removed, adhesions sepa- rated, and a portion of the scar exsected. The change in this case for the better has been most marked and most gratifying. While it is too much to say that he has not had a single seizure since the operation, they have been reduced to very mild and very rare attacks, and I believe it is now some months since he had anything that could be called a fit. In temper and disposition he is also quite his old self again. The result in these cases may be summed up as follows: cured 10; improved 6; not improved 11; died 2. These cases are sufficient to show that in many cases of epilepsy the attack begins with a clearly localizable spasm which extends from the part in which it begins to other parts in a definite order of progression. The majority of such cases have developed subsequently to an injur}". The operation of trephining often reveals decided pathological conditions in these cases which require special notice. 68 BRAIN SURGERY. Pathological Changes Observed. In studying the cases here described the most interesting feature is the pathological conditions which have been revealed during the operation. These have been mentioned in connection with each case, but some general discussion seems warranted. We may consider these changes in the order in which they have been met with during the operation. I. Scalp. — Exposure of the scalp by close shaving very frequently reveals scars hitherto undiscovered. Such scars are rarely found to be tender, and, in fact, in no case has pressure upon the scar been followed by a fit. Some years since considerable notice was taken of a few cases in which the epilepsy was clearly traceable to compression of nerves in the scar tissue of the scalp, and it was thought to be characteristic of these cases that pressure upon the scar would lead to a fit. I have tested carefully very many patients, but have failed to find such tender scars upon the scalp. Two years ago I saw a little girl afflicted with left- sided convulsions, each convulsion being preceded by a sharp pain in the left supra-orbital nerve, and pres- sure upon this nerve produced sensations in the entire left side and the feeling of anxiety identical with that which usually preceded the fit. But in this case the division of the supra-orbital nerve, performed by Dr. McBurney, in the hope of removing peripheral irrita- tion, failed to relieve the fits. From my experience I I TREPHINING FOR EPILEPSY. 69 consider that true reflex epilepsy from scars in the scalp is a very rare occurrence. II. Periosteum. — In a number of cases when the scalp has been divided and laid back a perceptible thickening of the periosteum over the fractured bone has been noticed. In one case this was so extreme that the periosteum could be likened to a piece of canton flannel. It is often found to be very vascular and more closely adherent to the skull than normal. I have never seen any apparent bony deposit beneath the periosteum as an evidence of repair of a broken skull. III. The Skull. In the cases operated upon frac- tures of all kinds have been met with. It is impossi- ble, as a rule, to determine whether the fracture in- volves the external table only or the internal table as well ; it is only by trephining that this fact can be settled. It is not always safe in operating for epilepsy to be guided by the position of a fracture unless that fracture coincides quite closely with the spot selected for trephining from the character of the fit. Thus, in one of my cases a depressed fracture lay over the left first frontal convolution, but the spot selected for trephining was over the middle of the pos- terior central convolution where the bone was normal (Fig. 12, page 30). When the button of bone was re- moved, however, a splinter of bone from the internal table was found penetrating the dura and brain. Thus the medical indication was proved to be the correct one to follow in spite of the fact that at the spot selected for trephining there was no evidence of fracture. 70 BRAIN SURGERY. In many cases there is a fracture of both tables with decided depression of bone. Usually when the tre- phine opening is made a very distinct thickening of the skull is revealed and the density of bone is greater in and about these fractures. IV. The Dura. — In many cases the dura has been found roughened upon its external surface, more vas- cular than normal and more adherent to the bone than in a state of health. It is not uncommon to see white lines and bands running across the dura of white con- nective tissue, the remains of chronic inflammation. When the dura is divided and reflected, adhesions to the pia are quite commonly found. These may be in the form of little thread-like attachments which are easily broken as the dura is reflected. They may be very close and vascular adhesions which have to be dissected up with care. The dura itself is quite com- monly thickened and that to a very great degree, so that I have seen a dura three millimetres in thickness. Under these circumstances the thickening appears to have been upon the under surface of the dura. Not infrequently the dura forms a part of the ex- ternal wall of a cyst. V. The Pia. — When the pia is exposed in an oper- ation, it is almost always found to present the appear- ance of oedema and only after the wound has been opened for a few minutes and the pressure of a sponge or finger has been made upon the pia does the sub- pial fluid disappear, revealing the vascular surface of the brain beneath it. It would appear that in a state TREPHINING FOR EPILEPSY. 71 of health a thin layer of fluid is normally interposed between the cortex of the brain and its dense cover- ings. As the result of pathological changes the pia may be altered in its appearance. Small white dots of the size of the head of a pin have been seen many times, resembling tubercles, but not at all tubercular in their structure or nature. Again there may be white Fig. 25. — Section through Pia Mater and Cortex to show Thickening of the Pia. The normal thickness of the pia is indicated at yy. x^ groups of small round cells— fibroblasts. 1, 2, 3, indicate the chief layers of the cortex. At 2; a wedge- shaped mass of neuroglia tissue is seen. Such a sclerotic patch may form a focus of ii'ritation sufficient to cause a local spasm. lines or narrow bands whiter than normal pia in its tissue. Again the pia may be much thickened, very vascular, and so closely adherent to the cortex that any attempt to elevate it with a fine forceps fails. Under these circumstances it is very difficult to avoid hemor- rhage from these new vessels. But such hemorrhage can usually be checked by pressure maintained for a 72 BRAIN SURGERY. few minutes evenly, or else by a light touch with the Paquelin cautery. The appearances of a localized patch of chronic meningitis with thickening are shown in Fig. 25, which was drawn by Dr. Van Gieson. He writes : " The pia mater is about three times thicker than in the normal condition, which is approximately indicated by the lines at y. The thickened pia mater is composed of fairly dense connective tissue, and as more and more fibro-blasts are developed apparently from the groups of small round cells at x, the mem- brane slowly grows thicker and thicker. Hand in hand with this localized growth of connective tissue of the pia mater, there is a disappearance or oblitera- tion of the blood-vessels, and in Fig. 25 it is to be noted that there are very few blood-vessels and there is no distinction between the two layers of the mem- brane. The effect of all this upon the structure of the subjacent cortex cannot be described in this case, for the material was not especially well prepared. One important change in the cortex associated with this condition of the pia mater is the production of a wedge-shaped mass of neurogliar hyperplasia. Fig. 25, ^, which passes inward from the outer margin of the cortex, and is composed of spindle-shaped and branch- ing cells. The neuroglia cells of the barren layer are also slightly increased in number." The pia not infrequently forms the inner wall of a cyst, and under these circumstances it is usually so much congested and thickened as to be quite opaque. When the pia is closely adherent to the brain and is TREPHINING FOR EPILEPSY. 73 very vascular, the appearance of the cortex as seen through it is different from that of the normal cortex. It is blue instead of being red, and capillary vessels, which in the normal cortex are seen to radiate toward the summit of a convolution from the two sulci in which the chief pial vessels lie, are no longer visible. In some cases there has been found beneath the pia but closely connected with it a delicate mesh- work of new connective tissue and vessels, making a mass re- sembling honeycomb, usually of the thickness of a centimetre. ' This connective-tissue formation is usu- ally full of fluid and collapses when the pia is incised. It is probably a relic of an old hemorrhage. YI. The Brain.— Is oYvasl cortex during life has evidence of a vascular supply most profuse and per- fect. Everywhere over the cortex a fine netv/ork of capillaries is visible, the larger capillaries running toward the summit of each convolution from its sides. It has a firm feel and a double pulsation, the pulsation of the heart and the pulsation on respiration. As the result of fractures or of meningitis the cortex may be changed in its appearance. It may have undergone compression and be indented. It may be stained with haematin as a remainder of an old hemorrhage. It may be changed in color to a darker tint and perceptibly hardened by new connective tissue growing into it from ^ In an old case of right hemplegia with contractures of twenty years' standing the entire motor area of the left hemisphere was re- placed by such a honeycomb mesh of connective tissue. Secondary degeneration could be traced into the spinal cord. 74 BRAIN SURGERY. an adherent pia. Or finally, it may be softened and lose its firm consistency and present a flat or depressed appearance very different from the normal. It may be actually destroyed and disintegrated by bony splinters projecting into it, and then it is semi-fluid in character or else hardened by sclerosis. The microscopical changes are described later by Dr. Van Gieson. It is not uncommon to find cysts in the brain. These may have a distinct connective-tissue wall, or may merely be surrounded by normal brain tissue. They are usually the remains of a hemorrhage or of a spot of softening from thrombosis or embolism of a small vessel. The fluid in them is usually clear serum. If they are divided the walls unite and the fluid does not collect again. If they are merely emptied the fluid re-forms. As we shall see in the chapter on tumors, cysts are not infrequent in the midst of glio- mata. It is possible that some of the cases of epilepsy in which cysts were found were really cases of be- ginning glioma. For the presence of a cyst can hardly be thought sufficient to cause irritation of the sur- rounding tissue, while a growing tumor might easily do so. The facts just stated in regard to the pathological conditions found in the brain at the time of operation prove conclusively that in these cases of epilepsy there was an organic basis for the disease, and this fact makes it seem very probable that in all cases of epi- lepsy commencing after injuries there is at some point TREPHINING FOR EPILEPSY. 75 in the brain an actual pathological change. It is evi- dent from what has already been stated that in some cases this focus of disease lies immediately beneath the point of injury ; it is evident that in other cases it. lies near the cortex at some distance from the point of injury. It is evident that when the .part of the cortex involved is a part the function of w^hich is known, the local symptoms will indicate the situation of the focus of disease. It is evident, finally, that in traumatic epilepsy when the disease is not found under the point of injury, and when it does not give rise to any local symptoms, we have no means of knowing where it is in the brain, even though we are sure of its existence, and we have no means of treating it surgically. I think it may be stated, as a result of the facts derived from pathological studies of the conditions, found at operations in epilepsy, that Jacksonian and traumatic epilepsy are always due to a pathological change in the brain. When the pathological change is not apparent to the naked eye at the operation, and yet the approxi- mate situation of it can be determined by the local symptoms, Horsley proposed to determine by the ap- plication of faradism to the cortex the exact spot irri- tation of which will set up a fit like the one spontane- ously occurring, and then cut this spot out. This has been frequently done, in some cases with success, in others with a return of the symptoms. Several cases are mentioned in the collection given. The chief ob- jection to this method — an objection which has been 76 BRAIN SURGERY. urged by numerous operators — is that excision of brain cortex is necessarily followed by the formation of a cicatrix which becomes the centre of a sclerotic patch in the brain. Such a patch or even a cicatrix may act as an irritant and give rise to localized epilepsy when arising from other causes. It is not unreasona- ble to fear that it may act as an exciting cause of a continuance or renewal of the fits when it is produced by the surgeon. Later experience rather confirms this fear, for even in two of Horsley's cases the fits re- turned in spite of the excision of the cortex. Hence the excision of the focus of irritation, when such a focus is not apparently abnormal tissue, is not to be recommended, since to do so is to produce a brain lesion comparable to that found in the cases reported. The exact pathological changes which take place in the brain after wounds have been studied by Ziegler ' and by Coen.^ Ziegler describes them as follows : "If a pointed instrument is thrust into the brain at any point a hemorrhage occurs at that point and the neighboring tissue is destroyed in greater or less ex- tent. In this way there is ^Droduced a necrotic anaemic or hemorrhagic focus, and the pia and sub-arachnoid space over this is infiltrated with blood. At the bor- der of the dead and living tissue there occurs a more or less intense inflammation in the first few days, 1 Ziegler: "Lehrb. d. Path.Anat.," Spec. Tlieil, 1887, 5te Auflage, S. 358. ^ Coen : " Ueber d. Heiliing von Sticliwunden des Geliims. " " Bei- trage zur Path. Anat. u. Pliys. , " ii. , p. 107, 1888. TREPHINING FOR EPILEPSY. 77 which soon results in a well-marked line of demarca- tion between them. At the spot of inflammation, which extends especially along the course of the ves- sels which enter the brain vertically from the pia mater, the brain tissue becomes softened and simul- taneously the cell infiltration advances toward the necrotic focus. This latter in the course of time be- comes dissolved and absorbed. It may take months, even years, for the products of inflammation to be finally removed. " Other changes meantime go on in the adjacent tis- sue. The nervous tissue undergoes a degeneration in consequence of the change of nutritive conditions, and the ganglion cells and nerve fibres swell, become fatty, become disintegrated and destroyed. The focus of inflammation is thus surrounded by a zone of degen- eration. " In the first weeks the focus of inflammation consists of vessels, small round cells, larger corpuscles, and fatty and pigment granules. The last are in large numbers so long as the absorption of the dead tissue and of the extravasated blood are in progress. The fatty granules are also found in the zone of degener- ation. After weeks and months there occurs a grad- ual formation of connective tissue, which evidently commences along the vessels which penetrate the in- flammatory focus from the pia, and this surrounds the necrotic tissue or takes its place. The connective tissue is partly radiating in character and thick, partly areolar and meshlike in structure, and develops out of 78 BRAIN SURGERY. the cells of the pia and of the vessels of the pia. The formation of connective tissue requires a long time, and even months or years after it has hegun it may be rich in round cells." Authorities differ as to the possibility of reproduc- tion of ganglion cells of the brain after destruction (see Coen, I. c). Coen denies that it can occur and holds that after a wound the new tissue found is entirely connective tissue containing no nerve elements. He says : "A true regeneration of the central nervous sys- tem was never observed in my experimental investi- gation ; the tissue which developed at the spot wounded, replacing the destroyed brain tissue, contained no newly-formed nervous elements. The ganglion cells are, however, able to resist the traumatic attack and this they do very early by indirect division of their nuclei. This inclination to division subsides and ceases when healing begins. A reproduction of brain tissue fails to occur in the region where brain was destroyed, and connective tissue fills its place which forms a scar in the true sense of that word" (I.e., p. 125). Microscopical Appearances of the Brain Tissue Excised, in Cases III. and II. By Dr. Iea Van Gibson, First Assistant in Histology, College of Physicians and Surgeons. In describing these morphological changes in the motor cortex which harmonize very well with the symptoms of epilepsy, it is of especial importance to preface the details of the examination with some gen- 1 TREPHIXIXG FOR EPILEPSY. 79 era! remarks about the technical limitatioDS of inves- tigations in the finer pathology of the cortex, and the extreme difficulties of detecting and attaching signifi- cance to the very early and subtle changes in the cortical elements. In such a preface the investigator should indicate the great caution and most refined technique which a study of minute cortical changes demands; for then the reader will appreciate that the observer has guarded against mistaking for lesions entirely artificial changes, or normal structures which, especially in the cortex, are by no means easy to define. The difficulty in the way of research in cortical pathology is the complexity of the brain cortex ; it is most highly organized, and is far beyond all other organs and tissues in the textural delicacy of its an- atomical elements and complexity of their arrange- ment. In most of the other organs the structure of the parenchyma is comparatively simple, and the stroma is arranged in such a way that there is a con- trast between the two in the sections; thus in the kidney or liver, for example, the changes in the stroma or in the parenchyma attendmg a chronic inflamma- tion may be determined very accurately. The stroma is so distinct from the parenchyma and its distribution is so readily followed, that a very beginning of an in- crease in its substance may usually be easily and posi- tively recognized. In the same way the distinctive dis- tribution of the comparatively simple parenchyma cells permits early changes in them to be determined with but little difficulty. 80 . BRAIN SURGERY. When we come to the brain cortex, however, the contrast between stroma and parenchyma which in other organs affords most valuable topographical aid is lost, and the determination of changes in either stroma or parenchyma is correspondingly difficult. For in the brain cortex the neuroglia and ganglion cells, corresponding respectively to the stroma and parenchyma of other organs, are not only more in- tricately constructed but are diffusely arranged. The neuroglia and ganglion cells are mingled together in a most intricate way, and are surrounded by a great wilderness of processes derived from both, which forms a very large part of what is conveniently called the basement substance of the gray matter. Thus it can be understood what a difficult matter it is to determine any beginning increase or proliferation of the neuroglia, which in ordinarily stained sections presents itself as multitudes of small round nuclei scattered all through the gray matter without any boundaries or limitations. This problem of the deter- mination of a very early increase in the neuroglia becomes the more baffiing because, as a rule, this tissue grows so slowly that the all-important criterion of the proliferation of cells, namely, the phases of karyokinesis, are difficult to find. The investigation of minute and early changes in the other intrinsic element of the cortex — the gan- glion cell — is rendered difficult by the presence of arte- facts or artificial changes occurring after death. The structure of the ganglion cell is so delicate and intri- TREPHINING FOR EPILEPSY. 81 cate and the cortex is so slowly permeable to the bichromate solutions that a number of post-mortem changes are liable to occur in the cell or are induced by the action of the hardening agents. Such artificial changes may simulate very closely the results of dis- ease, and when these artificial changes are present in a cortex with suspected disease of the ganglion cells it becomes exceedingly difiicult to understand the lesions, or to determine in what degree the changes are due to disease and in what degree to artificial con- ditions. With the best of care we can recognize after all but the coarser and grosser lesion in the ganglion cell body, which is only a part of the cell. Changes in the great forest of processes of the cell, representing a volume of protoplasm tally as large if not larger than the cell body itself, are beyond our cognizance even with Golgi's methods, which seem to be of little service in showing minute changes in the ganglion cells. The aid of mitosis as an index of pathological changes in the ganglion cells is also absent, since the latest studies on this subject show that the ganglion cells seldom if ever proliferate. Thus owing either to perplexing artefacts, or to the inherent complexity of the cortex, its more minute changes seem beyond recognition at present, and when we do detect cortical disease processes it is only after they have gone on to some considerable extent beyond the initial stages and have become rather coarse, ex- tensive, or materially destructive. Since the wonder- 82 BRAIN SURGERY. ful revelations of the Golgi methods, one can reason- ably enough conceive that changes may occur in the cortex which are of the greatest etiological signifi- cance, but so subtle that they are entirely hidden from our view. It certainly seems appropriate, therefore, to speak with all this detail about these peculiar difficulties in the way of pathological investigation of the cortex, for if real advances are to be made in the finer pathol- ogy of the cortex its difficulties of investigation should be appreciated, and if the lesions to be described in these particular cases are to be at all considered as underlying the phenomena of epilepsy we must ap- proach the problem with all possible caution. I also wish to show that the material placed at my disposal by Professor Starr has such great advantages for in- vestigation both in its stracture and preparation, that the difficulties and errors in determining early cortical changes are considerably reduced. From the fact that these minute fragments of the cortex were immediately transferred from the living body to the hardening fluid the changes in the gan- glion cells are especially significant, for the element of artificial change incident to post-mortem alteration or the process of hardening larger portions of the cortex, which frequently interferes with making positive statements about the minute changes in the ganglion cells, is more thoroughly excluded than in the material from an ordinary post-mortem examination. Even allowing for the fact that Mliller's fluid does not pre- TREPHINING FOR EPILEPSY. 83 serve the ganglion cells perfectly, the damage to the ganglion cells, presently described, must have existed during life. Microscopic Examination of Case III. We may now go on with the detailed microscopical examination of the removed portion of the brain in Case III., and this comprises a description of (1) A rigid plate of connective tissue acting as a foreign body and pressing against the brain. (2) Changes in the pia mater. (3) Certain lesions of the cortex of the brain consisting of both changes in the ganglion cells and in the neuroglia. Description of the Inwardly Projecting Plate of Connective Tissue Indenting the Surface of the Brain. — The removed portion was hardened in Miiller's fluid plus one-sixth its volume of strong alcohol for three weeks. The specimen was very small, measuring about ten by six millimetres in diameter, and its cen- tral portion furnished about one hundred sections which were cut in series and stained double with hsematoxylon and eosin and by the picro-acid-fuchsin method. Sections from the centre of the specimen when re- constructed show that a tiny plate of very dense par- tially calcified connective tissue projected obliquely downward apparently from the dura mater against the surface of the brain. Here the plate is firmly attached to a minute localized patch of thickened pia mater and seems directly or indirectly to have pressed 84 BRAIN SURGERY, on the brain, for the cortex shows an abrupt little pit or depression (see Fig. 26) just beneath the inwardly projecting plate. This cortical depression correspond- ing to the plate is cone-shaped (with the apex pro- jecting inward) and has approximately an altitude of % ''%&kds%p^^ FiG. 26.— A Section from the Centre of the Removed Portion of the Brain in Case III. The topographical relations of the rigid calcified spiculum of connective tissue, the thickened pia mater, and the depressed region of the cortex, rrx. Calcific spicu- lum of connective tissue, yy. 3Ioderately thickened pia mater, z. Anastomosing wedge-shaped group of capillaries passing into the cortex from the pia mater. 1. 2. and 3. First, second, and third layers of the gray matter, i, Upper portion of the third layer. three and three-fourths millimetres and a base four to five millimetres in diameter. In the individual sections from the centre of the specimen the plate of connective tissue appears as a very dense, finely lamellated, partially calcified spicu- lum about three-fourths of a millimetre broad and three-fourths of a millimetre long (see Fig. 26, xx). At its inner extremity the spiculum has a globular TREPHINING FOR EPILEPSY. 85 enlargement and the lamellae do not run parallel as in the outer portion, but pass in various directions mostly concentrically arranged about a tiny central nodule or core. The outer end of the spiculum is entirely free in all of the sections, so that it is difficult to determine what the spiculum is a part of or where it grew from. The inner end of the spiculum is attached in all direc- tions by many diverging fascicles of the thickened pia mater. As the sections approach the margin of the specimen at one side, the plate grows a trifle smaller, but still persists to the free edge, so that it seems probable that not all of the plate was removed at the operation. At any rate it may be said that the removed portion was not large enough to completely surround the plate. From the very dense structure of this connective tis- sue, and from the fact that the edge of the microtome knife was turned in cutting the sections, this plate must have formed a fairly rigid body. The Changes in the Pia Mater. — The pia mater not only at the attached end of the spiculum, but for some little surrounding distance (say three to four millimetres), shows the lesions of chronic meningitis, or productive or hyperplastic inflammation of the pia mater (Fig. 26, yy). The pia mater in the region con- tains an increased amount of connective tissue, which consists of fibro-blasts in different stages of develop- ment, but most of them show the more mature or final stages. The resultant thickening of the pia mater, however, is only of a moderate degree, and has not 86 BRAIN SURGERY. gone on to the extent of obliterating the two layers of the membrane. The inner vascular layer still presents its normal features, although in places (see right- hand portion of the pia mater in Fig. 26) the vessels appear to be somewhat diminished in number. The meshes of the inner layer of the pia mater in the depressed region of the cortex are distended and form a network (Fig. 26, rv) filled with extravasated red blood cells. This extravasation of blood as well as some minute hemorrhages in the gray matter seem to be of artificial origin, and are very likely referable to the manipulation in the removal of the specimen at the operation. TJie Lesions of the Cortex. — The lesions of the cor- tex in this case might easily escape detection without the most careful scrutiny and technique. There are hardly any gross changes in the cortex which would attract attention with the low power, and it is only with the oil immersion lens that slight changes in the neuroglia cells and scattered damaged ganglion cells become fully apparent. These cortical changes are very minute and not at all striking, and yet they are none the less definite and significant. The Ganglion Cells. — The ganglion cells are affected by a series of degenerative changes which in their most advanced stages result in an almost complete dissolution of the cell, and yet this degeneration is not extensive enough to involve the cells so universally as to interfere with their topographical distribution. Besides this, most of the damaged cells are in the TREPHINING FOR EPILEPSY. 87 earlier stages of the degeneration so that they still retain their form and appropriate position. Thus in reconnoitering the sections with the lower powers the ganglion cells do not appear deficient in number ; they are properly arranged and their several layers are perfectly distinct. The following description applies to all of the ganglion cells excepting the layer of small Fig. 27. — Various Phases of the Earlier Stages of the Degeneration of the Ganglion Cells, The thin lines enclosing the cells at and to represent the- pericel- lular spaces ; the cells x and y show the earliest stages, w and s later stages, and iT shows the ultimate destruction of the whole of the ganglion cell body, leaving nothing but the nucleus lying in an empty space. pyramids. For especial reasons this layer will be dealt with separately later on. It will be convenient to describe the appearances of the nucleus and protoplasm of the degenerated gan- glion cells separately. The prevailing form of nuclei shows a distinct peripheral zone, indicating the nuclear membrane ; just inside of the nuclear membrane is a narrow clear zone surrounding the chromatic elements 88 BRAIN SURGERY. of the nucleus, appearing in the form of a skein of finely dotted interlacing filaments which show the usual thickened appearances at the nodal points and surround unstained interstices. The nucleolus is seen in most of these skein-like nuclei, and both the nucle- olus and the character of the skein show no variations relating to the different degrees of dissolution of the ganglion cells. In both the early and ultimate stages of the degeneration the form cf nucleus as shown in Figs. 27, 28, and 29 remains about the same in all of the cells. This particular form of nucleus in some of the cells is a trifle suggestive of one of the initial stages of karyokinesis, but none of the other stages of mitosis are present, so that this appearance of the nucleus must be regarded as an indication of retrogressive changes. There are no indications of mitosis in any of the ganglion cells, and this agrees with one of the latest papers on the ganglion cell reproduction by Fiirstner and Knoblauch {Arcliiv filr Psych. , XXIII. , 135). Some different appearances of the nucleus are shown in Fig. 27, in the cells t', lu, and y. The nucleus of the cell tu has its chromatic elements resolved into a number (some twenty to twenty-five in optical section) of larger and smaller globules or discs resembling very much the ordinary nucleolus. In the cells ^ and v the chromatic substance is collected into thickened strands or large lump-like masses. The protoplasm of the cells shows a series of changes TREPHINING FOR EPILEPSY. 89 which finally result in an entire disappearance of the cell body — for a very complete series of intermediate stages can he observed between the slightly and most completely degenerated cells. The earlier stages of degeneration consist in larger and smaller solutions of the substance of the cell so that hollow-looking vesi- cles appear in the cell body. Such cells are shown in Fig. 27, X and y, Fig. 28, x, and Fig. 29, a. The cell X in Fig. 27 also shows a ragged or roughened profile Fig. 28. —Shows Other Phases of the Degeneration of the Ganglion Cells. The cell X shows liquefied vesicles at the junction of two processes with the cell body and three small round cells crowded in the pericellular space ; the cell y shows a series of liquefying seams or channels. at one margin of the cell body. These vesicles fre- quently appear at the junction of one of the larger processes with the cell body as in Fig. 28, x, Fig. 29, a, or in the process itself some little distance from the cell (Fig. 29, a). In a somewhat later stage, by the increase of these vesicles, and by their apparent coalescence, the cell body becomes more reduced in volume, deformed in its contours, and loses its processes. Besides the vesi- cles, liquefied seams and communicating channels also 90 BRAIN SURGERY. appear and contribute their share toward the destruc- tion of the cells. A very beautiful example of these channels or seams is shown in Fig. 28, y. This is one of the very large ganglion cells peculiar to the deeper layers of the motor zone and it was situated on the extreme edge of the section, so that it must have been immediately fixed by the hardening solution, and may be regarded Fig. -Other Variations of the Phases of Degeneration of the Ganglion Cells described in Figs. 27 and 28. therefore as showing very nearly the same condition possessed during life. The cell c, Fig. 29, also shows a somewhat similar condition and illustrates how the apical process is being separated from the cell; the protoplasm sur- rounds the nucleus as a deformed or deficient mass such as is shown in Fig. 27, w and s, and Fig. 29, h. In some of the degenerated cells the protoplasm at the bounding surface becomes frayed out, or loosened from the cell body in little granular islands or cord- TREPHINING FOR EPILEPSY. 91 like masses, while the remainder of the cell body may be comparatively intact. This is represented in Fig. 27, u, and in Fig. 29, a. The cell a, Fig. 29, is again one of the very large cells in the deeper layers and was situated just at the free edge of the section so that it must have been fixed in a perfectly natural condition. In still others of the ganglion cells the protoplasm is studded with irregularly distributed shining dots. In most of the cells affected in this way, and they are comparatively few in number, these dots seem akin to and react like hyaline material, and their appearance is shown in Fig. 27, v, y. These hyaline dots are present in both the slightly and severely damaged cells (Fig. 29, e). In focussing on the surface of the cell z in Fig. 27, some larger lump-like hyaline masses were noted. Thus far, to the rather restricted extent that we are able to recognize them, the beginning and most limited changes in the ganglion cell body have been described. There were larger and smaller vesicular or channel- like solutions of the substance of the cell body, and a tendency toward disappearance or separation of the processes. We may now go on with the consideration of the final and more grossly destructive phases of the gan- glion cell degeneration. Some of these cells undergo- ing the later stages of the degeneration are reduced to a mere shell or skeleton of the former cell ; the out- line of the cell is preserved, but the cell is hollow ; the 92 BRAIN SURGERY. bounding surfaces are intact, and enclose the nucleus lying in an empty space or surrounded by a few shreds or granules of the former i^rotoplasm (see Fig. 27, A;, and Fig. 29,/). This condition seems to result from the extension and coalescence of the liquefactive seams and vesicles already described, and it is easy to trace the extension of the changes in the cell y, Fig. 28, to the cell cZ, Fig. 29. These skeleton cells, when followed still farther in their degenerative course, show gradual dissolution and disappearance of the bounding shell, so that ulti- mately nothing remains of the cell but the nucleus, which lies bereft of protoplasm in the space once occu- pied by the ganglion cell (Fig. 27, k; Fig. 29,/). Another way in which the ganglion cell ultimately becomes reduced to a mere nucleus is not so much by a solution of the protoplasm internally, as just de- scribed, but by a direct abstraction of portions of the external zones of the cell body. There is at first a slightly roughened surface of the cell, at some portion of its extent, with a fraying out of shreds and most minute fragments of protoi3lasm into the pericellular space. Then there is a tendency toward a distinct sequestration of a portion of the protoplasm (Fig. 29, 6, e), so that the cell body grows smaller and smaller as the solution of its substance proceeds from without inward. Thus the cell becomes deformed and atro- phied ; it loses its processes, and the pericellular space sometimes contains minute fragments of the loosened protoplasm (Fig. 29, e). Ultimately the cell becomes \ TREPHINING FOR EPILEPSY. 93 reduced to a naked nucleus lying in the pericellular space, as just described (Fig. 27, k; Fig. 29,/). Very often this wasting away of the cell body from without inward is also combined with the liquefactive vesicles and channels or other forms of degeneration in the interior of the cell body (Fig. 29, a). The ultimate fate of these nuclei bereft of the gan- glion cell body cannot be determined positively, but some of them become destroyed. The nuclear mem- brane and chromatin skin become disintegrated and finally nothing is left but some fragments of the chromatin elements, surrounded by a complete or in- complete ring, which still take up the color of the nuclear dyes. The description of the changes in the ganglion cells refers to the deeper layer of cells, and especially to the very large ganglion cells of the fourth layer, charac- teristic of the motor zone. The very large size of the cells renders the detection of the degenerative changes much more positive than in the other small cells. To be more certain of the ante-mortem origin of these lesions in the cells as many as possible were selected for study in glycerin mounts at the extreme edge of the specimen where they must have been immediately fixed in a natural condition. The spaces about these cells are small, and altogether the element of artificial changes may be more thoroughly excluded from them than in the much smaller cells. One of the most striking features of this degenera- tion of the ganglion cells is the extensive involvement 94 BRAIX SURGERY. of these very large cells of the fourth layer. It may be that this feature is so evident, from the fact that the degenerative changes are so much easier to recog- nize in these cells, but it would appear as if they were especially selected by the degeneration. At any rate very few of the large cells are left intact, they show quite universally one phase or another of the degen- erative changes. In cutting out the fragment at the operation, the knife seems to have sliced it off just at or below this layer of cells, so that very many of them lie right at the edge of the sections. Many of the smaller cells of the third and fourth layers, however, show precisely similar degenerative changes. There are many normal ganglion cells in deeper layers, and the degeneration affects apparently, excepting the very large cells, only isolated or small groups of cells here and there, and yet the aggregate number of the damaged cells muot be very large. Still another feature about the ganglion cells re- mains to be described. This consists in the accumu- lation of clusters of from one to four or five small round cells crowded together in the pericellular spaces of both the diseased and normal cells. These cells have a very thin envelojDe of j)rotoplasm and they are generally situated at the base of the cell. These cells are not infrequently found in brains with normal ganglion cells, and which have given no symptoms, and in the present case I am unable to interpret their meaning or determine what kind of cells they are. We may now describe the layer of small pyramids TREPHINING FOR EPILEPSY. 95 which has been held apart from the deeper layers, because the element of artificial changes cannot be as positively excluded. The small pyramids are quite universally altered, and but a very small number of natural cells are found in the sections. The nucleus surrounded by little if any protoplasm lies in a rather large empty pericellular space, as shown in the right- hand portion of Fig. 31. But just such a picture of the small pyramids as this is generally found in any cortex unless prepared by especial methods, and is generally to be regarded as largely of an artificial character. The small pyramids are especially prone to artificial changes, apparently from their very small size which seems to render them correspondingly liable to shrinkage. Artificial changes in this case, how- ever, must be considered reduced to a minimum, and these alterations in the small pyramids in this case are not present in sections of the motor cortex of an electrically executed criminal, prepared in the same way and studied along with this case as normal con- trol sections. So that while there may be reason in this instance for regarding these changes in the small pyramids as the results of actual disease, there is still doubt about it, and I prefer to disregard or exclude the small pyramids entirely from the larger, deeper cells where the lesions are definite, positive, and significant. The Pericellular Spaces. — There is very little to say about the lymph spaces of the ganglion cells. They show no striking changes and are not enlarged. The space about the deeper cells fits fairly closely, and the 96 BRAIN SURGERY. relations of the cells and spaces is especially well pre- served. The spaces of many of the degenerated cells appear very large, but this effect is produced by the atrophy of the enclosed cell. The Basement Substance of the cortex, consisting, as it does, largely of the processes of the ganglion cells, must contain changes corresponding to the degene- rated and destroyed ganglion cells, but such a lesion is entirely too subtle to be recognized at present even with Golgi's methods. Some of the larger isolated processes in the basement substance show with the very highest powers an irregularity of outline of the process. These processes show minute nickings or a jagged outline of the edges. In one such process a clear vesicle was found like those described in the bodies of the degenerating ganglion cells (Fig. 29, a). As regards the distribution of these ganglion cell changes^ they are not especially concentrated about the region of the foreign body, but are scattered all through the sections, even to the lateral boundaries. There is no positive support for making statements about the duration of the ganglion cells degeneration, but the impression is conveyed that the process is an exceedingly slow and gradual one. The cells do not showv the swollen and other appearances of rapid de- generation such as are seen in the acute processes of the spinal cord. It seems probable that these dam- aged cortical cells may persist for a long time in the earliest stages of degeneration before advancing to the later or final stages. TREPHINING FOR EPILEPSY. 97 The Changes in the Neuroglia. — There is a limited and very early stage of hyperplasia of the neuroglia tissue. This statement, however, can be better relied upon if the excessive difficulties attending the de- tection of this stage of a slowly growing neuroglia hyperplasia are indicated. The neuroglia cells appear- ing in ordinarily stained sections as small round cells are very profusely scattered throughout all of the corti- cal layers except in the barren layers, and their true form is only apparent by Golgi's methods. Then again, these cells are irregularly distributed, and vary somewhat in different cortical regions. In some lay- ers they are very thickly aggregated together, and in other layers more sparsely arranged. Thus in this diffusely arranged tissue, without contrast to the surrounding tissues, in determining a slight increase of newly formed neuroglia cells which look exactly like their surrounding progenitors we often have an insol- uble problem. When the young neuroglia cells have become more mature, and possess a larger cell body with beginning branches, a new difficulty arises in their identification, for frequently they cannot be dis- tinguished from the surrounding ganglion cells of the same size. So the earlier diffuse increase of neuroglia is unfortunately liable to escape recognition until the process has become fairly extensively developed. Notwithstanding these difficulties there are a few places in the sections which show quite distinctly clusters of an increased number of a very young and seemingly proliferated neuroglia cells. These are most ■m 98 BRAIN SURGERY. distinctly seen in the layer of small pyramids. In a few places in the layer there are groups of small round cells, which, although they are not sharply circum- scribed, are still so closely aggregated that they stand out more clearly than the remainder of the rather sparsely distributed neuroglia cells of this layer (see Fig. 30). The contrast of the barren layer is also an aid in distinguishing these cell groups. These cells are often arranged in groups of twos or ill -defined r^* ^ Fig. 30.— a Group of Young ]Seuroglia Cells Situated in the Layer of Small Pyramids strings of four to six in number. In two cells only were positive evidences of mitosis discovered, and these are shown in Fig. 30, a, and more highly magnified in Fig. 32, h. In the deeper layers there are some similar groups of increased neuroglia cells, but they are much less clearly defined. Thus the production of neuroglia in the deeper layers is hidden from view, because the normal neuroglia cells are so thickly aggregated that TREPHINING FOR EPILEPSY. 99 the newly formed cells cannot be distinguished from them. In one single instance in all of the sections, a cluster of neuroglia cells on the edge of the specimen, in the deeper layers, was quite circumscribed from the surrounding cells and grouped differently and seemed to be a cluster of proliferated young neuroglia cells. These young neuroglia cells at first seem to be indif- ferent cells. They have a thin, spherical envelope of Fig. 31.— a Group of more Mature Neuroglia Cells in the Layer of Small Pyramids. protoplasm, which at first appears to have no pro- cesses. At a later stage of development the protoplasm in- creases in volume and they lengthen out into spindle or oval -shaped masses and send out branching pro- cesses. Groups of these more mature neuroglia cells were also found in the sections, and they could be identified most clearly in the layer of small pyramids, because here there was no danger of mistaking them for small ganglion cells, for the small pyramids were so universally and thoroughly shrunken (see Fig. 31). 100 BRAIN SURGERY. If there are other groups of these more mature neu- rogha cells in the deeper layers, they cannot be dis- tinguished plainly because of their close resemblance to the small or polymorphous ganglion cells. Fig. 30 at a shows this difficulty of distinguish- ing newly formed neuroglia cells from ganglion cells. These two sets of cells seem to be neuroglia cells ; they have large, glassy cell bodies, and suggest a phase of cell division. Both of these two groups of neuroglia cells were found among the larger ganglion cells of the fourth layer, and are significant in evidencing an overgrowth of neuroglia in this important layer of the motor zone. Finally, in a single instance, a very large mature branching neuroglia cell was found in Fig. 32. —Isolated Neuroglia Cells from Different Layers of the Cortex. A, Two neuroglia cells from the deeper layers, apparently undergoing proliferation. 5, The cells indicated at a in Fig. 30 more highly magnified, which show Karyo- kinetic figures. C, A large spider cell lying alongside of the nucleus of a com- pletely degenerated ganglion cell. the deeper layers, as shown at Fig. 32, c. Lying alongside of this large spider cell is the remains of the nucleus of a degenerated ganglion which may, per- haps, convey a suggestion as to the destiny of the pre- viously described small round cells crowding the spaces of the ganglion cell, but there is no real evidence to connect these two sets of cells together. TREPHINING FOR EPILEPSY. 101 There is then an increase of neuroglia in these sec- tions, and it is of a very early and limited stage of development, and yet the impression is conveyed that only a portion of this growth is apparent in certain favorable situations, as in the narrow layer of the small pyramids. Still there are several indications of neurogliar growth in the deeper layers, as for exam- ple in Fig. 32, inviting the belief that the process is not limited to the region where it may be recognized most easily, but is a diffuse growth and involves the layers beneath the small pyramids, but possibly to a less extent. The neurogliar hyperplasia is irregularly distrib- uted throughout all of the sections, even at a distance from the foreign body, and often occurs in snots or patches. Most of the sections of the depressed region of the cortex show a slight concentration ot the neu- rogliar growth as young, small, round cells or more mature spindle-shaped cells scattered about among the lesser pyramids. This growth of the neuroglia, like the degeneration of the ganglion cells, seems to take place exceedingly slowly. The blood-vessels of the cortex are normal in struc- ture, but in places they are not properly arranged. In places anastomosing networks of capillaries penetrate the cortex from the pia mater and, accompanied by and surrounded by more or less neurogliar increase, appear as wedge-shaped areas in the section. This is shown schematically at Z, Fig. 26. 102 BRAIN SURGERY. Microscopical Examination of Case II. In this case there is a development of rather a large mass of connective tissue which has altered very materially the structure and topography of the con- volutions which it has grown into. In this way the gray matter at the seat of the operation has been irregularly replaced by connective tissue, and has been rather largely converted into neurogliar tissue. The removed portion was a flattened disc and meas- ured about two cm. in diameter and was from five to seven mm. thick; it was hardened in strong alcohol and the celloidin sections were stained in the same way as in the preceding case. The specimen consists of two layers, an outer layer of connective tissue and beneath it a layer of damaged cortex. At one side of the specimen a new layer makes its appearance, from the fact that a bit of the scalp is adherent to the specimen and has been re- moved with it. Throughout the remaining extent of the specimen the scalp is absent and the connective- tissue mass referred to is the outermost layer. Sec- tions from the region of the specimen where the scalp is attached show the appearances in Fig. 33. The scalp (a) with its clusters of fat cells and obliquely cut hair follicles covers and partly surrounds a bit of damaged cortex (c) . The scalp shows atrophic changes of a moderate degree and the attachment to the brain is rather a loose one. The brain, in this particular part of the specimen at any rate, simply lies against TREPHINING FOR EPILEPSY. 103 the scalp rather than being attached to it, and there are no blood-vessels passing from the one to the other. A tongue-like projection of rather dense connective tissue (Fig. 33, h) passes inward from the scalp at one place — just at the edge of the specimen — and tends to partially surround the degenerated fragment of the cortex. This tongue-like mass blends with, or is perhaps a portion of, the extensive lamina of connec- -C.. ~^-0^ CL. Fig. -A Section through the Scalp in Case II., and Degenerated Cortex be- neath showing their Loose Attachment. five tissue forming the upper layer throughout the rest of the specimen (see Fig. 34). The bit of cortex lying underneath the scalp is very extensively changed. The ganglion cells are severely degenerated, many of them are reduced to mere hollow shells or skeletons surrounding the nuclei, and many others must have disappeared entirely. There is also a very perceptible increase in the size and number of the neuroglia cells. Both of these changes have reached such advanced stages that there is no difficulty attending their positive recognition. 104 BRAIN SURGERY. Sections through the centre of the specimen show in a general way masses of dense connective tissue which encroach upon and cause material changes in the con- volutions, as depicted in Fig. 34. Such a section from the centre of the specimen shows three convolutions, A, B, and C, two of which are involved by the con- nective-tissue growth, while a third, A, has escaped this encroachment. The convolution A, although uninvolved by the connective-tissue growth and retaining its proper form and volume, is yet considerably changed. The gan- glion cells are fairly extensively affected by various phases of a series of degenerative changes. Very many of the cells show the earlier and less well- pronounced stages of the degeneration, while a lesser number show the more extensive changes in the cell body tending toward complete disintegration of the cell as described in the previous case. Altogether the degeneration of the ganglion cells in this convolu- tion is so well marked as to do away with the difficul- ties attending the recognition of the very early stages of the same process. The neuroglia of the gray matter does not seem to be increased to any appreciable extent, but the white matter (x) is quite extensively involved by a growth of spindle-shaped and branching neuroglia cells. At the apex of the convolution this neurogliar increase extends a little distance into or seems to follow the passage of the nerve fibres into the gray matter. In the convolution B the dense growth of connec- TREPHINING FOR EPILEPSY. 105 3 g C3 =<; 3^ 2 - 5' t^. < gs (X> a P CD J £ ^ g ^ W U M 3 S^ ;^ ST. (/I J^ i=; St CD p CD q 2 ^ §1 II o 3 3 3 O 3- s; 2 o ^ O r+ o 0" a is- CD CD — CD s O 3- 3 O p. 2j ^. ^ ^ S m O r+ m' <^ tL o p ^ -TS o a§ 2 § C 3 "G FOR ABSCESS OF THE BRAIN. 191 abscess after ear disease is also true of abscess after disease of the nose or orbit. It is thus evident that cerebral abscess produces marked general cerebral symptoms. If to these the local symptoms of aphasia or of cerebellar staggering are added, or if the general pressure of the abscess affects the function of the motor and sensory region, causing hemiplegia and hemianaesthesia of the op- posite side, the situation of the abscess may be esti- mated with sufficient certainty to guide the surgeon in his search. Even when the situation is uncertain, it is his duty to explore. For cerebral abscess is a hopeless condition portending certain death, and some risk may be taken in an attempt to save the patient. The best spot for trephining is one and three-fourths of an inch above and one and one-fourth of an inch behind the external auditory meatus, since at this point the temporo-sphenoidal lobe will be reached with greatest ease.' An attempt has been made by some aurists to approach the brain through the mas- toid cells, but this seems to me to be very bad practice, as the thickness of the bone is great, the position is too low to reach the brain, there is danger of entering the lateral sinus, and it is impossible to lay bare a large region of the brain. We have seen already that large openings in the skull are preferable to small ones, as they are less liable to be followed by hernia cerebri, and give the surgeon plenty of room, and ^ See Birmingham : Dublin Jour. Med. Sci. , Feb. , 1891. 192 BRAIN SURGERY. they are specially desirable in trephining for cerebral abscess near the base of the brain, for it may be nec- essary to explore the brain, in these cases with a large aspirating needle and subsequently to drain the ab- scess if it is found. Ballance,' in an admirable article on the operation of trephining for the removal of pysemic thrombi from the lateral sinus, gives a figure which I here repro- duce and which shows the relations of the external meatus to the brain, to the lateral sinus, and to the cerebellum; and the best positions for trephining to reach the various parts (Fig. 54) . It occasionally happens that abscesses developing after ear disease are so superficial that there is a marked tenderness of the scalp and bone over them, but, as a rule, abscesses lie very deep within the white matter of the brain, and to be reached and emptied the brain must be incised. Horsley has invented an ex2)loring instrument for this purpose which is very useful — a cylindrical speculum, long and pointed, and so divided that its sides can be separated gently after it has been thrust into the brain. Even with this in- strument the wall of the abscess may be pushed on- ward and not perforated. The pus is entirely too thick to be withdrawn by an ordinary hypodermic syringe. When the abscess has been evacuated it must be washed out and drained. It usually heals slowly, and constant care is necessary to prevent the occurrence of a secondary meningitis. 1 Lancet, May 17th, 1890. TREPHINING FOR ABSCESS OF THE BRAIN. 193 Fig. 54.— Lateral Aspect of a Small Adult Skull (Ballance). The illustration shows the relations of the lateral sinus to the outer wall of the cranial cavity and the position of the trephine opening (a) which should be made when it is deemed necessary to expose it. The base line (Reid's) passes through the middle of the external auditory meatus and touches the lower margin of the orbit ; it is marked out in eighths of an inch, as are also the perpendicular lines drawn from it. The measurements are made along the base line from the middle of the bony meatus. The drawing also shows the convolutions of the temporo-sphenoidal lobe, the Sylvian flssiu"e, and the position of the lower end of the furrow of Rolando (Rol.). ccx indi- cates the site of the tentorium as far as it is in relation to the external boundary of the skull. The anterior x shows the point where the tentorium leaves the side of the skuU and is attached to the superior border of the petrous bone, a, Trephine open- ing to expose sinus, five-eighths of an inch in diameter, its centre being one inch be- hind and a quarter of an inch above the middle of the bony meatus. This opening can easily be enlarged upward and backward and downward and forward (see the dotted Unes) by suitable angular cutting bone forceps. It is always well to extend it forward, so as to open up the mastoid antrum (c) and the gutter of the carious bone (if there be one) which leads from the antrum, tympanum, or meatus down to the bony groove. The position of the trephine openings which must be made for the rehef of inflammatory intra-cranial affections secondary to disease of the ear other than for sinus pyaemia have been added to the drawing for the sake of contrast and completeness. They are as follows : fo. Trephine opening to explore the anterior surface of the petrous bone, the roof of the tympanum, and the petro-squamous fis- sure, half an inch in diameter, its centre being situated a short inch (seven-eighths of an inch) vertically above the middle of the meatus. At the lower margin of this tre- phine hole a probe can be insinuated between the dura and bone and made to search the whole of the anterior surface of the petrous, c. Trephine opening for ex- posing the mastoid antrum, a quarter of an inch in diameter, and half an inch behind and a quarter of an inch above the centre of the meatus ; or a quarter of an inch above the centre of the meatus and a quarter of an inch behind its posterior border. The trephine should be directed inward and slightly downward and forward. When a superficial disc of bone has been removed it is well to repeat the operation with the gouge. A larger trephine may with advantage be employed, especially in adults, d, Trephine opening for temporo-sphenoidal abscess, half an inch in diameter. Situa- tion recommended by Barker, one inch and a quarter beliind and one inch and a quarter above centre of meatus. The needle of the aspirator is to be directed at first 13 194 BRAIN SURGERY. inward and a little downward and forward. Birmingham prefers one and tliree> fourths of an inch above in order to avoid the lateral sinus, e, Trephine opening for cerebellar abscess half an inch in diameter and one inch and a half behind and a quarter of an inch below the centre of the meatus. Birmingham prefers two inches behind and one inch below to avoid the occipital artery. The anterior border of the trephine should just be under cover of the posterior border of the mastoid process. The drawing shows that a trephine hole made in this situation is far away from the lateral sinus, and that the trocar and canula of the aspirator, if directed forward, inward, and upward, would hit an abscess occupying the anterior part of the lateral lobe of the cerebellum, which is the usual site of collections of pus in this part of the brain. Cases of Abscess of the Brain Successfully Opened. Stimson has reported the following interesting case : M. D., aged 39, took cold and developed an acute otitis media with discharge of pus from the left ear in Decem- ber, 1890. A month later he was admitted to the New York Hospital suffering from the chronic ear discharge and from severe pain in the left side of the head. He had had a convulsion two days before his admission and had been in a semi-comatose condition with intervals of rest- lessness and delirium since. On admission there was tenderness on pressure over the mastoid process but no redness or oedema. Pupils were normal; temperature 102°. He remained in a semi-comatose state for six days, growing worse, and then Dr. Stimson operated. A curved incision was begun behind the base of the mastoid process and carried forward and upward, passing close to the ear for about four inches ; the flap was reflected, the bone ex- posed, and an opening three-fourths of an inch in diameter made through it with a chisel above and slightly behind the external auditory meatus in the posterior part of the squamous portion of the temporal bone. An incision through the dura gave exit to about three ounces of pus. The finger passed freely upward and backward. It was thought that an abscess had formed between the meninges and not in the substance of the brain, and that it had es- pecially compressed the posterior part of the temporal lobe TKEPHINING FOR ABSCESS OF THE BRAIN. 195 in its inferior and outer surfaces. A drainage tube was inserted and the wound closed. A few hours afterward his mental condition had im- proved and pain was less. The improvement was progres- sive and the wound healed six weeks after the operation. Meanwhile his cerebral functions presented interesting features. During the first fortnight he seemed intelligent, but unable to comprehend his surroundings; he would listen intently when addressed and answer inarticulately, occasionally uttering a word that could be understood but which was usually unrelated to the question. It was not until the second week that he could name objects. He still failed to recognize faces at the end of the fourth wxek and was still unable to read. A month after the opera- tion he began to remember things, and then little by little the recollection of the past and of his illness returned; but he had no memory of his admission to the hospital or of his first month's stay. He spoke of the difficulty he had had in calling things by their right names, and said the difficulty still persisted although it was very much less. He also had difficulty in reading. He could write his name rapidly. Thare was no paralysis but his walk was feeble. He eventually recovered entirely. — N. Y. Med. Jour., May 30th, 1891. The following case, which is described by Von Berg- mann,' offers a good illustration of the history of an abscess secondary to ear disease: The patient had suffered from time to time during fifteen years from a purulent discharge from the ear, with occa- sional earache. The pain suddenly became more severe than usual and he began to have attacks of vertigo ; in the course of a few days his appetite failed; he began to feel sick and to have chills and fever at night. At the same time headache became very severe and kept him awake at 1 " Die Chirur. Behandl. d. Hirnkrankh. , " p. 59. 196 BRAIN SURGERY. night; this headache was general, but more intense upon the right side, which was also tender to percussion. When admitted to the hospital, a few days after these acute symptoms had begun, he gave the impression of being a very sick man ; was apathetic and stupid, and answered questions with difficulty and slowly; his skin was slightly yellowish and his tongue thickly coated ; his temperature was 99° and pulse only 50 ; there was a slight difference in the power and sensation of the extremities, his left arm and leg being somewhat weaker and less sensitive than the right ones. There was an occasional twitching in the right side of the face ; the pupils were equal and re- acted promptly ; the right ear was filled with granulations and was discharging pus; the hearing was much dimin- ished. The mastoid process was not swollen or tender, but percussion above the ear over the temporal lobe was very painful. The symptoms mentioned increased in intensity during the following week ; his pain became greater and his men- tal condition more stupid. Yon Bergmann then trephined above the ear, exposing a space 3 cm. square. The dura pulsated, and when it was divided the brain bulged into the wound. Incision into the brain did not at first reveal the abscess, but the third incision directed somewhat for- ward gave exit to 30 c.c. of fetid green pus. Exploration by the finger showed the abscess cavity with a thick wall. This was washed out with iodoform ether and drained by a tube 4 cm. long; the tube was surrounded by layers of iodoform gauze which protected the brain and membranes from contact with the pus, and the wound was thoroughly washed out before being dressed. The pulse rose from 50 to 88 as soon as the pus was dis- charged ; a daily change of dressing with a progressive closing of the abscess followed, so that on the ninth day the drainage tube was shortened, and by the end of the sixth week the wound had entirely healed. From that time for a year following the patient was in perfect health. TREPHINING FOR ABSCESS OF THE BRAIN. 197 Another case is the following by Barker : ' Male, aged 33. Previous trouble in right middle ear, and epileptic attacks when young. In 1886 weakness and coldness in right leg; subsequently severe headache; tenderness over mastoid and right occipital regions. January 23d, 1887, two epileptic spasms within an hour; right side of body convulsed; subsequently unsteady gait, staggering to the left, and contraction of right pupil. January 25th, mastoid trephined in usual way; no pus found. Later, became semi-comatose, with paresis of left arm, and right pupil dilated. Diagnosis : Suppuration over or in arm and face centres of right side. February 3d, 1887, operation. Trephine applied over fissure of Rolando ; dura bulging ; serum found at depth of an inch and a quarter; when an inch and a quarter behind ex- ternal meatus, pus found at considerable depth, and nearly half an ounce removed ; abscess cavity drained by rubber tube, after which as much more pus escaped. Serious collapse of patient; reaction finally established. Patient soon convalesced, made nearly complete recovery. Von Bergmann records seven other successful cases of operation for brain abscess quite similar in their history to his own.^ Other cases have been success- fully treated by Truckenbrod, Poulsen, Mayo, Pritchard, Cheyne, Paget, and others, and the records of the past three years show that a con- siderable percentage of cerebral abscesses secondary to ear disease, which have been accurately diagnosti- cated, have been reached by the surgeons and emptied. Inasmuch as this disease had been uniformly fatal ' Brit. Med. Jour. , 1888, April 14th. ^ These cases are by Schede (1) , Barker (3) , Greenfield, Macewen (2), Horsley. 198 BRAIN SURGERY. before the treatment by trephining was introduced, success in its treatment must be reckoned as among the brilliant results of modern brain surgery. Abscess secondary to disease of the nasal cavity is less common than after disease of the ear. It is usually frontal in situation and produces no distinctly localiz- ing symptoms. Park ' has recently reported a case of abscess devel- oping in the frontal lobes after the removal of a polyp from the nose. The patient developed general cerebral symptoms about four weeks after the operation and became unconscious. In the comatose condition there were no localizing symp- toms whatever, and it was from inference rather than from any safer guide that Park decided to explore the frontal lobe. He raised a frontal flap and trephined above the orbit on the side from which the polyp had been removed. Exploration with a needle finally revealed an abscess cavity from which 12 c.c.of pus was evacuated. The cavity was drained with rubber tubing and the wound was closed and dressed. The patient died the following day. An autopsy showed the existence of a second abscess in the other frontal lobe corresponding in situation to the abscess opened. Conclusions. Whenever severe cerebral symptoms develop rapidly after an injury to the head which has broken the scalp, or after an operation upon the nose, orbit, or ear, or during the progress or subsequently to an otitis media or chronic nasal discharge, an abscess of the brain ' Med. News, Dec. 3d, 1892. TREPHINING FOR ABSCESS OF THE BRAIN. 199 must be thought of. If other conditions can be ex- cluded, and if the situation of the abscess can be de- termined either by a study of the local symptoms or by a knowledge of the cause producing it, an opera- tion should be undertaken at once. The earlier the surgeon is called in the better the chance of the patient. The opening in the skull should be large enough to allow of free exploration of the brain and to secure free subsequent drainage. The drainage should be kept up until the abscess cavity closes from the bottom. Every endeavor should be made to pre- vent the pus from coming in contact with the mem- branes. The wound should be dressed frequently and kept clean. The general condition of the patient should be attended to, so that every opportunity for recovery may be afforded. CHAPTER VI. TREPHINING FOR TUMOR OF THE BRAIN. The Frequency and Varieties of Tumors in the Brain. Analysis of Six Hundred Tumors. Tumors in Children Contrasted with Tumors in Adults. The Diagnosis of the Nature of the Tumor. The Diagnosis of the Situation of the Tumor. The Percentage of Brain Tumors Open to Operation. The Results of Operation for Brain Tumors. Analysis of Ninety-seven Cases. I. Cerebral Tumors. Selected American Cases. Personal Case. Tumor of Frontal Lobes. II. Cerebellar Tumors. Diagnosis. Difficul- ties of Operation. Three Personal Cases. Table of all Brain Tumors Operated upon. Conclusions. Until a recent date the interest in a case of tumor of the brain appeared to end with the diagnosis, for prognosis was hopeless and treatment except in tumors of syphihtic origin was useless. But with the advance in the power to diagnosticate the nature and exact position of tumors came the possibility of turning that power to a practical use. And the marvellous development of aseptic surgery opened the way to achievements in the removal of brain tumors more brilliant than in any other field. The work of Macewen, Durante, Horsley, Weir, Keen, and Park, and the later successes of Von Bergmann, Czerny, Lucas Championniere, Troissier, McBurney, Deaver Gerster, and others, have placed upon a sure and permanent basis the surgery of the brain. And in no department of thi^ field of surgery have the re- TREPHINING FOR TUMOR OF THE BRAIN. 201 suits been more striking and successful than in the excision of new growths. These facts have lent a new interest to the study of brain tumors. It is essential to investigate their fre- quency, their varieties, their various situations, their structure, and their diagnosis, and thus to reach some estimate of the prospects of success in their treat- ment by the trephine. The Fr^equency and Varieties of Tumors of the Brain. Authorities agree that brain tumors occur with about equal frequency in childhood and in adult life. Gowers states that one-third of the cases occur in per- sons below the age of tw^enty, so that it would seem that children were somewhat more liable than adults to this disease. In the list of organic nervous diseases of childhood cerebral tumor stands high, being only exceeded in frequency by meningitis, infantile spinal paralysis, and cerebral hemorrhage. In adult life it does not hold as conspicuous a place, being mentioned after cerebral hemorrhage, embolism, and thrombosis, and being less frequent than locomotor ataxia and than paretic dementia. Some years ago I made a collection of 300 cases of brain tumor in children and youths, deriving the cases from Bernhardt 's and Steffan's collections and from the journals published prior to 1888. The table then prepared is here reproduced, as it demonstrates the varieties and most common situation of these tumors in childhood. 202 BRAIN SURGERY. To afford some information with regard to the points of difference between tumors in childhood and in adult life, I have now prepared a second table con- taining 300 tumors occurring in persons above the age of twenty. These have been collected from Bern- hardt's tables; from my own collection of American cases of cortical lesion; from Br am well's book, and from the critical digests by Bernhardt in Virchow's Jahresbericht from the years 18S8 to 1892 inclusive. Table II.— Brain Tumors in Children and Adults. Situation. Mi .2 5 il 6 w a 3 6b s 6 3 1 o 1 -3 g I. Cerebral axis : 1. Basal ganglia and lat- eral ventricles i 14 3 3 9 5 8 1 1 1 2 1 3 5 27 34 2. Corpora quadrigemina and crura cerebri.... 16 1 1 2 3 2 5 1 1 7 21 14 3. Pons 19 11 10 5 1 2 1 2 3 1 38 17 4. Medulla 2 1 2 1 6 2 5 Base 3 2 1 1 3 1 1 1 1 1 4 1 1 11 s 4 6. Fourth ventricle 1 1 2 5 II Cerebellum 'IT S' 15 «^ 10 13 J fi ^ 11 3 10 OR 45 M '^ o ^ 5 *> 3' 43 17 IV Cortex cerebri IS f)! fi in I H 'i! 1 11 13 1o ''1 107 V. Centrum ovale 6 2 1 11 5 1 1 4 15 1 3 1 5 4 35 51 152 41 \S7 54 |34 86 5 25 30 2 10 33 2 20 30 41 300 300 The first columns are children's tumors; the second columns adults' tumors. It will be noticed in comparing these tables that the relative frequency of the different varieties of tumors differs in children and adults, tubercular tumors pre- ponderating in childhood, but being relatively infre- quent in adult life. Glioma and sarcoma appear to be about equally frequent in childhood, but in adults sarcoma is more frequent than any other tumor, glioma being the next in frequency. Carcinoma, as would naturally be ex- TREPHINING FOR TUMOR OF THE BRAIN. 203 pected, is more frequent in adults than in children, so also is gumma. It is rather singular that so few gummata have been recorded in literature. It is my impression, de- rived from clinical observation, that gumma is the most frequent form of brain tumor occurring in adults. Eumpff in his book upon "Syphilis of the Nervous System" has been able to collect a very large number of gummata of the brain and has described this class of cases fully. That gumma may be ab- sorbed by specific treatment is a fact which the ma- jority of syphilographers hold and which, my own ex- perience confirms ; it is, however, denied by Horsley, who recommends operation for gumma as well as for other tumors. It seems to me that the infrequency with which gummata are recorded in literature as having killed the patient would indicate that, though these tumors may be frequent in occurrence, they are susceptible to medical treatment and do not prove as fatal as other tumors do. Cystic tumors of the brain may arise either in con- nection with glioma or glio-sarcoma or independently as the result of parasitic infection. Hydatid cysts, echinococcus, and cysticercus are very much more fre- quently met with in the German and Australian records than in English or American journals. Kiichenmei- ster, in an article on this subject, has collected 88 cases, but I have not included them in the table, as they would give an appearance of undue frequency of this disease, which would mislead. In America a cerebral cyst of 204 BKAIN SURGERY. parasitic origin is a curiosity, and but few cases are to be found in our journals. Cysts which are merely the result of preceding softening or hemorrhage are not to be reckoned among tumors, as they do not produce symptoms of tumor. Primary carcinoma of the brain is a great rarity. Among the cases tabulated are four which invaded the brain secondarily, after beginning in the retina of one eye, a not infrequent form of the disease in child- hood; the remainder being secondary to carcinoma elsewhere in the body. In comparing this list of the relative frequency of the various forms of tumors with smaller lists, I find that the relative frequency is about the same in all lists ; and therefore I think that this may be consid- ered fairly reliable, though statistics are always to be looked at with care. The diagnosis of the kind of tumor present is always a matter of probability in any case ; and hence such a list has a certain diagnostic value. It will, of course, occur to any one in the presence of a child with brain tumor to inquire carefully into any history of hereditary tendency to tubercular disease, and to examine carefully for other evidence of tuberculosis, such as enlarged glands, scrofulous joint disease and phthisis, chronic diarrhoea, etc. Occasionally the tu- bercular tumor has been found, after death, to be the only manifestation of infection, but this is not the rule. Tubercular tumors are so frequently multiple that the occurrence of local symptoms pointing to TREPHINING FOR TUMOR OF THE BRAIN. 205 more than one tumor will also point to tubercular tumors. The determination of the question as to the existence of tubercular disease is of the greatest im- portance, in view of the possibility of surgical interfer- ence. Supposing that a brain tumor is diagnosticated and is located in a place accessible by trephining : if it is thought to be tubercular is an operation justifiable? Such an operation may prolong life, but the disease may reappear in the brain or elsewhere. The opera- tion is certainly attended by greater danger than in a non- tubercular person. Yet the existence of tubercu- losis does not prevent the surgeon from attacking tubercular joints or tubercular testicle. Should it prevent his attacking a brain tumor? Von Berg- mann ' thinks that it should, affirming that it is im- possible to remove the cheesy masses from the soft brain coverings and tissue with the thoroughness that is possible in dealing with bones. He claims that the operation will be incomplete, and that a relapse is then certain. In support of this view is the fact that a tubercular tumor of the brain was recently removed at St. Luke's Hospital in this city by Dr. B. Far- quhar Curtis from a patient of Dr. J. A. Booth, but within three months it had recurred. English surgeons have taken a different view, and have re- moved successfully several tubercular tumors com- pletely without relapse. But further experience is certainly necessary before any rule can be laid down in the matter. The greatest drawback met with in ' "Chirurg. Behandl. d Hirnkrankheiten, " p. 58. ^06 BRAIN SURGERY. dealing with tubercular tumors by surgical measures is the possibility of the presence of more than one tumor, the failure to detect and remove more than one, and the consequent need of a second operation when the second tumor develops sufficiently to give rise to special symptoms. If there is no probability in a case of tumor that tubercular disease is present, the diagnosis of the kind of tumor present is difficult. Carcinoma of the brain, though in a few cases pri- mary, is usually secondary to carcinoma elsewhere. Should such a tumor be found in the body, especially if it should be found in the orbit and in connection with the retina, the diagnosis of the nature of the cerebral tumor can be made. Otherwise it cannot be thought probable. To remove a secondary cancer in the brain when the primary cancer remained would liardly be undertaken by any good surgeon. Gumma is the form of tumor most likely to develop in adults, but unless there is a distinct history of ac- quired syphilis with other sy^^hilitic manifestations, and unless nocturnal headache and insomnia are pres- ent, the diagnosis will be uncertain. The test of spe- cific treatment should be applied in every case. Horsley limits the duration of medical treatment to six weeks. I would urge that unless the tumor is far advanced a more thorough trial be given. If no re- sult in the amelioration of symptoms is obtained in three months it is probable that further treatment will avail nothing. TREPHINING FOR TUMOR OF THE BRAIN. 207 Cysts in the brain of parasitic origin form very slowly, never destroy but always displace the brain tissue, and rarely, if ever, give rise to localized symp- toms. In a case of brain tumor in which the symp- toms are all general and not local the possibility of cyst should not be overlooked, and the child's history should be investigated in regard to any exposure to infection, the presence of tapeworm or of hydatid tumors elsewhere. There is no reason vfhy such cysts should not be removed. The remaining varieties of tumor — glioma, sarcoma, or glio-sarcoma — cannot ])e absolutely differentiated from each other. Occasionally sarcomata in other regions of the body may lead to the suspicion that there is one in the brain, but secondary sarcomata are relatively rare in the brain. Hence this point of diagnosis is not to be relied upon. Glioma and sar- coma may be equally slow in growth, may produce very marked symptoms or none at all, and do not differ markedly in their selection of situations in which to develop. Bramwell believes that glioma starts in the white matter and invades the gray matter. Zie- gler afSrms the contrary, and the cases here cited cer- tainly confirm the statement of the German patholo- gist; but from, a disputed pathological question no diagnostic conclusions can be drawn Nor does the mode of origin throve any light upon the differentia- tion of sarcoma and glioma, for both result from blows and falls upon the head with equal frequency. There is but one fact which may make a differen- 208 BRAIN SURGERY. tiation possible, viz. , that glioma is usually very vas- cular, much more so than any other tumor. A tumor which is vascular varies very much in its size, being, as it were, erectile. Variations in size within the brain are impossible, but the corresponding condition to erection in such tumors is an increase of intracranial pressure. Variations of intracranial pressure mani- fest themselves, subjectively, by varying intensity of symptoms, and by the possibility of modifying symp- toms by means of agents which affect the blood pres- sure, and objectively by the state of venous congestion of the retina. Furthermore, in glioma, hemorrhages within or near the tumor sometimes occur, giving rise to symptoms of apoplexy. Therefore, in a case of tumor, great and sudden changes of intensity in the symptoms, accompanied by visible changes of circula- tion in the retina, and affected in one way or another by such measures as hot baths, cold douches to the spine, hot mustard baths to the feet, or free watery purgation, will indicate a vascular tumor, probably a glioma. And this diagnosis will be reinforced by the occurrence of attacks apoplectic in character in the course of the case. And yet there are cases of glioma in which the tumor is quite hard and encapsulated, and in which these symptoms will be wanting. But there is a practical application of these points of diagnosis regarding the vascularity of the tumor in view of surgical interference. The form of tumor most suitable for removal is the hard, encapsulated, non-vascular tumor. That is the usual form of sar- TREPHINING FOR TUMOR OF THE BRAIN. 209 coma, and is occasionally the form of glio-sarcoma but not of glioma. A case, therefore, is much more suit- able for operation in which no vascular symptoms, such as those mentioned, are present, whether it be sarcoma or glioma. And, vice versa, a tumor showing marked vascular symptoms will not be a favorable one for operation, no matter what its variety or position. Passing now^ from the consideration of the varieties of brain tumor and their differentiation, let us look at the situation of the tumor. The Situation of Bi^ain Tumors. It is evident from Table II. that all parts of the brain maybe invaded by tumor, but that certain parts are invaded with special frequency both in childhood and in adult life. These parts are the cerebral axis and the cerebellum in children and the cortex in adults. By the cerebral axis is meant that part of the brain which includes the basal ganglia and internal cap- sule ; the corpora quadrigemina and crura cerebri ; the pons and the medulla oblongata (Fig. 55) ; and which lies upon the cranial floor and is therefore invaded by tumors lying upon the base of the brain. Of the 600 tumors collected, 185 were in the cerebral axis. The diagnosis of such tumors is not difficult, as they usu- ally give rise to very numerous local symptoms, chiefly those of involvement of the cranial nerves. It is not my purpose to discuss these here : they may be found in all the recent articles upon the local diagnosis of cerebral disease. The point of interest is that no case 14 210 BRAIN SURGERY. of tumor of the cerebral axis can be reached by the surgeon. The situation of the parts is such that a tumor in them is not near enough to the convex sur- FlG. 55.— The Cerebral Axis, Basal Ganglia, Crura, Pons, and Medulla, with the Cranial Nerves.— Allan Thompson. face of the skull to be accessible (see Fig. 56). And therefore, in estimating the number of the cerebral tumors in this collection which might have been the TREPHINING FOR TUMOR OF THE BRAIN. 211 subject of surgical treatment, this class, constituting one-third of the number, must be at once excluded. Coming next to tumors of the cerebellum, we find Fig. 56.— Photograph (Fraser) of a Dissection showing the Situation of the basal ganglia, cerebellum, pons, medulla, and spinal cord, and their relation to the other parts. The entire cortex of the left hemisphere has been removed so as to expose the basal ganglia and the left cerebellar hemisphere. that they number 141. They are twice as common in children as in adults. Thus in a collection of American cases of cerebral tumor without res'ard to 212 BRAIN SURGERY. age which I have made, I find that of 45 cerebral tumors 3 occurred below the age of nineteen, while of 29 cerebellar tumors 11 occurred below the age of nineteen. It is, therefore, evident that children are es- pecially liable to develop cerebellar tumors. The re- sults of attempts at the removal of cerebellar tumors will be carefully considered further on in this chapter, but it may be stated here that they are most difficult to reach or to remove. Multiple tumors form the next class in the table, 60 in number, and these must be at once dismissed as outside the field of operation at the present time. It may be remarked in passing that where numerous local symptoms are present in a case which cannot be explained by a single lesion, the diagnosis of multiple tumor is justifiable. The remaining classes are tumors of the cortex and tumors of the centrum ovale, not deep enough below the cortex to involve the basal ganglia, 56 in number in children and ITS in number in adults. Both these classes of tumors can be reached by the surgeon. There are no especial indications for their detection and, removal in children as distinguished from adults, hence they may be considered together. As to the differentiation of cortical from subcortical tumors, that is still impossible, tumors near the cortex giving rise to the same symptoms as cortical tumors. Let us now look at the situation of these tumors in the various parts of the accessible cortex, so far as the histories enable one to classify them. TREPHINING FOR TUMOR OF THE BRAIN. 213 Table III. — Tumors Open to Operation. Cortex and Centrum Ovale. Tuber- cle. Gli- oma. Sar- coma. Glio- Sarc. Cyst. Carci- noma. Gum- ma. Not Stated. Frontal Central Parietal Occipital Temp, splien. . 9 3 1 27 9 11 3 ? 26 13 22 ~3 4 8 50 6 1 1 8 4 i 5 5 3 2 5 3 18 4 7 2 13 9 6 1 1 17 Of this total of 164 tumors near enough to the sur- face of the brain to have been reached by the surgeon ' there were 46 in which an operation was clearly indi- cated from the general and local symptoms, and there were 37 in which had the attempt been made the operation would probably have been successful. Thus out of 600 tumors 37 could have been removed, i.e., about 6 per cent. It would require too much space to give in detail the history of each of these cases and to discuss the reasons for and against an operation. Suffice it to say that this conclusion is reached by a study of the local symptoms which during life would have given distinct evidence of the situation of the disease, and by a con- sideration of the pathological condition found at the autopsy which demonstrated whether the removal of the growth during life could have been accomplished. Many tumors in this collection could have been diagnosticated and located, but could not have been removed had the attempt been made. Others could have been removed, but the symptoms did not point - The remaining 70 were inaccessible. 214 BRAIX SURGERY. with sufficient clistiuctness to the situation to give an adequate guide to the surgeon. The majority of the removable tumors were encapsulated sarcomata lying on the cortex in the central region and giving rise to spasms and to paralysis. Three of the occipital tumors producing hemianopsia and five of the frontal tumors causing aphasia might have been removed. The large majority of the gliomata and of glio-sarco- mata were infiltrated in the brain substance to such an extent as either to have escaped detection at an operation or to have been impossible of excision. The same is true of the carcinomata. Many of the tuber- cular tumors were multiple, and when one might have been reached the others wotild have eluded diagnosis. There were several cases of tumors within the brain either in the optic thalamus or in one lateral ventri- cle, which demonstrate how both diagnosis and opera- tion might fail. In these cases the symptoms might easily have led to a diagnosis of cortical tumors in the motor area, but had an operation been undertaken no tumor would have been found. Such cases should serve as a warning. They teach that under the most careful examination diagnosis is never absolutely ac- curate, and that many operations must necessarily be exploratory. This latter fact, however, is familiar to surgeons, and need not prevent the progress of cere- bral surgery. It may be remembered that in a review of 100 tumors in the museum of Guy's Hospital. Dr. Hale White found 10 which might have been removed safely. His TREPHINING FOR TUMOR OF THE BRAIN. 215 percentage, 10 per cent, is larger than my percentage — 6 per cent including tubercular tumors. Mills and Lloyd found 10 cases in their collection of 100 which could have been operated upon. Knapp found but 2 cases in his collection of 40 cases, and he estimates that Y per cent of the 4S5 cases tabulated by Bern- hardt could have been removed. Dana states that 5 cases in 29 under his observation could have been removed. If we add these together the result is 7 per cent for operation. ' This conclusion appears to be very unfavorable to surgical interference in brain tumors. It is to be re- membered, however, that in many cases the patients were only observed in a late stage of the tumor, when it had grown to such a size that early local symptoms were obscured, as they are likely to be, by later symp- toms. And it is also to be remembered that at present the observation of nervous symptoms is more careful and accurate than in former years, and that many cases now come under observation at an earlier stage than formerly, so that the diagnosis can be made be- fore the tumor has made much progress. Turning now from these theoretical considerations, let us see what have been the results of experience in the removal of brain tumors. Analysis of Operations for Removal of Tumors. The number of cases of tumor of the brain in which surgical relief has been attempted up to the present ^ See also Knapp : " Intracranial Growths. " Cerebellar. Total 16 97 9 35 216 BRAIN SURGERY. time, so far as I have been able to find them in cur- rent Hterature, and including my own cases, is 97:' 81 of these were tumors of the cerebral hemispheres; 16 of them were tumors of the cerebellum. The re- sults of these cases are stated in the table given below : Table IV. — Table of Eesults of Operation for Brain Tumor. Cerebral. Total number of cases operated upon 81 Cases in which tumor was not found 26 Cases in which tumor was found but not removed 1 2 3 Cases in which tumor was removed and patient recovered 39 3 42 Cases in which tumor was removed and patient died 15 2 17 It will be seen that the percentage of recoveries after the successful localization and removal of the tumor is 46 per cent. Considering how recently the facts of localization have been determined and how novel is the surgical procedure of operation upon the brain , this large percentage of successful results is both interesting and encouraging. It makes it imperative that every case in which a tumor of the brain is sus- pected should be studied with increased care, and that 1 The literature is extensive. Recent important articles are as follows : Weir andSeguin, Amer. Jour, of Med. Sci., July, August, and September, 1888. Keen, Amer. Jour, of Med. Sci., November, 1888. Park, " Surgery of the Brain, " Transactions of the Association of Amer. Physicians aud Surgeons, 1889. Von Bergmann, "Die Chirurgische Behandlung von Hirnkrankheiten, " 1889. P. C. Knapp, " Intracranial Growths, " 1891 ; the last contains tables of all cases up to June, 1891. Theodore Diller, the Pittsburgh Medical Review, Oct., 1892. Articles in Virchow's Jahresbericht and in Sajous' Annual. TREPHINING FOR TUMOR OF THE BRAIN. 217 the question of operation should be thorouglily con- sidered. It seems best to distinguish broadly between tumors of the cerebral hemispheres and tumors of the cerebel- lum. The diagnosis between these two conditions is perfectly easy, and the risk of operation in the two conditions is so different as to demand their separate consideration. First. Cerebral Tumors. As shown in the table, 81 tumors of the cerebral hemispheres have been treated surgically. In 54 cases out of these 81 the tumor has been suc- cessfully located and removed from the brain. Thirty - nine of the patients recovered, 15 died. Of these 54 tumors 43 have been removed from the motor (central) region of the brain. It is in this re- gion that the location of a tumor can be most easily determined and in which few mistakes of diagnosis have been made. The occurrence of spasms or of paralysis limited to one limb, or extending from one to the others in a definite order, is diagnostic. In one of my own cases the motor symptoms were certainly of the greatest service in determining the location of the tumor. So too in a case reported by Erb in July, 1892, in the Deutsche Zeitsclirift filr Nervenheilkunde. This case deserves mention on account of its unique history. The patient was a male and had suffered from the gen- eral symptoms of brain tumor, viz., headache, vertigo, vomiting, and optic neuritis, for some months. The de- 218 BRAIN SURGERY. velopment of occasional spasms followed hj paralysis in the left arm and leg indicated the central convolutions of the right hemisphere as the probable position of the tumor. Czerny operated in November, 1890, and found the tumor to be an infiltrated glio-sarcoma, and removed a part of it, its complete extirpation being impossible. The patient recovered from the operation, was very much improved for eight months, and then began to suffer again from the old symptoms. In November, 1891, his condition had be- come so bad that it was thought best to repeat the opera- tion. The tumor was found to have grown again, and again a large part of it was removed. Again improve- ment was very striking, but at the date of the report, July, 1892, a third operation upon this man was in contempla- tion, the symptoms having again appeared. It is evident that in such a case where the complete extirpation of the growth cannot be attained, ultimate success cannot be expected. Yet this case demon- strates the possibility of relieving the serious symp- toms and of prolonging life in, a disease formerly con- sidered incurable. The operation may be compared to that of removal of cancer of the breast, which pro- longs life even at the risk of recurrence. The location of the tumor in the remaining 23 cases was as follows: in the frontal region in 5, in the parietal region in 1, in the occipital region in 2. In the remainder the location was not exactly stated in the history. Occipital tumors can be so easily diag- nosticated by the existence of hemianopsia that it seems singular that but two have been removed . Parie- tal tumors give rise to sensory symptoms associated with motor symptoms, and when in the left hemisphere TREPHINING FOR TUMOR OF THE BRAIN. 211) they also produce symptoms of sensory aphasia of the variety known as word-bHndness or alexia. It must be confessed, ho vf ever, that the diagnosis of tumors in tliis location is much less certain than that of tumors in the motor zone. Tumors in the left temporal lobe also produce sensory aphasia of the variety of word- deafness. Mental changes and secondary motor symp- toms occur in tumors of the frontal region. They v^ill be more fully discussed in connection with one of the cases here recorded. In 25 cases the operation was unsuccessful be- cause the tumor was not found by the surgeon at the point at which it was supposed to lie, or be- cause the operation was undertaken for the relief of the symptoms caused by intracranial pressure and not with a view to the removal of the tumor (8 cases). In some of these cases the local symptoms were clearly insufficient to indicate the position of the tumor, and a cautious neurologist would not have advised an at- tempt to find it. In other cases the local symptoms were well marked and the diagnosis seemed clear, yet the tumor really lay at such a depth as to be inacces- sible, or was so infiltrated in the brain as to make its removal impossible. These cases must necessarily be counted as failures in the estimation of the percentage of success. Yet exploratory operation is not to be condemned, for we are dealing here with a hopeless disease, and it is proper to make an attempt to save the patient even though that seem to be desperate. It is evident, therefore, that tumors have been sue- 220 BEAIN SURGERY. cessfullv diagnosticated and removed from almost all parts of the convexity of the cerebral hemisj^heres. It is impossible either to satisfactorily diagnosticate or to remove tumors lying on the median or basal sur- faces of the cerebral hemispheres, and no attempt at such removal has been made. It is impossible to give any detailed history of all of these cases. I select a fev American cases in which the diagnosis was clear both as to the nature of the dis- ease and as to its location, and in all of which the tu- mor was found at the operation. Selected Cases of Brain Tumors Removed. HiRSCHFELDER and MoRSE.— M., 33, in August, ISS-t, began to have j^ain in back of head and vertigo. Later he noticed dimness of vision and stiffness and weakness of left leg, then of left arm with occasional epileptic attacks and twitching of left side of face and left leg. When seen in February, 1SS6. he had frequent spasms of the left side, beginning in the arm, and a condition of left hemiplegia with loss of muscular sense in the left arm and anaesthesia of left face and general symptoms of brain tumor. Diagnosis was a tumor in middle part of posterior cen- tral convolution. Trephined February 15th, ISSH, by Dr. Morse. Bone thin. Dura found tense and white: when dura was di- vided brain bulged. The brain appeared to be hemor- rhagic and gliomatous. The growth. 2^ c.c. in size, was excised in part, it being difficult to separate it entirely from the healthy brain tissue. It was a glioma. Patient recovered from the shock of operation, but the paresis of the left side remained. The discharges from the wound became septic. The brain about the tumor was TREPHIXIXG FOR TUMOR OF THE BRAIN. 221 much softened. He died on February 23d. — Pacific Med. Jour., April, 1886. BiRDSALL and Weir. — M., aged 44. Paretic symp- toms in limbs of right side, with diplopia, nausea, head- ache, etc. ; later, hemianopsia and neuro-retinitis. Diag- nosis of tumor in cuneus. This diagnosis was fortified b}^ further observation, and symptoms of inco-ordination ex- plained by its pressure on the cerebellum. Operation, March 9th, 1887, by Dr. Weir. On opening skull, dura did not pulsate, but was of dark color ; incision ; appear- ance of tumor of reddish color, covered with vascular con- nective tissue ; enucleation of same after its incision, and removal in two parts ; hemorrhage troublesome. Tumor found to be spindle-celled sarcoma ; greatest circumference, eight inches and a half; weight, 140 grammes. Five hours later, patient in collapse from secondary hemorrhage ; infusion of salt solution ; bleeding continued. Death nine hours after operation. — Med. Neivs, April 16th, 1887, p. 423. Seguin and Weir. — M., aged 39. Spasms of right side and neck. In 1886 fell one day unconscious ; epileptic attacks preceded by aura in right hand and arm and right side of face. Diagnosis of tumor in left motor area. Operation, !N"ovember 17th, 1887, by Weir. Dura pro- truded slightly; appeared normal; extensively incised; brain seemed to protrude ; yielded deep resistance on pal- pation. Tumor, size of an almond, discovered at depth of an inch, not encapsulated, apparently infiltrating sur- rounding brain tissue. It was lifted out with a Volk- mann spoon. A small fragment, which had separated in process of loosening, was also separately removed. No hemorrhage from brain; wound drained and irrigated; discs of bone with several fragments replaced over the dura. Tumor found to be sarcoma, principally of round cells. Patient recovered; several months later was in good general condition ; better as regards paresis of face and hands; speech much improved. Five months later, 222 BRAIN SURGERY. HO recurrence of growth. — Am. Jour, of the 3Ied. Sci- ences, July, 1888, p. 225. Three years later this growth recurred and the patient died. Keex. — M., aged 26. Fell from a window when 3 years old, his head striking on a brick. A superficial TTOund was made, and no trouble was experienced until he was 23, when epilepsj^ developed, associated with aphasia and paralysis of the right arm and leg. Later there was recovery from much of this disturbance. Operation, De- cember loth, 1887. Keen removed a considerable area of bone and uncovered a tumor nearly three inches in length in its long axis. During the operation great trouble was experienced from hemorrhage, which was checked partly by hot water. Patient did well. For several hours on the third day symptoms of brain pressure were observed, and this was attributed to the presence of a large clot of greater size than the original tumor. This was removed by careful washing and all went well for ten days : then pressure symptoms were again observed. There was also some diarrhoea and a temj^erature of 104^°. The presence of pus was suspected and the wound reopened. No pus was found and a certain amount of hernia cerebri super- vened. It was inferred that the unfavorable symptoms were largely due to the diarrhoea, and two or three other similar attacks made this still more apparent. The hernia was finally overcome, partly by skin grafting. The wound was drained b}' bichloride gauze for eight weeks. It healed perfectly, but with a concave shape instead of convex. Four months later he was quite well, but had Iiad one epileptic attack. — Amer. Jour. Med. Sci., Oct., 1888. " As to the final results of the case reported in the American Journal in 1888, the man is still living, in Lancaster, Pa. He has occasional epileptic fits, not nearly so often nor so severe as formerh', and he has had an interval as long as a year or thereabouts between TREPHINING FOR TUMOR OF THE BRAIN. 223 his attacks. His eyesight has improved to a certain ex- tent, but not very much. His mental condition is, I think, a little better, but nothing of any moment. He has no headaches and locomotion is good." — Letter from Dr. Keen, Jan. 23d, 1893. Knapp and Bradford. — M., 32, had a blow on the head in 1868, followed the next day by convulsions. He was perfectly well until 1886, when he began to suffer from nausea, vomiting, and headache. In March, 1887, he had a spasm with extension and abduction of the left arm. About the same time there was loss of power in the left arm and leg and numbness of the left hand with in- creased reflexes and contracture. Optic neuritis then developed, and the convulsions continued and the paral- ysis increased. The convulsions usually began with a sen- sory aura in the left hand and a clonic spasm of the left wrist extending to the elbow. Sometimes the convulsion became general with loss of consciousness. In January, 1888, headache had become so severe that he had to give up work, memory began to fail, and speech became slow. In November, 1888, Knapp found impairment of motion of eyes to the left, left hemiplegia with contractures, and hemiansesthesia most marked in the arm. Convulsions which were observed began in various parts of the arm. Trephined Dec. 28th, 1888, by Dr. Bradford, over the mid- dle third of the anterior-central convolution. Tubercular tumor 4 by 3 centimetres, weighing 35 grammes, was re- moved from the middle third of the two central convolutions on the right side. The patient died of shock in about an hour after. — Bost. Med. and Surg. Jour., April 4th, 1890. Church and Frank. — M., 39, began to suffer from convulsions in July, 1888, which continued until his operation. Each began with pain and spasm in the right index finger, partially involving the rest of the hand and passing up the arm. The extremity presented a flexed attitude and rapid clonic movement ; when the body was reached consciousness was lost and the patient would fall. 224 BRAIN SURGERY. and the convulsion would become general and be followed by sleep. By January, 1889, the right hand had become con- tinuously painful ' and weak; he had become mentally dull and hemiplegic on the right side. He had constant severe frontal headache, tenderness to percussion on the left side of the head, but had no optic neuritis. He was trephined May 21st, 1889, over the middle third of the motor area on the left side. A small node was seen in the anterior part of the opening, and when a full exposure had been made a thickened, cicatricial-looking mass was found as large as a bone from which radiated filamentous processes. This was dissected away, causing a decortication of the brain over an area one and one-half of an inch in diameter. The wound was closed and drained and healed. During the following month his condition was stationary, the fits not recurring, but twitching of the arm being frequent. A rise of temperature then led to a reopening of the wound. The trephine buttons were found to be dead, and the cavit}^ in the brain was full of thick pus which was washed out. After this his condition improved. The wound healed, he recovered, and at the end of six months was in fair health. He was then having convulsions once in ten days ; had slight paresis in the right hand and arm, but was able to be about. — Amer. Jonr. Med. Sci., July, 1890. " This case was under observation until July, 1892. He had so far improved that the attacks were two and sometimes three times as far apart. The pain in leg and arm was entirely gone. He was strong and had gained greatly in flesh. I do not expect, however, that he will ever be further improved, or be able to earn an independent livelihood."— Letter from Dr. Frank, Jan. 30th, 1893. Thomas and Bartlett. — Female; spasms beginning in fingers of left hand associated with numbness, advancing up the arm, occurred at intervals from January, 1887, to ' This IS one of the few cases on record of '' central pain, " such as has been described by Edinger. TREPHINING FOR TUMOR OF THE BRAIN. 225 March, 1889. After that the attacks became more frequent and extended to the left leg, and occasionally to the face, both arm and leg remaining paretic after the attack. These attacks continued until June, 1889. Headache was a constant symptom, but there was no optic neuritis. Diagnosis, a tumor in middle third of central convolu- tions. Operation June loth, 1889. On removal of the bone a pointed conical projection of bone three-eighths of an inch long was found projecting into the brain through the dura. Under this a large tumor was found, to which the dura was adherent, measuring 3| by 2^ by 1^ inches. This was removed. The convolutions under it were flat- tened and softened. Two days later left hemiplegia devel- oped, the patient became comatose and died. The autopsy showed the cavity filled by a clot and the adjacent brain much softened. — Haluiemannian Monthly^ May, 1890. Bremer and Carson. — M., 23,was well until 1887, when he began to suffer from spasms in the left arm which ex- tended to the neck and later, as they increased in frequency, to the left leg. This condition was followed by spastic con- traction with frequent spasms in the left foot and in the muscles of the left side of the neck, which later extended to the left arm, and the rigidity was attended by some weakness. Vomiting, insomnia, and great nervousness had developed by 1889, when he first came under Dr. Bremer's observation. There was slight beginning optic neuritis. The entire left side was paretic and the limbs were contractured, but could by effort be straightened. Every voluntary movement was opposed by simultaneous contractions of the antagonist. There was no anaesthesia. Spasms in the left side occurred frequently, beginning in the neck. The local symptoms of slowly increasing severity indicated a tumor in the right motor area at the centres for platysma and wrist in the post-central convolu- tion. Near this spot an old scar was found. He was trephined by Dr. Carson, March 2Gth, 1890, over the site of the scar. The dura bulged but did not pulsate. On 15 226 BRAIN SURGERY. exposing the brain it presented a reddish-brown appear- ance with torpid vessels, and the tumor could be outlined on three sides. It was very pliable, about the size of a ^valnut, and was removed with a spoon. The tumor was a cavernous angioma. The cavity was drained and the wound dressed, and in a week the scalp had healed. The improvement after the operation was progressive. There was no return of the spasms, and the paralysis, which was somewhat more intense after the operation, gradually im- proved. Anaesthesia of the hand and arm was found after the operation and had remained up to the time of the re- port. — Aiiier. Jour. Med. Sci., Sept., 1890. " Although there was no return of the distinct spastic seizures resembling the Jacksonian type after the opera- tion, for the whole time that the patient remained under our observation at the Mullanphy Hospital (about sixteen months) the general improvement, i.e., the relaxation of the diffuse spasticity of nearly the whole muscular system, lasted only between three and four months, the general stiffness of the muscles reappearing and increasing as time wore on. At his own request he was transferred to a city institution, where his condition seems to have pro- gressivel}' grown worse, and where he died about a year later. The chief findings at the autopsy were : General miliary tuberculosis of the bowels; left kidney contracted. The brain was examined by Dr. Carson and myself. It showed the following pathological features: Right hemisphere (the one operated upon) was somewhat flat- tened at its upper margin, the dura firmly adherent to the brain substance below. On making a frontal section through the brain at the site of the operation, a subcorti- cal cavity was found at a depth of about an inch be- neath the adherent dura and corresponding approxi- mately to the middle third of the Rolandic region. This cavity was irregular in its outlines, about the size of a hickory nut. The surrounding brain substance was in a more or less softened condition and the whole brain was TREPHINING FOR TUMOR OF THE BRAIN. 2)17 cedematous. The cavity corresponded to the place where the spongy cavernous mass was scraped out at the opera- tion. The presumable pathological process which took place after the operation seems to have been at first the formation of a blood cyst, which, after the manner of the apoplectic cysts, changed into one containing lymph. The emptiness of the cavity is explained, perhaps, by the thorough draining which the whole system underwent in consequence of the excessive diarrhoea. The principal lesson taught by the case is the fact established by other observers, that subcortical tumors (or their equivalents, cysts, e.g.) are apt to give rise to tonic spasms, " The bone button, which had been replaced after Mac- ewen's method, was found to have formed a solid bony union with the edge of the trephine hole, rendering the vault of the skull practically intact. The completeness of the surgical success in this particular has no doubt mili- tated against a better and more lasting result of the oper- ation. For had the button not been replaced, leaving only the scalp to protect the injured brain, this more elas- tic and yielding cover would have mitigated the pressure from below. A second operation, tapping for instance or scraping out of the presumable post-operative blood cyst, would also have been facilitated." — Letter from Dr. Bremer, February 4th, 1893. Wood and Agnew. — In his address before the Ameri- can Surgical Association in September, 1891, Agnew re- ported briefly that he had operated in a case of H. C. Wood in which a cyst occupj^ing the cuneus was exposed and emptied, but that the patient died in thirty-six hours after the operation, and at the autopsy a large sarcoma was found in the temporo-sphenoidal lobe, which had offered no localizing symptoms previous to the operation. The following case of my own is given in full be- cause it illustrates the general symptomatology of brain tumor and the local guides to the surgeon : 228 BRAIN SURGERY, Case XXI. Sarxoma of the left frontal lobe — Mental and motor symptoms — Successful localization and removal — Subsequent death. C. S., aged J:0, a farmer by occupation, of good family history and of good general health until this illness (with the exception of specific disease acquired at the age of 22, but without subsequent manifestations), was suddenly seized with a convulsion in December, 1890, while driving a cart. He remembers a sudden feeling of dizziness and distress and then a turning of his head forcibly to the right side; he has no recollection of what followed, but learned that he had been found upon the road, had been picked up and carried home, where he remained uncon- scious for two hours and a half; he is not sure whether he had a general convulsion. On recovering consciousness he found his right side, including face, arm, and leg, slightly weak, and noticed some difficulty in talking ; this condi- tion gradualh^ subsided, so that in two weeks he was able to go back to his work, and felt in his usual health. This is the only convulsion or sudden attack of an}^ kind which occurred during his entire illness. But it is from this attack that his illness dates. The various symptoms which subsequently developed were very gradual in their onset, so that it is quite impossible to fix any dates for particular symptoms. During the six months from January, 1891, to July, 1891, he suffered occasionall}^ from headache and nausea, and in Jnlj began to notice that his sight was growing dim and that the headaches were becoming more and more frequent and intense. Between July, 1891, and January, 1892, the pain became localized over the forehead and top of the head on the left side ; it was not particularly worse at night, but at times was very severe. During this period he noticed a progressive dulness of thought, general hebetude, an aversion to work which was unnatural to him, and a slow- ness of mental activity which he described as increasing stupidity; and increasing difficulty in the use of Ian- TREPHINING FOR TUMOR OF THE BRAIN. 229 giiage, SO that it took him longer to express his ideas, there being, however, no difficulty in articulation and no lack of words. He also noticed by the close of the year that his right side had become a little weaker than his left side ; that his hand was slightly awkward and that his leg felt a little heavy. The symptom, however, which caused him most distress was his gradually increasing dimness of vision, and it was on account of this that he came to New York from his home in Alabama. He was seen at the New York Ej^e and Ear Infirmary by Dr. Derby, who discov- ered a well-marked condition of optic neuritis in both eyes, more marked in the left eye: V. O. D. = -^, V. O. S. =; -|^. In right eye upper and inner quadrant of visual field wanting. Dr. Derby referred him to the Nervous Department of the Vanderbilt Clinic for confirmation of his diagnosis of cerebral tumor and also for treatment. When I first saw him at the clinic on January 14th, 1892, the following symptoms were present: severe and constant frontal headache, located over the top of the head and more especially over the left side, about at the upper third of the coronal suture, and at this area, over a space about three inches in diameter, there was consider- able tenderness to percussion. There was no vertigo on rising or on change of position. There was a state of partial blindness due to the very well-marked condition of optic neuritis and decidedly worse in the left eye. There was a condition of mental dulness which was noticeable, and which he himself and a friend who accom- panied him insisted was wholly unnatural. This dulness consisted in a slowness of thought, which made him appear very stupid. It took him some time to appreciate the meaning of questions, and it was an effort to answer them. This effort was not due to any actual disturbance of speech, any loss of words, or any difficulty in pronunciation, though he complained that he could not talk as fluently or rapidly as heretofore. The condition was, therefore, in 230 BRAIN SURGERY. no sense an aphasic one, but could only be spoken of as a slowness in mental processes. His comprehension was good and his conclusions were correct when he had time to think, but rapid mental action was impossible, and if insisted upon he became confused and would say he could not think. Hence he distrusted his own mental power, and said that he did not think that his judgment was as good as formerly. He was disinclined to occupy himself in any way, and sat in a listless manner saying nothing for hours at a time. He would often sleep in the day- time, though at night his sleep was often broken by his pain. It was not easy for him to hold his attention to any subject continuously for any length of time. His mental state might be termed a dull listlessness, and gave the impression that he was a sick man. Careful examination detected the existence of a slight right hemiplegia; his face was slightly flattened and slow in motion on the right side; his hand was somewhat awkward and clumsy, the power being 140 by the dyna- mometer, that on the left being 160. He dragged the toe slightly in walking, though his gait was not noticeable. He had great exaggeration of the knee jerks and marked ankle clonus. He complained of a feeling of numbness, both in the hand and foot, but there was no objective ansesthesia. Diagnosis. — 'From these symptoms a diagnosis was reached of a brain tumor. The situation of the tumor was not easily determined. The slight right hemiplegia indi- cated that it was in the left hemisphere of the brain, near to but not within the motor region. The hemiplegia had appeared long after the other symptoms, hence it was evi- dent that the motor zone had been reached only when the tumor had become large. The position of the headache and of the tenderness to percussion over the frontal region, and the existence of the mental symptoms described, ap- peared to indicate the frontal lobe as the probable situa- tion. This was confirmed by the absence of ansesthesia TREPHINING FOR TUMOR OF THE BRAIN. 231 or of hemianopsia or of sensory aphasia, all of which conditions would have been likely to have been present in a tumor situated near to but behind the motor zone, in the parietal region. The mental symptoms were consid- ered of very great importance in the diagnosis of a frontal lobe lesion. A study of 23 cases of disease of the frontal lobes of the brain, made by me in 1884, showed that decided mental disturbance occurred in one-half of the cases. ' At that time the following conclusions were reached: " The form of mental disturbance in lesions of the frontal region does not conform to any type of insanity. It is rather to be described as a loss of self-control and a con- sequent change of character. The mind exercises a con- stant inhibitory influence upon all action, physical and mental, from the simple restraint upon the lower reflexes, such as the action of the sphincters, to the higher control over the complex reflexes, such as emotional impulses and their manifestation in speech and expression. This action of control implies a recognition of the import of an act in connection with other acts ; in a word, it involves judg- ment and reason, the highest mental qualities. By inhib- iting all but one set of impulses it enables one to fix the attention upon a subject and to hold it there. It seems probable that the processes involved in judgment and rea- son have for their physical basis the frontal lobes ; if so, the total destruction of these lobes would reduce man to the state of an idiot, their partial destruction would be manifested by errors of judgment and reason of a striking character. One of the first manifestations would be a lack of that self-control which is the constant accompani- ment of mental action, and which would be shown by an inability to fix the attention, to follow a continuous train of thought, or to conduct intellectual processes. It is this very symptom that was present in one-half of the cases ' Starr : " Cortical Lesions of the Brain, " Am. Jour, of Med. Sci. , April, 1884. 232 BRAIN SURGERY. collected. It occurred in all forms of lesion ; from injury by foreign bodies, from destruction by abscess, from com- pression and softening, due to the presence of tumors, and therefore cannot be ascribed to any one form of disease. It did not occur in lesions of other parts of the brain here cited. But its presence in such a large number of these cases warrants the suggestion that in cases of sus- pected lesion of the frontal lobe the mental condition of the patient, as shown by his acts of judgment and reason, should be carefull}^ examined, and a change of character or behavior accurately noted." Ferrier, in his Croonian lectures, 1890, again called at- tention to the occurrence of such mental symptoms in connection with diseases of the frontal lobes. Welt {Alienist and Neurologist, April, 1890) concluded from a study of eight cases under his observation that changes in character and disposition are characteristic of lesions in the frontal lobes. He says they may be the only symptoms present. W. Gilman Thompson {Medical News, May, 1890) has described changes in temperament and alterations in the intellectual sphere occurring in three cases of tumor of the frontal lobes under his observation. Schoenthal has also recorded a case diagnosticated as hysteria on account of the mental peculiarities and lack of self-control, in which a large tumor of the frontal lobe was found after death. Griffith and Sheldon {Jour, of Mental Science, 1890, p. 223), in reporting a case of tumor invading the median surface and base of both frontal lobes in which mental symptoms were absent, call attention to the fact that men- tal sj'mptoms occur chiefly when the cortex of the convex- ity of the frontal lobes is invaded, and this statement is borne out by my ov/n collection of cases before alluded to. The review of these cases, therefore, pointed to the con- clusion that mental symptoms are likely to be produced by a tumor in the frontal region. TKEPHIXIXG FOR TUMOR OF THE BRAIN. 233 The diagnosis of the nature of the tumor was some- what difficult. The existence of specific disease pointed to gumma and made it seem proper to try the effect of spe- cific treatment ; he w^as, therefore, put on inunctions of mer- cury and increasing doses of iodide of potassium, which was carried to the point of three hundred grains a day. This treatment was pursued without much apparent change in his condition. He then escaped from my obser- vation for months, but returned about the 1st of June to the clinic. It was then found that his headache was still severe, was still localized in the left side of the forehead. It was found that his sight was much worse, so that he was nearly blind in the right eye and could not read letters with the left eye. His hemiplegia was more marked ; his face was flatter on the right side, his arm and hand more clumsy, and there w^as a decided dragging of the right foot. He complained that his right leg was getting stiffer all the time and that it felt dead. He said that he had recently been having twitching in the right leg as often as two or three times a day. He also said that at times his hand became clinched without his power to resist it, but' he denied the existence of any clonic spasms. He had had some difficulty in micturition during the past months, it being impossible for him to control his bladder perfectly, the urine flowing unexpectedly. His speech was slower, and there was a noticeable tendency to the malposition of words in sentences, which, however, he noticed himself and corrected; he would often say "no" for "yes" and vice versa. His mental activity was evidently much weaker than it had been five months before. Under these circumstances it seemed evident that spe- cific treatment had failed of effect, and he was induced to enter Roosevelt Hospital and submit to an operation. Operation. — The operation was performed by Dr. McBurney on June 23d, 1891. Ether anaesthesia. A semi-elliptical incision was made in the scalp, outlining 234 BRAIN SURGERY. an area which measured about three inches in either di- rection, the attached base of the flap being below. The centre of the flap coincided with a point an inch and a half anterior to the fissure of Rolando opposite the junction of its upper and middle thirds. The tumor was believed to occupy the posterior part of the second frontal convolution, just anterior to its junction with the anterior central convolution. The hemorrhage Fig. 57.— The Opening in the Skull in Case XXI. caused by this incision was excessive, certainly treble the usual amount, and required a large number of pressure forceps and ligatures for its control. A button of bone one inch in diameter was then removed with the trephine from the centre of the area exposed by turning down the flap. This opening was enlarged with rongeur forceps downward and forward until it measured two inches by one and three-quarters (Fig. 57). The dura appeared to be thickened and was unnaturally TREPHINING FOR TUMOR OF THE BRAIN. 235 pale, but pulsation seemed normal and no bleeding was noted. Profuse hemorrhage occurred from the veins of the diploe, and no little difficulty was met within its man- agement. The largest of these veins were occluded only by plugging their orifices firmly with small bits of sponge. The dura mater was then incised near the edge of the opening in the bone and turned down as a flap. It was quite adherent to the surface of brain beneath it, which ;HiEllilS»lSitfOBlif!flKlfllff|iPii Fig. 58.— Photograph of a Sarcoma Removed from the Frontal Lobe. Case XXI. The measure above the tumor is divided into centimetres. was uniformly dark in color and very vascular. At the first inspection the surface seemed to be that of a much- congested ordinary cortical substance. It was, however, firmer in consistency than was normal, and a good-sized section was removed with the knife, and it was then clear that the whole area exposed was tumor tissue. At the end of the section removed a distinct capsule was met with, and following this with finger and blunt scissors, it was not difficult to completely enucleate the large tumor, 236 BRAIX SURGERY. which extended in every direction heyond the edges of the opening already made in the skull. The tumor (Fig. 58) was oval in shape, measuring three and one-half by one and three-quarter inches. It was completely inclosed by a capsule, and after its removal a large cavity in the cortex remained. This cavity bled profusely at every point, the hemorrhage requiring for its control complete packing with iodoform gauze. The flap of integument was partially replaced and sutured at the sides only, a large loose antiseptic dressing being applied over all. Loss of blood and shock produced a marked effect upon the patient's general condition before the close of the oper- ation, and both rectal and hypodermic stimulation were actively applied, and after the patient's removal to bed he was given constant attention and every effort was made to improA^e his condition. After a large intravenous infusion of normal salt solution temporary marked improvement was noted, but the pulse soon failed again and death oc- curred about midnight, eight hours after operation. The exact situation occupied by the tumor was as follows : It involved the posterior part of the second frontal convolution, the adjacent portion of the first frontal and the upper half of the anterior central convolutions. The entire anterior central convolution must have been com- pressed to some degree, and indirect pressure must have been exerted upon the third frontal convolution below the tumor. The situation of the tumor corresponded, there- fore, very accurately to the diagnosis made before the operation, but the size of the mass was much greater than had been anticipated. After hardening in Mliller's fluid and alcohol it displaced fift}^ cubic centimetres of water, weighed four grammes, and measured two and one-half by two by one and three-quarter inches. The tumor was carefully examined by Dr. Eugene Hodenpyl, and was re- ported by him to be a true sarcoma, consisting of a large number of delicate blood-vessels and rather large, irregu- TREPHINING FOR TUMOR OF THE BRAIN. 237 lar, but not branching, cells closely packed together with very little intercellular substance. An earlier operation, when the tumor was much smaller and the vascularity of the tissues much less, would very probably have been successful. It was proposed to the patient in February, four months before it was done. The delay, which he insisted upon, was more readily submitted to because of his specific history, which induced us to give him the benefit of the doubt and to try anti-syphilitic treat- ment. If Horsley's dictum had been accepted, namely, that gumma is not curable by medicine and should be operated for (a dictum, however, which the experience of others in several cases does not support), an earlier opera- tion would perhaps have been undertaken. The size of a brain tumor has undoubtedly much to do with determin- ing the amount of shock resulting from its removal. Summary. — In this case the diagnosis of the tumor of the brain was made from the general symptoms, headache, optic neuritis, and tenderness to percussion of the head, and from the local symptoms, mental dul- ness, slowness of speech, slight right hemiplegia with subjective numbness and occasional twitching in the paralyzed limbs. The situation of the tumor was de- termined by the slow onset of the hemiplegia, by the very marked mental symptoms, and by the location of the tenderness upon the head. Attention has already been called to the value of the mental symptoms in the localization of the tumor, and no further com- ment upon them is necessary. This is the first case, however, in which operative interference has been so distinctly directed by the existence of mental symptoms. 238 BRAIN SURGERY. Secondly. Cerebellar Tumors. As shown in Table IV. (p. 216), 16 cerebellar tumors have been operated upon. In 9 cases the tumor was not found. In 2 cases it was found, but could not be removed. In 3 cases it was removed and the patient recovered. In 2 cases it was removed and the patient died. The diagnosis of cerebellar tumor is not difficult. The general symptoms of brain tumor are fully and rapidly developed, viz., headache; mental disturb- ance, irritability, and apathy; vertigo; vomiting; optic neuritis, with or without blindness, and possibly general convulsions. These present themselves in rapid succession because the situation of the tumor beneath the tentorium cerebelli is such as to obstruct the venous flow from the venae Galeni and the free inter- change of fluid between and through the ventricles, and to produce both general hydrocephalus and a stretching of the dura mater which are supposed to cause many of the general symptoms of brain tumor. It may be remarked that while headache is almost invariably present in cerebellar tumor and is often re- ferred to the back of the head, it may be felt at any part of the head, and is as frequently frontal or tem- poral as it is occipital. In many of the tumors here collected the headache was entirely frontal. The pain does not indicate, therefore, the seat of the tumor. Tenderness to percussion over the occiput is, however, a valuable sign of cerebellar disease. TREPHINING FOR TUMOR OF THE BRAIN. 239 But, in addition to the general symptoms of tumor, there are local symptoms of great value. These are vertigo and cerebellar ataxia, or the staggering gait. The patient feels himself falling, staggers in walking, and often staggers toward one side with remarkable constancy. The occurrence of staggering indicates that the middle lobe of the cerebellum is either the seat of the tumor or is encroached upon by a tumor in the hemispheres. If it occurs quite early in relation to the general symptoms, it is the middle lobe in which the tumor began. If it occurs late, after many months of suffering, the tumor has started in one hemi- sphere, given rise to general symptoms, and has at last reached the middle lobe and produced the local symp- tom. The question at once arises, In which hemi- sphere has it begun? And here we are often in the dark. Patients are said to stagger, in walking, away from the side on which the tumor lies. An analysis of 20 cases in which staggering to one side was a prominent and constant symptom shows that in 16 cases the patient staggered away from the side of the lesion and in 4 cases toward the side of the lesion. No definite conclusion as to the side of the lesion can be drawn from the direction of the staggering. If there is no tendency toward one side in walking, there may be a tendency to fall forward or backward. As yet, no assertion is possible as to the significance of this symptom, as it is impossible during life to de- termine whether it is due to irritation or destruction of tissue. 240 BRAIN SURGERY. When these symptoms fail it is sometimes possible to determine which hemisphere is invaded by the tumor, by observing on which side cranial nerve symptoms, such as strabismus, facial or lingual anaes- thesia or paresis, deafness, or retraction of the head, appear. They usually come first on the side of the tumor, as this, by its presence, crowds the cerebellum down upon the base of the brain and presses on the nerves, or pushes it to one side and stretches the nerves. Paralysis of one fourth nerve, though diffi- cult to detect, is a valuable symptom, as it always occurs on the side of the tumor. By compressing one side of the pons or medulla a tumor may cause paresis or numbness, or increased reflexes in the opposite arm and leg, and these symp- toms may aid the diagnosis. The diagnosis being made, the question of operation arises: Can tumors of the cerebellum be removed? The cerebellum presents but one of its three surfaces to the skull, and there is, as yet, no means of deter- mining whether a tumor is near that surface or not. Any operation must, therefore, be primarily explor- atory. In case a tumor is seen upon the exposed surface, it may be removed. But great care should be observed in the manipulations about the cerebellar hemispheres in order that the medulla may not be compressed, or the pneumogastric nerves torn or stretched in the IDrocess. The figure (Fig. 56, page 211) shows how deep the TREPHINING FOR TUMOR OF THE BRAIN. 241 cerebellum lies in the skull and how impossible it is to reach its upper surface or its anterior lower sur- face. It is not surprising, therefore, that the diffi- culty of thorough exploration of the cerebellum* has prevented the discovery of tumors in this part of the brain The following cases of cerebellar tumor, which have been diagnosticated by me and operated upon by Dr. McBurney, illustrate the symptomatology of the dis- ease and the difficulties of operation. Case XXTI. Fibrosarcoma of the cerebellum and pons Varolii — Staggering aivay from the side of the tumor — Operation — Death. Male, aged 30, was under my observation from Janu- ary, 1890, until December, 1891, when he died. He was referred to the Nervous Department of the Vanderbilt Clinic by Dr. Weeks. When first seen he was suffering from severe frontal and occipital headache ; from vertigo, which was much increased by moving the head suddenly or by lying down ; from tinnitus aurium ; from numbness in the left side of the face and in the mouth ; and from a very continuous feeling of drowsiness and dulness. These symptoms had developed gradually during the preceding three years ; and within a year he had also noticed double vision and a gradually increasing blindness. His friends said that his speech had become slow and thick. Examination showed a large, very dull, stupid man, with prominent eyes, the left one deviating outward, dilated pupils and marked nystagmus on lateral movement of the eyes. Dr. Weeks had found well-marked choked discs and a diminution of the visual fields. There was some slowness of speech which was accounted for by his mental dulness, there being no evidence either of aphasia or of paralysis of the tongue. There was no disturbance 16 242 BRAIN SURGERY. of sensation or of motion or of reflex action, and there was no ataxia in his gait. The existence of headache, vertigo, tinnitus aurium, nystagmus, diplopia, and choked discs established the diagnosis of a cerebral tumor, but no conclusion regarding its localization could be reached. That the tumor was not a gumma was admitted, as he denied all specific infection, yet he was put upon mercury and iodide of potassium on the supposition that he might have acquired the disease without his knowledge. During the year 1890 the symptoms continued and grad- ually increased in intensity, so that by the 1st of October he had become quite blind, with well-marked optic atro- phy ; and also deaf in the left ear, in which ear the tinni- tus aurium had been intense. By this time also local symp- toms had developed which gave an indication of the site of the tumor. There was a considerable degree of stag- gering in walking with a tendency to fall forward and toward the right, and a marked tendency to turn toward the right in walking. In addition there was some weak- ness in his right hand, the dynamometer registering only 39 while it registered 60 in the left hand. There was no ataxia or disturbance of sensation in the limbs. There was no apparent difference in the power in the legs, but the knee jerk was exaggerated on the right side and a slight clonus was obtained on the right foot. The staggering was of the kind observed in cerebellar disease ; a gait like that of a drunken man, without falling but with every appearance that the balance was uncertain. The tendency to turn and to fall to the right was noticed on every occasion on which he was tested. Diagnosis. — The staggering indicated that the dis- ease was located in the cerebellum, and its direction to the right, while not considered sufficiently diagnostic to decide absolutely the question regarding which side was involved, was thought to point strongly to the left side. This supposition seemed to be confirmed by a study of the other symptoms. The patient had complained early in TREPHINING FOR TUMOR OF THE BRAIN. 243 the disease of pain and numbness in the left half of the face, though at no time did examination show any anaes- thesia. He had also had much tinnitus in the left ear which had been followed by progressive deafness. His headache, which had at first been frontal, was later referred with much constancy to the left occipital region, and in speaking of it he habitually put his hand back of his left ear. The weakness of the right hand and the exaggera- tion of the spinal reflexes on the right side, taken in con- nection with left cranial nerve palsies, appeared to indicate some pressure on the left side of the pons and medulla. Thus the staggering to the right, the left cranial nerve palsies, and the right hemiplegia all pointed to a lesion in the left side of the posterior cranial fossa. The diagnosis was, therefore, made of a tumor on the left side of the cerebellum. The negative result of spe- cific treatment indicated that it was not a gumma, and the very slow progress of the case indicated that it must be a slowly forming tumor, probably sarcoma, as such tumors are more common than any other kind. During the following year, from October, 1890, to Novem- ber, 1891, the patient was seen occasionally, being appar- ently in a stationary condition. Finally, he was induced to enter the Roosevelt Hospital for operation. And then he was quite willing to submit, though knowing the dangers, because his life was a burden, for he was blind and partly deaf and suffering from severe headache, vertigo on any movement, and such exaggerated staggering that he could not go about. A careful examination in the hospital on December 1st, 1891, confirmed the existence of all the symptoms hitherto mentioned, but failed to elicit others. Operation by Dr. McBurney on December 3d, 1891. — Ether anaesthesia. A vertical tongue-shaped flap was marked out with the knife over the left half of the occi- pital bone. The upper free convex border of this flap cor- responded nearly to the superior curved line of this bone. The attached base was on the back of the neck about op- 24-4 BRAIX SrRGEEY. posite the second cervical vertebra. The incision was carried down to the periosteum and all the coverings were removed in one flap. Experiments on the cadaver had satisfied the operator that the safest and most convenient method of entering the cerebellar fossa was by the use of the chisel and mallet. This method was adopted here, and an opening about one and a half inch m diameter was made through the thin bone, care being taken to be far enough away from the large venous sinuses. The dura mater was not diseased, but bulged very strongly through the opening in the skull in such a manner as to at once suggest intracranial pressure. Protrusion of cerebellar tissue was still more marked after- the dura had been turned back as a flap from over its sm^face. Otherwise, however, the surface of the cerebellum was normal in ap- pearance and palpation failed to give evidence of the exist- ence of tumor. It was found to be quite easy to introduce the finger for some distance into the skull on all sides of the cerebellar hemisphere, to thus examine a large part of its surface, and to distinctly palpate the lateral and vertical sinuses. But nowhere could the existence of a tumor be demonstrated. So much protrusion of cerebellar tissue existed that it was necessary, in order to close the opening in the skull at all satisfactorily, to shave off the excess, which was done with the less compunction as even the gentle manipulations practised had somewhat injured the delicate surface convolutions. Hemorrhage throughout the operation was \ery moderate and easily managed. The flaps of dura mater and overlying soft parts were then re- placed, fastened in all deeper parts with catgut, the skin wound being sewed completely with silk. A wet bichloride gauze dressing was applied over all and the patient was removed to bed in excellent condition. Convalescence was perfectly satisfactory, and on Decem- ber 9th, six days after the operation, the temperature being 90'' and the ])ulse 100, the dressing was changed for the first time. Primarv union was found throu2:hout the A TREPHINING FOR TUMOR OF THE BRAIN. 24:5 whole extent of the wound, and all sutures were re- moved. During the following night the patient fell out of bed, and immediate examination revealed the presence of a large blood-clot beneath the skin flap. No other injury seemed to have resulted from the fall, but at 5 p.m. on December 10th a chill occurred followed by a temperature of 103°. Difficulty in swallowing was then noted, and although at the end of two days the temperature fell to 99°, stupor gradually increased and involuntary evacuations of rec- tum and bladder began. The wound remained aseptic throughout, but the stupor deepened into coma and the patient died on December 15th with a temperature of 105°. The autopsy showed the presence of a tumor, a glio- sarcoma, whose limits were quite distinct from the cere- bellar tissue, though it was not encapsulated. It lay on the base and compressed the left hemisphere of the cerebellum and especially its anterior inferior (ventro- cephalad) surface, and also pressed upon the left half of the pons Varolii at its lateral part. The left crus was slightly indented by the tumor, and the fifth nerve had been flattened out by it without being so pressed upon as to be degenerated. The auditory and facial nerves were also compressed by the lower part of the tumor. The situation of the tumor was such as to have made it absolutely impossible to have reached it by operation, unless indeed the certainty of the situation of the tumor had been so complete as to justify full section of the cere- bellum. It was almost identical in situation and appear- ance with a tumor reported by Wollenberg in the Arch, fiir Psych., XXI., p. 791. Case XXIII. Glioma of the cerebellum — Characteris- tic staggering — Operation — Death. A little girl of 7 years of age had sufl^ered for a year from severe headache all over the head, but chiefly in the forehead, from severe vomiting and from gradually ad- 246 BRAIN SURGERY. vancing blindness, due to a progressive optic neuritis. For three months before she was seen it had been difficult for her to walk, on account of a tendency to stagger and on account of dizziness which was undoubtedly due in part to nystagmus, which was observed early in the history. The staggering was very marked, so that during the last month she could not w^alk without aid. She did not ap- pear to stagger in any one direction constantly, but there was some tendency to fall backward and slightly to the left. She complained at times of earache in the right ear, but there was no evidence of cranial nerve palsy or of hemiplegia. Tlie diagnosis of cerebellar tumor in this case was quite evident, but the only clew to the position of the tu- mor was the tendency to stagger backward and to the left. It was thought probable that the tumor was in the vermiform lobe of the cerebellum, more likely upon the right than upon the left side. The absence of cranial nerve symptoms showed that it was not near the base. The operation was, therefore, undertaken. Operation. — The operation was done by Dr. McBurney on December 29th, 1891. Ether narcosis. A horseshoe- shaped incision with the convexity upward was made over the right half of the occipital bone. The upper part of the incision lay a little above the superior curved line of the bone, and the flap which was then turned down included all of the soft fissures excepting the periosteum. The base of the flap was left attached to the upper part of the neck. With chisel and mallet a considerable plate of bone was removed from over the centre of the cerebellar fossa, and the opening was then enlarged with rongeur forceps as much as was safe, having due regard for the venous si- nuses. The dura obtruded forcibly but otherwise appeared normal. A large flap of dura was then cut and laid back, revealing only normal cerebellar convolutions. Examina- tion of the sides and imder surface of the cerebellum gave no information. A probe was then passed some distance, TREPHINING FOR TUMOR OF THE BRAIN. 247 about one and one-half inch into the brain substance, but no abnormal resistance was encountered. An aspirating-needle introduced about one-half inch from the median line and parallel with the base of the skull entered a cyst from which two drachms of clear serous fluid was withdrawn. A second introduction of the needle failed to detect the cyst and it was deemed unwise to make further explora- tion. The flaps were then replaced, being stitched deeply with catgut and superficially with silk. Hemorrhage during the operation was not troublesome, but before its close the patient showed the effects of shock. She rallied well, however, after rectal stimulation, and on the day fol- lowing operation seemed about as well as on the day before it, at intervals complaining of headache only. Two days later complaint was made of pain in the ears ; the wound was dressed and found to be aseptic. The temperature since operation had remained normal. On January 4th, six days after operation, vomiting oc- curred repeatedly, the pulse became weak, stimulation had no effect, and the patient died suddenly in a convulsion at midnight. , The autopsy revealed a large glio-sarcoma, two and one- half by two by one inch, which occupied the vermiform lobe of the cerebellum and extended into both hemispheres, chiefly into the right one. It lay just under the superior surface of the cerebellar cortex, but it nowhere reached the surface of the cerebellum. It projected downward, compressing the fourth ventricle. Its consistency was about that of the cerebellum, and in its centre was a cyst which had been evacuated by the operation. Case XXIV. Glioma of the cerebellum — Staggering to the left — Right cranial nerve palsies — Oper- ation — Successful reinoval of the ttimor. W. W., aged 10, of good family history, had been in perfect health until October, 1892, when he began to suffer 248 BRAIN SURGERY. from headaches in the forehead, usually worse at night. These annoyed him occasionally during October and No- vember, and he then began to suffer from occasional ver- tigo and from attacks of very intense headache associated with vomiting and occurring every third and fourth night. It was also noticed that he was becoming rather dull mentally and very irritable. These symptoms remained during December and to them was added the symptom of occasional uncertainty in gait so that he would fall while runjiing. In the early part of January, 1893, he noticed some dimness of vision, and this was found by Dr. Kipp, of Newark, who examined him on January 21st, to be due to a well-marked condition of optic neuritis. At that time he was able to read large print without much diflS- culty ; but within a month he had become almost totally blind. During February the headaches, usually noctur- nal, increased in severity; were always associated with vomiting and vertigo, and he began to have ringing in the left ear and some deafness in the right ear ; his gait was noticed to be very unsteady ; his eyes were noticed to be prominent and to be in constant oscillation, and mental dulness became intense. He was referred to me by Dr. William Pierson, of Orange, N. J., on March 12th, 1893, with the preceding history. Examination showed a fairly nourished but pale little boy, with large head, rather prominent forehead, protrud- ing eyes which were in constant lateral oscillation and with which he could see nothing. At rest there was a manifest tendency of the right eye to turn inward, but he could look in either direction without apparent paralysis of the ocular muscles. All ocular movement was attended by marked nystagmus. Very extensive optic neuritis was found in both eyes ; smell was lost in the left nostril ; there was no apparent paralysis or anaesthesia in any part of the body or face, but upon forced effort with the hands a slight facial paresis on the right side was noticeable, and TREPHINING FOR TUMOR OF THE BRAIN. 249 he was unable to whistle on account of inability to close the right half of the mouth. His hearing was decidedly defective in the right ear, both to nerve conduction with a tuning-fork and to the watch. His reflexes were dimin- ished in both knees. His gait was distinctly of a stagger- ing kind, and numerous tests revealed a marked tendency to stagger toward the left side. He described his head- aches as being agonizing and referred them entirely to the frontal region ; the skull was slightly tender to percussion over the vertex. The headache was much increased by a recumbent posture, so that for many nights he had sat up all night. Diagnosis. — The headache, vomiting, vertigo, mental dulness, and optic neuritis indicated clearly that the boy had a tumor of the brain. The cerebellar gait indicated its location in the cerebellum. The tendency to stagger to the left side, together with the deafness in the right ear and a slight weakness of the right side of the face and right abducens muscle, indicated that the tumor was upon the right side of the cerebellum and near to the base. An operation was therefore recommended. Operation. — On March loth Dr. McBurney operated at the Roosevelt Hospital in the presence of Dr. Pierson and Dr. Kipp. The occipital bone was exposed upon the right side by a horseshoe-shaped incision, and an opening was made in the bone below the superior curved line one and one-h-^lf by one and five-eighths inches in size. The opening was made by chiselling and by enlarging the open- ing by the rongeur. There was no adhesion of the bone to the dura. The dura was seen to be very blue, over two-thirds of the region exposed. On dividing the dura a cyst containing about a drachm of yellowish-green fluid lying upon the surface of the cerebellum was opened. When the dura was laid back and the wall of this cyst removed it was evident that a tumor was present, lying upon and in the cerebellum and extending toward the median line beyond the area exposed. It being impossible 250 BRAIN SURGERY. to get at this tumor through the small opening made on account of the extreme bulging of the cerebellum, a por- tion of the cerebellar tissue was cut off and thus access^ was gained to the tumor. The tumor was. soft gray and very friable, having the consistence of jelly and being very vascular in structure. In attempting to remove it a cyst within it was ruptured and about a drachm of clear yellow fluid flowed out. By the aid of a sharp spoon the tumor was scraped out from within the cerebellum. After all accessible tumor tissue was removed, the cavity remain- ing in the cerebellum was an inch and seven-eighths in depth by about an inch in the other directions and ad- mitted freely the finger of the operator. There was no distinct wall or capsule to the tumor, but as far as possible all tumor tissue was taken away, leaving clear cerebellar tissue about it. Hemorrhage was arrested by pressure b}^ sponges introduced into the cavity, and when it was reduced to slight oozing the cavity was allowed to fill with blood and a rubber tissue drain was introduced. The wound was then closed, the dura and scalp being stitched with catgut ligatures and the skin united by silk. The entire operation was completed within an hour, but the shock was considerable and the boy required repeated stimulations before being removed from the table. He rallied well, however, and the next day was very comfortable. He had no headache, had not vomited, the nystagmus had ceased, and he had no trace of the facial paralysis. His knee jerks were higher than before the operation. His mind was clear. During the following week he continued to improve.^ In the following tables "" all cases of brain tumor thus far operated upon are tabulated. The first table ' This case was added while this work was in press. The final result will be published later. ^ This list is made up from Knapp's list and from a search through the current journals from January, 1891, to January, 1893. (r, re- covered ; d, died. ) TREPHINING FOR TUMOR OF THE BRAIN. 251 contains a list of the tnmois found at the operation, their situation, and the result. The second table con- tains a list of the cases operated upon in which the tumor was not found at the operation, but was dis- covered at the autopsy. Table V.— Tumors Successfully Removed. Durante, Macewen, . Barton, Booth and Curtis, Frontal. Lancet, Oct. 1, 1887, Brit. Med. Jour., Aug. 11, 1888, Annals of Surgery, January, 1889, Trans. N. Y. Neurol. 1892 (recurrence), Jour. , December, Starr and McBurney, . Amer. Jour. Med. Sci., April, 1893, . . d Birdsall and Weir, Macewen, . Bennett and Godlee, Hirchfelder and Morse, Horsley, Macewen, . Seguin and Weir, Keen, .... Lucas Championniere, Ballet and Pean, Fitzgerald, . Rannie, Fischer, Thomas and Bartlett, . Limont and Page, Parker, Mercauton and Combe, Von Bergmann, . Occipital. Phil. Med. News, April 16, 1887, . . r Central. Lancet, May 16, 1885, . . . . r Med. Chir. Trans., 1885, Ixviii., 243, . d Pacific Med. Jour. , April, 1886, . . d Brit. Med. Jour.. April 23, 1887, 3 cases (1 recurrence) , . . . . r Lancet, Aug. 11, 1888, 3 cases, . . r Amer. Jour. Med. Sci., July, 1888 (recur- rence) , . . . . . , r Amer. Jour. Med. Sci., Oct., 1888, . . r Jour, de Med. et de Chir. , 1888, 298, . r Bull. Soc. Anat. de Paris, May, 1888, . r Sajous' Annual, vol. ii. , 1888, p. 36, . r Brit. Med. Jour. , May 19, 1888, . , r Verhand. Deut. Gesell. Chir. , 1888, p. 42 (recurrence and died) , . . . r Trans. Amer. Inst. Homoeop. , 1889, 464, . d Brit. Med. Jour., Oct. 26, 1889 (recur- rence) , . . . . . . r Brit. Med. Jour., Nov. 30, 1889, . . r Rev. Med. de la Suisse Rom., August, 1889 (unknown result) . Chirur. Behand. d. Hirnk., 1889, p. 137, d 252 BRAIN SURGERY. Table V.— Tumors Successfully Removed.— Continued. Clarke, Knapp and Bradford, . Church and Franke, . Oppenhein & Koehler, Graham and Chubbe, . Dunin, Lampiasi, Bremer and Castro, Eeynier, Doyen, Jeannel, Anderson, Pean, . Hitzig, Hitzig, Erb, . Poirier, Braman, Potempski, Llobet, Stieglitz, Carson, Central. Lancet, March, 1890, . . . . d Bost. Med. and Surg. Jour. , April, 1890, d Amer. Jour. Med. Sci. , July, 1890 (recur- rence) , . . . . . . r Berl. klin. Woch. , July, 1890 (recurrence) , r Aust. Med. Jour., July, 1890, . . . d Neurol. Central. , August, 1890, . . r La Psychiatria, 1890, 261, . . . r Amer. Jour. Med. Sci. , September, 1890, r Neurol. Central., Oct. 15, 1890, . . d LaSem. Med., April, 1891, . . . r LaSem. Med , April, 1891, . . . r La Sem. Med., April, 1891, . . . r Brit. Med. Jour., Mar. 14, 1891, . . r La Trib. Med. , June, 1893, . . . r Berl. klin. Woch., July, 1892, . . r Berl. klin. Woch. , July, 1892 (recurrence) , r Deut. Zeit. Nervenheilk. , July, 1890 (re- currence) , ..... r Eev. deChir., xii., 412, . . . . r La Sem. Med. , December, 1852, 2 cases, r Annals Surgery, December, 1892, . . r Rev. de Chir. , November, 1892, . . r N. Y. Med. Jour. , January, 1893, . . r Horsley, Verco, Region Not Stated. . Brit. Med. Jour., Dec. 9, 1890; 4 cases, 3 died, . . . . . . d . Trans. Intercol. Med. Cong. , 1889, ii., 377, d Horsley, May, . Suckling, Maunsell, Cerebellum. . Brit. Med. Jour. , April 23, 1887, . . d . Lancet, April 16, 1887, . . . . d . Lancet, Oct. 1, 1887, . . . . d . New Zealand Med. Jour., 1889, ii., 151, . r Starr and McBurney, . Case XXIV. , page 247, Table VI. — Tumors Trephined for but Not Found. Frontal. Dana and Pitcher, . . N. Y. Med. Rec. , Feb. 9, 1889. Eskridge, .... Knapp, " Intracranial Growths, " ix. , 24. TREPHINING FOR TUMOR OF THE BRAIN. 253 Table VI. — Tumors Trephined for but not Found. — Continued. Temporal. Fraser Lancet, Feb. 27, 1886. Wood and Agnew, . . Univ. Med. Mag. , April, 1889. Putnam and Beach, Stoker and Nugent, Twynam, Sands, Sciamanna, Hammond, Ross and Heath, Seguin, Morse, Dobson, Gray, . Keecley, Kerr, . Mitchell Clarke, Horsley^ Seguin, Chisholm, Parietal. . Bost.Med. and Surg. Jour., April, 1890. . Dublin Jour. Med. Sci., October, 1890. . Aust. Med. Gaz., May, 1892. Central. . Phil. Med. News, April, 1883. . Bull, de R. Accad. Med. di Roma, 1885, xi., 75. . Jour. Nerv. and Ment. Dis. , June, 1887. . Lancet, April 7, 1888. . Bost. Med. and Surg. Jour. , Feb. 5, 1891. . Pacific Med. Jour., Feb., 1891. . Lancet, May 14, 1892. . Brain, 1892, Ixi. Pons. . Lancet, Sept. 21, 1889. Basal Ganglia. . Occid. Med. Times, February, 1890. . Brit. Med. Jour.. June 13, 1891. Region Not Stated. . Brit. Med. Jour. , Dec. 6, 1890, 6 cases. . Bost. Med. and Surg. Jour. , Feb. 5, 1890. . Aust. Med. Gaz. , May, 1892. Maudsley and Fitzgerald, . Amidon and Weir, Wyman, . . . . Springthorpe and Fitzgerald, Lampiasi, .... Bullard and Bradford, Knapp and Bradford, . Potempski, .... Stewart, .... Starr and McBurney, . Starr and McBurney, . Cerebellum. Lond. Med. Recorder, June, 1890. Annals of Surgery, June, 1887. Phil. Med. News, February, 1890. Aust. Med. Jour., November, 1891. Wien. med. Wochen. , May, 1887. Bost. Med. and Surg. Jour. , April, 1890. Knapp 's Case XXIX. Annals of Surgery, December, 1892. Amer. Jour. Med. Sci., Nov., 1892. Amer. Jour. Med. Sci., April, 1893. Amer. Jour. Med. Sci., April, 1893. 254 BRAIN SURGERY. Conclusions. In any case which presents the general symptoms of brain tumor and in which during the progress of the disease such local symptoms appear as indicate that the situation of the tumor is in or near the cortex of the convexity of the brain, the operation of trephining is indicated. This operation is not to be undertaken hastily in any case, as it is important to try the effect of anti- syphilitic treatment in those patients who may have had syphilis, and to watch for other symptoms or for signs of multiple tumors in patients who may have tuberculosis. But if mercury and iodide of potassium fail to relieve the patient within three months, or if during that time the symptoms rapidly increase, the operation is not to be jDostponed. The chances of success are greatest in hard encap- sulated sarcomata and fibromata, and in these cases the history will show little variability in the symptoms during the progress of the disease. These tumors are usually on the surface and are easily removed. The chances of success are worth taking in glio-sarcomata and in soft infiltrating gliomata with or without cysts, as life may be prolonged by the operation and as sev- eral operations may be done successively if the tumor recurs. Such cases usually show much variability in the symptoms, as the tumors are vascular. The dan- gers are greater in their removal ; partly from hemor- rhage, partly from inability to excise them entirely TREPHINING FOR TUMOR OF THE BRAIN. 255 without great loss of brain tissue and consequent shock. It is not to be forgotten that these tumors are liable to recur. The chances of success are fairly good in cysts of the brain, provided the wall of the cyst is excised or the healing of the cyst from adhesion of its walls can be secured by permanent drainage. To empty a cyst and close the wound merely invites a refilling with fluid and is useless. Secondary carcinoma and sarcoma are not favorable for operation, as the chances of their recurrence are great and the endurance of the patient is impaired by the primary disease. CHAPTER YII. TREPHINING FOR HYDROCEPHALUS AND FOR THE RELIEF OF INTRACRANIAL PRESSURE. Hydrocephalus. Tapping the Lateral Ventricles. Keen's Cases. Robson's Cases. Broca's Cases. General Conclusions. Methods of Operation. Trephining to Eelieve Intracranial Pressure. There are certain cases of disease within the cranial cavity which are attended by a distention of the lateral ventricles with serous fluid. The exact pathology of acute congenital hydrocephalus is not understood, but secondary acquired hydrocephalus may be due to an inflammation of the lining membrane of the ventricle, to tubercular meningitis, or to venous stasis produced by pressure upon the veins of Galen. Tumors situ- ated in the corpora quadrigemina, or in the crus cere- bri, or in the middle lobe of the cerebellum, which produce pressure upon these veins are commonly at- tended by a great effusion of serum into the lateral ventricles. Distention of the ventricles is not neces- sarily associated with oedema of the pia mater of the convexity. It is perfectly easy to recognize the existence of hydrocephalus occurring within the first three years of life by the characteristic distention of the head, and the imperfect or delayed closure of the fontanelles and sutures. When in later life the bones are so firmly TREPHINING FOR HYDROCEPHALUS. 257 united as to resist any intracranial distending force the symptoms of an accumulation of fluid are very similar to those of brain tumor, viz., headache, optic neuritis, vertigo, vomiting, slow pulse, strabismus, and mental apathy. In the latter case it can never be de- cided clinically what is the cause of the symptoms, whether a brain tumor rapidly growing and of large size, or an accumulation of fluid in the ventricles of large amount, associated perhaps with a very small tumor. But in an}^ case it is a natural conclusion that the only possible relief for the patient is to be obtained either by arresting the accumulation of fluid or else by letting it out. The object of medical treat- ment by purgation, by mercurials, and by iodide of po- tassium in such cases is to arrest the secretion of fluid, and this rarely if ever succeeds. The surgical treat- ment by opening the skull and giving exit to the fluid is really the only one which promises much relief. For many years hydrocephalus has been treated in children by tapping the ventricle through the anterior fontanelle with an aspirating needle or by trocar and canula. The operation has been recorded as far back as 1667, it being said that Dean Swift, when a baby, was tapped in this manner. The usual method pur- sued has been to introduce the needle through the anterior fontanelle at one of its lateral corners, to press the needle or trocar deeply into the brain, and thus reach the anterior horn of the ventricle through its roof. This procedure is still practised, and several successful cases were reported as late as 1891 by 17 258 BRAIN SURGERY. Tordoff/ Illingworth/ Unverricht ' and Yinke/ The procedure is not one without danger and many deaths have been recorded. Thus Lawson ' and Smythe ' lost patients upon whoro they had operated, by a shpping of the canula and laceration of the brain. There is a lack of precision in this method of treating hydro- cephalus which condemns it in the eyes of many sur- geons. The operation of trephining the skull and making an opening into the lateral ventricle, inserting a tube and establishing a permanent drainage, was suggested by Wernicke in 1881, and again by Zenner in 1886, and again by Keen in 1888.' Von Bergmann, unbe- known to Dr. Keen, had attempted to tap a ventricle by opening into the anterior horn in July, 188Y; he had succeeded in reaching the ventricle, but the case proved fatal on the fifth day. The first operation performed in this country was done by Dr. Keen on January 11th, 1889.' The patient was a boy 4 years of age, who had acute hydrocephalus and was rapidly developing blindness. It was supposed that the hydrocephalus was due to a tumor of the cerebel- lum pressing upon the strait sinus, a suspicion subse- quently confirmed by autopsy. Keen was led to under- 1 Brit. Med. Jour., Apr. 18tb, 1891. -Brit. Med. Jour., Apr. 4tli, 1891. 2 St. Petersburg med. Wochen., Oct. 5tli, 1891. ^ Weekly Med. Review, St. Louis, Feb. 28th, 1891. ^Brit. Med. Jour., Mar. 21st, 1891. 6 Brit. Med. Jour., Mar. 28th, 1891. ' Med. News, Dec. 1st, 1888. 8 Med. News, Sept. 20th, 1890. TREPHINING FOR HYDROCEPHALUS. 259 take the operation of tapping the ventricle and thus relieve the condition of intracranial pressure by the fact that in a previous case, where he had made an exploratory trephining for supposed abscess in the temporo-sphenoidal lobe and had introduced a drainage tube, the autopsy had shown that the presence of this drainage tube had not produced any inflammation of the brain. The operation upon the boy was made by trephining at a spot one and one-fourth inch above and one and one- fourth inch behind the left auditory meatus, and by puncturing the brain with a hollow needle which was directed toward a point two and one-half inches above the opposite meatus. At a depth of about one and three- fourths inch, resistance to the passage of this needle suddenly ceased, and the cerebro-spinal fluid began to escape; three double horsehairs were then passed into the ventricle and the tube was withdrawn. The drainage thus estab- lished was kept up for fourteen days, when the horse- hairs were replaced by a rubber drainage tube. On the twenty-eighth day after the operation, the symp- toms returning, a corresponding operation was per- formed upon the right side and the drainage tube was passed directly into the right ventricle. On the thirty- second day the ventricles were washed out from side to side with a warm boric acid solution, eight ounces being run in, and two ounces only escaping. The child was very restless at the beginning of this pro- cedure, but as it was done he said that ''it felt good." Irrigation was continued subsequently at intervals, 260 BRAIN SURGERY. never producing any ill effects, but the child died on the forty-fifth day. The autopsy showed a sarcoma in the cerebellum and a distention of the ventricles with fluid ; the sinus through which the rubber tubes had passed was not surrounded by an inflammatory zone. Though the brain had been punctured in many directions at the operation in the attempt to find the tumor, no trace remained of these punctures at the time of the autopsy. Keen's second patient was a boy Si years of age, who had been a subject of hydrocephalus since the age of 4 months. He was an imbecile and epileptic. On March 5th, 1889, the left ventricle was tapped in the same manner as in the previous case, and drainage by horse-hairs was established. Four days afterward a drainage tube was inserted in place of the horsehairs, an opening on the opposite side being made. As the escape of fluid then appeared to be too free the tubes were plugged up. Then convulsions began, and it was concluded that too much, fluid had escaped, so warm water was allowed to run into the ventricle when the spasms ceased ; eight times the convulsions returned and each time were they arrested by the in- troduction of an ounce of warm fluid. The child then died. The autopsy showed great hydrocephalic dis- tention but no inflammation about the tubes. Keen's third case was one of tubercular meningitis with unilateral acute hydrocephalus of the left ventri- cle. The foramen of Monro was closed and the uni- lateral distention had produced right hemiplegia. The TREPHINING FOR HYDROCEPHALUS. 261 left ventricle was tapped through the arm centre and fluid evacuated, but the child died about four hours later. In his article recording these cases Keen refers to two cases reported to him by letter by Mayo Robson. These cases were as follows : A girl 10 years old, without preceding illness, began to have pain in the left ear and was feverish, December 19th, 1888. In three days a discharge followed, which gradu- ally lessened, but was still present a month later when admitted to the hospital. There had been also rigidity of the neck and twitching of the right angle of the mouth. No vomiting ; slight mental disturbance. On admission to the hospital January 19th, 1889, temp, was 105°; she complained of pain in the left side of the head ; there was paresis of the right arm and leg, which gradually devel- oped into complete hemiplegia and aphasia. Optic discs inflamed. Robson trephined February 7th, 1889, over the arm centre ; the dura was found healthy. On expos- ing the brain it did not pulsate, and seemed to be com- pressed. An exploring needle was passed deeply in various directions in the hope of reaching pus, but failing to find any the needle was pushed into the lateral ventricle and a half ounce of clear fluid was drawn off. After this pulsa- tion returned in the brain. The wound was closed, no drainage being employed. On the next day there was slight power in the arm, soon after in the leg, and on the third day she could answer simple questions. Within a month the hemiplegia was gone, and six months later she was perfectly well. This case cannot be called one of draining the ven- tricle, but merely of an accidental tapping in despair at failing to find an abscess. I have cited it as it has 262 BRAIN SURGERY. given rise to a discussion regarding priority in the operation. ' Robson's second case was one of an infant suffering from rapidly increasing hydrocephalus following treat- ment of spina bifida by Morton's injection. The skull was trephined an inch in front of the fissure of Rolando over the second frontal convolution. The dura was opened, and the needle of an exploring syringe was inserted into the ventricle, which was reached an inch from the cerebral surface. By means of Lister's sinus forceps a rubber drain was inserted, following the needle as a guide. The drainage was so free as to wet the dressings freely, and after it the patient seemed much relieved. The drainage soon became less free, and on the third day the child died in convulsions. The post-mortem showed that the brain had shrunk so much that the end of the tube was lying between the dura and the brain. In the Revue de Chirurgie for January, 1891, Broca gives a translation of Keen's article just cited and describes two cases of tapping the ventricle, one by himself and one by Thiriar of Brussels. Broca 's patient was a boy of 4, years of age, who had suffered from hydrocephalus and was an imbecile, and who had a contracture of the right arm which had followed a series of convulsions. The trephining was done at the point indicated by Keen, three centimetres above and three centimetres behind the left auditory meatus. It was noticed that there was no pulsation of the dura or of the brain when this was exposed. Broca punctured the ventricle with a trocar and canula iBrit. Med. Jour., Feb. 2d, etc., 1891. TREPHINING FOR HYDROCEPHALUS. 263 and evacuated sixty grammes of fluid ; he introduced a drainage tube through the canula and allowed it to drain into the gauze dressings, which were changed every day or two. Pulsation returned in the brain after the operation. On the sixteenth day a very marked improvement was noticed in the child, the contracture in the right arm having disappeared. The amount of fluid drained away became progres- sively less, and on the fiftieth day after the operation the wound had entirely healed, and the child was dis- charged from the hospital very much better physically and mentally. This is the first successful case on record. The case of Thiriar was one of epilepsy and hydro- cephalus with very great exophthalmos and nystag- mus. Drainage was established and the ventricle washed out. The exophthalmos and nystagmus en- tirely disappeared, but several days later the child died in convulsions. From a review of these cases it is evident that tre- phining in hydrocephalus with drainage of the lateral ventricle is a possible and fairly safe operation, and when the hydrocephalus is not secondary to some in- curable affection, the operation may be attended by a cure as in Broca's case. It is never possible to deter- mine absolutely in the presence of a case of hydro- cephalus, whether the distention of the ventricle is primary or secondary. In every case, therefore, tre- phining should be done, for if the disease is primary it may be cured, and if the disease is secondary the 264 BRAIN SURGERY. patient will die and the operation will not necessarily hasten the fatal termination. A few cases of rupture of the lateral ventricle, of abscesses and hemorrhages rupturing into the lateral ventricle have been gathered by Keen in his paper upon the surgery of the lateral ventricles, but in con- ditions of this character it is impossible to make a diagnosis sufficiently early to attempt trephining, and where trephining has been done in such cases the actual condition has not been diagnosticated before the operation. It is true that these cases do not all die, and Keen has shown that when they have been operated upon a few have recovered, but surgery of this' character is not to be commended, being venture- some and not based upon accurate diagnosis. The operation for reaching the ventricle and drain- ing it, according to Keen's directions, seems to be a simple one. The trephine opening is to be small, one inch in diameter, and to be made one and one-fourth inch above and one and one-fourth inch behind the external auditory meatus, and the direction of the puncture of the brain, which is best made with trocar and canula, should be toward a point two inches above the opposite auditory meatus. Birmingham has shown that at this point there is some danger of opening into the lateral sinus, and recommends placing the tre- phine one-half inch higher. The drainage should be kept up by a large bundle of horsehairs, as drainage by a tube gives exit to the fluid at too rapid a rate. If the drainage is not free. Keen recommends that a TREPHINING FOR HYDROCEPHALUS. 265 similar operation be done upon the opposite side and the ventricle he irrigated with a warm boric acid solution. The nearness of the descending horns of the lateral ventricles to the surface when the ventricles are dis- tended with fluid is well shown in Fig. 59. This operation is necessarily one of very limited application, and when it is considered that its result is Fig. 59.— Dilatation of the Lateral Ventricles in Hydrocephalus.— Delafield and Prudden. to relieve symptoms rather than to remove a patho- logical condition, it becomes evident that it is not an attractive one either to physician or surgeon. Trephining has been done in a number of cases of brain tumor with a view of relieving the general in- tracranial pressure when the situation of the tumor was unknown but the symptoms were exceedingl}'- severe. Horsley reported at the Berlin Congress six cases of "exposure of cerebral tumor for the relief of 266 BRAIN SURGERY. pressure symptoms with recovery and immediate union in all." As he also reported the number of cases of cerebral tumor which he had removed (8), it is to be supposed that in these cases no tumor was found. Mills, Knapp and Bradford, and others have noticed a relief of the symptoms in cases of brain tumor which had been trephined even though the tumor was not removed. Trephining in this case is, of course, merely palliative, and yet it may prolong life for several months and hence may be employed. It seems to be best in such cases to tap the ventricles, since these are usually distended with fluid. If this is done. Keen's method already described should be the one adopted. CHAPTER VIII. TREPHINING FOR INSANITY. Traumatic Insanity in Relation to Insanity in General. Report of Cases Operated Upon. TreiDhiuing in General Paresis. Useless- ness of the Operation. While it is perfectly evident to any one familiar with mental disease that trephining has no place as a method of treatment in general, yet there are a few cases upon record in which the symptoms of mental derangement have developed immediately after a seri- ous injury to the head with or without depressed frac- ture of the skull. The percentage of cases of insanity traceable to traumatism is small. Kiernan ' states that 45 cases in 2,200 cases under his care were trau- matic. Hays'' found 61 cases in 2,500 under his ob- servation; two per cent is therefore a fair estimate. In these cases the apparent connection between the injury and the development of the mental symptoms is so clear as to leave little doubt that the insanity is due to the trauma. Under these circumstances tre- phining has been thought of and has been successfully practised as a method of treatment of the mental disease. Dr. Carlos F. MacDonald reported such a case as ^ Jour. Nerv. and Med. Dis., July, 1881. ^ Amer. Lancet, November, 1891 . 268 BRAIX SURGERY. long ago as 1886/ and collected other cases of the same character which had heen recorded prior to that time (see page 65). Frank and Church have rejDorted ' a case of a young woman who developed delirium immediately after a severe injury to the head. She became constantly worse and finalh' was so unmanageable as to require asylum restraint. She suffered from the ordinary symptoms of mania, which became chronic and went on to complete dementia. She was destructive at times, noisy, but for the most jDart sat idly silent and stupid. This condition remained from April, 1884, until February, 1889, when she was admitted to St. Elizabeth's Hospital, Chicago, and carefully examined by Prof. Brower. The diagnosis was "that the insanity was caused by the injury, because of the absence of any other possi- ble cause and the immediate connection between the two; that the injury need not have jDroduced fracture or depression of the skull to have resulted in insanity ; that the depression of the skull found might be con- genital, but its situation over the right parietal region made it possible that it might be the cause of the in- sanity ; that this possibility justified exploratory tre- phining, and that the danger of the operation was so slight that it should not weigh against the possible benefit." In accordance with this opinion Dr. Frank trephined, removing a large portion of bone about two 1 Amer. Jour. Med. Sci., July. 1886. 2Araer. Jour. Med. Sci., July, 1890. TREPHINING FOR INSANITY. 269 inches in each direction from the anterior part of the right parietal bone. On dividing the dura a consider- able amount of cerebro-spinal fluid gushed out. No gross lesion of the dura or brain was found. The wound was closed after the buttons of bone had been replaced. During the following six months the im- provement of the patient was very striking, though her mental powers were still very feeble, but in Feb- ruary, 1890, she was readmitted to the hospital in about the same condition as a year before. The sec- ond operation was performed March 24th, 1890, at the same location as the first. The buttons of bone were found to have united with the skull, but the small fragments which had been replaced had been absorbed. A large section of bone was removed, the dura and brain were again explored without finding anything, and the wound was closed, this time without replacing the bone. A month later the patient manifested a considerable degree of intelligence, memory, and ap- preciation of her condition and surroundings; she showed natural emotion when told of a slight illness of her father, and read a letter without difficulty. She presented a great contrast to the condition which had been manifest before the operation. This im- provement had continued up to the time of the report^ one month after the second operation was performed. While this case cannot be regarded as a marked success, the report having been made too soon to war- rant any general conclusion, it gives evidence that the ^70 BRAIN SURGERY. <3ourse of a dementia following trauma may be influ- enced by trephining. Dr. Keen reports the following case : A male, aged 41, after a fall from horse developed delusional insan- ity. He heard imaginary Toices and these led to delusion. These delusions led in July, 1890, to an attempt at suicide ; the imaginary voice told him that he was about to be killed by some one pursuing him, and another voice said, ''Don't let them kill you, but do it yourself." Accordingly he ^Drocured a revolver and shot himself, but recovered from the wound. For several mouths later his delusions continued and hal- lucinations of sight were also present. In October, 1890, he complained of constant headache, especially in the right parietal region which was the seat of the injury, and he heard voices constantly. He had no delusions of persecution and was quiet and docile; there were no physical symptoms of brain disease. Dr. Keen trephined October 17th, 1890, over the depressed bone. The scalp was adherent to the skull, the bone was rather thin, the dura was adherent to the bone, there were no adhesions to the pia, and the brain appeared normal. He made an uneventful re- covery and was up two weeks after the operation. The pain in his head was very much less, and he did not hear voices nor did he have any delusions after the operation. Six weeks later he was considered by his wife and employer much more rational than he had been, and was able to do light work. The im- j)rovement was not, however, permanent, and four TREPHINING FOR INSANITY. 271 months later he was reported in about the same con- dition as before the operation. The number of cases thus far trephined for trau- matic insanity is too small and the operation has been performed at a period too far removed from the trauma to warrant any definite conclusion as to the propriety of this form of treatment. But it seems probable that in appropriate cases, where the derange- ment begins soon after the trauma and where an injury of the skull is evident, an early trephining may cut short the mental disease and prevent its going on to a condition of chronic dementia. The mental symptoms which are likely to develop after injury of the head are those of mania or of de- mentia, other forms being rarely recorded. There is no reason to conclude that insanity not traumatic in origin is amenable to surgical treatment, and Burck- hart's proposal made at the Berlin International Medi- cal Congress, to trephine in chronic cases and make in- cisions at random into the brain, deserved the severe censure which it met with. Trephining has been proposed as a form of treci- ment of general paresis, and it has been performed in several cases under the direction of Batty Tuke and Claye Shaw in England, and by Wagner in this coun- try.^ In some of these cases it has failed to produce 1 Claye Shaw: Brit. Med. Jour., Nov. 16th, 1889. Revington : Brit. Med. Jour. , Nov. 23d, 1889. T. Batty Tuke : Brit. Med. Jour. , Jan. 4th, 1890. R. Percy Smith : Brit. Med. Jour. , Jan. 4th, 1890. Claye Shaw: Brit. Med. Jour., Sept. 12th, 1891. St. Bartholomew Hosp. Rep., 1892. Wagner: Amer. Jour. Insanity, July, 1890. 272 BRAIN SUROERY. any effect ; in other cases there has been a shght tem- porary improvement, such as may occur spontaneously in any case of general paresis at any time. No per- manent results have been obtained, and the consensus of opinion at the British Medical Association at its meeting in 1891, when the subject was fully discussed, seems to have been against this method of treatment in general paresis. The plea was made for the opera- tion that it would relieve the condition of intracranial pressure and give exit to fluid which is usually found upon the convexity of the brain in states of dementia. The reply made to this was that the state of fluid exudation was secondary to the lesion in progress in the brain, and that the trephining in no way affected .the actual disease, which was the primary cause of the symptoms. It seems to me that in general paresis, a disease which has an. organic lesion, a diffuse chronic meningo-encephalitis, it is impossible for the operation of trephining to do any good whatever. Even should it act as a palliative treatment, it is not to be encour- aged, for it is very questionable whether there is any gain in prolonging life in such a hopeless and progres- sive form of mental derangement. CHAPTER IX. TREPHINING FOR HEADACHE, AND OTHER CONDITIONS. HoRSLEY and Weir have performed the operation of trephining in two cases of localized headache of trau- matic origin with success. The patients had both de- veloped the headache subsequently to a blow without any fracture of the skull, and every form of treatment had been employed in vain before the aid of the sur- geon was sought. In both cases the pain was a strictly local one, not of the nature of ordinary headache. In Horsley's case there was found an enlarged Pacchi- onian body eroding the dura and skull. In Weir's case the mere removal of a button of bone relieved the pain. Such cases are certainly rare, and it is evident that no special consideration need be given to trephin- ing as a form of treatment for headache. It has been suggested that in cases of meningitis it might be possible to make two or more openings in the skull and wash out the pus from the meninges ; this idea having been suggested by the successful sur- gical treatment of peritonitis. Any one, however, who is familiar with the surgery of the brain will realize that trephining does not give access to any great ex- tent of the meningeal surface, and any one who is 18 274 BRAIN SURGERY. familiar with pathology will realize the impossibility of removing pus from the interstices of the cerebral membranes. Trephining for the treatment of thrombosis of the lateral sinus occurring in connection with middle ear disease has been proposed. Those who are interested may consult the article by Ballance in the Lancet for May mh and 24th, 1890. Trephining for the removal of bullets and foreign bodies from the brain is a purely surgical subject and is treated in the text-books upon surgery. CHAPTER X. THE OPERATION OF TREPHINING. This book would be incomplete did it not contain a chapter upon the technique of opening the skull. I have seen this operation performed so many times in such different ways, by different surgeons, that I am quite familiar with it. But in the preparation of this chapter I have made use of articles by Park, by Horsley, by Von Bergmann, by Weir, and by Keen. ' I have to thank Dr. McBurney for reading this chapter and for many valuable suggestions in its preparation. It is an absolute requisite of success in cerebral operations that every detail of aseptic surgery should be carried out to perfection . It is useless to make elaborate preparations, to sterilize instruments, and to apply antiseptic solutions to the hands, if in the midst of the operation the surgeon stops for a moment to ^ Horsley : Brit. Medical Journal, October lOtli, 1886, and April 23d, 1887. Transactions Berlin Internat. Med. Congress, 1890. Park: "Surgery of the Brain," N. Y. MedicalJournal, November, 1888. Von Bergmann : " Die Chirurgische Behandlung der Hirnkrank- heiten," 1891. Keen : " Surgery of the Brain, " " Reference Handbook of the Medi- cal Sciences, " vol. viii., 1888, and "American System of Surgery," 1892. Weir : American Journal of the Medical Sciences, July, 1888. Macewen: Brit. Med. Jour., Aug. 11th, 1888. 276 BRAIN SURGERY. adjust his septic eyeglass, or to blow his nose on a septic handkerchief without subsequently washing his hands again, or receives an instrument from the hands of assistant or nurse which have not been specially prepared for the operation. By covering his hand with a wet aseptic towel, the surgeon can safely handle anything which he desires. When aseptic measures are carried out in perfect detail, the rapidity of healing after these operations upon the brain is something marvellous. Thus, in an extensive opera- tion, by Dr. McBurney where the incision in the scalp measured seven inches, and the division of the skull along a line measured six inches, and the entire bony flap was broken away, exposing an area of the dura several square inches in extent, the wound was entirely healed within a week of the time of operation. And in the majority of the cases which have been here given in detail, a favorable and immediate healing was secured. It is to be understood, therefore, that in these operations the patient is to be properly pre- pared and the scalp made aseptic; that the hands of the operator and his assistants shall all be prepared ; that the field of operation shall be surrounded over a wide area with sterilized towels either wet or dry (preferably wet), and frequently renewed; that every instrument, sponge, towel, etc., shall have been ren- dered aseptic, either by subjection to boiling heat in a steam sterilizer or by being soaked in a strong anti- septic solution, such as carbolic acid 1 : 50 or bichlor- ide 1:1000. THE OPERATION OF TREPHINING. 277 The Preparation of the Patient. — The patient's head is to be entirely shaven twenty-four hours be- fore the operation and carefully washed with soft soap, being scrubbed with a nail-brush, then washed again with warm water, and then again with sulphuric ether, each successive drying being done with an aseptic towel sterilized by heat. The head is then to be en- veloped in a corrosive-sublimate gauze dressing which is applied moist, having been soaked in a solution of bichloride, 1 : 2000, and bandaged with aseptic ban- dages. Stronger solutions may cause eczema of the scalp. This bandage is to be left on until the opera- tion is begun. The preparatory treatment by a pur- gative and the selection of a time for operation several hours after a meal are not to be neglected. It is best to suspend the administration of bromides for a week before any operation. The choice of an ancBsthetic may be left open to the surgeon, but I can verify the statement that the hem- orrhage from the cerebral vessels is much less intense when chloroform rather than ether is used. Horsley has suggested the hypodermic injection of morphine, one-sixth of a grain, prior to the operation. Keen has recommended ergot, two to four drachms. The object of both is to produce a contracting influence upon the cerebral vessels. I have seen morphine act efficiently in this respect. The marking off upon the^ scalp of the fissures of Eolando and Sylvius requires some time and should in my opinion be done before the anaesthetic is admin- 278 BRAIN SURGERY. istered . These lines, after being carefully laid down, should be marked upon the scalp with iodine. A light touch at a series of points with the Paquelin cautery, after the anaesthetic is administered, fixes the lines. It is also well to puncture the scalp at three points with a sharp instrument, an awl or gouge, and thus mark the bone along the line which it is most important to regard; so that when the scalp is re- tracted the position of the guiding line, whether it be the fissure of Eolando or the fissure of Sylvius, shall be clearly evident upon the bone. This I think is impor- tant, as it is difficult to replace the scalp in the exact position after it has been dissected up, and the mark- ings of the scalj) may be somewhat obliterated by the solutions used in cleaning it after the lines have been laid down. It is also well to make a mark on the skull through the scalp with a sharp instrument at the exact point at which the centre of the trephine is to be placed before the scalp is divided. After the ansesthetic is administered the scalp is to be again carefully washed with (1) soft soap and hot water with the nail-brush, (2) with sulphuric ether, (3) with absolute alcohol, (I) with a solution of corrosive sub- limate, 1 : 1000. The application of a rubber band around the scalp just above the eyebrows for the purpose of compress- ing the vessels and preventing hemorrhage on the principle of the Esmarch bandage, which I suggested to Weir in 1887, is a failure. It cannot be applied with sufficiently even pressure to compress the arte- THE OPERATION OF TREPHINING. 279 lies ; it merely exerts pressure upon the veins and in- creases venous hemorrhage; it should be abandoned. Weir's device of passing four long needles at right angles to one another through the scalp, thus making- pressure on all the vessels leading into the flap, is far better. It is of great service both during and after the oiDeration to have the patient's head on a level above the body, and a semi-sitting posture is the one in which hemorrhage is the least. It is not to be for- gotten that when chloroform is used as an ansesthetic this position is attended by danger. The incision in the scalp should be of horseshoe shape, base downward, or so directed as to secure the best nutrition and sufficiently large to allow of the easy enlargement of the bone opening in case it should be necessary to enlarge this to twice the size antici- pated. The chief hemorrhage during the operation comes from this incision in the scalp, yet nothing is to be gained by making the incision little by little, inas- much as the edges of the incision must be easily accessible in order to reach the bleeding vessels. The better way appears to be to make the incision in three- fourths of its expected length with the first sweep of the knife, to have the scalp compressed by sponges or sterilized gauze in the hands of assistants as fast as the cut is made, and then to catch the vessels one by one with forceps as the sponges are lifted. Several varieties of forceps are in use for this purpose ; either the blunt dog-tooth forceps of McBurney or the broad T-shaped end forceps of Gerster may be employed; 280 BRAIN SURGERY. the latter grasp a portion of the scalp nearly an inch in breadth and hold it firmly for a time : a series of these may be applied along the incision, and then one by one they may be removed and the vessels caught with a single- tooth forceps and tied. When the bleed- ing is arrested from the original incision it may be extended at both ends to its intended size, the vessels near being successively caught and ligated. In dissecting up the scalp the periosteum should he left upon the bone and not dissected up with it. Surgeons differ as to the best method of making an opening through the skull, but all agree that whatever opening is made should be at least one and one-half inch in diameter, and many prefer the opening at least two inches in diameter. Such openings may be made by trephining at one spot with a trephine one and one-fourth inch in diameter and enlarging the opening with a rongeur, or by making two trephine openings an inch in diameter and cutting away with a rongeur the bridge of bone between, or by chiselling with gouge and mallet through the skull, or lastly by the use of the rotary saw run by an electric motor. If the trephine is used care should be taken not to wound the dura when nearly through the skull. In using the rongeur the instrument of Horsley with its jaw at an angle with the shank is far more conven- ient than a straight instrument. If the gouge is used great care must be exerted to prevent its slipping and cutting the dura. The concussion produced by ham- mering is an objection to the use of the gouge or chisel THE OPERATION OF TREPHINING. 281 urged by some American surgeons. But this objec- tion is not sustained by Dr. McBurney's experience. German surgeons prefer this method. If the gouge is used the opening in the skull may be made of i2 shape and the plate of bone be then gently pried up, the attached part being broken but not separated. The electric motor with a rotary saw is a satisfactory instrument for cutting the bone. In order to use it safely a trephine opening must first be made, the dura must be carefully separated from the bone by a thin flat metal instrument, and the instrument must be held in place to protect the dura, and be pushed for- ward in advance of the saw as this is used. The difficulty of directing this flat instrument through the trephine hole, and the danger of sawing into the dura and brain if it is not properly placed, are great. It requires much practice and skill to handle the electric saw safely, and to an observer the danger of sawing through into the dura and brain seems to be great unless the metal plate between skull and dura is very flrmly held and accurately adjusted. Yet the labor of trephining is so great and so wearisome that any mechanical electric motor would appear to be prefera- ble to the hand, and as Horsley's apparatus can be so adjusted as to revolve the trephine, it seems as if the first two-thirds of the trephining can be safely done with it, the last third being done by hand so that touch shall guide the degree of pressure made upon the trephine. It is of course in a hospital only that the electric motor can be used. 282 BRAIN SURGERY. The question of replacing the piece of hone that has been removed is an open one. If a single button of bone is removed, or if two buttons and the bridge be- tween them are taken out, it is possible to replace them and to secure bony union. It is also possible to re- place the large plate removed by the Horsley saw. But of late when larger openings are made by gnaw- ing away the bone about the original trephine opening the bone is rarely replaced. If it is to be replaced it should be kept at a temperature of 99° by being wrapped in warm damp gauze wet with a corrosive sublimate solution, 1 : 2000, or in a sterilized salt solution, and kept in a warming box or in a jar im- mersed in w^arm water. It is also possible to preserve the small pieces of bone and to cut up the larger piece and replace them all by strewing them over the dura. It should be remembered, however, that such pieces of bone, no matter how carefully taken care of in the interim, may necrose after replacement. To avoid this accident McBurney never replaces a piece which has been entirely separated, and for the same reason he prefers lifting a plate of bone which is never en- tirely detached, and so never entirely cut off from a source of nutrition. There is sometimes considerable liemorrliage from the diplo'e, and occasionally a vein or a large canal in the diploe will bleed profusely. Pressure with sponge at the bleeding spot usually stops this. If it persists Horsley's wax may be used, which consists of wax seven parts, oil two parts, carbolic acid one part. THJE OPERATION OF TREPHINING. 28)3^^ This may not be sufficient to arrest hemorrhage from a large vein, and then a small plug of decalcified bone or of aseptic sponge may be forced into the opening. The two tables may be forcibly crushed together by a heavy forceps and thus the bleeding from the diploe stopped. The division of the dura is made by the point of a curved bistoury, or an ordinary scalpel. A fine tena- culum then seizes the dura and draws it up from the brain surface, and into the small incision a curved blunt scissors blade can be inserted and the dura freely divided. The dura should be divided about one- fourth inch from the edge of the bony opening and the incision should be horse-shoe in shape. The dura can then be refiected downward leaving the brain ex- posed. It should be lifted carefully away from the brain, for very frequently close adhesions exist which cannot be roughly torn without incurring great risk of opening one or more large veins of the pia mater. If arteries are found passing over the dura they should be ligatured before the dura is divided. This is best done by Keen's small, curved needle attached to a handle, similar to an aneurism needle but very minute. A curved Hagedorn needle may be used. This can be passed around the vessel through the dura and a liga- ture threaded into it and drawn backward, thus sur- rounding the vessel. The same needle can be used in sewing up the dura at the end of the operation, the ordinary curved surgical needles being too large. Hemorrhage from little vessels of the dura is best ar- 284 BRAIN SURGERY. rested by a light touch with the cautery if pressure is insufficient. The brain is now exposed — covered by pi a mater, whose numerous vessels are easily torn at the least rough manipulation. If it is necessary to dissect off portions of the pia — in removing scar tissues or tumors — or if it is necessary to incise the brain for the exci- sion of cysts or tumors, hemorrhage may give some trouble. It can usually be arrested by continued pressure with sponge or with aseptic gauze. During the time that this pressure is being maintained, liga- tures may be applied to bleeding vessels of the scalp, or the wound may be cleaned and new towels applied ; thus no time is wasted. If pressure alone is not enough to stop hemorrhage from the pia a clamp or forceps may be applied for a time, and if it continues when this is removed the vessel may be tied with very fine catgut. As a last resort the Paquelin cautery may be employed, but it is less useful in the vessels of the pia than in those of the dura. Pressure alone is usually sufficient to arrest hemorrhage from the brain substance itself, though a cautery may be needed. It is impossible to tie the little brain arteries and veins. Solutions of antipyrine 1 : 40, or of cocaine 1 : 100, have been used as styptics by Keen and Park. Exploration of the Brain may be made by palpation, and this is exceedingly satisfactory, for the degree of resistance to pressure may be contrasted at various points and the fluctuation of a deep cyst or the hard- ness of a solid tumor can be easily noticed. THE OPERATION OF TREPHINING. 285 If necessary a probe may be thrust into the brain or a hypodermic needle may be introduced quite freely and without danger, as Spitzka has shown. Incisions into the brain are not dangerous, but if they are made the knife should be passed down through the summit of a convolution, as then hemorrhage is less free than when the side of the convolution or the brain at the bottom of a sulcus is incised. When it is remembered that large portions of brain tissue have been destroyed by accidents {e.g., in the crow-bar case and in the linch-pin case) without fatal results, less fear will be felt on wounding the brain. Yet it is to be also re- membered that certain parts of the cortex have im- portant functions — such as the speech areas or the mo- tor areas — and all needless incision or excision should be avoided. If there is much oedema of the pia, a few small in- cisions in it followed by pressure will evacuate the fluid. If a clot is found it may be wiped away by fine sponges or, if organized, picked out with fine forceps, care being taken not to tear the pial veins. If a tumor lies upon the surface, and is surrounded by a distinct capsule, it can be enucleated with the blunt point of curved scissors or with the finger with- out cutting. If it infiltrates the brain tissue and so has no distinct capsule, it should be cut out with the knife. The sharp spoon does not do good work in the brain. If the tumor lies below the surface, the brain tissue lying over it must first be incised and then enu- ^86 BRAIN SURGERY. cleation or dissection of the tumor from its bed may be done, the overl^'ing substance being held away with flat retractors. If a cyst exists, it may be when superficial completely excised, or its superficial sur- face wall may be cut away and the remainder packed and healed by granulation. If the cyst lies deeper, it may be freely incised and packed, or a small incision for drainage may be made, and continuous drainage kept up by introducing a folded strip of rubber tissue through the incision. The same device may be resorted to in draining an abscess. After the removal of large tumors or cysts, or after the excision of large scars from the brain, a de- pression of the surface or a deej) cavity may remain which if left to itself inevitably fills with blood. This may be avoided by packing such a cavity lightly with iodoform gauze, which at subsequent dressings maybe removed little by little. It is well to use a single strijD of gauze, otherwise the number of pieces used may not be accurately counted or remembered and one piece may never be removed. A tampon of folded aseptic gauze may be used in place of the iodoform packing. If the operator has confidence in his methods, he might in some suitalle cases, where bleeding was not active, practise the ideal method by allowing the cav- ity to fill with blood, and so get healing with organi- zation of blood clot. One or more openings must be left in the suture line to allow of the escape of super- fluous blood. THE OPERATION OF TREPHINING. 287 A very marked bulging of the brain tissue through the opening in the dura mater sometimes occurs at the time of the operation, or subsequently to it, as a hernia cerebri. It has been found that the smaller the opening in the dura the more likely this is to occur. If the bulging tissue be held back by a fiat spatula while the stitches are put in the dura and a continuous suture be used, and then the edges of the dura be rapidly drawn together as the spatula is re- moved, the bulging will be slowly reduced. If this is impossible the bulging brain may be sliced off or wiped away with a sponge. Hernia cerebri develop- ing after the operation is rare when asepsis is perfect. In case a sinus or a large vein is opened and hem- orrhage becomes alarming the wound may be pa.cked with iodoform gauze with safety, or the wound in the sinus having been closed with a pressure forceps, the forceps may be left in place for a day or two supported by the dressings. Sewing up a bleeding sinus is diffi- cult, but has been done successfully. The closing of the ivoiind should be preceded by a thorough irrigation with simple sterilized salt solu- tion, one per cent, or with corrosive sublimate, 1 : 5000. A small drain of a folded bit of rubber tissue should be left in the most dependent part of the wound. The dura should be stitched with catgut ex- cept where the drain passes through it. The scalp is then to be stitched with silk. The head is to be washed with antiseptic solution. The wound is then to be covered with rubber tissue. It is to be covered .288 BRAIN SURGERY. with aseptic gauze and this with many layers of cot- ton, and the whole held in place by a large bandage covering the entire head and held under the jaw. In some cases there may be no necessity for a drain, in which case the entire dressing need not be changed for a week, when everything may be found to have united by first intention. In other cases the drain may be removed on the third day and a second dressing applied — removal of which may be found to show a healed wound. Damming up of blood giving rise to pressure symp- toms, or the extreme oozing of cerebro-spinal fluid, or the development of a temperature with evidence of infection, necessitate an immediate inspection of the wound by the removal of dressings, and proper care upon general surgical principles. THE END. INDEX. Abscess of the brain, 179 capsule in, 182 cases of, 183 cases operated upon, 183, 184, 194, 195 causes of, 180 diagnosis of, 188, 189 differentiation from menin- gitis, 190 from sinus thrombosis, 190 following ear disease, 188 fevers, 180 injury of the skull, 183 pathology of, 181 position for trephining in, 193 symptoms of, 189 trephining for, 182 varieties of, 180 Agnew, 181, 227, 253 Agraphia, 6 Alexia, 6 Amidon, 253 Anaesthetic in trephining, 277 Anderson, 252 Anger, 137 Aphasia, 6, 23, 42, 45, 48, 145, 158, 160, 162, 174, 183, 188, 214, 219, 228, 261 Apoplexy, trephining in, 176 Arm, motor area of, 3 spasm in, 20 AsJiby, 117, 133 Association tracts in the brain, 10 19 Atrophy of the brain, 125, 129 Auditory area of the brain, 6 speech, 7 Ball, 158 Ballet, 251 Barker, 197 Barr, 188 Barton, 251 Bartlett, 137, 224, 251 Basal ganglia, 11 Base of the brain, 11 tumors of, 210 Beach, 252 Bennett, 251 Bennie, 137 Von Bergma^in, 195, 20j, 251, 275 Bernhardt, 215 Birdsall, 221, 251 Birmingham, 194, 264 Birth palsy, 116 Blindness, 121, 229, 246, 248 Bone, lesions after injury, 69 replacing after trephining, 282 Booth, 205, 251 Boyd, 166 Bradford, 137, 223, 252, 253 Brain, bulging of, after trephin- ing, 287 changes in, in epilepsy, 73 exploration of the, 284 wounds of the, 76 Bramivell, 207 Braman, 252 Bremer, 225, 252 290 INDEX. Briddon, 41 Broca, 262 Brower, 268 Bryant, 62, 184 Bullard, 137, 253 Carcinoma of the brain, 202, 204, 206 Carson, 225, 252 Castro, 252 Centrum ovale, 10 Cerebellum, 11 abscess of the, 188 tumors of the, 238 cases operated on, 241-253 staggering in, 239 symptoms of, 238 Cerebral abscess, see Abscess, 179 diseases, 1 functions, 3 hemorrhage, see Hemor- rhage, 131 tumor, see Tumor, 200 Championniere, 173, 251 Charcot, 21 Chisholm, 253 Choked disc, 189, 190, 217, 238, 257 Chubbe, 252 Church, 55, 223, 252, 268 Clarke, 252, 253 Claye Shaw, 271 Clinical types of microcephalus, 114 Coen, 76 Combe, 251 Compression of the brain, 167 Congenital defects of the brain, 128 Consciousness after hemorrhage, 169 Corpora quadrigemina, 11 striata, 11 Cortical areas, 3 Cranial nerves, symptoms of in- jury to, 240 Cranio- cerebral topography, 15 Craniotomy for microcephalus, 114, 136 table of cases of, 137 Crura cerebri, 11 Cunningham, 15 Curtis, B. F., 205, 251 Cysts in the brain, 74, 130, 203, 207, 284 Czerny, 218 Dana, 215, 252 Danger of trephining in epilepsy, 27 Deaf -mutism, 120 Deafness in brain disease, 7, 240 Deaver, 55 Dementia, 268, 271 Derby, 229 Detmold, 179 Diller, 57 Direction of staggering as a local symptom, 239 Dobson, 253 Donaldson, 120 Doyen, 252 Drainage of lateral ventricles, 256 Dunin, 252 Dupuytren, 179 Durante, 251 Dura, changes in, in epilepsy, 70 treatment of, after trephin- ing, 283 Elcan, 183 Epilepsy, trephining for, 19 aphasic attacks, 23 cases open to trephining, 24 cases trephined, 29-69 causes of, 25 following injury, 261 idiopathic, 19, 117 INDEX. 291 Epilepsy in microcephalic chil- dren, 124 in tumor of the brain, 217 Jacksonian, 20 lesions of, 68, 75, 78-112 pathology of, 68-112 psychical attacks, 23, 65 reflex, 68 results of trephining for, 112 sensory attacks, 22 traumatic, 25 varieties of. 19 with insanity, 65, 267 Erh, 217, 252 Eskridge, 252 Excision of cortex, 27 Extra -dural hemorrhage, 168 Eyes, motor area of, 3 Face, motor area of, 3 Facts of localization, 3 Feiiger, 183 Ferraro, 126 Ferrier, 21, 232 Fischer, 251 Fisher, E. D., 62, 63, 64, 122, 129, 138 Fissures of the brain, 3, 15 Fitzgerald, 251, 253 Fracture of the skull, 69 Frank, 55, 133, 137, 252, 268 Eraser, 253 Freimd, 123 Frontal lobe, functions of, 8 lesions of, 219, 231 Functions of cerebellum, 11 of cortex, 4 Gerster, 59, 60, 61, 62, 137, 279 Glioma, 202, 207, 245, 247 Glio-sarcoma, 207 Godlee, 251 Gowers, 116, 133 Gray, 253 Griffith. 232 Gumma, 203, 206 Hahn, 185 Hallucinations, 22 Hammond, 137, 138, 253 Hartley, 48, 138, 144 Hays, 267 Headache, trephining for, 273 Head, injury of, as cause of ab- scess 183 of epilepsy, 26, 121 of hemorrhage, 158 of insanity, 267 motor area of, 3 Heath, 253 Hemianopsia, 7, 121, 123, 167, 214, 218 Hemiplegia in children, 115 Hemorrhage, 131 cases of, 158, 161, 166 extra-dural vs. intra- dural, 168 from the brain after trephin- ing, 284 from the diploe, 282 from the pia, 283 intra-cerebral, 176 non- traumatic, 172 traumatic, 123, 158, 167 trephining for, 131, 157 Henschen, 7, 123 Heurtaux, 137 Hirschfelder, 220, 251 Hitzig, 179, 252 Hodenpyl, 236 Horsley, 5, 76, 136, 138, 203, 206, 237, 251, 252, 265, 273, 275, 280, 281, 282 Hydrocephalus, 132, 256 cases of, 259 diagnosis of, 257 draining ventricles in, 258 trephining for, 256 Imbecility, 114 292 INDEX. Incision in scalp in trephining, 279 ^ i Infantile hemiplegia. 115 I Insanity. 267 cases open to operation. 267 cases ti-ephined. 268 dementia. 268 paresis. 271 traumatic, 267 trephining for. 267 Internal capsule, 11 Inti'a-dural hemorrhage, 168 Jackson, Hughlings. 19. 20 Jacksonian epilepsy. 20 Jacobson, 168 Janeway. 183 Jeannel. 252 Kelly, 64. 65 Keen, 55, 56. 57. 136. 137. 2-22. 251. 258. 260. 270. 275. 283. 284 Keetley, 253 Kerr, 253 Kieman, 267 Knapp, 58, 59, 215, 223. 252, 253 Koehler. 252 Koerner, 188 Kuchenmeister, 203 Kundrat, 133 Lanipiasi, 252, 253 Lannelongue, 136 Leg, motor area of, 3 Llobet, 252 Lloyd, 55. 215 Limont, 251 Localization of brainf unctions, 3 JlacDonald. C. F. JLaceicen, 157, 251 Jdaiidsley. 253 JIaunoury, 137 Maunsell, 252 i5. 267 :\laAj. 252 Mal-development of brain. 124 Marking the scalp before trephin- ing. 177 McBurney. 30. 32, 33. 35. 39. 44, 45, 50, 52, 53. 68. 138, 141, 147, 163, 233. 243. 246. 249, 251, 252, 253, 275, 279, 282 Mcaintock. 137 Mcyutt. 133 Medulla, 11 Meningeal hemorrhage. 117 Meningitis, 72, 273 Meningo-encephalitis. 117. 129. 271 Mental defects in frontal lesion, 219, 231 in microcephalus, 118 faculties, 9 Jlercauton, 252 Michaucc, 173 Microcephalus. 114 cases of, trephined. 137 clinical types of. 114 conclusions regarding tre- phining for, 155 epilepsy with, 115, 117 imbecility from, 118 paralysis from, 115 pathology of. 124 results of ti^ephining for. 139 sensory defects with, 120 Microscopic lesions in epilepsy, 79. 83, 102 Middle meningeal artery. 169 MillS: 215 Moeli, 123 Jlorrison, 57. 138 Morse, 253 Motor aphasia, see Aphasia area of brain, 3 ti-act in brain. 9 Neuritis optica in abscess of brain, 189, 190 INDEX. 293 Neuritis in hydrocephalus, 257 in sinus tlirombosis, 190 in tumor of brain, 204, 206, 212, 217, 238 Neuroglia, changes in, in epi- lepsy, 99-106 Nothnagel, 21 Nugent, 253 OcTJLO-MOTOR paraljsis, 209 Opening the skull, methods of, 280 Oppenheim, 137, 252 Operation of trephining, 275 Optic neuritis, see Neuritis op- tica Optic thalamus, 11, 214 Organic epilepsy, 20 Osier, 116, 128, 133 Page, 251 Paralysis from brain disease, 3 of cranial nerves, 209 Paresis, trephining for, 271 Park, 66, 138, 149, 153, 275, 284 Parker, 251 Pathology of abscess of the brain, 181 brain diseases, 79 cerebral atrophy, 126 cerebral sclerosis, 124 epilepsy, 25, 68 hydrocephalus, 256 insanity, 272 microcephalus, 256 porencephalus, 128 tumors of the brain, 208 wounds in the brain, 76 Pean, 251, 252 Periosteum, changes in, 69 treatment of, 280 Peterson, 122 Pia mater, changes in, 70, 71 treatment of, 280 Pitcher, 252 Poirier, 252 Pons Varolii, 11 tumors of, 209 Poore, 46, 185 Porencephalus, 125 Post, 58, 59 Potempski, 252, 253 Poulson, 188, 189 Preparation of head for trephin- ing, 277 Preugmeber , 138 Projection tracts in the brain, 9 Psychical epilepsy, 23 Punctured wounds of the brain, 158, 285 Pupils in cerebral compression, 170 Putnam, 253 Rannie, 251 Reid, 16 Relation of fissures and sutures, 13 of skull and brain, 12 Replacing bone after trephining, 282 Results of trephining in abscess of brain, 181 in epilepsy, 28, 54, 67, 112 in hemorrhage, 167, 171 in hydrocephalus, 263 in insanity, 271 in microcephalus, 137, 155 in tumor of brain, 216 Retinal carcinoma, 214 Reynier, 252 Rheinhardt, 120 Robson, Mayo, 261, 262 Roland, 21 Rolando, fissure of, 16 Ross, 253 Rumpff, 203 Sachs, 59, 60, 61, 62, 116, 133, 137 294 INDEX. Sands, 253 Sarcoma of brain, 202, 207 Scalp, incision in, 279 wounds of, 68 Scars in brain, 76 in scalp, 68 Sciamanna, 253 Shattenberg, 125 Schneider, 160 Schoenthal, 232 Schultze, 128 Sclerosis of brain, 125 Seguin, 221, 251, 253 Sensory aphasia, see Aphasia areas of cortex, 3 aura in epilepsy, 22 defects in imbeciles, 120 epileptic attacks, 22 Shaw, 58 Sheldon, 232 Sight area of cortex, 6 Sinus, thrombosis of lateral, 190 treatment of, in trephining, 287 Skull, fractures of, 69 relation to brain, 12 Smell area of cortex, 8 Sound area of cortex, 7 Spasms localized, 22 order of extension of, 21 Specific treatment in tumor, 254 Speech areas of cortex, 3 Spitzka, 285 Springthorpe, 253 Staggering, as a symptom, 239 Starr, 21, 138, 231, 251, 252 Statistics of trephining, see Ee- sults Stewart, 253 Stieglitz, 252 Stimson, 184, 194 Stoker, 253 Strumpell, 133 Suckling, 252 Sylvius, fissure of, 17 Table of cases of craniotomy, 137 of tumors of the brain, 202 open to operation, 213 operated upon success- fully, 251 operated upon unsuccess - fully, 252 Taste, area of, in cortex, 8 Thiriar, 263 Thomas, 224, 251 Thompson, 232 Thrombosis of lateral sinus, 190 trephining for, 190, 274 of veins of pia, 133 Topography, cranio-cerebral, 15 Tracts within the brain, 10 Trauma as a cause of abscess, 180 epilepsy, 25 hemorrhage, 160 insanity, 267 Trephining for abscess of the brain, 180 clots on the brain, 170 epilepsy, 13, 19 headache, 273 hemorrhage, 157 hydrocephalus, 132, 256 imbecility, 114 intracranial pressure, 256 insanity, 267 meningitis, 274 tumors, 200, 265 methods of, 280 operation of, 276 personal cases of, 29-54, 140-149, 161, 174, 185, 228-250 statistics of, see Statistics technique of, 276 Trimble, 137 Trunk, motor area of, 4 Tubercular tumors, 202, 204, 205 INDEX. 295 Tumors of the brain, 200 analysis of operations for, 216 analysis of 600 cases, 202 cases open to operation, 209 cases operated upon, 220-250 cerebellar, 238 cerebral, 217 conclusions regarding opera- tion for, 254 cortical, 217 diagnosis of, 204, 306, 212, 238 frequency of, 201 hemorrhages in, 208 in adults, 201, 212 in centrum ovale, 212 in cerebellum, 211, 238 in cerebral axis, 209 in cerebral cortex, 212 in children, 201, 211 multiple, 204 per cent of cases operable, 213, 214 situation of, 209 structure of, 208 symptoms of, 208, 212, 238 tables of cases of, see Tables varieties of, 201 Twynam, 253 Uncinate gyrus, 8 Van Gieson, 72, 78-111 Varieties of abscess, 180 aphasia, 6 epilepsy, 19 tumor, 201 Verco, 252 Visual area of brain, 6, 7 tract in brain, 9 Wagner, 271 Weeks, 241 Weir, 38, 148, 174, 221, 251, 253, 273, 275 Welt, 232 Wernicke, 258 White, Hale, 214 Wilbrand, 122 Willard, 138 Wollenhurg, 245 Wood, 227 Woolsey, 63 Wounds of the brain, 76 Wyeth, 137 Wyman, 253 Zenner, 258 Ziegler, 76