measures, the surgeon is, of course, guided in his estimation of the
case by the general condition of the patient--depth of unconsciousness,
&c.--but more especially by the temperature changes and alterations in
blood-pressure. In my own practice I am guided very largely by the
temperature changes--as described on p. 114. On the other hand, some
surgeons pin their faith more especially on the blood-pressure changes.
Thus Archibald writes: ‘If the blood-pressure be 130 mm. Hg. on
admission, an hour later 150, still later 200 or 250, we are immediately
in possession of the fact that the available intracranial space is being
steadily, dangerously reduced, and that the vaso-motor centre is
straining every nerve to stave off defeat.’
I am, of course, ready to concede the great value of blood-pressure
tracings, but, in my experience, the temperature changes have been even
more consistent, so much so that I base my treatment of a case very
largely on such changes. One word of warning--the temperature must be
taken every half-hour, and active surgical measures adopted _so soon as_
the rising temperature, slowing high-tension pulse, and deepening
unconsciousness point to advancing compression.
There is undoubtedly a growing tendency amongst those who have carefully
studied the effects of trauma on the skull and brain to carry out
exploratory and decompression operations at an early period, even in
cases which present no symptoms of special localizing significance. The
pathological conditions so commonly found and the excellent results that
have been obtained prove that the adoption of early surgical treatment
is founded on a very sound basis.
=Points in the differential diagnosis between traumatic and other forms
of coma.= The previous history of the case, the nature of the accident,
and the lesions found may enable the surgeon to arrive at ready
diagnosis. Often, however, it is impossible to exclude non-traumatic
forms of coma without an exhaustive examination of the patient. In the
process of examination, it is convenient to have in one’s mind a simple
memoria-technica. Thus,
A stands for Alcohol and Apoplexy.
E „ „ Epilepsy (post-epileptic coma).
I „ „ Injury.
O „ „ Opium poisoning.
U „ „ Uræmia.
To this list must be added Diabetic Coma.
Having these conditions in mind, the patient is examined from head to
foot in the following manner:--
The _vault of the skull_ is first examined and all evidence obtained as
to the presence and extent of external injury.
The _ears and nose_ are investigated for escaping blood or
cerebro-spinal fluid, important symptoms in the diagnosis of fracture of
the base.
The _eyes_ are next examined. Ocular palsies suggest injury or apoplexy;
hæmorrhages--subconjunctival or palpebral--point to injury; whilst the
condition of the pupils and disks may offer valuable information. Thus:
In concussion, the pupils are equal, dilated, but responsive to light.
In irritation, they are equal but contracted.
In compression, they are either equal, dilated and fixed, or unequal.
In alcohol, they are more or less normal, except in the deeper stages of
intoxication, when they are dilated and irresponsive to light.
In apoplexy, dilated and fixed, or unequal. Pin-point in pontine
hæmorrhage.
In epilepsy, usually equal and responsive.
In opium, immovably and symmetrically contracted.
In uræmia, dilated and sluggish.
In diabetes, equal but dilated. React to light.
In doubtful cases an examination of the disks may clear up the
diagnosis. The presence of albuminuric retinitis, optic neuritis and
atrophy (diabetes and uræmia), retinal hæmorrhages (injury), offer
material diagnostic aid.
The _tongue_ should be examined for such biting as is observed in
epilepsy. The odour of the _breath_ is investigated--the sickly smell of
alcohol, the sweetish odour of uræmia, the peculiar smell of opium, the
chloroform-like smell of diabetes.
The appearance of the _face_ may be suggestive. The unilateral facial
palsy of trauma and apoplexy; the stertorous respiration, puffing out of
the cheeks, and general turgidity of compression, uræmia, apoplexy and
deep alcoholism; the quiet breathing and pale face of concussion, opium
poisoning, and of post-epileptic and diabetic coma.
The _urine_ should be examined for albumen and sugar, and the body and
lower extremities for œdema.
The _extremities_ are investigated with respect to unilateral palsy, a
condition only present in trauma and apoplexy. General convulsions point
to injury, uræmia, and epilepsy. Resistance to manipulation is
suggestive of alcoholic excess. Unilateral palsy may be associated with
corresponding alteration in the deep reflexes.
The _pulse_-rate and the condition of the arteries supply valuable
evidence. The coats may be atheromatous, whilst the slow, full pulse is
strongly suggestive of compression, apoplexy, and alcoholism.
The _temperature_ should be taken on both sides of the body. A rise of
temperature is usually dependent on brain injury, apoplexy, and
alcoholism. In opium poisoning, uræmia, and epilepsy the temperature is
more likely to be normal or subnormal. In pontine hæmorrhage,
hyperpyrexia is commonly observed.
Some difference in the temperature on the two sides of the body points
to injury or apoplexy.
The _depth of the coma_ is often of the greatest assistance in the
differential diagnosis. Thus, in concussion, alcohol poisoning, and in
the minor grades of epilepsy and uræmia, the patient may often be
sufficiently aroused by shouting in the ear, digital pressure over the
supra-orbital nerves, or by the application of the battery, as to give
some account of the accident, &c. In compression, in the deeper states
of uræmic and diabetic poisoning, and in the status epilepticus, the
patient can seldom be aroused from the deep coma into which he is sunk.
In all cases of doubt the patient must be kept under careful
observation.
[26] _Syst. of Pract. Surg._, vol. ii.
[27] _Deutsche Zeit. für Chir._, Bd. 4, vols. i and iii.
[28] _Guy’s Hosp. Reports_, 1885-6.
[29] Bergmann’s _System of Surgery_, vol. i.
[30] _Ruptures de l’Artère méningée moyenne._
[31] _Guy’s Hospital Reports_, vol. lix.
[32] _Traumatic Injuries of the Brain._
[33] _Traumatic Injuries of the Brain_, p. 138.
[34] _System of Surgery_, vol. i, p. 179.
[35] _American Practice of Surgery_, Bryant and Buck.
CHAPTER VI
THE REMOTE EFFECTS OF HEAD-INJURY
=General considerations.= It is often stated that a patient who has
received a severe head-injury is ‘never the same man afterwards’. Before
accepting such a sweeping statement--the gravity of which is obvious--it
is essential that an extensive survey should be made into the remote
effects of head-injury, and, in their consideration, the surgeon must
not be biased by those cases that seek hospital relief. It is the
unfavourable cases that present themselves for examination, the more
favourable are usually lost to view. Furthermore, whether the early
results are completely satisfactory or not, but little guide can be
obtained into the more remote results unless, as a routine procedure, an
attempt be made to trace all such cases in their after-history. The more
remote results can then be estimated at their true value.
The difficulties attendant on all attempts at following up hospital
cases are considerable, and consequently we are greatly indebted to
Crisp English[36] for his tabulation and discussion on the after-history
of 300 cases treated at St. George’s Hospital--300 cases personally
investigated at periods varying from one to twenty years subsequent to
the time of the injury.
English’s conclusions have been compared with those derived from my own
personal experience, with the result that they were found to coincide so
closely that they may be accepted as affording an accurate guide into
the remote results of head-injury in general.
English classified his cases into three series--each 100 in
number--according to the severity of the lesion.
Series 1. Fracture cases.
Series 2. Cases of concussion, contusion, and laceration.
Series 3. Miscellaneous cases.
The remote results as observed in the first and second series were as
follows:--
Series 1. No effects 31
Slight effects 50
Marked effects 19
Series 2. No effects 48
Slight effects 42
Marked effects 10
In the 200 cases, therefore, that come under Series 1 and 2, 79
experienced no ill effects from the injury, 92 developed slight effects,
and definite defects were present in 29 cases.
Before alluding further to the mental and bodily condition of the
patients subsequent to the accident, including their wage-earning
capacity, it is necessary to enlarge on the fact that the depreciation
in mental and physical faculties depends, not only on the severity of
the injury, but also on the age, disposition, and status of the patient.
_The effect of age._ All evidence tends to prove that head-injuries in
the young and the old are more serious than when the accident occurs
during middle life. In the old, the power of repair is impaired; in the
young, the developing faculties are impeded in their progress.
_The effect of disposition._ The temperament of the patient must always
be taken into consideration, the neurotic type seldom recovering so
quickly or so completely as the more plethoric.
_The effect of status._ A complete recovery is far more likely to occur
when the status of the patient allows of complete rest, bodily and
mental, for some considerable time subsequent to the accident. A
premature return to work, with possible added family troubles,
invariably acts as a deterrent to complete recovery. In the milder cases
a few weeks suffice to allow of restoration to health, in other cases an
interval of at least one year should be allowed before the patient again
takes up his duties. It is obvious, therefore, that family troubles and
business emergencies influence to a marked degree the completeness of
recovery. It might be anticipated that the financial necessities of the
case would cause the various after-results of head-injuries to be more
marked amongst the labouring classes. The personal equation, however,
enters largely into the question, and due allowance must be made for the
greater financial and social losses entailed when the injury involves
one who occupies a high social sphere. It must also be borne in mind
that those occupying such spheres may not benefit from the Workmen’s
Compensation Act.
On referring again to English’s cases, it was found that the
wage-earning capacity of the patient afforded a valuable clue in the
estimation of the remote results in general. Thus in Series 1 and 2 the
following results were obtained:--
Series 1. 86 cases:
52 carried out the same work at the same wages.
13 carried out lighter work.
7 could do but little work.
8 had to take to other work, less dangerous.
6 were totally disabled.
Series 2. 78 cases:
51 carried out the same work at the same wages.
12 worked as before, but without much interest.
6 were compelled to undertake lighter work.
4 could do a little work.
2 gave up their trade for another, less dangerous.
3 were totally disabled.
Thus 59 per cent. in Series 1 and 80 per cent. in Series 2 were able to
do the same work at the same wages as previous to the accident.
It will be of interest to compare English’s results with those obtained
by other investigators. Thus, in 48 cases examined by Graf, the
following results were obtained:--
In 9 cases, no bad results.
10 cases, slight troubles or impaired work-power.
12 cases, limited power of work.
17 cases, complete incapacitation from work.
Thus 35 per cent. of cases were completely incapacitated from work,
results far more serious than according to English’s investigations.
Again, Crandon and Wilson made inquiries into the after-effects in 38
cases, with the following results:--
_Yes._ _No._
Headache 13 25
Eye troubles 17 21
Dizziness 15 23
Deafness 16 22
Paralysis 1 37
Faints 4 34
Fits 2 36
Loss of memory 4 34
Troubled by the sun 13 25
Troubled by alcohol 6 32
On investigating those cases reported by English, in which the patient
was compelled to take on lighter work or change his vocation, one at
once encounters a diversity of symptoms, some so indefinite as to be
included under the term traumatic neurasthenia, others so distinct as to
fall naturally under certain well-recognized groups, such as traumatic
cephalalgia, epilepsy, &c.
=Traumatic neurasthenia.= All those cases characterized by the
indefinite nature of their complaint require the most careful
sifting--to separate the wheat from the chaff--for there is always a
certain proportion of malingerers, such as realize the pecuniary
advantages of their position. When these are excluded, a large class
remains in whom the injury must undoubtedly be regarded as the _fons et
origo mali_. A curious and interesting train of symptoms supervene after
the accident, indefinite from a localizing point of view, but quite
definite from the standpoint of the patient himself. Mental
irritability, with a ready tendency to fly into a passion--Kaplan’s
explosive diathesis--may be regarded as an almost constant symptom. The
patient is changed in his manner towards those near and dear to him,
restless, irritable, and intolerant of noises, morose, and incapable of
managing his financial affairs.
The change may be insidious in origin, but, in the absence of
appropriate treatment, steadily progressive. The mental changes, unless
checked in time, tend to merge into definite insanity, not infrequently
of a homicidal or suicidal character.
Insomnia, with terrifying dreams, loss of appetite, emaciation,
headache, vertigo, nervousness, amnesia, lack of power of mental
concentration, and mental depression are all noticeable features. All
such symptoms are aggravated by indulgence in alcohol, exposure to the
sun, &c.
From a localizing point of view the symptoms are obscure, but they are
probably none the less dependent on pathological changes--thickening of
the meninges, effusion into the subdural and subarachnoid spaces, œdema
of the cortex, &c. Furthermore, it will usually be found that, during
the height of the attacks, the pulse-rate is slowed, the temperature
raised, and the respiration embarrassed--symptoms suggestive of
cerebritis and alterations in the intracranial pressure.
In exploratory operations conducted in cases of this nature, I have been
particularly struck by the fact that in a large proportion of cases one
finds what appears to be a condition of local œdema--some fluid beneath
the dura mater, and a greater excess of the same in the pia-arachnoid
meshwork. This œdema is a manifest condition readily demonstrated to
onlookers. I am not an advocate of ventricular puncture in these cases,
mainly on the ground that it complicates the operation and brings no
added benefit in its train, but in such cases as it has been carried out
the jet of cerebro-spinal fluid proves the added existence of an
increased intraventricular pressure. From Leonard Hill’s experiments it
would appear that this œdema is dependent on chronic vascular
changes--arterial anæmia, venous congestion, and cerebro-spinal and
serous accumulation.
At a later date the meninges may become thickened and adherent to one
another and to the surface of the brain, whilst false membranes and
arachnoid cysts may develop.
=Treatment.= For these more general and indefinite remote results of
head-injury the treatment comprises REST, bodily and mental, light diet,
fresh air, cheerful but quiet surroundings, and encouragement. Potassium
iodide and mercury (preferably by inunction) often do good, whilst
phenacetin and antipyrin are perhaps the best drugs for relief of
headache. For sleeplessness potassium bromide is perhaps the best
remedy.
I have found in some cases that Turkish baths and massage have brought
about considerable improvement. In advising such energetic treatment the
surgeon must be guided by the case before him, these measures being more
or less restricted to the less serious and more chronic cases.
In the more serious cases, especially when slowing of the pulse during
the height of the attacks and some blurring of the disks point to a
probable increase of intracranial pressure, operative measures must be
considered. The greatest circumspection is required in determining the
class of cases in which operation may be proposed, and the surgeon must
be most guarded in his prognosis. So far as my personal experience goes,
the operation has invariably brought about some amelioration in the
condition of the patient, whilst now and again a complete cure may be
anticipated. Those cases which on exploration evidence an œdema of the
brain are the least favourable; those in which the surgeon finds a
subdural cyst or hæmatoma offer the best prognosis.
With respect to the details of the operation, two courses are available:
(1) examination of the meninges and brain at the seat of injury, and (2)
a ‘decompression’ operation. The former course should be adopted
whenever the local conditions are favourable, that is to say,
whenever depression or absence of bone, localized headache, &c.,
suggest a localized lesion. Under other circumstances Cushing’s
intermusculo-temporal method of decompression should be carried out.
This operation should be conducted first over the right temporal region,
thus avoiding all possibility of inclusion of Broca’s area, a similar
operation being done on the left side at a later date in the event of
incomplete success.
=Traumatic cephalalgia.= Of all the after-results of head-injuries,
headache is the most constant symptom, either localized to the region
primarily involved or diffuse. Even when diffuse, however, the aching is
frequently referred to the frontal region. Localized headaches are the
more acute. The patient can place his finger over the site of the
trouble with accuracy and constancy. Examination on the part of the
surgeon causes him to wince or cry out. Percussion with the tip of the
finger not only leads to marked exacerbation but also induces a dull
aching sensation, which lasts for some time afterwards. Whether acute or
dull, exacerbations are of frequent occurrence, and during these
attacks the patient is entirely incapacitated, desiring nothing more
than to be left alone.
In some cases the pain is referred along the course of one of the
superficial nerves, in which case it is probable that the affected nerve
is caught up in the scar.
Headache, of whatever nature, is increased by exertion, indulgence in
alcohol, exposure to the sun, &c.
Crisp English considers that many cases of localized headache are
dependent on a localized chronic osteitis, and recommends trephining and
removal of the affected bone. There can be no doubt that the mere
removal of a disk of bone will occasionally bring about a cure, but,
from my own experience, I take a different view with respect to the
pathological lesions present. I have operated on over a dozen cases of
chronic cephalalgia, and I have found in nearly every case definite
pathological lesions--depression of internal table, thickening of the
meninges, subdural cysts and subdural hæmatomata. The mere removal of a
disk of bone may relieve the symptoms by reducing the local pressure or
by removing a source of meningeal irritation, but such treatment seldom
brings about permanent relief. The dura mater should be opened in nearly
every case, the frequent discovery of a subdural complication--cyst or
hæmatoma--showing that such a course is necessary.
These patients suffering from chronic headache are often pitiable
subjects, spending their time in wandering from doctor to doctor, from
hospital to hospital, seeking relief. They are only too eager to obtain
benefit from surgical intervention. The greatest care is required in
deciding as to operative procedures. Injudicious surgical measures are
not only disappointing to both surgeon and patient, but also
discreditable to this branch of surgery. On the other hand, it must be
acknowledged that remedies other than surgical are generally
inefficacious. The surgeon, therefore, takes considerable responsibility
on his shoulders when he states that an operation is inadvisable. Though
guarded in my prognosis, I generally advise operation on the ground that
it is impossible to foretell the cause of the headache, and brilliant
results may be obtained.
=Treatment.= When the headache is diffuse, REST, aided by the
administration of phenacetin, &c., may exercise some effect. Operative
treatment should not be recommended unless the intensity of the attack,
blurring of the disks, and slowing of the pulse suggest that there is
some increase in the general intracranial pressure. Under such
circumstances, exploration should be carried out over the region at
which the injury was received. In the absence of evidence with respect
to external injury, a subtemporal decompression operation is the
operation of election.
When the pain is localized to some special region, the outlook is more
favourable. Operative measures should then always be carried out over
the painful spot. A scalp-flap is framed according to the region which
it is desired to expose, the disk of bone removed, and the meningeal
territory examined. For detailed operative technique, see p. 20.
When the pain is referred along the course of one of the scalp nerves,
it may be relieved by alcohol injections (see p. 314), or by exposure of
the nerve, followed by removal of at least 1 inch of its trunk.
=Traumatic epilepsy.= When epilepsy arises after a head-injury, it is
almost the invariable rule that the attacks should partake _at first_ of
the focal or Jacksonian type. A case of traumatic epilepsy should,
therefore, possess the following characteristics:--
1. The fit should be preceded by some sensory or motor aura--the aura
corresponding to the region of the brain primarily involved.
2. The fit should always start by twitchings of the parts supplied by
the motor area which is in direct relation, or in close proximity, to
the site of dural or osseous lesion.
3. The fit may remain localized to the region first affected, or, as is
more commonly the case, may spread to other regions. In the latter case
the various motor areas are affected in a certain definite order,
according to their cortical arrangement. Thus, a fit arising from
irritation of the right cortical face-area leads first to twitchings,
then to convulsions, and perhaps finally to paralysis on the
contralateral face-muscles, the movements then spreading from the face
to the upper extremity, and from the arm through the trunk to the lower
extremity. When the fits become generalized, spreading to the opposite
side of the brain, the cortical areas are affected in the reverse
order.
4. The patient should retain consciousness throughout the attack.
5. The fits should not be succeeded by any paresis or paralysis.
Later on, when the fits become more frequent and severe, they lose their
typical Jacksonian characters, the various regions being affected so
rapidly one after the other that all focal symptoms tend to be obscured.
The fits are then often associated with definite loss of consciousness,
and succeeded by paresis or paralysis of the parts primarily affected.
The patient also usually complains of lassitude or headache, this
lasting some hours after the termination of the fit.
Traumatic epilepsy does not always partake of the typical Jacksonian
type. Sometimes the fits are so sudden in onset and violent in character
that, from the first, the more typical features are absent. Again, fits
of the focal or Jacksonian type do not necessarily imply that some
pathological causative agent will be found on exploration. Ordinary
epilepsy sometimes partakes of the focal type. I have myself operated on
three cases of focal epilepsy, deceived by their Jacksonian
characteristics, and found nothing abnormal. On the other hand, in all
these cases definite and permanent improvement was observed subsequent
to the surgical procedures.
It might also be added that encouraging reports are to hand, not only in
cases of idiopathic epilepsy with focal symptoms, but also in cases
without focal symptoms. A decompression operation is carried out on the
basis of Kocher’s statement to the effect that the fit is immediately
preceded by a rise of intracranial pressure, for which a safety-valve
must be supplied--such as is afforded by an intermusculo-temporal
operation of decompression. Whether Kocher’s statement is correct or
not, the fact remains that some cases of idiopathic epilepsy, without
focal symptoms, benefit considerably from operation.
=The localizing symptoms of traumatic epilepsy.= When the cause of the
trouble is situated over the motor area--the pre-Rolandic cortical
strip--the fits should commence by twitchings of the fingers, toes,
corners of the mouth, &c., according to the site of the lesion. The fits
are seldom preceded by any sensory auræ, though occasionally such may be
the case, for even at the present day some doubt exists as to whether
the precentral area should be regarded as purely motor or sensori-motor.
In other cases, the patient, without being able to state definitely his
sensations previous to the onset of the fit, may be able to foretell its
immediate development, and still more rarely he may be capable of
aborting the fit or diminishing its intensity by grasping firmly or
massaging the region of the body in which the fit first develops.
When Broca’s motor speech-area is primarily involved, the fits are
preceded by difficulty in phonation, mumbling of words and incoherence,
grinding of the teeth, &c., the fits then rapidly spreading to the parts
responsible for the movements of the muscles of face and upper
extremity.
When the fits arise from a post-central source of irritation, they are
usually preceded by well-marked sensory auræ--tinglings, burning and
painful sensations--again according to the region affected.
When preceded by sensations of taste and smell, the lesion is probably
situated over the anterior part of the temporo-sphenoidal lobe.
When by visual impressions--flashes of light, &c.--the lesion is
probably situated over the occipital lobe of the brain.
=Pathology.= The pathological conditions responsible for the development
of fits are various, resolving themselves, when fully investigated, into
two main groups: those associated with meningeal changes only, and those
accompanied by definite cortical scarring and tract degeneration.
In the event of osseous deficiency the scalp is usually more or less
adherent to underlying structures, and the gap in the skull filled with
dense fibrous tissue, which is itself adherent to the membranes of the
brain and perhaps to the brain itself.
In the absence of osseous deficiency, the cerebral irritation is usually
dependent on depressed fragments of bone, on subdural hæmatomata and
cysts, and on meningeal thickening.
In the event of cerebral degenerative changes it may be presumed,
whether there is a deficiency in the bone or not, that considerable
matting of meninges and cortex is existent with pyramidal degeneration.
In the absence of evident signs of external injury, cases of focal
epilepsy in the young require careful investigation, inquiry being made
as to difficult labour, for, as Harvey Cushing points out, ‘When we
consider the widespread lesions associated with those cases that later
on are recognizable as Little’s disease, and that presumably an enormous
number of children receive at birth some trifling injury which, from
lack of symptoms, is overlooked, may it not be that many cases of
so-called idiopathic epilepsy dating from childhood can be safely
attributed to the effects of early traumatism?’
In all these, and in other doubtful cases, before undertaking surgical
procedures, the surgeon should obtain the services of a skilled
neurologist.
=The clinical course of the case.= If a typical case of Jacksonian
epilepsy can be observed from beginning to end, many curious and
interesting features will be observed. The fits, at first typically
Jacksonian, gradually lose their typical character, becoming more
frequent and less focal in nature, the patient losing consciousness
during the fit, and the fits succeeded by weakness or paralysis of the
parts primarily involved. The general mental state of the patient
suffers proportionately--he becomes morose, despondent, irritable,
homicidal, or suicidal in tendency. How far these retrograde symptoms
are dependent on degenerative processes in the brain, and how much they
result from the moral effect of the frequent epileptiform seizures, are
questions that can only be determined by observing the effect of
treatment, surgical or otherwise. Some cases respond readily to
treatment, others are too far advanced to experience any material
benefit, some end their days in the lunatic asylum.
In any case, surgical treatment, if adopted at all, must be carried out
before definite brain-degeneration arises--such changes being evidenced
by spasticity of the limbs, exaggerated knee-jerks, &c. When such
pathological changes are existent, there can be but little hope of
benefiting the patient.
Further points in the clinical course of the case, and such also as
throw further light on the pathological conditions present, will be
obtained by a survey of 21 cases that have come under my own care or
close observation.
_Time elapsing between the date of the accident and the first fit._
Between 1 and 19 years 9 cases
Within 8 months 9 cases
After a few days 1 case
Uncertain 2 cases
_Age at time of accident._
Before 15, 12 cases. Youngest, 3 years.
After 15, 9 cases. Oldest, 55 years.
_Sex._
Males 20. Females 1.
_Conditions found on external examination and on operation._
External examination: Depression of bone and scar, 6 cases.
Deficiency of bone, 3 cases.
Scar only, 5 cases.
Nil, 7 cases.
At operation: Sclerosis of bone, 1 case.
Tuberculous mass, 1 case.
Subdural cyst or hæmatoma, 8 cases.
Scalp adherent to dura, 3 cases.
Scar in brain, 1 case.
Œdema of brain, 3 cases.
Nil found, 1 case.
Some lesion, such as might be accepted as responsible for the
development of the fits, was discovered in 17 out of 18 cases. Duret’s
experience tends to bear out the view that some pathological lesion will
be found in almost every case. In 67 cases reported the following
conditions were found:--
Depression of bone, 27 cases.
Splinters of the internal table, 15 cases.
Cysts, subdural, 4 cases.
Thickening of membranes, 7 cases.
=Operation.= When the localization of the trouble is suggested by the
presence of focal symptoms, and by a corresponding scalp- or
bone-injury, no difficulty need be experienced in determining the site
of exploration. When the fits are associated with definite focal
symptoms, but without the supplementary evidence obtained by visible
signs of external injury, exploration should be conducted over that
region of the brain from which the fits appear to emanate. In the
absence of all localizing brain symptoms, operative measures should be
carried out over the site of scalp or bone lesion.
Whatever the circumstances of the case, the preliminary details are
identical. The scalp is shaved, cleansed, the head enveloped in gauze,
and the scalp-tourniquet applied.
=The formation of the scalp-flap.= When the scalp is adherent to the
bone, the incision, carried throughout down to the bone, is made in such
a manner that the flap will not only allow of the detachment of the
scar, but will also permit of the complete exposure of the neighbouring
portion of the skull.
When the scalp is adherent to dura or brain, as the result of osseous
deficiency, the edge of the knife should be directed towards the under
aspect of the flap, and the flap carefully peeled away from the region
of the gap.
The examination of the bone.
_When no fracture is found_, the operator should trephine over the
cortical area from which the trouble appears to emanate.
_When a fissured fracture is found_, trephining is carried out where the
line of fracture cuts across that region of the brain which appears to
be involved.
_When a depressed fracture is found_, the trephine is applied in such a
manner that the circle just includes the outer segment of the
depression. After removal of the disk, the dura mater should be peeled
away from the under surface of the bone, and the whole of the depressed
area cut away with the craniectomy forceps.
_When there is osseous deficiency and when the gap is filled in with
fibrous tissue_, adherent to the margins of the gap and probably to the
dura or brain as well, it is essential that this fibrous tissue should
be freely removed. All evidence goes to substantiate the statement that
meningeal irritation is the main cause of the fits, &c.
The removal of this tissue is best carried out by beginning at the most
promising part of the gap, detaching the tissue adherent to the most
prominent portion of the bone, and exposing the underlying dura mater.
The central mass of scar tissue should then be seized with forceps,
lifted up and detached as completely as possible, both from the margins
of the gap and from the underlying dura or brain. In the more
complicated cases, where the scar tissue is adherent to dura and brain,
the most careful dissection is required, and in many instances it is
necessary to include that part of the dura mater which is incorporated
with the scar. The cerebral substance should be carefully protected (see
below).
=The treatment of the dura mater.= When the dura has not been injured
during the process of exposure, pulsating freely, and presenting a
normal appearance, preparations can be made to close in or protect the
gap in the skull.
When the membrane bulges outwards, and when, in other respects, the
indications point to an increase of intradural pressure, the dura must
be incised in a crucial manner, and further investigation carried out in
the search for a subdural hæmatoma, arachnoid cyst, or other lesion. A
hæmatoma is washed out and drained, an arachnoid cyst shelled out or
treated by excision of the parietal wall (see p. 204).
When the dura is thickened, matted, and adherent to the brain, it is
picked up at the least adherent part and carefully dissected away,
exposing the pia-arachnoid region. The surface of the brain being so
brought into view, the scalpel and dissecting forceps may be required to
remove all tags and shreds of matted tissues, this process being
continued till a reasonably healthy region has been brought into view.
=The treatment of a cortical scar.= There is no reason why a superficial
scar should not be freely removed, but, unfortunately, this procedure is
necessarily followed by the formation of another scar, at least as
extensive as the original fibroid condition. The removal of cortical
scars has therefore justifiably fallen into disrepute, and most surgeons
content themselves with an exposure of the pia-arachnoid region, the
actual cerebral substance being left intact. All bleeding must be
arrested, blood extravasation merely favouring the formation of fresh
adhesions.
=The prevention of fresh adhesions between the dura and the brain and
between the scalp and the dura or brain.= ‘It is useless to talk about
the prevention of fresh adhesions; they form in spite of anything that
may be done’ (English). With this statement, I am in complete accord. It
has been recommended that fresh egg-albumen, gutta-percha tissue, silver
foil, &c., should be inserted beneath the dura or between the scalp and
the brain. Experience shows, however, that all these substances are
useless, being invaded or surrounded by granulation tissue, and, later
on, absorbed by or enclosed in dense fibrous tissue.
The formation of adhesions between the scalp and the dura or brain can,
however, be effectually prevented by the insertion of plates, &c. (see
below).
The closure or protection of gaps in the skull.
_Indications for operative treatment._ Large defects, post-operative or
traumatic.
Small defects situated over exposed portions of the skull or over the
more important regional areas.
Both large and small defects associated with chronic headache, insanity,
Jacksonian epilepsy, &c.
Certain congenital defects in the vault.
Small defects, unless situated in exposed regions or associated with
symptoms, seldom demand protection.
Methods.
_(a) The formation of bone-flaps, derived from neighbouring parts of the
skull, from some other bone of the patient, or from the bones of a
freshly-killed animal._
_(b) The interposition of plates of some foreign material between the
scalp and the bone, or the insertion thereof into the osseous
deficiency._
_(a) Bone-flaps. The osteoplastic method of König and Müller._ Two flaps
are framed in the manner described below, and the two interchanged in
position. A ⋂-shaped flap, comprising the whole thickness of the scalp,
is turned down so as to expose the region of the deficiency, the margins
of the incision lying about ¹⁄₂ inch outside the margin of the gap. The
flap is dissected from underlying structures to which it may be
adherent, care being taken to avoid injury to the blood-vessels entering
at the base of the flap.
A second flap is framed from the scalp immediately to one side of the
first flap. This second flap corresponds in size and shape to the one
already framed, but differs in that its base points in the opposite
direction. It is also peculiar in that it consists of the whole
thickness of the scalp plus the external table of the skull. The scalpel
is carried down to the bone, and the margins of the incision retracted
in such a manner as to allow of the application of the hammer and
chisel. The external table is cut through along the line of the scalp
incision and split away from the rest of the bone. The two flaps are
now interchanged in position and sewn down with a few salmon-gut
sutures.
[Illustration: FIG. 59. THE KÖNIG-MÜLLER OSTEOPLASTIC FLAP. _a._, The
scalp-flap; _b._, The osteoplastic flap; _g._, The gap in the skull.]
The osteoplastic flap is by no means easy to frame, the external table
tending to split up during the process of separation; moreover, its
formation is confined to the upper-occipital and parietal regions of the
skull, regions where the two tables are separated by diploic tissue. In
the temporal and cerebellar regions this method cannot be adopted, and
in the frontal region the deformity and scarring act as a bar to such
operative procedures.
In suitable cases, however, good results may be obtained by this method.
Asepsis is essential to success.
Bone-flaps derived from some other bone of the patient (e. g. the
tibia), or from the bones of a freshly-killed animal (e. g. the scapula
of a dog), seldom yield satisfactory results. The gap in the skull is
first exposed, the margins refreshed, and the size and shape estimated.
The bone-graft is then cut from the other bone, suited in every respect
to the deficiency, inserted in the gap and sewn into position. The
graft, however, seldom retains its vitality, being invaded by
granulation tissue, and converted, in the course of time, into dense
fibrous tissue. Furthermore, in the event of the slightest failure of
aseptic technique, it acts as foreign body and must be removed.
The attendant difficulties and the frequent failures of these auto- and
hetero-transplantations of normal bone lead to the utilization of
decalcified, calcined, and boiled bone-plates. Between these there is
very little to choose, for, whether due to the absence of calcium salts
or the destruction of bone-cells, they merely act as scaffolding media
for the formation of fibrous tissue and are more or less completely
absorbed.
_(b) Plates of some foreign material._ The following method has been
found to give the most satisfactory results. Plates of pure annealed
silver are utilized, ⁹⁄₁₀₀₀ inch in thickness (No. 2 Birmingham metal
gauge). The plates are light and of fair malleability. Supposing now
that it is required to protect a deficiency in the vault--irregular in
shape, round or oval, it matters not--the maximum antero-posterior and
vertical diameters are measured and a piece of silver cut out, which is
about ¹⁄₂ inch greater in both diameters. The convexity of the skull in
the region of the gap is estimated and the plate hammered into
corresponding shape. This is readily carried out by placing the plate on
a heavy leaden base and hammering to the required convexity. The
convexity is regulated by the site of application of the blows, the
heavier being applied to the central or apical portion of the plate, the
weaker to the periphery. A rough general convexity is so produced. The
edges of the plate are smoothed with the file, and a few holes bored to
allow of the escape of any blood or cerebro-spinal fluid that might tend
to collect beneath.
[Illustration: FIG. 60. THE AUTHOR’S METHOD OF COVERING IN A GAP IN THE
SKULL. _s._, The scalp; _pc._, The pericranium; _p._, The plate; _g._,
The gap in the skull (inside the irregular dotted line); _sc._, The
scalp-flap.]
The plate is then boiled and applied as follows. The osseous defect is
exposed by a scalp-flap--not including pericranium--the margin of the
scalp-flap lying _at least 1 inch_ external to the margin of the
gap.[37] The flap is dissected down so that its base is situated _not
more than ¹⁄₂ inch_ below the lower limit of the gap. The pericranium is
then stripped away towards the periphery. The plate is applied so that
it rests below against the base of the scalp-flap, lies throughout
between the scalp and bone, and overlaps the margins of the gap by about
¹⁄₂ inch. The pericranium is heaped up around and over the margins of
the plate, and the scalp-flap replaced. The plate is maintained in
position by the support received from the base of the flap, marginally
by the pericranium, and generally by the reposition of the
scalp-flap.[38] In the process of time, new bone is formed by the
pericranium, this and fibrous tissue developing along the line of the
scalp incision fixing the plate accurately and firmly in position.
Needless to say, absolute sterility of the field of operation and of all
media is essential. In the event of failure in cleanliness, however
slight, it will become necessary to reopen the wound and remove the
plate. In such cases a second attempt may be made at a later date.
=Results.= The results attained by operative treatment must always be
considered under two headings: the immediate and the more remote.
The immediate results are almost always of a satisfactory nature, the
fits being more or less completely controlled, or so diminished in
quantity and quality as to satisfy both surgeon and patient. Such early
results may be regarded as the general rule, and some enthusiasts
believe that the ultimate results are equally satisfactory. However, in
following up these cases, it will be found that, in a considerable
proportion of cases, the more remote results are by no means so
satisfactory. A complete and permanent cure is seldom obtained, though
the great majority of cases evidence considerable improvement, the fits
recurring, though less frequent and less intense than previous to the
operation.
The results which may be obtained should therefore be considered as
follows:--
Cases of complete and permanent cure.
Cases of definite amelioration.
Cases in which no benefit is derived.
In 20 cases that have come under my own care, the following results were
obtained:--
Complete cure in 2.
Marked improvement in 14.
No change in 4.
Cushing reports on 128 cases of traumatic epilepsy, operative measures
being adopted in 58, 40 cases of focal epilepsy and 18 exhibiting no
localizing feature. The results were as follows:--
12 cases were free from attacks for from 1 to 5 years.
30 were greatly improved or showed some improvement.
17 exhibited no change.
2 died in status epilepticus.
=Traumatic insanity.= Traumatic insanity is closely allied to traumatic
epilepsy, occurring, as a general rule, late in the history of the case,
when the frequency of the fits and the associated disturbance of the
higher faculties breaks down the mental and moral control of the
patient.
The particular form of insanity varies according to the circumstances of
the case. Kraft Ebbing reported on 42 cases, the disease partaking of
the following types:--
18 cases of mania.
13 cases of dementia.
5 cases of dementia with epilepsy.
3 cases of general paralysis.
3 cases of melancholia.
Of 104 cases reported by Christian,
16 were of dementia.
29 of mania.
47 of general paralysis.
12 were of epilepsy.
Mania--of a violent type--usually develops within a short time of the
accident--a few hours or days. Its development is probably dependent on
an _acute cerebral œdema_--the result of a most severe grade of
vaso-motor depression--and it is often, though not necessarily,
associated with extensive cerebral injury. There is marked engorgement
of the cerebral venous system, and considerable increase of
cerebro-spinal fluid, both on the surface of the brain and in the
ventricular spaces.
When insanity develops at a later date, of whatever variety, it is
probably dependent on definite pathological changes. Ll. Powell, Duret,
and others, after investigating the conditions, came to the conclusion
that the injury was comparatively superficial--subdural cysts and
hæmatomata, pachymeningitis, osteosclerosis, ossification of the dura
mater, &c. They also maintain--an opinion that I also hold--that the
nervous phenomena are, in most cases, due to reflex meningeal
irritation.
Ll. Powell reports on 67 cases submitted to operation, with the
following results:--
In 41 there was mental recovery.
12 there was marked mental improvement.
5 there was slight mental improvement.
4 there was no change.
Death resulted in 5 cases.
The results obtained by surgical treatment are largely dependent on the
time that has elapsed since the accident. Lapse of time is no bar to
operation, but the sooner this procedure is carried out the better for
the patient.
=Treatment.= I think that it must be accepted that, without surgical
interference, the prognosis is of the most unfavourable type. These
cases, if left to themselves, drift into the public and private lunatic
asylums, there remaining to the end, hopeless wrecks.
If such is the case--and I think that refutation is impossible--and if
it be accepted that definite pathological changes are usually present,
then it is obvious that surgical interference offers the only hope of
cure or alleviation. The surgeon must be guided by the case before him,
but, in the absence of hereditary taint, exploration should be carried
out, preferably at the site of the original injury, and as early as
possible before the advent of definite cerebral and pyramidal
degenerations.
The operative details vary according to the necessities of the case.
Thus, in acute mania, acting on the supposition that the development is
dependent on an acute cerebral œdema, the surgeon should carry out a
decompression operation. Personally, I hold the view that Cushing’s
subtemporal decompression operation (see p. 121) should be carried out
on both sides of the skull, with or without lumbar puncture.
In the more chronic cases, operative procedures are conducted over the
region injured in the anticipation of discovering depressed bone,
subdural cysts, hæmatomata, &c. The operative details peculiar to all of
these conditions are discussed in other sections.
With special reference to general paralysis of the insane, Dr. Claye
Shaw holds the opinion that a general increase of intracranial pressure
is commonly present. At his instigation, and on other occasions, I have
carried out decompression operations, but I have not been able to
satisfy myself that the patients have experienced any benefit other than
temporary. There was on each occasion a considerable excess of
cerebro-spinal fluid with surface œdema of the brain, but the ultimate
results were certainly disappointing.
MENINGEAL CYSTS
Amongst the pathological conditions responsible for the development of
epilepsy, chronic cephalalgia, &c., meningeal cysts must be regarded as
of frequent occurrence.
Traumatic meningeal cysts are varied in size, site, and structure. They
may be classified as follows:--
1. _Cysts within the calvarium._ Between the dura and the bone.
Between the dura and the brain.
Within the brain-substance.
2. _Cysts projecting through a gap in the calvarium_ (traumatic
cephaloceles). For a description of these cysts the reader is referred
to p. 40.
=Cysts within the calvarium.= Traumatic cysts within the calvarium,
whatever their situation, may be divided into two definite groups:--
1. Where the cyst possesses fibrinous walls (in which hæmatoidin cysts
may be deposited) and contains a grumous material. These cysts are
usually subdural in position, are dependent on the previous existence of
a hæmatoma, and are known as ‘blood-cysts’.
2. Where the cyst--often of considerable size--is lined by a thin,
shiny, membranous wall. The contained fluid is almost colourless,
closely resembling cerebro-spinal fluid, but albuminous and having no
sugar-reducing reaction. The fluid is at high tension, spurting out when
the cyst is punctured. The cyst usually lies in relation to the
arachnoid membrane. Hence the name, ‘arachnoid cyst’.
To account for the development of these ‘arachnoid cysts’ two theories
have been advanced. Firstly, that they arise as the ultimate result of a
long-continued circulatory disturbance of the vessels of the membranes
or of the cortex, with consequent local cystic accumulation of
cerebro-spinal fluid or serum; and secondly, that shrinking of the brain
occurs in the region of an injury as the result of sclerotic changes in
the cerebral substance, any contraction tending to lead to the formation
of a vacuum which becomes filled with fluid derived from the surrounding
membranes. According to this latter theory, arachnoid cysts are in
reality ‘cysts ex vacuo’.
As regards symptomatology, little need be said. Occasionally ‘arachnoid
cysts’ of considerable size have been discovered at post-mortem
examinations which appeared to have exercised no local or general
pressure effects during life. More often the cysts, whether ‘blood-cyst’
or ‘arachnoid cyst’, lead to the development of Jacksonian epilepsy,
chronic headache, and the like, and are discovered during the
exploratory operation carried out for such conditions. Occasionally they
may be shelled out entire, but it is more usual for the surgeon to
remain content with the removal of the parietal wall (see p. 195). The
results obtained by surgical treatment are sufficiently gratifying.
TRAUMATIC ORBITAL ANEURYSM
(_Pulsating Exophthalmos_)
This condition was first investigated by Rivington in 1875. Since that
date many other cases have been reported, and the following remarks are
based on the examination of the records of 26 cases, 2 of which have
come under my own care.
The nature of the trouble, the results obtained by operative treatment,
and the direct evidence supplied by post-mortem examination furnish
sufficient proof to justify the statement that the symptoms are
dependent on the formation of an arterio-venous aneurysm, the internal
carotid artery and the cavernous sinus intercommunicating by means of
one or more fistulous channels. That such a lesion may arise from direct
violence--the introduction of some sharp weapon along the upper and
inner portion of the orbital cavity---is readily comprehensible. Such
injuries are, however, of rare occurrence, and the formation of the
aneurysmal communication is usually the result of indirect violence--the
application of severe blows to the antero-lateral and lateral aspects of
the head.
In explanation, the following preliminary facts may be accepted:--
In the great majority of cases the blow was applied to the temporal
region, the patient was rendered unconscious, bleeding freely from the
ear, nose, and mouth, and remained under treatment for some considerable
time. From these facts it may be assumed that the patient suffered from
a fracture of the base of the skull--anterior or middle fossa, or both
fossæ. Evidence has already been brought forward to show (1) that the
majority of fractures involving both anterior and middle fossæ traverse
the body of the sphenoid, and (2) that the cavernous sinus is very
susceptible to injury. It was also demonstrated that the internal
carotid artery is only liable to injury in that part of its intracranial
course where it is embedded in the outer wall of the cavernous sinus.
Two instances of such a lesion have been described in the section
dealing with injuries to intracranial vessels (see p. 148, and Figs. 53
and 54).
From these facts and from the post-mortem evidence supplied by the few
cases that have come to autopsy, it may, I think, be concluded (1) that
traumatic orbital aneurysm implies a condition of arterio-venous
aneurysm with direct communication between the internal carotid artery
and the cavernous venous sinus, and (2) that the aneurysmal formation is
dependent on a basic fracture which traverses the region of the body of
the sphenoid bone.
The exact nature of the communication between the two vascular channels
may be estimated from the fact that proptosis--usually the first symptom
to make its appearance--seldom becomes apparent till one or two months
have elapsed after the accident. It would appear, therefore, probable,
that the artery is not ruptured but merely weakened at the time of the
injury, the weakened arterial wall gradually giving way before the force
of the blood-stream till a definite communication is formed between the
two channels.
The male sex, by reason of its greater liability to severe injuries, is
generally the one involved, especially between the ages of 20 and 30.
=Symptomatology.= 1. _Proptosis_--usually the first symptom to
develop--seldom makes its appearance till after the lapse of one to two
months. The eyeball is protruded in the downward and outward direction,
the main pulsating tumour presenting at the upper and inner quadrant of
the orbit. Proptosis is generally steadily progressive, and, in the most
marked cases, the globe may be almost pushed out of its socket. In any
case the ‘whites’ of the eye are unduly prominent.
2. _Aneurysmal symptoms._ The tumour pulsates synchronously with the
heart’s beat, whilst compression of the common carotid of the same side
results in cessation of pulsation and great diminution in the size of
the aneurysmal swelling. On releasing the compression force the tumour
regains its original size in two or three beats of the heart, and, for a
short time, pulsates more forcibly than before. A definite thrill is
imparted to the examining finger, and, on auscultation, a loud murmur is
heard, not only over the tumour itself, but also widely conducted over
the bones of the vault, especially along the line of the superior
longitudinal sinus. The free collateral circulation between the angular
and ophthalmic arteries permits of the involvement of vessels in the
inner orbital and upper nasal regions. This is well shown in the case
depicted in Fig. 61.
[Illustration: FIG. 61. A CASE OF TRAUMATIC ORBITAL ANEURYSM.]
3. _Pressure symptoms._ The impairment of venous flow in those radicles
which drain into the cavernous sinus is evidenced by the marked
engorgement of palpebral, conjunctival, episcleral, and retinal veins.
Obstruction to lymph flow is shown by a hazy cornea, chemosis, and œdema
of the parts surrounding the orbit. The danger thus incurred by the
cornea is rendered more serious by the inability on the part of the
patient to close the eyelids over the protruded globe. Keratitis and
sloughing of the globe are to be feared. From muscular involvement,
squints and diplopia are frequently observed. The pupil may be fully
dilated through paralysis of the third nerve.
4. _Subjective symptoms._ Defect in vision is experienced at an early
date, but perhaps the most prominent subjective symptom lies in ‘noises
in the head’, compared by the patient to the thud of a steam-hammer, the
whirring of wheels, the buzzing of bees, &c. These noises are more or
less constant, most annoying to the patient, and increased on bending
down, straining, &c.
All these symptoms tend to become more severe as time lapses, though
cases have been recorded in which the symptoms remained _in statu quo_.
In the event of failure at relief or cure, the patient runs considerable
risk of losing his sight from corneal ulceration, whilst repeated
hæmorrhages and secondary infection may place the patient in imminent
danger of his life.
=Treatment.= In the consideration of the treatment of this condition,
the results obtained in the 26 cases investigated will afford a valuable
guide.
In 4 cases an expectant attitude was adopted, the patient being kept
quiet, restricted in diet, and dosed with potassium iodide. One case
improved, two experienced no material benefit, and the fourth,
dissatisfied, discharged himself from the hospital.
In 10 cases compression was applied to the common carotid artery, with
the result that in 3 cases the conditions remained stationary whilst in
the remainder, either on account of the pain produced or from complete
failure to bring about any improvement, this mode of treatment was
abandoned in favour of ligature of the common carotid. In some cases the
carotid compression was carried out by means of tourniquets, in others
intermittent digital pressure was utilized by means of relays of
assistants.
In 18 cases the common carotid was ligatured, in 12 cases as a primary
measure, in 6 after failure of other methods. The immediate and remote
results were in all cases as satisfactory as could be anticipated.
Proptosis at once diminished, the globe receding in some cases to the
normal position, and the distressing subjective symptoms were almost
entirely relieved. In many cases the patients were enabled to return to
work.
Some defect in vision commonly persists, dependent on muscular paresis
(on account of the previous stretching), retinal thrombosis, or corneal
changes. The longer radical treatment was deferred the greater and more
distressing were the after-effects of the lesion.
According to Sattler, however, the results obtained by ligature of the
common carotid are less favourable than as stated above, and by no means
devoid of danger to life. Fifty-six cases were collected with results as
below:--
39 cases recovered and showed marked improvement.
11 cases experienced no benefit.
8 cases died.
It has been urged that ligature of the _internal_ carotid artery would
suffice to bring about equally satisfactory results, combined with less
danger to life and diminished risk of secondary cerebral degeneration.
Such, however, does not seem to be the case, for the anastomosis between
the angular arteries and between the terminal branches of the ophthalmic
is so free that the results obtained by ligature of the internal carotid
appear to be unsatisfactory. Indeed, even when the larger trunk was
tied, secondary operations have been occasionally required in order to
excise some large anastomotic channel in the region of the inner canthus
of the eye and over the bridge of the nose.
From these data, the following conclusions can be drawn:--
1. That by means of rest, careful dieting, and administration of
potassium iodide in large doses, the progress of the case can sometimes
be arrested, but that much patience is required and the ultimate result
is entirely problematical.
2. That compression--digital or instrumental, intermittent or
continuous--is painful, tedious, and usually quite inefficacious.
3. That ligature of the common carotid affords the best chance of cure
or alleviation.
When should the common carotid artery be ligatured? How soon after the
development of symptoms? This depends largely on the severity of the
accident that produced the arterio-venous communication. If the blow was
severe and the depth and duration of the stage of unconsciousness of a
prolonged character, it may be presumed that the brain was injured.
Under such circumstances early ligature of the common carotid presents
an appreciable danger by reason of the development of hemiplegia on
account of the further interference with the arterial supply to the
brain. In such cases the patient should be confined to bed or kept
quiet for not less than two months, the operation being carried out when
the general condition warrants surgical interference.
In the event of early operation being imperative, periodic digital
compression of the common carotid, for a few minutes at a time, may be
carried out with the object of accustoming the brain to the proposed new
form of circulation. In ordinary cases the sooner the common carotid is
tied the better is the ultimate result.
[36] _Hunterian Lectures_, February 1904.
[37] It is absolutely essential that the scalp incision should lie some
distance away from the outer margin of the plate. Failure to adopt this
procedure impedes the healing of the wound and adds to the risk of
infection.
[38] If desired, the plate may be anchored in position by means of a few
small silver-plated screws.
CHAPTER VII
TUMOURS OF THE BRAIN
=Tumours of the brain.= Tumours may develop in any part of the cerebrum
and cerebellum, from the sheaths of the efferent nerves, from the
vascular tissues, and from the membranes of the brain. Tumours arising
from the bones of the skull are considered elsewhere (see p. 325).
The regional distribution of these tumours may be estimated by reference
to the following table[39]:--
Cerebellum 33 cases.
Deep or subcortical 32 „
Precentral 30 „
Post-central 25 „
Extra-cerebellar 19 „
Pontine 15 „
Temporo-sphenoidal 13 „
Multiple 7 „
Fourth ventricle 5 „
Third ventricle 4 „
Pituitary 2 „
Schüster,[40] from an investigation of 1,000 cases, showed that
cerebellar tumours are relatively more common than cerebral, the
comparative size of the two regions being taken into account. An
examination of Paton’s table shows that cerebellar and extra-cerebellar
tumours together form rather more than 25 per cent. in 202 cases of
brain-tumour formation.
=Pathology.= Gliomata, sarcomata, and endotheliomata are the three
commonest types of tumour formation. Other forms are fibromata,
tuberculomata, syphilomata, cysts, and carcinomata.
[Illustration: FIG. 62. A GLIOMA OF THE BRAIN.]
[Illustration: FIG. 63. A SARCOMA OF THE BRAIN.]
=Gliomata= occur with almost equal frequency in cerebrum and cerebellum.
They are generally primary and single, the boundaries but ill-defined,
and the tumour is seldom amenable to radical surgical procedures.
[Illustration: FIG. 64. AN ENDOTHELIOMA OF THE DURA MATER.]
[Illustration: FIG. 65. A FIBROMA OF THE DURA MATER. Indenting the
cortex and attached to the pia-arachnoid by fine filaments.]
=Sarcomata= grow from the meninges, periosteum of cranial bones, and
from the sheaths of nerves and vessels. They are either primary and then
single, or secondary and then multiple (sarcomatosis). Sarcomata are
often more or less encapsuled, tending in the first instance to exercise
a compression force, and only in the later stages to invade the
surrounding regions. It is during this early stage of development that
the tumour is capable of removal.
[Illustration: FIG. 66. AN ACOUSTIC TUMOUR. Attached loosely to the
seventh and eighth nerves.]
=Endotheliomata= grow from the meninges of the brain. They are hard,
nodular, and, in their early stages, definitely non-infiltrating, and,
when accessible, removable.
=Fibromata= are especially prone to originate in the cerebello-pontine
angle, usually possessing a narrow stalk representing an atrophied
nerve-trunk or vascular bundle. From the frequency with which these
cerebello-pontine tumours are attached to the eighth nerve they are
often designated _acoustic_ tumours. They may be as small as a pea or as
large as a hen’s egg. In their early stages they are probably pure
fibromata, appearing as pink-red lobulated tumours. They are of slow
growth, primarily compressing the brain-substance without invasion.
Later on degenerative changes are prone to occur, with invasion of the
cerebellar substance and extension into the internal auditory canal.
Whether growing in the cerebello-pontine angle or in other parts of the
skull, fibromata are often readily removed.
[Illustration: FIG. 67. SYMMETRICAL TUBERCULOMATA. Situated on either
side of the falx cerebri above the tentorium cerebelli.]
=Tuberculomata= are most commonly situated beneath the tentorium. They
are often multiple. They cannot be considered as favourable tumours from
the surgical point of view, insomuch as they are frequently associated
with tuberculous lesions in other parts of the body and complicated by a
tuberculous infiltration of the meninges.
=Syphilomata= occur with greater frequency in the cerebrum than in the
cerebellum. Sometimes they are totally unaffected by anti-syphilitic
remedies, and, under such conditions, appear as densely hard and
definitely encapsuled tumours. These more chronic gummata are usually
cortical or subcortical in position, and, when accessible, are readily
removable.
=Cysts= are of frequent occurrence. They may be (1) of traumatic origin,
containing a grumous material characteristic of the incompletely
absorbed blood-clot; (2) of parasitic origin (e. g. echinococcus); (3)
due to cystic degeneration of a sarcomatous, carcinomatous, or gummatous
mass; or (4) simple arachnoid cysts (see p. 203). Many of these cysts
are amenable to surgical treatment.
=Carcinomata= are always secondary to cancer in other parts of the
body--more especially carcinoma mammæ. They are usually multiple, and
quite unsuited to surgical procedures.
Any of these tumours may be complicated by the presence of internal
hydrocephalus, this condition being dependent on the pressure exercised
by the tumour on the veins of Galen, or on the interference with the
normal transudation of fluid from one ventricle to another.
=Symptomatology.= The symptoms resulting from tumour formation may be
considered under two headings:--
1. _General symptoms_, dependent on the general increase of intracranial
pressure.
2. _Localizing symptoms_, dependent on local compression.
Previous to discussing the symptomatology of brain tumours, it cannot be
too forcibly urged that the surgeon is seldom justified in embarking on
an extensive operation for tumour removal except after consultation with
a neurologist. Ill-planned and ill-timed operations are usually
disastrous in their results, and little creditable to cranio-cerebral
surgery in general. On general grounds also, the symptomatology of brain
tumours, as given below, must be accepted in the light in which it is
offered, not representing the complete neurological aspect of the case,
but affording an index to general diagnosis. For further information the
reader is referred to more extensive works on brain tumours.[41]
I. GENERAL PRESSURE SYMPTOMS
Headache.
Mental disturbances.
Optic neuritis, &c.
Vomiting.
Alterations in pulse, respiration, and blood-pressure.
Alterations in temperature.
=Headache.= Headache is an almost constant symptom, and presumably
dependent on general or local dural tension. It may be general or
localized, intermittent or continuous, intense or comparatively mild in
character. It is the more intense when the tumour develops in the
confined space of the subtentorium, and when the tumour is of
considerable size. In young subjects, before the skull is synostosed,
some compensatory enlargement of the skull may postpone the development
of headache, or diminish its intensity.
The diagnostic value of a localized headache is rather problematical,
but, when constantly referred to some particular region and when
associated with definite tenderness on percussion, the localization of
the headache assumes considerable importance in the regional
determination of the tumour. Still, too much stress must not be placed
on the site of the pain. A cerebellar tumour may give rise to frontal
headache, and vice versa.
=Mental disturbances.= In the earlier stages of tumour development the
patient is irritable, depressed, or apathetic, shows his objection to
his fellow mortals on all possible occasions, is unable to concentrate
his attention or exhibits impairment of memory. As has rather quaintly
been observed, he appears in every sense to ‘have a weight on his mind.’
Inquiry amongst relatives will show that he has ‘changed in every way’,
or ‘is not the same man’.
Mental changes vary according to the site and size of the tumour. For
example, it has been stated that a general air of elation or
exhilaration (Witzelsucht) may be regarded as almost diagnostic of
tumours situated in the anterior part of the frontal lobe.
As the tumour increases in size, somnolence becomes the marked feature,
progressing on to stupor and coma. In rare cases, mania may develop.
=Optic neuritis.= Optic neuritis must be regarded as one of the most
constant and valuable symptoms in the diagnosis of intracranial tumour
formation. The degree to which it progresses depends more on the site of
the tumour than on its size. In general, it may be stated that it is
most constantly associated with tumours of the temporo-sphenoidal and
cerebellar regions, less common in frontal tumour formation, still less
frequent in post-central tumours, and perhaps least common in tumours of
the pons. In this last-mentioned case optic neuritis is always late in
development, and not infrequently absent throughout the whole stage of
the illness.
Primary optic atrophy only occurs when the tumour exerts direct
compression on the optic chiasma and tracts--for example, pituitary
tumours.
Paton,[42] from a series of 252 cases treated at the National Hospital,
of which 202 were accurately diagnosed, found that optic neuritis or
atrophy was present in 81·2 per cent. cases. The fundus change, though
usually bilateral, may be confined to the ipso- or contra-lateral side.
Considerable discussion has taken place as to the localizing value of
unilateral disk changes. For instance, it has been stated that a
unilateral neuritis indicates that the tumour is situated on that side
of the brain, and that when disk changes are bilateral the side which
evidences the higher grade of inflammation is the side on which
operation should be conducted. In the light, however, of the most recent
research it would appear that unilateral symptoms are not to be relied
on in establishing the localization of the tumour. Gowers[43] lays
stress on the statement that with strictly unilateral neuritis one
should always suspect a general rather than a local exciting cause.
The actual cause of the neuritis is still a matter of doubt. It is
possible that the same cause is not present in every case. Still,
sufficient evidence is to hand to justify the probability that neuritis
is dependent on the general increase of intracranial pressure--there is,
at any rate, a close relationship between the two. The cerebro-spinal
fluid is forced into and dammed up within the vaginal sheaths of the
optic nerve, leading, in the first instance, to an œdema, and later on,
to compression of the lamina cribrosa and interference with the
circulation.
The increase of intraventricular pressure may also act directly on the
optic tracts and chiasma--the anterior boundaries of the third
ventricle--the pressure being then transferred directly to the nerve
tracts.
Furthermore, the great intensity, great frequency of occurrence, and
rapid development of optic neuritis when the tumour is subtentorial in
position may be explained on the hypothesis that the rigid enclosure of
the cerebellum permits of the ready application of pressure to the veins
of Galen or to the iter, thus leading to an increase of intraventricular
pressure, this pressure being then transferred to the optic region.
The alternative theory states that the old tissue destruction and the
new tissue formation sets free certain toxic substances which act on the
optic nerve-fibres, leading to œdema and inflammation. Paton, however,
comes to the conclusion that ‘the nature of the tumour does not play any
part in determining the onset of neuritis except in so far as the nature
determines its localization’.
Whatever be the localizing value of optic neuritis, it is generally
accepted that it commences in the upper nasal quadrant.
Visual acuity is but little impaired in the earlier stages of optic
neuritis, but so soon as atrophic changes develop, diminution in the
field of vision occurs.
The pupillary changes associated with tumours of the brain are closely
connected with these fundus changes. In the early stages, the pupils may
be contracted with the object of protecting the inflamed surfaces
exposed to light, whilst, when atrophy develops, the pupils may steadily
dilate, becoming fully dilated and fixed as the atrophic changes become
fully developed.
These pupil changes must therefore be taken into consideration in
estimating the value of pupillary changes in general.
=Vomiting.= Vomiting is dependent on stimulation of the medullary
vomiting centre, or on irritation of the dura mater in the immediate
neighbourhood of the tumour. The dura is supplied by branches of the
fifth cranial nerve, the stimulus being referred to the vagus centre in
the floor of the fourth ventricle.
Vomiting is of the so-called ‘cerebral’ type. It is of frequent
occurrence, generally irrespective of ingestion of food and seldom
preceded by any nausea and retching. The attacks are often associated
with exacerbation of headache, and more rarely with some slight
elevation of temperature. The more severe the vomiting the more likely
is the tumour to be subtentorial in position.
=Alterations in pulse, respiration, and blood-pressure.= In the early
stages there is but little alteration in pulse and respiration. Later
on, the increasing intracranial pressure acts as a stimulus on the vagus
and vaso-motor centres, the pulse becomes slowed and the blood-pressure
raised. When the pressure is considerable, the slow pulse and deep, even
stertorous, respiration evidence the effect produced on the medullary
centres. In the terminal stages the imminent exhaustion of these centres
is heralded by progressive acceleration of the pulse, by great fall in
blood-pressure, and by the advent of Cheyne-Stokes respiration.
The more marked the alterations in pulse and respiration the more likely
is the tumour to be subtentorial in position.
=Alterations in temperature.= The temperature tends to remain subnormal
throughout the progress of the case, except during the terminal stages
when pyrexia is often observed. Occasional elevations of temperature
during the course of the illness may be explained by transient attacks
of ependymitis or cerebritis.
Differences of temperature on the two sides of the body may occasionally
be observed, especially when the tumour involves the basal ganglia.
II. LOCALIZING SYMPTOMS
(_A_) =To the non-excito-motor frontal region (anterior frontal).=
_Headache_ tends to be localized to the frontal region, _vomiting_ is
seldom a conspicuous feature, and _optic neuritis_ is not only rather
later in development, but also less progressive than when the tumour is
placed in other situations. If the tumour occupies the orbital aspect of
the lobe, primary optic atrophy (from pressure) may be existent on the
affected side with optic neuritis of the contralateral fundus.
The _mental condition_ is often profoundly altered and, according to
some writers, more especially so when the tumour is situated on the left
side. The quality of mental change varies considerably in individual
cases. In some there is an attitude of general suspicion, the patient
following all points in his general examination with a curious air of
suspicion, in others moral perversion is the rule, whilst in a third
group of cases a state of elation and exhilaration is the predominant
feature, a condition which, as previously stated, is said to be
pathognomonic of a tumour frontally situated.
_Anosmia_--uni- or bi-lateral--may be present, but, on account of the
general condition of the patient, considerable difficulty is experienced
in endeavouring to demonstrate the existence of this symptom.
[Illustration: FIG. 68. THE CORTICAL MOTOR AND SENSORY AREAS.]
_Incontinence of urine_ has been observed, independent of the condition
of the patient--in other words, without a sufficient degree of coma to
account for the state.
When the tumour is of considerable size, some degree of _paresis_ of the
contralateral side of the body may result, due to backward pressure
exercised by the tumour on the corona radiata preceding from the
pre-Rolandic motor area. Associated with this paresis the deep
_reflexes_ may be increased with extensor plantar reflex (Babinski) and
some diminution of superficial reflexes. The more posterior the tumour
the greater the degree of paresis, and the more exaggerated the
reflexes. When the tumour is situated on the left side the _motor
speech_ centre may be affected.
_Fine tremors_ may be noticed, usually involving the muscles of the
upper extremities, and best demonstrated by asking the patient to hold
his arms horizontally with the palms downwards.
Paresis on the contralateral side may be preceded by or associated with
_fits_, these partaking of the Jacksonian type and accompanied by
conjugate deviation of the eyes towards the side opposite to that on
which the tumour is situated. This association of fits suggests that the
tumour occupies the second frontal convolution.
(_B_) =To the excito-motor frontal region.= In the early stages symptoms
of irritation predominate, the patient suffering from _fits_ of a focal
or Jacksonian type (see p. 189), whilst, later on, _paresis_ of a
progressive type, involving the face or extremities unequally, becomes
evident. In children, however, the rapid transference of impulses from
one motor area to another causes the fits to soon lose their focal
character, _general convulsions_ taking their place.
If the tumour occupies the left side of the brain (in right-handed
individuals) the _motor speech_ centre of Broca may be involved, with
difficulty in or failure of the power of speech.
_Apraxia_ may be present, a condition characterized by inability on the
part of the patient to perform certain familiar purposive movements,
such as sewing, turning a key in the lock, &c.
The contralateral _pupil_ may be contracted from irritation, or dilated
from paralysis; the ipsolateral is variable, more commonly dilated.
In the event of extensive tumour formation and when the growth is
associated with tract degeneration, the deep _reflexes_ will be
increased on the contralateral side, with well-marked extensor plantar
response.
(_C_) =To the post-central, angular, and marginal convolutions.= Attacks
of focal _epilepsy_ are frequently observed when the tumour occupies the
post-central convolution, such developments being probably dependent on
forward pressure effects. These epileptiform attacks, however, are
almost invariably preceded by some _sensory auræ_. Furthermore, the fits
will usually be followed by ‘some degree of anæsthesia or analgesia, a
loss of tactile sensation over half the body, affecting mostly the hand
and foot, with loss of power and astereognosis (inability to recognize
the form and consistency, and to name objects placed in the affected
hand)’ (Beevor).
When situated in the left angular gyrus, _word-blindness_ may
result--inability to appreciate the meaning of written words, &c.
When the tumour presses on the optic radiation, _hemianopia_ results,
with ipsolateral temporal and contralateral nasal blindness.
(_D_) =To the temporo-sphenoidal lobe.= When the tumour occupies the
anterior part of the temporo-sphenoidal lobe, more especially when it is
situated on the internal aspect of that lobe, the degree of _optic
neuritis_ is intense. Perversion or loss of _smell_ may be noticed--a
symptom of difficult determination on account of the general condition
of the patient.
As the result of pressure exercised on the optic tracts
_hemianopia_--with hemianopic pupillary reaction (the pupil not reacting
to light)--may be observed. Pupillary reactions, however, are
complicated by possible paralysis of the third nerve.
Some _weakness of the face muscles_ on the contralateral side is a
fairly constant symptom, presumably dependent on the upward pressure
exercised on the lower motor areas.
A tumour involving the more posterior and central portions of the lobe
may bring about a certain degree of _word-deafness_, whilst objects may
be incorrectly named or named with difficulty, the patient being more or
less aware of his mistakes and evidencing considerable annoyance of the
same.
In whatever part of the lobe the tumour be situated, certain sensory
auræ may be present. Not infrequently the patient falls into the
so-called ‘dream-state’. When sensory auræ are associated with crude
sensations of smell and taste, with chewing or spitting movements, the
tumour is probably situated on the antero-internal aspect of the lobe.
(_E_) =To the occipital lobe.= _Headache_ may be localized to the back
of the head, and _optic neuritis_ is usually both early in onset and
intense in degree. Perhaps the most important localizing symptom is
_homonymous hemianopia_--blindness in the temporal half of the retina on
the same side as the lesion and in the nasal half of the opposite eye.
This is explained by the fact that the fibres of the optic radiation,
passing forwards from the affected occipital region, supply those
retinal areas. The reaction of the pupil will be unaltered, for the
pupillary nerve-fibres, in their course towards the third nerve nucleus,
are only directed backwards as far as the anterior corpora quadrigemina.
Consequently, an interruption of optic fibres between retina and third
nerve nucleus brings about a loss of pupillary reflex when light is
thrown on the blind portion of the retina, whilst if the lesion be
situated further back, pupillary reaction is unaltered. This is
Wernicke’s sign.
(_F_) =To the subtentorial region.= Certain symptoms are more or less
common to all subtentorial tumours, whether they arise within the
cerebellar substance (intra-cerebellar) or immediately outside the
brain-substance (extra-cerebellar). _Headache_ is very severe, and in
about 50 per cent. cases, localized to the back of the head, perhaps
associated with stiffness of the neck muscles and retraction of the
head. _Optic neuritis_ is early in onset and intense in degree. It is
more constant in cerebellar tumour formation than in tumours located in
almost any other part of the brain. The choking of the disk is marked
and hæmorrhages are frequent. _Vomiting_ and other symptoms referable to
increased subtentorial pressure--slow pulse, altered rhythm of
respiration, &c.--are usually well marked.
[Illustration: FIG. 69. THE VISUAL PATHS. O.L., Occipital lobe; O.R.,
Optic radiation; O.T., Optic tracts; P., Pupillary fibres from optic
tract to third nerve nucleus; O.C., Optic chiasma; O.N., Optic nerve; 1,
Blindness of affected eye; 2, Bitemporal hemianopia; 3, Bilateral
homonymous hemianopia, with hemianopic pupillary reaction; 4, Bilateral
homonymous hemianopia, pupillary reaction normal.]
_Vertigo_ is most apparent when the patient is suddenly changed in
position or tries to stand or walk. It appears in two forms, either as a
definite sense of movement of self (subjective vertigo) or of objects
(objective vertigo), or merely as a giddy feeling. In objective vertigo
the sense of displacement of objects is more commonly from the side of
the tumour towards the sound side.
Vertigo is dependent on the influences exercised by the tumour on the
cerebello-vestibular apparatus, and on irritation of those branches of
the fifth nerve which are distributed to the dura mater in the immediate
neighbourhood of the tumour, the impulses being then transferred to the
bulbar nuclei of that nerve and thence to the pneumogastric nucleus.
_Ataxia and inco-ordination of movement_ are also prominent symptoms.
Ataxia results from one or more of the following causes: (1) co-existent
vertigo, (2) asthenia of the muscles of the affected side, the muscular
contractions being irregular in their nature, ill-timed in their action,
and often in excess of actual requirements, and (3) involvement of the
spino-cerebellar tracts and their terminations.
The patient, when standing with the eyes shut and one foot advanced in
front of the other, is unable to maintain his balance, staggers and
tends to fall. No great diagnostic value can be attached to the
direction in which he sways or falls, though, from my own experience, it
would appear more probable that he should lurch towards that side on
which the tumour is situated. In walking, however, there is occasionally
a definite tendency to deviate towards the opposite side, probably due
to over-correction of the weakened muscles on the affected side. The
gait should present the typical appearance of cerebellar ataxia, and the
patient may walk with the head drawn down towards the shoulder of the
affected side, the chin being tilted in the opposite direction.
Inco-ordination of movement is rendered most obvious during active
movement of the limb, decreasing towards the termination of that
movement, and ceasing so soon as the object is attained. This is most
readily demonstrated by the well-known ‘finger-to-nose’ test.
_Nystagmus_ is one of the most frequent symptoms of cerebellar tumour,
usually lateral, the movements coarse or fine, and most marked when the
eyes are directed towards the side of the lesion.
In the more differential diagnosis between _extra- and intra-cerebellar_
tumours, the following points should be noted:--
_Extra-cerebellar_ tumours situated in the cerebello-pontine angle tend
to lead to compression of the eighth nerve (with deafness and tinnitus),
of the seventh nerve (with paralysis of the face muscles), of the fifth
nerve (with anæsthesia of the parts supplied by that nerve), and more
rarely of the sixth nerve (with paralysis of the external rectus). The
ninth, tenth, eleventh, and twelfth nerves are but rarely involved.
_Intra-cerebellar_ tumours seldom give rise to pressure effects on
isolated cranial nerves. On the other hand, one expects ipso-lateral
paresis or paralysis, with exaggerated reflexes (see Fig. 78). Conjugate
deviation of the eyes to the side opposite to that on which the tumour
is placed is a fairly frequent symptom, the deviation being associated
with well-marked lateral nystagmus. When the tumour is of considerable
size, or placed nearer the central portion of the cerebellum, pressure
may be exerted on the pyramidal fibres with paresis or paralysis on the
contra-lateral side of the body.
In addition, allusion should be made to Dana’s symptom--‘cerebellar
fits’--said to be almost pathognomonic of an extra-cerebellar tumour (or
abscess) situated in the cerebello-pontine angle. In such cases, there
may be sudden attacks of tinnitus, vertigo, and apparent loss of
consciousness, during which the patient falls to the ground as if struck
with lightning. The final stage of falling is said to be dependent, not
so much on actual loss of consciousness, as from the absence of
cerebellar innervation and a total loss of equilibrium. These attacks
are brought about by sudden alterations in position.
(_G_) =To the pituitary region.= Considerable research has recently been
carried out, and much knowledge obtained as to the functions of the
pituitary body and the symptoms that result from lesions of the
gland.[44] As is well known, the pituitary body consists of two
portions, an anterior (derived from upgrowth of buccal epiblast) and a
posterior (formed from neural epiblastic downgrowth).
Complete removal of the body in animals invariably terminates fatally,
the patient exhibiting a definite train of symptoms--cachexia
hypophyseopriva--and dying within a few days or weeks, the younger
animals living longer than the older. The symptoms of apituitarism are
as follows: fall of body temperature, lowering of blood-pressure,
increasing feebleness, muscular tremors, a curious attitude resembling
that of defæcation, coma, and death.
On further investigation it was proved that all these symptoms were
observed when the anterior portion of the gland was alone removed,
whilst, on the other hand, extirpation of the posterior half created no
great change in the animal’s general health.
[Illustration: FIG. 70. A PITUITARY TUMOUR.]
In the human being it would appear that the symptoms resulting from the
development of pituitary tumour formation may be classified into two
groups, those of hyper-pituitarism and those of hypo-pituitarism.
In the former case the secretion being superabundant, acromegaly and
giantism are observed. Keith[45] considers that one of the substances
secreted by the gland is of the nature of a hormone, rendering the
osteoblasts hypersensitive to the various stresses that fall upon the
human skeleton during life, and that the osteoblasts, at the origins and
insertions of muscles, become increasingly sensitive to the traction of
muscles. Muscular impressions and processes of the skeleton become
exaggerated by the new bony matter, and if the epiphyseal lines be
still open, the osteoblasts of which appear to be specially affected,
giantism is produced. The skull and skeleton of the giant O’Brien are
regarded as typical examples of the results due to over-secretion of the
gland.
Hypo-pituitarism leads to a striking and rapid development of fat
(adiposity), loss of sexual power and amenorrhœa, persistence of sexual
infantilism (if the patient be attacked when young), harsh skin and
œdematous tissues, subnormal temperature, and psychic disturbances.
In any case, whether the secretion of the gland be increased or
decreased, the developing tumour tends to compress those cranial nerves
with which it is in close anatomical relation. For instance, the gland,
being situated immediately behind the optic chiasma, tends to compress
the mesial nasal optic fibres producing bilateral temporal hemianopia,
with primary optic atrophy as a final result. In some cases optic
neuritis is observed with secondary atrophy. The third, fourth, and
sixth nerves may also be affected, with consequent squints, ptosis, and
perhaps complete ophthalmoplegia.
In addition, it should be noted that glycosuria and albuminuria have
been observed.
* * * * *
In the _general diagnosis_ of brain tumours, reference must be made to
_Lumbar puncture_ and _X-ray investigation_.
=Lumbar puncture.= With respect to the desirability of carrying out
lumbar puncture in brain tumours and the value of the information
obtained, considerable difference of opinion exists. Lumbar puncture
supplies information as to the tension of cerebro-spinal fluid and as to
its bacteriological and cytological character. The evidence so obtained
as to tension is of little value in view of the proved increase of
intracranial pressure as evidenced by the mental condition of the
patient, the headache, optic neuritis, &c. On the other hand,
bacteriological and cytological examination of the fluid may point to
the tuberculous or syphilitic composition of the tumour, thus offering
help from the point of view of treatment. Still, information of almost
equal importance can be obtained by tuberculin, Wassermann, and other
tests. There is also considerable risk attendant on the process. The
rapid withdrawal of cerebro-spinal fluid has been followed by
disastrous results, the medullary stem being suddenly forced downwards
into the foramen magnum, with corking up of that aperture, and complete
upset of the medullary centres. Such a disaster is the more likely to
occur when the tumour is subtentorial in position. Looking at the
question from the broadest point of view, it would appear that the
performance of lumbar puncture in cases of suspected brain tumour is
fraught with considerable peril.
=X-ray examination.= X-ray examination should always be carried out.
More commonly the results are negative, the nature of the tumour seldom
permitting sufficient shadow formation. Occasionally the firmer and
denser tumours allow of a more definite result. When the tumour arises
from the bone, or is so situated as to change the shape of the part with
which it is in contact, valuable information will be obtained. For
example, the hollowing out and general enlargement of the sella turcica
in pituitary tumour formation.
=Treatment.=
_Indications for operation._ The indications for operation must be
considered under two groups:--
Those for radical operation aiming at the removal of the tumour.
Those for palliative operation aiming at the alleviation of symptoms.
_For the radical operation._ According to Risien Russell,[46] the
following are the main indications:--
(1) Cases in which the tumour can be accurately diagnosed.
(2) Cases in which the tumour is situated in an accessible position. The
more favourable sites are the surface of the cerebrum, the lateral lobe
of the cerebellum, and the cerebello-pontine angle.
(3) Cases in which there is reason to believe that the tumour is simple,
and of such a nature that it can be removed from its bed.
(4) Cases in which there is reason to believe that the removal of the
tumour will not greatly imperil the patient’s life, and, furthermore,
will not result secondarily in the development of fits, paralysis,
aphasia, &c.
_For the palliative operation._ The following are the main indications
for operation:--
To prolong life.
To alleviate the severe and persistent headache.
To stop fits.
To save the sight.
And, in general, to benefit the patient by reducing the increased
intracranial pressure, _even though it may be quite impossible to remove
or even locate the tumour_.
Of all the considerations enumerated above, for which palliative
measures are indicated, there is no symptom which more urgently demands
alleviation than optic neuritis. This question of sight-saving may be
accepted as a basis on which to estimate the value of palliative
measures in general. It is obvious that no mere ‘decompression’
operation will save the sight when the optic inflammation has progressed
to atrophy, and even in the earlier conditions of neuritis cases must be
carefully chosen. Herbert Bruce[47] admirably clinches the matter in the
following words: ‘As to the prediction of improvement of vision after
trephining, everything depends on the condition of the disks. Yellowish
white patches of exudate or white atrophic changes, especially when
associated with macular changes, all indicate that the secondary changes
in the disks will be permanent. In proportion to this development will
the vision be impaired, whilst when the loss of vision has been
dependent on the swelling of the disks, then not only will the sight be
saved but largely improved. In other words, one might say, therefore,
that when the neuritis has not progressed on to atrophy the sight would
be saved.’ Even in the event, however, of the ocular conditions being
unfavourable for palliative operation, other factors in the case still
remain--the terrible and persistent headache, the fits, the emaciation
from vomiting, &c., all of which require the most careful consideration,
and all of which can be remedied by an efficient decompression
operation.
=Radical operation for cerebral tumours.= After the usual preparatory
treatment and the application of the scalp-tourniquet, the skull is
opened either by craniectomy or craniotomy. The two methods--with their
relative advantages and disadvantages--have already been described (see
Chapter II), but there can be no question that a brain tumour should be
exposed by the formation of an osteoplastic flap. Such a procedure is
called for on the ground that the exact localization of the tumour is
always a matter of very great difficulty, and that it is impossible to
foretell with certainty as to whether it will be feasible to remove the
tumour or not.
[Illustration: FIG. 71A. FIRST STAGE IN THE FORMATION OF AN OSTEOPLASTIC
FLAP. Gigli’s saw, protected from the dura mater by the special
director, passing between the two trephine holes. For further
description, see text.]
[Illustration: FIG. 71B. SECOND STAGE IN THE FORMATION OF AN
OSTEOPLASTIC FLAP. The bone-flap turned down and the dura mater
exposed.]
[Illustration: FIG. 71C. THIRD STAGE IN THE FORMATION OF AN OSTEOPLASTIC
FLAP. The dural flap turned down and the brain exposed. Note the
relation of the scalp, bone, and dural incisions to one another.]
A bone-flap is framed suited to the occasion, and permitting adequate
exposure of the dura. The question then arises as to whether the dura
should be incised, the brain explored, and an attempt made at the
removal of the tumour, or whether these procedures should be postponed
till the patient shall have recovered from any shock attendant on the
first stage. The two-stage operation--first advocated by Horsley--is
insisted on by some surgeons. By others it is maintained that it is
preferable to complete the operation at one sitting, mainly on the
ground that two anæsthetics and two operations are more dangerous than
one. As to which course should be adopted is entirely dependent on the
general condition of the patient at the termination of the bone-flap
formation. If his condition is quite satisfactory, if there has been but
little hæmorrhage, and if the blood-pressure shows no tendency to drop,
then it is perfectly justifiable to ‘carry on’, opening the dura mater
and searching for the tumour. Still, as the shock entailed during the
first stage may be considerable, as the surgeon cannot possibly foresee
with certainty what lies beneath the dura mater, and as considerable
time must elapse, and some hæmorrhage result during the further
procedures required for the reflection of the dura mater and removal of
the tumour, it follows that it is generally advisable to conduct the
operation in two stages, the second operation being carried out some
days later. Not less than five to seven days should elapse between stage
one and stage two, the scalp-flap is then but lightly healed, whilst all
blood-vessels should be sealed. The patient also will have entirely
recovered from any shock attendant on the first stage.
At the second stage, the dura may be more or less covered with a film of
coagulated blood, meningeal arteries and the outline of venous sinuses
being correspondingly obscured. Consequently, if the dural flap proposed
for the second operation should include these structures, the meningeal
vessels may be ligatured and the sinuses mapped out with guide-threads
at the completion of the first stage.
_Examination of the dura mater._ Considerable help may be obtained by
examination of the dura mater, both with regard to the localization of
the tumour and investigation as to its nature. Pulsation may be
abolished or diminished, whilst the tenseness of the membrane is
increased in direct proportion to the size and site of the tumour. The
membrane also may be œdematous or adherent, anæmic in colour from
pressure exercised by an underlying tumour, reddened from
vascularization, grey-brown from the immediate presence of a malignant
mass, plum-coloured from the adjacency of a subdural hæmorrhage, opaque
from the presence of an arachnoid cyst.
Some evidence as to the nature of the tumour may be obtained by
palpation--fluctuation suggesting cyst formation, solidity pointing to
more definite formation.
_Opening the dura mater._ The membrane can be opened either by crucial
incision or by flap formation. The latter method is to be preferred. All
meningeal vessels that cross the line proposed for dural section must be
underrun on either side of that line. The dural incision should always
fall short of the margins of the gap in the skull by at least ¹⁄₂ inch,
in order to allow of accurate approximation at the termination of the
operation.
The following points with respect to the opening of the dura mater,
though already enumerated in Chapter II, should be noted. The membrane
is lightly incised with the scalpel, and, so soon as the pia-arachnoid
is exposed, the section completed with the blunt-pointed scissors, or on
a grooved director. The dural flap is then turned down and the brain
laid bare. It is most essential that every precaution should be taken to
avoid injury to superficial cerebral veins--the cortex is probably under
high tension, firmly compressed against the dura mater and bulging out
forcibly so soon as tension is relieved.
_Examination of the brain._ In the event of the exposure of the tumour,
its removal can at once be attempted. If, however, the tumour be
subcortical in position, its position and boundaries may be estimated by
electrical stimulation, palpation and exploration.
_Electrical stimulation_ will evidence whether the area exposed
corresponds to the symptoms evinced by the patient. With respect to the
actual technique, one pole is placed on the patient’s extremity--it
matters not which, though preferably on the homo-lateral side--the other
over the exposed brain. The current should be just strong enough to
contract exposed muscle--some of the fibres of the temporal muscle are
generally available for the purpose. If there is much pia-arachnoid
œdema, some of the fluid should be evacuated--by gentle scratching of
the membranes--and the bare brain stimulated. In the event of complete
degeneration of the pyramidal tracts there is little or no response to
such stimulation. Under other circumstances the results are quite
definite.
_Palpation_ may reveal the nature of the tumour, whether fluid or solid.
_Exploration of the brain_ should only be undertaken in the light of a
reasonably certain diagnosis, and every precaution must be taken to
avoid needless damage to the cerebral substance. The exploration should
invariably be preceded by incision with the brain-knife or scalpel,
introduced in such a manner as to avoid injury to all visible vessels
and directed at right angles to the surface of the brain, so as to cause
the least possible damage to the corona radiata, &c.
_Extirpation of the tumour._ The proportion of brain tumours surgically
removable is small, and even when the tumour is fully exposed
considerable experience is required in estimating the possibility of
removal.
When the tumour is circumscribed, whether meningeal, cortical, or
subcortical, it may be shelled out of its bed with greater or lesser
ease according to its nature and position. This shelling out process is
carried out with an ordinary tea-spoon or scoop. Hæmorrhage may be
severe though generally readily controlled by lightly packing with dry
gauze. More rarely one or more of the superficial vessels will require
to be underrun with a small needle threaded with the finest catgut.
Muscle grafts (see p. 18) may be of considerable assistance.
If a cyst be found it may be possible to shell it out entire, failing
which the parietal wall is freely dissected away, and the cavity drained
for two or three days.
[Illustration: FIG. 72. COMBINED FLAP FORMATION AND DECOMPRESSION. After
osteoplastic resection, the tumour has been found irremovable. The dura
mater is therefore sewn back in position, after which a portion of the
bone is nibbled away from the bone-flap--as depicted in the
illustration--and the underlying dura mater freely incised.]
If the tumour be extensive and ill-defined in margin, no attempt should
be made at removal, the surgeon remaining content with the second
desideratum of brain tumours in general--the production of a general
decrease of intracranial pressure. This might be readily effected by
leaving the dura open and by removing at the same time the osseous
portion of the osteoplastic flap. The bone is readily dissected away and
free decompression would be permitted. In such cases, however, the
hernial protrusion is usually excessive, and insomuch as an osteoplastic
flap is more often than not framed over the Rolandic region, the
protrusion would include the motor area with disastrous results on the
contra-lateral extremities. This course, therefore, should never be
adopted. In such cases it is infinitely preferable to follow Cushing’s
method of combined exploration and decompression. This is done as
follows: ‘From under the portion of temporal muscle which has been
turned back with the flap, a roughly semicircular area of bone is cut
away with heavy rongeurs, which remove bone without jar, and so without
risk of stripping the remainder of the resected bone from the soft
parts. This accomplished, a similar area is rongeured away from the side
of the skull well down the temporal fossa under the tourniquet, the
temporal muscle being held away by a retractor. If the base of the bone
has been made sufficiently broad, a margin possibly a centimetre in
width can be left on each side as a support for the flap after its
replacement. A subtemporal bone defect is thus secured with even less
difficulty than is experienced in making the usual subtemporal opening
from without through a split muscle incision. The dura is then carefully
opened and incised in a stellate fashion to the margin of what promises
to be a sufficient circle of denuded cortex for a generous
decompression.’
_Closure of the dura and reposition of the flap._ Whether the tumour has
been exposed and removed, is deemed irremovable, or has not been found,
the dural flap should be approximated and carefully sutured in position.
In many cases, however, this dural approximation is exceedingly
difficult to accomplish, by reason of the outward bulging of the
diseased or œdematous brain. This difficulty may be overcome by adopting
one or more of the following methods:--
_Elevation of the head_, thus reducing the amount of blood in the brain.
_Lumbar puncture_, a method that presents some danger when the surgeon
has to deal with a subtentorial tumour, but which bears in its train
excellent results from the point of view of reduction of intracranial
pressure. The danger arises from the fact that the sudden escape of
cerebro-spinal fluid may cause the brain-stem to be engaged in the
foramen magnum, with disastrous results on the medullary centres.
_Ventricular puncture_, when the ventricles are dilated. A blunt-pointed
aspirating needle is introduced into the lateral ventricle through the
most prominent portion of the exposed brain, and a sufficient quantity
of cerebro-spinal fluid evacuated.
_‘Milking’ the pia-arachnoid_, the pia-arachnoid being pricked with a
needle in several places and the contained fluid squeezed out.
_Subtemporal decompression_--the final resource. When all other measures
fail, a subtemporal decompression may be conducted on the opposite side
of the brain.