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be reported later. One I will briefly sketch.
A colored boy, 12 years old, developed A FURTHER REPORT ON THE SURGI
epilepsy after an attack of typhoid fever. CAL TREATMENT OF EPILEPSY;
He had been treated medically in a hos
pital and circumcised without benefit. He NEW METHODS AND POSSI
was rapidly getting worse.
At the operaBILITIES OF BRAIN
tion he was found to have a well marked SURGERY.1
and very extensive chronic meningitis, with adhesions between the pia and dura
as far as could be seen. These adhesions W. P. CARR, M. D.,
were separated with the finger, over most
of the left cortex and in the longitudinal Washington, D. C.
fissure. Last Thanksgiving day, three
weeks after operation, he ate very At the last meeting of this Society I re
heavy turkey dinner and then stuffed himported the results of twenty operations for self with oranges and bananas. He epilepsy; nearly all cases of long standing, promptly went into status epilepticus for
24 hours, but recovered and had no more not traumatic, having several seizures
seizures for the two weeks more that he a day at the time of operation. All remained in the hospital. Since going but one
benefited and at that home he has relapsed and this case must time five of them had been cured for
go as a failure; and yet he showed so much
temporary improvement that I feel he three or more years. I may now add that
might have been cured could he have had none of the five have relapsed, though one a long course of proper diet and hygiene. died of pneumonia nearly eight years af
When we remember the advanced stage ter operation; the remaining four have and severe type of these twenty cases, that now been free from epilepsy four or more they were with few exceptions not traumatyears; the longest period being ten years. ic, that six out of twenty may be called Another case has now gone three years
cured and at least six more greatly imwithout recurrence, making six cases out proved, it seems almost too good to be of twenty that may be called cured.
true. I can only say that these are facts Another case overlooked, and accidental
that will be vouched for by many of my ly omitted from my first report, recently
associates who saw the cases before and came to my office for some minor trouble after operation. It may be mere coinand reported herself well after more than cidence or it may be, as a distinguished two years. One extremely bad case re
alienist said to me after personally exammained well for one year and five days; ining some of these cases, that there is then had a few mild seizures and has since something in it.
something in it. At least I think these been well, two months to date. During results justify a further trial of explorathe past year I operated upon two more
tory craniotomy when other measures have and refused to operate upon about twenty
been found inefficient. mild cases that I did not feel warranted
There is still a very general belief that in exposing to operation in the present
idiopathic epilepsy cannot be cured nor state of our knowledge.
even improved by such operations. But These cases will
this belief is not founded upon any exten
sive observation since improved surgery * Read before the Southern Surgical and Gynaecological Association, Dec. 17th, 1909.
has made such operations safe.
It is only within the past few years that toxins from the alimentary tract, or by anything more than simple trephining was some peripheral irritation, the brain finally safe and few surgeons have attempted suffers, and becomes distinctly abnormal these operations since then, because they even in its appearance to the naked eye. have regarded them as hopeless except in In all my cases marked lesions, gross and recent traumatic cases.
microscopic, were found. The epileptic habit has been a serious Even after removal of a peripheral cause stumbling block, but is one that ought now if it has existed long enough to produce to be removed. There is no such thing a brain lesion, the seizures will continue. as the epileptic habit per se. The con- Hence the so-called epileptic habit. It tinued attacks are the result of a lesion. would appear also that simple exploration And if the lesion can be cured or removed of the brain in many cases benefits or cures the attacks will cease. The length of time the cerebral lesion; but, if a peripheral that seizures have been occurring has cause be still active, a cure of the epilepsy
which is the best instrument for exploring panying diagram their structure and use the brain. The osteoplastic flap is the will be easily understood. method par excellence of opening the They are easily applied, effective, out skull. Much loss of bone is to be de- of the way, clear of the operative field, plored.
and not dangling across it as does the ordinary haemostat. A few haemostats or clamps may be required on the flap proper as the clamp across the base does not per
fectly control hemorrhage without too FIG. 4.
much pressure and crushing. After the
bone flap is turned down, this pin had betWith increased experience I am mak
ter be removed and
any number of ing flaps larger than ever, especially where haemostats required may then be applied no definite location of a lesion has been to the edge of the flap and will be out of made, and I have gradually developed a method of opening the skull and some in- For boring the skull I use a small struments that I believe are of value in trephine fitted with a handle like a brace saving time and preventing shock and and protected by a guide which regulates hemorrhage. My plan is to place the pa- the depth to which it will cut. This tient upon the operating table before trephine may be fitted to any brace, cuts anesthesia is complete, make the final very rapidly and safely a hole 5-16 inch preparations and mark out the proposed in diameter. There is advantage in the flap upon the skin while it is being com- small opening and the rapidity of boring, pleted. The base of the flap should al- as several openings may be made and the ways be toward the blood supply and con- cutting of the flap with a De Vilbiss siderably narrower than the middle. craniotome facilitated. small incision is then made in the skin and I have found no instrument that will one blade of a long clamp passed under do the cutting so rapidly and satisfactorily the base of the flap in the loose tissue be- as a good De Vilbiss, provided we do not tween the skin and the periosteum and try to cut too far away from the trephine closed tight enough to check bleeding from hole. Two holes will do, but three or four the flap. The outer blade of this clamp are better in a large flap. The base of the should be covered with rubber. It must bone flap is made narrow so that it will not crush the scalp nor remain on too long.
be certain to break in the proper line, and Safety pins may be used or a long pin with break easily. a rubber figure of eight.
The saving in time by the use of these The flap is then cut with one sweep of instruments is very considerable and the the knife through skin and periosteum, control of hemorrhage almost perfect. one careful sweep—not a slash. The con- These are important factors; more imcave edge of the incision is rapidly loosen- portant, I believe, than is generally thought ed and special clamps applied to stop
to be the case. bleeding. These clamps are an invention With a large flap in the parietal region of my own and by a glance at the accom- the greater part of the motor sensory area is exposed to view and a finger can be and had the patients recover, and recover passed under the skull and carefully swept easily without symptoms of shock or other over the surface of the brain from the serious disturbance and with less nausea anterior frontal to the post-occipital lobes, and general discomfort than follows an orand down under the base in the middle dinary laparotomy. Nor have there been fossa and over the tentorium. The falx any sequelae in a dozen cases followed up cerebri may be palpated almost from end
for 3 to 10 years. to end and all this may be done without Quite recently I removed a large clot injury because the large opening allows a from the middle fossa which was lying partial displacement of the brain and against the side of the pons. The patient makes room in the skull cavity for the regained consciousness, recovered from finger.
his paralysis, was comfortable and apparNo cortical clot of any size on the side ently well on the way to recovery two days of the opening can escape detection by later.
later. Unfortunately he then developed a such exploration and deep-seated clots in rapidly fatal double pneumonia. Leaving the brain substance or ventricles can often out cases of severe injury to the head, I be detected by the tension which they have had no deaths following this extencause and by the lack of pulsation over sive exploration, and in a dozen cases done them. I have even been able to detect a several years ago there have been no tumor situated half inch from the sur- sequelae. None of my epileptics died, face by the sense of resistance to touch. none appeared dangerously ill after operaCareful exploration of the brain substance tion and in at least three of them the most with a grooved director does no harm if extensive exploration was made. properly done, and may be used with con- It may be said that cerebral lesions siderable freedom. The blunt end of the should be located before operating, but in director will not tear blood vessels nor practice this is often impossible. The cause much laceration of nerve fibres or most careful localizations by skilled cells, but will push these structures aside neurologists have often gone wrong, and and separate them without injury.
in cases of severe traumatic hemorrhage The exploratory needle with a sharp there is no time for elaborate methods. point is dangerous. It may puncture large But even when we feel sure that a lesion vessels and is useless because it does not is pretty definitely located it is necessary evacuate thick pus nor give an altered to recognize it by touch or sight before it sense of resistance in meeting ab- can be removed and this often requires normal tissues. Even the finger may experience and thorough knowledge of be introduced into
any part of the pathology as well as of technique. Many lateral ventricle with little damage to lesions become practically accessible and brain tissue, if it is carefully worked in discoverable only by the large opening and through one of the deep fissures that reach thorough training of the operator. With nearly to the ventricle, after making a the possibilities now before us, however, small opening with some blunt instrument there seems no reason why the field of such as a haemostat. I have done all these brain surgery should not be much enlarged. things in a considerable number of cases There is now no reason or excuse for al