ORIGINAL ARTICLES.

A FURTHER REPORT ON THE SURGICAL TREATMENT OF EPILEPSY; NEW METHODS AND POSSIBILITIES OF BRAIN

SURGERY.1

BY

W. P. CARR, M. D., Washington, D. C.

At the last meeting of this Society I reported the results of twenty operations for epilepsy; nearly all cases of long standing, not traumatic, having several seizures a day at the time of operation. All but benefited and at that one were time five of them had been cured for

three or more years. I may now add that none of the five have relapsed, though one died of pneumonia nearly eight years after operation; the remaining four have now been free from epilepsy four or more years; the longest period being ten years. Another case has now gone three years without recurrence, making six cases out of twenty that may be called cured.

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Another case overlooked, and accidentally omitted from my first report, recently came to my office for some minor trouble and reported herself well after more than two years. One extremely bad case mained well for one year and five days; then had a few mild seizures and has since been well, two months to date. During the past year I operated upon two more and refused to operate upon about twenty mild cases that I did not feel warranted in exposing to operation in the present state of our knowledge. These cases will

1 Read before the Southern Surgical and Gynaecological Association, Dec. 17th, 1909.

be reported later. One I will briefly sketch.

A colored boy, 12 years old, developed epilepsy after an attack of typhoid fever. He had been treated medically in a hospital and circumcised without benefit. He was rapidly getting worse. At the operation he was found to have a well marked and very extensive chronic meningitis, with adhesions between the pia and dura as far as could be seen. These adhesions were separated with the finger, over most of the left cortex and in the longitudinal fissure. Last Thanksgiving day, three weeks after operation, he ate a very heavy turkey dinner and then stuffed himself with oranges and bananas. He promptly went into status epilepticus for 24 hours, but recovered and had no more seizures for the two weeks more that he remained in the hospital. Since going home he has relapsed and this case must go as a failure; and yet he showed so much temporary improvement that I feel he might have been cured could he have had a long course of proper diet and hygiene.

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When we remember the advanced stage and severe type of these twenty cases, that they were with few exceptions not traumatic, that six out of twenty may be called cured and at least six more greatly improved, it seems almost too good to be I can only say that these are facts that will be vouched for by many of my associates who saw the cases before and after operation. It may be mere coincidence or it may be, as a distinguished alienist said to me after personally examining some of these cases, that there is something in it. At least I think these results justify a further trial of exploratory craniotomy when other measures have been found inefficient.

There is still a very general belief that idiopathic epilepsy cannot be cured nor even improved by such operations. But this belief is not founded upon any extensive observation since improved surgery has made such operations safe.

It is only within the past few years that anything more than simple trephining was safe and few surgeons have attempted these operations since then, because they have regarded them as hopeless except in recent traumatic cases.

The epileptic habit has been a serious stumbling block, but is one that ought now to be removed. There is no such thing as the epileptic habit per se. The con

tinued attacks are the result of a lesion. And if the lesion can be cured or removed the attacks will cease. The length of time. that seizures have been occurring has

FEBRUARY, 1910

, Vol. V., No.

toxins from the alimentary tract, or by some peripheral irritation, the brain finally suffers, and becomes distinctly abnormal even in its appearance to the naked eye. In all my cases marked lesions, gross and microscopic, were found.

Even after removal of a peripheral cause if it has existed long enough to produce a brain lesion, the seizures will continue. Hence the so-called epileptic habit. It would appear also that simple exploration of the brain in many cases benefits or cures the cerebral lesion; but, if a peripheral cause be still active, a cure of the epilepsy

which is the best instrument for exploring the brain. The osteoplastic flap is the method par excellence of opening the skull. Much loss of bone is to be deplored.

FIG. 4.

With increased experience I am making flaps larger than ever, especially where no definite location of a lesion has been made, and I have gradually developed a method of opening the skull and some instruments that I believe are of value in saving time and preventing shock and hemorrhage. My plan is to place the patient upon the operating table before anesthesia is complete, make the final preparations and mark out the proposed flap upon the skin while it is being completed. The base of the flap should always be toward the blood supply and considerably narrower than the middle. A small incision is then made in the skin and one blade of a long clamp passed under the base of the flap in the loose tissue between the skin and the periosteum and closed tight enough to check bleeding from the flap. The outer blade of this clamp should be covered with rubber. It must not crush the scalp nor remain on too long. Safety pins may be used or a long pin with. a rubber figure of eight.

The flap is then cut with one sweep of the knife through skin and periosteum one careful sweep-not a slash. The concave edge of the incision is rapidly loosened and special clamps applied to stop bleeding. These clamps are an invention of my own and by a glance at the accom

panying diagram their structure and use will be easily understood.

They are easily applied, effective, out of the way, clear of the operative field, 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 perfectly control hemorrhage without too much pressure and crushing. After the bone flap is turned down, this pin had better be removed and any number of haemostats required may then be applied to the edge of the flap and will be out of the way.

For boring the skull I use a small trephine fitted with a handle like a brace and protected by a guide which regulates the depth to which it will cut. This trephine may be fitted to any brace, cuts very rapidly and safely a hole 5-16 inch in diameter. There is advantage in the small opening and the rapidity of boring, as several openings may be made and the cutting of the flap with a De Vilbiss craniotome facilitated.

I have found no instrument that will do the cutting so rapidly and satisfactorily as a good De Vilbiss, provided we do not try to cut too far away from the trephine hole. Two holes will do, but three or four are better in a large flap. The base of the bone flap is made narrow so that it will be certain to break in the proper line, and break easily.

The saving in time by the use of these. instruments is very considerable and the control of hemorrhage almost perfect. These are important factors; more important, I believe, than is generally thought to be the case.

With a large flap in the parietal region the greater part of the motor sensory area

is exposed to view and a finger can be passed under the skull and carefully swept over the surface of the brain from the anterior frontal to the post-occipital lobes, and down under the base in the middle fossa and over the tentorium. The falx cerebri may be palpated almost from end to end and all this may be done without injury because the large opening allows a partial displacement of the brain and makes room in the skull cavity for the finger.

No cortical clot of any size on the side of the opening can escape detection by such exploration and deep-seated clots in the brain substance or ventricles can often be detected by the tension which they cause and by the lack of pulsation over them. I have even been able to detect a tumor situated half inch from the surface by the sense of resistance to touch. Careful exploration of the brain substance with a grooved director does no harm if properly done, and may be used with considerable freedom. The blunt end of the director will not tear blood vessels nor cause much laceration of nerve fibres or cells, but will push these structures aside. and separate them without injury.

The exploratory needle with a sharp point is dangerous. It may puncture large vessels and is useless because it does not evacuate thick pus nor give an altered sense of resistance in meeting abnormal tissues. Even the finger may be introduced into any part of the lateral ventricle with little damage to brain tissue, if it is carefully worked in through one of the deep fissures that reach nearly to the ventricle, after making a small opening with some blunt instrument such as a haemostat. I have done all these things in a considerable number of cases

and had the patients recover, and recover easily without symptoms of shock or other serious disturbance and with less nausea and general discomfort than follows an ordinary laparotomy. Nor have there been any sequelae in a dozen cases followed up for 3 to 10 years.

Quite recently I removed a large clot from the middle fossa which was lying against the side of the pons. The patient regained consciousness, recovered from his paralysis, was comfortable and apparently well on the way to recovery two days later. Unfortunately he then developed a rapidly fatal double pneumonia. Leaving out cases of severe injury to the head, I have had no deaths following this extensive exploration, and in a dozen cases done several years ago there have been no sequelae. None of my epileptics died, none appeared dangerously ill after operation and in at least three of them the most extensive exploration was made.

It may be said that cerebral lesions should be located before operating, but in practice this is often impossible. The most careful localizations by by skilled neurologists have often gone wrong, and in cases of severe traumatic hemorrhage there is no time for elaborate methods. But even when we feel sure that a lesion is pretty definitely located it is necessary to recognize it by touch or sight before it can be removed and this often requires experience and thorough knowledge of pathology as well as of technique. Many lesions become practically accessible and discoverable only by the large opening and thorough training of the operator. With the possibilities now before us, however, there seems no reason why the field of brain surgery should not be much enlarged. There is now no reason or excuse for al