Neurosurgery

“ In other instances, the results of a blow or a fall without injuring the skull may cause profound damage and subsequent hemorrhage. In all these cases operative interference, now extremely safe and easy, may readily save life. Gunshot wounds of the brain are now only occasionally fatal, provided opportunity offers for prompt and clean operative work. Even where the ball has traversed the entire length of the cerebrum, recovery has followed operation. The results of brain surgery in relieving certain forms of epilepsy are occasionally most brilliant and frequently much relief is afforded. ”

“ In writing on surgery of the brain he records the loss of brain substance with recovery, and notes the recovery, under expectant treatment, of many patients with suspected fracture of the skull. His study of the surgical anatomy of the ribs and diaphragm as applied in opening the thorax, shows sound surgical sense. In wounds of the intestines he gives an unfavorable prognosis unless the abdomen be quickly opened and the wounds sewed up. He describes his sutures and his special needle-holder, like any modern surgeon. ”

“ It is therefore only necessary to enter into those cases of fractured base which are associated with concussion, irritation, and compression of the brain—in other words, the average case of fracture of the base of the skull.
The surgeon must always be guided by the general condition of the patient—the blood-pressure, character of pulse, state of respiration, depth of unconsciousness, &c.—but, in my opinion, the temperature chart affords perhaps the most valuable basis on which rules can be formulated guiding the surgeon in his general line of treatment. ”

“ The dura is stripped away from the base of the skull, partly with the fingers and partly with the blunt dissector, and a flat, slightly malleable retractor introduced along the floor of the middle fossa, the dura and overlying temporo-sphenoidal lobe being gently lifted upwards. The surgeon should take upon himself the responsibility of retracting the brain, holding that instrument with the one hand and working inwards with the other, directing his course towards the foramen spinosum (middle meningeal) and foramen ovale (third division of the fifth nerve) . ”

“ It is impossible to say at what period of time the brain may become irritable, and no longer admit of its being touched without convulsive movements ensuing; but when this state of irritation has commenced, and its existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body. The brain under ordinary circumstances is much more likely to recover from an injury, all foreign or irritating matters having been removed, than when suffering from their presence. ”

“ As a rule, there was no want of courtesy; and the doctors met with the kindest consideration on all sides.
A more trying type of visitor was a celebrated neurologist who, as he went round the wards, looked over the patients as though they were goods on a counter, and said in front of them:
‘I want to see some good head cases. Have you got anything shot through the brain? Any paralysis? No fractures of skull! Nothing good. You don’t seem to have much in. Deaf and dumb! ”

“ It is unnecessary to enter into details with regard to the symptoms arising from bullet-wounds of the skull and brain, for they closely resemble those previously enumerated in the chapters dealing with fractures of the skull and injury to the brain. There are, however, a few special points to which attention should be directed.
1. External hæmorrhages are seldom profuse.
2. The escape of cerebro-spinal fluid is of infrequent occurrence, probably due to the fact that the apertures of entry and exit are blocked up with scalp, fragments of bone, and pulped and swollen brain. ”

“ If the inflamed brain tissue protrudes to an excessive degree during the operation itself, the opening in the skull should be enlarged, if it be not already of considerable magnitude, and the dura mater incised to the full limits of the opening. The protruding mass may then be cleanly excised by means of a scalpel. If, however, the brain tissue continues to prolapse, the wound cavity should be simply cleansed and protected by a dressing of sterilized gauze. If the encephalitis subsides, the hernia will not increase in size, and if the wound cavity be kept aseptic, it may gradually shrink. ”

“ The trephine is applied, the disk removed, and the gap enlarged with the craniectomy forceps in the forward and backward directions. The hæmatoma is evacuated and the bleeding arrested after the methods enumerated above.
Results. The ultimate result of operation for middle meningeal hæmorrhage depends on two factors—the time at which operation is carried out, and the question of brain lesion. There is every reason to believe that, when treated early and when uncomplicated by brain injury, the prognosis, both immediate and remote, is wholly satisfactory. ”

“ The hospital surgeon continually meets with cases exemplifying the more remote effects, varying from slight lesions associated with chronic headache to others showing considerable deficiency in the vault of the skull with cortical degeneration.
Some of these cases are still capable of being cured, others are hopelessly inoperable.
In the consideration of the more remote results, it must be remembered that the surgeon comes mainly into communication with those cases which require further treatment. The more favourable are lost to view. ”

“ 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. ”

“ One night, when brooding on his miseries, he heard a bell ringing violently at his surgery door. Opening it, he found that a man had been thrown out of his cab and nearly killed, and they wanted to bring him into the surgery. The medical man found that there were concussion of the brain and dislocation of the shoulder-joint. His card-case showed that he was a man of birth and a well-known politician. He stopped some time at the surgeon's house, who was thus enabled to lay the foundation of a large and lucrative connection. ”

“ So long, however, as surgeons will persist in burrowing into the brain substance for a supposed subcortical tumour, so long will the mortality remain high. The great secret in operating on a brain tumour lies in knowing when to terminate the attempt at removal of the tumour and when to rest content with a pure ‘decompression’.
It is obvious, therefore, that cortical tumours—more especially such as give rise to early localizing symptoms, e.g. Rolandic tumours—offer a better prognosis than when the surgeon has to deal with subcortical, central, and basal tumour formation. ”

“ In all cases of head injury, the questions that dominate the whole clinical outlook are, whether the brain is directly damaged or not, and whether it is likely to become the seat of infection.
It is impossible to consider separately in their clinical aspects injuries of the cranium and injuries of the brain. It seldom happens that one is seriously damaged without the other suffering to a greater or less extent. Sometimes the skull suffers comparatively little, while the brain is severely damaged, but it is rare for a serious injury to the bone to be unaccompanied by definite brain lesions. ”

“ 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. ”

“ 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. ”

“ Cerebral Injuries.—The recent advances in brain-surgery have, in a measure, diminished the interest and wonder of some of the older instances of major injuries of the cerebral contents with unimportant after-results, and in reviewing the older cases we must remember that the recoveries were made under the most unfavorable conditions, and without the slightest knowledge of all important asepsis and antisepsis.
Penetration or even complete transfixion of the brain is not always attended with serious symptoms. ”

“ Every care must be taken to avoid unnecessary damage of the brain-matter.
When the tumour is situated in the cerebello-pontine angle, a somewhat favourite site for tumour formation, ‘lateral displacement’ of the cerebellum towards the middle line will aid considerably in the exposure. A flat retractor, bent to a suitable curve, is introduced between the dura and the cerebellum, and the brain-matter gently but firmly retracted towards the middle line. As the brain yields to the pressure the tip of the retractor is insinuated towards the posterior surface of the petrous bone. ”

“ Treatment. The age of the patient must not be allowed to [55] weigh in the balance against operative treatment, for, if due precautions be taken, the new-born child stands operation well. Cushing points out that ‘the possibilities of surgical relief are limited to the first week or two after the hæmorrhage has occurred, for old cortical scars can neither be helped by medicine nor by the scalpel’.
The clot can be exposed by craniectomy or by craniotomy. The latter operation results in a more complete exposure, but the shock is undoubtedly more severe. ”

“ A compression force—whether foreign body, blood extravasation, abscess or tumour—must act on the brain substance or on the fluid constituents of the skull. The brain, however, is itself incompressible. It may be squeezed like a sponge, but its actual structure is unalterable. Consequently, the compressing force exercises its main influence on the fluid contents, driving out the cerebro-spinal fluid, depleting the cerebral veins and emptying the arterioles, producing in other words a state of brain anæmia. ”

“ The rapid withdrawal of cerebro-spinal fluid has been [228] 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. ”

“ Middle meningeal hæmorrhage, uncomplicated by brain injury, is of infrequent occurrence, the associated injuries to bone and brain confusing the diagnosis. Moreover, the special pressure effects are dependent not only on the absence of serious brain lesion, but also on the non-existence of a safety-valve, such, for instance, as is afforded by a comminuted fracture of the bones entering into the formation of the temporal fossa, or of the roof of the middle and external ears. ”

“ When you cut your finger, it can heal in two ways. Usually it bleeds, scabs, and skin grows under the scab, taking a week or so. But if you align the edges exactly, at once, they may join almost immediately healing by First Intent. Likewise in the brain, if they line up cut nerve fibers before the cut-off bit degenerates, it'll join up with the stump. So, take a serum-conditioned brain and fit it to the stem of another brain so that the big fiber bundles are properly fitted together, fast enough, and you can get better than ninety per cent recovery. ”

“ There is a steadily increasing record of cures of intractable neuralgia, especially of the face, by division or removal of the affected nerve trunks. ... The ends of cut nerves have also been re-united, and solutions of their continuity have been filled up with portions of nerve taken from animals. ... The heart naturally cannot be made so free with, even by the most enterprising surgeon, as the brain or the lung. Yet within the past twelve months a Norwegian practitioner has reported a case which encourages a hope that even wounds of the heart may not be beyond surgical treatment. ”

“ With regard to active treatment, the majority of the cases were complicated by fracture of the roof of the orbit, and in many instances concurrent brain injury was present. In all of these, as a general rule, it was advisable to await the closure of the wound in the orbital roof prior to removal of the injured eye, if that was considered necessary. The only exception to this rule was offered by instances in which the bullet passed from the orbit into the cranium; in these primary removal of fragments projecting into the frontal lobe was preferable. ”

“ In more advanced cases, thin patches of lymph, or more extensive strata of it, cover the arachnoid and the inner surface of the dura mater; a puriform fluid is found effused between these membranes, and sometimes blood and matter are deposited in some part of the cerebral substance; bloody serum is effused into the cavities, and at the base of the brain. The above symptoms and appearances sometimes follow injuries not at first thought severe, but are most frequently the result of such as are attended with læsion of the bone, or of the internal parts. ”