Brain Surgery.—This branch of surgery is practically a triumph of recent years. Formerly the brain was never interfered with except for injury (traumatic), and even then nothing was done excepting for the removal of pressure, as from a piece of depressed bone, and the institution of drainage. To-day the skull is opened for epilepsy; abscesses of the brain are opened and drained successfully, and tumors of the brain are removed, thus not only in numberless instances saving life but—what is equally important—saving the usefulness of the life and mind. The first actual successes in this line are recorded by Bennett and Godlee in 1884, who localized and operated on and ultimately found a tumor. The patient died, but the bold beginning was followed by a number of other surgeons, till this new region for exploration, hitherto untouched, has become a fertile ground for successful efforts. Abscess of the brain, until twenty years ago, was almost invariably fatal. MacEwen in 1879 located an abscess of the brain and begged to be allowed to operate, but was refused by the family of the patient. After the death of the patient he operated precisely as he would have done in life, evacuated the pus and demonstrated that had he been permitted to do so he could have saved life.
Where the cranium is wounded surgeons nowadays will not hesitate to open the skull, secure the bleeding vessels, remove clots, and thus many lives are saved. Even comparatively slight injuries to the skull, where the brain is damaged, involve oftentimes destruction to the arteries and blood is effused, producing such destructive pressure as causes very serious symptoms or even death. 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. Where the epilepsy is of the character known as focal, and where there is evidence of irritation of the brain, due to a local pressure, whether of the cranial walls or of some new growth within the brain tissue, the removal of these sources of irritation has in many reported instances been most satisfactory. Again, certain cases of protracted headache, so severe as to render life insupportable, have been cured by trepanning the skull. Certain forms of insanity have been modified and relieved where this had followed upon brain injuries. It is of great interest to reflect upon the methods by which students of brain disease are enabled to determine so exactly the location of tumors, abscesses, hemorrhages, clots, scars, and other alterations of tissue giving rise to epilepsy and brain disorders, and which afford no indication of the diseased locality by any changed condition of the surface. In dealing with other parts of the body, if the precise locality of the part to be operated on cannot be at first determined, there is no hesitation in the minds of the surgeons in cutting down upon, and searching for, that which he proposes to remove. In dealing with so delicate an organ as the brain, however, this cannot be permitted; for a variation of the very smallest dimension will sometimes change the manipulations from those of perfect safety to the most fatal results. Our knowledge of the location of the functions of the brain and the areas from whence arise governing influences has been derived almost solely from experiments upon living animals. Among the names of the great pioneers in this direction must be mentioned those of Ferrier and Horseley, of England; Fritsch, Hitzig, and Goltz, of Germany. The researches which have thus opened up a new realm of operative possibility are among the very greatest triumphs in our means of saving life and affording opportunity for relief of the most serious disablements known to modern times.
For illustration of how these studies are pursued, it may be of interest to review the method used by Horseley.
The brain of a monkey having been exposed at the part to be investigated, the poles of a battery are applied over squares one twelfth of an inch in diameter, and all the various movements which occur (if any) are minutely studied. One square having been studied, the next is stimulated, and the results are again noted, and so on from square to square. These movements are then tabulated. For example, all those adjacent squares which, when stimulated, produce movements of the thumb are called the region for representation of the thumb, or “the thumb centre;” and to all those squares which produce movements of the hand, the elbow, the shoulder, or the face, etc., are given corresponding names. In this way the brain has been mapped out, region by region, and the same minute, patient study given to each.
These animals are etherized so that they do not suffer the least pain. Such operations, with few exceptions, even without ether, are not painful. The brain itself can be handled, compressed, cut, or torn without the least pain. A number of cases have already been reported in which a considerable portion of the human brain has been removed by operation, and the patients have been about their ordinary avocations within a week or two.
Studying in this way the brain in the lower animals, it is now possible to get a very fair knowledge of the localization of many of its functions in man.
Moreover, portions of the body can be entirely severed, and, if suitably preserved, can be replaced, and they will adhere and grow as if nothing had happened. When a wound is slow in healing, we now take bits of skin, either from the patient’s own body or provided by the willing family or friends, or even from frogs, and “graft” them on the surface of the wound. They usually adhere, and as enlargement takes place at their margins, they coalesce by one half the time required for healing. Even a large disk of bone, one or two inches in diameter, when removed from the skull, can be so saved and utilized. It is placed in a vessel filled with a warm antiseptic solution, which is again placed in a basin of warm water, and it is the duty of a special assistant to see that the thermometer in this basin shall always mark 100° to 105° Fahr. The bone may be separated from the skull so long as one or two hours, but if properly cared for can be replaced, and will grow fast and fulfill its accustomed but interrupted duty of protecting the brain.
X-RAY PICTURE OF A COMPOUND FRACTURE AND DISLOCATION OF THE FOREARM.
Röntgen Rays.—One of the most recent advances in the art of surgery is the discovery and use of the X-rays. In December, 1895, Professor Röntgen, of Würzburg, announced his discovery, and since then its utility has continually increased, until to-day no large hospital or properly equipped teaching institution, indeed no first-rate surgeon, is without the X-ray apparatus. By its use many doubtful cases of both injury and disease in surgical practice are thus entirely rendered clear. In the diagnosis and treatment of many fractures it is nearly indispensable, showing the exact location of the break and the position of the fragment before and after dressing. Probably in no other condition, unless it be in fractured bones, has the X-ray proved itself of so much value as in the location of foreign bodies lodged in any of the organs or tissues of the body. Before Professor Röntgen’s discovery it was not of infrequent occurrence that an exploratory operation was necessary to positively prove the presence of a foreign body, and even this was at times of necessity a failure. To-day the X-ray picture enables the surgeon to learn the exact location of the foreign body and indicates to him the best point from which it may be attacked. With repeated improvements in apparatus the time of exposure required for making the picture of the part has been greatly reduced. The advantage of this was made manifest when it was discovered that destruction of the skin, the so-called “X-ray burns,” might follow long and repeated exposure to the rays. It is not always necessary to make a plate of the part to be examined, since by simply studying the parts by the eyes through the fluoroscope or the fluoroscopic screen the surgeon can readily see everything that a photographic picture could show him. The fluoroscope or screen is now often used during the operation of removing foreign bodies; through it the surgeon can watch the various steps of his operation, his approach to the foreign body and its final removal.