RESULTS OF BRAIN SUROERY IN EPILEPSY" AND CONOENITAL • MENT^' JDEPi&ST. ^ ^ " WIT^LIAM F*. SF»RATLI]S^G, M. D. UEl?rtINTKr> KROM t*'ROCEEr)lNGS OIT AMERICAN MEOICO-RR YCHOEOGtCAE AHSOCIATTON* WASHINGTON, I>. C., MAY, 1003. ' : ’ 1 ■y-'> RESULTS OF BRAIN SURGERY IN EPILEPSY AND CONGENITAL MENTAL DEFECT.* By William P. SpraMing^ M. D., Medical Superintendent of the Craig Colony for Epileptics, Etc., Sonyea, N. Y. Since surgical intervention is practised in epilepsy for the possible relief of conditions of certain types, and in idiocy and imbecility for the possible relief of certain conditions of other types, we can readily divide the subject into two parts, taking up epilepsy first. The limit on time requires that both be treated in a greatly abridged form. THE TYPE OF EPILEPSY PROPOSED FOR SURGICAL TREATMENT SHOULD BE SPECIFIED. Used without qualification, the word “epilepsy” carries little meaning to the analytical student of the disease. So varied is its etiology, and so numerous are its types, that the synthetical designation of “epilepsy” only has but little value. In some epilepsies medical treatment promises most; in others, surgical; and it is well to differentiate the cases of each at the outset, doing this broadly, if not specifically, always reserving, however, specific distinctions before undertaking the surgical treatment of any particular case. We may first lay down this general rule: The epilepsies that most seriously impair the conscious operations of the mind are less amenable to treatment by the surgeon than the epilepsies that leave the mind most largely unaffected. There is a vast difference between fits of different types in the degree in which they affect the mind. Some blot it out in a flash, completely and instantaneously; others blot it out gradu- ally; others impair it in various degrees without effecting its * Read at the Annual Meeting of the American Medico-Psychological Association, held at Washington, D. C., May, 1903. 2 BRAIN SURGERY. complete destruction at any time during the fit; while still others do not even disturb it in an appreciable degree, the latter being the case with the milder monospasms, Jacksonian in character. This being true, we first single out the epilepsies that mostly affect the motor side of the body as promising most for surgical treatment, to the exclusion of those that invade the psychic side to the greatest degree. We may illustrate this by saying - that in grand-mal convul- sions in which consciousness is destroyed through the intensity of the “ explosive discharge ” or through the sudden snapping of restraint ” in the motor zones, surgical measures are far more rational than when the attacks, being psychic, are silent in forrp, causing no commotion in the muscular system and no change in body posture. Operations for the possible relief of epilepsy should be con- fined to cases in which the attacks are grand-mal or Jacksonian, and will seldom be found of any use in petit mal or psychic types. This takes no account of partial, reflex, or other rudimentary forms of the disease, many of which are well adapted to surg- ical treatment, being due as they are to puch causes as old cicatrices, an adherent prepuce, foreign growths in the nose^ middle-ear disease, and other peripheral organic conditions, including recent injuries to the brain in which the early repair of the damage removes the cause of the attacks. RESULTS OF BRAIN SURGERY IN THIRTY- THREE CASES OF EPILEPSY. The types of epilepsy in which surgical intervention is often- est a rational proceeding comprise the bulk of all the epilepsies. In 1325 cases that have come under my observation during the past eight years, 774 were grand-mal and 9 Jacksonian; together a little over 60 per cent of the gross number. We do not wish to be understood as claiming that 60 per cent or over are sub- jects for surgical treatment; we mean that there are 60 per cent only in which some cases will be found that surgery may bene- fit. Before operating in any case, the patient should be carefully watched so that the exact order of invasion, the precise manner in which the fit begins, the manner in which it extends, involv- REMOTE STORAGE •S p W. P. SPRATLING. 4 ing one group of muscles, one part of the body after the other, should be carefully observed on repeated occasions, together with the nature, frequency and recurrence of the aura;, for all these constitute valuable signs that help to guide us to the cer- ebral seat of the disease. The study of such symptoms to their full advantage demands a knowledge of cerebral localization we cannot, either as epileptologists or as surgeons, fail to acquire. We can form, in a measure, some idea of the value of brain surgery in epilepsy by noting the results in the 33 cases pre- A sented at this time. All of them have been under my daily observation for periods varying from one to eight years. Five of these operations were performed at the colony in cases se- lected with great care. The remaining 28 were operated on ■ prior to their admission. i£ Case 1. — Male, aged 29 years. Family history negative. Epilepsy , began at 17 years. Supposed to be caused by malaria. Trephined, October, 1895, six years after the first seizure. Result: No improvement. Case 2. — Male, aged 31 years. Father tuberculous; otherwise family history negative. Epilepsy began at 13 years. Supposed to have been caused by trauma to bead. Trephined in August, 1894. Right motor fv/ region. Operation 11 years after the onset of the epilepsy. *'"■ Result: No improvement. Case 3. — Male, aged 22 years. Family history negative. Epilepsy began at 15 years. No assigned cause. Patient grew steadily worse V and bad as many as 24 attacks daily. Trephined in October, 1897, three years after the onset of the epilepsy. Since the operation the V r:attacks have been less frequent, but more severe. Trephined again at the Craig Colony in April, 1900. His attacks bad been growing steadily worse. A portion of thickened and adherent dura was removed. Since ^ the last operation bis attacks have been markedly lessened in fre- ^ quency. On large doses of bromides ever since the operation. Result: Great decrease in frequency and severity of attacks. Case 4. — Male, aged 31 years. Mother’s father insane and syphilitic. .Mother’s sister committed suicide. Brother and sister died in convul- sions. Paternal relatives intemperate. Epilepsy began at age of 17 years. Supposed to be caused by an injury to the head when 7 years old. Trephined during 1895, eight years after the onset of the epilepsy. ^ Result: No improvement. ^ Case 5. — Male, aged 38 years. Maternal grandmother had epilepsy. Assigned cause of epilepsy, heredity. Trephined over the left motor , '^gion in 1893, fifteen years after the onset of the epilepsy. ^ Result: Slight temporary benefit. V VI 4 BRAIN SURGERY. Case 6. — Male, aged 8 years. Family history negative. Epilepsy began at 5 years. Supposed to have been due to a fall on the head. Two months after the fall he had the first attack. Attacks increased In frequency and at the age of 5 years he was having 50 attacks a day. Two years after the injury he was trephined over the right motor region. Since the operation he has had no attacks during the daytime. Result: Decrease in number of attacks. Case 7. — Male, aged 30 years. Mother rheumatic. Father inebriate and died of tuberculosis. Epilepsy began at 21 years. Assigned cause, injury to left side of the head. Was run over by a wagon. Two weeks later he had the first attack. Attacks at first 3 or 4 daily. One week after the first attack he was trephined. Since the operation his attacks have been about 20 each month. Result: No improvement. Case 8. — Male, aged 19 years. Family history negative. Epilepsy began at 11 years. Was struck on the head with a bale-stick and had a severe convulsion half an hour later. Second attack occurred one month later and then they occurred with increasing frequency. Tre- phined in 1896, three years after injury. No benefit as the result of the operation. In April, 1900, he was trephined again at the Craig ‘Colony. This time the opening was made over the left parietal bone, as this was the side injured. (The first operation was performed on the right side.) No adhesions nor gross pathological changes were exposed. He has about 4 grand-mal attacks each month at present. Result: No improvement. Case 9. — Male, aged 20 years. Family history negative. Epilepsy began at 7 years. Supposed to be due to an injury to his head, which occurred when he was 3 years old. Trephined in February, 1899, 16 years after the injury which was the supposed cause of his epilepsy. Attacks at first were all psychic, but gradually have changed to grand- mal. Result: No improvement. Case 10. — Male, aged 20 years. Mother died of tuberculosis. Maternal grandmother and aunt died of tuberculosis. Epilepsy began at age of 12 years. Assigned cause, a penetrating wound of the skull caused by a nail when 8 years old. Four years after the injury he had the first attack. Trephined over the left parietal region in 1899. Trephined again at the Craig Colony in November, 1900, over the same area as at first operation. Thickened dura removed and gold foil inserted. Result: No improvement. Case 11. — Male, aged 36 years. Father inebriate. Maternal uncle and aunt insane. Mother and grandmother had heart disease. Epilepsy began at 34 years. Supposed to be due to trauma to head at the age of 23 years. Claims he had a fracture of the skull at that time. In July, 1898, he fell from a ladder and had a convulsion 12 hours later. Since then he has had attacks every 6 weeks. In September, 1899, he W. P. SPRATLING. 5 was trephined over the left frontal region at the Presbyterian Hospital, New York. Six weeks after the operation he had another attack. In March, 1901, he was placed on bromide treatment and during the six months since that time he has had no attacks. Result: Temporary improvement, probably not due to operation. Case 12. — R. J. Me., male, aged 11 years. Mother neurotic. Maternal grandmother had 2 strokes of paralysis. Epilepsy began at 8 years. In January, 1898, he fell 8 feet from a shed and struck the right side of his head. Had a convulsion the same day he met with the accident. In April, 1900, over two years after the accident, he was trephined over the right side of the head at the seat of the injury. Result: No improvement. Case 13. J. S., male, aged 31 years. Nothing known of family his- tory. Epilepsy began at age of 19 years. Supposed to be caused by yellow fever, contracted while in Brazil in 1891, since shortly after this he had his first convulsion. In 1893 he was trephined over the right frontal region, 2 years after the onset of the epilepsy. Result: No improvement; attacks more frequent after operation. Case 14. — W. F. C., male, aged 20 years. Family history negative. Epilepsy began at age of 15 years. At age of 5 years he was pushed off a wagon and injured his spine. Had first attack one month after the injury. In 1897 he fell from an engine and remained unconscious for some time. In September, 1900, he was trephined, 4 years after the onset of the disease. Result: No improvement. Case 15. — E. K., male, aged 15 years. Family history negative. Epi- lepsy began at 6 years. Assigned cause, trauma. He was hit on the head with a shovel about one month before the first attack. Had attacks every 2 or 3 days. In January, 1901, he was trephined over the site of the injury. Operation 9 years after the injury. Since the operation the attacks have been more frequent and severe. Result: No improvement; disease exaggerated. Case 16. — J. M. P., male, aged 19 years. Family history negative. At age of 6 years he was struck on the head by a train. Eight years after he had the first convulsion, and he has had them about every 10 days since. In January, 1900, he was trephined over the site of the injury. Operation 4 years after the onset of the disease. Attacks have been worse since the operation. Result: No improvement; disease exaggerated. Case 17. — Male, aged 29. Family history negative. Epilepsy began at age of 21 years. In October, 1893, he was thrown from a wagon and struck on the back of his head. Two years later he was trephined and following the operation he remained free from seizures for four months. In February, 1901, he was trephined again and more bone removed. Has had severe pains in head since the last operation and the epilepsy is unimproved. 6 BRAIN SURGERY. Result: No improvement. Case 18. — N. W., female, aged 20 years. Family history negative. Epilepsy began at age of 13 years. Fifteen months prior to the first seizure she fell on the ice and struck on the right side of the skull. In November, 1894, she was trephined over the left parietal bone. During the five months following the operation she had no seizures. Attacks at present 4 or 5 per month. Result: No permanent improvement; some temporary. Case 19. — C. M. S., female, aged 27 years. Family history: paternal great-grandfather and grandfather insane. Two maternal aunts epi- leptic. Father inebriate. Maternal uncle died insane. Mother has been epileptic since 16 years of age. Patient’s epilepsy began at the age of 11 years. Assigned cause, heredity. At the age of 20 years she was trephined over the motor region of the left side. Operation 9 years after the onset of the disease. Had no attacks for one year following the operation. Since that time the attacks have returned. Result: No permanent improvement. Case 20. — J. D. R., male, aged 38 years. Family history negative. Epilepsy began at 27 years. Assigned cause, injury to the head by being caught between two ice wagons. Eight years after the onset of the epilepsy he was trephined over the right Rolandic region. Result: No improvement. Case 21. — S. S. M., male, aged 22 years. Family history unknown, except that all (?) paternal relatives were intemperate. Epilepsy began at 11 years. Supposed to be due to injury to the head by a kick from a horse. He was trephined over the seat of the injury and the dura found thickened. Result: No improvement. Case 22. — Female, aged 8 years. Father intemperate. Epilepsy began at age of 2 years, following an infantile cerebral palsy which was the cause of her epilepsy. At the age of 4 years she was trephined. Skull very thick. Operation 2 years after the onset of the epilepsy. Result: No improvement. Case 23. — Female, aged 38 years. Family history unknown. Epilepsy began at the age of 8 years. At the age of 8 years she fell down stairs and was also injured by a runaway horse. She had spasms imme- diately following the latter accident and remained in an unconscious condition for 3 days. She was trephined over the left parietal bone 3 days after the injury. The convulsions continued with varying fre- quency until she was 13 years old, when she had immunity from them until 30 years of age. At the age of 30 years the spasms appeared again and she has had them at various times until April, 1900. During April, 1900, she was operated upon for a cystic uterus. The uterus was removed with the appendages. There was an imperforate cervix and the uterus had become a retention cyst. She made an uninter- W. P. SPRATLING. 7 rupted recovery from the operation and since that time she has had no return of the convulsions. Result: No attacks for 5 years; cure probable. Case 24. — F. F., female, aged 9 years. Family history unknown. Epilepsy began at the age of 3 years. No assigned cause. At the age of 6 years she was trephined over the left parietal bone. Result: No improvement. Case 25. — A. S., letter carrier. G. M. Onset at 32. Multiple sclerosis. Trephined June, 1901; left parietal region (in Syracuse). Result: No improvement. Case 26. — S. V., aged 20. No occupation. Epilepsy of 6 years’ dura- tion. Has right hemiplegia. Jacksonian type. Trephined by Dr. Ger- ster at Mt. Sinai Hospital, Nov. 18, 1901; 2V^x2^ inches of bone removed. Result: No improvement. Case 27. — G. D. B., 40. Laborer, married. Onset at 39. Family his- tory negative. Cause (?) G. and P. M. attacks frequently. Right arm and leg most frequently affected. Trephined in Syracuse. Attacks occurred again 12 days after operation. Operation six months after injury to head caused by a falling stove pipe. Result: No improvement. Case 28. — W. B., 10. Family history negative. Epilepsy for 9 years. Right hemiplegia. G. M. attacks beginning in right face, right arm and leg. May 7, 1902, operated upon at Colony. Result: No improvement in epilepsy. Case 29. — J. A. S., 29. G. M. for 25 years, following typhoia. Paralysis of left arm. Trephined at Massachusetts General Hospital 7 years before admission. Result: No improvement Case 30. — W. B., 16. Onset at 2 years. Cause unknown. P. and G. M. Attacks began in left hand, extending to left arm, face and head, then to left leg. Trephined June 7, 1902, at Colony. No marked path- ological condition found at operation. Result: No improvement. Case 31. — J. O. P., admitted Sept. 12, 1902; aged 16. At age of 7 received a fracture of skull, and was afterwards trephined. Epilepsy developed 2 years after injury. G. M. No heredity; no paralysis; two or three attacks per month. Result: No ipiprovement. Case 32. — C. E. E., aged 26. Admitted Feb. 24, 1903. Epilepsy for 14 years, following traumatism to head. G. M. Paralysis of right arm and leg and left side of face. Trephined in Syracuse in 1899. Seizures more frequent after operation. Result: No improvement. 8 BRAIN SURGERY. Case 33. — I. G., aged 21. Admitted April 29, 1903. Epilepsy of five years’ duration. Cause, blow on head by pitchfork. G. M. No paralysis. Trephined over right motor area previous to admission. No definite history of the operation. Result: No improvement; patient an imbecile. Twenty out of the 33 cases cited above were due to trauma of the head. The average duration of the epilepsy before the oper- ation was approximately 5^ years, being 16 years in one case and 3 days in another. The results, noted in no case less than eleven months after the operation and in most of them several years after, were as follows: In 21, no improvement in the disease, either temporary or permanent. In 8, the attacks were lessened in frequency and severity, the operation being a part of the treatment only. In 3, the disease was much worse after the operation. In 1, apparent recovery; the patient in this case being a woman, whose first convulsion had appeared after a severe head injury in her eighth year, caused by falling down stairs. She was trephined three days after the injury, while the convulsions continued five years longer, disappearing when she was 13 to recur at 30. Some years later when she was admitted to the Craig Colony, her uterus, being a retention cyst, was removed with all appendages, the result now being no attacks since the operation, a period of five years. In this case, the operation on the brain did not relieve the convulsions, the relief being due to the removal of a cause that periodically produced a form of auto-intoxication. The retained menstrual discharge was a sys- temic poison. Twenty-eight of the 33 cases were males; 12 of these had good family histories, 10 had not, while in 6 the family history could not be ascertained. Of the 5 women, 2 had good family histories, 2 had not, while 1 was unknown. It is worthy of note that none died as the result of the opera- tion. Similar treatment of idiocy is attended with a compara- tively high rate of mortality — fully 20 per cent, as we shall see later. W. P. SPRATLING. 9 CASES OPERATED ON AT THE CRAIG COLONY. Seizure Records. Case 1. — Operation, April, 1900. 1900 January 559 February 136 March 131 April 205 May 14 June 0 July 3 August 0 September 0 October 0 November 0 December 3 Total 1051 Case 2. — Operation, April, 1900. 1900 January 3 February 1 March 7 April 13 May 1 June 11 July 1 August 1 September 6 October 1 November 5 December 4 Total 54 Case 3.* — Operation, November 25, 1900. 1900 January 12 February 14 March 31 April 13 May 19 June 16 July 0 August 0 September 5 October 13 November 2 December 0 Total 125 1901 1 3 3 1 2 0 2 4 7 7 1 0 31 1901 4 2 1 3 3 2 3 1 6 8 3 4 40 1901 4 5 6 2 3 6 4 11 14 10 12 9 86 ‘Cases 1, 2, 3 reprinted from “Operative Interference in Epilepsy,’ by R. E. Doran, Albany Medical Annals, December, 1902. 10 BRAIN SURGERY. Case 4. — Operation, May 7, 1902 1902 January February March April 2 May 4 June 2 July 5 August 1 September 2 October 2 November 4 December 0 1903 5 11 3 3 We have no accurate information regarding the seizures in Case 4 before admission, and are unable to compare the number of attacks before operation with those occurring afterward. Case 5. — Operation, June 7, 1902. 1902 January 10 February 13 March 208 April 5 May 6 June 5 July 13 August 7 September 2 October 7 November 10 December 18 1903 25 13 75 2 (The large number of seizures in the last case in March, 1902, was due to status epilepticus.) Concisely summed up, the results in the five cases operated on at the Colony were as follows: Case 1. — During the 4 months preceding the operation there were 1031 attacks. During the 4 months following there were 17 only, while during the 20 months following the operation there were 51 attacks. Case 2. — During the 4 months preceding the operation there were 24 attacks. During the 4 months following, 14; this ratio of disease keeping about the same thereafter. Case 3. — During 11 months preceding operation there were 125 attacks. During the 11 months following, 66. Case 4. — Number of attacks before operation unknown. Dur- ing the 12 months following there were 45. W. P. SPEATLING. 11 Case 5. — Darlns: 5 months preceding the operation there were 242; daring the 5 months following, 54; during the 10 months following there were 193. It will thus be seen that absolute cure did not result in any case, while improvement followed in one out of four — 25 per cent. It should be stated that the five cases detailed were all reoperations the first operation having been performed before the patient entered the Colony. It should also be stated that all of the apparent improvements could not be laid to the results of surgery, for all of the cases were kept rigorously under a defi- nite general treatment, especially under the suppressive effects of the bromides. The marked improvement in Case 1 was attributed as much to the after treatment as to the operation itself. The importance of doing this is clearly pointed out by Roswell Park in the fol- lowing statement:^ “Operation, when indicated and undertaken, should be re- garded as a first measure to be followed, and often preceded, by others looking to a correction of all faults of diet, elimination, etc. Long continued attention to these matters is the price of success.” This has long been our doctrine, and how true it is can only be appreciated by those who have watched through many years a large number of cases subjected to the knife, the chisel and the saw. Surgeons, as well as neurologists, are apt to advise oper- ation in non-traumatic cases presenting distinct localizing phe- nomena. In many cases of this kind operation will prove use- less from the fact that while diffuse cortical conditions (three words I would like to emphasize), productive of epilepsy, may have a central point of greatest initial discharge, the area is too diffuse by far for the knife to remove. Roswell Park ^ credits Matthiolus with collecting 258 cases of Jacksonian epilepsy subjects of craniotomy, the results being, “ some 20 per cent were reported as cured, though only ten of the entire number had been followed for over three years, and only eighteen of them for over a year. Of the others, 15 per ®The Surgical Treatment of Epilepsy, American Medicine, Vol. IV, No. 21, 1902. *Op. Cit. 12 BRAIN SURGERY. cent were reported improved, while in 65 per cent there was no improvement; 13 per cent died. Braun collected 30 cases due to trauma, in which Horsley’s plan of excision of the affected cortical area was carried out, 13 of the patients bein^ reported as recovered, 9 improved, and 8 unimproved. Of the 13 reported as recovered, only 3 were fol- lowed for 3 years, a fact that must vitiate any claim so striking as this one appears to be. Kocher regards the methods of electrically locating the area to be excised, in the manner advised by Horsley, not sufficiently accurate to always reach the seat of the disease. Broca and Manbrac credit Ferrier with reporting a total of 21 cases of partial epilepsy operated on, with 12 recoveries, 6 ameliorations, and 3 negative results, adding: “It must be re- membered that such observations are often published before 6 months have elapsed.” They hold that recoveries are not rare, and that the relief of headache and attenuation of the severity of the attack, which mean a great deal, are at times attained. In 1893 Starr reported 13 cases operated on, with 3 cures; but three years later admitted that the cases reported as cured were reported too early. Gowers believes that trephining in idiopathic epilepsy is never justifiable. It is unfortunate, on the whole, that so little help can be gained from statistics; not that they are essentially unreliable, but because the view-point of those who make them is often so widely different. There is also often failure to specify the type of epilepsy in which the operation is done, the comparison, of statistics being consequently impaired. Another thing that creates confusion is the lack of any rule or uniformity in the length of time that should elapse before results are announced. Bergmann rather caustically remarks that this is sometimes done “before the wound heals.” It is difficult to fix a time limit in this respect. Such limit, in our opinion, should be regulated in a measure by the type of epilepsy operated on — the cause likewise being considered. As a general rule, it should not be less than two or three years in any case, while in all cases possible observations should be kept up after that. If we accept two or even three, years as the period W. P. SPRATLING. 13 thfit should elapse after the operation before results are reported the ratio of recoveries from epilepsy under brain surg^ery will be disappointingly small. RESULTS OF BRAIN SURGERY IN IDIOCY AND IMBECILITY. The picture of success following brain surgery in epilepsy just presented was not bright. In idiocy and imbecility, under the light of increasing time, its hue is more sombre still; so disappointing is it in color, in fact, that we feel a strong inclination to turn from it, saying, “ There is nothing in it that brings any gratification; we do not want it, nor are we disposed to help in its creation.” Craniotomy, linear and “ a lambeaux,” was introduced by Lannelongue, who published 25 cases in 1891 in which he claimed results, not only so far as recovery from the operation was con- cerned, but also as to mental improvement in a remarkably short time, so striking and so novel, that, to use Jacobi’s words, “Physicians began to hope, surgeons to glory, and the idiotic children” — he significantly adds— “let us see.” Nothing finer or more exhaustive on the subject, from the standpoint of the incredulous, if not of the positive opponent, has appeared in medical literature to our knowledge since Jaco- bi’s masterly address, “ Non Nocere,” delivered before the Elev- enth International Medical Congress in Rome in April, 1891. The essence of that address, so true then, is none the less true now; the pathology of mental deficiency has not changed, nor have we in all these years elevated the cause of craniotomy in the treatment of idiocy in any degree. The “furor operandi” so generally acclaipied ten years ago has largely passed away, but it may return at any time, when the great principles that underlie “Non Nocere” in this par- ticular field of medical work will await a wide application. “What,”, asks Jacobi, “are the underlying conditions of idiocy? ” In the main, as shown by the results of the autopsies, they are as follows: “ Chronic encephalitis, diffuse or circum- scribed; diffuse (syphilitic) disease of the blood vessels; arrest of vascular development in the cortex; inequality in the hemi- spheres; inequality in the peripheral cortical layer on the two sides; defect of the third frontal convolution and the island of Reil; meningo-en cephalitis, with thickening and adherence of 14 BRAIN SURGERY. the pia and brain, such as may occur after forceps or trauma, kephalo-hsematoma internum, spontaneous hemorrhages; embo- lism from heart disease; thrombosis from cholera infantum, fol- lowed by destruction of cerebral cells and atrophy of the cor- tex.” Starr found the last condition in 21 cases out of 343. In the same cases in 32 instances he also found maldevelopment and apparent atrophic conditions of the brain structure of the hemi- spheres, chiefly cortical, the cells resembling those of a new- born child, but with no apparent gross defects in the brain; atrophic and hypertrophic sclerosis, congenital or post-natal, in 97 ; atrophy by softening produced by embolism or thrombosis, and limited to certain arterial districts, in 23; arrest of devel- opment, such as porencephaly, in 132; cysts, which produced atrophy by pressure or were associated with the atrophy due to the original lesion, in 14; hemorrhages which were discernible by the remains of a clot, or by the blood-staining of a cyst, of the pia, or of sclerotic tissue, in 18. In addition to all these causes of idiocy, there remain to be mentioned hydrocephalus, microcephalus and premature ossifi- cation of the fontanelles and sutures. These, in the main, are the pathological conditions in the brain that surgical intervention seeks to remove or modify for the re- lief of idiocy and imbecility, and while it would be of the great- est interest to look deeper into the relative frequency, degree and kinds of the different causes and pathological states, we must, perforce, for lack of time pass on to what surgery —never more brilliant or wondrous in the world’s history than it is to- day — has been able or unable to accomplish in the way of relief. While the literature is replete with histories of individual cases, that teach valuable lessons, I am able to present 194 such cases under two heads in condensed form; the first group in- cluding the more immediate results in 111 cases; the second, results somewhat more permanent in 83 cases. . TABLE I, ONE HUNDRED AND ELEVEN CASES. ^ Case 1. — Microcephalus, imbecility from early synostosis in a child. Left craniectomy. Death 24 hours after operation. (Lane; Journal of Am. Ass., Jan., 1892.) “Both tables are made up from the results noted by Lowenstein, in references given. W. P. SPRATLING. 15 Case 2. — Girl, 4 years, microcephalus, craniectomy in two sittings. Results excellent. Marked improvement of general condition. (Lan- nelongue; Gaz. hebdom., 1890.) Cases 3-26. — 24 cases. 13 boys, 11 girls. Microcephalies and idiots, young subjects, showing (with or without epileptiform crises), motor or psychic troubles. Operation for the most part “Kraniektomie A lambeaux.” Dura opened in one case. Three died after operation. In a very large number of cases mental improvement; also in regard to the gait. (Lannelongue; Gaz. des hop. 1891, Congres frang. de chir., 1891.) Cases 27-30. — First case, craniectomy. Improvement, but a second operation was without results. Second case, 19-month girl. Idiocy. Premature suture synostosis. Failure of fontanelles. Craniectomy on both sides. After three months, improvement, distinct, if not satisfac- tory. Third case, 16-month boy. Microcephalic idiot. Synostoses of suture and fontanelles, convulsions. Craniectomy. Death immediately after operation. Fourth case, 4i/^-year girl. Microcephalic idiot. Failure of fontanelles, convulsions, craniectomy. Death immediately after operation. (W. Keen; Amer. Jour. Med. Sciences, 1891.) Case 31. — ^Girl, 3 % years. Microcephalic idiot, epilepsy. Premature synostosis of sutures and fontanelles. Left parietal bone lapped over right. Left arm paralyzed. Left craniectomy. Brilliant results 3^/^ months after operation. Epilepsy disappeared. Arm useful. (Ran- schoff; Medical News, 1891.) Cases 32-34. — ^^Three cases. Only in one exact history; 6-year boy. Microcephalus. Idiot. Synostosis. Convulsions. No trace of intelli- gence. Craniectomy. Excellent results. In the other two cases good results. (Wyeth; Med. Record, 1891, and Gaz. hebdom., 1891.) Case 35. — 2i/^-year boy. Microcephalic and idiotic. Could not walk, stand or speak. Epilepsy. Left craniectomy. Eight weeks after opera- tion, improvement. Epilepsy disappeared. (Will. Morrison; Med. Rec., 1891.) Cases 36-37. — 3-year boy. Microcephalic and idiotic. Craniectomy. Improvement in ten days. 7-year boy; microcephalic and idiotic. Craniectomy with incision over the speech center. Death after operation. (V. Horsley; Brit. M. J., 1891.) Case 38. — 8-month boy. Microcephalic; idiotic; blind both sides. Left craniectomy. Sight improved. Great improvement. (Miller R. Shalders; Ibid., 1892.) Cases 39-45. — (1) 3%-year boy. Microcephalic; idiotic; epilepsy. Right craniectomy. Improvement. (2) 4-year boy. Microcephalic and idiotic; epilepsy. Left craniec- tomy. Result, negative. (3) 18-year boy. Microcephalic; idiotic; epilepsy. Craniectomy. Death. 16 BRAIN SURGERY. (4) 15-year boy. Same symptoms as above. Craniectomy. Death In 26 hours. (5) 9-year boy. Microcephalic; idiotic; epilepsy. Craniectomy. Improvement (6) Symptoms in 12-year girl as in 5. Right craniectomy. Result, negative. (7) 14-month child. Microcephalic; idiotic. Left craniectom>. Death, soon. Case 46. — 3-year child. Did not walk, sit or speak. Salivation. Right craniectomy. Improvement. (M. Gould; Med. News, 1891.) Case 47. — 4i/^-year boy. Microcephalic and idiotic. Epilepsy. Crani- ectomy on right side. Improvement. The author is not absolutely satisfied with this improvement. (Clayton Parkhill; Ibid., 1892.) Case 48. — 9 years; microcephalic and idiotic. Like 3-year child. Right craniectomy. Improvement. After two years grew much worse Died in 1893. (Preugrueber; Gaz. hebdom., 1892.) Cases 49-50. — 4-year girl. Microcephalic; idiotic; craniectomy both sides. Improvement. lli/^-year boy. Microcephalic and idiotic. Left craniectomy. Im- provement. (Chenieux; Ibid.) Case 51. — 3-year boy. Microcephalic. Slight improvement in seven months. (Largeau; Ibid, und Congres. frang. de Chirurg., 1892.) Case 52. — Eight months; microcephalic; craniectomy. After opera- tion, deterioration, then slight improvement. (Gersuny; Gaz. hebdom., 1893.) Case 53. — Microcephalic and idiotic. Temporary craniectomy. Im- provement. (Jonnesco; Ibid., 1898.) Case 54. — 16 months; microcephalic and idiotic. Craniectomy both sides. Improvement, but death after five days. (Griffiths; Ibid.) Case 55. — 19 months; microcephalic and idiotic. Craniectomy. Re- sult, negative. (Boyd; Ibid.) Case 56. — 8 years; microcephalic; epilepsy. Left craniectomy, im- provement. (Auger; Congres franc, de Chirurg., 1891.) Cases 57-58. — 4 years; microcephalic and idiotic. Craniectomy. Re- sult, negative. 2-year boy; microcephalic and idiotic; epilepsy. Craniectomy. Death 21 hours after operation. (Mannoury; Ibid.) Case 59. — 8-month girl. Microcephalic and idiotic. Craniectomy. Improvement at first. Five weeks after operation again the old condi- tion. Death shortly after. (Heurteaux; Ibid.) Case 60. — 3%-year girl. Microcephalic and idiotic. Craniectomy on both sides. More intelligent expression. (MacClintock; Centralbl f. Chir., 1892.) Case 61. — 11-month boy. Microcephalic. Craniectomy, left. Improve- ment. Operation should be repeated. (E. Kurz; Ibid., 1893.) W. P. SPRATLING. 17 Case 62. — Microcephalic child. Craniectomy. No result reported. (Postempsky; Ibid.) Cases 63-64. — 1%-year; microcephalic boy. Craniectomy, both sides. No result after one year. 21/^-year; microcephalic girl. Craniectomy, both sides. Death 8^ weeks after operation, unimproved. (Tillmanns; Ibid., 1894.) Case 65. — 14-year boy; idiot. Right craniectomy. Seven trephine buttons removed. Improvement, (A. Szpanbock; Ibid., 1895.) Cases 66-77, — 12 cases; microcephalic and idiotic. Ages 2i/^ to 8 % years. Linear craniectomy. 3 improvements; 5 negative results; 1 doubtful; 3 deaths. (C. L. Dana; Ibid., 1897.) Case 78. — 31^-year boy; microcephalic and congenital occipital men- ingoceles. Idiocy. Craniectomy left and right, and extirpation of the meningoceles. 21^ years after operation physical and mental improve- ment. (Parona; Jahresbericht f. Chir., 1895; and Contributo alia Chirur. Cerebrale e spinale.) Cases 79-90. — 9 operated cases. The majority craniectomies; Two improvements. (Oed & Cotterall; Ibid.) Cases 91-92. — 1, after a year, no improvement; 1 died. (Isuardi; Ibid.) Case 93. — 9-month child; microcephalic and idiot. Craniectomy both sides. Result, negative. Death after 2 years. (Bourneville; Lombard & Pillier; Ibid., 1896.) Case 94. — 8-year girl. Idiot. Craniectomy. Improvement. (Reca- sens; Ibid.) Case 95. — 5-year idiot. Craniectomy. Result, doubtful. (Lilanus; Ibid.) Cases 96-102. — 7 cases of microcephalus and idiocy. Craniectomy. In all seven cases, result negative. (Blank; Ibid., 1895.) Case 103. — 3%-year boy. Microcephalus and idiocy. Craniectomy both sides. Improvement. (Joos; Corresp.-bl. f. Schweizer Aerzte. 1893. ) Case 104. — 14-month girl. Microcephalus. Craniectomy, circular. Improvement. (Dumont; Ibid.) Case 105. — 12-year child. Microcephalus. Craniectomy, both sides. A little improvement. (Schede; Deutsche Med. Wchnschr., 1895.) Cases 106-107. — 15-year girl. Idiocy. Microcephalus. Left crani- ectomy. First improvement, then old condition. Result, negative. 2-year boy. Microcephalus and idiocy. Craniectomy, left and right. Death seven days after operation. (Beck; Prager Med. Wchnschr., 1894. ) Case 108. — 2-year boy. Microcephalus and idiocy. Craniectomy, both sides in two sittings. Improvement. Half a year after operation no progress. No improvement after second operation. After eight weeks a slow improvement noted by the mother. (Akermann; Volkmann’s Sammlung Klin. Vortrage, 1890-94, Nr. 90.) 18 BRAIN SURGERY. Cases 109-110. — (1) 6-year boy. Microcepbalic and idiotic. (2) microcephalic and idiotic. Left craniectomy. Both children neater. (Rabow & Ronx; Therap. Monatshefte, 1891.) Case 111. — Girl. Microcephalic and idiotic. Epilepsy. Craniectomy both sides. Result, negative. (Starr; 1894.) SUMMARY OF RESULTS IN ONE HUNDRED AND ELEVEN CHILDREN OPERATED ON. 19, or 17^, died in consequence of operation or soon after. 25, or 22.5^, were operated upon with no result. 10, or 9^, were operated upon with slight result, but not satis- factory. 24, or 21.5^, were improved in stated ways. 30, or 27^, improvement without reports as to its character. 3, or 3^, with no reports as to the results given in general. TABLE II, EIGHTY- THREE CASES. Cases 1-4. — 3 boys; 1 girl. Ages 3, 5, 7, 9 years. All were micro- cephalic and idiots. 2 were epileptics. Linear craniectomy. 2 died after operation. Old hemorrhage of brain. One disappeared after the first improvement. One was improved. (Parkhill; Denver, June 19, 1899.) Cases 5-26. — 22 cases, in age from 14 months to 8 years. All were idiots and microcephalic. Linear craniectomy. The results were such that Lamphear since 1896 has not done the operation in general. Some died within a few years after the operation. (Manoury; Chartres, Juin 10, 1899.) Cases 27-41. — 15 cases of craniectomy. 5 died immediately after the operation. 1 died after having become maniacal a short time after the operation. 6 showed absolutely no result. 3 were only quieter after the operation. (Roswell Park; Buffalo, June 22, 1899.) Cases 42-45. — See other table (27-30). 2 died immediately after the operation. 2 showed practically negative results. Keen from his re- sults became opposed to the operation. (W. Keen; Z. Lt. Hamburg, June 30, 1899. Case 46. — ^See 38 in last table. Died four years after operation. At first improvement; then 2 years after operation return to old condi- tion. (Miller R. Shalders; London, June 15, 1899.) Case 47. — See case 81 in last letter. The writer says: “The operation of Lannelongue has given no result; no one of my acquaintance prac- tises it in France.” Hemicraniectomy. Result nil. (Doyen; Rheims, Juin 19, 1899.) Cases 48-49. — 4-year girl. 2-year boy. Microcephalic and idiotic. Craniectomy. 1 died immediately after operation. 1 showed improve- W. P. SPKATLING. 19 ment in the first 2 or 3 months after operation. 5 months later the old condition returned permanently. (Mannoury; Chartres, Juin 10, 1899.) Cases 50-52. — 11-year child. Microcephalic. 13-year boy« Microceph- alic, idiot and epileptic. 4i/^-year boy. Microcephalic; idiot; spasms. Craniectomy, both sides. At first, results . Then “The patients remain idiotic and epileptic and have only temporary ameliorations for 1 or iy 2 months. (Jaboulay; Lyon, Juin 14, 1899.) Case 53. — Case 61 of first table. At first improvement. Then patient grew worse and died in 1897. (E. Kurz; Florenz, Juni 16, 1899.) Cases 54-75. — 22 cases of microcephalus, idiocy and epilepsy in children not over 5 years. (66-77 in first table.) Craniectomy of various kinds. 5 died. 14 were operated upon without results. 3 were improved. (C. L. Dana; N. Y., Sept. 18, 1899.) Case 76. — Result, nil. Child died IV 2 years after operation. The whole left hemisphere showed cystic degeneration. (Gersuny; Wien; Juni 25, 1899.) Cases 77-78. — 1 (Dumont, 104, Table 1). Epilepsy remained till death, 1896. (Operation, 1893.) 2 (Joos & Walder, 103, Table 1). After 2 years the results disappeared and the patient was in a sad state. (Dosseker; Corresp.-bl. f. Schweizer Aerzte, 1899.) Case 79. — Idiocy. Craniectomy, both sides. No change after opera- tion. After five years the old animal condition. (Czerny.) Cases 80-82.— 3 cases. 2 girls; 1 boy. Ages 6, 7, 11 years. Idiocy; 1 with microcephalus. Circular craniectomy. 2, much quieter, one died after some years an idiot. (Dumont; Bern., Oct. 21, 1899.) Case 83. — 3i/^-year girl. Microcephalic and idiot. Epilepsy. Craniec- tomy. At first improvement, then deterioration. The child became insane and died in this condition in 1900. (Perry; Kolombo, Sept. 20, 1899, together with letter of Jonathan Bird Kandy, July 10, 1899.) SUMMARY OF RESULTS IN EIGHTY-THREE MORE PERMA- NENT CASES. 20, or 24^, died. 54, or 75^, unimproved. 9, or lOi^, improved. Seventy-five out of 83 received no benefit. The 9 who were improved showed it mostly in being quieter. This was the result in a case of restless imbecility and epilepsy operated on at the Colony; mental deterioration after the operation being rapid. The sudden lull in purposeless activity that follows the operation in some cases must not be mistaken for gain in mental powers. The opposite is generally the rule. Note the results in Roswell Park’s 15 cases. Five died imme- diately after the operation; one died after having become 20 BRAIN SURGERY. maniacal a short time after it; 6 showed absolutely no improve- ment; while 3 only were quieter. Also the results obtained by Lamphear in 22 cases, ranging in age from 14 months to 8 years, all microcephalic idiots, the results being such that since 1896 Lamphear has not performed the operation. Doyen says, ‘‘The operation of Lannelongue has given no results; no one of my acquaintance practices it in France.” Dana’s 22 cases turned out as follows: 5 died; in 14 there were no results; while 3 were improved; none being over five years of age, all having idiocy and epilepsy. Wilson states that since Fuller, of Montreal, trephined an idiot’s skull, in 1878, to improve the mental condition, and Lannelongue. of Paris, did linear craniectomy on microcephalic idiots with the same object, craniectomy has been done a num- ber of times with varying success. Some think with Lanne- longue that the premature ossification of the skull is the cause of the microcephalus and deficient brain development, and jus- tify the operation on the theory that after it the imperfectly formed brain improves its function and takes a greater amount of nourishment. “With the hypothesis,” says Lowenstein,\ “ of the primary synostosis of the sutures and fontanelles and the secondary hindrance of brain development, stands or falls the right of Lannelongue’s operation. The hypothesis is false and therefore the operation is not a suitable one. Death or no result fol- lows. ” Keen says that no good can possibly come from operation on an idiot with a skull of average size, in extreme microcephalus, or in a patient over seven years of age, and concludes that in some few cases of moderate microcephalus, craniectomy is justi- fiable; that slight improvement will follow in a small number of cases, but in the majority there will be no change. He places the mortality at from 15 to 20 per cent. Dana holds that craniectomy is justifiable in a selected class of cases. He believes that the clinical reports show improve- ment too often for the facts to be ignored. He thinks the oper- ation is indicated in simple lack of development rather than where extensive lesions exist. W. P. SPRATLING. 21 Jacobi gives 41 operations on 33 cases with 14 deaths, and of the 19 recoveries from the operation there was slight improve- ment in 8 and considerable improvement in 2, and says: “ It appears that in the face of so many deaths and so few results, the operation is not promising to mankind. The operations thus far performed do not effect what they were intended for; they do not even enlarge >the cavity If any cases be at all amenable to treatment by such operations, they must be those of incomplete premature ossification of the sutures and fontanel les.” Goethe once said that ‘‘The most interesting book that could be written would be a treatise on the errors of miankind,” and Jacobi adds, “Let us see to it that our mistakes do not swell that book.” Carl Beck concludes that craniectomy is justifiable and apt to be successful in microcephalus with idiocy. Acquired and late forms give a better prognosis than the congenital forms, while the dangers of the operation, he says, are not very great. Norbury is of the opinion that the basis of much cerebral sur- gery in mentally defective states has been grossly theoretical. “ Especially,” he goes on to say, “ does this apply to operations for the relief of microcephalus.” Operation from a pathological standpoint is utterly hopeless. Synostosis is not necessarily indicative of arrested mental devel- opment, and it is not a factor in producing microcephalus. Broca has modified Virchow’s views by saying it is a result and not a cause of microcephalus. Lannelongue now accepts the same view, but believes that as the brain is capable of de- velopment until past the 8th year, the operation is justifiable as a stimulant to brain growth. Idiocy is a “vice of the entire organism,” and the improve- ment of the mental condition depends upon the improvement of the entire physical system. This cannot be done by the assist- ance of surgical means, for brain growth is not dependent upon stimulus from such a source, but from true physiological educa- tion— the training of the bodily powers — without which no mental improvement can be expected. The marked improvement noted in the few cases which have survived the operation of linear craniectomy is not to be won- dered at, as all . interested in the case have sought by every 22 BRAIN SURGERY. means to improve the child, and it must respond to a certain ex- tent. On the whole, Norbury is vastly in favor of educational in contradistinction to surgical measures for the improvement of the mental conditions of the feeble-minded. Bourneville, in reviewing in detail the histories of 13 original cases, concludes: “It is, then, the medico-pedagogical treat- ment to which we must turn and upon which we must depend. This is for the amelioration,* and even the cure, of a notable portion of children afflicted with the divers forms of idiocy. Pelliet states that the pathological anatomy of the brains of idiots confirms the opinion expressed by Bourneville. It is not difficult to formulate conclusions on the results to be expected from surgery of the brain done for the possible relief of epi- lepsy and congenital mental defect. If the epilepsy is general and of some years duration, we need scarcely expect a cure, though in selected cases operations may ameliorate the symptoms to a marked extent — temporary ameli- oration being oftener obtained than that which is permanent. If the epilepsy is unessential, reflex, rudimentary in type, or of short duration, and the operation removes the cause early enough, we may expect the convulsions to cease in many cases, provided the patient is free from the vices of heredity that are always beyond the reach of the knife. We fail to find a single case of congenital mental defect in which a normal mental status was established through surgical intervention. We find many reports of cases benefited — the degree not being given — so that it is extremely difficult to judge of specific results in any case. The fact that such operations are so few, as compared to what they were ten years ago, is the strongest argument against their utility in the great majority of cases. Surgical interference may still be used in isolated cases of idiocy, but it seems clear that it is slowly finding its position in rational treatment along a plane far lower than seemed possible at the time of its inaug- uration. REFERENCES. Broca & Manbrac: Traite de Chirurgie Cerebrale, 1896. Binne, (J. P.) : The Operative Treatment of Non-microcephalic Idiocy. Ann. Surg., Phil., 1894, XIX, 453. W. P. SPRATLING. 23 Norbury, (P, P.): Surgical versus Educational Methods for Im- provement, &c., of Feeble-minded. Am. J. Insan., Utica, 1892, XLIX, 391. Jones, (B): Limitations in the Treatment of the Idiot. Am. J. Surg. & Gynaec., Kansas City, 1893-4, 240. (Not in library.) Bourneville: Cranes et Cerveaux dTdiotie. Craniectomie. Bull. Soc. Anat. de Paris, 1896, LXXI, 49. Lamphear, (F.) : The Operative Treatment of Idiocy. Internat. Clin., Phil., 1893, Ser. 3, II, 227. Lowenstein, (S.): Ueber die Mikroc. Idiot, u. ihre chirur. &c. nach Lannelongue; Beitz, (Z.): Klin. Chir., Tubingen, 1900, XXVI, 133. Wilson, (W. J.): Craniectomy, &c. Canada J. M. & S., Toronto, 1899, VI, 425. Park, (Roswell) : The Surgical Treatment of Epilepsy. American Medicine, Nov. 13, 1902.