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JULY 29, 1922.

An Address[ABRIDGED]

ON

BRAIN SURGERY.Being the Presidential Address delivered at the

Annual Meeting of the British MedicalAssociation in Glasgow on July 25th

By SIR WILLIAM MACEWEN, C.B., LL.D., D.SC.,F.R.C.S., F.R.S.,

REGIUS PROFESSOR OF SURGERY, UNIVERSITY OF GLASGOW.

[AFrR welcoming to Glasgow, " one of the mostcosmopolitan of industrial cities," the members of theAssociation and mentioning some of the distinguishedmedical men of the past whose names were associatedwith Glasgow University, Prof. Macewen went on :]EVOLUTION OF THE KNOWLEDGE OF BRAIN FUNCTION.

In my student days physiologists taught us thatthe brain acted as a whole, without recognition oflocalised areas within it endowed with specialisedfunction. ’

’

In 1861 Broca demonstrated at the AnthropologicalSociety in Paris the brain of a man who had for41 years lost the faculty of speech. The specimenshowed softening of the third frontal convolution onthe left side. Broca deduced from that and otherobservations that the base of the third frontal convolu-tion on the left side was the seat of the faculty ofarticulate language, and further advanced thesuggestion that there were probably other areas inthe brain connected with localised function. Broca’sdiscovery was iconoclastic ; it shook the notionentertained regarding the unity of brain function toits foundation. Clinicians such as Charcot andPitres were generally aware that lesions of one sideof the brain were often associated with paralysis ofthe opposite side of the body ; and Hughlings Jacksonsuggested that unilateral convulsions indicated in thesame way disease of the opposite side of the brain.In 1869 Hughlings Jackson stated that, in his opinion,there were many limited areas in the brain connectedwith distinctive functions, founding his opinion onclinical experience and direct observation of patho-logical facts. He also foreshadowed the existence ofhigher psychic centres.The views of Broca and Hughlings Jackson were

subjected to much controversy and doubt. A newmethod of investigation was introduced by Fritzigand Hitzig in 1870, who applied the faradic currentto the brains of dogs, and found that in response tosuch stimulation of certain localised areas coordinatedmovements were evoked in distinct groups of muscleson the opposite side of the body. Ferrier publishedin 1873 the results of his memorable research on thebrains of the higher apes, mapped out definite areas(chiefly in the central convolutions) which respondedto faradic current, producing definite movement ofgroups of muscles on the opposite side of the body,differentiating areas for the various parts of the faceand upper and lower extremities.Whether deductions made from. the localisation of

function in the motor cortex of the brain of thelower animals were applicable to man had yet to beproved. This I had the opportunity of doing, bydirect observation of the effect of injuries, especiallythose of a limited character. By the application ofthis knowledge and the deductions drawn therefrom,cerebral neoplasms were diagnosed, and the restora-tion of function after their removal aided in confirmingthe localisation.

Opportunities afforded for observation on manconvinced me that both in Broca’s lobe and in theascending central convolutions there were areas inthe brain with spepialised functions, and by deduction

that the same existed in other parts of the brain.

MOTOR LOCALISATION.

In the early " seventies " numerous occasions pre-sented themselves for noticing the effects of interferencewith the brain of man, and it was early apparent thatinjury to the ascending convolutions induced motordisturbances of the opposite side of the body ending inparalysis, when due to pressure or destruction of braintissue ; and to spasms when due to irritation of thecerebral cortex. Especially were these convincingwhen cases of limited lesion were followed by mono-plegias on the opposite side of the body. These wererelieved by operation, the function of the part beingrestored by the removal of the lesion from the brain.This was also demonstrated in hemiplegias, due insome cases to extra- and in others to sub-duralhaemorrhage exercising pressure on the brain, and thespeedy recoveries following their removal ; whereas,in the intra-cerebral haemorrhages in the same regionsthe recoveries after removal were protracted andincomplete in proportion to the damage done to thebrain tissue itself. Such traumatisms were notalways accompanied by external evidence of injury,and where external evidence of injury did exist itdid not always correspond to the damaged part ofthe brain. ’

When motor function was interfered with bypressure it was found safer to operate over the areaof the brain whose function was implicated than totake external injury of the scalp or skull as a guide.Lesions of an idiopathic kind, when they presentedthemselves with disturbance of localised cerebralfunction, were exposed in the same way and wherepractical were removed. Several of these idiopathiclesions were found to present more definite symptomsof their localisation than most traumatic lesions.Thus, when an abscess of the brain presented itselfwith symptoms of motor aphasia, it was diagnosedto be located in or near the base of the third frontalconvolution, and where it was found ; and when atumour with multiple symptoms indicative of primaryinvolvement of the anterior part of the left frontallobe with secondary extension to the ascendingfrontal convolution presented itself, the diagnosis,though more difficult, was made with sufficientapproach to accuracy to enable the tumour to belocated and removed by operation (1879), givingcomplete relief to the symptoms and curing thepatient. There were several tumours in the motorcortex and one in the para-central lobe diagnosed(in 1883) and operated on. All of them were diagnosedand the neoplasm successfully removed from thebrain with the restoration of function. One case

described as a focal lesion in the motor cortex fromwhich blood and disintegrated tissue were removedwas probably a disintegrated glioma into whichhaemorrhage had occurred, though at that time theappearances of disintegrated gliomas had not beensufficiently recognised.At this period Ferrier visited the Royal Infirmary,

making inquiry into the function of the brain inman. The question was raised as to whether theinformation laid before us by Ferrier in his work onthe brain of the chimpanzee had borne fruit in our

I operations on man-especially as to whether theascending convolutions in man had been found tocorrespond in function to the analogous parts in thebrain of the chimpanzee. To this question an

affirmative answer was given, and it was suggestedthat a demonstration such as we could give wouldbe welcomed by the scientific world, where confir-mation of these points was eagerly awaited.

In the year 1888 I had the opportunity of addressingthe British Medical Association on the subject ofbrain surgery, and then presented lesions from manydifferent regions of the brain which had been diagnosedby localisation of functions and had been removed byoperation. - In the years that followed - much workwas done by surgeons toward the elucidation of thefunctions of the brain, the pathology of the lesionsand their mode of removal. Hughlings Jackson,

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Mott, and Growers continued to give inspiration fromthe clinical side. Ferrier and Horsley and Beevordid much painstaking investigation on the brains of.a variety of animals, and their results were of muchvalue. Horsley, Godlee, Ballance, and many of theirLondon colleagues followed these by brilliant opera-tions on man. Horsley was indefatigable in hisresearch work, and everyone regrets that in hisdevotion to national duty his life was sacrificed onthe burning plains of Mesopotamia. In these earlydays Ferrier in London was the vis a tergo to manyof the surgeons and helped to stimulate and give themconfidence.

In America there was likewise a vigorous growth ofcerebral surgery, and those who took up the subjectenlightened it, such as Allan Star, my old friendKeen-the youngest man in America-HarveyCushing, and many others, all doing valuable andaccurate work. D’Antona of Naples, ,Durante ofRome, Lucas-Championniere of Paris, Bergman andKrause of Berlin, were prominent at the earliestperiod of this evolution.

SENSORY LOCALISATION.From direct experiment on animals it was at first

announced that both pre- and post-Rolandic convolu-tions were concerned in the production of movement,and were included therefore in the motor area. While

accepting tentatively this conclusion founded on

direct experiment, cases arose in man in which sensoryimpressions were the only phenomena produced bylesions in the cortex of the post-Rolandic convolution. iIn other instances the lesion produced primarily ’,,sensory impressions, yet from extension forward thefloor of the Rolandic fissure became involved and ’,motor symptoms developed. ’

Such cases were recorded by.me in 1888 : in one ofthem a’ protospasm of the hallux was preceded bysensory impressions-what was described by thepatient as a " curious sensation "-and pain in thegreat toe. The pain in the great toe was alwayspresent, but occasionally it became so severe as to makethe patient cry out. The lesion was found mainlyin the upper portion of the ascending parietal con-volution ; a smaller one of more recent origin- wasdiscovered in the upper part of the ascending frontalconvolution, and this was the cause of the later motorspasm of the toe.A somewhat similar instance appeared in another

case in the same brain centres some years after.In this a sensory impression of the right footheralded the invasion of the upper parietal con-

volution of the opposite side. The lesion was

removed in a wedge-shaped portion of brain tissue,the patient quickly recovering under one dressing.Pain and discomfort in the foot entirely dis-appeared after the operation, but there was insteada numbness or-when the foot was left to itself-a" want of precise sensation of how to place the foot."Automatic associated movements, such as walking,were easy on a pavement, and when the patient con-centrated attention in the movements of the footthey could be made according to will. After thefirst three months the patient walked very well,though she said there was still a trace of the defect" in the feeling " of the foot.

In several other cases neoplasms and traumatismsin the post-central convolutions produced sensoryimpressions in various parts of the body withoutmotor phenomena. In others the sensory impressionswere associated with motor phenomena-mono-spasms or convulsions, and others with paralysis. Inthe majority, however, the lesions in the motorarea involved both ascending convolutions, and themotor phenomena, being more obtrusive, were morenoticed.

It was evident that a discrepancy which requiredexplanation, existed between the clinical data inman and those of direct experiment on the chimpanzee.Could it be due to the inability of’the lower animalsto express their sensations in language intelligible toman that the sensory phenomena were missed ?

Even were it so, it would not account for creditingthe ascending parietal convolution with the functionof producing motor phenomena when faradicallystimulated.From such clinical experience one was therefore

prepared to accept the conclusion drawn from Sher-rington’s notable research on the brain of the higherapes in which, contrary to the deductions of otherexperimenters, he found that the ascending parietalconvolution did not respond by production of move-ment when stimulated faradically. This was a com-forting conclusion to the clinician, as it brought directexperimental research into line with the observationon man, and confirmed the latter in a way which wouldhave taken many decades to have made positive byclinical observation alone. He showed that theascending frontal and the floor of the fissure of Rolandoalone responded to faradisation, producing move-ments of the affected parts on the opposite side ofthe body. In clinical work the invading lesion doesnot always limit itself to special areas of localisedfunction. When sensory symptoms, which do notprevent the use of the limb, appear primarily, they areapt to be overlooked or their importance minimised,and when by extension of the lesion into the pre-Rolandic area motor phenomena are presented, thesensory are apt to be overshadowed.The cyto-morphology of the anterior central con-

volutions differs from that of the post-central. TheNeister-Betz pyramidal giant cells exist in the anteriorconvolutions and not in the post-central. This maybe made use of in examining specimens taken fromthe brain by operation, but cannot contribute to theprimary diagnosis. The difference in the archi-tectural arrangement of the cells in the two ascendingconvolutions would a priori indicate difference infunction.

’ The sensory phenomena exhibited when otherregions of the brain have been the seat of lesions havebeen previously recorded by me, and subsequentexperience-by many others as well as myself-hasabundantly borne out the conclusions there arrivedat. The word-deafness and psychic-blindness havebeen particularly illustrated in one patient who had alesion of the posterior area of the upper temporalconvolutions with extension to the angular gyrus.This patient heard and saw physically, but did notcomprehend what he saw or heard. " Hearing heheard not, and seeing he saw not." He asked for adrink and would persist in asking for it. Though thenurse had duly presented him with the drink andrequested him to take it, yet he did not take it, butagain repeated his request. When, however, hissense of touch was brought into play by placing theglass on his lips, he at once perceived and took itinto his own hands and drank. When the lesion wasremoved, he saw and heard correctly and appreciativelyand tried to explain his previous difficulties.

LESIONS IN SILENT AREAS.

Though there are some areas of the brain whosefunctions we do not yet know sufficiently to enableus to determine when they are invaded by smallneoplasms, yet when these neoplasms increase insize sufficiently to involve adjacent parts, by pressureor otherwise, the implication of these parts, in definiteorder, aids in indicating the position of the lesion inthe silent area. Take, for instance, the invasion ofthe temporo-sphenoidal lobe by a large neoplasm.While localising symptoms of a small abscess

situated in the middle of the temporo-sphenoidal lobeabove the tegmen are still insufficient to enable oneto make a definite diagnosis, the symptoms occasionedby a large abscess (or tumour) in that region are quitepronounced. This symptom-complex of large lesionsin the temporo-sphenoidal lobe was pointed out byme in 1884 and again in my address in 1888. Sincethen it has borne the test of further experience. Thesymptoms are due to pressure extending upwardsfrom the temporo-sphenoidal lobe to the adjacentstructures and affecting them in ordered sequence. ,They are, first, a passivity over the face on the opposite

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side from the lesion, which, as the lesion extends,becomes a definite paresis, and may ultimately passinto paralysis. The facial paralysis is, however, likethat from all lesions of the facial centre of thecerebral cortex-not complete-as the power ofemotional expression is retained to a slight degree,and the patient has the power of closing the

eyelid by an effort of will, though it remains partiallyopen during sleep. This is of importance as, in

many cases where the temporal bone is affected,facial paralysis is present on the same side as the lesion,and as it arises in such a case from damage to thenerve trunk it is complete. The power of emotional

expression is not retained in the upper part of the face.The arm on the opposite side from the lesion

becomes affected with paresis after the involvementof the face, and it may become completely paralysed-though in abscess it is seldom that it is allowed toreach that stage. The leg is not affected.Coincidently with the facial paresis, and some-

times preceding it, there is dilatation of the pupil onthe same side as the lesion, along with a degree ofptosis when the neoplasm is large. The pupil on thesame side as the lesion is affected early, but at firstso slightly that the degree of dilatation may easilybe missed unless specially looked for and both eyestested for accommodation. It soon becomes dilated,however, and very sluggishly responds to light andaccommodation, and latterly it becomes fixed-stablemydriasis. The ptosis is usually very slight, and maybe absent. The explanation of these phenomena issimple if one looks to the contour of the cavity whichcontains the temporo-sphenoidal lobe, which else-where has been described by me as a " box withouta lid "--so that the way pressure from within can berelieved is upwards, and consequently the motorcortex becomes affected, while the third nerve iscaught by pressure against the posterior clinoidprocess.The same symptom-complex was found by me to

accompany a tumour growing in the temporo-sphenoidal lobe and displacing the brain tissue up-wards. The symptoms succeeded one another veryslowly but in perfect sequence.The varieties and characteristics of cerebral tumours

are now well known. We have the simple subduralmeningeal fibromata which exercise pressure on thebrain and which are so easily removed-of which thisis a specimen. It was forcibly ejected so soon as thedura was opened, the cerebral pressure within speedingthe parting guest. At the other extreme we find thesarcomas of the meninges and gliomata of the brainwhich are both often difficult to eradicate.The size of the tumour of the brain ought not alone

to determine the question of removal. The smallerthe tumour the greater the credit in diagnosing andremoval, as extent of invasion and the pressure effectstherefrom will be the less. The larger the size of thetumour the greater is the destruction of brain tissueand the greater will be the encroachment on themembranes and cranial walls necessary to give relief.One ought not, however, to be deterred from operatingon a large tumour merely on account of its bulk, as inmost cases the opening of the cranial walls will at leastgive relief to symptoms and often will retard or preventblindness ensuing upon optic neuritis with choked disc.Some of the larger tumours are amenable to removalwith good results, as, though large, they are of a naturewhich lends itself to easy removal, because the tumourhas undergone degeneration. After each operationmany patients have experienced relief of symptomsand restoration of function.

TUMOURS OF THE HYPOPHYSIS.

Many such tumours have been reported as havingbeen operated on with a considerable measure ofsuccess. Horsley had at an early period four cases.Their interest has been heightened by the growth of

1 Wernicke has subsequently also drawn attention to thedilatation of the pupil and ptosis consequent on pressure on thetrunk of the nerve on the same side.

knowledge as to the influence of the pituitary body ongrowth and the production of acromegaly.There have been four cases in my experience in

which the pituitary body was diagnosed as beinginvolved. Two of these were not operated on : one

on account of the general weakness of the patient, theother as the progress was slow and the symptoms soslight that operation was not advised.One of the cases operated on was a firo-addeomaa

growing from the hypophysis which had causedabsorption of the sella turcica, as seen by X rays-theabsorption taking place principally forward toward thefrontal lobe. The patient had a degree of bilateraltemporal hemianopsia, unilateral loss of smell(anosmia), and severe frontal headache. The tumourwas removed by the temporal route and the patientmade a good recovery. Though the slight degree ofacromegaly which was present before the operationdid not seem to have been much relieved, there was,however, no increase after the operation.The other case was of a peculiar type-a fibro-

cellular tumour or bundle of tumours-of muchelongated polypoidal form, springing from the mem-brane of the hypophysis and involving its substance.The radiogram showed much destruction of thesella turcica forward and downward. The sense ofsmell was absent in the left side and it was defectiveon the other ; the sight was so defective on the leftside that hemianopsia could not be made out, thoughhemianopsia was present on the opposite side. Therewas proptosis of the left eyeball, evidently frompressure in the orbital cavity. He complained of a.

constant heavy feeling in the left side of the brow andpain in the left eyeball and over the supra-orbital nervedistribution. There was a slight degree of acromegaly,the hands and the lips and nose were thick.The operation in this case was through the fronto-

temporal route. On opening the dura and lifting thefrontal lobe, what seemed at first to be a single tumourwas exposed, but on attempting to remove it the massseparated into a series of polypoid growths with theirbase forward lying in line with the olfactory lobe.The longest of them measured one inch and three-quarters, the shortest one and a half inches. Thebreadth of the broadest part was about half an inch.They were deep red in colour and vascular and some-what firm to the touch. There was a depression in thefrontal lobe in which they lay. Four of these elon-gated masses within the subdural space, when elevatedor turned aside, showed a fifth one, the base of whichhad softened and thinned the dura and made adepression through the orbital plate of the frontal bywhich it exercised pressure on the orbital cavity. Thebone under this growth was dark coloured and vascular.The attenuated pedicles were attached to the mem-branes of the hypophysis but also involved thetissue of the gland, a portion of which had to beremoved with each. Free bleeding ensued from theveins of the cavernous sinus during and after removal,which pressure arrested.The patient made an uninterrupted recovery. The

hemianopsia and anosmia disappeared along withthe pain in the head. He lost the appearance ofacromegaly, though part of this might be due to thegeneral thinning of the whole body. He lost flesh andweight, but remained healthy.

Polypoid growths are much more likely to arise inthe sphenoidal cells, and, a priori, when growing fromthe membranous covering and body of the pituitary,one would have expected them at least to haveinvaded the sphenoidal cells in process of growth.This, however, they did not do in this case.

PHYSICS OF THE BRAIN AND MENINGES.

Questions have been asked, especially by foreigncolleagues, as to what were the essential elements inbrain surgery that promoted success, and how it wasthat pyogenic invasion of the brain in the form of brainabscess would be overcome. It is apparent that onemust have an intimate knowledge of the brain and its

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function-its anatomy and physiology-and there-after observe the rules whereby one may gain access tothe structure with the least possible damage. Theanatomy of the brain must be taken in relation to itsenvelopes, the head as it is normally and not thesoft contents of the cranium, separated from supportslifted apart and altered in form by being laid on aflat surface.As it is leptomeningitis that is the most fatal

complication in abscess of the brain, attention to thepia arachnoid and the subdural cavity is necessary.Not so long ago the peritoneum was supposed to be

inviolable ; its opening was to be avoided on accountof peritonitis, which ensued from the entrance oforganisms. Now, with asepticity, that problem hasbeen overcome, and the peritoneum is invaded dailywithout evil consequences. The pleura likewise wasnot to be opened, as the physiological dogma of the daytaught that the lung was only kept in place throughatmospheric pressure, and to open the pleural cavitywas to induce instant collapse of the lung. A differentview- of the physics of the lung recognised that-molecular cohesion-or surface tension-between thetwo layers of the pleura is the main factor in maintain-ing the lung in full expansion, and that after the twolayers have been separated while performing opera-- tions on the lung, the aid of this force may be relied onto restore the lung to its normal state of expansion.So that, by making use of this force, operation onthe lung can be freely undertaken, without resort tospecial apparatus.The physics of the brain and its meninges are also

worthy of attention, especially by those who desire toinvade the subdural cavity-as anyone must who isgoing to perform an operation on the brain.

Doubtless everyone knows the elemental anatomicalfacts regarding the cerebral coverings and theirrelations, but do we fully realise and act upon them ?We know that there is a subdural space, but there is aconfused idea that the spider has spun its web withmany attachments between the dura and the surfaceof the brain.

The arachnoid scarcely exists as a distinct con-tinuous detachable membrane over the surface of thecerebrum, but rather as a few sparsely distributedcobweb strands of connective tissue bridging thesurface of the sulci, and from which a few detachedstrands may occasionally be seen during life suspend-ing the blood-vessels on the surface of an oedematousbrain. Therefore one agrees with Henle 2 ratherthan with Bichat in his views of the arachnoid. Aslight extra separation of the pia from the dura byfluid, such as external hydrocephalus or a subduralhaemorrhage, disrupts many of the cobweb strands,and a clear, subdural space exists, extending from thevertex to the base, and from that to the spinal cord.When this free subdural space obtains, a subduralhaemorrhage occurring on the vertex would be free tospread in a thin layer over the surface, and to envelopthe brain, extending to the base, and might penetrateinto the spinal canal and prove fatal by pressure on therespiratory centre.How many times after traumatism does the blood

effused into the subdural space spread and gain accessto these vulnerable basal parts, especially where thepractice obtains of placing an insensible man on hisback, gravity thus aiding toward the fatal issue !

During the process of exposing the brain for theremoval of neoplasms and while pushing aside theexternal coverings, if haemorrhage occurs into thesubdural space it is serious, and the more so if, afterwounding a large surface cerebral vessel, the freeopening of the skull and its membrane is delayed. Forthis reason, among others, the ordinary trephine isseldom used, a large osteoplastic nap being raisedinstead. The dura is opened from the centre of theexposed surface, care being taken to do so withoutinjuring any of the vessels of the pia mater. In this

2 Henie describes the arachnoid as a connective tissue ofextremely "loose make-up."

way a clear view is obtained of the fresh normalsurface of the brain without obscuration by blood.The delicacy and tenuity of the superficial cerebralvessels is so great that they abrupt on very slighttraction, and in order to ligature them successfullyone ought to have previous practice, by ligaturingthe strands of a suspended cobweb-and so realise howbig and how forceful the fingers are. One has also toeducate oneself to refrain from ligating any vessel thatmay be circumvented, as anaemia of even a minutearea of the brain may lead to degeneration andperversion or destruction of its function.

MENINGEAL INFECTION.

Pyogenic organisms introduced into such a cavitywould be disseminated along the loose strands ofconnective tissue of the pia arachnoid with greatrapidity, so that in a few hours the whole pia arachnoidwould be diffusely affected and the whole cerebro-spinal system involved. When the pia is affectedthe whole cerebral cortex is involved.Though this is well recognised in the steps taken to

secure asepsis from without, is it equally carefullyobserved when removing pyogenic or pathogenicorganisms from within a walled-off area in the brainalready guarded by defensive adhesions ? Does theoperator follow the rules he would observe were heabout to deal with a localised abscess bound off byadhesions from the general cavity of the peritoneum ?Presumably no one would care to open such an abscessthrough the healthy peritoneum and thereby exposethe general cavity to invasion, even though it mightbe the easier route to follow.

In the earlier periods it was believed that abscessof the brain was pyaemic, and therefore regarded ashopeless.3 3 Even were the abscess of the brain pyasmicin origin and located in the white substance it couldbe dealt with surgically, assuming provision were madefor the uncontaminated preservation of the subduralspace by preventing pyogenic matter from coming intocontact with the soft membrane and setting up aleptomeningitis. Therefore adhesions, natural or

artificial, must be sought before opening the abscessthrough the subdural space.

It has been recognised that the majority of uncom-plicated brain abscesses-such as those occurring inthe temporo-sphenoidal lobe-form by continuity ofinvaded tissue directly from the point of origin, andsoldering of the meninges occurs in process of, and inmany cases prior to, the formation of the abscess.There is thus a route or pathway of invaded tissuebetween the point of origin and the abscess roundwhich Nature attempts to form a defensive barrier.

In endeavouring to relieve the contents of theabscess one must keep within the limits of theadhesions by traversing the parts through the affectedarea from the original focus to the abscess itself. Theevacuation would then be accomplished under favour-able conditions-as leptomeningitis would be unlikelyto occur. It is doubtless more difficult to follow thistract to the abscess than to open directly through theskull, and the latter gives more room for manipulation.But in adopting this course one is opening the generalsubdural cavity and exposing it to contaminationunless one affects the closures of the space by solder-ing the membranes artificially before proceeding toevacuate. As leptomeningitis is the most fatal com-plication of brain abscess it is of paramount importanceto prevent its occurrence.The method of removing the osseous covering in

order to gain access to the abscess is of importance, as,if in so doing, vibration of a rude kind is produced,the spicules of eroded bone at the seat of disease beingbathed in pyogenic matter are apt to penetrate thesoft membranes with their jagged edges, and toinoculate the pia-arachnoid and set up leptD-meningitis.

3 At an early period it was said by a very eminent member ofour profession that it was useless to attempt removal of a brainabscess, as they were all pyæmic and would all prove fatal. Isthis belief quite dead?

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Instruments which do their work more gently with-out producing violent vibration, such as the surgicalburr, which may be held lightly like a pencil in theguiding fingers, remove the bone in minute flakeswithout injuring the soft parts.Though having used the osteotome and mallet in

performing thousands of osteotomies on the bones ofthe extremities, it has never been used by me on theskull, as it was feared that the violent impact andvibration occasioned thereby would be detrimental tothe delicate contents. Even for the removal ofcerebral neoplasms the violent vibration in opening theskull by chisel and mallet must in many cases bedetrimental to the softened cerebral substance andthe enlarged thin-walled blood-vessels in the vicinityof the tumour or abscess.

PREVENTION OF POST-OPERATIVE ADHESIONS.

Having removed the neoplasm from the brain withas little interference of its structure or its blood-supplyas possible, one has to endeavour to mitigate thedamage to the surface of the brain and to restore thesubdural space to its normal conditions.Can adhesions between the brain surface and the

dura or skull itself be prevented ? .In the abdominal cavity adhesions give rise to con-

siderable and sometimes serious trouble. In the intra-cranial cavity adhesions between the pia mater or thenude brain and its rigid envelopes may mar the sub-sequent results of the most brilliant operation. Bythe constant dragging of these adhesions on the braintissue extensive degenerative processes may be setup, giving rise to fresh brain areas being involvedwhich may prove fatal. Normally the brain floats inits water bed and is contained within its covering like aspecimen in a bottle which has been specially shapedto the form of the specimen ; this economises spaceand fluid. Its surface is not adherent to any part ofits fixed coverings, though attached basally by certainnerves. This allows of accommodation to the varyingconditions of the brain in expansion and contraction,in response to vascular conditions and to the vary-ing positions of the body. When the brain becomesfixed by an adhesion to the rigid wall two thingshappen: the motor cortex at that point does not ’,function properly, and secondly, there is a dragging ’,at the point of fixture and for a considerable distancebeyond, and as this dragging is repeated with varying Iconditions of the brain the mechanical interferencetends to produce degeneration in the white substanceas far as the strained brain fibres extend. This maybe mitigated by guarding against sudden changes in

Icerebral vascularity and quick alterations of posture ;the patient himself realising his altered condition, 111,aids in these directions.

It is very desirable to prevent such anchoring ofthe brain, or if this be impossible to mitigate the evilby making the adhesions as long as possible, so thatthere would be a little play or yield in the cable ; thebrain would not then be so suddenly checked inresponse to its varying conditions.

In endeavouring to prevent adhesions one misses thearachnoid membrane. The spider’s web would beuseful to cover a wound in the brain and to intervenebetween the cerebral surface and the dura. Veryoccasionally by diligent search a tangible portion ofthe web has been found sufficient to cover a smallsurface. If one only had in the brain coverings anapron like a modified omentum, which is of so muchservice in preventing adhesions between parietal andvisceral layers in the abdomen, it would answer thepurpose admirably. On one occasion a thin portionof omentum was used to cover such a defect betweena large nude portion of the brain and the dura. Itwas carefully prepared and easily applied, accom-modating itself to its new situation, and apparentlyserved its purpose, as this patient had no after-evidence of .adhesion. The specimen was taken froma redundant omentum, removed during a radicalcure of hernia. One of the most easily procurablesubstances is blood clot. It is bland, mild, and

accommodating, and allows sufficient time to elapsefor the healing of the wound in the brain before com-plete absorption takes place. Gold-foil is also of use,but it does not become absorbed and sometimes seemsto occasion irritation. On one occasion a portion ofgold-foil had to be removed by subsequent opera-tion as it had occasioned irritation and slightspasms.Whatever method is adopted the main point is to

secure the closure of the defect in such a manner asto refloat the organ and to restore the free flow ofcerebro-spinal fluid. Although brain anchoring doesproduce serious effects it does not affect all equallyseriously. Some who have been operated on at anearly period of the new era of brain surgery and hadthe misfortune of having a certain degree of brainanchoring, have lived many years of useful lifeone patient over 30 years. They exhibited slightdefects, such as vertigo and sickness on suddenchanges of posture, such as stooping and then risingquickly. One had in addition occasional faintness,slight unconsciousness, and convulsive movements ofthe muscles of the opposite side, which only lasted afew minutes. Games such as tennis could not beplayed except with restraint. One patient had moreserious fits and mental confusion whenever he tookinfluenza. He had to remain in bed while theattack lasted. Otherwise he lived for over 20 yearsand did good work. He is still, alive and atwork.

It has been advised to leave the large aperture inthe skull open to obviate some of the effects of cerebraladhesions, and though benefit in this direction mayensue, other more serious disadvantages obtain. Thebrain is never so happy as when at home containedwithin its own normal case. The restoration of theosseous covering by reimplantation of bone has longbeen practised by me.

TUBERCLE OF THE BRAIN.

Regarding the most frequent invaders of the brain,syphilis and tubercle, one is seldom called on to affordrelief for such lesion by operation. They are diseasesdue to organisms which in the former are always andin the latter are apt to be generalised throughout thebody. Though these diseases are amenable to medicaltreatment, yet both produce neoplasms which undergodegeneration and often caseate, and once such anecrotic neoplasm forms, medicaments circulatingthrough the blood-stream, though they may affectthe living tissue in their periphery, cannot penetrateinto the dead mass, and therefore it remains. Thoughit might be otherwise quiescent, it presents itself inthe brain as a foreign body exercising pressure on thedelicate brain structure to its detriment, producingfocal irritation or generalised symptoms according toits extent and distribution.

Tubercle is often meningeal, and in the form ofacute diffuse cerebro-spinal tuberculous leptomeningitisso impresses itself as a hopeless condition which atleast no operative measures can permanently relieve,that this picture overshadows other forms of tuberclein the brain which are apt to be placed in the samecategory. Yet tubercle is not always meningeal, andeven where it is it may be localised.

Tubercle may be deposited primarily in the brainsubstance, in the white matter, where the finer vesselsof the brain penetrate, and there cause concentricnodules which grow occasionally into very largetumour-like masses. Some of the largest solid neo-plasms in the brain are tuberculous, and from theirsize threaten life and do kill from pressure-mainly,if not alone. That is important, as in these casesthere is no meningitis or evidence of dissemination,and therefore had the bulk been removed relief andprobably cure could have resulted.When tubercle is deposited in the fine vessels of the

white matter of the brain primarily, if near thecortex, the extension of the nodule peripherally mayinvolve the meninges and set up a secondary lepto-

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meningitis if soldering of the membranes had not I,preceded and prevented the invasion of the subduralspace. This is a second source of danger from theprimary cerebral tuberculous nodule and anotherreason why such nodules would be better removedwere that possible, with a reasonable margin ofsafety and the prevention of dissemination. Whenpossible one ought to secure adhesions of the mem-branes before removal of such foci.A number of these deep-seated tuberculous neoplasms

in the brain are single or solitary ; this has been provedat the autopsy. Some of those that have been removedfrom the brain during life were apparently solitary,no others having signalled their existence, and thepatient has either lived years and has died from othercauses, or from tuberculous attacks in other parts ofthe body without signs of recurrent cerebral involve-ment. Liquefaction of such tuberculous neoplasmsoccurs and forms one of the so-called " encapsulatedabscesses " containing the characteristic white creamyemulsion-like fluid which are found in the brain.The histories of many of these point to their longduration-many years, some a lifetime. If there bean exit through the meninges and skull throughwhich they may empty themselves, it is possiblethey may do so at intervals over long periods, andwhen such an exit exists other organisms may enter.The pyogenic organisms finding in the tuberculousemulsion rich pabulum, readily invade the cavityand set up therein an acute pyogenic action. In oneinstance the pyogenic organisms invaded the peripheryof the encysted abscess, destroying the brain exten-sively in its circumference and forming a sea ofpyogenic pus, in which the encysted abscess, containingits characteristic creamy tuberculous liquid, was seenfloating intact and from which it was removed byoperation.One of the patients from whom an encysted

tuberculous so-called " abscess " of the brain wasremoved 35 years ago is still living and at work.Presumably this was a "solitary" tuberculousbrain lesion.When tuberculosis invades a localised portion of

the brain it may give rise to sensory or motor

symptoms and to epilepsy of a Jacksonian typewith the usual phenomena. Removal of theaffected portions stops the epilepsy and preventsdissemination of the tubercle.

NEOPLASMS OF THE CEREBELLUM.

Tuberculosis occurring under the tentorium cerebelli,where it forms formidable neoplasms, presents quiteanother problem. Here the pressure of the growthgradually persists until it affects not only the vitalcentres-the respiratory and cardiac-but is far-reaching in its consequences. The whole cerebrumis benumbed from the distension of the ventricleswith cerebra-spinal fluid and the production of oedemaof the brain. The eyesight is involved by the induc-tion of optic neuritis and nerve atrophy which destroysthe sight. In the later stages the patient presents adeplorable aspectthe earthy pallor of the face,the complete atony, scarcely able to move a limb, thedisturbance of equilibrium so marked that while lyingflat in bed the bed heaves, the furniture, the nurses,and the ward gyrating like a ship in a tumultuoussea. As the patient lies groaning with pain, headache,vomiting, scarcely able to breathe, with slow pulse,he completes a picture of agonising misery whichcompels relief. He is virtually being crushed todeath.

The free removal of the osseous envelope aids, thefull opening of the dura affords much and instantaneousrelief, which is increased by inducing the neoplasmto escape from the cerebellar contents. To this endthe opening may be extended over the whole cerebellarfossa, the strong girders being left intact-and even,if need be, the opening may extend into the foramenmagnum at its posterior aspects. This gives speedyand effective relief to pressure on the medulla, andthe cut edges of the foramen are guarded by that

portion of the cerebellum which normally dips throughthe foramen magnum into the upper portion of thespinal canal, and which does so to a much greaterextent when the cerebellum is under severe pressurefrom abscess or neoplasms. When a patient after anoperation of this kind has recovered from the sleepof exhaustion induced by his long suffering and isable to appreciate that he is actually free from histerrible ordeal with all its pain, vertigo, and sickness,the look of relief-the smile that lights his face-isworth much !

It is, however, at the very early period of invasionof the cerebellum that the diagnosis is of so muchimportance, as the disease could then be removed bya smaller operative procedure, and the prognosiswould be much more hopeful; and even were theoperation unsuccessful in affording permanent relief,it would prevent the patient from undergoing thecrushing agony. At the early period, however, thediagnosis of tubercle in the cerebellum is difficult,and sometimes months elapse-sometimes manymonths-before symptoms occur sufficiently obtrusiveto arrest attention. As these neoplasms formfrequently in children, some of school age, their earlyindications are insidious and are often misconstrued.They occasionally occur in bright children who havedone well in school, who after a time cannot maintaintheir place, appear careless and negligent, and aresometimes treated on this assumption. Later theybecome listless, dull, and apathetic, and no longerengage in the vigorous games they previously enjoyed.The tumour is in the cerebellum, yet it is the cerebrumthat affords these early symptoms. The cerebrumhas become affected by the distension of the ventriclesand involvement of the optic tract. The differentialpercussion note reveals the presence of the distendedventricles.

In one such case-one of many seen-the wiseteacher, instead of punishing the boy, sent him to thefather, relating the change in his school behaviour andhis seeming loss of interest in his work. The parentscould not find anything the matter, but brought theboy to me for examination, as they said if there werenothing wrong with him mentally or physically theywould know how to act. Much to his astonishment,the father was told that the boy was suffering from aform of tumour, probably situated in the posteriorpart of the brain, which would eventually declare itselfin certain directions unless it were relieved. Althoughthe boy thought he could see quite well, yet the visualacuteness had diminished ; there was slight turges-cence of the optic discs. Though he had no ataxia atthe beginning of the examination, it became distinctafter his pupils had been dilated with homatropine,and the accommodation was suspended. He wasaware of not being so sure of his movements in thedark as he used to be. The percussion note over thehead-the pterion-revealed the presence of con-

siderable fluid in the ventricles, and that, alongwith other phenomena, explained the cerebralsymptoms.

Abscess of the cerebellum when small and limited iseasily removed, the difficulties lying more in the earlydiagnosis of the location of the abscess than in theremoval of it once the diagnosis has been made. Whendue to extension backward of pyogenic processes fromthe middle ear the location of the infected tract in thevicinity of the knee of the sigmoid sinus is so constantthat it aids in determination of the point of access tothe pus.

In large abscess of the cerebellum, however, pressureresults ensue, though the pyogenic process being muchmore acute the pressure effects on the adjacentstructures are intensified by the inflammatory actionwith its attendant cedema-hence the respiratorydifficulties threaten life occasionally with tragicsuddenness. Though usually there are premonitorysigns of respiratory involvement sufficiently in advanceto afford time to rectify the condition by operation, yetsudden access of oedema may precipitate a fatal issue.In four instances of large cerebellar abscess, so quicklyhad the respiratory difficulties ensued that operation

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Jhad to be performed by me while artificial respiration- was being carried on. In one of these a patient whohad become unconscious before admission to the

hospital had only reached the ward when his respira-- tion ceased. Artificial respiration was commenced at.once and continued until operation could be performed.’The whole operation had to be conducted simul-- taneously with the performance of artificial respiration,and as the respiration was paramount the positionof the patient had. to be arranged to accommodate it.consequently the operation had to be performed frombelow. No anaesthetic was given as the patient wasunconscious. On reaching the abscess two ounces ofpus escaped, and shortly after the first spasmodicrespiratory gasp occurred, which was repeated, and:gradually the automatic respiratory movement wasre-established-much to the relief of the staff. Whilethe house surgeon and nurses, who had just beenrelieved from their arduous and fatiguing work ofprolonged artificial respiration were still on the alertwith drawn faces and strained anxious expressions,watching the man whom they had such great difficultyin rescuing from the brink, the patient recoveredconsciousness, and seeing his strange surroundingsand the anxious theatre staff exclaimed, " What isall this damned fuss about ? " It had a startlingeffect on the astonished staff-the unseeing eyes,which had been open all the time, suddenly saw IThe removal of the pressure and the inflammatoryoedema from the respiratory centre situated on theposterior part of the rhomboid fossa had relieved the- cardiac and respiratory centres, and the consciousnesswas restored by the relief of the ventricular pressureon the brain. The patient made a complete_ andrapid recovery.

CONCLUSION.

Doubtless the dome of thought ought to be leftinviolate. It was built that way, but occasionally rudetraumatisms and peccant matter invade the sanctuaryand have to be followed and removed. It has beensaid that the brain stands much handling. Possibly !One cannot open the skull as a box and rummageuntil the object is found. The accuracy of diagnosis is-of paramount importance. Many errors of diagnosismay be rectified by exploratory incisions in theabdomen. This is much more difficult in thebrain.The more one sees of the intricate, delicate structure

the greater the reverence one entertains for it, and theless one. is inclined to disturb its arrangements or tointerfere with its function. When it does require to betouched it ought to be with the greatest gentleness, byan acutely sensitive finger, carefully trained andguided by the blessed gift of memory of tactile sensa-tions, to which each new impression may be quicklyrelegated, grouped, and correlated in ordered sequence.When neoplasms have to be removed therefrom theendeavour is to do so with minimal disturbance ofbrain tissue. It is for this reason that the impetusreceived from the intrinsic cerebral pulsations are

utilised to aid the extrusion of blood clot or neoplasmthrough the incision in the brain once adhesions havebeen loosened, as, though this method takes moretime, it does less damage.

Cerebral surgery has been the means of adding to andconfirming the knowledge of brain function in man,especially of the regions of the cerebral cortex otherthan motor, to which experimentation on the loweranimals can with difficulty contribute. It has laidbare physical lesions in the cerebrum producingmental aberration, and, by the removal’ of the lesionand the restoration of. cerebral function, has therebyproved that the presence of the lesion was the causeof the perversion of function. In a sense some ofthese lesions produced in the brain of man may beregarded as experiments carried out by nature with adelicacy, accuracy, and refinement which no humanexperimenter could equal. Surgery of the brain hasits limits, but these have not been reached. There isstill a large field for careful observation and accuratework.

An AddressON THE RELATIVE RÔLES OF

COMPULSION AND EDUCATION INPUBLIC HEALTH WORK.

Presidential Address delivered on July 25th to Section I.of the Congress of the Royal Sanitary Institute at

Bournemouth.

By SIR ARTHUR NEWSHOLME, K.C.B.,M.D., F.R.C.P.LOND.

THE general problem of the relative spheres ofcompulsion and education has important bearing onevery branch of work for the amelioration of humanwelfare. The social history of the nineteenth centuryconsists very largely in a steady extension of theenforcement of compulsory duties and restrictions invarious aspects of communal life. Each of theseduties and limitations has been made obligatory byParliament as the result of public agitation, directedto the support of the weak against the strong, thedefence of the exploited against the exploiter, of thepurchaser against the vendor, of children againstnegligent parents, or of the careful against the carelessparent. I need only mention Poor-law enactments,enforcing contributions from all in support of thedestitute, the various factory and mining Acts pro-viding against accident and overwork, especially ofwomen and children, and the compulsory provisionsrelating to infectious diseases, to sanitary defects, tofood frauds, and so on.Ignorance being a communal peril, compulsory

elementary education has been universally enforced.The parent is no longer free absolutely to controlthe education of his child ; and taxpayers and rate-payers are constrained to pay for the education ofother people’s children. The nexus of restriction andregulation has extended in all directions ; and thediminution of personal liberty thus produced is notonly justified but necessitated by communal life.Each restriction has, in fact, been called into beingto defend the liberty of the weak against oppressionand injury, to diminish the inevitable and unnecessaryburdens on the common purse which are associatedwith unrestrained license, and to aid normal progressin health and civilisation.

In the prevention of disease compulsory measuresbulk largely, their success depending almost entirelyon the extent to which they carry with them theconvictions of the vast majority of the population.They may thus be said to be effective inversely to theextent to which compulsion is needed. Compulsoryvaccination against smallpox is the most strikinginstance of this general rule. This almost uniquesafeguard against infection is, in substance, onlyenforceable by consent, though this consent maysometimes be unwilling ; and in practice compulsionis limited by exemption on the ground of conscientiousobjection. The segregation of cases of acute infectiousdisease now causes no difficulty. It has becomerealised that compulsion for this purpose confers aprivilege, and it is when this is realised that a

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compulsory measure becomes universally effective.In the above cases the necessary measures, as, for

instance, for enforcing segregation, are strictly limitedin time, and for this reason, among others, they areenforceable. But when dealing with chronic infectivediseases like tuberculosis and syphilis, we enter intoanother sphere, in which the practicability of anyform of compulsion is necessarily limited by the logicof facts. These cases therefore deserve specialstudy.

Compulsion in Tuberculosis.In tuberculosis the necessity for controlling infec-

tivity by compulsory means arises chiefly when apatient, for instance a vagrant, continues to indulgein indiscriminate expectoration. in circumstances of