938

THE LANCET.

LONDON: SATURDAY, APRIL 22, 1893.

CEREBRAL SURGERY

IN an account of the diagnosis and operative treatment ofthree cases of brain tumour recently published in the AmericanJournal of the Medical S’ciences Drs. McBuRNEY and ALLENSTARR have furnished an interesting contribution to this

subject. The cases are perhaps all the more important fromthe fact that they were not quite satisfactory in their result,and we would emphasise the plea which is urged in thisarticle that all results in this branch of medical science,even those which are unfavourable, should be recorded,in order that it may be more easy to properly estimate the

dangers of operation and the difficulties of correct localisa-

tion. In this paper the various steps of the operation itselfand the best methods of carrying them out are considered.

Very careful antiseptic precautions are of course insisted

upon. The head should be completely shaved and the scalpthoroughly cieansed. The scalp incision should be free, andthe usual horseshoe shape is recommended. The bleedingfrom this is apt to be considerable, and the method

advised for controlling it is to compress the entire wound

with dry gauze, lifting the gauze at point after point and

immediately securing the vessels with pressure forceps. For

entering the skull WAGNER’S method is recommended. This

C insists in cutting through the skull with a chisel in

the line of the scalp incision before the skin flap is re-

flected, afterwards reflecting the flap consisting of bone

and scalp united. Haemorrhage from the bone may betroublesome, and it may be necessary to plug some of

the vessels with gauze or sponge. The dura mater is then

incised and reflected, and the tumour dealt with by eithertotal or partial removal. To control bleeding it may be

necessary to pack the cavity with gauze. In operating forcerebellar tumour trephining is to be preferred, the openingbeing afterwards enlarged with forceps.The first case narrated is that of a man aged forty, who

in December, 1890, had a fit commencing with giddiness anda feeling of distress, and followed by forcible turning of thehead to the right. Consciousness was lost, and when it

was recovered there was evidence of weakness of the whole

of the right side and of some difficulty in talking. Subse-

quently the patient su-Eered from occasional attacks of

nausea and impairment of vision. When first seen he hadsevere and constant frontal headache, especially on the left

side, with tenderness on percussion. There was no vertigo,but optic neuritis existed in both eyes, and vision was

more defective in the left eye. Dulness and slowness

to appreciate the meaning of questions were noticed ;there was also slight weakness on the right side, affect-

ing the face, arm and leg, but, although numbness was

complained of, there was no anaesthesia. Anti-syphilitictreatment brought no amelioration of the symptoms, and sixinonths after the man was first seen the condition remained

unaltered, but the symptoms were more marked ; the right-

sided weakness was greater and the mental condition more

sluggish. The tumour was believed to occupy the posteriorpart of the second frontal convolution and at the operation itwas found in that region. It was, however, very large,measuring two and a half by one and three-quarter inches.It was encapsuled and was shelled out with comparativeease and completeness. The loss of blood and shock,however, led to the patient’s death eight hours after the

operation.The case of the next patient was one in which the

prominent symptoms were severe headache, frontal and

occipital, vertigo, tinnitus aurium and numbness on the leftside of the face and in the mouth, with drowsine3s and

dulness. There was double optic neuritis, together withdimness of vision, which soon culminated in blindness. The

patient also became deaf in the left ear. Staggering, with

tendency to fall to the right side, also developed, with weak-ness of the right hand and exaggeration of the right knee-

jerk. The diagnosis was made of the existence of a tumouron the left side of the cerebellum, but an exploratory opera-tion failed to substantiate it, although the great bulging ofthe cerebellum made it evident that a neoplasm was presentwithin the cranium. Recovery from the effects of the

operation was satisfactory, but eventually the patient rapidlypassed into coma and died. After death a tumour was found

lying on the base and compressing the left cerebellar hemi-sphere and also the left side of the pons. The fifth nerve on

this side was flattened, and the auditory and facial nerveswere also pressed upon. The position of the tumour of coursewas such as to render it inaccessible.

The third case was that of a child aged seven who hadsuffered for a year from severe headache, chiefly frontal,impaired vision going on to blindness, the result of opticneuritis, and staggering gait, which was not, however,marked in any particular direction. It was thought that thetumour was situated in the vermiform process of the cere-

bellum and at the operation puncture with an aspiratingneedle resulted in the evacuation of two drachms of clear

serous fluid. The patient died six days after the operation,as a result apparently of a severe attack of vomiting, andat the necropsy a large glio-sarcoma, two and a half inches

long, was found to occupy the vermiform lobe of the cere-bellum and to extend into both hemispheres, especially the

right.The last two cases are particularly interesting with

reference alike to the diagnosis and the technique of the

operation. These points are fully discussed in the article

under consideration, and a list of the cases in which

operation has been attempted in cerebellar cases is added.Including the two mentioned, there are now records of

thirteen operations of this kind. In six of these the tumour

was not found at the operation and the patients died ; in onecase the tumour was not found, but the patient lived; in twothe tumour was removed, but the patients succumbed; intwo it was found, but could not be removed and the patientsdied ; in one case it was found but not removed, and thepatient lived ; and in only one case has it been successfullyremoved. The percentage of deaths after operation in

cases of cerebellar tumour is found to be so far 77 per cent. as

compared with 51 per cent. in cerebral cases. Although suchresults may be disappointing they need not be discouraging,

939SHOULD PHTHISICAL PATIENTS BE SENT TO AUSTRALIA ?

and such -cases as those recorded in this paper are most

valuable for their suggestiveness, in regard both to diagnosisand treatment.

WE receive from time to time communications from

medical men, clergymen and others in Australia protestingagainst the practice of sending advanced cases of phthisisto that country, and asking us to use our influence to

prevent what they regard as a great error, entailing severe

suffering and disappointment upon an unfortunate class ofinvalids and often involving discredit to the medical pro-fession. Our correspondents draw distressing pictures of

patients far advanced in consumption who land in a

strange country friendless and almost penniless, cherish-

ing a most exaggerated idea of what the climate can do

for them, driven by the stress of circumstances to enter

laborious and unsuitable occupations and too frequentlysinking rapidly into the grave, the only result of their longjourney and numerous hardships being, as one correspondentexpresses it, that " the bitterness of exile is added to the

bitterness of death." We have no doubt whatever that

these pictures are in the main correct and that the complaintof our Australian brethren is well worthy of the most seriousattention of the public and the medical profession at

home. The idea (on the whole a correct one) that

"Australia is a good climate for consumption " havingtaken hold of the public mind, the most erroneous and

sweeping conclusions have been drawn from it. It is for-

gotten that Australia is a vast country, almost as large asEurope ; that it includes the widest diversities of climate,that immense regions are undeveloped and o:Eer no facilitiesor comforts to the invalid. It is also forgotten that thereare types of even early pulmonary phthisis for which

Australia is quite unsuitable, and lastly, that in the greatmajority of very advanced cases of the disease no climatein the world can effect a cure. When dealing with

advanced and incurable cases physicians have a hard

and thankless task to perform. Such patients are eagerto try a new climate. Having often trifled with their maladywhen in its earlier stages and ignored significant warnings’and timely advice, they are now quite alive to their dangerand will go anywhere or do anything if the least hope ofcure is held out. We will not undertake to define pre-

cisely what constitutes an "advanced and incurable ’’

case of phthisis, but physicians of experience can do

this for themselves. Our point is that such cases should

hardly ever be sent on distant journeys and that in

particular Australia is most unsuitable for them. We

would urge medical men to be quite frank with such

patients, to tell them that palliation and not cure is all thatremains to be hoped for, and to throw upon them the whole

responsibility of undertaking distant journeys where the

prospects of benefit are so slight and the various risks toadvanced cases of phthisis so grave. Such advice is painfulto give as it is painful to receive, but frankness is in this casea positive duty and the only real kindness. Patients of this

class should be advised either to remain amongst the comfortsand affections of home or to select some mild and sheltered

resort within easy access of their friends.

The hardship and uselessness of sending advanced casesof phthisis to Australia are much aggravated by the fact ’ ’

that the great bulk of -such patients are slenderly providedwith money, and are soon driven to undertake unsuitable

occupations. The physician, properly enough, talks to such

patients of the importance of an easy out-of-door life, of

light and congenial work, of abundance of sunshine and freshair, but unhappily the large majority of cases have only a verylimited choice in the matter. Being in most cases city-bredthey linger about the great towns, knowing little about theconditions of life on the large up-country "stations, "andshrinking from what is unfamiliar and repellant. They driftinto warehouses and factories, and soon find that they have

gained nothing by their change of country and that thecourse of their disease is steadily downwards. It is easy to

define what should be the course of conduct of such patientslanding in Australia, but the difficulty is that the requisite con-ditions are only exceptionally attainable. The sufferer from

phthisis who selects Australia should be warned that an in-doorcity life means almost certain death to him. He should be

advised to select some one of the regions of the interiorwhich have an acknowledged reputation in the treatment

of phthisis. In the selection of the particular spot heshould be guided by the recommendation of the best medicalopinion in Melbourne, Sydney, or Adelaide. He should

undertake, at the most, only some light out-of-door workuntil the course of his disease and his prospects of cureseem clear. If, through straitened means or other causes,these conditions are unattainable, it becomes a most serious

question for physicians at home whether they should assentat all to their cases resorting to Australia. Climate is still

our most potent aid in fighting phthisis, but it is easy to

exaggerate the influence of climate quâ climate. The reallyimportant point is that certain climates favour the return toa healthful mode of life and the practice of a sound hygiene,and on these two points everything turns.Much of what we have written regarding Australia applies

equally, ntutatis mutandis, to other resorts, but our attentionhas been specially drawn to our great southern dependencyby complaints to which we could not turn a deaf ear.

We earnestly commend them to the most serious attentionof all concerned in this subject. We must not conclude

without remarking that our correspondents, whilst deploringthe disastrous consequences of sending advanced cases of

phthisis to Australia, are eloquent about the great benefitswhich the climate often confers upon early and incipient cases.We believe this opinion also to be well founded and we muststrive to avoid anything like panic or one-sidedness on thissubject. Our decided belief is that for certain cases of earlyphthisis, especially in lymphatic or phlegmatic subjectswho are likely to benefit by the stimulation of the climate,certain parts of Australia-e.g., the Riverina of New SouthWales and the Darling Downs of Queensland-offer greatadvantages. But we must carefully discriminate betweenour cases, and we quite agree with our correspondents thatthe time has come for checking the wholesale deportation of

phthisical patients of all types and in all stages under theillusory idea that the climate of Australia is a universal

panacea.

INTE-REST in the medical aid question is shown in the various

meetings of Friendly Societies and their medical associations.The Friendly Societies’ Medical Alliance held their four-

Q 3

940 THE FRIENDLY SOCIETIES AND THE MEDICAL AID QUESTION.

teenth annual conference on Easter Monday at Gloucester.The chairman, Mr. JAMES ALLEN, President of the Gloucester

Association, said the subject of most pressing importance wasthe relationship existing between the association and themembers of the medical profession, together with the controlwhich it is proposed should be exercised by the GeneralMedical Council over such associations. He remarked rightlythat the privileges enjoyed by the medical profession weregranted not for personal benefit so much as for the public goodand at the same time said that the associations were desirous

of meeting all reasonable suggestions from the members ofthe profession. The question of medical officers’ agreementswith associations gave rise to much discusssion, manyinstitutions having experienced considerable disadvan-

tage through the want of an agreement which would

be acceptable to medical men. The representatives who hadbeen called by the committee of the General Medical Councilwhich was investigating the subject gave reports as to

the questions which were asked and which seemed to requireattention. They concerned chiefly the admission of "publicmembers," alleged touting or canvassing, the admission of

registered societies, the employment of unqualified men, thesuggested imposition of a wage limit and the disposal of

surplus savings or so-called profits. It was resolved that the

imposition of a wage limit was impracticable and undesirable.As regards the admission of unregistered societies it was

agreed that this could only be satisfactorily dealt with bythe local association affected. Thanks were voted to Mr.

LABOUCHERE, M.P., and Mr. T. ROBINSON, M.P., for raisingthe question in the House of Commons and for their interest inother ways. The best interests of the Associations in this

matter cannot conflict with those of the medical professionand it may be hoped that the Associations will cooperatewith the General Medical Council in their adjustment.

Dr. HUTTON, medical officer of the Scarborough MedicalAid Association, speaking at a recent meeting of that body,said he thought the opponents of these associations failed torealise the purpose for which the associations were established.

They were not for the upper classes, but for those who wereunable to pay the ordinary fees of the practitioner, and wereintended to promote thrift amongst those who would other-wise require the aid of the parish doctor a good deal morefrequently. Dr. HUTTON fails to realise that the chargeagainst these associations is that they do not restrict their

operations to the classes which he enumerates. There would

be little difference of opinion if this were so. Dr. HUTTON

thought that if the conclusion of the General Medical Councilshould be adverse to the associations it would be a question forthe consideration of Parliament. This suggestion is not onethat should proceed from a medical man. Parliament cannot

look at all the bearings of this question as the GeneralMedical Council can, and members of the profession shouldshow confidence in a body appointed by Parliament to repre-sent the profession and its best interests.

ST. ANDREWS MEDICAL DEGREES FOR WOMEN.- The teachers of the Medical College for Women, Edinburgh, have been recognised as "lecturers specially appointed " under the recent ordinance of the Scottish Universities Com- 1

missioners. The Medical College for Women, Edinburgh, claims, therefore, to be just as much a part of St. Andrews ’University as is the Edinburgh School of Medicine for Women.

Annotations." Ne quid nimls."

THE NATIONAL LEPROSY FUND.

WE understand that the date of the simultaneous publica-tion in England and in India of the report of the commis-sioners has been fixed for May 1st. The report will be

prefaced by a memorandum thereon which has been preparedby the executive committee of the fund. We think itdesirable to make this statement in view of certain prematureand unauthorised announcements which have appeared fromtime to time in the public press. It is greatly to be regrettedthat the ’’ private and confidential" nature of the documentsconnected with the report has not been respected. It is onlyright to explain to our readers that our reason for not

furnishing them with earlier information on the subject hasbeen due to the fact that we did not feel justified in dealingwith a matter which was not considered by the responsibleauthorities to be ready for publication.

THE WATER-SUPPLY OF CHICAGO.

WE have received from the Secretary of the Royal Com-mission for the British Department of the Chicago .Exhibitionthe following message by telegram, dated from Chicago, the13th inst., but which reached us too late for insertion in THELANCET of last week :-

"To LANCET, Strand, London."Have been requested by Waukesha Hygeia Company to

correct error in your recent report. There will be charge forthe pure drinking water as furnished by the Waukesha HygeiaMineral Springs Company from their springs in Waukeshacounty, Wisconsin. This water will be brought to Expositiongrounds, distance 100 miles, through six-inch steel pipes and, toavoid using ice, cooled by refrigerating process and dispensed toconsumers from 250 booths at temperature of 380 at 1 cent aglass, but to State buildings, exhibitors and concessionistswill be delivered at 5 cents a gallon meter measurement,meters, faucets and connexions being furnished free.

" SIR HENRY WOOD,Secretary, British Commission."

We give the message exactly as received, because it is notclear to us what is the correction which we are asked to

make ; indeed, reading in the light of Sir Henry Wood’stelegram the references to the Waukesha Hygeia water

contained in the report of our Special Commission

they appear to us to be perfectly accurate, and we

imagine that additional information and not correctionis what the present communication is intended to supply.In the course of our inquiries a considerable amount ofinformation concerning the Waukesha water supply wasbrought together, of which only the main result could beembodied in the published report, as the exigencies of ourspace compelled us to compress into the smallest possiblecompass the results to which our inquiry led. It may, how-

ever, help to elucidate the telegraphic message which we havegiven above-somewhat obscure as it is, after the fashion of

telegrams through excessive condensation-if we state some-what more fully what we understand to be the arrangementsmade as to the supply of Hygeia water in Chicago during theWorld’s Fair. The village of Waukesha is situated on thewestern shore of Lake Michigan, about 104 miles fromChicago and near the town of Milwaukee. It has anatural elevation of about 200ft. above Chicago and possessesseveral springs of water which enjoy a considerable reputa-tion throughout the neighbourhood of Lake Michigan-areputation which our analysis has shown to be well founded.The Hygeia Spring and, we believe, another in the same

locality, are owned by the Waukesha Hygeia Mineral Spring