- Email: [email protected]
INTRACRANIAL TUMOURS
192 demand on the part of the public for painless labour is becoming more and more vocal and something will have to be done to meet it. The opposition of certain medical men to the use of drugs by midwives is not based on considerations of professional monopoly, but on a real fear of accident due to ignorance. The answer may be that such accidents are among the risks that the public must run; and that while a midwife, as district nurse, is allowed or even encouraged to drive a car-surely a potentially dangerous machine, of the mechanism of which she may know nothing-it is illogical to refuse her the right to use dangerous drugs under controlled conditions.
INTRACRANIAL TUMOURS SINCE the pioneer work of McEwFx and HORSLEY steady progress in intracranial surgery has taken -
of the true post-operative deaths. Some information of their number and immediate cause would therefore be an advantage. Accepting this inclusive definition of postoperative fatalities, a comparison of the figures presenting’the four major groups of tumours suggests that most improvement has taken: place with tumours situated outside the cerebral substance. Acoustic tumours show a decline in operative mortality from 25 per cent. prior to 1912, to 4-4 per cent. for the period 1928-31. The rate for meningiomas has fallen from 21 per cent. to 7-7; for pituitary adenomas, from 13-5 per cent. to 5-7 ; for gliomas, from 30-9 to 11-0 per cent. Prof. GUSHING does not accept the view that these improved results are due to earlier diagnoses ; as a whole he thinks that the operations each year become increasingly critical and difficult. The principal steps that have made it possible not only to attack these more formidable but actually to lower the operative mortality, he enumerates as: (1) the generally accepted methods of decompression to relieve tension; (2) such irreproachable wound healingthat
problems
In 1929, in a statistical study, Dr. Lo’msE ElBENnABDT gave evidence of this progress by publishing some encouraging figures of the operative mortality in a series of intracranial tumoursat the Johns Hopkins and Peter Brigham Hospitals. secondary infections are practically unknown; Between 1922 and 1929 she reported a progressive (3) the separate closure of the galea by buried tendency to improvement, notwithstanding the fine black silk sutures, which has made the once I dreaded fungus cerebri nearly forgotten ; (4) in fact that each year more difficult and more operations were being performed than were place of ether inhalation, the introduction by previously undertaken. In a recent paper2 Prof. DE MARTEL of local anaesthesia, now supplemented HARVEY CUSHING gives a further review of these when necessary by the rectal administration of figures, and continues the sequence to the middle tribromethanol; (5) the more precise tumour of 1931. These data are reproduced in themain localisation which in obscure cases Dandy’s in his new monograph on the subject.3 The later ventriculography permits us to make ; (6) the figures reveal a still further reduction in mortality. use of a motor-driven suction apparatus as an In the year 1922-23 the operative mortality indispensable adjunct to every operation; and for all verified tumours, including new and old (7) the successive improvements in methods of cases, is reported as 16’9 per cent., and this figure hsemostasis, which, since 1927, have been most has fallen to 11-0 per cent. in 1926-27 and again advantageously supplemented by the introduction to 6’8 per cent. in 1930-31. The fall has not been of electro-surgical devices. To which must be entirely steady, and it is too early to say whether added the institution of a more careful régime the very low level reached in 1930-31 is likely to and observation during the immediate postbe maintained. That this low rate is not due operative stages. to a lax definition of post-operative death seems,i This work should be a source of encouragement rather the standard to all interested in brain surgery, and stands as however, quite certain; tends to be too severe. For every death in hospital proof of the value of a highly organised technique (the average hospital sojourn in the last 100 which admittedly takes up much time and demands eases was 39 days), following an operation, skilled team-work. The statistics hitherto preno- matter how long the interval or what the sented by no means exhaust the interest of the cause, is recorded as a post-operative fatality. material. We would welcome a further survey So that, for instance, if a patient gets out of in which the survival period following operation bed at night to go to the lavatory, trips on an is considered ’and the degree of benefit to the obstruction, and dies in a few hours from a fracture patient is judged by his ability to resume his place of the base of the skull, the death is automatically in society. recorded as a post-operative death. Similarly recorded is the death of a patient who has a fatal infection during an epidemic of influenzal pneu- ANTISYPHILITIC TREATMENT AND THE monia. This severe standard may have its drawEXPECTATION OF LIFE backs as well as its advantages. If the deaths ANYONE who looks into the history of the use subsidiary to operation, as instanced above, ’ of drugs in the treatment of disease will soon find form any large proportion of the total, their that most of them, at one time or another, have reduction or increase may mask the movement been employed in doses likely to do serious damage to the patient. 1 Arch. of Surg., April, 1929, xviii., 1927. Mercury is a notable example, 2 Arch. Neur. and Psychiatry, June, 1932, p. 1273. severe stomatitis with gangrene of the gums and 3 Intracranial Tumours. London : Baillière, Tindall and Cox. necrosis of the jaw, skin eruptions, nephritis, even 1932. Pp. 150. 26s. 6d.
place.
radical
INTRACRANIAL TUMOURS SINCE the pioneer work of McEwFx and HORSLEY steady progress in intracranial surgery has taken -
of the true post-operative deaths. Some information of their number and immediate cause would therefore be an advantage. Accepting this inclusive definition of postoperative fatalities, a comparison of the figures presenting’the four major groups of tumours suggests that most improvement has taken: place with tumours situated outside the cerebral substance. Acoustic tumours show a decline in operative mortality from 25 per cent. prior to 1912, to 4-4 per cent. for the period 1928-31. The rate for meningiomas has fallen from 21 per cent. to 7-7; for pituitary adenomas, from 13-5 per cent. to 5-7 ; for gliomas, from 30-9 to 11-0 per cent. Prof. GUSHING does not accept the view that these improved results are due to earlier diagnoses ; as a whole he thinks that the operations each year become increasingly critical and difficult. The principal steps that have made it possible not only to attack these more formidable but actually to lower the operative mortality, he enumerates as: (1) the generally accepted methods of decompression to relieve tension; (2) such irreproachable wound healingthat
problems
In 1929, in a statistical study, Dr. Lo’msE ElBENnABDT gave evidence of this progress by publishing some encouraging figures of the operative mortality in a series of intracranial tumoursat the Johns Hopkins and Peter Brigham Hospitals. secondary infections are practically unknown; Between 1922 and 1929 she reported a progressive (3) the separate closure of the galea by buried tendency to improvement, notwithstanding the fine black silk sutures, which has made the once I dreaded fungus cerebri nearly forgotten ; (4) in fact that each year more difficult and more operations were being performed than were place of ether inhalation, the introduction by previously undertaken. In a recent paper2 Prof. DE MARTEL of local anaesthesia, now supplemented HARVEY CUSHING gives a further review of these when necessary by the rectal administration of figures, and continues the sequence to the middle tribromethanol; (5) the more precise tumour of 1931. These data are reproduced in themain localisation which in obscure cases Dandy’s in his new monograph on the subject.3 The later ventriculography permits us to make ; (6) the figures reveal a still further reduction in mortality. use of a motor-driven suction apparatus as an In the year 1922-23 the operative mortality indispensable adjunct to every operation; and for all verified tumours, including new and old (7) the successive improvements in methods of cases, is reported as 16’9 per cent., and this figure hsemostasis, which, since 1927, have been most has fallen to 11-0 per cent. in 1926-27 and again advantageously supplemented by the introduction to 6’8 per cent. in 1930-31. The fall has not been of electro-surgical devices. To which must be entirely steady, and it is too early to say whether added the institution of a more careful régime the very low level reached in 1930-31 is likely to and observation during the immediate postbe maintained. That this low rate is not due operative stages. to a lax definition of post-operative death seems,i This work should be a source of encouragement rather the standard to all interested in brain surgery, and stands as however, quite certain; tends to be too severe. For every death in hospital proof of the value of a highly organised technique (the average hospital sojourn in the last 100 which admittedly takes up much time and demands eases was 39 days), following an operation, skilled team-work. The statistics hitherto preno- matter how long the interval or what the sented by no means exhaust the interest of the cause, is recorded as a post-operative fatality. material. We would welcome a further survey So that, for instance, if a patient gets out of in which the survival period following operation bed at night to go to the lavatory, trips on an is considered ’and the degree of benefit to the obstruction, and dies in a few hours from a fracture patient is judged by his ability to resume his place of the base of the skull, the death is automatically in society. recorded as a post-operative death. Similarly recorded is the death of a patient who has a fatal infection during an epidemic of influenzal pneu- ANTISYPHILITIC TREATMENT AND THE monia. This severe standard may have its drawEXPECTATION OF LIFE backs as well as its advantages. If the deaths ANYONE who looks into the history of the use subsidiary to operation, as instanced above, ’ of drugs in the treatment of disease will soon find form any large proportion of the total, their that most of them, at one time or another, have reduction or increase may mask the movement been employed in doses likely to do serious damage to the patient. 1 Arch. of Surg., April, 1929, xviii., 1927. Mercury is a notable example, 2 Arch. Neur. and Psychiatry, June, 1932, p. 1273. severe stomatitis with gangrene of the gums and 3 Intracranial Tumours. London : Baillière, Tindall and Cox. necrosis of the jaw, skin eruptions, nephritis, even 1932. Pp. 150. 26s. 6d.
place.
radical