For operation, the surgeon is more apt to choose the surgical indications, while the neurologist prefers the symptomatic indication.
Operation is indicated in all cases of (Jacksonian) epilepsy; in all cases where the epilepsy, be it general or partial, has followed and is apparently caused by a depression of the skull, the result of a traumatism. In many cases where a severe head-injury—even though there be external evidence—has been followed by a partial epilepsy, and where the "signal-symptom" indicates a defi nite area in the brain. A. J. McCosh (Amer. Jour. Med. Sci., May, '98).
Statistics prove that operative meas ures should only be employed in trau matic cases in which there are localizing features. J. C. Oliver (Canada Lancet, July, '98).
Results of operations for epilepsy in 160 cases collected from literature and 4 personal ones. In 31.1 per cent. no results were obtained. In 20.1 per cent. the time of observation after the opera tion was too short to warrant judgment. Fifteen and one-fifth per cent. were im proved, and the majority of these perma nently so. The cured cases reached 14.6 per cent.,—i.e.. 24 cases,—of which 3 were observed for over three years, 13 over one year, and S over half a year. In short, 293 per cent. of cases were bene fited by the operation, while 70.2 per cent. were not. The cases of traumatic Jacksonian epilepsy show a larger per centage of favorable results than ob served in general epilepsy, while the death-rate after operation is much greater in the general epilepsy than in the cases in which the seizures are local ized. Matthiolius (Deutsche Zeits. f. Chic., June, '99).
Idiopathic epileptics with typical grand-mal seizures should never be tre phined. Subjects of this kind, in whom seizures a-re of the Jacksonian type, should be trephined only when infantile cerebral palsies can be excluded, and when the family and personal degener acy is at a minimum; if operation is determined upon in such cases, a very thorough removal of the epileptogenic area should be made; even then but a fraction of 1 per cent. recover from their epilepsy.
Traumatic epileptics may be trephined when the injury is definitely proved and stands in direct causal relation and has existed not more than two years. The prognosis will then largely rest upon the degree of the neurotic predisposi tion present. The earlier trephining is resorted to after convulsions begin, the better the prognosis. L. Pierce Clark (Med. Record, Jan. 12, 1901).
Epilepsy is the last disease to which surgical measures should be indiscrimi nately applied. In judiciously selected
cases, radical operations of various kinds, suited to the individual needs of each ease, have given far more satis factory results than has non-operative or medicinal treatment. Every case must be studied as a problem by itself. The only general laws applying are those regarding the removal of peripheral or local foci of irritation and the destruc tion of paths of conduction which con vey disturbing impulses. In each case we must decide as to the operative method by which we may best meet these indications. In order to attain the best results patients should be seen early. It would be well to have every epileptic carefully studied by an accom plished surgeon, who should review the case with a view to the possibility of surgical intervention. 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, of elimination, etc. Long-continued atten tion to these matters is the price of eventual success.
In those cases characterized by blanching of the face, when the seizures can be warded off or mitigated by the prompt use of amyl nitrite, we may well consider the propriety of an exsec tion of the cervical sympathetic. Ros well Park (Amer. Medicine, Nov. 22. 1902).
To the above class of cases may be added that small number included in the etiological variety known as re flex epilepsies. In organic epilepsies the results of surgical treatment de pend upon the accuracy and prompt ness of diagnosis, including localization chiefly, and secondarily upon the promptness with which surgical inter ference is adopted, and the personal skill and surgical judgment of the operator. Shock and haemorrhage are practically the only immediate sources of danger, asepsis having eliminated other surgical complications. Both shock and hmmor rhage are avoidable or can at least be reduced to a minimum which does not endanger life. Wyeth's method of ac complishing this result in intracranial operations by dividing the operation of entrance into two or more surgical upon succeeding days is emi nently satisfactory. So safe, indeed, is this method, as to have rendered perfectly legitimate surgical entrance of the skull for purely exploratory purposes. The technique of the operative procedure varies with each case appropriate for operation, as well as in accordance with the surgical peculiarities of the operator.