Eric Turner

Report of 10 operations under local cerebral hypothermia

A method of local cerebral hypothermia with circulatory arrest of one or more of the major vessels of the neck is described. Ten clinical cases have been operated upon, and much has been learned of the operative difficulties including an increased operating time and a high complication rate. There were four post-operative deaths, in one (case 1) there was some evidence that the technique protected the perfused part of the brain from anoxic damage. In case 9 the method itself caused particularly bad operating conditions and eventually the patient died. Case 2 and case 4, like case 1, were patients who were severely ill and who might well have died whatever technique had been used in operating upon them. Of the survivors, one patient (case 3) had a post-operative intracerebral clot which developed during closure and another (case 6) had an intracerebral clot which required removal after 24 hours. Another patient (case 8) had some delay in return to full mental function. In the light of this experience we cannot regard the method in its present form as satisfactory for general use. In our view, its further development requires the discovery of a more effective means of neutralizing the anticoagulants, or doing without anticoagulants altogether. It is also necessary to develop a method of monitoring parts of the brain distant from those directly perfused to give warning of threatened anoxia. Until such time as these problems can be solved we have returned to other procedures but are publishing our results in the hope that other workers will be able to improve upon them.

A new approach to unilateral and bilateral lobotomies for psychomotor epilepsy

The surgical treatment of focal epilepsy cannot be regarded with satisfaction. Formerly (Foerster and Penfield, 1930) an area of scarring was excised but later with the aid of electrocorticography surgical excision was directed more to an area of abnormal electrical activity which might be near a scar or destructive lesion (Penfield and Paine, 1955). Temporal lobe epilepsy received close attention and Penfields observations on focal stimulation in the conscious patient were employed to aid in identifying epileptogenic zones (Penfield and Jasper, 1954). In time, larger volumes of tissue were removed in the first instance and partial temporal lobectomy has been much practised in recent years (Penfield and Flanigin, 1950; Bailey, Green, Amador, and Gibbs, 1953; Falconer, Hill, Meyer, Mitchell, and Pond, 1955). Even so difficulties have been encountered owing to the strong tendency for abnormal temporal lobe activity to be bilateral. The effects of bilateral temporal lobectomy on memory have been disastrous but they have contributed to our knowledge of the physiology of memorizing (Scoville and Milner, 1957; Russell and Espir, 1961). Recent physiological advances demonstrate the extent to which different areas of the brain are in such close relationship to others that mutual interaction on thresholds of activity can be assumed and indicate a holistic view of brain function. To express this hypothesis in another way, the brain can be considered as a number of goal-seeking circuits with descending and ascending influences competing for the central neuronal pool. Some of these descending systems involve the temporal lobes which are very rich in connexions with other parts, including the diffuse projection systems of the thalamus, hypothalamus, and reticular formation. It is reasonable therefore in the light of current knowledge to attempt the treatment of focal epilepsy not by excising brain but by exploring the effect of interrupting connexions to and from the part of the brain affected, theoretically leading to a useful degree of cure with a minimum of deficit. METHODS AND MATERIAL

THE SIGNIFICANCE OF HYPERKINESIS IN LESIONS OF THE ANTERIOR STRIATUM IN RHESUS MACACCUS

In the course of an investigation into respiratory control by cerebral structures (Turner, 1954), a comparison was made between the levels of kinesis shown by four animals with lesions in the anterior striatum and other animals with lesions elsewhere or with no lesions. It was found that the animals which had lesions in the anterior striatum were significantly hyperkinetic after operation (Figs. 1 and 2). Further study of these four animals was directed towards elucidation of the neurophysiological mechanisms involved in the hyperkinesis they showed. Augmented forward progression in the monkey has been described by Ruch and Shenkin (1943), by Mettler and Mettler (1942), and by Mettler (1945). In the monkeys described here it took the form of long-continued, methodical pacing of the floor of the cage. The stereotyped pattern of the path covered depended on the shape of the cage, but since this was usually a long, narrow rectangle, the path was usually from end to end, the turns at the end being made in either direction indiscriminately. In addition, especially in the immediate post-operative period, the animals climbed up the walls of the cage, and bored their heads on the roof. One animal burst open its wound by doing this, and died of meningitis. Thereafter, the roof of the cage was made plain, not meshed, and no further injury occurred. Hyperkinesis has been described from injury to various cortical areas in the frontal lobe, but Richter and Hines (1938) showed that the factor which consistently produced a gross increase in kinesis was damage to the anterior end of the caudate nucleus and putamen. Davis (1951) pointed out that such damage might be the result of impairment of the vascular supply, especially in relation to the orbital gyri. He also emphasized that special methods of recording the increased number of movements should be employed, and the reason for this necessity will emerge from the present study. Daviss recording apparatus has been previously described (Davis, 1951; Turner, 1954). In an attempt to find out what factors might increase or decrease the hyperkinesis in these animals, they were studied under various conditions. The movements made in each hour of the 24 were separately recorded; the effects of light and of darkness, of time, of stimuli releasing previously taught conditioned reactions, of specific visual and auditory stimuli, and of anoxia were recorded. On the postulate that the kinesis was reflex in nature certain sensory modalities were selectively cut offsomaesthetic impulses in one animal, vision in another. The anatomical structures damaged were tabulated from serial sections, and the physiological results compared with the tables. All the animals were observed and examined for neurological abnormality before and after operation.