Neurosurgical Classic--XXVIII
ROBERT H. WILKINS, M.D.
Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
HE prognosis of p a t i e n t s w i t h i n t r a -
T c r a n i a l n e o p l a s m s has s t e a d i l y im-
p r o v e d since t h e first a t t e m p t s a t t h e i r
r e m o v a l were m a d e in the n i n e t e e n t h cen-
t u r y . 5~ M u c h of this progress has b e e n
a t t r i b u t e d to the i n t r o d u c t i o n of m o d e r n
d i a g n o s t i c p r o c e d u r e s a n d the d e v e l o p m e n t
of s u p p o r t i v e t e c h n i q u e s such as the t r a n s f u -
sion of b l o o d a n d t h e a d m i n i s t r a t i o n of a n t i -
biotics a n d i n t r a v e n o u s fluids. B u t t h e great-
est single c o n t r i b u t i o n to the i m p r o v e m e n t in
the p r o g n o s i s of these p a t i e n t s was m a d e b y
H a r v e y C u s h i n g w h e n he i n t r o d u c e d t h e
p r i n c i p l e s a n d s t a n d a r d i z e d the t e c h n i q u e s of
m e t i c u l o u s cerebral surgery. 52,5~
T h e e a r l y o p e r a t i o n s for b r a i n t u m o r s
" . . . were all done by general surgeons who had
no training or experience in brain surgery and no
special interest in it; they simply felt compelled
'to do a brain case' and report it in order 'to keep
up with Jones.' One unhappy experience usually
sufficed to rid the general surgeon of his compul-
sion to be a 'brain surgeon,' and only the rare
individuals let themselves in for another similar
experience. A survey of the Surgeon General's
Index Catalogue for the years 1886 to 1896 re-
vealed the amazing fact that during the 10 year
period immediately following the successful
removal of a brain tumor by Horsley, more than
500 different general surgeons reported operations
performed upon the brain! The fact that in the
next 10 years from 1896 to 1906 the number of
surgeons reporting cases had fallen to less than 80
reflected discouragement and a beginning return
to sanity . . . . -43
D r . P h i l i p C. K n a p p , a l e a d i n g n e u r o l o g i s t
a t t h e t u r n of t h e c e n t u r y , was one of several
o b s e r v e r s who collected the r e s u l t s of these
e a r l y o p e r a t i o n s for b r a i n t u m o r s , a-6,2s,~5-4~
42,4~-46 B y 1906,
" . . . he was able to see some improvement, due
he says to the improvement in surgical technic,
b u t even so the results were far from encouraging.
I n this final report K n a p p was able to collect from
the literature 8~8 cases of brain tumor which had
been operated upon. Out of this number, 471 of
the tumors were said to have been 'removed,' b u t
as we now understand it, the removal in many in-
188
stances, even of the benign growths, was doubt-
less far from complete. I n the remaining 357 eases
the tumor was not removed, and there were ~65
deaths in the series, a mortality of 3~ per cent . . . .
"After the year 1906, when Knapp had eol-
ieeted his dreary operative statistics on brain
tumors, a great deal of progress was made during
the next decade. I n 1913 Tooth [4s] analyzed a
series of 500 probable tumors from the National
Hospital, Queen Square, and of these, ~65 had
been operated upon between 190~ and 1911, in
the majority of instances unquestionably by Sir
Victor Horsley. Out of the ~65, there were 187
verified tumors and from this number there were
at least 83 operative deaths, a mortality of 44 per
cent. Nevertheless, there were 31 patients living
at the time of Tooth's paper, a much better record
than the figures K n a p p had indicated in
1906 . . . . -33
"Keen [341 in 189~ advised that cerebral tumors
be enucleated, if possible, with the finger, but if
this were impossible, then a knife, scissors, sharp
spoon or ordinary teaspoon be used to remove the
entire mass piecemeal. If the tumor were sub-
cortical, then a tiny incision was made into the
cortex and the tumor could be palpated and re-
moved with the little finger.
"This rapid removal of tumors was common
practice until the advent of Cushing with his slow
careful technique. I n his 1908 monograph [71 he
stated, 'An encapsulated tumor may be shelled
out of its bed, with b u t little bleeding, by careful
manipulations and the proper use of cotton which
I prefer to hot irrigations as a hemostatic. When
the cortex is to be incised above a tumor which has
not reached the surface, the individual cortical
vessels radiating from it must be doubly ligated
with delicate strands of split silk, and the cortex
incised between ligatures. Below the cortex there
is often surprisingly little bleeding. The brain
must be carefully separated from the growth with
smooth, fairly b l u n t dissectors, and if bleeding
occurs, a pledget of cotton is placed in the gap
while another side is worked upon. I n this way, by
slow dissection, the tumor can often be clearly
outlined with but little loss of blood and the pro-
duction of no shock. The a t t e m p t to hurriedly dis-
locate a tumor outward by plunging fingers into
the brain is atrocious. There should be a legal
penalty imposed for 'speeding' in brain surgery.'
(I71, p. ~40.)"30
"Tooth's figures of Horsley's tumor patients
were . . . eclipsed . . . by the statistics offered by
 Neurosurgical Classic--XXVIII
Cushing E81in 1915. I n this report, which was an
elaboration of his discussion of a paper by Pro-
fessor ]~iittner on the operative treatment of
brain tumors, Cushing reviewed the current
operative mortality statistics pertaining to brain
tumors as published at that time by the leading
surgeons doing this type of work. Kiittner's own
mortality was 45 per cent; that of Krause about
50 per cent; and of Eiselsberg 38 per cent. We
have seen that Horsley's mortality was in this
general neighborhood. Cushing astounded his
listeners by submitting a mortality figure of 6.6
per cent for supratentorial tumors, and of 17 per
cent for those below the tentorium or a combined
mortality of 8.4 per cent for all patients operated
upon. A further feature of extreme importance in
Cushing's report was the fact that he had lost but
one patient from meningitis, whereas in the
Vienna series 10.5 per cent, and in the London
series 11.7 per cent, of the patients had suc-
cumbed from this type of infection. As Cushing
pointed out, the reason for this absence of sepsis
in his cases was due to his careful closure of the
galea as well as of the skin, thus preventing the
wounds from breaking down, with the resultant
fungus and meningitis.T M
D u r i n g the e n s u i n g y e a r s D r . C u s h i n g a n d
his associates e n c o u n t e r e d a large n u m b e r of
i n t r a c r a n i a l t u m o r s , w h i c h t h e y classified,
studied, a n d t r e a t e d . 1,2,9-~7,31,41,49,54 O u r pres-
e n t knowledge of b r a i n t u m o r s is largely
b a s e d o n these experiences.
I n 1931 D r . C u s h i n g p e r f o r m e d a n oper-
a t i o n which
" . . . served to verify the 3000th brain tumor in
his series. Without his knowledge the staff had
made elaborate preparations for photographs,
movies, and a gala tea party reminiscent of that
held on his sixtieth birthday . . . .
"Louise Eisenhardt, fully prepared for the oc-
casion, had all the tumor statistics available and
was able to point to a steady lowering of Cushing's
mortality rate during the previous ten years, save
for a brief increase . . . immediately after the in-
troduction of electrosurgical methods. Since there
was no other comparable tumor series with which
to compete, Cushing had become consumed with
a desire to improve his own figures from year to
year. He accordingly began in earnest to prepare
on these lines for the 'paper' to be read at the
International Neurological Congress in Berne
- - a paper which grew into a monograph and
was later published by his friend, Charles
Thomast20-=] . . . . -29
A t a m e e t i n g of t h e A m e r i c a n N e u r o l o g i c a l
Association o n M a y ~4, 1931, D r . C u s h i n g
189
gave a p r e l i m i n a r y a c c o u n t of
" . the mortality statistics pertaining to his
. .
large series of verified brain tumors, a grand
total of 3,0~3 patients, 1,870 of whom were
operated upon.J16,2~ There were 38~ postoperative
deaths, namely, patients who died in the hospital
from any cause whatever after operation, giving
a case mortality of 30.4 per cent. This series, of
course, included all of Dr. Cushing's brain tumor
patients, starting with his earliest experiences in
Baltimore in 190~. When the extremely high
mortality of the early years is considered, it is
indeed amazing that his total mortality was as
low as it proved to be. As a contrast to the figures
for the whole series, Cushing included the statis-
tics for the three years previous to the communi-
cation. These showed that 413 patients with veri-
fied intracranial growths had been operated upon
during that time, with 55 postoperative deaths, a
case mortality of 13.3 per cent . . . . -32
A few m o n t h s later D r . C u s h i n g p r e s e n t e d
a revised version of the same m a t e r i a l a t t h e
F i r s t I n t e r n a t i o n a l N e u r o l o g i c a l C o n g r e s s in
Berne. 17-19 T w e n t y - f i v e of his p u p i l s at-
t e n d e d , m o s t of t h e m to hear D r . C u s h i n g
p r e s e n t his paper.
"Much of the life of the Congress centered
about Dr. Cushing. He was returning after thirty
years to the town where he grew up, as it were,
and where he received the greatest inspiration for
his life's work--and he was returning now to give
an account of himself in the interval . . . .
"The Congress opened on Monday, 31 August,
in the Municipal Casino. The high point of this
session was the awarding (by the University of
Berne) of honorary degrees to Cushing and Sir
Charles Sherrington. That the degrees were to be
given had been kept in the utmost secrecy and
was to be a surprise to both of the recipients. Con-
siderable difficulty was encountered in persuading
Cushing that his presence at the session was im-
perative, for as usual he was belatedly putting the
finishing touches on his paper for the afternoon
session . . . .
" I n the introduction to his paper, fourth on the
program of the afternoon session, Cushing de-
scribed his experiences in Berne in 1900-1901. At
the beginning he spoke somewhat haltingly, but
within a few minutes the hall was silent as he
described the various factors which had led to the
dramatic fall in his mortality rate in cerebral
operations. 'Younger men,' he went on to say,
'picking up where I leave off, can reduce the
mortality still further.' Then came the devastat-
ing and unexpected climax: 'Gentlemen, this will
be the last report on the statistical results of brain
tumors as a whole that I shall ever publish.' After
190 Robert H. Wilkins
a m o m e n t of complete silence there was a burst of
prolonged applause. The Chairman, Ari~ns
Kappers of A m s t e r d a m , broke the precedent of no
votes of thanks for individual papers by express-
ing heartfelt gratitude to Cushing in the n a m e of
the Congress for placing before t h e m in such an
inspiring w a y the brilliant results of his life's
work."29
S i n c e D r . C u s h i n g ' s d e a t h in 1989, his
patients have been followed through the
Brain Tumor Registry at the Yale Univer-
s i t y S c h o o l of M e d i c i n e . A t t h e S e c o n d I n t e r -
n a t i o n a l C o n g r e s s of N e u r o l o g i c a l S u r g e r y
h e l d in W a s h i n g t o n , D . C. in 1961, D r .
E i s e n h a r d t r e p o r t e d t h a t a l a r g e n u m b e r of
t h e s e p a t i e n t s w e r e still l i v i n g 3 0 - 5 0 y e a r s
a f t e r t h e r e m o v a l of a g l i o m a W D r . C u s h i n g ' s
o u t s t a n d i n g a c c o m p l i s h m e n t s in t h e t r e a t -
m e n t of b r a i n t u m o r s h a v e r e m a i n e d a c h a l -
l e n g e f o r t h e n e u r o s u r g e o n s of t o d a y .
References
1. BAILEY, P. Intracranial tumors. Springfield, Ill. :
Charles C Thomas, 1938, xxii, 475 pp.
2. BAILEY, P., and CVSHINO, H. A classification of
the tumors of the glioma group on a histogenetic
basis with a correlated study of prognosis. Phila-
delphia: J. B. Lippincott Co., 1926, 175 pp.
3. BALLANCE,C.A. Some points in the surgery of the
brain and its membranes. London: Macmillan &
Co., 1907, xv, 405 pp.
4. VON BERGMANN,E. Die chirurgische Behandlung
yon Hirnkrankheiten. Berlin: A. Hirschwald, 1889,
2nd ed., 189 pp.
5. BRUNS, L. Die Geschwtilste des Nervensystems.
Hirngeschwtilste.--Rfickenmarks- und Wirbelge-
schwiilste. Geschwiilste der peripheren Nerven.
Berlin: S. Karger, 1908, 2nd ed., xvi, 480 pp.
6. CHIPAULT, A. Chirurgie op6ratoire du syst~me
nerveux. Paris: Rueff & Cie, 1894-1895, 2 vols.
7. CUSHING,H. Surgery of the head. In: Surgery, its
principles and practice. W. W. Keen, Ed. Philadel-
phia: W. B. Saunders Co., 1908, 3: 17-276.
8. CUSHING,H. Concerning the results of operations
for brain tumor. J. Amer. reed. Ass., 1915, 64: 189-
195.
9. CUSHING,H. Tumors of the nervus acusticus and
the syndrome of the cerebellopontile angle. Phila-
delphia: W. B. Saunders Co., 1917, viii, 296 pp.
10. CUSHING, n . Brain tumor statistics. Med. Rec.,
N.Y., 1920, 97: 417-418.
11. CUSHING, H. Distortions of the visual fields in
cases of brain tumour. (Sixth paper) The field
defects produced by temporal lobe lesions. Brain,
1922, 4~: 341-396.
12. CUSHING, H. Notes on a series of intraeranial
tumors and conditions simulating them. Tumor
suspects; tumors unverified; tumors verified. Arch.
Neurol. Psychiat., Chicago, 1923, 10: 605-668.
18. CUSmNG, H. Studies in intracranial physiology
and surgery. The third circulation. The hypophysis.
The gliomas. London: Humphrey Milford, 1926,
xil, 146 pp.
14. CVSHING, H. Experiences with the cerebellar
medulloblastomas. A critical review. Acta path.
microbiol, scaud., 1930, 7: 1-86.
15. CUSHING, H. Experiences with the cercbellar
astrocytomas. A critical review of seventy-six cases.
Surg. Gynec. Obstet., 1931, 52: 129-204.
16. CUSHING, H. The surgical mortality percentages
pertaining to a series of two thousand verified intra-
cranial tumors. Standards of computation. Trans.
Amer. neurol. Ass., 1981, 456-463. Also: Arch.
Neurol. Psychiat., Chicago, 1932, 27: 1273-1280.
17. CUSHING, H. Une s6rie de deux mille cas de
tumeurs intracraniennes v6rifi~cs histologiquement.
Rev. neurol., 1931, 2: 378.
18. CUSHING, H. The surgical-mortality percentages
pertaining to a series of two thousand verified intra-
cranial tumours. In: Proceedings of the First Inter-
national Neurological Congress (Berne, 1931).
Berne: StRmpfli & Cie, 1932, xxv, 440 pp. (see pp.
73-78).
19. CUSmNG, H. Bemerkungen fiber eine Serie von
2000 verifizierten Gehirntumoren mit der dazuge-
hsrigen chirurgischen Mortaliti~tsstatistik. Chirurg,
1932, 4: 254-265.
~0. CUSmNG, H. Intracranial tumours. Notes upon a
series of two thousand verified cases with surgical-
mortality percentages pertaining thereto. Spring-
field, Ill. : Charles C Thomas, 1982, xii, 150 pp.
21. CUSHING, H. Intrakranielle Tumoren. Bericht
fiber 2000 bestiitigte Fiille mit der zugehSrigen
~-~ortalitiitsstatistik. F. K. Kessel, Transl. Berlin:
J. Springer, 1935, viii, 139 pp.
22. CUSmNG, H. Tumeurs intracraniennes. ]~tude
analytique de 2000 tumeurs v6rifi6es et de leur
mortalit6 op6ratoire. J. Rossier, Transl. Paris:
Masson & Cie, 1937, 194 pp.
23. CvsmNo, H., and BAILEY,P. Tumors arising from
the blood-vessels of the brain. Angiomatous mal-
formations and hemangioblastomas. Springfield,
Ill.: Charles C Thomas, 1928, x, 219 pp.
24. CUSHING, H., and EISENHARDT,L. Meningiomas.
Their classification, regional behaviour, life history,
and surgical end results. Springfield, Ill. : Charles C
Thomas, 1938, xiv, 785 pp.
25. EISENHARDT, L. The operative mortality in a
series of intracranial tumors. Arch. Surg., Chicago,
1929, 18: 1927-1935.
26. EISENHARDT, L. Long postoperative survivals in
cases of intracranial tumor. Res. Publ. Ass. nerv.
ment. Dis., 1985, 16: 390-416.
27. EISENHARDT,L. Discussion of T(innis. 47 IInd int.
Congr. nellrol. Surg. (Washington, D.C., 1961).
Excerpta med., 1961, No. 86, El0.
28. FRAZIER,C.H. Remarks upon the surgical aspects
of tumors of the cerebellum. N.Y. reed. J., 1905,
81: 272-~80; 832-337.
29. FULTON, J. F. Harvey Cushing. A biography.
Springfield, Ill.: Charles C Thomas, 1946, xii, 754
pp. (see pp. 604-608).
30. GREEN, R. E., and STERN, W . E . Techniques of
intracranial surgery. In: A history of neurological
surgery. A. E. Walker, Ed. Baltimore: Williams &
Wilkins Co., 1951, xii, 588 pp. (see pp. 80-110).
31. HARVEYCUSHINGSOCIETY. A bibliography of the
 Neurosurgical Classic--XXVIII
writings of Harvey Cushing. Prepared on the
occasion of his seventieth birthday April 8, 1939 by
the Harvey Cushing Soeiety. Springfield, Ill.:
Charles C Thomas, 1939, xv, 108 pp. (see pp. 59-
89).
32. HORR~.X, G. Some of Harvey Cushing's contribu-
tions to neurological surgery. J. Neurosurg., 1944,
1: 3-2~ (see p. 19).
33. HORRAX, G. Neurosurgery. An historical sketch.
Springfield, Ill.: Charles C Thomas, 1952, xi, 135
pp. (see pp. 70, 71, 86, 87).
34. KEEN, W. W., and WroTE, J. W. An American
text-book of surgery, for practitioners and students.
Philadelphia: W. B. Saunders Co., 189~, xx, 1209
pP-
35. KNAPP, P . C . The pathology, diagnosis and treat-
ment of intra-cranial growths. Boston: Rockwell &
Churchill, 1891, viii, 165 pp.
36. KNAPP, P. C. The treatment of cerebral tumors.
Boston reed. surg. J., 1899, 141: 333 337; 859-363;
384-387.
37. KNAPP, P . C . The results of operation for the re-
moval of cerebral tumors. Boston reed. surg. J.,
1906, 15~: 1~4-1~6.
38. KNAPP, P. C., and BRADFORD, E. H. A case of
tumor of the brain: removal; death. Boston reed.
surg. J., 1889, 120: 3~5-330; 858-859; 878-881;
386-388.
39. KOe~Ea, T. Text-book of operative surgery.
H. J. Stiles, Transl. London: A. & C. Black, 1903,
xxv, 440 pp.
40. KaAUSE, F. Surgery of the brain and spinal cord
based on personal experiences. H. A. Haubold and
M. Thorek, Transl. New York: Rebman Co., 1909-
191~, 3 vols.
41. LOCKE, C. E., JR. A review of a year's series of
intraeranial tumors, June, 19~0, to June, 1921.
Arch. Surg., Chicago, 1921, 3: 560-581.
42. MARIOn, G. Chirurgie du syst6me nerveux.
CrAne et enc6phale. Rachis et moelle, nerfs. Paris:
G. Steinheil, 1905, ii, 531 pp.
43. SCARFF, J . E . Fifty years of neurosurgery, 1905-
1955. Int. Abstr. Surg., 1955, 101:417-513 (see pp.
419-421).
44. STAR~, M . A . Brain surgery. New York: William
Wood & Co., 1893, xii, 295 pp.
45. STAR~, 1Vs A. A contribution to brain surgery, with
special reference to brain tumors. Med. Rec., N.Y.,
1896, 49: 145-150.
46. STARa, M . A . The results of surgical treatment of
brain tumors. J. nerv. ment. Dis., 1903, 30: 398-
407.
47. T0rc~m, W. Gliomas. I I n d int. Congr. neurol.
Surg. (Washington, D.C., 1961). Excerpta reed.,
1961, No. 36, E9-E10.
48. TOOTH, H. H. The treatment of tumours of the
brain, and the indications for operation. In:
Seventeenth international congress of medicine
(London, 1918). London: H. Frowde, 1918, Sect.
11, pt. 1, ~79 pp. (see pp. 161-!~57).
49. VAN WAGENEN, W . P . Verified brain tumors. End
results of one hundred and forty-nine cases eight
years after operation. J. Amer. reed. Ass., 1934,
102: 1454-1458.
50. WmKINS, R. H. Neurosurgical classic--I. J. Neu-
rosurg., 1962, 19: 700-710.
191
51. WILKINS, R. H. Neurosurgical classics--II. J.
Neurosurg., 196~-, 19: 801-805.
5~. WmKINS, R. H. Neurosurgical classic--V. J.
Neurosurg., 1963, 20: 267-270.
53. WILKINS, R. H. Neurosurgical classics--VI. J.
Neurosurg., 1963, 20: 366-369.
54. WILKINS, R. H. Neurosurgical classic--XVIII.
J. Neurosurg., 1964, 21: 815-347.
19. T h e Surgical-Mortality P e r c e n t -
ages pertaining to a Series of T w o
T h o u s a n d Verified I n t r a -
cranial T u m o u r s .1
b y Prof. Itarvey Cushing, B o s t o n
Standards of computation. I n c a l c u l a t i n g t h e s e
m o r t a l i t y p e r c e n t a g e s t h e s t a n d a r d w h i c h we h a v e
set for ourselves is t h a t every death in hospital fol-
lowing an operation f r o m any cause whatsoever, no
matter how long the interval, is recorded as" a post-
operative fatality. T h e r e is no possibility of a n y
e x c e p t i o n b e i n g m a d e to this rule, h o w e v e r justi-
fiable it m i g h t a p p e a r to be, for t h e r e c o r d is a u t o -
m a t i e a l l y m a d e b y a s e c r e t a r y from t h e c o m p l e t e d
ease record a f t e r t h e p a t i e n t ' s h o s p i t a l discharge,
living or dead. W e r e this p r e c a u t i o n n o t t a k e n ,
those p e r s o n a l l y i n t e r e s t e d would, n o w a n d t h e n ,
find t h e t e m p t a t i o n to e v a d e a n a d m i t t e d l y severe
s t a n d a r d well n i g h irresistible.
B u t s h o u l d o n e b e g i n to m a k e exceptions to t h e
rule, t h e r e would b e n o e n d t o t h e m - - a p a t i e n t
a b o u t t o b e d i s c h a r g e d a f t e r a successful o p e r a t i o n
has a p e r f o r a t e d g a s t r i c ulcer; a n o t h e r gets o u t of
b e d a t n i g h t to go to t h e toilet, t r i p s o v e r a n ob-
s t r u c t i o n a n d dies in a few h o u r s f r o m a f r a c t u r e
of t h e b a s e of t h e skull; a n o t h e r d u r i n g a n epi-
d e m i c of influenzal p n e u m o n i a h a s a f a t a l infec-
t i o n ; still a n o t h e r h a s a c o r o n a r y t h r o m b o s i s five
weeks a f t e r m a k i n g a perfect r e c o v e r y f r o m his
t u r n o u t e x t i r p a t i o n . Similar examples m i g h t b e
m u l t i p l i e d a n d were t h e y n o t a u t o m a t i c a l l y re-
corded as p o s t o p e r a t i v e d e a t h s , t h e t e m p t a t i o n to
exclude fatalities f r o m o t h e r c o m p l i c a t i o n s m o r e
o b v i o u s l y p o s t o p e r a t i v e , s u c h as p u l m o n a r y e m -
bolism, p o s t o p e r a t i v e p n e u m o n i a , t u b e r c u l o u s
m e n i n g i t i s a f t e r t h e successful r e m o v a l of a
t u b e r c u l o m a , a n d so on, would be difficult t o re-
* Reprinted from Proceedings of the First International
Neurological Congress (Berne, 1931). Berne: StKmpfli &
Cie, 1982, 78-78.
1 This paper represents the last portion of the com-
munication made at the International Neurological
Congress in Berne, 1931. The mortality statistics for
tumours of different kinds and situations, separately
considered, which form the basis of these tables, has
been published as a monograph: 'Intracranial Tumours,'
by Charles C Thomas, Springfield (Illinois), 1932.
Has appeared in part in the Journal 'Der Chirurg'
(Berlin), Band IV, Heft 7, April 1932; see also: 'Archives
of Neurology and Psychiatry,' Vol. 27, June, 1932.
19~ Robert H. Wilkins
sist since no sharp line can be drawn between
those due and those not due to the operation.
Having no convalescent home to which patients
may be transferred and since a large proportion of
them come from a distance, they are necessarily
retained in hospital longer than would otherwise
be necessary, 2 and there is ample time for inter-
current disorders to develop which bring addi-
tional risks. Another element which tends to in-
crease the percentage of postoperative fatalities
among histologically verified tumours is the high
incidence (averaging over 90%) of postmortem
examinations that are secured. Owing to this,
many tumours are identified at autopsy which
otherwise, owing to negative explorations, would
have remained in the list of tumours unverified.
What is more, we frequently retain in hospital for
indefinite periods--five months in one instance--
patients whose tumours we have failed surgically
to verify with the understanding that in the end
permission for an autopsy will be given.
Then, too, as was stated in another connection,
the case mortality of all malignant gliomas, in the
process of working out their life history, should
theoretically be 100%; for if operations for recur-
rences are systematically pursued to the end, it is
almost a certainty that the last of them will be
followed by a postoperative fatality. With all
these things to consider, it is obvious that the
operative statistics of two surgeons with equal
skill and experience may legitimately vary within
wide limits.
I n all calculations of operative-mortality per-
centages there is still another element to consider:
viz., W h a t is and what is not to be recorded as 'an
operation'? E yen though they may be attended with
risk and lead to a fatality which permits post-
mortem verification of a tumour, we exclude, as
all others would do, the simple punctures--lum-
bar, cisternal, transphenoidal or ventricular. Nor
do we record as operations the minor surgical pro-
cedures necessary for the securing of muscle from
the patient's leg, nor those for blood transfusions
or those for ventriculography, even though the
latter procedure may at times be hazardous and
occasionally lead to a fatal issue. We do, however,
record as separate operations those requiring
2 The average hospital sojourn of the last 100 con-
secutive cases with surgically verified tumours has been
39 days.
TABLE III. Showing Case-Mortality Percentages for Acoustic Tumours in Successive Grou )s of Fifty
Time Number
Dates Interval Cases
Jan. 18, 19O6--Oct. 5, 1915 9 years 9 mos. 21
Jan. 22, 1916--Feb. 13, 1923 7 years 1 mo. 50
Mar. 6, 1923--Sept. 6, 1927 4 years 6 mos. 50
Oct. 18, 1927--July 1, 1931 3 years 9 mos. 50
more than one session for their completion as they
are almost invariably critical performances; and
for the same reason we also record emergency re-
elevations of osteoplastic flaps necessitated by
postoperative clot formation.
T h e n there is a final point to be decided: viz.,
W h e n does the operation begin? Does it begin with
the ward preparations or with the anaesthetic or
only after an incision has been made? I n m a n y pa-
tients with brain tumours having an advanced
syndrome the condition at best is serious. Sudden
respiratory failure may occur should a patient
with a cerebellar tumour strain to expel a prepar-
atory enema, or have the neck unduly twisted
while the scalp is being shaved, or, in days when
ether anaesthesia was employed, from the early
effects of the anaesthetic. Many patients after
such accidents have been immediately operated
upon under artificial respiration and some few of
them thus saved.
No surgeon would conceivably hesitate for a
second to face emergencies of this kind though
they are very bad for one's mortality percentages.
I n the last consecutive 50 operations for acoustic
turnout, for example, one of the two recorded
fatalities (cf. Table III) was that of a patient
operated upon in an agonal state after a sudden
respiratory failure. Had the surgeon been thinking
of his score rather than of possibly saving a life,
his mortality figures for this particular group of
cases would have been cut in half. One must draw
the line somewhere and it seems fair to do so with
the incision of the scalp.
1. Mortality percentages or the series as a whole.
The writer's experience in neuro-surgery may be
divided into three decades; the first as a beginner
at the Johns Hopkins Hospital, from 1901 to
1912; the second, with its lost ground difficult to
regain, due to a two years' absence during the
War; and the third, from 1 9 ~ to 1931, during
which period detailed week-to-week statistical
records with annual compilations of the intra-
cranial tumours have been kept by Dr. Eisen-
hardt, who made a detailed report on the subject
two years ago? A highly condensed table (cf.
Table IV) limited to the operative mortality per-
centages of the four major groups of verified
8 Eisenhardt, L. The operative mortality in a series of
intracranial tumours. Arch. Surg., 1929, xviii; 1927-
1935.
Number Number Case Op'e
Oper'ns Deaths Mortal. Mortal.
32 6 28,6% 18,7%
64 10 20,0% 15,6%
62 7 14,0% 11,8%
58 2 4,0% 3,4%
 Neurosurgical Classic--XXVIII
TABLE IV. Comparison of Operative Mortality
Percentages for Verified Tumours of Four Major
Groups Divided in Three Periods
Gliomas (varia) .... Hopkins
to
Series
1912 Brigham
toSeries
1929
~ l ,~-o
IPituitary a d e n o m a s . . . 13,5% [ 5,3%
Meningiomas . . . . . 21,0% 10,3%
IAcoustic tumours . . . . 25,0% 11,5%
tumours, as given in her paper, contrasted with
the results the past three years, is appended.
~. Mortality percentages year by year. The pre-
ceding table shows, as would be expected, a pro-
gressive improvement in the figures t h a t has come
with the experience of later years. As a matter of
fact, during each year of the last decade there has
been a definite tendency to an annual lowering of
the case and operative mortality as shown in Ta-
ble V. This table gives the m o r ta li ty figures for
the cases discharged living or dead between M a y
1st and M a y 1st of each successive year. And
were the figure included for the 549 patients ad-
mitted or readmitted with tumours unverified
during these years, the percentages would be still
lower in view of the relatively few fatalities (2,9t)Vv
case mortality and 2,5v/v operative mortality) in
the unverified group.*
This table points out, what the operating mem-
bers of the neuro-surgical staff were themselves
conscious of: namely, that in 1927 and 1928, on
the introduction of electro-surgical methods, a
number of patients, whose tumours when exposed
had been regarded as inoperable, were called back
and reoperated upon with a high mortality rate,
partly because of the dangerous procedures under-
taken and partly because of inexperience with
electro-surgical principles.
It should be clearly understood that the computa-
tions on which the figures in Table III are based rep-
resent each year's work taken by itself, including there-
fore both new and old patients, with primary operations
as well as those for recurrences.
193
Apart from the figures for this particular 1927-
1928 twelvemonth, there has been a. slowly pro-
gressive decline in the mortality percel)tages with
a pronounced drop during the last year, which
July
Julyt~192871931[
--[
| came somewhat as a surprise even though we were
aware that it has been a good year. This is all the
i~l more gratifying in view of the fact that as time
[ 5,7% 1
I 7,7% 1 goes on the clinic carries an ever increasing burden
4,4% |
of patients readmitted for recurrence of symp-
toms; and though reoperations for medullo-
blastomas and glioblastomas are perhaps less
readily undertaken than formerly, even the most
conservative among us can hardly refuse to re-
operate upon the less malignant lesions like
mcningiomas, neurinomas and astrocytomas
when symptoms recur.
3. Mortality percentages for the separate turnout
groups. These calculations are particularly illumi-
nating in that they show how the percentages
tumble so soon as the life history of any particular
tumour has been thoroughly worked out. Of only
a few tumours can it be said that this has been
done with sufficient thoroughness to affect the
operative results, b u t these few furnish striking
illustrations. For example: The operative mor-
tality of the once dreaded acoustic tumours (as
shown in Table I I I ) has fallen for each successive
50 cases from a s to ~0~v to 14~v to 4c/v case
mortality. Th e present operative mortality for
the chromophobe adenomas, formerly circa 13~v,
has also dropped to slightly below 4 percent. Th e
figures for the cerebellar astrocytomas, practically
unknown ten years ago, have fallen from a 28~v
case mortality for the first 25 patients to 4~v for
the last ~5 cases. E v e n the highly malignant
glioblastomas of the cerebrum have shown a drop
from 24c/v for the whole series to 14(~v; and now
that the cerebellar medulloblastomas are better
understood, even t h e s e - - t h e most disheartening
of all brain t u m o u r s - - m a y be expected to show a
great improvement in their operative percentages.
In Table VI, the mortality figures have been
assembled, not only for the eleven major subdi-

TABLE V. Annual Statistics of Operations for Verified Tumours including New and Old Cases from 1922-1931

Number Patients Number Post- Case Operative

Successive
of operated of operative mortality mortality
M a y l to M a y l patients on operations deaths (per cent) (per cent)

1922-1923 . . . . . . 104 94 130 92 23,4 16,9

1923-1924 . . . . . . 156 140 190 26 18,6 18,7
1924-1925 . . . . . . 137 113 142 21 18,5 14,7
1925-19~6 . . . . . . 155 133 172 25 18,8 14,5
1926-1927 . . . . . . 184 161 217 24 14,9 11,0
1927-1928 . . . . . . 185 149 183 28 18,7 15,3
1928-1929 . . . . . . 205 179 2o~6 26 14,5 11,5
1929-1930 . . . . . . 178 147 191 24 16,3 12,5
1930-1981 . . . . . . 200 170 219 15 8,8 6,8

Total 1504 1286 1670 211 16,4 12,6

194 Robert H. Wilkins
visions of the verified tumours, but separately for
the unverified tumours. Th e table has been divided
into two sections, the first giving the operative
figures for the entire series which carries the heavy
load of fatalities of the early years of inexperience.
I n the second section the figures are those only for
the new cases t h a t have first come under observa-
tion in the three-year period from July 1, 19~8, to
July 1, 1981.
This table, therefore, by the exclusion of old
cases readmitted during the last three-year period
because of the symptomatic recurrence of tu-
mours imperfectly treated at an earlier day, gives
a clearer idea of what results may reasonably be
expected of those newcomers to neuro-surgery who
can profit, not only by the present-day improve-
ments in technique, but by the existing state of
our knowledge regarding the life history of the
various lesions. And should they take warning
from the experience of others in avoiding over-
radical attempts to remove large congenital
craniopharyngiomas, in refraining from operating
on obviously metastatic tumours, and in refusing
all secondary operations for recurrences, they
could easily attain a case mortality of four or five
percent for the whole.
Factors influencing mortality percentages. These
wholesale statistics, given in the last three tables,
will serve, I hope, to give others who engage in
like tasks something to play against. The more
important figures are those which pertain to
special tumours in special situations and they will
be found in the body of the paper (to be published
in another place) where the various lesions are
separately considered. Had it not been for the in-
dustry of Dr. Eisenhardt, these calculations would
never have been made; but now t h a t they have
been, they m ay well enough be published even
though there is no reason for taking pride in what
they show. Th e high mortality percentages of the
early cases still cast their shadow over the figures
for the complete series.
I t has been erroneously assumed in some quar-
ters t h a t the improved results of recent years are
due to earlier diagnoses rather than to greater
skill and experience--in other words, t h a t the
neuro-surgeon of to-day deals with a selective list
of relatively favourable lesions. This assumption is
far from the actual facts. I n reality, each year
problems become more difficult than those of the
year before. Th e proportion of patients admitted
as <<forlorn hopes>) in the terminal stages of their
malady, often after illjudged procedures at the
hands of surgeons with little or no neuro-surgical
training, is as large as it ever was. W h a t is more,
each succeeding year sees tumours surgically ex-
posed, like tumours of the third ventricle, which
formerly were regarded as hopelessly inaccessible.
Hence, all things considered and in spite of the
constant improvement in diagnosis and surgical
technique, the operations as time passes become
increasingly critical and difficult.
T h e principal steps which have made it possible
not only to attack the more formidable problems
of the present day but at the same time to lower
the operative mortality may be chronologically
enumerated: 1. the generally accepted methods of
decompression to relieve tension; ~. such irre-

TABLE VI. Comparison of Mortality Percentages for Complete Series and Past Three Years

Entire series (30 years) New cases (past 3 years)

Verified tumours Pts. ] % %

No. op. , No. P.o. I CaseOp. No. No. P. o.
P. i Ca%e Op.
deaths ~ort.
%
pts. on ops. deaths mort. mort. pts. ops. __deal mort.

I.
II.
Gliomas (varia) . .
Pituitary adenomas
86~
36(
780
349
1173
403
202
25
25,9
7,1
17,2 198
6,2 [ 59 7O 181
282 I 31
4
15,7
6,8
11,0
5,7
III. Meningiomas . . . 27] 260 489 54 20,8 11,0 69 103 8 11,6 7,7
IV. Acoustic tumours . 17( 171 219 25 14,6 11,4 41 45 2 4,9 4,4
V. Congenital tumours
(varia) . . . . . 11~ 106 160 23 21,7 14,4 17 25 4 23,5 16,0
VI. Metastatic and in-
vasive . . . . . 8~ 68 80 18 28,6 22,5 10 11 4 40,0 36,4
VII. Tuberculomas and
syphilomas . . . 4~ 40 49 15 37,5 80,6 4 5 0 0,0 0,0
VIII. Blood-vessel tumours 41 37 59 6 16,2 10,2 7 10 1 14,8 10,0
IX. Sarcomas (primary) 14 12 17 6 50,0 35,8 0 0 0
X. Papillomas . . . . 12 11 23 8 27,8 13,4 1 2 0 0,0 0,0
XI. Miscellaneous 44 41 68 5 12,2 7,9 6 9 1 16,6 11,1

Total 2028 1870 2785 882 20,4 18,9 412 562 55 13,8 9,8
Unverified tumours 859 496 557 12 2,4 2,2 66 73 0 0,0 0,0

Grand total 2886 2866 829*. 394 16,6 11,9 l 478 685 55 11,5 8,7
 Neurosurgical Classic--XXVIII
proachable w o u n d healing t h a t secondary infec-
tions are practically u n k n o w n ; 3. t h e separate
closure of the galea by buried fine black silk su-
tures which has m a d e the once dreaded fungus
cerebri nigh f o r g o t t e n ; 4. in place of ether inhala-
tion, t h e introduction by de Martel of local anaes-
thesia now supplemented when necessary by the
rectal a d m i n i s t r a t i o n of t r i b r o m e t h a n o l ; 5. t h e
more precise t u m o u r localisation which in obscure
cases Dandy's v e n t r i c u l o g r a p h y p e r m i t s us to
m a k e ; 6. the use of a m o t o r - d r i v e n suction ap-
p a r a t u s as an indispensable a d j u n c t to e v e r y
operation; and 7. t h e successive i m p r o v e m e n t s in
m e t h o d s of haemostasis which since 1927 h a v e
been m o s t a d v a n t a g e o u s l y s u p p l e m e n t e d by t h e
i n t r o d u c t i o n of electro-surgical devices.
B u t the operation itself is b y no means t h e
whole story. T h e after care is equally i m p o r t a n t
for unsuspected complications m a y arise at a n y
m o m e n t which if overlooked or neglected m a y
wholly t u r n the scale. This has been well sum-
marized in Dr. Eisenhardt's p a p e r of t w o years
ago:
Rarely is more than one major operation for tumour
scheduled for one day. Most of the operations are
carried through under local anaesthesia, and all are
started in this way. Patients who have been subjected
to a craniotomy are not moved from the operating suite
195
until the danger of the formation of a postoperative
extradural clot has passed. After critical cerebellar
operations, particularly if inhalation narcosis has been
necessitated, the patients are usually left on the table
for several hours until they have fully recovered, and
they are often kept in the operating suite for a number
of days. Those with deglutitory difficulties must often
be fed through the nares for prolonged periods. For
charity patients who are in a critical condition, from this
or some other cause, special nurses are provided and paid
for out of a fund donated for the purpose.
Since this was w r i t t e n we h a v e t a k e n an addi-
tional safeguard: namely, in p r o v i d i n g for t h e
individed service of a highly trained nurse, who,
while the surgeons are engaged in their time-con-
suming operations, can d e v o t e her a t t e n t i o n to
the more critically ill of t h e t h i r t y or forty patients
either awaiting operation or already operated
upon w h o m we sometimes h a v e under observa-
tion at one time. U n q u e s t i o n a b l y m a n y lives h a v e
been saved in this way, for less experienced nurses
or junior house officers can hardly be expected to
appreciate the significance of s y m p t o m s which in-
dicate t h a t something is going wrong with a pa-
tient recently operated u p o n for a brain t u m o u r ;
and a few hours' delay due to the misinterpreta-
tion or neglect of a warning signal m a y m e a n the
difference between a f a t a l i t y and a recovery.