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·MOTOCICAL
CLINICAL
NEUROSURGERY
20
1951
KURCE
ERUDITIO ,
SOCLATAS
OBSERVANTIA

·1 ILDER GRAVES PEYFIELD M.D

·CLINICAL
NEUROSURGERY
Proceedings
OP TUE
CONGRESS OF NEUROLOGICAL SURGEONS
Chicago, Illinois
1956
SAKS
TICHE
BALTIMORE
THE WILLIAMS & WILKINS COMPANY
1957

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·Preface The fourth volume of Clinical Neurosurgery contains the edited proceedings of the Suth Annual Niccting of The Congress of Neurological Surgeons field in Chicago, Nosembor 1-3, 1050 Tho Congress of Neurological Surgcons tahes great pleasure and 19 pavileged in dedicating this volumo to Doctor Wilder Penfield, thus years honored guest and speaker Ench previous annual mecting has honored an outstanding ochilor acurosurgeon as the Society's gucat sxakor-1052, Profesor Herbert Olivierona, Stockholm, Sweden, 1953, Sir Geoffrey Jefferson, Alenchester, England, 1954, Doctor Kenneth McKenzie, Toronto, Canada 1055, Doctor Carl Rand, Los Angeles, California. The format of this volumc is much the same as in previous proceedings Tho papers, uscept those of Doctor Penfield, are doroted to the Vanous Deurological aspects of the pituitary region The contributors to this rolumo are all men of considerable experience and aro authonties in their particular field. The editors extend their sinccre appreciation to the program committeo and officers of Tho Congress of Neurological Surgeons, to the contributors, and last but not least, to the publisher Only becauso of the excellent cooperation of the contnbutors and the publisher, has this volume been made posable TRA J JACIBOR, AD Echtor in-Chief Associato Editora LEE CHRISTOFFERSOX, N.D RICHARD DASSAUBSURE, M.D ROBERT FISHER, M.D WILLIAN MoonBo MD + ·Contributors JOHN DEXTER CAMP, Chief of the Department of Radiology, Hospital of tho Good Samantan, and Clinical Professor of Radiology, University of Southern California Medical School, Los Angeles, Califoma (Chapter II') GILBERT HORRAX, Cluef, Department of Neurosurgery, Lahoy Clinic, Nou rosurgeon to New England Dcaooness nnd Not England Baptist Hospitals, Boston, Massachusetts (Chapter VI) JAMES GRAITON LOVE Professor of Neurosurgery, University of Minnesota Graduate School, Hoad of Section of Neurological Surgery, Mayo Clinio, Rochester, Minnesota. (Chapter V) OLAF HJALER PEARSON, Associate Professor of Medicino, Cornell Uni vorsity Medical School Associato Sloan Kettering Institute, A860- ciate Attending Physician, Dicdical Service, Memorial Hospital, New York, New York. (Chapter VIII) WILDER G PENFIELD Director, Montreal Neurological Institute, Mont real, Canada. Professor of Neurology and Neurosurgery DicGill Uni versity Medical School Alontrcal, Canada. (Chapter I and II) BRONBOY BANDS RA Professor of Neurosurgery and Chief of the Depart inent of Neurosurgery, Cornell University Medical School and Tho Net York Hospital Netr York, Ner York. (Chapter VI CHARLES TV ROCKER Head of Section of Ophthalmology Mayo Clinio Professor of Ophthalmology, Graduate School of the University of Alinnesota Rochester Minnesota (Chapter III)

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·Contributors JOHN DEXTER CAMP, Chief of the Department of Radiology, Hospital of the Good Samantan, and Clinical Professor of Radiology, University of Southern California Medical School, Los Angeles, Calfomnia (Chapter IV) GILBERT HORRAX, Clucf, Department of Neurosurgery, Lahoy Choo, Neu rosurgeon to New England Deaconess and New England Baptist Hos. pitals, Boston, 11assachusetts. (Chapter VI) JAMES GEAFTOY LOVE, Professor of Neurosurgery, University of Minnesota Graduate School, Head of Section of Neurological Surgery, Mayo Clinic Rochester, Minnesota (Chapter V) OLAF HJALMER PEARSOV Associato Professor of Medicine, Cornell Uni versity Dledical School Associate, Sloan Kettering Instituto Asto ciate Attending Physcian, Medical Survico Memorial Hospital, New York, New York (Chapter IIII) WILDER G PENTIELD Director, Vontrcal Neurological Institute, Dront real Canada. Professor of Neurology and Neurosurgery, McGill Uni vcrsity Bicdical School, Ilontreal, Canada (Chapter I and II) BROYBOY SANDS Rar Professor of Neurosurgery and Cluef of the Department of Neurosurgery Cornell University Medical School and The Not York Hospital Netr Vork, New York (Chapter VII) CHARLES W RUCTER, Head of Section of Ophthalmology, Mayo Clinio Professor of Ophthalmology, Graduate School of the University of Minncsota, Rochester Minnesota. (Chapter III)

·Officers of the Congress
of
Neurological Surgeons
1956
BLAND V CANXOY
Pro dent
FREDERICK CRERFILOT
Pintip D GORDY
Vice Prendent
Secretary Treasurer
Erecutive Committee
BLAXD Y CAXXOY
TNHAS M MARSHALL
RICHARD L DEAUBSURE
FREDERICK CREIFELDT
PHILIP D GORDY
NABTIA P SATERS
FRAXTLIX EARXEST ILI
HEXBU NI SUCKLE
ROBERT F ΜΑΡΟΥ
DOVALD B SWEENEY, Er-officio
RICHARD L DEXA UBRUBE, General Chairman, Program Committee
THALAS MI MARSRALL Chairman Arrangements Committee

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·CONTENTS CHAPTER V by / Grafton Love, M.D Operative Approach to the Pituitary Gland Indications for operation on the pituitary gland Restoration of vision Emergency operation for pituitary tumor Questions and Anstacre 75 70 78 78 85 CILAPTAR VI by Gilbert Horror M.D Tho Surgical and Irradiation Treatment of Pituitary Adenomas Discussion Summary Questions and Answers 88 03 90 CHAPTER VII by Bronson S Ray, AI.D Hypophysectomy for Cancer of the Breast 100 Indications for hypophy sectomy 100 A satisfactory surgical techniquo 107 Results of hypopbygectomy in mammary carciooma 114 Other techniques for abolishing the pituitary or its function 117 Comments on a 12 minute technicolor 18-mm. film of the surgical technique of hypophysectomy 118 Questions and Answers 120 CHAPTER VIII by Olof H Pearson JD Phymological Effects of Hypophycectomy Adrenal function Thyroid function Gonadal function Other pituitary factors Diabetes insipidus Questions and Answers List of members 121 121 123 125 127 128 120 132 Inder 141 ·INTRODUCTION Wilder G Penfield: A Brief Blographical Sketch* IRA J JACKSOY, M.D Doctor Penfield us a man of many facets. To the reader of this book an enumeration of his medical acromplishments would be redundant and thereforo is omitted. He was born in 1891, at Spokane, Washington, though sinco 1934 has been a naturalised Canadian citizen. At Princeton University, lio tras an excellent student and & football star Ho started one of the first Wilson For President Clubs on the Princeton Campus. In 1914 and 1919, he was a Rhodes scholar and has received 3 degrees from Oxford Unii crsity In terrupting hus studies during the first World War, Doctor Penfield seried in France the latter part of 1916 as a dresser and was wounded in 1917 while at sea aboard the S S Sussex During his recuperation in England, he had the good fortuno to convalcsoc at the bomo of Sir William and Lady Osler The association with Sir William Osler exerted a great influence on our guest in the years that follored. After graduating from Johns Hopkins Medical School in 1918 and spending several ycars in postgraduate study in Europe he became associated with Columbia University and Presby terian Hospital in New Lord. In 1928 he was selected to head the Department of Neurology and Neurosurgery at McGill University in Montreal When the Rockefeller Foundation donated a million and a quarter dollars to McGill Univernty to establuh a Neurological Center to be second tonone on this continent it was understood that Doctor Penfield would be at its head He enjoys membership in many societiegboth on this continent and abroad He is a Fellow of the Royal Society of London the Royal College of Surgeons, the Royal College of Physicians and the Royal Society of Medioine He 18 also an Honorary Fellor of Merton College at Oxford Since 1939 he has received fourteen honorary degrees and has been specially honored by having received the Order of Saint Michael and Saint Gcorgo in 1043 the United States Medal of Freedom With Silver Palms in 1918 the Chevalier of Legion of Honor in 1950, and in 1953 tho pinnaclo of awards the Order of Ment conferred by Queen Elisabeth II The Order of Vert 18 the highest hopor that the Qucen can confer upon her Common Thu wa remixed vernon of the mtroduction by Dr Ira Jackson gren Doctor Penfield to The Congress of corological Surgeous and their guests on Moi ember 1 1956 1 ·CLINICAL NEUROBOROERY wealth subjects and 18 limited to only 24 member. In 1954 he was elected to membership in the Athenacum Club in London, which 18 reserved or clunvely for men of great accomplishments in the Arts and Science Turning to the literary field in 1964, Doctor Penfield wrote "No Other Gods," a fictionalized version of Abraham's search for a monotheistic religion and his leadership of the Hebrew people on tho journey to Canaan and a new destiny When Doctor Penfield visited his mother in Los Angeles in 1935, she had completed 8 novel on the life of Sarah, wife of Abraham, leader of the Hebrew people Since she appeared somewhat diouatisfied with her work he offered to take the manuscript yith him and join her in authorshup Howo er, aho died a few months later Nothing was done to this manuscript for the following 8 years. In 1943, during the War, Doctor Penfield was in Mesopotamia and read in a private library at Teheran an account of the excavation of Ur Ten days later he crossed the desert to Ur and 11 years later completed his novel "No Other Gods "Ho twicc vinted the ate of ancient Ur while yriting his book and brought to the recreation of those ancient days the scientist's thoroughness At prevent time he is writing a povel about Hippocrates and, with his usual thoroughness, he hos visited the islands of Greece to obtain first hand information. He heads the Montreal Neurological Institute as a father, watching and guding his largo international family Both he and Mrs. Penfield gavo each new Fellow, no matter what part of the world he came from 8 feeling of belonging. They shared Sundays and holidays-especially Christmas with the Fellows in the Penficld home, along with their own children, In conclusion it is apropos to quote the preordent of Princeton lo con ferring on him an honorary degree?"A strong and gentle man with extra ordinary dexterity BIBLIOGRAPHY OF DR. WILDER PENFIELD Books Published Cytolor uod Cellular Pathology of the Noryou System. Hocber Now York, 1932 (Editor) Epilepo and Cerebral Loanluation Charles C Thomu Sprm peld IIL 1941 (With TC. ERICKBOY) Manual of Diilitary Neurosurgery Government Protmg Bureau, Ottan 2011 The Cerebral Corta of MAD Macmillan, New York, 1980 (TWith TB RAYOBALY) Epulcptio Soutro Patterne Charla C Thoma, Springfield IL 1850 (With KUSTAN KOTLAXIN) Fpilepay and the Functional Anatomy of the Human Bruno Little Brown, Boston 1854 (Tith Hooler Jura) No Other Gods A Moral of tbe Time of Abraham in Ur of the Cheldeen Liitto Brown Boston 1954.

·ATRODUCTION 3 3 Reports 1 The treatment of octo and progremde hemorrhage by intrarcnous in Joction Am J Phycol 48, 121 1010 2 Contraction was in the normal and liy dronephrotic areter Am J M So., 160, 30 1920 3 Alterations of tho Golgi apparatus in note cells. Brain 43 200-305 1020 4 Tho Golga apparatus and its relationship to Holmgrens trophorgongium in neno cells. Comparison during retigerson Anat. Rco, 22, 57 1821 5 d study of the Sherrington decerebrato animal in the chronic as well as the acute condition. Brain 45, 185-204 192 6 Crannal and intracranial endotheliomata-bemicranroms. Surg., Gynco & Obst. 36, 657-674 1923 7 Osteogenetic dural endotheliomas The true nature of hemicraniogr. J Neurol & Prychopath, London, 4 7-31 19:23 8 Prolonged intravenous infusion and the clinical determination of venous proste Rure Arch Surg 7, 111-124 1923 (With Dam TEPLITZKY ) 9 Subdural effuaon and internal hydrocephalus. Am J Dis. Child., 26, 283-300 1923 10 Dienmgo-cerebral adhesions. Surg., Gynec it Obst., 39, 803-810 1824 11 Microglio et son rapport avec la degeneration neri oglule dans un gliome Tray du lab de rechercher brol de l'Unry Aladnd 22, 777-203 1024 12 Oligodendroglia and its relation to classical neuroglia Bram 47 430-452 1824 13 Tho cranul subdural mace (A method of study) Anat Roo. 28, 173-175 1824 14 Microglia and the process of phagocytoos in gliomas. Am J Path, 1, 77-80 1925 15 Oligodendroglia and its relation to clarcal neuroglia Bol do La Soc. Espanola de Historia Natural, 218, 1925 16 Phagooytic activity of microglia m tho central nervous system Proc New York Path. Soc. 25 71-77 1825 17 Cerebral pnoumography its dangers and usor. Arch Neurol & Paychiat., 13 580-591 1825 18 Surpcal ampeots of the sympathetic nervou quem m the work of Rene Loriche Bull. Johns Hopkins Hoop, 37 380-375 1925 19 The neurological mochanwen of angina pectors and its relation to surgical therapy Am J MSc., 170 88+873 1925 20 Acuto sellmg of oligodendroglia. A specifio type of neuroglia change Arch Neurol & Pwychut 16, 131-153 1928 21 The acute regretare change of neuroglu (Amoeboid due and acute selling of oligodendroglia.) J I Purcholu Neurol 34 204-220 1920 (With W V Coxt) 22 The career of Ramon y Cajal. Arch Neurol. & Prychiat, 16, 213-219 1920 2. Medical Hudents memories of the Regius profesor Sir William Osler Memorial Volume Dontreal 1940, p 385 24 The encapsulated tumors of the nervous system Sury, Graec & Obet, 45, 178- 188, 1827 25 Cerebral cicatri. The reaction of neuroglia and microglia to bram wounda. Bull. Johns Hoplans Hom 41 278-303 1977 (Tith P Da Rro-HORTEGA) 20 Prmciples of the pathologs of neurosurgery In Nelson Loos-Leal Larmg Surgery 107 Vol 2 Chap 8 77 Chronic menmgcal (post-traumatic) headache and its specific treatment by lum bar air insuffilatron Enerphalography Surs Gynec & Obet, 45, 747-759 1807 28 The mechanism of cicatrical contraction in the brain Bram, 50 493-517 1937 ·4 OLINTOAL NZUROSURGERY 2 Method of Faining oligodendroglia and microglia. Am J Path, 163–157 1928. 30 Neuroglia and microglia The interstitial tinuo of the central nervous system. In Cowdry E V, Special Cytolog Now York Paul B Hoeber 1828 Vol 3 pp 1032-1085 31 Needle pulling forceps J AM 1,91 1187 10:23 32 Puncturos of the brain. Arch. Nourol & Prychiat, 20 1-13 1828 (TYith READ C BUCILAY) 33 The field of neurosurgery an address on Canad. MAJ, 19 854-655 1828 84 Nouroglu and microrlia (the metallic mothods) In McClang's Handbook of Microscopical Technique Now York Paul B Hoeber pp 369-388 1929 (With TT V Core) 35 Tho scope of acurology Arch Burg, 18, 1835–1338 1029 30 Cerebral pressure atrophy A Ra Nerv & Ment. Du, Proc (1977) & 346-303 1920 37 Cerebral calcification epilepey Arch Neurol. & Prychiat. 21 1020-1013 1929 (With H RABLE GETALIN) 38. Diencephallo autonomio epilepty Arch Neurol. & Piychaat, 22, 358-374 18:29 39 Nature of von Recklinghausen s dimewe and the tumons amociated with it. Arch Nourol & Paychiat, 23 370-344, 1850 (With A. Y Youxa) 40 Traumatio opilepsy Zachr ses Neurol u Prychiat, 125, 478-572 1830 (With 0 Fons172) 41 The radical treatment of traumatic epilepsy and its ntiogalo Canad. DIA J 23, 189-197 18:30 43. Further modification of Del Rio-Hortega's method of stalong oligodendroglio. Am J Path 6 446 448 1830 43 Tho structuni bes of traumatio epilepty and results of mdıcal operation Brain 53 09-120 1930 (With O FOARD ) 44. Clasification of brm tumours and its practical application. Brt. NIJ, 1 337- 342 1031 45 Neuroglia normal and pathological. In Cytology and Celluler Pathology of the Nervous System Vol 3 Chap 9 pp 473-470 Hoeber Now York 1832 48 The clanfiction of gloomas and neuroglia cell types. Arch Neurol & Puyehnat. 26, 745-763 1831 47 Tumors of the sheaths of the DCTTOUL byrtem In Cytology and Celloler Patholog of the Nervous System Vol 3 Chap 19 pp 064-000 Hoeber Now York 103 48 Ini cerebral vascular normal. Arch. Nogrol & Prychust, 17 30/44 1832 40 Spina bifida and cranium bifidum. J A N A., 98, 454-160 1830 (IYith TV Coyu) 50 Operatre treatment of migreino and obrervations on the mechanit of vurular rain. Tr Am Acad Opbth 1952 81 Principle of the pathology of neurosurgery (rorirod) in Nelson Loose-Lauf Limog Surgery Vol 2 Corpo Nalan Philadelpha 1812 52 Cerebral urodilator Derro and their pathway from tho medulla oblongate. Arch. Neurol & Pryebut., 28. 1257-1299 1830 (Yith Jeny Choron) 83 Tumors of the cheaths of the Dorrow mitom. Arch Nourol & Paychut 17 [218-1309 1163 84 The operature trestment of spontaneous intracerobral hemorrhage Cannd. MI A J, 28, 32-372 1933 55 Hydrocephalus and the atrophy of cerebral compreson In Cytologs and Cellular Pathology of the Nery ou 6sztet lol 3 Chap 28 pp 1201-1217 Hocbor Now York, 190 (With A R. Euro) ·INTRODUCTIOY 5 56 Cerebral localization of cpileplio manifestations Arch Nourol & Pos chlat, 30 701-771 1833 (11th Luz Gact) 57 Tlie er dence for a cercbral vascular mechanism in opileno don. Int Med., 7, 303-310 1933. 68. Ventriculographic interpretation Arch Trurol & Psychiat, 30 1011-1021 1833 (TWith ARNE TOLLY) 69 Neuropathology of the brain In Bentloy 11, Tho Problem of Mental Duoriler 178-183, BCGraw Hill, Nety lorh, 1831 60 The mfluenco of the diencephalon and hypophrou upon general autonomic func tion. Canad, M A. J., 30 689-598, 1831 01 Tradition in medicine Il est J Burg, 42, 20-H2 103-1 Surgery m the treatment of epilepay Surg, Gynec & Obat, 58, 1011-1013 1034 03 The trainmng of a neurologut. Arch. Neurol & Paychiat, 31 812-814 1931 04. Aguaces of the corpus callosum its recognition by ventriculography Arch Neurol & Po chat, 37 1251-1270 1037 (With O HEYDAY) 63 Visual pathram in man with particular reference to macular representation Arch Neurol & Procbiat 33, 816-834 1835 (With J MACMILLAN AYD J P EvAXs) 86 Prinecton and medicine Princeton Alumni lleelly Vol 31 No 31 June 1 1834 67 Achievement m medicine (Addrew at Coni ocation Queens University May 23rd, 1931) VOL 8 NO 1934 68 La effets des spasmes vawulaires dans 1 épilepale L'Union Medicale du Canada 63, 1875-1282 1931 (Read at Congreso de Québec) The agnificance of the Montreal Mourological Institute Reprinted from Neurological Biographies & Addressac-Foundation Volume of Montreal Neurological Institute 1038 mo Hydrocephalus and spina bifida. Sury, Gynec & Obert, 60 313-300 1835 71 A contnbution to the mochaniam of matracranial pan. A Ren Mer & Alent Dis., Proc (1831) 15 399-416 1035 9 Focal epilepto ducherge in a case of tumour of the posterior temporal region. Canad AJ 33 38 1935 73 The frontal lobo in mana clinical Hudy of maximum remorals Bram 58, 115 1030 74 Subdural traction and post-traumatic headacho a study of pathology and thera poure. Arch. Neurol. & Prychiat, 86, 75-81 1836 (With NC NOCHONS) Santiago Ramon y Cajal (obituary) Arch Neurol. & Psychiat, 13, 172-173 1835 78 Epilepsy and surgical therapy Arch. Neurol & Paychiat 36, 440-484 1938 77 A technique for demonstrating the periyuxular nerves of the pia mater and central nervous tyrem Am. J Path., 1007-1010 1935 78 The princples of phynology mohed in the management of increased mtr Cranial pressure Ann. Surg 102, 548-384 1835 79 Special fieldlo in modicine McGill Dfodical Undergraduates Journal, p 3-12 Afontreal Canada, Dec 1938 80 Haney Cuabing (biography) Arch Neurol & Pevchat, 34 635-012 1835 (With I ELLIOTT AXD LTLE G) 81 Hubtemporal and riboccipital myoplastic craniotomy Arcb Neurol & Poychiat, 35 1-11 1830 Almo Canad. AI AJ 34 16-21 1936 (With IV Coxe) 82 Wir Charles Sherrington, Arch Neurol & Pn chiat, 34 1201-1309 1938 (With R Elroe) 83 Inatomic and pacumographic Audies of the temporal hom, with a further noto on pneumographic analye of the cerebral rentricle. Arch. Neurol & Pochut. 37 1021-1034 1837 (With A E. CHILDE) ·0 OLIKICAL NEUROSURGERY 84. The Montreal Neurological Institute ita noeda Ponted as . Bepanto booklet, March 1936 85 The cerebral cortex in man. I. The cerebral corter and consumer. Arch. Neurol. & Puychiat., 40 417-442 1838 Also translated into French by Prof H Boron, 1 Année Pochologique 1838 VOL 39 80 Amold-Chiani malformation. Arch Neurol & Payohust. 40 8-3030 1838. (With DOBALD F Cours) 87 The gliomas of the central nervous syutem A study of 210 verified as A. Remarch Norr & Ment. Dus., Proc (1935) 16, 107-181 1837 (With A. EL VIDAL AXD Y COX) 88 Operative cipoare of the facul capul. Arch. Otolaryng, 23 673-678 1978 (With E. TIED) 8 Tumor of the brain and weful kurvival. Arch. Neurol. & Prychut, 36, 899-101 1930 10 Yilbur Sprong. Obituary note taken from Neurological Blographics and Addremen, Foundation Volume of Montreal Neurological Institute 1830 91 Tho alumnus phenometion. (Addrcos before Princeton alumni) Princeton Alumni Weekly 37 No 28 Apr 1837 92 Bomatic motor and remsory representation in the cerebral corta of men u studied by electraal stimulation. Brain, 60 380 443 1937 (TVith E B BOLDOGT) 83 Tho arculation of the epileptic brzin. A. Res. Nery & Ment. Da, Proo (1937) 18, 000-637 1938 91 Cerebral blood dor dunng induced epileptiform seirures in animals and man. J NeurophFnOL 2, 257-257 1839 85 Intracranial tumors. In Christinn, H F, Oxford Bytem of Medicine, Vol. O pp 137 Oxford University Press, Now York 1838 Do Cortial pread of epileptio dorcharge and conditioning effoct of habitual padaren. Am J Paychiat, 96, 255-281 1039 (With E. B BOLDery) 07 Traitement chirurgical de l'hyperten.xon artérielle Ball Apoc d. mod. do lang franc do L Amorique du Nord, Vol 07 No 11 Nov 1838 (With W V Com) 88 Tho opilepaes. Proceedings of the Inter-State Postgraduate Medical Ambly of North America Oct. 3la to Nov 4th, 1838 99 Medicine and other things. The Megiu Now Díontreal Canada, Aurch, 1939 100 The epilepach with noto on radical therapy Now England J Med, 221 200- 218, 1919 101 Epilepsy od the cerebral leddons of birth and infuncy Cand. MAJ, 41 527- 94, 1930 102 Epuleptogenic lemous of the brain . hatalogio study Arch. Neurol & Prychlet, 43 240-261 1940 (With S P HOTEUTO) 103 The pamint of Harvey Cubing Yalo J Biol. & Bled., 12, 123-520 1940 104 A now mothod of proventmg adhooou Tho um of amnioplastin after craniotomy Brit Bled. J., 1 817–518 100 (TYith YC CHAD and S P HOWART) 1016 Amploplastin e paming. Bnt NJ, 2, 668, 1910 105 Focal epileptogene lessons of birth and Infancy Am J Du Child, 59 718-738 1010 (TYith H. M KEITH) 100 Dunl headache and indervation of the dura mator Arch Neurol & Pochut, 44 43-78 1940 (Tith F L. DIC\AGETOS) 107 Human bekerior efter atendre biletena) rezzoral from the frontal lobe. Arch Tourol & Porchut., 44 421-439 1940 (With D H) 108. Relation of intracranial tumor and ymptomatic cpilepay Arch. Neurol & Psychiat, 44 300-315 1910 (With TC. EXCKHOY AND I TALLOY) ·109 81r William Orlor West, Ontario 31 J, 11, 79-88 1011 110 Acuto postoperative axpuc loptomeningitis. Areli Neurol & Paychat, 46, 250- 276 1911 (With A I FINLATSON) 111 Oneptation of scientific research to kar Sigma di Quart., Vol 30 No 2 April 1012 112 Somo problems of wartimo nourologo Arch Neurol & Pay chint, 47, 830 841 1042 113 Clinical noted from a trip to Great Britam. Arch Neurol & Pechint, 47 1030 1036 1012 114. The Torkildsen procedure for inopcrablo occluson of tho pylvian aqueduct Canad. MAJ, 47 4-3 10-12 115 Health insurance and medical education Canad M A J., 47 523-628 1042 116 Elementary pnaaples of the treatment of head injuries Canad MA J., 40, 90- 104 1013 (With V V Come) 117 Bocialisation, education and research Canad MAJ, 48, 141-142 1943 118 The special bompital in time of prar Arch Neurol & Prychiat., 50 193–196 1913 (With WV COME) 110 Electroencophalograma in post-traumatio epilepay Am J Poychiat, 100 885– 577 1913 (With H H Janiz) 120 Growth Asymmotry due to lesions of the postcentral cerebral cortex Arch Neurol & Prychut., 50 406-430 10-13 (With J 8 M ROBEATBOX) 121 The Bntish American-Canadunn Surgical Moon to the UBS R. Canad. MAJ, 49 48 461 1943 122 A purgical viat to the USSR. Publishod in Proceedings of Modical Panel of Science Congrera, Amorhan-Soviet Friendship Council 55-01 1913 123 Tbo role of stay in the rady of local atrophio lowons of the brain. Am. J Paychiat., 101, 20-35 1944 (With A. CALL) 124 Posttraumatio cpilepsy Am. J Prychiat, 100 750–751 1044 125 Modiano in Free China Brt. M J., 1 891-843 1944. 120 The incidence of traumatic epilepay and headache after head injury in avil praotico. A. Rer Nery & Dient. Dus, Proon (1043) 24, 621-634 1945 (With M BRATA) 177 Obituary Pio Del Rio-Horteps Arch Neurol & Poychiat, 34, 413-416 1915 128 Neuromurgery in the war period. Proo. 2nd Annual Meeting American-Sonet Medical Society Philadelphia, Dee 15 1943 120 Ur of the Chaldeco. Bon. Hist. Med. 19 130-147 1946 120 Notes on operative techno m neurosurgery Ann Surg., 124, 383-385 1946 181 Prychical N, Bot. MJ, 2, 630-141 1946 130 Somo oboervations on the cerebral cortor in man (Ferrier Lecturo) Proo Roy Boo, London LB 134 320-347 1947 133Neurobiology Arch. hustol. Domm y pat., 3, 5–7 1040 134 Obituary-Nikita Nilovich Burdenho Arch Neurol & Psychiat, 57 231-232 1947 135 Medulloblastoma of the cerebellus with aiyal for seventeen years. Arch Neurol. & Peychlat., 57 481-484, 1947 (With FZINDA) 186 Further studies of the sensory and motor corebral cortex of man. Fod Proc, 6, 452-400 1017 (With T RUSZT) 137 The treatment of focal cpilepo by cortical acision. Ann Surg 126, 740-702 1917 (With H STUHAN) 138. Higher level suure, A. Ra Nery & Ment. De Proc. (1046) 26, 252-771 1917 (177th H. Jasz) ·8 CLINICAL NEUROSURGERY 139 Calafyme epileptogenic loods. Arch. Neurol. & Paychiat 60 20-30 1848. (With A VYA) 140 Cleafication of the epilepsie Arch. Neurol. & Psychiat, 60 107–118 1918 141 Histochemical and action potential studies on opileptogeno ertu of cerobral corte in man and monkey A. Res. Nero Mant. Du, Proc. (1046) 26, 218- 233 1948 (TYith Aur Porn, SETTIVA Bomas Hoi JASPO, AND K. A. O ELLIOTT) 142 Bilatoral frontal gyrectomy and postoperative intelligence. A Re Nety & Mient. Due. Proc (1947) 17 $19-634 1918 143 Rcspintion and glycolyps of focal opuoptogenic human brun tue. J Neurophynol 11 485-400 1048 (With K AC ELLIOTT) 144 Late spmal panlyns oftor Avulson of the brachial plane J Bone & Jomt Burt 31 B 40-41 1940 145 Vocalluuon and arrest of specah Arch. Neurol & Psychiat, 61 21-27 1849 (With T RASVUSSAN) 146 Nourosurgory yesterday today and tomorrow J Neuromurg, 6, 8-12 1919 147 Movement of the head and eyes from stimulation of the human frontal cortex A. Ron Nory & Ment. Due Proc (1947) 27 316-381 1918 (TWith T RAR NURSEN) 148 Epileptio manicotations of cortial and mupracortical duscharge E. E G Clin Neurophycol I 3-10 1849 149 Neurology m Canada and the Ouler Centennial Canad MAJ 61 60-73 1049 160 Hero worsłup Arch. Int. Bied 84, 101-109 1919 151 Instability of response to stimulation of the songonmotor cortex of man. J Phraol 109 338-385 1049 (TWith WELCR) 152 Birth injury focal cpilopes and cortical acmon Pednatric 4 167–167 1919 (With 9 LIVIXSTORY) 163 Electrocorticomme on mon effect of valmtery morement upon tho electrica) Activity of the procentral gyrus Arch. Paychut, 183, 163–174 1940 (Tith H JASPTR) 184. Focal epilepsy mensory procpitation and ovoked cortial potential E E. Cim. Neurophynol, 1 349-356 1949 (With F M Fousta, H. JADID AND Lzo Mapon) 16 wliam Oaler - 1001h Birthday McGill New Montreal, Canada, Autumn 1919 180 Tho mupplementary motor area m the cerebral carta of man. Arch Paychiat, 185, 070-674 19.50 167 Oberrations on the anatomy of memory Foln Prychiatrica, Neurologia ot Nourochir leerl, 53, 310-81 1980 188 Obituary_Dr Bons Bablan. Proc Roy Soc. Canada, 44 0600 1850 169 Pardanical improvement in bemiplegia following cortical cocinan. I Neurocury 7 414-420 1950 (With K WELCH) 100 Surgical therapy of temporal lobo xiprer Arch Neurol & Pryebiat., 64 491- 500 1050 (With I FLEXICAN) 101 The state and medical remareh. An address to the Voluntary Health Commuttco of the Senate and the Hour of Commons, Day 3 19.50 Halth Magno, Jaly- August 1 1950 10 Parus L Clinical clarification of the cpilepaon. Comptes Rendus 4 Congo Neurologquo International (1919) 3 28 434 1031 103 Paru II. Oberrations on ccrebral localuation of fonction Comptes Rendur 4 Coopeo Neurologique International (1949) 845 40 1851 ·INTRODUCTION 0 161 Tho rupplomontary motor area of tho corebral cortex. Arch Nourol & Payehuat, 66, 289-317 1031 (With h Vacu) 165 Cranial clues to intracranial lemons. Caldwell Looturo Am J Rocntgenol., 67, 635-50 1052 169 The mechanion of memory Gordon Yiloon Lecture Tr Am Clint Ciumatol A, 62, 1-5 1950 107 Epileptic automation and the centrencephalic integration autem A Roo. NCTT & Dient. Du, Proc (1050) 30 613-623 1052 108. Dicmory mechanisms. Arch Neurol. & Psychiat, 67 178–101 1002 100 Obituary-Sir Charles Sherrington, Nature 169 600 1062 170 Ablation of abnormal cortex in ccrobral palsy J Neurol Neurosurg & Psychiat 15, 73–78, 1962 171 Mortication and conocioumcts in opileptic mirures. Acta Paychiat et Neurol, 27 91-116 1952 (With O MACXUG AND H. JASPZA) 172 Temporal lobo Beures and the tochniquo of subtotal temporal lobectomy Ann Sury, 136, 05-031 1962 (With M BALDWIN) 173 Ictus epilepticus. Cincinnati J Med, 34 35-39 1953 174. In moural sclerosis and temporal lobo sutures produced by hippocampal herniation at birth. Arch. Neurol. & Prychut, 69, 77–42 1853 (lith h DI EALLE AND DI BALDWIN) 175 A congdoration of the neurophynological mechanisms of opecch and como educa tronal conæquencoe Proo. Am Amd Arts & Sciences, 82, 201-214 1953 176 Temporal lobe opilctory Huntetan Lecturo Bnt. J Surg., 41, 1-7 1854. 177 Surgery and science John Stewart Dfemoral Lecture Nora Scotia Med. Bull., Docember 1953 178 The results of surgical therapy for focal opileptic meirures Proc of Internat Nourol Congress, Lisbon, 1953 179 Somo obarvations on amnena. Am J Psychiat, 110 834 1954 180 Mechanisms of voluntary movement. Brain 77 1-17 1951 181 Combined regional and general anesthean for craniotomy and cortical ploration Part I Neurosurgical canaderations. Current Res. m Anesth & Analg, 35, 146- 16 1854 182 Somo obeervations on the functional orgnnuation of the human bram, Proc Am. Philos. Soc., 98, 293–297 1854 183 Localization of discharge in temporal lobe automation Arch Neurol & Psychiat, 72, 606-630 1954 (With Y FANDEL) 184. The permanent record of the stream of consciou nem. Acta Poy chologica. 19.5.5 Proc. 14th Internat. Congress of Paychology Montreal, 1954 185 The role of the temporal corte in certain poychical phenomena. Maudoley Locture J Ment. Bc., 101, No 124 451-465 1806 186 Results of surgical therapy for focal epileptic remares. Canad. MAJ, 73, 515– 831 1858 (With K V E Pam) 187 A glimpee of neurophynology in the Soviet Union. Canad MA J., 78, 891-899 10:55 188 The inmula further obeervations on its function. Bram, 78, Part IV 448_470 1965 (TYith M E FAULE) 180 Epileptogenic lenoni, Acta Neurol. et Pas chual Belgica 2, 76–88 1856 100 The syndrome of aptactoga-orin duo to lerons of tho mmor cerebral hom uphere Arch Neurol & Psychiat, 75, 400-434 1950 (TYith H. Htcazy C BemZAND AXD R. BIALYO) ·10 OLINICAL NGUBOJUBIERT 101 Hippocrate come to a sympoaum on epilepsy In “Epilepte Seisureo Edited by Joho R. Green and Harry F Stealmen Tho Willum & Wilkins Co Baltimoto 2 Md, 1956 192 The Aegean cradle of medieme Tros, and Studies College of Phynchos of Philadelphia, 4 Ser, Vol 24 No 1 20-30 1858 Werr Mitchell Locture.

·CHAPTER I From Hippocrauc Facts to Fiction Ilppocratic Foreword WILDER PENFIELD, MI.D When I was a surgical interno in Boston, at the Peter Bent Brigham Hospital, I found that I was to have a littlo free time during one quarter of the service. So I approached the Chief of the Urological Service, William Quinby Have you some omall problem you would like me to investigato?" I asked him. "I have a little free timo coming." He called me into his study "Before you begin any piece of research," he said "mahe a preliminary study Learn all that is hnown about the subject regardless of what language it is written in." He gave me Nagels ponderous volume on the physiology of the ureter full of dreadful unending German sentences, each of them bristling with verbs at the end like the tad of a porcupine. The preliminary tool longer than the experiments which were carried out on rabbits at night After a proper period of gestation a little publication appeared on Contraction Waves in the Normal and Hydronephrotic Ureter The work was great fun and it almost made a urologist of me! Again I saw the opportunity for a little free time, in November 1953 I could begin to tabe longer holidays with a clear conscience Free time! It comes to a physician lihe golden sunshine through & crack in the door, and with it should come fresh air and excitement. I decided would enquire into the beginnings of Medicine Was it posoble I wondered to find out a little more about Hippocrates! We all know something about his teaching and bu ideal. We call him the Father of Modern Medicine How strange to hnots nothing about him or his life! Every physician cames in his mind some sort of picture of the heroes of medicine Tou neurosurgeons know Ambroise Paré John Hunter, and William Harvey m medicine You hnom Osler, the warm hearted medical scholar the good physician. You knot Cushing well, the man of many talents and many moods who made the surgery of the brain safe and reputable But I dare say you know nothing about the man, Hippocrates. I decided to learn something about the influence that made him what he Fas But once there is no medical literature before Hippocrates, I found myself committed to a study of the Life and thinking of Classical Greece os mell as of modern Archeology-10 small task for the vacation time of a more surgeon! It is that preliminary study I shall talk about this morning ·12 CLIKICAL NEUROSURGERY FACTS TO FICTION WILDER PENFIELD, M.D Tho beginnmge of Modern Dledicine are to be found in the Wntingo of Hippocrates They were collected, copied by hand and used as text books by physicians They were edited first in the tenth century after Christ and were translated and dissected in the Ninteenth and Twentieth Centurics. Alany booke make up the body of writings, the Corpus Hippocraticum. Since none was signed we cannot pot decide that was written by Hippocrates and what may have been written by his teachers, pupils or Associ ates, and how much was added by later coypista But through these writings there shines the light of unustakable genius It seems altogether reasonable to conclude that this light comes from the thinking of one man, and that his name was Hippoorates. He was born in 460 BC and died about 377 when Plato was 50 years of age and Anistotle was age 7, Socrates had been dead then for 22 yours. All of these great men referred to Hippocrates of Cos of the family of the Asclepiads who trained men, for a fec, to be physicians Anstotle, writing some years after Hippocrates death, used him as cxample of the great physician (in his Politics VII, 4) and he did 80 in a way that shows hot Well he was known to Grecks in general "Hippocrates," he said would be called greater not as a man, but as a phyacian than a man who is superior to him in stature.' Aside from ouch obliquo references there is little reliable information about his lufo There is the legend that he and the physician Euryphon from Cadus, were called to treat the King of diacedonia and that Hippoorates refused a omilar invitation to the court of the King of Perma in spite of the promise of great wealth There lingers tho scandalous rumor that he burned the medical library of a nral medical school Appearing in another form thus ancient gossip suggests that he burned the temple of Aesculapius on the Loland of Cos, a preposterous accusation especially apce we now know the temple was built after he left the Island. Other great men of Classical Greece are botter known and theso philosophers pocts dramatists artists mathematicians still live today and move in the minds of many scholars. We manol at the miracle of Greek mind and Greek culture for it uves today in our own minds and culture But Grcel cities are gone and some are lost. Forlorn pillare still stand or havo been set up again in Athens Delphi Epidaurus Mycenac Olympia Troy has been brought to light by digging down into the hill that guarded the entrance to their Hellespont our Dardenelles But the cities of the south castern lcgcan there modern medicide tas bort still wait for the spade of tho acavator ·13 HIPPOCRATIC PACTS TO FICTION In the Fifth century before Christ thc senport cities that hned tho slions of thio Aegean ere Grech. They were proud, independent citics bound to cach other bs tics of culture and by (nendly malucs of nthlctics and intellectual crcrcise. But, in the latter part of tho Fifth Century, (car of conqucat by the rising pon cr of Persia lind made men look to the defcnsce of these cities. Perbia, at lcast, had Icarned from & nntion of sailors, the Plochicano, lot to conqucr by sea as well as by land The inade Persin A sudden trcat to all thic seaport citics of the Acgean The Acgcap Sesi 18 the body of woter Letncen tho peninsula of Greeco proper and the mainland of Asia dudor then called Caria Beyond Car was the mighty kingdom of Persin The result was that Athens had to build the great sell for her protection and many soport citie larther cast actually migrated to defcnable p1081 tion, buildsog och harbors that could be defended They sometimes took their old nained with them The fact that the dates of migration often aro not known explains the Archeological confunons to which I shall rcfer With Mrs Penfield, I have made two soyages of exploration scarching for clues to the life of Hippocrates, first in 1954 and secondly in 1956 In the autumn of 1954 wo 1781ted Greece and Turkey and since I had accepted the conclusions of the medical histomans (1) at that tunc, yo examined and photographed the west end of the Island of Cos where, it Tras thought, Hippocrates must have lived We did the same for the sup prosed ste of the sivul medical school of Cnidus, chartering for the purpose A Turkish caigut, a sailing lessol cqupped with aunlikry enginc Thus, fe cxplored the ruins of Cnidus the city having been excavated by Newton a hundred years ago but deserted sinco that time (2) After our returo to Athens, and as the result of many discusnons and much ndded reading me concluded that to wero probably wrong in both instances First of all the capital of Cos had already been moved from the west to the defrable caster end of the Island when Hippoorates ined there and second the city of Cnidus had not made its more to Tcher point until after that timelt on the * The city behind a great bill of rock led Capo kno or the Troprum promontors It forms the up ol PenD xbore of bad Minor The Penin fula w called the "Dorcan promontory or Ancient Tnopium on the British Admiralty Map The up of the peninsula called Tekur by the Turka. † Afost uportaat were the discurtonu with LUCIADO Laurenn m Rome BD Nenit in Princeton und G E Bend in Istanbul. A long discusson with Hmry Bionit (8) whom to finally met in Rome Tout most helpful umes tho cottopondence with I AI Cook, formats Prector of the British School m Athens and now in Brotol. This U Ripplepted by the opportunity to resd in the London Library tho Library of Pracetoo Unisernts and tho Library of the American School of Classical Studio me Athens 1 ·14 CLIKICAL NEUBOSUBOER The little Island of Cos is close to the southern corner of Ana Minor It has boasted for 25 centuries that Hippocrates Fas born there. * Today the Coan cituene point with pride to a plane tree (Fig. I-1) near the barbor at the eastern end of the Island Hippocrates, they say, once taught his disciples beneath its branches We differed with them in 1954. But, on our return to the Island in the spring of 1956, we could agree with them that it was possible How often ancient and unlikely tradition i found to have some truth in it! It a certain that the tree has been tended through many centuries by Greek and Turk and Greek again. Its mighty limbs are oupported by marblo pillars while new shoots groty up with strength from its roots The most important ovidence, in favor of the opinion that the major city in the time of Hippocrates was already in its present poution came to light when a destructive earthquake occurred in 1933 The city was nearly destroy ed at that time and in the debris was found a fragment of marble, bearing the fifth century Athenian law on currenoy It had been thrown down from the wall of a house where it had long been hidden from sght. This seems to indicate that the city located there, called Cos Díeropis, was consdered by Athens to be the capital of the Loland in 449 B C when Hippocrates was a boy † The rival school of medicine was located at Caidus, pot far away It seems likely that some of the books of the Corpus Hippocraticum were written by physcians from this city which was even more cclebrated for medical teaching than Cos until the 180 of Hippocrates Like Cos, Cniduo also changed its mte, because of the Pernan menace, no doubt But the dato of the move to the second ste has never been certain. Tho Codian peninsula which was referred to as Caidia or Triopia 18 A TRITOw ridge of bare mountains extending from the mainland of Turkoy out into the Aegcan torrard Cos. Only at two or three points are there fertile • It wu because of the fame he brought to the Island that tho splendid temple of Aesculapiu mu budt thero in the mored cyprou grore a short walk from the eastern harbor It us becitime of that modical Indition that Pharoah tbe first Ptolemy brought bla wifo there to be under the care of Coan phyrcan and thus Ptolemy II Tu, born there + Thu ovidence is dixcuted by Dietitt and hu boutco (1) Tho marble coma from the Pentelle quartos of Athens and the seript is Athenu. It u. statement of the tu dve from Com as a member of the Delian Laguo and it was apparently tho m tention of Athens that the marble should be placed in the market place It Betou tery unlikely that much a heury marble would bere been transported for bulldog purporn from dotypalana on the Bay of Caman at the other end of the land to Cos Díeroph a distance of 25 miles. The arthquake occurred during the penod of Italien occupation of the Loland. Extente archeological studies rere caned out at that time under the direction of LaUTCDZI (8) (see also Segro 6) and the damage u restored admirably or authonty of the Buwolini povernment.

·JIPPOCRATIC FACTS TO FICTION 16 Fra 1-1 Tbo Hippocratio place tree Island of Cos A group of German tourist at beneath the tree whilo one of their number lectures to them on Eppocrates. valleys sbuch support the total 6,000 prosen day Turkish inhabitants, though scantily Health came from the sea in thoso early days and Cudus II could seat more than that number in the smaller of its two outdoor theaters where Grech drama tras played. The peninsula is 50 narTot at the base, that it is almost an wland and in deed the Cnidians once started to dig a canal at that point to defend them selves against Perma. That would have converted it into an island but the work t'as Dover completed Instead they moved the city from the south shore of the peninsula to its tsp where they had tro harbors, magnificently defensible behod a totrening island of rool As mentioned above Cnidus II was certainly at that ote after the time of Hippocrates and in later Hellenımtıc tinies The first Greek historan, Herodotus was still a young man in his twen tica living in the cits of Halicamasous then Hippocrates was born From that city he could see the white buildings of the harbor of Cos Meropis 12 miles away Across the water From carly times these three otiega Halicama.cus Cos and Caidumth three others on the Island of Rhodes ere joined together by a Icague that tras as much religious as it Fras political called the Donc Hanapolis (Donc because they were settled by Donc Grecha from the Peloponacour) For many centuries they went their athletes mert vear to compete in the annual Festival of the Tropian ·10 CLINICAL NEUROSURGERY Apollo Almost the only record of the bustory of these cities has to do with this competition and with tho successes of their athletes at Olympia, Delpby and in other pan Hellenic game It is unfortunato that during the middle ages the crusadere used these wlands and cities as bases of their campaigns against the so called "infidel in the Holy Land. The Christian knights destroyed with ruthless bands any beautiful Grech and Roman buildings that had escaped the recurring carthquakes At Halicamassus they used for their fortress the marble from the tomb of Mlausolus, called the mausoleum. It had once been one of the seven wonders of the world At Cos the walls of the knights castle contain lovely carvings from the temple of Aphrodite used as common building stones. Fortunately Herodotus gave us & description of the Cnidian Peninsula as it was in the years when he (and also Hippocrates) knew it Recently two English archeologists Bean and Cook (7) recognised that this desorption did not fit the location of Coidus and Tropion at Cape Kno or Tekir Point Consequently they made a guney of the peninsula examining tho fragments of ourface pottery Thcy demonstrated that, during Hippocrates lifetime and on into the Fourth Century, Cadus must have been located farther east at the ote of the present nllage of Datça Tropion, where tho games were held, they argued was at the site of another tiny village called Kumyer On our second wait to Turkoy we explored tho length of the peninsula approaching it, this time by car from the State Capital of Mugla thanks to the Governor of that State and the courtesy of the Turkish government We passed along hair raising roads that wound over the mountain mdes and so came to the village of Datça where we accepted generous hospitality in the home of Mr Ziya Ekincioglu, the local governor or Kaymakam The first city of Caidus was located on the Bashore in this small but fertile valley The ground 15 covered with sherds or pottery fragments of the clasacal patterns. Evidently the migration of the city west to Tebar Port did not take place until well after the time of Hippocrates. The analyms of the surfaco pottery of the two otes carried out by Profesxor Cook secms quite adequato to prove this. And the descriptions of Herodotus fits that interpretation as we can testify In the second fertile area of the peninsula a bill nges in a commanding position above the village of Kumyer tno mole perhaps from the sand circled Bay of Palamut. A thousand meters off shore is the island called Baba Ada To this it would seem that a sea wall must have been built which made it a safe harbor for all the ships of the cities of the Hexapoli.. This statement requires scrification from others Fortunately to entered tho bay in a calque provided for us by the haymakam while he drore hig ·17 HITTOCRATIC FACTS TO FICTION "}ccp' (the only motor on tho peninsuln) from Datça to Cumalı, so as to tako ug back in the creningI poted that tlic bay hould be an impossible karbor in a soutlierly mind and that there was only one position where & ma all, or mole, irould convert thic taland into a suitable harbor On landing we inquired of tlic custom officer, who entertained us with coffcc Ho undo the statoinent that there was a nall below the surface of thic och running from shore to island at eactly that point. He apparently opends most of his time fieling and his lines, lic said, regularly cnught bottom there although there the deep rater on csther side Also, le liad often seen the fall mith his glass-bottom fiplung box Passing or cr thio position back and forth is the Kaymakam's caique, 1 was ablo to bed bottom, in tho line of the supposed Fall, at a depth of 1 to 3 fathoms screral hundred yards out from short and the same dustanco out from the winnd. On the other land, the soundings ahotta on the British Adurulty map gave the depths of 14 and 31 fathoms there On the towering bill above humycr, the Tropian Temple of Apollo might rell have stood but this must be proven by exoavation. We found the hull very rich in sherds of the same type as those found at Datça. The sloping hullade and level plane boloty would haso made an ideal stadion for the sports in honor of Apollo The conclusons of Bean and Cook (7) must be accepted, it seems to us. Our approval carries no more waght than that of any amateur But it veems clear that sro aro the first amateurs or professionals to explore this fxninsula Mith an interest in the matter since the publication of their study in 1952 We may even tahe satisfaction in the fact that our report of a subinerged sea wall at Palamut Bey adds real support to the contention of Bean and Cook that Triopion nas in the valley at Kunyer and that the games were held thero both before and after the migration of Cordus So I came to the end of my preliminary study There is always a time when you stop perhaps m despair It 18 not that you have learned all there 18 to lcann. But you conclude that you have a fair sample of what could be luarded On lcaring the Cordian Peninsula, we rested then for a delightful penod at the Hotel des Roses on the Island of Rhodes This gnyo us time to roconsider After all, these quction of geography are not of primary soportance, but it is necesary to deal riti them as a preliminary To be understood a men should be seen in hud own environment After he u gone tho environ ments all that us lcft to investigate. I choose not to belicte that Hippocrates 28 a young man lired out to the harbor at Cor Vícropio H. probably taught beneath a plane tree on the short of the sea The nral school of medical teaching in Cnidus was ·18 CLINICAL XEUROSURGERY situated at Datça, 25 miles by boat across the blue water of the Aegean. The great festival of Triopian Apollo tras colebrated cach year in the lovely valley at Kumper, 3 or 4 hours' walk from Cnidus Many other things that cannot be drawn on a map Tero part of his environment. I've experienced some of them Ive been the sky and the Frater, the birds, the trees the flowers that Hippocrates bars I've snelled the air and felt the mind that he felt. I've read his writings and atudied the lives of men he might have mct. All this us written into my card inda and lucs in my memory Thche things add to environment or background. Shall I turn aray in disappointment norr that I can find no morc? Or shall I try to dwcover the man, presenting a picture based on hypothes? I asked myself these questions whilo at Rhodes and one day I wrote out a message from the god of Medicine Don t think that I am a spiritualista Take it as an allegory If I were living in olden times I would begin by telling you that I had a drcamed a dream. And in that dream I heard the voice of a man who cried out to me Asying Let me speak! Let me speak! I am the God of Medicino, Asclepius the Greek god of Healing. After the Greeks the Romans called me Aesculapius. Hundreds of temples were built to do me honor and thousands of men found comfort and cure in them. 'You have forgotten the gods of Mount Olympus, vou modern men. You think of us as myths and fancies of the people of the past. Those people knew that the many gods trore masks, and through those masks they could see the eyes of the living God 'You medical men pay mo tnbute still in every land on carth for you have taken my staff and the serpent coiled about it as a symbol of the best in your profession of medicine. Because of your tribute I will help you if you will but listen to me "I can tell you much about Hippocrates. He is my oan descendant, for I FAB not always a gou First, I tad & man I practiced medicine in Thessaly ten-daye journey on foot north of Athens That was in the days when the Grecks were storining the walls of Troy and my two cous Podalınus and Machaon sailed to join the siege In the writings of Homer you may rend bow tell they served King Agamemnon The trete cunning lecches as well a8 Warriors They pulled out Trojan arrots and spread on the soothing simples 1 had gain them. After Troy fell and the Greeks sailed home agai in troubled triumph my kong returned to practice the healing art Podalınus excclled in the use of medicine and Machaon in surger but they taught the whole art as Chiron had taught it to me They taught it to their pons and those sons to their cons generation after generation These iny descendants were called by the Greek. Asclepiads Tuero ·HIPPOCRATIC FACTS TO FICTION 19 Foro many of thein on the shores of Asia, especinlly at Syrna and Cnidus. But the greatest of the Asolepiads was Hippocrates He wroto down the medical scarets of our family, adding much wisdom of Inis own, 80 that medical men might hnot thicse things for all tino and for all people He separated the true from the false, tho proich fact from unprovablo hypothesis. That was the beginning of medical science as you know it today "Somo centuries after my death, but long beforo Hippocrates was born, Zous raised me up and made me an unmortal god, the Greek god of medicine The Greeks, you know, had a ray of telling and re-telling tho stories of their herocs until they became great. They called me the blameless physician of Thessaly and told stories of mo that were no moro than fancy With their help Zeus created immortal children for me Thcy symbolized the good things in medicinetto daughters Hygeia and Panacea and a pon, the genius of healing, Telesphore 'Hippocrates was born in the Island of Cos in the year that the great Pericles came to power in Athens He lived through the golden age of Hellas. And he is still my chief source of prido although there trore in those lays other good Aeclepiads practicing in Cos and in Cnidus You havo lcarned a little about the way of life in the Greece of that day You have lived where he lived and read nhat ho wrote You have read the scandals the falsehoods men told of him, saying he burned the library of medical manuscripts in Cnidus from joalousy But don t turn away because you have discovered so little Study the problem with reverence, for he is your first medical hero Mon Ine by their heroes The voice was alent and I feared that Asclepius was gone so I called out to him. But the voice began again. It seemed to be at my elbot DOW 'Listen to mel Paint a picture for yourself dipping your brush in tho colors of fanoy There will be errors in the minor detail But you may male fiction tell a truth to which history is blind After all fiction is the stuff that clothes all heroes and I will guide your hand. Tako for the time of your tale a few months in the year when Hip poorates was 28 You would call that year 432 BC Tale that as the year in n huch the library at Cnidus tras burned The burning occurred just after the festis al of Apollo at Tropion It was a woman 11 ho burned it. She set the stage so that men should blame Hippocrates. Say that her name was Olympias and that her son loved Daphne, the daughter of Euryphon, the great physician of Coidus Hippocrates loved Daphne also Through ronance and tragedy temptations and successes Hippocrates continued with single purpose lou know now his way of healing teaching studying. Begin the story as though you were embarking on a project in medical roxarch Obrerie the laws of nature, the law of cause and effect Dfen ·20 CLINICAL NEUROSURGERY reactions have not changed any more than diseases have. Inte 88 well as you can Bo simple and clear Recognize the beauty in life as well as its ugliness "Start on the work, though you cannot see the outcome No man should hope for inspiration until he has carned it by his labor That 18 As true of writing as it is of research Inspiration comes to the man who work with an open mind, the man who waits for wisdom" REFERENCES 1 SUDUOTT h. Letcho on Cos ind Caidus. Ann. Ned. Hot. 2, 13–19 1830 2 NowTOX CTA. A History of Discoveries at Halicamarus, Cardus and Brunchidie Vol 2 London 1882-3 3 BazausT HE A History of Medicino Orford Unur Pren, 1961 4 M DITT B D., Wane-Gey E.T., and Moupons, DI F The Athenun Tribute Lula. VOL I p 609 Am. School of Clasical Studies Athone, 1839–1950 8 LAURENI L L'Odeon di Coo Histone X, 592-06 1931 6 Span, M Clara Rhodos, IX 176–178 1838 7 BBAN G E. AND Coor, JM The Cnidia. Tho Annul of tho Bntuh School m Athene YLVII, 171-212 1952 ·CHAPTER II Thoughts on the Function of the Temporal Cortex WILDER PENFIELD, M.D Some people say that thic licart is the organ with which te thunk and that it feels pain and annety' But I hold, “That to consciousness tho brain is nietsenger For when a nan drans brcatii into himself, the air leaves in the brain its quintouunco and all that it has of intelhgenco and sense "Men ought to knon that fron the brain, and from the brain only, arise our pleasures joys, laughter and Jests as well as our Borrows, pains, griefs and tears. Through it in particular, ne thinb, sco, hcar, and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant." Those words were written Hippocrates 2500 years ago and it is ag nificant that they were found in a book on cpilepsy trhuch was called "The Divine Disease It 18 of course, as casy to say that men think with the brain as it tras to say that they thought with the heart or the lover How is the brain used? That is the question today What subdivisions of function are there within the brain? How do the parts forh? What integrates their action? It was a surgeon nho started off the work in cercbrol localization. Paul Broca pointed to what ho called the seat of the faculty of articulato language in 1801 A physician Hughlings Jachson, became the prophet of the gospel of functional localization within the brain He had a guido to the trorhing of the brain the same guide that Hippocrates must have used He sat in the patterns of epileptic scirurCS a mapping of the funotional areas The serial represcatation in the cerebral cortex, of the crude movements of the different parts of the body and crude sensation of those parts as well are clear almost at once He Batt in that he called the dreamy states, cluck to the nature of the luglier intellectual functions These are the functions that we must discuss in any consideration of the temporal lobe He referred to them as-"Poychucal Htates during the onect of epileptic seisures states thich are much niore clalorate than crudt sensations I speak first' he continued "of certain highly claborate mental statcs sometimes called intellectual aura Taduit the term intellectual aura is not a good onc The state u like that occasionally experienced by healthy people as a feeling of 'reminis 21

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·FTYCTION OF THE TIBORIL (VRTILI 21 During an experiential hallucination #patunt mai lunr 1e, for maniple But if so, le litary # single playing of the musiam tra, piano, or dicent and lie mas like uware of hinın it is ponent in the run or hall. He may bicar 101cm, the avims of friends or of stranger If thing comcd familiar to lum during the internt of time non lxing nendeel, thes are fapuliar to him nor If the men trung then, they art #rme 1101 He may me the people who en Ajanking and the piano l* duh pin), with the man who played it Ile mai on the otiur linnud see things that 110 1911 in an earlier period without bring an At Of wound II lut selt fright then, lu {ccls fright now If he felt a plcusurulli adultion then, die fehle it now It is a m-creation of those things on which he nos fornuing his attention in that inter al of Pret tinc Nor, lowever, lut ix monariour of the pratint as well as tho past It is a little like the double mz* ritnict of man who Katclics a play and yet 18 conscious of lint in golog on Almut lim in the audience. Tho diferenco is that ho diuorcm limueli on the state of tho past as well ns in tlic nudienco of thic porrent W bca such an experience constitute the beginning of n mizure, we have called it n poychical hallucination It is clearer to call it an experiential serrure During tlint and during na periential linluciuntion zirelucual by clectrical simulntion, thero coming back into his prevent tona INA RR an avantacoo of the stream of cxperience that pinance through con riourney in that carlier period There 18 then stored on ay in the ganglionic connections of the briu a permanent record of the strenin of consciouTCH A ricon thnt lx mrti more complete and detailed Hinn the memorie Uhint any and can rull by voluntary effort I made a map of the area of brain froin which etsinslation laurd produced such experiential hinllucinations (91 Tlie frenthint ia mtipplext is Figura 11-1 was that from such sunulation nollt}32% brought back a viviil #trip of past experience But it 18 airo mulin thus farmerni ana dhatjurerptum? illusions are produced and it sniglit he north while to reronickr u lunt there things, in terms of normal function may man Dr Jolip Alullan* and I liavi inace a kukly of the ser just illum1935% among recent cases of temporal folk mrizure* All pontiants in the wrina had clectrical stimulation of the toporal Inly during omtation Tim stimulation was carried out as an axi in planning the theonwyilir (r-inn of cortex. Vfullan revod 214 con cutive 064* to lutris 3 (rior 1> araples acte addel betale of Presel intrritt In this group of 217 ptml, Formely my umorante m llomtrial but no mamme of the brynmirriend I have portmorot of the Carettir of China + This stodr lr mortal du at the end tw Min Minimal เ Avocation in Sunr 1957 hrepented luat in preliminary form only ·24 CLINICAL NEUROSURGERY Inferior pari ingular bank IHEARING Inferior Sylvian batik nsion VISION Fra II-1 Phyacal regonres, stippled. The supenor Arriaco of the temporal lobo is tumed upward The boundary of this cortex, from which stimulation has produced paychical illusons and evoked recollections, is not qute certain in the panetal and in ferior temporal regions (3) 73 had experienced perceptual illusions as an aura before operation or they had such illusions produced by stimulation. In many cases they had both Most of the perceptional illusions may be easly examined under the head ings shown in Figure II-2 The auditory illusions of change in loudness distance or tempo of sounds nere produced by stimulation in the temporal lobe of the minor or major hemisphere with equal frequence and the stunulation points were on the first temporal convolution or close to it. (Fig. II-3) Visual illusions of alteration in clcarce distance neamous shape speed of movement and crectness which occurred dunng cpulcptic dio charge arose in the temporal lobe of the non-dominant-thic minor heti sphere for handedness-in 10 out of 11 cases In this exception it was in the tempomal cortex of the dominant hemisphere ·AUDITORY ILLUSIONE STORY ILLUSIONS FICTIUS or mr Turizi! (OKTIX 2.3 PICHCIL ILLINOx ALTTILITJOY FT MEEST IN ITATINY 1 Auditory tllant Ditaar lour Tomo 2 Iuwal allumons Distance Dimennon turretne Trino 3 Miunoni o compLWIN Familunds Sironmhet Unreality + Muround cmortok Frar Logrlich Synonton Somo* Dioglist Fro. 11-2. Interprise wons of propeat cinerenec On the other hand stimulation produced these illusions in the minor hemisphere for handedncas only The points of stimulation turc scattered Orcr the lateral surface of that tcmpornl lobe. (Fig. 11-4) To more surprised to discover that thesc illusions depended in such a farge ruajority upon the non-dominant licmaispuere and therelore e re called 2 earlier cases in which we remembered that such illusions had been produced in the hemisphere dominant for alxerch In both cams, hometer, the hemisphere was found to be non-dominant for hand! This would suge gest strongly that the interpretation of position and shape-As Tell as of clear cox and speed of things depende particularly upon the function of the tumporal corter of the hemiphere which controls the minor handa Howeer thu actually is in conformity with the findings of our associate Dr Brenda Milner (who will report in the next meeting of the Association ILLUSIONS ILLUSIONS MAR Fra 11-3 Areas from which stimulation at operation produced (s) Auditors illu Hochchango dutietoets, loudner, duaracter of things heard largely og first tetapon cooroutka od either hemuphere (b) Plukoos of lear-namelew fear fricht. Derrot leelma, largeh from mode marface of anterior temporal polo o ather hecat sphere ·26 CLINICAL NEUROSURGERY 1 o VISUAL ILLUSIONS Fra 1144 Vprual illurons, Aren in which stimulation produced an illumon of chango m pontion dimenmon rate of moroment, dutinctness of the things seen. In 12 dulcrent aus simulation produced these illusione, but all were in the minor hemisphere al though 40 per cent of tho total oporations wore on the major homiphore Amode 11 patients who had wch vinul ulunods at the beginning of attackı, the localinton in 10 per mu in tho mmor temporal lobe for handedners and only one in the major hem uphere (see Pcofield and Mullan, 1957) for Rescarch in Ners ous and Mental Diseases) that psychological tests of patients after antenor temporal removal on the minor sido show that thoy have some defect in the recognition of the significance of pictorial material. Anterior remov als on the dominant ode do not produce this defect but leave them with some difficulty in remembering storico expressed to thom verbally, although they have no apbasia Illusions of familianty (déjà vu) were produced by stimulation only in cases in which this had been reported by the patient as an aura They also occurred predominantly as the result of discharge or stimulation in the temporal lobe of the hemisphere which was minor for specch and handed nese (Fig. II-5) Fcar in different forms occurred frequently and we accepted it as an illu son of interpretation It was produced from onc hemisphero as of from the other The localuation was usually in the anterior and infcrior surface of one temporal lobo (Fig. 11-3) To summanic then illusions in regard to things hand and the feeling of fear are produced by discharge in the temporal cortar of both sides AS ·VICTIOS or Tir TIONAL (OKTTX 27 h ILLUSIONS FAMILIARITY - Fro II-5 Illupons of familiarity In 10 came patients had much illumons as epileptic auras. In 9 the ongin was minor temporal lobo and in one the temporal lobe of the major hemmphere Stimulation reproduced the illusion in 6 care all on the minor edo for mpeech and handednem. (Penfickl and Blullan 1957 ) equally The illusions of familiarity in regard to things soen arise most often from discharge in the temporal cortex of ono side that of the minor hemisphere DISCUSSION It is obvious that a large portion of the corter of the temporal lobes » somehow employed in the understanding of present experience and the re cording of that experience This is neuronal activity which is on a higher funotional plane than that of motor or sensory areas of cortex. The motor ind sensory areas seem to serve only as transmitting and perhaps transjuting stations for the motor outflow and the sensory inflot that conets the integrative circuits of the centrencephalic system with the body periphery The evidence as to location of sensory areas in the human cortex as de termined by stimulation 18 shown in Figure II-6 The motor areas of the corter are summarized in Figure II-7 It may be said that the temporal cortex is det oted to the normal processes of perception But perception must be understood to mean something more than reception of sensory stimul Thu perceptional cortex 18 involved frith the centrencephalic system of the higher brain stem m the interpre ·O ONTAALATERAL CLINICAL NEUROSURGERY Alimentary system sensation (Insula) SENSORY LATERAL ROLAN Sylvian (second) sensory (Sup bank) KERINO UOTTORVET histrand SUAL SENS Sagittal (supplementary) sansory? (Contro + peilateral) SENSORY ROLANOK Body sengation, flush palpitats Second sensory Gustatory Heechle ENL. Body thorax bead sengation, cold & heat sens VISUAL TENSORS Olfactory sen Fio 1-6. Sensory areas of the human corta u judgod by stimulation crplor in conscroUS patients. The insula, in which thero y romo port of reprexentation of almentary tnct hu been removed in the lover dnring of the medal surfaco od brain. The "body thort haad nation cold and heat renmtion" whom in the terior temporal polo calls for further şerification. (Penfield and Afullan, 1857 ) tation of those things of which an individual 18 aware and tho compan of the present with past experience This conclusion follows because of the naturo of tho illusions produ by independent ganglionic discharge in that area. It 18 as though cort routine questions Fore asked of the temporal cortex at the time of c. new experience and as though replies were returned through a limi Dumber of standardized anstrering mechanisms. The anstrers indicate thether this has been experienced before whet strange Flicther familiar whcther fcurful And other judgements expected concerning the individual o enviroment Thero must be a fi: common path that leads back into the centml integrating circuits

·PSYCHICAL RESPONSES
(EXPERIENTIAL E INTERPRETIVE
FUNCTIO OF THE TEXTORAL CORTES
20
SOMATIC SENSORTI
SECSEK
SENSORY
VISUAS
Insula and
brain stem
removed
sutom
мо
Heschis
gyrus
AUDITORY
ineren
Fro 11-7 Prychical responset. The corter which w important in interpretation of
present experience (perceptional cortex) = marked pos chical response. Stimulation
there may produce mterpretatire allurons or experiential hallucinations. The insula
has been remored in the lower drawing
Certain constantly recurring conclusions are thus handed on, such as
1) I have experienced this before " "at is famılar 2) There 18 danger'
something to be afraid of 3) Things coming closer' or 'going away
4) Dimensions changing
Before these final interprctations of prevent experience are possible it
is obvious that the prevent must be compared with the past. In order to

·30 CLINICAL NEUROSURGERY carry out such a companion the record of the past must somehow be made available Take, for example, & simple experience lou focus your attention on a man who 18 approaching-ell the previous experiences in which that man tras the center of your attention are suminoned and retreted with no voluntary effort on your part The smile and the gesture of the hand in greeting are familiar, but he is limping—that 18 strange Gray hair at the templc that 18 DCT He speaks, the voice is familiar There is a gun in his other hand, pointed at you. You feel the ugnal of fear, a secondary sensation in the epigastrium perhaps Tho90 samo signals that may come to the consciouFNCE8 of an epileptic as illusions during a perceptual serrure are now brying their normal uso ful purpose familiarity strangeness, familianty, fear They are simple signals to consCIOUSTICss derived now from the most complicated comparison of the present with many past experiences. All these signals are sounded without conscious effort to recall memory Even the name of the man is suddenly provided Jolu Jones,' the bad man of past acquaintance The area of corter which turns in these alarms or mgnals must of necessity also be closely connected with the recordings of past experience and so it is not surprising to discover that the other phenomenon produced by local independent neuronal activity in tłus area of corta is the recall of otups of past experience you had compared the man approaching you wth John Jones as he appeared 10 earlier meetings walking toward you or away, waring smiling or speaking perhaps many years earlier And you called on other strips of experience in which guns were pointed and danger sygdalled Once some days afterward a patient questioned me about her operation You forced mc she said to liyo again things I had forgotten What were you doing? Were you stimulating my subconscious mind?' I laughed at her naire question And then I stopped to wonder (Tam t that cractly what my electrode had done? les in a sense she was right. The identification of John Joney no le approaches 18 camed out by the subconscious processes of memory The perception and recognition 18 all done for you before your conscious com mand of memory tales over Then you recall something about the man but your conscious memory of him is & port of generalization of the many meetings and the things you have heard of him. Hanng focused your attention on him vou begin to record thus mecting and because of the fear of the gun perhaps that record will remain indelibly available to conscious recall as well as for the subconscious purpose of companson, Our pcx evidence suggests that when you are laying down the record of ·FUNCTIOY OF THE TEUTORAL CORTEX 31 your mecting with "John Jones" you are using the amy gualad auclu and thic hippocampal comple of the tno temporal lobe. The complote sotegration of the expericace can only be carried out by combined action of the sensory systems with the coordinating centrenccplialıc system, much of Trhich must be in tlic brain stem It would seem, lowover, that the comparison of tho present with the past is a function of the temporal cortex COYCLUBION In conclusion, it may be said that the temporal cortex, cspecially that of the superior and lateral surfaces of cach temporal lobe, is devoted to to perception. (oco tho area of psychical responses, Figuro II-7) It provides certain interpretations of present caperience interpretations that are cunously standardized Thoy make it possible for the consciour man to recognize any present experience as familiar, strango, fearful, ncarcr, farther, louder, fainter, disproportional, etc A pormanent record of present expericacO 18 only possible when the bilateral mechanism of the amygdala and hippocampal complex is func tioning normally It is certain that the past record is called upon subconsciously dunng the interpretation of present experience This is prerequiste to normal perception The record of the past may mell consist in a faoilitated path- Tay formed by the passage of acne impuloes through ganglion cells of the temporal lobe. These conclusions are rendered more probable by the fact that stimulation of the perceptional cortex may produce detailed recall of the past as well as illuson of interpretation of the present. REFERENCES 1 HiPPocRATES The Bacred Diene tr by W H 8 JOY Loeb Clostal Labrary TOL 2 2 Fexda, W LYD PAXTD V Areb Neurol. & Pochut, 72, 605-630 1054 3 PENDID " Memory Blechanisms. Arch Neurol. & Psychiat, 67, 178-191 1960 Quotions and Answers QUESTION In poychic serrures, should tho minor lobo always be reseoted? uso how much of the lobe should be resected? DR. PENFIELD We use the word psychical seisures because Jackson did and seemed to take it out of the pochic research field.I take it that temporal lobe mesures 10 meant. I dont use the word porchomoter, other because one ix pot sure just that localisation is meant. I like to be as anatomical as possible In temporal lobo seisures of courgo, tho nte of resection depends on where the fit us coming from Temporal lobo seifures are exactly like other focal seirures in that they are arising sometrhere Il the ahnonnality 18 all in one temporal lobe, you have a chance of having ·32 CLINICAL NEUHOSURGERY reasonably good results, providing you remove the origin. There is no reason always to take tho minor lobo rather than the major, except that on tho major sido you have a littlo more to pin it on With respect to the extent of resection, usually there 18 & vein that in dicates tho frontier of rcmos al Actually on cither major or minor sido, you can remove about 5 cm, mcasured back from the top Coming down to tho mcdial surface you take the hippocampal formation back to the end of tho hippocampus. That is the only difficult part of the operation, but it is rcally quite simple if you stay ingido the reflection of tho pia as it runs upon tho midbrain In my opinion, no surgery on the temporal lobo for seisures will over be satisfactory or successful unless this zone is removed. If you have a bilateral focus that is, if the scuzure is coming from both temporal lobes-then there is danger in the bilateral removal of tho hippocampal gyrus. You may interfero with memory, a. I mentioned in my talk. You will not get aphasia on tho dominant ado if the removal 16 restricted to tho antenor 5 or of the temporal lobe QUESTION Can you tell the obstctricians anytbing about the provention of cpilepsy once you thunk that most of the temporal lobo injuries are at birth DR. PEXFIELD Yes, I can tell them, but I don't think tlicy will listen. A very short time ago #c began to realize that temporal lobe opilepsics aro caused by an obstctrical lesion, and no obstetrical clinio as far as I know has taken an interest in it In looking at tho shape of the infant's brain and the shape of the incisura of tho tontonum, I would assume that bilateral presaure from ado would tend to keep the incisurs closed and not promoto the herniation of the temporal lobe whereas pressure from the back would relax tho tentorium and make herniation casier I think that this is somothing in which the obstetricion should begin to take an intcrest. The diffl culty is that the tomporal lobes are not used for the first year or two of life and there is no way to examining now born infants and saying this child has had decrease in circulation of the temporal lobe and in later llfo ho is going to havo temporal lobe scirures It 18 an obstetrical problem. How the thing is going to bo studied and prevented I do not know QUESTIOY Is there a specific arca for cortical representation of tho genitalia for instanco sexual sensation or association? DR. PEXFIELD It sa curious fact that in my oan uporenoo I have found no evidence of any relationship of the cortar to serual activity The only idence of such the patient reported by Ericson #bo had a Dcoplana Ixetween the tro hemisplicres and who had suures that seemed to brolve great rcxual acitement. In the cortex itrelf in my copenence thero 18 no representation or placo for sexual sensation or activity ·FUNCTIO OF TIIE TERITORIL CORTEX 33 QUESTION Do you liave physiological ar nbatomical data explaining the mechanism of ganglionic memory recordings? DR. PEXFIELD That is a very fundamental question Icdon't know what the meclianem is for this record which we knots is certainly there. Thero have beco various suggestions, in my own opinion, I can only assume that tho millions and millions of ganglion cells in the temporal arcas, (coch cell having anythcro from 600 to 700 collateral branches), there is a tremendous opportunity for patterning through theo cclle. With the progress of cach conscious CIDINDCC, tlicre 18 a facilitated pathway through these ganglion cells such remains permanent. It 18 passed over only once with cach experience, and the requence of this pathway becomes pertancnt. I guppose it is from ccl to cell across the connections of cclls that this facılıtation remains in a permanent basis, that must be the basis of memory There are many other forms of memory Once there has been a passage through a cortical system, there is a permanent lowering of threshold, somebot QUESTION Pull you comment on the question about visunl and motor Ilusons experienced by patients durog attacks of Nepierc's Disease 49 related to the temporal lobe? DR. PEYFIELD I don't understand that question, but I suppose that certainly there are calles in which during an illusion coming at the begin ning of an attack-the patient has a change in the may be sees things. They are no longer erect, or they may be com og closer to bem or going farther away, or they become lop-aided. This seems to be a function related to the non-dominant temporal corter. Certainly all of those cases that we have been able to localize have been due to discharges in the non-domibant, that is the temporal lobe which ua minor for hand. You see the same type of difficulty after all up the patient who has a lesion of the temperoparietal cortex in the non-dominant hemisphere after removal or after an Djury there. The patient can no longer visualize the form of external objects and he CRNDOT visualise bis own relationship to them, so that he gets his clothing all mxed up, and he can't draw a picture of a square Those things arai hang together ·CHAPTER III Ocular Manfestations of Pituitary Tumor C WILPUR RUCKER, M.D INTRODUCTION It is appropriate that an ophthalmologist should present the first paper in this sympogum on pituitary tumors as a large proportion of patients who have pituitary tumors complain first of disturbanco of 17310n. An alert ophthalmologist, when he cannot readily explain a reduction of gcuity by the patient's refractive error or by ophthalmoscopic examination charts the 17bual fields. It is to the diocredit of ophthalmology that some patients with pituitary tumors have had several changes of glasses before their oculists have charted their visual fields and localised the source of their difficulty A few patients, on the erroneous diagnosis of chronic retrobul bar neuritis have even received fever thcrapy or large doses of vitamins or cortisone The ophthalmologist, alone cannot make the diagnosis of pitui tary tumor but he can find endence of involvement of the optio chiason, and even determine where and hotr extensively it may be involved. After roentgen ray or surgical treatment of the tumor the ophthalmologut can report on the immediate and later visual changes, whether they are in the direction of restitution or of further logo Sunco it 18 largely for preservation of vision that surgical treatment 16 performed, the ophthalmologist's role 18 ntal, both in diagnosis and in long term follow up DETECTS LY THE VISUAL FIELDO The course of the fibers through the optio chiasm is indicated in Plate I It should be pointed out that the drawings are based on studies made 30 years ago by Wilbrand that some of the details are unconfirmed, and that consequently there may be minor inaccuracies. The drawings aro acceptable as a norling baru horrect the reader must bear in mind that tboy represent the current concept of the chiasm and that they are subject to change in the futuro as more precise knowledge b woes atailable According to Wilbrand (7 8) tho c Arrest picture of the chiaSTO 15 obtained by thinking of it as composed of three layers in the upper layer Aro fibers from the upper quadrants of the retinas, non crossing fibero out PLATE I COURE OF FOOD THROUGH TRE OPTIC CTX (5) (From Rucka he permison of the American Academy of Opht} Imolop and Otolaryngolog) 344 ·35 OCULAR UANIFESTATIONS OF PITUITARY TUVOR number the crowing fibers In the middle layer the crossing fibers are largely from tlic upper nasal quadrants of the retina, the non-crossing fibers largely from the lower temporal quadranto, the pumbers of crossing and non-crossing fibers are about equal In the lower layer of the chiasm the crossing fibers arise in the lower nasal quadrant of the retina and loop forward into the optic nerve of the opposite sido beforc they turn backward to enter the optic tract It is this bundle which is usually interrupted first by a pituitary tumor pushing against the lower and antenor portions of the chiasm. The relatively for non crossing fibers in the lower layer arc from the lower temporal quadrants of the retinas Kostenbąum (4) 188 clanfied tlic complet relationships within the chiesta by the concept of a 45-degree rotation of thc optio nerte around its longitudinal axis as it enters the chiam The upper part of the Derie rotates nasally, the lower part temporally There is a further 45-degrec rotation in the same direction m the optic tract This leads to the upper quadrants of the retinas being projected onto the nasal portion of the lateral geniculate body and the lower quadrants onto the temporal portion. The projection of the horizontal midline of the retina stands vertically m the lateral geniculate body Counter rotation ocmurs in the beginning of the optic radiation where original relationships are resumed the upper quadrants of the retidas are projected superiorly, the lower quadrants are projected inferiorly Patutary tumors produce defects in the visual fields when they becomo large enough to press against the optic chiasm. The pressure and displacement obstruct the function of the nerve fibers Even more important, probably, is the interference with their blood supply The tumor obliterates the capillary bed at the site of pressure and, by pressing against small arteries and veing may occlude vessels in other portions of the chiasm and interrupt bundles of nerve fibers not directly involved by the tumor Large tumors may push the optic nerves and chiasm against firm neighboring structures, ruch as the edges of the optio canale or arteries of the anterior portion of the circle of Willis, and these in tum may interrupt more fibers than the tumor itself This 18 a late effect however The early disturbance in vision has reliable localizing value For the demonstration of defects in the fields of v1100 A vast number of instruments have been designed over the years, and a wide variety 18 81 ailable today Some are merely fancy gadgets, some are research tools, some have special features of distinct but limited value, other relatively ample models are best outed to office use The ideal perimeter, to my mind, 18 not presently available anec manufacturers find greater profit in elaborato equipment than they do in omple basic instruments For oploration of the periphery of the field I prefer a perimeter with an ·30 CLINICAL NEUROSURGERY arc having a radius of 0.33 meter and painted dull black or covered with blaok felt. A 3-mm, whito bead on the end of a black wand 18 a stable target, larger white disks are employed as necessary for charting the dengty of defecte. For adequate exploration of the central area of the visual field the perimeter offcts such a short working distance that tho rcquisto test objects are too small for practical handling. A tangent screen seves this purpose, sinco it permits the meticulous examination of the field out to 30 degrecs. A l-mm. white bead should be pablo over most of the screen at 1 meter except at the physiologic blind spot if there 18 no defect. Any defect discovered and charted mth a small target 18 net explored with larger targets which may be bends or may be rlute disks fastened to the ends of dull black wands The largest target that can be made to disappear indicates tho denety of the defect. The fields aro recorded on charts that represent the field as the patient himself sees it. The field for the night eye us placed to the night on the chart, its upper portion above, its temporal portion to the night its nasal portion to the left. The test object used 13 recorded by a fraction the numerator indicating the size of the test object, the denominator the distance at thich It was used For example 3/330 indicates that a 3 mm. bead was used on the arin of a perimeter which had an aro radius of 330 mm. Likovise 1/1,000 indicates that a l-mm bead tras used at the tangent screen at a distance of 1 meter The boundary of the field for a gren target is known as tho 18opter for that target (6) The characteristic change in the visual fields from a lesion at the optic chiasm 18 bitemporal hemjanopera the result of interruption of crossing fibers Then the lemon 16 a chromophobe adenoma it may not necessarily grow upward in the midline. It may cxtend to one ado or the other, forward or backward. In growing forward it may impinge on the optio nerves and produco scotomas or it may completely interrupt the optic nerve on ono ade before it grots across the midline to the other It may grow backward against one of the optic tracts and produce incongruous homonymous dofects. When the tumor attams a large sve it may press the chiasm or tbo optic nerves against nigd ocighboring structures 67th resultant further tual loss. An Cample of the ordinary bitcmporal hemianopsia 1. furushed by the following Case 1- 47 y car-old farmer complained of failing von weakness and headache Vision had been impaired for 5 years and the patient him self had noticed that with cach eye tho log was to the outer de Two усяга after the onset of the visual disturbance he lost most of his pubic hair and his friends told him he looked pale. His local physician aroured him he ·OCULAR MANIFESTATIO18 OF PITUITARTUXOR 37 Tas not anemic and said l118 symptoms were most unusual, but did not suggest further consultation For 1 month prior to admission he had felt escoicly weab, and for 3 wechs had suffercul fron numerous headnches, intenso but of short duration. Ophthalmoscopic examination dreclosed moderate pallor of both optic disks Perimetric fields demonstrated complete bitemporal hemianopola (Fig III-1), indicating interruption of all of the crossing fibers at the optic chiasm. Roentgenographic cxamination of the licad sloned the sella turcica to bo greatly enlarged by an intrasellar tumor At general physical etamination there was coidence of hypopituitarism Ancurosurgeon, through nght transfrontal craniotony, encountered a huge chromophobe adenoma which had extended upward 6 cm. from the base of the sella 2%20 2%50 V OB. VOD 3 330, 1000 Fia III-1 (core 1) Completo brtemporal hemianopala ·38 CLINICAL NEUROSURGERI turcica and had displaced the optic nerve laterally and the charm posteriorly Ho Tas able to remove the tumor and its capsule There was no improvement of 11810n, and probably none ras to be expected, for the optic nervo heads were atrophro at the time of operation. The pationt has returned at regular intervals duriog the past 10 year At his last vist, about 1 year ago, he tras taking deaccated thyroid, corti sone and testosterone The optic disks pere nearly white Tho bitemporal hemianopsia has remained unchanged. Minimal defects in the visual fieldo may be demonstrated at the tangent screen with small targets in our expenenco, a 1 mm bead at 1 meter u the smallest practical target for the arerage patient. Patients who are unusually alort bay give reliable responses to the 1 mm bead at 2 meters, but we have not found a target as small us that to be useful in everyday clinical work An examplo of a sinall dcfect in the fields follows Case 2-A 24 year old woman complained of a muld disturbance of vision first noticed 9 months previously For 1 year she had been chrodi oally fatigued and liked to havo the temperature of her house about 80 For 2 weeks there had been frequent pains about the mght eye Her men strual periods had begun at the age of 18 years and had cessed at the age of 20 ycars 3 years before the onset of her visual complaint. The ocular fundi appeared normal Perimetrio fields (Fig 121-2) showed a depression in tho upper temporal quadrants, indicating 8 partial D volvement of crossing fibers at the anterior margin of the chiamm Roentgenograms of the skull shoned decalcification in the dormin sellae op tho postarior clinoide and on the left anterior clinod characteristio of an intro sellar tumor The nourosurgeon found and removed a cellular chromophobo adenoma, which presented under the chiasm and between the optic nerves A week after operation viral fielde mere normal and remained so for the year the patient stayed under our care Occasionally the visual lose assumed the form of bitemporal scotomas Since the fibers thet erude in the central portion of the retina decussate largely in the posterior part of the obiasm, it might be inferred that br temporal ecotomas point to pressure at the postenor margin of the chiasm This is truc et timca, but not invanably by any means Bitemporal seotomus may be associated with relatively recent visual loses, inost often less than oct eral months. The reason for this is not clear Case S-A 60-year-old housefe 8 months beforo adminon had noted A vogue blurring of vision and some black specks before her cyce, not of sufficient Andoyance to marrant seeking medical attention three months previously sho had begun to llave intense headaches which Fakuded her at 48 m #th stabbing pain Vithin an hour the paid Fould oubside to be

·39
OCULAR MANIFISTATI018 or TITUITARI TUNOR
6
6%
%
VOD
VOA:
2
1000
*
1000
)
Fra HI-3 (como 2) Partial bitomporal bemianopara
followed by blurring of v781on Tho optometrist she consulted referred hier
to an internist who treated lier for ancinia Because of continued loss of
vieron sho consulted an ophthalmologist, who ordered roentgenograms of
the skull and sent hier to a clinic for scurosurgical consultation. On ad
mission vigunl acuity was somethnt reduced, the ocular fundi appeared
normal visual ficide (Fig III-3) contained largo, dende bitcmporal sco
tomas Roentgenograms of the head bhon ed cnlargement of the eclla turcica
by intrarellar tumor Thoncurosurgeon advised nod carried out an opera
tion at which lio found a largo chromophobe adenoma anterior to the
chuann which had compressed both optic neries and displaced the chiasın
postcriorly He resected a large part of the tumor and its capsule. Ten dayo
Inter tlic voual fields were almost normal
Since the optic neric heads had good color and the sunl loss as of

·40 CLINICAL NEUROSURGERY 20 VOS 2100 2%25 VOD: 330 Fra, III-3 (case 3) Bitcmporal wotomus relatively short duration, this fortunéto outcome was perhaps to be a peoted. In this case the bitemporal scotomes are apparently to be attributed, not to the prease location of the tumor, but to the recent in volvement of the chiasm, When the pressure of the tumor 18 against the optio nerves rather than the chiaan, either central or arcuate scotornas may anso Case A 24-year-old woman complained of headache and amenorrhea of 2 years' duration. Her menstrual periods had begun at the age of 15 years and had been regular until tho age of 22 years when they conmed On camination of the eyes the fundi were normal and the perimetrio fields full Roentgenographic camination of the head showed colargement of the sella turcica with erogon by intrasellar neoplasın. The neurosurgcon advised deep roentgen therapy to the region of the pituitary body Thrce treatments were administered. After 4 months sho returned again. Frontal and ocapital headaches had been constant smce tho previous viat She was depressed and had frequent crying spelle. The optic nervo heads appeared normal Charting visual fields (Fig 111-4) demonstrated in the field of the left eye an arcuato scotoma Roentgenographio examination of the hicad sbored cyidence of an intra relar tumor croding the bella turcica and its posterior clinoida Becqueo of the impairment of 178100 of the left eye the neurosurgeon advised and carried out a craniotomy, encountering & pitutars tumor projecting ustard anterior to the chiasm and compressing the left optio perve Ho removed all of the tumor that he could occ On postoperative recheck the perimetrist found (Fig III-5) that the scotoma had increased in depoity and that there had been further risual loss in the nature of a bitemporal depression Five years later the arcuato scotomas Fero so olight that tboy were ·OOVLAR HANIFESTATIO18 OF MITUITARI TUTOR v os: 2925 330 20 VOD /// 1000 xiooo Fro, III-A (case 4) Scotoma n the field of the left oyo demonstrated with difficulty (Fig III-6) in the wterm the patient had been aware of improvement in vinon, but continued to havo daily head aches and was tired all the time, worried and canly upset Central scotomas occur uncommonly as a consequence of pressure from pitutary tumor An example is furnished by the next case. Case 5m.An 11 year-old boy complained of polyuria and polydipsia, listlerances and occasional vomiting of 30 months duration. Pitressin, pre urbed by five family physician had given somo relief For 1 month prior to admiton there had been pain in the night cye and over the right ndo of the lead. On examination visual acuity and the ocular fundi vcro normal Roentgenographic cxamination of the licad shored an irregularity of the floor of the sella turcica on the left ade that was interpreted as a ·42 CLINICAL NEUROSURGERY 2925 2%25 VOS VOD 330 1000 35 10000 ܬܘܪ̈ܐ 1000 FIQ 11-5 (ause 4) Bitemporal deprenson der elopmental Fanation. It was suggested that roentgenograms be taken again in 6 months for compan800. The pediatmcian made a diagnours of diabetes insipidus and recommended that administration of pitressin be continued although he noted that it was not altogether successful in redering the boy & symptoms. Tho patient returned 2 months later complaining of continued pain over the right cyo and of failing 17310n The ocular fundi appeared normal At permetry i central scotoma ras demonstrated in the field of cach cyc (Fig. III-7) indicating mvolvement of both optio den co Rocotgctographic examination of the bead as repeated and was interpreted by tho roentgenologist on that occanon as showing an crosion of the floor of tho ·43 OCULAR WA VIFESTATIOV8 OF PITUITARI TUVOR 2775 20% 25 VOS. VODI 330 1000 1000 Fio. II- (AS 4) Relatie motoinas in the fields of both wet uclla turcicu by a primary intrasellar tumor The neurosurgeon who was called in consultation made a tentative diagnoos of Rathe-pouch tumor, probably on the bans of the patient & age, and advised left transfrontal craniotomy Ho carried out this operation A fex days later and exposed a large purplish cellular tumor, which completely cncircled the left optio acrte spread out into the left muddle fossa, filled the sella turcica and attended above the sella and undercath the night optic neric Ho tras able to rumoro most of the tumor true The pathologist's diagnosis ras cellular petisi cliromophobe adenoma Because of the nature of the tumor, a course of deep roentgen therapy was administered Perimetric fields pero charted I frech alter operation and were found to have returned to normal.

·44
CLINICAL NEUROSURGERY
20
VOS:
7200
2%
VOD:
60
H
36
1000
9
1000
Fra. Il-7 (* 5) Bilateral central motoru
The patient has returned at y carly intervalo for tho past 9 years and to
dato the visual acuity and the rzual fields have remained normel He 16
DOF 20 years old and feels well although he has not developed a beard or
anllary hair He is taking cortisode deoccated thyroid patresin powder
and testosterone
Pressure on an optio tract produeca incongruous homonymous hemi
Anopoa that is def
In corresponding half fields that are die ular
The charts of such fields are not superimposable
Case 6- A 44-year-old man complained of hcadache He said that 8
years proriously ho had noticed a gradual cnlargement of bus hands feet
and mandible and recalled penods of dooking CICERIT amounts of Fater

·OCULAR LAXIFESTATIONS OF PITUITARI TUNIOR 45 VOD vos 10 35 330 3 330 Pro III-8 (car 6) Incongruou left homonymous hemianopas Four years previously & phy 51cian had told him he had trouble with hus pituitary gland, and 6 months previously lie had had roentgen treatment directed to it Recently there had been headaches and nausea Visual fields (Fig III-8) showed incongruous left homonymous hemianopea indicative of involvement of the nght optic tract Roentgenographic examination of the head showed considerable enlargement of the selle turcica cspecially on the right ode, and widence of Associated acromegaly Since operation was not performed, this 18 not a proved case, yet there can be little question that this is an excellent examplo of incomplete woterruption of the night optio tract Tho dissimilarity in the homonymous defcots need not be as extreme as these In the following caso there was less incongruity Care 7-A 50-year-old women complained of a vague disturbance of vision which she had noticed for 1 year and a definite clouding of vision for 2 weeks Ophthalmoscopic examination showed a mild pallor of both optic dishs Vimal fields (Fig 11-9) showed an incongruous left homonymous hemjanopara which the perimetrist interpreted as indicativo of in volvement of the nght optic tract Roentgenographic examination of the head shotred decalcification and erosion of the antenor floor of the sclla turcica and of the anterior clinoids, due to intrasellar tumor with suprasellar extension General and neurologic examinations did not res cal ab normalities Preliminary right carotid arteriography disclosed a slight clevation of the nght antenor cerebral artery The neurosurgeon, by tray of a night transfrontal craniotomy apored the optic chJasm and found underneath it a large tumor which had extended backnard and displaced the night optic tract upward The tumor a chromophobe adenoma, tras thoroughly removed. Tipe days later Visual fields tere charted again and ſound to be greatly

·40
CLINICAL XEUROSURGERY
2950
VO..
VOD
,
30
330*
IR
1000
1000Y
1060
Fig. III-O (caso 7) Incongruou left homonymotu homianopou
improved (Fig. III-10) Thrce months later when the patient returned for
observation the fields were almost normal and the patient said she folt
Fell There las been no subsequent follow up
Another cxample of involvement of an optic tract is the following.
Cast &-A 54-year-old farmer 1 year before we baw him had been told
that he had a pituitary tumor His youal fields were normal at that time
On admission his complaint was log of vision. His nght optic pero head
was slightly pale and perinctnc ficlds (Fig. III-11) shoved a ngbt lonct
quadrant homonymous lcmniapopsia 60 incongruous as to indicato in
Volrenent of an optic tract in this case tho left Rocntgenographio cam

·47 OCULAR VANIJEXTATIONS OP TITUITARI TUMOR 2%25 2920 VOD: VOS. 330 w 1000 1000 Fio HI-10 (7) After operation ination of the head showed erogion of the sella turcice and of the olivoide by and intrasellar tumor wth suprusellar extension A partial paralysis of conjugate gase to the night pointed to a disturbance in tho pons, further cvidence of artcanon backyard of the tumor The neuropurgeon found and removed a chromophobo adenoma which had grown backrard under the chiasm and extended behind it. Postopcratie chrch of the eyes showed greater defects than had been prevent proviously (Fig. 111-12) There Tas bitcmporal liemianopsia plus a large loko centrally in the left ce Vinon continued to deteriorate Four years efter operation the left ere was blind Vate in the course of mtwton tumor the loss of vion in the result

·18
CLINICAL ATUROSUROERY
V O S.
%40
VOD
%
3
330
re
ne
Fra III-11 (cm 8) Incongruou nght lower quadrant bomonymou bemianopa
not only of pressure on the part of tho tumor itself but of displacement of
the chiasm uppard against the artcral arch of the antenor portion of the
circle of Willis. The constant hammering of the arteries may cut deop
grooves in the chiasm and destroy nerve fibers promously spared by tho
lcoser pressuro of the tumor carlier in its course.
During recent years the skill of the neurosurgeons has so improved that
no specimen of thus has come to my attention for some time For an ex
ample I have had to rexort to a cam pretiously reported (6)
Caso -Tho patient tras a 68-year old man who complained of blind
ness of his left eye He stated that 1700n of the left cyo had becomo blurred
1 year previously about a month later the eye ouddenly becamo blind. At
the same time he had noted an intense headache whuch had lasted coveral
VOS.
Moving
ahjects
VOD
720
IN
Tio III-12 (rame 8) Bitemporal hemjanopga after operation

·OCULAR VAYIFESTATIOYS OF TITUITABI TUSON 40 V O S. Blind VOD 6/42 35 330 3 330 HO Fra 111-13 (cam 9) Bliadnete of left eyo lot of tempoma hall of field of nght cyc (0) (From Rucker and Kernohan by permison of the AMA Archives of Opbthalmology) days. On being questioned, he admitted intolerance to cold for 2 years and loss of strength and potency On examination, the acuity of the nght eye AB 6/12 and its field (Fig 111-13) was contracted temporally, the left eye was blind The optic dioks Terc pale, and the left third cranial nerve was paralysed Roentgenograms of the head disclosed great enlargement of the selle turcica by an intra sollar tumor, with suprasellar extension The clinical diagnosis was chromophobe adenoma of the hypophymus. The neurosurgeon performed a transfrontal craniotomy and encountered a huge oyatio mag containing blood, this mess was stuated between the optir nerves. He was unable to determine whether it was an ancurysm or hemoorthage into a pituitary tumor, no attempt at removal was made. The patient dicd 2 days later At necropsy, tho tumor and overlying structures were removed The portion of the anterior ccrcbral nitenes and the grooves in the chiasm produced by them are shown in figures 111-14 and 111-16 APPLARANCE OF THE OPTIO XEHTE ILADS In the pituitary tumor the optic nerve heads retain a dorma) pink color until visual lose has been prezent for at least several months In some aceptional cases thic nerve licado aro pinh cven after 4_known visual loss of social ycare Pallor occurd much more quickly after trauma to the NCT 18, in a few reported instances as early as 3 reche From a clinicni nekrpoint most patients with pituitary tumor chibit ·60 CLINICAL YEUBOS URGERY Fia. III-14 (ar 0) Patutary tumor underlying the opuc nenes and churn and anterior cerebral arteries. Abore is the tuberculum relas turciane (6) (From Rucker and Kernohan, by perminion of the AVA Archnes of Ophthalmology) F10 111-15 (cure 9) Same specimen ur in Figure 14 Homing sooring produced by the overlook artene (6) (From Rucker and hapoban br permion of the AA Irchive of Ophthalmologs) come rallor of their optic dirks ito intenets being gorerned by the amount and tlie duration of the virual lo & There is much induzdual variation Pallor har definite value in prognosi, nei crthelets IThen the norte lreads on pink (117 if urual lo-s has cuated for many months there is a good chance for improvement in s7rual fields and cten a return to Dora) following craslication of the tumor When the nerse heads are slightly palc ·51 OCULAR VANIFESTATIO14 OI PITUITARI TUNOR and the visual loss is relatively grcnt, improveincnt may be expected and perhaps cien n blight Icoaching of the pallor Whion the nerve heads arc distinctly palc, improvement in 1 1910n is not to be expected, although partini return is noted occasionally When tho disks aro pale and, in addition, tlicrc 18 visiblc loss of nero substance, then truo optic atrophy exists and thero 18 little possibility of recover) of any 17810n or of diminution of the pallor of the disks Tho pallor of the nerve leads may be explained by a constriction of ther capillary networh. In any nerous tissue the volume of the blood Bupply 18 determined by functional activity When function ccases, as in interruption of the optic nerves, a lessened amount of blood 18 required and a physiologic constriction of their copillones ensues Thus 18 evident on ophthalmoscopic camination by the fading an ay of thic capillary petworl on the duk Another factor, probably of Icss importance, is the pro- Iferation of glial tissue that follows the death and degeneration of nervo tissue Papillcdema very seldom occurs in cases of pituitary tumor Then it does, it is a late finding and indicates intagion of the third ventricle. PARALYSIS OF OCULAR XUSCLES Paralyns of the extra oculer muscles 8 infrequent in adenoma of the pituitary, Bardram (1), for example, found 8 instances in 90 verified adenomas, Chamlin, Davidoff and Foinog (3) found 8 in 109, Barrett (2) noted 9 in 308 A rou estimate of the incidence may be 5 to 10 per cent, although my personal observations would lead me to a number some what less than 5 per cent In a group of 15 cages that have come to my attention dunng the past 10 years, the third nerve was involved in AYTY instance, in was the only motor nere to the eye to be affected, in 3 instances the third and the fourth nerves were affected, and in 3 others the third, fourth and exth nerve. In this group of cases there was not a single wamplo of paralyous of the fourth or sixth actie without the third serve also being paralyzed The oculomotor nerves are protected from lateral pressure of the ex panding tumor by the carotid artery Paralysis of the extra-ocular muscles indicates intracranial cxtension of the tumor and ncarly always a rolaticly malignant growth and an unfavor ble prognons. An cxample of unplıcation of the thurd nerro follosa Cave 10-4 58-year-old man complained that for 6 years he bad been tired all the time Wealnces in his legs liad gice difficulty in going up stairs. He had no headaches The consultant in metabolic discares noting hu pasty color omooth dry skin and sparse axillary hair, ipade a diagnosis of mild pituitar infufficiency lloual acuity and visual fields were normal. Illica the patient returned 7 months later he complained that for 2

·52
CLINICAL NEUROBURGERY
months ho had suffered from repeated oramps in his legs and four or five
cpisodes of blurred vision of about 1 hour each. Roentgenographio camina
tion of the head showed enlargement of the sella turcica with clevation
of tho nght postcrior clinoid by intrasellar tumor with atengon to the
right side. Charting visual fields demonstrated a bitemporal hemianopola
(Fig. III-16) Treatment conasted of uradiation of the region of the pitu
tary with the cobalt 60 teletherapy unit.
A month later the patient began seeing double as a result of partial
paralysis of the right thud nerve Tho defects in the roual fields were un
changed The nourosurgeon, through a nght transfrontal craniotomy, found
a laminated pituitary adenoms of moderate size, which he was able to
remove. Ho was not able to explain the paralyns of the third nerve by tho
location of the tumor, and tontatively assumed that there had been an
20125
20/30
VOS.
VOD:
3
330
Toco
1000
Fra III-16 (nux 10) Bitcmporal depresson

·OCULAR MANIFESTATION OF PITUITAR) TUYOR 53 ustension of thic tumor wbiol lie could not ucc A wech later thc dcfccts in the fields and the third nero paraly as had lossened Ninc months later, on the occasion of the patient's most recent vist, nsual fields were normal and tho ncahacae of muscles supplıcd by the third neric was minimal Thicro was no diplopia The paticnt still tired readily, and was rcccinog cortisone, thyroid and testosteronc. When the pence to the muscles of the cycu aro nolied by pituitary tumor, the tumor is usually large and rapidly growing. Case 11-A 47-year-old mind was first sech jp August, 1950, when ho complained of intense intermittent pain at the apex of the right orbit which had been present for 1 month He stated that lie kas double from time to time, but we were not able to demonstrate any weakness of the eye muscles The ocular fundi appeared normal and the visual fields were full Roentgenograpluc camination of the head showed extenstic destruction of the Bella turcica, capecially on the right side. An arteriogram was negative The ocurosurgeon then explored the region of the charm and demonstrated a mass between the right optio pertc and the central carotid artery, tissue from it was recorded by the pathologist as "inflammatory During the following 2 y cars the patient suffered from licadaches of modcrato intensity and genoralized weaknese. Ho returned in October, 1952, complaming of double 1781on, which was found to be due to a partial paralysis of the nglit third nere On November 3, 1952, a defect in the visual field was demonstrated for the first time, a bitemporal deprersion (Fig. 111–17), indicating an involvement of the optio chiasın. On November 6, a second transfrontal craniotomy was performed and an extensive tumor mass was encountered, a specimen of it 1000 Tobo 1000 Fx. 111-1" (case II) Bitemporal deprcanon ·51 CLINICAL NEUROSURGERY 1000 1000 FIO III-18 (care 11) Bitemporal depression and central scotoma was reported by the pathologist to be chromophobe adenoma of tho pitui tary Postoperatively there was complete paralyas of the night third nerve The following year, in August 1963, when the patient returned for observation, the dofect in the visual field was unchanged, but there was a complete paralysis of tho right third and susth nerves with sparing of the fourth nerve and also a paralysis of the night ade of the face By Noi cmber of that year, the condition had become worse and the defect in the field was more extenove than it had been proriously (Fig III-18) At that time thcro was a complete paralysis of the third fourth sixth and ser enth norres Tho patient received roentgen treatment but responded poorly and died in 1955 In this case the carly involvement of the third nervo Tarned that the growth had already utcnded out of the sella turcica that it was more malignant than most, and that the outlook was discouraging. In several cases paralysis of the third neric has appeared after the intr cranial operation. An examplo follows Caso 12-A 41 year old man complained that his vzpon had been failing for 6 months. Ophthalmoscopio examination disclosed a mild pallor of both optic dishs On charting permctnc ficids (Fig. III-19) there was demon strated a bitemporal hemianopera Rocntgonographic examination of the hcad showed the vella to be cnlarged by an intrasellar tumor Operation was advised and carried out and tie pcurosurgeon removed a chromophobo adenoma Sex yo later the patient complained of seming double and there was found to be a complete paraly dle of the night thurd nerc It was assumed that the paraly 318 was probably due to edema of the brain and ·55 OCULAR VAKIFESTATIONS OF PITUITARY TUNOR 20 20 25 VOS 25 V O D M 10 35 330 H 01 Fra TTT-10 (cax 1) Bitemporal hernianopOA hertuation of the hippocampus with pressure of the thud nen e against the edge of the tentorium When the patient returned 3 months later, the visual fields were greatly improved (Fig III-20) and the paraly818 of the third nerve had lessened, there being at that time only a wide pupıl and sught weakness of the superior rectus and the inferior oblique muscles. After another 6 months the patient returned for observation once again Visual fields were unchanged, but the paralysis of the third nerve had completely dwappeared. Oculomotor paralysis 85 & postoperative complication does not carry the ominous implication of such a paralysis seen preoperatively vo: 2920 VOD 20 20 LO 330 JO 4 CT No Fra III-20 (cure 12) Bitemporal scotomas ·50 CLINICAL NTUROSURGERY DUFTHENTIAL DIAGNOSIS OF CHLASUAL LISTOYS Adenoms of the pitotary is by for the most frequent tumor in the region of the optio chraon Other types of lesions to be differentiated are numer ous, yet each indivdually 18 uncotnmon. Adamantinoma belongs near the top of the list. Visual los occurs early and is the presenting symptom in half the cases The defects m the fields tend to be irregular and asymmetrical, and may be bitemporal or homony mous The roentgenologist 15 often able to make the diagnosis on the bans of suprasellar calafication. A meningioma ariang at the tuberculum gellae may produce bitemporal hemianopaa, one arinng at the medial portion of the sphenoidal ndgo may produce loss of 1280n in only one eye Symptoms are restricted to loss of Vision until late. Too often, roentgenograms fail to show evidence of the growth, and neurologio atamination fails to show any other abnormalities. Then the neurosurgcon may be forced to rely solely on the findings of the ophthalmologist Astrocytoms of the chiasm occurs usually in childhood and is sometimes Associated with cale au lait spots and Douroibromatosis. Visual lose u early and may be rapid, the defects in the fields are often bisarre There are no symptoms except loss of vision until late, when the growth extends into the third yentricle and the hypothalamus Stall more rarely the malignant leon may be a chordoma, e pinealoma or a carcinoma of the sphenoid or may even be metastatic as from a breast or a lung. It is becauso of this wide range of possibilities that a comprehen AIVO camination is advisable in every case of involvement of the chiasm. An aneurysm of the circle of Willis may preus against the optio chiasm, producing a visual low that u characteristically abrupt in onset, utegu larly progresnio and fuctuating in ste course with intervale of partial recovery The field defects aro asymmetrical, since the aneurysm u seldom At the midline There is likely to be pain localised behind tho eye. A blow on the head may cause bitemporal hemianopeia the hwtory of injury 11 80 obvious that thero should be no difficulty mits differentiation from pituitary adenoma Chiqsma Larachnoiditis 16 A real enough entity, but in my experienco a rare opo. I have encountered a fos surgically proyed cases due to syphilus a fer presumably due to tuberoulous and a fow of nonspecfic etiology Each presented chiasmal field defects and was explored in order to inves tigate the possibility of a Det grorth. In most instances tho diagnoso bad been suspected prior to operation Thero is nothing of spendio diagnostic value in the visual fields. Dilatation of the third sentnolo through increased intracranial pressuro may result in chiamat or prechlasmal field defects by stretching or dis ·57 OCULAR MAXIFTSTATIONS OF PITUITARY TUMOR placing the chiasm or by interfering with its blood supply In this condi tion the optic disho are alıpays choked This one finding is suficient for differentiating dilatation of the third ventriclo from A pituitary tumor, since tho optio disks are gonnal or atrophic in pituitary tumor CONCLUSIONS The diagnos18 of pituitary tumor cannot be made by the ophthalmologist alone He can report involvement of the optic chiasm, and can nomo with considerable accuracy the portion of the chiasm affected, whether it to to one side or the other or antorior or posterior, but usually ho must leave to others the determination of the nature of the lesion and the extent to which other structures may be implicated H18 finding of an occasional case of paralysis of one of the motor nem es to the eyes gics helpful information regarding crtennon of the tumor REFERENCES 1. BADDR4 M T Oculomotor pareser and non-paretic diplopia in pituitars adenomatu. Acta ophth, 27 225-258, 1910 2 BARRETT J W Malignant Pitmitary Adenomas Thema, Gnduate School, Univerty of Manerota, 1953 3 CHAULIN DIAX, DAVIDOFT L. M, AD FHUYG, E. H. Ophthalmologo change produced by pitotary tumors. Am J Ophth. 40 383–388 1058 4. KUTENBAUM, ALIZED Clinical Plethods of Neuro-ophthalmologic Emmination. Wm Hennemann, Diedical Books Ltd., Loudon, pp 1-22 1918 8 Rucin, C W Interpretation of Vimial Fielda. A Manual Prepared for the Um of Graduates in Bledicine Ed 2 Amencan Academy of Ophthalmology and Oto- Laryngolog Rochester Minnesota, 1056 6 RUCKER CW AXD KIXOTAX J V Totching of the optic chian bg overlying arteria in pituitary tumot. A M A. Arch Ophth, 51 161-170 1954 7 WILDLAND HVAXY Bchema des Verlaufs der Sehnerrenfasern durch das ChasDA Zachr Augenh, 59 135–144 1928 8 TIARAXD HERMANX Der Faserverlauf durch das Chaqma und die intrakraniellen Sehnerven. 8 Karger Berlin 1929 Questions and Answers QUESTIOT What is your opinion regarding further loss of vion from A surgical procedure or from roentgen therapy, and what is meant by suf ficient visual improvement and sufficient visual loss? DE RUCKER Speaking as an ophthalmologist, I would say that any degree of voual loss is serious We regard it as very serious, even if there 10 only a minute defect in the upper temporal portion of the field. I bave been an interested bystander in this for a long time. At times I baie wondered what would be the best way to handle pitutary tumors, but that was acier my direct responsibility I happen to work in a clinic in which, in the carly days, at least, the emphasis pas largely surgical. I am ·OLINICAL NEUROSURGERY sure that our attitude there is influenced somewhat by this emphasis on surgery Consequently, most of our patients are treated gurgically for a year or so, I have been reading various papers on this subject by neurosurgeons It seems to me that in this problem ono series of patients cannot be compared with another series For instance, in one institution surgical treatment 18 proferred, whereas in another institution roentgen tay therapy 18 used. It is not possible, so far as I can see, to compare successfully the results of one institution with the results of another institution. Neither can We compare--for the purposes of our work patients who have been opcrated upon with those who have not been operated upon In former years, at least, patients who were not operated upon did not come to operation for rather definito reasons either the surgeong felt the patients were too ul to withstand tho stress of surgery or there was no vory definite visual loss or some special consideration super ned Hence ve actually havo do berics which we can compare, ono with the other as "surgical" and "nonsurgical I find that our surgeons of considerable experience, such os Dr Lovo, are more inclined toward operation, while I notice that domo of the younger ones prefer roentgen ray therapy I am going to be very much interested, in tho years ahead to see what the results of the tiro at tatudes will be Regarding the other part of the question it is true that some patients exhubit larger delccts in the visual fields after operation. Still I would way that most of them shot improvement after operation Some patients, Ipho appear to be a little worse after operation, aperience their improvement during the succeeding months Once in a while surely we do neo como defects that are rather large after operation I demonstrated one or two of them to you a couple of days ago in my talk on hypophysectomy in the absence of tumor It is true that we see dofects in the usual field after that type of operation also In most cases we are careful to chart tho visual fields prior to operation so that postoperatively we shall have data for companson QUDSTIOY Is thicre como way to interest ophthalmologists in neuroophthalmology in order to obtain competent field studies? DR. RUCTER Thoso ophthalmologists who were so unfortunate as to have taken their training in institutions in which they saw largely oph thalmic surgery and diseases of the eyes naturally became more intercsted in refractions and removal of cataracts and treating glaucoma and such diseases That is not quite as true, as it was years w the oph thalmic board requires ophthal to undergo exe # in neuroophthalmologs and a special on in per hat most younger ophthalmologists probir ad adequat n perimetry So far as I know most of t sirom ) mc tcach ·50 OCULAR WAXIFESTATIONS OF PITUITARI TUMIDA a fair amount of prometry and beuro-ophthalmology As I have rated various parts of the country I have found that residents in neurosurgery in many cases were examining yisunl ficids thenisch ca. The neurosurgeon in charge of the scrice did not call on the ophthalmologist Possibly this was because he had not been able to obtain the kind of holp he wanted on previous occanons, but as he TTBB not in the habit of oulling ophthalmologets for the pork, the residents in oplthalmology did not have access to neurosurgical patients to carry out the caminations in question Parhans neurosurgeons could improro tlo situation by calling for an ophthnlmolo gist ance in a wlule to cxamic some neurological patients In this way rexdent ophthalmologists might become intcrested in the perimetry I think the crentual dovelopment of such rapprochement would work an adiantage to both fieldo llcaoshile, I am sure the younger ophthalmologists are more competent in this regard than ophthalmologists wero in premious years, and they can do perimetry for you, so that you need not resort to doing this type of examination yourgell De Rar Too often in my vicinity, when we get visual fields from an ophthalmologisten in the University Ophthalmologcal Department, tho best has been done by tecbnjuang Vinual fields take time, and it is hard to induce an ophthalmologist, in his busy day, to do the kind of fields that a scurosurgical resident will do De Honra. That is exactly my experienco, we haven't an ophthalmolo gust at the Labey Clinic Wo send patients whom we feel need special types of field studies or any other types of veral diagnosis to some of the neighboring ophthalmologists. However, our fellowe do the ordinary visual fields or me do them ourselves. I Trould agree with Dr Ray, that often opbthalmologists do not obtain as satufactory fields as you would from some of the residenta Da Rock We are cry well aware of this problem. It is one aspect of ophthalmologie practice that must be improved, but I am confident it will be QUDITION TO DR. PESTTELD Could you comment on the problem of x-ray therapy and ncuro ophthalmology in the treatment of pituitary tumors? DR. PEXTIELD In regard to the problem of roentgen therapy, I baren't anything to add Hore er mer experience with ophthalmologists has been qutc different Then a patient retums to bus homo much w a long distance agar me ash some ophthalmologist in his home town to grow regular reports of visun) fields. In my opinion our capericace is a very happy one and the ophthalmolograt'ı milagrck to cooperate with us is a bit hgher than has been preured. As far as loss of Tiaon is concerned, I would just add that it 1 bot question of the les el of 7784al acuty, but rather a question of the rate of the loss of 1990n that should cause the beurosurgeon ·60 CLINICAL NEUROSUBOERY to become alarmed. Above all, we must keep the conception that pituitary tumors are neurosurgical problems and must be handled and followed by neurosurgeons, whatever the method of treatment may be This series that Dr Horrex has studied and reported to us 15, in my opinion, the best studied series in existence, and I think that each of us in handling these 088es should try to follow hus outline as carefully as we can. QUESTION TO D. Homers How often do you see a piturtary tumor er tend beyond the sella without visual changes or extraocular disturbance? Dr HORRAX I think that 18 rare Off hand I don t recall any case of a pituitary adenoma coming into that category On the other hand, we see many ped with cortain endocrinological stigmata and an enlarged della turcica who do not have any visual changes whatover, but I don't know of any that have extended beyond the sella without causing virual changes. DR. RUCKER I bayo DO Fay of arrying at an opinion on that point, but so far as I know our yurgeons do not operate on patients for lesions around the optic chiasms unless there u & defect in the visual floldo QUESTION In traumatio amblyopia Associated with basofrontal fracture, where the fracture goes through the optic foramen, what is the prognosis for the return of vision? DR. RUCKER I praotice out on the prairies of Dinnesota where, A. A rule, we do not seo many traumatic injuries of that pature. In respect to the ones I have seen, I would say that the progonbis 10 poor QUESTION TO DR LOTE Do you ever think it necessary to decompress an optic nerve? DR. LOTE I would say that if there has been complete blindness, the prospects of restoration of vision by carrying out a transfrontal procedure and then clevating the fracture at the optic canal would be very slight. I think there would bo no chance of restoring vigon which was suddenly and completely lost. I have in mind however a very important case which I think was reported many years ago by Adoon and Lallio I had the opportunity of cramming the visual fields of this particular patient on many different occasions. She had sustained a fracture through the optio canal and progressive imporment of zon in that cye developed as the result of formation of callus. Dr Adson decompressed the optio nene and tho result was improvement in her vision. I think, horrever that sudden and complete blindness under the circumstances mentioned is comparablo to the immediate traumatio paraplegia or quadriplegia caused by severe damago to the spinal cord. Restoration of won is not likely, any more than return of nerve function 10 likely after damage to the cord.

·CHAPTER IV The Rocntgenologic Aspect of Lesions About the Sella Turcica Jox D CAP, N.D DIFFICULTIES OP RECOGNIZLRQ CILAXGDS IN TIE BELLA There are many lessons which influence the salla turcica and the optio obiem. These differ greatly in their site of ongin, history, symptoms, progreso, and last but not least, their surgical operability In my opinion they also produce various changes in the rocntgenogram which serve to identify at least some of them from each other The normal wella turcica varies widely in me and shape So great 18 this variation that recognition of disease based on alterations of suc alone 13 frequently difficult and even misleading. Rasmussen (1) has shown, also, that there is no constant relation between the sue of the sella and the sixe of the pituitary gland This further decreases the value of measurements of the sella alone as an index of pituitary diseas. Aly own expericruce indicates that in the past the arcrage radiologzat has paid too much attention to variation in the dimensions of the sella turcica and his underestimated the significance of ourtain basic changes in structure whiob will indicate the presence of discoso long before measurements alone have any value These basio changes, erosion, decalcification and destruction of bono are intimately related to one another They may express themselves in local or generalued changes in contour of the sella or its related processes depending on the type and location of the lemon. Erosion of the Bella, or any of its related processes, 18 due to pressure from a contiguous mass abnormal pulsatian or generalised pressure reflected froin a more remote lesion. This focal or gcncralized pressure produocs a loss of substance of the corter of the exposed surface of the sella or contiguous proocoses. A certain amount of localized decalcification accompanies the presa sure crogion, the degree being directly related to the ate and Beventy of the asociated pressure If the presne 16 of a lot degree and persistent, it may be reflected only in a change in contour of a single process or of tho entire sella mth little cridence of decalcification since in such cases thero 3 natural reparative recalcification at the ate of erosion. On the other hand, of the pressure at acute severe, and progressive, erosion occurs rapidly without opportunity for repair by recalcification and the picture is soon one of completo loss of bone substance, either focal or generalued.

·02 CLINICAL NEUROSURGIRI Classical examples of the decalafication of bono are seen in severe infections of the sphenoid nous and in varying degrees in the presence of contiguous meningiomas In the former, the decalafication results from hyperemia of the walls of the sphenoid moue which accompanies the in fection, in the latter it results both from hyperomia due to increased vas oulanty at the ate of A tumor and from actual pressuro by tumor cells which grow into the haverulan canals of the adjacent bone. Actual invasive destruction of the selle or its related processes occurs mth malignant tumors which may ongipate in the bony structures or involve them secondanly by extension from a contiguous soft tissuo maso Such changes because of thar location and extent are usually not difficult to distinguish from CTOHIOD incident to beniga lesions. Ertepsve pressure erosion of the selle resulting from large pituitary tumors or generalized in creased intracranial pressure may be imitated by a malignant losion of the sphenoid bone such as chordoma, myeloma or carcinoma. In any disoussion relating to erosion, decalcification or destruction of the sella, definite cvidenco indicating the relation of such changes to the duration of the primary disease 18 of great value On the bacas of my own experience I believe that ono can conservatively say that in the preence of increased intracranial pressuro erosion or decalcification of the sells may occur within one month after the inception of abnormal pretrure The abilty of the roentgenogram to reveal this change is dependent on the type of sella and whether or not it is undermmed by a well pneumatured sphenoid onus If the sphenoid below the floor of the sella 18 not poeuma tucd (and it frequently 18 not in children before the age of tirelio years), erosion of the floor may not be recognised until more extensive changes haro occurred NOENTGELTOGRAPHIO RECOGNITION OF BELLAR CHANGES Roentgenographic technique plays an important part in contributing to the carly recognition of changes in the sells and its related processes Stereoscopio roentgenograms are necessary but in order to be of the greatest valuo in this area, these should be made with the tube shifted along the coronal plane The shift of the tube will separate the images of the clioid processes and the edges of the solla, A very important maden er since it facilitates the recognition of focal changes wluch may involve only one process or side of the sella This 16 clearly shown in Figuro IV-1, in which the focal erosion and foreshortening of the right anterior clinoid prooeso tra due to an enourysm of the internal carotid artery IVhen such changes are observed the roentgenologist can be very preciso add exact in the location of a lesion. The mechanics of this crosion are photn in Figure IV-2 a case in which the walls of an aneurysm of the internal carotid

·03
LESIONS ABOUT THE BELLA TUROICA
.
b
Fro. IV-1 Btereoscopic laten vero of the pella, indicating the value of shifting
tho xray tube along the coronal plane & (left) The images of the antenor clinod
processes which are superimposed, appear normal. b (nght) After shifting tube,
images of anterior almond processes are separated focal eronon and foreshortening
of right antonior clinoid due to preapure from a contiguous aneurysm of the right in
tornal carotid artery are evident.
4
Fro IV-2 Lateral vier of rella revealing focal erosion and foreshortenmt of tho
right anterior dinord proces due to pressure from a contiguou calqfied aneuryan
of the right mternal carotid artery

·01 CLINICAL VEUROSURGERY 1 . b Fra. IV-3 Stereoscopro lateral roentgenograms of tho skull. a (left) Images of the anterior clinord processes are sperimposed and therefore appear normal. b (center) Images of antenor clinord process have been separated by thift of tube aloog coronal plane c (nght) Postero-anterior how revealing deakifiation of right anterior climord procem duo to meningioma of tho nght sphenoidal ridge artery are partially calcified Foreshortening of the contiguous anterior clinoid process due to pressure erosion may be seen At the point of contact with the wall of the aneurysm the corter of the anterior clinoid process bas disappeared as a result of pressure and decalcification. Normally the clinoid processes are outlined by a shadow of thin cortical bonc. Dehiscence in this shadow is the first indication of contiguous pressure The images of the anterior clinoid processes are superimposed in Figure IV-38 and do abnormality is evident. Howerer, in Figure IV-3b which 15 the matching stereoscopic film tho images of the antenor clinoid processes are separated and it is obvious that there is a great difference in donaty between them. The same difference is also apparent in Figuro IV-3c, which 18 & postero-anterior viet In this case the tumor cells from an adjacent meningioma invaded the bone and with the associated incrcased vas culanty, have produced diffuse decalcification which results in a diffuse hary mage in contrast with the focal type of pressure erosion shown ID Fig. 11-1 and 2 Therefore the roentgenologist, if he has good roentgenograms and has had reasonable experience may be able to predict the typo of contiguous lesion from the observation of such changes The postero anterior 107 degree angle net onginated by Granger (2) for depicting disease of the sphenoid sinus 16 valuable aloo for revealing and lateraluing focal changes resulting from lesions about the vella tuberculum or opuc neries. Local changes in bone which consist of defects in continuty (Fig.

·05 LESIOVS ABOUT THE SELLA TURCICA Fra. IV-t. The postero-enteror 107-degree projection of skull (Gmoger poaton) revealing focal Tomon and defect in continuity of the called & linc an the result of contiguous meamgromu of the left optic nerro sheath IV-A) or abnormal thuchening (Fig IV-5) of the so called g-line may be more clearly defned rocntgenograms obtained in this pontion than in Conventional lateral or postcro-anterior wewe Tho ostcomatous changes resulting from meningiomas arising about tho tuberculum sellae and poste nor portion of the olfactory grocie may be seen very clearly in the VICTE taken in the Granger position. Such tumors as they enlarge frequently produce croato changes in the floor of the sella and posterior clinoid processes Erosion of the posterior clinod processes may be the result of 1) direct pressure from a contiguous tumor most commonly a partially calcified cradioplaryngoma (Fig. IV-B), 2) pressure from a dilated third rentncle (Fig. 11-71, and 3) mass lesions of the braio (trithout hydrocephalus) #hich produce indirect pressure on the odord processes and sella. In the past it was not uncommon far roentgenologists to accept the prerence of decalcification and circular expa06100 of the sella as endence of a primary intrasellar tumor, (Fig IV-8) Experience has shown, hor. erer that these changes may be produced also by tumors located clson ·66 CLINICAL NEUROSURGERY } Ha IV-5 Meningioma umg from tuberculan Lao (top) Portaro-anterior How of atoll rerealing ortoomatous thickening of so-called aloo at dite or tuunor b (bottom) Late viow of wella, rorealing osteoma at oto of ongin of tumor and warty premuro eroson of floor of sella hero in the cranial cavity (Fig. IV-9) In such cases a displacement of the shadow of the calcifiled pincal gland or evidence of generalized in creased intracranial pressure will provide a clue to the extrasellar location of the lesion. Such evidence may of course, be laching and thereforo it 18 important to remember that whenever the rocntgenogram suggests an intrasellar tumor and the clinical ovidence does not agrec, additional ·LESIONS ABOUT TILE SELJA TUHCICA Fra IV-6 Calefied Craniopharyngoma producing focal cronion of the posterior clood procences and donum relle Fra 11-7 Tentneulomu rerealmg dilated third rentricle with brodoo of posterior cupold protests and rella u s teruit of hydrocephalw due to a corbeler tumor ·Fra 118 Circular apannon and decalcification of the Le produced by primary intrusellar pitaitary tumor Fio IV - Circular cypanton und dealdiation of the welle produced by night temporal lobe tumor The changes onolate thor of intrusellar tumor 68 ·LESIO18 ABOUT THE SELLA TURCICA 9 b F10 11 -10 a (top) Invason of opbenoid bone and destruction of posterior portion of wella caused by lymphocpithelioma of sphenoid mouses. b (bottom) Appearance of rella 5 months after radium treatment. Moto recalcification and restoration of contour of wela. methods of localization such as encephalography, ventriculography or arteriography must be considered. The capauty of bone to recalaly after pressure on it has been relieved, or an invading tumor has been destroyed by radiation is well illustrated br the sella turcica and its related bony processes Roentgenologic evidence of such recalcification us important ovidence of a favorable response ·70 CLINICAL NEUROSURGERY b Fio IV-11 Chromophobe adenoma of pituitar . (left) Decalcificatron and en- Lartement of alle before purgical removal of tumor b (oenter) Realallation of Bella 6 eun after operation and roentgen therapy There WAS DO clinical cridence of Activity of tumor o (nght) Estepave docalcsfication Add further enlargement of mella doe to recurrenco of tumor 11 years after original operation and roentgen therapy to treatment. This phenomenon 18 particularly well illustrated in radiosenative malignant tumors of the sphenoid which invade and destroy the cella without actual onlargement of the pituitary fossa (Fig. IV-10) Since the sella is not expanded measurements are of no diagnostic value and the significant rocntgenologio signs are those of destruction and subsequent repair of bone. When the selle has been decalcified and cnlarged by pressure from an intrasellar (Fig. IV-11a) or extrasellar lesion and the prescure has been subsequently removed by one means or ano her, the margins of the solla will recalcify but the pituitary fossa till maintain its abpormal size and shape (Fig. IV-11b) A roentgenogram always will reveal this evidence of antecedent disease and it should not be interpreted as evidence of an active process. In this connection serial roentgenograpbic studiey made before during and subsequent to treatment are most important in the evaluation of the prognoos. Then an intracranial tumor recurs and the pressure phenomena of tho original discase are re-enacted the sella which had recalcified following trcatment of the lesion will again undergo decalafication and this m portant evidence of recurrence soll be readily apparent if previous roentgenograms are available for comparison (Fig IV-11. 11b and 110) Hero again it 18 the character and density of the bony margins of the sella and not primariy ang tanation in size that indicate disease SULLARY In conclusion, I Tould be to emphasize 1) the importance of focal changes in the body contour of the colla turcica and its related procerect As an index of disease before any significant change in size of the sella ·71 LASIOV8 ABOUT TA SELLA TURCICA occurs, 2) the value of decalcification and recalcification of the contour of the vella in follomog the course of intracranial duscate, 3) the fact that a circular, uniformly enlarged sella, long recognized as characteristic of a pitutary tumor, may be produced by tumors atuated clocohero within the cranial cavity, and 4) the indication for supplementary methods of localization such as rentnculograply, cnccphalography and arteriography when the clmcal and rocntgenologo findings do not agree. I believe that the radiologist and clinician should be concerned first with courentional roentgenograms of tho sella and chrasnal area. If they do not ove ovdence of a lesion then one must consider what other procedure to use. Certainly if you nuspect a chiasmal lesion, arachnoiditis or pacudo-tumor syndrome thes & pneumococephalogram Tould be more fruitful. However, when you consider the type of tumor seen most free quently in the parisellar region, and there is nothing to stay you from the clmical findings, I think that angograpby has a greater chance of being helpful than encephalography Frequently you will bare to use both. REFERENCES | RAKUSEN AT A quantitative study of the human hipopbyu cerebn or pitu tory bodr Endocrinola &,509-0H 1924 2. Gud, A Poniture identification of sphenoid and ethmoid anuses. J AMAR 81, 1338-1340 1923. Questions and Answers QUESTION Have you ever seen a look, eroded fragment of bone above tho sells which simulated calcification within e pituitary adenomat DR CAMP Yes, I have been that and it is very easy to confuo calcification of a carotid artery with calcification of a chromophobe tumor Calcı fication in the latter does not occur very ofte-only in about 4 per cent of rich tumor in my experience. Fragments of detached bone may fool you and I don't know of any definite vay to distinguish them, ercept that they are usually not as aharply defined or as sharply curvilinear in character as 1 Akular calcification or calcification in the capsule of a chromephobe tumor QUEXTTOY Cao intrasellar pressure be differentiated from intracranul pressure by Iraj alone? DA CAMP Nothing is 100 per cent in thu business but I do think that in most cares it 18 posable, rith good I ray films, to come pretty close to telling whethu the change renult from a lesson within the sella or contrguous to it, or tracther they are the result of pressure reficcted from a geacral increase of intracranial prexture. There are a number of things that mll help In the young individual, before suture union occur you hare reparation of suture lines and ranations in contour of the outure ·72 CLINICAL NEUROSURGERY shadows. In an adult there is thinning of the bones of the skull and par ticularly in the postero-anterior view you may see a thinning on one do of the calvanum You may also get a shift in the shadow of the pineal gland. Certainly, if the pineal gland obadow is displaced 1 cm, to ono mdo or the other and tho sella has a round configuration simulating that of erosion from a pituitary tumor, you would not make a diagnosis of a pitwtary tumor I think if we connder all of the changes which may be present, it should be possible in most cases to differentiate primary intra Bellar pressure from generalised intracranial pressure QUESTION Please repeat the significance of a double contour of the floor of the selle Dr. CAP Brofiy, tho sella, in the presence of a pneumatized sphenord sinus should give a sharply outlined contour of the patient is properly poortioned. When there is increased pressure within the sella itself or within the calvanum, the pituitary gland is pushed downward and that pressure will first produce a decalcification of the floor of the sells so that instead of being sharp and clean-cut bke the wall of a normal ethmoid cell, the outline of the polls becomes fury and industmot and that produces a po called double coutour If the pressure 18 relieved or the tumor 18 removed, the sella will recalcıy but it will have a double contour and double denoty because it never goes back to its original shape again Orcasonally, the false appearance of a double contour may be produced by a partial rotation of the head of the patient, and OCCasonally by variations in tho pneuma tisation of the sphenoid itself Usually you can recognise that, but if thero 18 any doubt a planigram will frequently help QUESTION Have you been a rounded calcifioation in the cavernous anus without accompanying bove changes and in the presence of a normal angiogram? If so what is it? Dr. Care I have ney or been one QUESTION Please repeat the agnificance of a double contour of the floor of the rella DL CAMP Briefly, the sella, in the presence of a pneumatused sphenoid distinguishing and evaluating lesions about the selle but unfortunately encephalography is a mechanical procedure and good filling with air 13 dependent upon an adequate drainage of the subarachnoid spaces Because inadequato drainage us so frequent I think it is hazardous to bo too pool tive about the presence of small cuprasellar Icoons from changes in ad cncephalogram alone If you have a unilateral alteration of the rostral rulcus and you can be certain that it is persistent from a study of stereoscopic films or planigrams then I think it is of value. Sphenoidal ndgo tumon and even meningromas of the tuberculum sellae are dificult for me to recognise in an cocephalogram and certainly in attempting a diagnosis ·73 LESIONS ABOUT TIE DELLA TURCICA of chiammal arachnoiditis you may run into a trap because of incompleto drainage of the basal cisternac. There are so many is about it, that unless the change in an encephalogram are very obnous and delidate, I think the chances of recognizing a small lesion are really better with an angiogram. QUESTION That causes the erosion of the clinoids and dorrum with increased pressure? DA. Caur Itaa mechanical phenomenon It does not make any dullerence whether the increase in pressure is due to an internal hydrocephalus or whether it is due to the mass effect of a bug tumor which has increased the size of the brain. The eclla happens to bom the central portion of the akull and is very vulnerable to prcsuro wherever at may ongipate. The pressure causes a demineralization. If scade pressure I exerted upon any bone of the body and held long enough, demineraluation of that bone mill ocour at the ate of pressure. This bas been seco many times in experiments The skul is a closed box and pressure from a tumor on one side of the brain us distributed rather generally throughout when the mass is large cough, 80 that the change from a large nght occipital tumor for instance is not going to be much different from that caused by a large left occipital or left frontal lobe tumor There may be certain minor distinctions but bancally the changes are about the same. If you observe the sella at outopsy you will see how the pituitary is pushed night down into the pituitary fossa by increased intracranial pressure QUESTIOY Does the nature of crosion of the clood processes belp greatly m localling a paravellar lesion? DR. CAMP Yes, I think it does because of the erosion 18 unilateral you can lateralso the tumor Also, If it is not only unilateral but has involved an aaterior cunoid process or varolves only the posterior chood and the dorm you have been mort precise in localizing it, not only as to the ode but also as regards the area of the lesser wing or the dorsum of tbe kella staclf Such changes also help in distinguishing on intrasellar tumor from the usual paragellar tumor QUESTION What is the significance of a lateral pineal shift of 5-6 mm in the abecnce of clinica) symptomst De Cue te are getting a little away from the chiar but in tho absence of clinical findings of any sort and so other x-ray change I would be hesitant about putting too much value on a 5 mm lateral pineal shift I believe honerer that s lateral shift of the pineal 18 much more agnifi rant than a forward or backward shiit. A lateral shaft occun moro frequcatir mth a temporal labe tumor than with a tumor located elsewhere. If the patient has only . lateral shift and there is reason to rusprct a tumor I could bet on to being in the temporal area Hotever I think ·74 CLINICAL NEUBOSURGERY you have to be a little bit practical about it all too The shape of the head has some influence on the position of the pneal gland. The scaphooepbalio will nullify the normal measurements in a fore and aft pincal localization. Similarly, & turricephalic skull vill throw off the vertical mcasurements An asymmetrically developed skull 18 lik c# 180 81 cxception I have seen one patient who had a hemi hypertrophy of the body in which the hemi hypertrophy of the brain caused asymmetry of the skull. The pineal and falx as well were over from the inidline but that condition 1. not common and the physical appearance of the patient would keep you from accepting the lateral pincal shift alono as evidence of a tumor QUESTIOY What about the roentgen therapy of pituitary tumors? DR. CAMP Yith the advent of super voltage x ray and radio-active cobalt therapy, the results from the radiation treatment of pituitary tumor have been improved I think it is largely a matter of efficiently getting adequate dosage into the tumor You have the over present problem of proserving noon and whether you give x ray therapy or not the patient should be very carefully followed. If the vision is decrcanng, the proscuro had better be relieved one tray or another Dr HorTax bas discussed the question of r ray versus surgery in Chapter VI BO I think we liad better let that angiver muffice for not ·CHAPTER V Operauve Approach to the Patutary Gland J GRAFTOY LOVE, MID Wint I shall say docs not necessarily reflect the attitude of my associates in the Section of Neurologic Surgery of tho Mayo Clinic With 8 neurosurgeons la1z06 their indivdnal services, there are lound to be difference of opinion regarding surgical techniquc. Wat 18 stated here 18 not meant to be considered as the only night way to handle a patient with a pituitary tumor but rather 18 a way that lias prosesi satisfactory in my hands The late Dr Charles I Frazic (1), of Pluladelphia, introduced in 1913 a technique of approach to the lıypophy us through the anterior cranial forsa, a modification of vluch 18 in mather general use todav At that time Dr Frasier said the hypophy B15 as the last of the ecrehral structures to como within the scope of surgical therapy Tho hypophysis had been conadered 'noli me tangure' by the surgron because of its deep location and surrounding important structured the cavernous sinuses, the optic nerveg chiasm and tracts and the internal carotid artence Alane(2) in 1880 had pointed out the etiologlo relationship of aoromegaly and perverted function of the hypophy Blb He gave the incentive to therapy of the hypophy818 There are two principal modes of attack on the decply situated structure One u the intracranial aprroach and the other the catracranial or trangsphenoidal approach Horsley (3), in 1908, removed a oy at of the pituitary through the midcranial fosos after elevating the temporosphenoidal lobe. This approach 18 not very direct and necessitatet too much traction on and elevation of the penative temporal lobe According to Frasier (1) Krause in 1005, as the first to suggest approaching the hypophyes through the anterior cranial fossa by rerecting the frontal bone and proceeding estradurally until the Icsser wing of the herojd 18 reachd at which juncture the dura is incused and the hypophyos is casily exposed. Surgery the Irypophyus 18 kad according to Frazier (1), to have had its adrent in 1007 mhrn Schloffer performed his first sucessful operation by approaching the hypophysis by the ertracranial and trans mphenoidal route Horrever Frauer considered Schloffer & Operation rather 75 ·76 CLINICAL NEUROSURGERY crude and disfiguring Hirsch (4) introduced tho endonasal approach, which still seems to be the best extracranial procedure. There are two main objections to the extracranial operation first, the ruk of infection from tho mucous membranes (with the introduction of antibiotics, this objection Tas largely overcome), and second, the small exposure that is possible by this route Suprasellar and paranellar e tensions of the tumor cannot be removed by this approach Frasier's orginal operative approach to the hypophysis through the interior cranial fossa vas needlessly complicated, laborious and very likely to be disfiguring Ho resected an osteoplastic flap from the right frontal region, removed en bloc tho supraorbital ridge the portion of the roof of the orbit, later replaced, and rongeured atray the remains of the arbital roof to the optic foramen He then opened the dura to axpose the tumor and visual apparatus It is of interest that he used intratracheal anesthena in his first case Later Cusłung, Adson, Nafinger and others modified the frontal approach into the more or less standard transfrontal craniotomy which 18 employed today INDICATIONS FOR OPERATIOY ON THE PITUITARY OLAND Indications for operation on the pituitary gland are as follows (1) To pregetic and restore viaon, (2) to relieve increased intracranial pres sure that is when tho tumor 18 suprascllar and compressed the third ventricle and in the rare caso of intraventricular tumor, (3) to preseri o life when the tumar 18 so large that it compresses a temporal or frontal lobe of the brain or obstructs the third ventrcle Before undertaking surgical treatment for a suspected pituitary tumor, It is essential to ovaluate the paticnt : gencral and metabolical status as well as his ophthalmological neurological and roentgenological status. The chromophobe adenoma the most common tumor of tho pitutary requning surgical treatment is often associated 17th hypopituitarism, and the degree of lack of function of the gland should be determined so that the patient may be adequately prepared for surgical trontment and a base line established so that postoperative therapy may be more satisfactorily planned. Eosinophilic adenomas of the pituitary thich rarely receive surgical removal because they rarely impair vision are often ASRociated with adenomatour goitert which may be very large and may impair tho pa ticat & AITTAT Onzag to compression of the trachea Occioonally the goiter may be hyperfunctioning Usually if there are (1) a bitemporal rigual dcfect (2) an enlarged and croded sella turcica and (3) evidence of disturbed pituitary function the ·OPERATIVE APPROACH TO PITUITARI QUAND diagnosis of pituitary tumor 18 well founded Hotrover, other types of tumor may compress the pitutary gland, interfere with yzkon and orodc the bella turcica. Such tumors are adamantinomos (craniopharyngomas), epidermoido, meningiomas and ancuryams. I there w a history of unilaternl retro-orbital pain, third acrve palsy or unequal ar unilateral erosion of the salla turcica, carotid angography should be performed to exclude an ancuryam. Choking of the optic diska raroly occurs with pituitary adenomas, there fore, if there 2 edema of the duke in a patient suspected of having a pituitary tumor, at 18 rise to perform ventriculography (Fig. V-1) to localize the lesion more accurately It may be a suprasellar adenoma blockung the third ventricle or å foramen of Monro, or rarely the admomna may bo ntuated in the third rentrcle Edeme of the disks 18 more common wth adamantinom In some cases of homonymous ruual deſeot, particularly if there is unilateral erosion of the cella, angography, Air studies or both are indicated to exclude aneuryan, astrocytoma of the chiasm, parasellar tumor and temporal lobe tumor Foo I-la Tho anteroposterior ventriculographic projection, shorin metal sdro ceptualus nth testing of the third Teatncular shadow due to . large nuppellar de Doma of the pitutan Tho bumaor awed marted dustorison of the third rentarle with Ritfirent bocbage of the rentricular system to product obstructive hydrocephalus FI V-16 Bame caso s-lo showing lateral Tes of bead uter substitution of air for dud in the sentricular gutta Tho enlarged eroded ril á viable The distortion of the third yetnete mtb enlargement of the lateral sentschen because of obstruction robo ·76 CLINICAL NEUROSURGERY crude and disfiguring. Hirsch (4) introduced tho endonasal approach, which still seems to be the best extracranial procedure Thero are two main objections to the extracranial operation first, tho nok of infection from tho mucous membranes (with the introduction of antibiotics, this objection was largely overcome), and second, the emall coxposure that 16 possible by this route. Suprasellar and parasellar en tensions of the tumor cannot be removed by thu approach Frasier s ongipal operative approach to the hypophyns through the anterior cranial fossa was needlessly complicated, laborious and very likely to be disfiguring. He resected an osteoplastic flap from the night frontal region, removed en bloc tho supraorbital ndge with a portion of the roof of the orbit, later replaced, and rongeured away the remains of tho orbital roof to the optio foramen. Ho then opened the dura to expose tho tumor and visual apparatus. It 18 of intcrest that he used intratracheal anesthesia in lus first case Later Cushing, Adson, Naffziger and others modificd the frontal approach into the more or less standard transfrontal craniotomy which is employed today INDICATIONS TOR OPERATION OF THE TITUITARY GLAND Indications for operation on tho pituitary gland are as follows (1) To preserve and restore nigon, (2) to roller c increased intracranial prese sure that is when the tumor 18 suprasellar and compresses the third ventricle and in tho rare case of intraventricular tumor (3) to prescrvo life when the tumor 1960 largo that it coinpreuses a temporal or frontal lobo of the brain or obstructs the third ventnolc. Before undertaking surgical treatment for & suspected pituitary tudor, it 16 essential to ovaluate the patients general and metabolical status as well as huis ophthalmological, neurologoal and rocntgenological status. The chromophobo adenoma, the most common tumor of the pituitary requinng surgical treatment, 18 often associated with hypopitutanam and the degree of lack of function of the gland should be determined so that the patient may be adequately prepared for surgical treatment and a base line established so that postoperative therapy may be more antiefactorily planned. Eosinophilic adenomas of the pituitary which rarely receivo ourgical removal because they rarely impair vision Arc often associnted with adenomatous goitcrs thich may be very large and may impair tho pa tients airway oming to compression of the traclien. Occasionally, the goiter may be hyperfunctioning. Voually if there are (1) a bitcmporal visual defect, (2) an cnlarged and croded sella turcica and (3) ovidence of disturbed pitwtary function tho ·77 OPERATIVE APPROACH TO PITUITARY GLAND diaga 0818 of pituitary tumor 18 well founded. However, other types of tumor may compress the pituitary gland, interfere with vinon and erode the sella turcica Such tumors are adamantinomas (craniopharyngiomas), epidermoida, meniugiamas and aneurysms. If there is a history of unilateral retro-orbital pain, third nerve paloy or unequal or unilateral erosion of the sella turcica, carotid angiography should be performed to exclude an aneurysm. Choking of the optic disks rarely occurs with pituitary adonomas, there fore, if there 18 edems of the diaks in a patient suspected of having a pituitary tumor, it 18 wise to perform ventriculography (Fig. V-1) to localize the lesion more accurately It may be a suprasollar adenoma blocking the third ventricle or a foramen of Monro, or rarely the adenoma may be atuated in the third ventricle. Edena of the disba 18 more common with adamantinoma. In some cases of homonymous vioual defect, particularly if there 18 unilateral erosion of the sella, Angiograpby, Air studies or both are indicated to exclude aneurysmn, astrocytoma of the chiasm, parasellar tumor and temporal lobe tumor Fia 1-la. The anteropostenot ventnculograpbo projection, showing internal hydrocephalus with tenuing of the third ventricular shadow duo to large suprorellar ado Doma of the pituitary Tho tumor caused marked dutortion of the thurd ventricle with icient blockage of the centrular system to produce obetructivo hydrocephalu, Fic V-16 same care u V-10, thormg lateral no. of hoed after abstitution of air for flud m the ventncular system Tho enlarged eroded als u vidble, Tho dutortion of the third reatncle mth enlargement of the lateral rentncles becau of obstruction u obrion ·78 CLINICAL NEUROSURGERY RESTORATION OP VISION The best and quickest way to restore lost yaon caused by pressure of a pitutary tumor on the visual apparatus is by surgical removal of the tumor For the surgeon who operates only occasionally on the pituitary, it may bo best, if the visual lose 18 minimal, to try a course of roentgen therapy, then check the visual flelds after 6 weeks, if the vidion 18 not improved, ho should consider surgical removal of the tumor While the therapy is being administered, if there 18 deterioration of vioon, surgical intorvention should pot bo delay cd In the presence of pallor of the optic disks and moderate-to-marked loss of vision, it 18 probably best to operato at once. If there is sudden loss of vion, a bitemporal bemianophia or complote loss of central vision in ono or both cyes, cmergency operation should be performed because of tho possibilty of hemorrhage into a pituitary tumor When a decision has been made to operate for a pituitary tumor, the patient should be prepared with cortisone and suitable blood should be available for a transfusion It 18 tho practice of my colleagucs and myself to give 200 mg. of cortisono 2 days before operation 1 day beforo and the morning of operation Thi8 18 administered intramuscularly Following operation, tho paticnt receives cortisono in decreasing doses for a few days for example 100 mg the day ofter operation and 50 mg cach day for 2 morc days EMERGENCY OPERATION FOR PITUITABI TUNOR If it 18 necessary to operate on a patient for a pituitary tumor a on cmergency procedure, then the intra cous preparation of cortisone may be administered dunog tlic opcration. The patient should be given a sedative tho night beforo operation to insuro a good night 8 rest I prefer pentobarbital bodium (ncibutal) 192 grains at bedtime for adults. All food and donk are withheld then until after operation. If tho patient 18 to be operated on at 8 00 a in. hc 18 given pentobarbital sodium 142 grains and atropine sulfate 1/150 grain at 7 16 a m. and the licad is completely shared. For fussy patients a restricted shave may be used but it is necessanly messy and cortainly increaBC he risk of infection At 7 30 a m. the patient is taken on a cart to the operating room and anesthesia is induced I prefer to have the patient put to sleep with nitrous oride and oxygen and then maintained dunng operation with open-drop ether orer an intratracheal tube Usually it is advisable in the absence of choked disks to use a malleable necdlo in the lumbar region for removal of cerebrospinal fluid to facilitate cxposure of the tumor If a needle is to be used it is placed after the patient ·OT ERATIVE APPROACH TO PITUITAR) OLAND 79 18 on the operating table After the needle lins lucco place and a clear for of Aud lias bein neured, the needle is bent over against the back and connected by a long pieco of rubber tubing to a 100-cc syringe Bo that at the proper tioc thc anestlictist can runore fluid aseptically without moving the patient. Thil patient is then placed on his back with the head resting in a doughnut made of cotton stapped with gaurc Tho head 18 turned slightly to the side opposite the proposed flap The operating table is tilted slightly so that the bend higher than the buttocks. For a night handed surgeon the nght transfrontal approach is best and it is Bafer for the night-banded patient, once the traction is on the nondominant henusphere There are occasions, los crer, when it 18 necessary to operate through a left transfrontal flap For cxample, if the vibal HokB 38 principally in the left eyo or there is a night homonymous henuanopsia, It mas be impossible to reach tbc leon from the night ode In marling the scalp for thic flap the rocntgenograuis of the head should bo on a vietting bor in the operating room and thcy should be carefully studied The flap should extend down on the forehcad as far as posablo, but if at all possible one should aroid its entering the frontal sinus. If the situs je unavoidably entered it should be closed immediately or if it 13 necessary in order to expose the tumor to open the einua mdely, it should be excntcrated and obliterated by removal of the posterior wall If there is only a small perforation of hc sous, the hole should be plugged with bone tax and the should be corcred with a piece of ivalon sponge or the dura should be pulled tightly against tio opening by setting the dura to the pericranium. . The Rap (Hg V-2) ubeul CODBIELB of A reflection of the stan and galea downtrard and forrard through an incidon starting in the midline of the forehead and proceeding backtard to the hairline and then curving dowotard in front of the car Adson skin clips are used on the edge of this flap to control bleediog, and muall pointed forceps are used on the galca of the opposite skin edge The pericranium temporal fascia and temporal music arc then incised around the edge of the flap and retracted for tho making of five perforator openings For many years now I have used a perforator only rather than perforator and bur, in order to avoid unsaghtly depreeeions and the acreseity of using anythung to plug the bur openings The wo«t mportant perforator opening is the one placed bcluad the 11 gomatic process of the frontal bone It aliould be placed no low as rocybki in order to facilitate exposure across the roof of the orbit At tince it ** nomable to ach the perfontor opening 13th a DeVilbiss bone biter in order to hold the Gigli gw to the lorrerinost portion of the hole A corresponding dick in tik antenor míerior (ruidforelicadı jurforntor open ing mill at tumey enable the purgeon to arord liaving to operate orer a

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·81 OPERATIVE APPROJMI TO PITUITARI CLAND & elevated and the dura 18 mcrcd, it 81xablo extrndural olot mny do clop As thio iud 18 rwoved from the lumbar arua, the cposcul dura and brnin shnok (Usually 25 to 50 cc of cercbrospinal flud is rcmoi ed ) It is preferable to crpose the tumor by an citradurol npproach to the eplenoid ndgo. If tho durn has been extensii cly lacerated wlule the flap was being turned, it 18 just as aoll to proceed sptmdurally By operating atradurally there 18 a lap of dura ruch proteots tho retracted frontal lobe, and thero 18 loge danger of a neurologio deficit, postoperative convulsions or both The dura 1, dissected array from the roof of the orbit backyard to the sphenoid ridge It oliould not be opened until the ridge is reached. An open- IDB w made in the dura at tho middle of the ndgo with a nghit-angled halo cutting toward the bore Then the dum is opened to the midline and then upward parallel to the falx cerebr with dural scissort This incimon 18 extended by making en opening in the dura over the top of tho temporal lobe with a straight knilo and then cutting with scissors to the beginning at the middle of the sphenoid ridge The dural edgca particularly those below, should be coagulated for they bave a tendency to bleed The frontal love, protected by the flap of dura, 18 then elevated wth a ganglion light wlulo the fluid bencath the brain 2 aspirated with the ruction apparatus The first serve to be seen is the olfactory and usually there 18 sufficient traction to partially disrupt this nerve Because it 18 nchly vascularised it is better to coagulate and divde it at this stage to avoid troublesome bleeding during the operation or a postoperative hemorrhage. With further olevation of the frontal lobe the tumor becomes vwble If the tumor is still confined to the selln, one or both optic neries and the chiam can be seen. At times there is a supraxellar extension of tumor which obecures the catre visual apparatus. When the tumor has been approached a cottonoid strip, to which a black silk stitch 18 tied, sliould be placed berond the tumor to prevent blood escaping beneath the opposite frontal lobe This strip should not rest on the optic nerve. The tumor 18 then aspirated (Fig V-3) with a finc-borc sharp pointed Reedic attaclied by means of a short rubber tube to a 20-cc. Lucr syringe to exclude an ancury om and to determine if there is oystic furd in the tumor Occasionally blood will be obtained froin a pituitary tumor It may be the result of hemorrhago into a tumor or it may result from a 1073 vascular adenoma It u adriable whep blood is obtained on aspimtion to match the capsule of the tumor carcſully to see if it immediately becainct tense again and to see if there are expobasic pulsations It is adrianble alko to lave a piece of temporal muscle a piece of gelloam or both ready to patch the opening if it should prove to be an aneurym If the tumor e cjelic the fuld should be aspirated to collajxo the ·82 CLINICAL NEUROSURGERY Coagulation Aspiration ! Fra 1-3 See test In the drah7g the rubber tube between peodlo and synpge 1 not shown. The prevence of a rubber tubo prondes better mon and afford the ar geon more freedom of movement, once the appiration can be done by a nurme or an amcastant while the murgeon holds the needle capsule and shrink it away from tho ncru es and chjasm It may bo necessary to use a brain cannula if the fluid 18 of a thich consistency when the lesion is proved to be a neoplasm * the capsular vessels Aro coagulated (Fig. V-3) and then the capsule 18 inci&cd in a cruciate fashion (Fig. V-4) and intracopsular rcmoral is begon. A piece of tissue is taken for im mediatc fresh frozen section diagn0818 (Fig. V-4) by the pathologist then the entire intracapsular portion of the tumor 18 removed by means of a wall gallstone scoop curet, pitutary forceps and Gruenwald punch (Fig 1-51 Often the adenomatous tissuc can be removed by use of the sucher (Fig 1-5) As the adenomatous tissue is removed, the capsule collapses and folds into the cplarged sella away from the nerves and chiasm. The capoul 16 gently teard frec (Fig. 1-6) and resected to the floor of the sella, thus removing all pressure from the roual apparatus A careful inspection is carried out in order to detect any parabellar ox tepmon If such is found it should be renoi ed also Sometimes this tissue 18 found between the optic nerve and its corresponding internal carotid I Dually start & transunod of blood when the tumor K eTpored und let it run in domly the patient receining the last of the blood as the dreamos un benog applied or while reacting from the anesthetic in the poradenthera or recovert room Fire htuadred cubic centimeten of blood ar wnd for adults and 250 er for childrca ·OPERATIVE APPROACIL TO PITUITARI GLAND Incision Punch- Fio V 1. See test Curet--- Patustary forceps Suction FIG V-5 See text Muscle Capsule 70 froke Fro - See text ·81 CLINICAL NEUROSUBIER artery-sometimes lateral to the artery and rarely imbedded in the tip of the temporal lobe It is advisable in most cases to leave a small pledget of musclo (Fig 1-6) on the floor of the sella to minimise the danger of postoperatiro hemorrhage. The cerebrospinal fluid in the largo syringe connected to the malleable needlo in the lumbar region may not be replaced or it may be discarded. I usually send it to the laboratory for Mamination No attempt 18 mado to outure the dural incidon along the sphenoid ndge and parallel to the falı, The edgey fall back into juxtaposition and heal well If the approach has been tranedural from the convexity of tho frontal lol the dure should be sutured with a continuous bill stitch Tho bone flap is then inspected no decompression is made The edges of the flap are carefully waxed and the central portion of the pericradium and temporal muscle are stripped from the bono fap This minimises bleeding from the bone and the danger of postoperatii c estradurni olot In dealing with ununually vascular bone, occasionally the bone flap is stripped frec of pericraniun and muscle The edges of the skull and the bone flap arc drilled in order that the flap may be anchored firmly in portion by two stainless steel wires. Then the anchoring dural otitches applied at tho time of elevating the bone flap are sutured to the galea around the skull edges and all oozing points on the exposed dura (over the convexity of tho brain) an controlled by means of electrocoagulation and bits of gel foam The bono flap is then tired in position The percranium, temporal musclo and temporal fascia are then closed in layers, a continuous stitch of fino chromic catgut being uød. The antenor portion of the pericranium, trhich was so opened in the forehcad region as to orcate a little flap for covering the anterior inferior perforator opening, jo sutured beforc the posterior portion so that an accurate coverage 18 accomplished Thus like WI8C minimises tho risk of an unsightly depression in tho forehead The scalp flap 18 then replaced and the galca 18 outured with a continuous stitch of fino chiromic catgut. The skin is appraumpated with interrupted black oil Occasionally in children in order to sborten the operativo proccdure and the ancothctic, I have used a continuous silk stitch in the skin without any untotard de clopment. After the application of a gauso dressing held in place with a circular bandage of 2 inch gauzo and adhesire tape the patient 18 transferred to the recovery room on a cart, to remain until he is out of anesthesia. Immediately in the recoi cry room the rectal temperature is obtained If the temperature u belof normal extra blankets and hot frater bottles are applıcd until a normal temperature is recorded. It lies been my experi coce mince first operating in an air conditioned operating room that most patients undergoing cradiotomy will have & subnormal temperaturo im mediately thereafter ·85 OPERATIYE APARICIL TO TITUITARY OLAND REFERENCES I Hum Cn approach to the hyraghyun through the antenor crasial focu Ann. Burg, 57, 14-160 1913 2 BLADE, P. Sur deux cau d acromegalo Hypertrophic nogulite DOD Congénitale de entrimites supérieures initncures, et céplualue Hm de model. Puns, 6, 297-333 1886 1 BODLEY licton Dicas of the pituitary gland Bnh 1 J, 1 3 1008 Hack OKKAR, Endonaral method of removal of hypophrral tumon nith report of two alcoolul caused JADI 4., 55, 772-774 1910 Questions and Answers QUESTIO. At the time of operation, 38 then ady danger of increanog the damage to the optic acro thich has been proluced by the aptenor cerebral artery? De Love To be rather dogmatic, I would say no Still, thorc 18 always danger la operating for a pituitary tumor or any losion in the area. I would judge that the questioner would liko to know whether, in capoeng the tumor and removing it, such a procedure rould scopardive the visual apparatus further as a result of preasure of the antenor cerebral artery on the optic nerve or chigan. Of course, if the frontal lobo and the anterior portion of the crcle of Fillis arc elevated to cipose the visual apparatus and tho tumor, then the groove can be seen very distinctly on the visual apparatur. I reler, of caurso, to the groos e produced by the pulsating artery Non, if that groove u detected and if decoloration and rather marked compression of the visual apparatus also are reen, it is fairly clear that erca though the pituitary tumor which lies belot or cten extends above the level of the visual apparatua may lae rumoved successfully, the prognous for return of the visual lost 18 not good It w true that If dissection and removal of the tumor are done with the usual care, in the presence of such a groove, the operation mill not cause the vision to become orde Ict me must realue that in the presence of the groove the prognosis cannot in as good as it would be if the grooving procere caured by arterial compregnon #cre not present QUENTIOX What 36 your opinion regarding 1 may therapy in the treatment of pitutary tuniors as expressed by Dr Horrax in & following chapter? Dr. LOLE I was extrendly interested in the fino presentation and Acurosurgeons gencrally would be opened much trouble if they could dupla call the results that he has shorn so beautifully Sereral aspects of this matter gve me considerablt concern For instance, there 18 & group of patients about 20 I thuh- 10 whom there 108 DO 12sual love It tould be dificult for me to caluate the result of any type of therapy in that group of patients Ind I think I would liesitate to ad174 any therapy for the patients with an enlarged fella turcica and also mild symptoms ·86 CLINICAL NEUROSURGERY referable to the pituitary without any yel lose For instance, I should hesitate to adv780 roentgen ray therapy, and I certainly would not advise Burgical inter cntion in such a CABO What disquets mo is that on more than ono occanon I havo encountered a patient who has received what would be considered adequate radiation therapy but who nevertheless continues to sustain losses in 17010n and experiences copaiderable headache I emphasized, the other day, that I personally do not connder headache as A prominent symptom in the average patient who has a chromophobo tumor On occasion I bave dono surgical exploration (without beneficial effects) for such patients, who have received that has been called "adequate therapy" by radiotherapists In such instances, much to my surpniec, Then tho sella turcica 19 exposed I have found a few strende of fibrous tissue, but no mass legion whatever, and tho cries are atrophic The pa tient obtained no benefit, oo far as his vision was concerned, and I should be the first to hasten to suggest that in ono case the patient probably should be classed with the group to which Dr Horrax rcferred as 'im properly treated' In this case the bono tras deztalved it did not heal and the bonc flap had to bo removed The roentgenologic cffect was very marked I also recall a woman from A neighboring country who came to us with the symptoms and signs, ophthalmologically, roentgenographically and othervise, of a pituitary tumor At the time of operation Fo found a cystic legion of the sella turcica which has causing marked compression of the optic nem cs and chiasm. Tho contents of the cyst were evacuated they proved to bo clear fluid, with . lot protein content. The oyst was removed and submitted to the pathologist, it proved to bo only a simple fibrous cyst After rapoval of the tumor the woman o menstrual periodo wcro restored. She went home, became pregnant and gave birth to a pormal child Morcover her visual loss was restored or at least licr vision was restored to Dormgl. I question of the should treat the chronophobe adenoma with roentgen rays I would omit chromophile tumors from such questioning for I will Agree with any body thet roentgen my therapy is the procedure of choice for this type of tumor but fortunately only about 5% or less of the chromophile lesions crer come to operation because of compression of the visual apparatus I have had the pleasure of soing one of Cushingo famour patients I did not know this until after I had told her that she had acromegaly and that she did not need any treatinent because she was doing very well She said Thank you very much Dr Cushing told me that about 20 years ago Il ell no have all then the acromegalic patient do very rell with radintion therapy The symptoms of endocrine hyperfunction abate under ·87 OPERATIVE APPROACH TO PITUITARY GLAND such therapy But I would restrict my remarks principally to the chromophobe adenomas I question whether radiation therapy directed to the pella turcica with sufficient intensity to destroy a chromophobe adenoma of the pituitary would not also destroy or sei crely impair the function of the remaining pitutary gland I think one of the greatest satisfactions a neurosurgeon ever cxperiences 18 to operate upon a woman for a chromophobe adenoma, to remove the tumor and then to learn that the patient's menstrual cycle has become normal again, so that subsequently she gres birth to a child IVe might oven recall the apt remark that "maternity 18 a matter of fact, paternity w a matter of opinion" DR LOFE Several men have asked about the sponge which I recommended for closure of the frontal sinus when that structure 18 inadvertently or purposely opened. It is known as lalon sponge, it 18 e plastic material I went down to the drugstore this morning to see if I could buy one, but I was not successful. Still, I understand that the sponge can be bought at any ten cent store Fomen use it for cleaning in place of a sea sponge or A rubber sponge. We leamed about this sponge from our associates in the sections of general and vascular surgery It can be sterilized in the autoclave it can be cut into any size of sheet or any thickness that may be needed. The reason it 18 80 satisfactory 18 that the fibroblasts grow into the interstices of the sponge and produce very firm closure of any defect which you may wish to close. If ivalon material 18 placed around the aorta or about an aneurysın for instance it constricts the reseel as the fibrous tissue grows into the sponge I would not recommend it for the enclosure of intracranial aneurysms because it stimulates the production of fibroblasts and scar tissue. I have however, used it intracranially We reported one case in which we cmployed this material to close a fistula after complete removal of a tumor of the cerebellopontine angle. However, if this matenal 18 used to close a cerebrospinal fluid fistula, the fluid may continue to leal for 6 or 8 days afterward, because the sponge obviously cannot be a solid barrier As I have said the purpose of the sponge is to provide a substance into which scar tissue will grow, and that is why we use it. We have ured it to close defects in the frontal sinus and other opening. QUESTIO\ Do you ever feel that the anterior cerebral artery should be divided because of the compression on the optic nerve? DR LOVE No, I have no er deliberately clipped and divided the anterior cerebral artery to remove the tumor in question On more than ono occasion I have applied alicr clips and then divided the anterior communicating nrtery to allow retraction of the circle of Willis laterally for proper exposure of the tumor ·CHAPTER VI The Surgical and Irradiation Treatment of Pituitary Adenomas GILBERT HORRAX, NI D During the last decade of the nincteenth century the clinical diagnosis of pituitary tumors became established, and soon thereafter (12) intra cranial surgical procedures were attempted for the removal of these growths The excesoryc mortality of these early intracranial operations led to a scarch for lees hazardous methods of approach to the cella turcica, and thus the transphenoidal operation was dereloped and perfected by Schlof fer (3), Hanauel (4) Hirsch (5) Halstcad (6), and Cusbing (7) In these carly days, surgery was the only known method of attackmg pituitary tumors and the transphenoidal approach fas utilued with considerable success and eventually with a relatively loi mortality until the late 1920 5 Since then with the advent of modern neurosurgical techniques and vari ous helpful adjuncts, the intracranial operation for the exposure and remoral of pituitary tumors has been the procedure of choice by practi cally all neurosurgeons and it was shown by Henderson (8) in rericing Cushings entire series in 1939 that this method combined with postopera tire radiation gave the highest percentage of good results I bave dis cussed elsewhere (9) the reason for the somewhat higher present day mortality of the intracranial operation compared with the transphenoidal procedure This 18 due solely to the radical operations on large intracranial estendons of adenomas many of which can be salvaged by heroic meas urey only The treatment of pituitary turnors by means of deep roentgen therapy Har fint attempted by Béclère (10) and Gramegna (11) and Beclerc rcported 13 years later that the patient le had treated in 1909 was in excellent health It was 4 years after this report by Béclére that the first farly large Brics of patients with pituitary lesions treated by radiation was reported by Heinumann And Cserny (12) There authors collected 73 cases from the literature and added 15 of their own. In general they felt that the best resulto had been obtained in patients with acromegaly although some of the patients with presumed chromophole adenomas were benefited. However no mention was made ar to the length of time that patients had maintained their improvement From this time Orard manr reports concerning radiation trcatment for pituitary adenomas have appeared As early as 1025 Bailey (13) and ·89 THEATZTEIT OP TITUITARY ADE YOXLA Fronic and Grant (14) felt that a tral of radiation should be given to patients with only slight visual disturbance, and this attitude was likewise adrocated with some mugiving by Dott (15) in 1927 Totne (16) in 1030 Tas the first neurosurgeon to show any real enthusiasm for radiation Verous surgery in the treatment of pituitary adenomas He concluded as folloss It is proposed that all pituitary adenomas be treated by roentgen ray under the obser ation of the ophthalmologist and the neurosurgeon, that the treatment be stopped as soon as Improiement begns, and that murgery be undertaken short of 6 months only then visual acuity and fieldo recede under roentgen ray therapy Townc reportel 5 patients, 3 of mom had their vision restored for considerable periods one for 5 years, one for 2 years, 8 months, and one for 2 y cars, 10 months Hor. crer, 2 of these patients had recurrences and were not relieved by further raduation This report by Totne ies little more than "a roico crying in the wilder- Dess," as an article by Frazier (17) in the same year dampened any pros pects for good results to be expected frotu rentgen treatment In retroming hus series of chienal lemons, among which there mere 129 pituitary ade nomas, he stated that only one patient had had any sustained bencfit from radiation. He did not say how many patients had been gren thu treat ment Fraser's attitude as to surgery verrus radiation for pituitary tumors may be said to have been tho gencral feeling of most beurosurgeons at that time and has reflected in similar reports by Cairns (18), in 1935 and by Rand and Taylor (19) in the same y car All, however, agreed that patients suffering from acromegaly were more likely to be benefited than were those having chromophobe adenomas. The neurosurgical point of viet contioucd in spite of foronable reports by roentgenologists, such as that of Pfabler and Srachman (20) w 1931 but the report dealt in generalitics only with out giving any end results What scived at the tune to be the lethal blow to radiation for pituitary tumors was delivered by Cushing (21) in 1932 when he said So far as concerny radiotherapeuss at least in the case of chromophobe adenomas It is one to say that it will come to be discarded just as radiation for mophthalmic goiter has been XO 6OON as neurosurgeons As a class perfect themeli es in the details of the operative procedure” lo estenuation of this remark it may be said that certainly up to that time redintson therapy for pituitary tumors had shown extremely inconsistent results to say tho fcast and in not a fett instances patients had had irrercreble damage to their ontic neries wlule undergoing radiotherapy and ncurosurgeons Fero okousl arcrae to taking any chance of this kind Blace the good results obtained in surgical removal had long been established.

·CLLILL VETROSUECERY 14 Thus, then, was the general attitude in respect to the treatment of pitui tary adenomas until about the middle aineteen thirtica, Damely, that in cases in which 1700n Fas slightly to moderately affected, a tral of radia tion therapy was warranted, but if improvement did not take place within 4 to 6 weeks, or if yzaion became significantly worse at any time during such treatment then prompt operation was adized From about the year 1838 onward there began to appear more hopeful reports on the radiation treatment of pituitary adenomas ln 1939 Henderson (8) renewed Cuali ing's large series of these tumors in a comprehensive monograpll He showed conclunvely that when patients with adenomas had been given x ray therapy after operation, the prolonged results were distinctly better than then operation without radiation had been employed. Even before Henderson a rericts Sosman (22) in 1937 had stated that his results indicate that satisfactory remission of symptoms and signs will be obtamed in over 50 per cent of patients with chromophobe adenomas, in 90 per cent of the chromophile adenomas and in the majority of basophile adenomas ” This same attitude tas again expressed by Sosman (23) in 1939 at which time there had been a longer follow up period for luis patients In this paper ho uken ise put forward tlie bebef that radiation results would continue to be better with further refinements of technique and larger doses delivered to the growth Thus prediction has been abundantly confirmed Further support of radiation therapy pas offered by Davidoff and Feiring (24) in 1948 Of a total of 88 patients with either chromophobe or chromophile adenomas treated only by radiation 43 or 48 per cent Fere esther improved or their vision held at a useful les el On the other hand, even up to thu tie the general neurosurgical attitude tocard radiotheramy tras still very much the same as it had been dunng the previous 10 years. Thus in a paper written in 1948 Grant (25) Rayo If the vzsual acuity 10 better than 6/9 in each eye and if the atrophy of the optic nerve 15 pot ad vanced irradiation therapy is indicated regardless of changes in the vzsual fields or sella. Our own attitude as to the advisability or indication for roentgen treat ment of pituitary adenomas was very much like the viens exprimed by Grant until the year 1830 when we began to treat these tumors with the 2 million rolt apparatus at Vassachusetts Institute of Technology using the rotational method and delivering a tumor dose of 4000 r Previous to that time me liad used the standard 200-kr machine and usually an 1800-T dose was delivered to the tumor through bilateral temporal ports At timeh thu dose tras repeated once or twice at varying intervals of progress mas pot as satisfactory as we thought it should be and of 17non did not deteriorate greatly or rapidly The main purpose of this paper therefore is to compare the results ob- ·01 TREITUENYT OP PITUITARY ADELOULAS tained in the treatment of pituitary adenoinas, particularly as to the efficacy of roentgen therapy as utilized in the ways and in the amounts just described Tlc comparison to be made 18 between that period from 1932 to 1949 inclusive, when gnaller amounts of radiation Terc dchvered to the adenomas by the 200-ks machine, and the period from 1950 through 1955 then we have utilized a higher tumor dosc by means of rotational therapy trith the 2 million volt apparatus 1 lave not tried to collect large series of cases from vamous clinics whicre differing methods both as to surgery and radiation therapy might have been cmployed and from rich any comparisons nould be either difficult or mpossible The patients those treatment is to be described here trere cather operated upon by a omilar nacthod or were given tucir radiation by a nngle group in a uniform man- Der It would thus seem that a fair estimate could be made as to the re sults obtained during the 2 periods with which we have been concerned It is recogpued at obce, however, that for the patients who have been treated since 1950 a follow up course of only 1 to 5 years 18 available, and it is conceivable that alter a longer interval the end results may have to be re-evaluated. In the statistics and discussion which follow it should be understood clearly that only chromophobe and chromophile pituitary ndenomas aro considered. The baxophilic adenomas are too fos jo dumber and their problems are different and such suprascllar tumors as cratiopharyngiomas, meningiomas and other rare growths in this region are rarely if crer radio- Gnotive For the purpose of over-all statistics it may bo soud that our material consists of a total of 335 pituitary adenomos Thich have been so diagnosed At the Lahey Clinic from 1932 to 1955 wclusire Of this number, 141 hare Lees venied pathologically whereas in the remaining 194 the diagnosis har been made by the finding in all caxs of a large ballooned out sella in the r-ray together Tith other pituitary stigmata such as optio ntrophy, sual Acld delccts and so forth (Table 1) In previous papers with vanous collaborators (20, 27), I have set forth our experience with certaw aspects of our treatment of pituitary adenomas other by surgery or radiation or by a combination of the two both before and after the period when ne lave had nccess to the 2 million volt apparatus In the carlier period 173 patients were treated by radiation only, or were operated upon caure radiation had not improved their condition of the total number there mere 74 who were treated in the hope of hencfiting certain endocrine disturbances The TemsidIBG 99 xerc treated for 17808) lose or such symptoms as intractable headache especially w acromegalics There 99 Ieteiore, are the only oncs for whom there would ever hare ben ·92 CLINICAL NEUBOSURGLARY Tar 1 Pintary Adenomas Venfied pathologically Chromophobo Chromophile 10 Total 141 Yenfiod by x-ray ctc Chromophobe Chromophila 140 Total 101 Grand total any indication for surgery, so that it is from this number that figurce must bo drawn as to the necessity of an operation when radiation failed. There were 68 of these 99 patients or 68 5 per cent who were operated upon bocaur radiation in the amounts they had received had failed in that their vision deteriorated or was not held at a weful les el (Table 2) In other words, in this period from 1932 to 1949 inclusivo, in addition to a fairly large group of patients, 46 in all, who were operated upon because of poor vzoon before any radiation was gi en to them, subsequent operation was considered necessary on acarly 60 per cent of the 99 patients in whom e previous trial of radiation therapy had been made This figure should bo compared with that which is to be given for the period of 1950 to 1955 in clusve So far as the end results for thus group of patiento 18 concerncd, we have the following data Fne of the 68 paticats operated upon died following opcration Threo showed no improvement for periodo of 1 3 and 7 years and it has been impossible to obtain follow up information in 4 instances. The remaining 48 patients have been followed from a few months up to 21 years for Ad Average of 772 year It is hown that 39 of these patients Tor ? Results of Roentgon Trealmont 1033-100 Incl Ave Raduation only or surgery berdum aduti Dot fertiid Subtract patients without mual lot 13 74 Total 09 Operatrd upon because moduation not offcetivo 68 (8 5%) ·THEATLEST OF PITUITARY ADEYOSAS 93 TABLE 3 Rohulla ol Roertoca Treatment 1950-1965 Incimmie Total patients treated with 2-million volt apparatus Subtract patients without real love Total Operated upon becauro reduton not effective 20 00 8 (12.1%) maintained their improvement for 4 years or more, and that 16 maintained thcar improvement for orer 10 years. Tro of the 39 died, ono after 7 y CATE, the other after 10 years From the year 1980 to tho present time our Departmcbt of Radiology has treated nearly all of tho pituitary adenomas which have been so diagnosed at the clinic. Out of the total 100 patients in tlus period, 11 were operated upon before radiation because it was thought that their vision was so greatly impaled it would be unwise not to give them prompt operative relics from pressure on the optic nerves of the remaining 95 there were 60 who had some degree of visual impairment or intractablo headaches Only 8 or 12 1 per cent of these 66 patients have so far had to be operated upan kcause of the failure of radiation Table 3) When thu figure of 121 per cent is compared with the 58.5 per cent of patients who had to be operated upon in the earlier period, it is obrious that a substantial gain has been made in the results to be expected from radiation in the treatment of pitutary adenomas Incidentally, this figure of 121 per cent u even distinctly better than the figure of 18 4 per cent which we reported previously when statistics through the year 1953 were available Furthermore, as mentioned in this previour report, 2 of the patiente operated on trere shown to have po pretoure mrhaten er of the adenoma on the optic acrt es. In one of these patients vision returned to normal and in the other it remained stationary but it was clear that the operation could not be pyen the credit for this As to the cod results for patients treated from 1950 to 1955 inclusive, it 18 of course obvious that only 1 to 6 years have clapeed since their treatwcat nas instituted and that a longer period mu be necessary for final couclanons lp to the preeent, hottetet me feel there 23 etery reason for corouragement because such a small percentage of patients have had to be operated upon. DIBCUSSION From a Me of the treatment in this erics of patimta having pituitary Adenomas it would sem unmistahenly madent that neurosurgeons in gen * Tho of the patients were operated upon rolelt for the control of cerebrospinal trzarstra bih vas the reason for their adaton.

·CLINICAL NEUROSURGERY cral must reviso their thinking in respect to surgery verrus radiation in the treatment of these lesions In Our expenence, even when 18100 18 consider ably impaired, in somo instances as lon os 20/60 mth ono oye and olen lower with the othor, & carcful trial of radiation, preferably with the 2 million volt apparatus using the rotational method, 18 indicated. We have Icarned, too, that vision may become sometshat more disturbed for soveral days or possibly a week or two during the course of treatment but mill eventually improvo However, if thero i rapid or corious pigual failure, operation should be undertaken promptly Certain other aspects of the atuation concerned with radiation therapy should be noted. To have never seen any ill effects of radiation on any brain function por the dovelopment of cataracts resulting from this type of thorapy Likewise tlo uso of the x ray does not make subsequent surgery more difficult It has been said that approximately 20 por cent of pitutary adenomas are cystic and therefore would not be affected by radiation. Our figures would by no means bear thub out since during the past 6 ycars radiation has benefited some 90 per cent of our patients In only 1 of the 8 patients operated upon was a cystic tumor found In his articlo in 1937 Sosman stated "It might be more valuable to ana lyzo and compare failures rather than to consider only good results A brief word thereforo may be in order as to our 8 patients upon wbon wo felt it was necessary to operate because of the apparcnt failure of radiation therapy In ci cry case vision lad declined oo greatly that surgical relief of pressure on the optic nerves decined urgently indicated One patient had a huge intracranial extcntion of her adenoma in one the tumor was largely cystic in a third nothing fras found in the sella cxcept a collection of colorless cerebrospinal fud and in a fourth the growth was extremely firm and fibrous Onc patient had had sudden hemorrhage TAAL 4 Palueris Operated upon 1950–1456 Incluri Aller Recerng ? Vilhon 1 oll Therapy Operadre Fdlog Raut 1 Hugo intracranul ertennon 2. Sella filled with screbroqmal fluid 3 Cystio tumor 4 Fibrow tumor 5 Saft depona Soft adenoma 7 Soft adenoma 8 Hemorrhage in odedoms No mmprou ement To mprosement Improied Great improvement Normal tiro Improved Improied Died ·05 TREATVENT OF PITUITARI ADEKOVAR into tlo adenoma and one hnd a coniulsion follon ing a head injury There ser no vnusurl fcatures in the remaining 3 patients although in one of them, as iucntioned before, the adenomn bunk an ay from the nerves and was excrtiog no pressure on them, and she recovered pormal 1910n subsequently of the 8 patients, 5 improral greatly, in 2 47810n was unchanged, and opo paticot died (Table 4) BUNLARI The hustory of the treatment of pstustary adenoines both by surgery and by radiation, or a combination of the two lias been reviewed briefly Although surgery at times 18 brilliantly successful, it carnes a distinct hazard, especially 10 cases with a large intracranial extension of the ade- DOMA. Surgery is indicated in patients whose vinon 16 merously impaired, or if vision has failed rapidly presumably from hemorrhage into the tumor In all other patients baving the usual cnteria of a pititary adenoma, cither chromophobo or chromophile, a trial of radiation therapy 18 indicated beforo surgery u consdered. Even if 17810n declines somewhat during the course of such therapy, careful observation of the vzual fields and acuity will nearly always shows eventual unprovement In our experience a total d060 of 4000 r delivered to the tumor 16 the opturaum. When given by the 2-million volt apparatus using the rotational method there seems to be less clinical reaction, no porinenent depila ton nnd no dermal difficultics. Utilizing this od, only 121 per cent of our patients have thus far had to be operated upon during the last 6 years REFERENCES 1 Bokunt V On the technique of operations on the central nervou rystem. Bnt. DI J, 2, 411 1800 1 hus, F Birnchirurgo (Freilerung der Hypophyre) Deutrehe kum, & 1004 1905 1 SCELOFTE, E Erfolgrecho Operation einer Hypophrentuinon auf Toualem Were The Elm. Wehnocbr 20, 821 1076 1907 4 haAVE, A B Remos al of tumors of the pituitary body by an infninaml routo JAMA, 53, 101-1707 1009 & HACE O Endonesl method of removal of hypopurreal tumors with a report of tro at JAMA,55 772774 1910 & Malete LE Remarks on the operative treatmcat of tomon of the hypophyou Report of txo eaxy operated on by an orodamlwethod Surn Ginet & Obst, 10, 491-502 1910 7 Cubung H The Patuitars Body and its Disorder, Lippincott, Phladelplua and London 1912 & MexxxOY I Patuitary adepodalA folor-up kode of Arpoal resulta in 358 eur (Dr Martes Cubme's Arnes) Bot J Surg., 26, 811-21 1839 # Homu G Te chromophobe pituitary adenomas urgical and mediation treat mrat Sury Cim Amer 31 577-591 1841 ·90 CLINICAL NEUROBURUERY 10 Btakan, A Lo traitement médical des tumeurs hypophymre du pointimo et de lacromegalie par la radiotliérpio Bull, et mém Soc med hop Pung Sonics J, 20 274 100.1 11 GRAXAXA A. Un cas d Acromegalie traité par le radiothémpic Re Dourol 17 16-17 1900 12 HEXIBYAXK J I AND Can L. I Do Röntgentherapie der Hypophyrntumorto Strahlentherapie 24, 331-335 1828 13 BULET P Results of roentgea thorapy on brain tumors am J Roentgenol 13 48 &3 192:8 14. FRAZI, CHAD GRAXT FC Pittutary disorder & dugest of 100 case, with romarts on the surnaal treatment. J AMA, 85 1103-1100 1926 18 Dort NM Diecares of the pituitary body Mied Ann. pp 1-15 1977 10 TONE, E. B Treatment of pituitary tumor, Rolo of rontgen-tay and of surgery therein Ann Sang, 91 23-58 1830 17 FRAZINI, CHA Bries of pituitars pictures commentares on the pathologic clinical and therepouuc pects Ark. Veurol & Porchiat., 23 a5a-045 1830 18 CAIRY H Promons of pituitary tumours Lancet 2, 1310 1363 1935 19 RAXD C T AND TAYLOR R G Irradiation in treatment of tumor of pituitary gland Arch Surg 50 103–150 1835 20 Praha, G E XD SPACEXAS E N Roentgen therapy in pituitary tumor, Am J Ophth., 14 700-501 1831 21 CU ALYG H Intracranial Tumour. Notes Upon a Sench of To Thoumnd Verified Concs Rith Surgical Brortunts Percentages Pertaming Thereto Charles C Thomas, Springfield, Illinois, 150 pp 1832 22 SORXAN MIC Iraduation in the Treatment of Pituitan Adenomas. Proc. Inter Stote Postmnd. Died Amet. Nå pp 1-7 1037 23 Soux MIC The rocntgen therapy of pituitar adenomas. J AM A., 113, 1252-1285 1039 24 Daviport LD1 AXD FmYD E H Surnaal treatment of tomon of the pituitary body Am J Surg 75 09-136 1918 25 GRAXT FC Surgical aspenence with tumors of the pituitary gland J AMA, 136, 608-672 19-19 28 HORBAI, GHAA H. F, Porro JL, HURTIAL, L. M, AND LODYUHUA AND 0 2 Chromophobe Pitwtarr Tumors, II Treatment. J Clin Endocrino) 12, 631-641 18:52 27 Homux, G SUID AL NITKUWP J G Gun, RC, AND Walt h. A Promot day treatment of pitutart adenomas Surgery rernu Itay therapy Now Eng land J Med 252, 521-526 1955 Questions and Answers QUESTIOT That 18 your opinion regarding x ray therapy in the treat mcnt of pituitary tumors As expressed by Dr Horrax? DE PENFIELD From my own experience there hore becn a certain num ber of patients treated by radiation whose headaches Fero pot related and in whom we postponed operation much too long and left them with scans of suffering. I can remember at least 2 chromophile adenomos with acromegaly whose headaches frere deter relieved by Inay therapy Not cveryone has the great and enable advantage of living in Boston and pot everyone is as close to the Vassachusetts Institute of Technology ·TREATUET OF PITUITARI ADEXOVAS and the 2 million volt machinc. I would like to ask Dr Hornex, should To take the samo attitude and dran the same conclusion in regard to radiation therapy that he bas drawn, or 18 that a horso of another color? QUESTIOY What causes the headache in patients with pituitary tumors? DR PENFIELD I used to think I c I anaye described such head aches as the bitemporal sort of prcoming licadache due to the tension within the sella. But as time has possed, I am not 80 guro. Occanonally you see tho intractable headache, cren mith x ray treatment, and yot sometimes there 18 nothing to cause tension within the solla turcicn I don't know that it is QUESTION I should like to ask Dr Penfield if, in his caperionec, head ache 18 a more prominent symptom of one tumor than of another? For instance, 18 headache more common in the presence of the chromophile or the chromophobo type of adenoma? DE. PERFIELD I can't anster that, my experience is not sufficient. QUESTION What is your opinion of headaches in patients with pituitary tumor? DA HORRAS I agree with Dr Ray that in our experience the acromegalica are tho ones who complain most bitterly of headache, and it's a curious thing to mo llunt in my cepenence headaches of that type are more benefited by x ray than they are by surgery-pot always, but in the vast majonty of cases. Someono also asked about the further deterioration of moon after operation. Of course that certainly can happen. We can all recall cases of that kind I tividly recall a well known wecutive who has operated on by Dr Cushing once or twice by the transphenoidal inctlod Ho then bød sonno I ray trontment but didn t do rery shell, probably from insufficient x-ray treatncnt Dr Culung next did & craniotomy on lum. He removed the tumor but the vision hept going downlull until the patient rar nearly blind in one cyc and 170on fras considerably impaired in the other Further r ray treatincat was given but this was in the carlier days before the 2-ullion rolt machine Thi paticat tas not benefited 20 operated on him Thero were many adhesions from the previous operations A large adenoma ras lound which was adherrnt to the optic neric In carefully tcasing the cap tule ntay from the good optic nerve there was endently come further danago Ho was already blind in one eye and as a result of the operation beame blind in the other Thu man did perfectly mell othertise and returned to hus erreutsit job This is the sort of thing that can happen when there hare been previour operations I do not believe the r ray treatment had anything to do with the adhesions around his chismu Dr Penfield asked about the tyth of x ray machine do 1 harc eaxl be- Core, 1 ou can get in 1000r (nlich we beliere is the optunum dose), by using ·98 CLINICAL NEUROSURGERY 99 tho 200-ky machine Dr Smedal, our roentgenologist, and others have as sured me that this is true I think that this same question was put to mc in Montrcal one time when I was up there talking about this same subject. On the other band, if you give 4000 r with the 200-kv apparatus you are likely to get depilation over the temporal areas which may not be very im portant in women because they can camouflago it, but you may also get a very marked dermatitis The value of the 2-million volt machine with rota tional therapy, whero the patient 18 rotated and gets the treatment through various ports is that you can get in an adequate dose without these mde of fects. Dr Love said he would not treat people ho do not show rigual disturbances. I thought I made it clear that I have eliminated thoro CASCA from the statistics which I showed you. Those patients would not have any operative indication. I am companng only the patients with vigual disturbances. I may bay a great many of our acromegalics, in addition to the intractable hcadaches did have some form of visual disturbance The patients without noual disturbance were given x ray treatment because of other pituitary or endocrine abnormalities and do not enter into this picture in so far as surgery verous x ray 16 concerned because they would not come to burgery in any case QUESTION Tell now I think there is some qucstion about what you mean by sufficient visual impairment whether it 18 acuity or fields, or what. DE HORRAX All I can say is this Te followed these paticnto at least once a week during the time of their treatment. This takes about three wees as wogica relativ cly mall dose at a mtting Wo found there was less danger of hemorrhage into the adenoma when they were treated m this manner After the treatment to follow them along at frequent intervals, and have follon ed nearly all the patients during the last 5 years What we mean by adequate improvement is that they havo either a normal visual acuity or adequate visual acuity to be able to get around and do their type of work or be useful useful 1780n in other ords. Now that may not mean that all of them improved to complete restoration of their visual fields and 20/20 rimon but they do hare adequate useful vion As I say this 10 only over 5 year period and it may bo that some of these peoplo whom I talk to you about today may come to operation at some time. How cver the point is this I think if you look up the statistics you will find that your mortality in pituitary lesions is a little higher than you thinkcfpecially in patients who have rather large intracranial tensions where you have to pull the adenoma out from behind the chiasm and so on. Il ith the ordinary type of adenomas which for the majonty of patients the mortality 18 eomewhere between 2 and 4 per cent This has been truc in our Acties and in Jefferson s herica in England It is also true of Oliverona o enes bowever with large intracranial extensions the mortality is much ·TREATEST OF PITUITARI ADEXOSLAS lugher Ip tlloso CAMA, surgery 18 almost always indicated because it is the only way you can waliage some of them on the other land, ne ar trying to get away from erca that 2 or 3 pcr ccat mortality because, although it u lor, if you happen to be onc of the people who falls into that category, cven a lot mortality rate cannot be overlooked That's thy me art stressing thus x ray treatment so much QUESTION Did you say that a satisfactory result from X-ray treatment 16 one in which there is no further visual loss or improvement? De. HORRAX Provided the 178100 which they had to start with was useful vision. QUESTOY Hot long would you continue a ray therapy or wat before starting surgery, if the vision did not improve or become progressively korse? DR. HORRAX If during the course of the I ray treatment or anthin tho subsequent fer Wecks or months vidon keeps on deteriorating, to occa- Bionally give a second x ray series Hommer, operation is performed if TiBlon cannot be held at a useful level, or if vision deteriorates very rapidly hich may be an indication that something like a hemorrhage into the adenoma occurred, making surgery mandatory Horerer I have seen a number of patients who bave some deterioration during their treatment, but then gradually begin to improve until they on entually got bach useiul VINOD QUESTION Then there are no definite standards to be used to when you feel that visual loss las actually come to the point where you might not have unful vison? DR. HORAX That 18 nght QUESTIOY Will you comment further upon repeated series of x ray treatments if symptoms return? Dr. Horret If the patient lias lost further vision 6 months or moro after radiation, should he be returned to the roentgenologist? I would make such a recommendation-munless rigon deteriorated very greatly I gradual deterioration took place aod vision was still useful in one ere, I rould cautiously try one more neric of x ray treatment We have had to do tbat with fewer than half-a-doren patients But, of course of vision detcnorated further FOU Trould have to operate and naturally personal judgemcot comes mto thi# All patients must be followed very carefully over long periods of time by the roentgenologist the ophthalmologist and the neurosurgeons because as I base said before sery careful follor up studi from nagy standpoints 18 neressary QUESTION TO DR Ras Do you agree with Dr Horraxt DA RAY I would agree with Dr Horres as he has outlined at Hoxes er one thing rom me When the emphans u put on tray therapy for ptuitor tumor and purgen is turned down, later it may becomo a belief ·100 CLINICAL NEUROSURGERY that these tumor aro no longer a neurosurgical problem. Then people who should not be treating these cases will start treating them and they may forget to follow tho oye field. The other thing that 18 a cause for concer 18 the frequency mth which the diagnosis may be in error I know it can happen, and it can happen to the best of us What may appear to be a chromophobo adenoma may actually not be that at all, and it 18 a mistake then to treat tho paticnt with x ray and delay the time of operation. DR. LOVE I would not say that I agree entirely with Dr Ray I bare in mind a patient who has been treated in our own institution, and whore condition has been followed, he was treated for what was thought to be a chromophobo adenoma of the pituitary body He returned with a very marked loss of 775on After examining him I told him that immediate operation was imperative although he had returned with the idea that he would simply receive more roentgen ray treatment Ho accepted opera tion and at gurgical exposure I found one of the largest intrasellar and suprasellar epidermoid lesions I have ever seen. You might say it extended ererywhere in the frontal lobe, all about the visual apparatus, and in nearly every other direction Now, this man obtained marked recovery of visual loss within a very short time, and he 18 one of the happiest men I know There have been other and comparable patients Two patients had been treated elsewhere trith roentgen rays for 'pituitary tumor," but actually neither of them had a pituitary tumor We have seen a number of such patients. I would heartily agrec rith Dr Ray that the diagnoos 10 not al way, perfectly clear and most of us are frank to indicate thus in our tals and writing. As you all koor, Dr Hortar has ponted out very beautifully hot important it 1. in treating another type of intracranial tumor to remove completely the ccrebellopontine anglo tumor If mubtotal removal only 18 done in the hope of thereby lessening mortality rates, morbidity rater very often increase and a second operation may involic higher mor tality rates. I am afraid that if thus method of treatment of chromophobe adenomas (meaning irradiation) becomes generally favored many chromophobe adenomas of the pituitary body are going to steal bke a thief in the rught behind the chiam and secure themselves under the optic nen es in the parasellar area and out into the temporal lobo If that happens we may expect the mortality rate to increase tremendously—per hapo to as lugh as 60 or 70%-when operation is finally attempted. By contrast if you have a patient with bitcmporal hemianopsia and a suspected tumor Thich docs not sem to have paraeclar extension but who doce not liare central scotomas to indicate severe damage of the optic bertes thien certainly, as Dr Hortux has indicated the risk between operation and no operation is very low After operation restoration of vision 18 60 rapid that I think it most important not to lose sight of the period in ·101 TREATMENT OF PITUSTABI ADŁYOWAR think much operability and curability are inost likely to lo obtained, cien thougli otlier iucthods admittedly are apocinted with less risk to tlo pa tient. DR. HORRAX II may make a comment, I am sun Dr Lose is might as to hesitancy regarding radintion, and as a matter of fnct, thint as exactly my attitude ton ard this whole situation befort wo started this newer type of therapy, however since then I live had to becomo optimistic klout it, because te hare apparently liad such good results so far I want to reiterto the follow these patients i cry carcfully, so that we hope tre can recogairc agns of deterioration carly Nor as to the noistakes in diagnosis, I am sure me hair all made them occasionally and como of the patients to have reported may not have pituitary arlenomas On the other hand they are doing well go for If we find that there 18 any reason able doubt us to the diagnosis we do cther an artcriogram, encephalogram, or ventriculograj to see if there is anything such as the cpidenpoid that Dr Love spoke about, and we have had occasional ones such as that I you must tum crery stone in all those patients to be sure that your dsagn 0616 18 right if there 18 any doubt in the vast majority of them I am sure there is very little doubt QUESTION Can radiologists throughout the country still trcat pituitary tumor without the 2 million volt machine? DR. HORRAX Yes, that is, if the roentgenologist can get in an adequate amount. But the difficulty is that it usually invoke depilation and possibly skin difficulties. QUEATION Is Cortisone combined with x may therapy at the Lahey Clinie Hof many s-ray treatments are given over what periods of time? De HORRAT lle feel that cortisode 18 indicated if then 18 somo general indication for it from the endocrinological standpoint and, of course, there are many people either those lasing x ray treatment or otheraitc, who 993)] profit by cortisonc Certainly, if a patient has to be operateri on to almost always administer ACTH cortisone both before and after opera tion. Sometimce sre have een patients whom we thought had not improveri mough after I ray thrrar nho trere improved both as to their endocrino logical status and their 178100 after they were gis en a courre of cortisone Ther mproind to much on cortuone that it tas not necetrary to do any further studies on them to determine if they had s poussble intracranial extension or plinther the pituitary adenoma A in such condition that operation or required An to further r-ra; treatment I commented before that we have had to fuggert to a fer patients a second eetics of treatment altet natyral months or mm longer but that has been very rarh Suh skyruent treatmt take about three wechs with thr 2 million volt machine u ing rolational therape QIETIOR I mng the 2 million volt x rar machine in destroying the ·102 CLINICAL EUROSUHTIRI pituitary, 18 it likely that these patients must be continued on Cortisone therapy, thereas those who are dealt with surgically might get by with out it DR. HORRAX You do not destroy the pituitary by thu machine by this dosage at all, I think you simply destroy the adenoma or shrink it in some Way As far as I know there has been no indication to use cortisone for replacement therapy because of any damage to the pituitary itself which 18 very resistant to the roentgen ray It's just the adenoma that is destroyed. QUESTIOS TO THE PANEL Have any members of the panel had the ex perience of exploring and finding an empty pituitary fosse after roentgen therapy? DR LOVE I was about to say that I have, and in fact I have already mentioned it DR. RAY I can't recall. DR. HOHRAX The patient in mbom I found this cmpty sella turcica must hove had some pituitary left because oho had no particular or outstanding pitutory deficit. In her case it was simply a loss of vision which to assumed was due to an adenoma and we do not know that there were frag ments of adenoma left there But, certainly just letting the fluid out did not affect her 17810n one way or the other QUESTION TO DR. HORRAX Then we can be assured that lypophysectomy cannot be effected through any method with your betatron? DE HORRAX Not with the dosages that we belice arc adequate QUENTTOV Is the use of air studies helpful in determining the surgical indications of pituitary Icsions and thether they aro improving or regress- 108 DR. HORRAS If we feel there is any rcal doubt ao to the diagnosis of A pituitary adenoma or suspect some other type of parasellar lesion to conduct diagnostic studies We prefer arteriograms or encephalograms but occasionally perform ventriculograms If there is evidence of further prog ress of the lesion any of the above studies may be done I think that bere again it is omply a matter of judgement as to how far it 18 necessary to go and I feel that we must all be a little bit careful in doing these procedures Eren encephalograms and rentriculograms cany s dlight hazard and they should not be taken lightly One should not subject a patient to an UD nccceary procedure On the other hand, if they do appear to be indicated then there is no contraindication to doing them. Tot if I may kay from my standpoint a final word on this I rcolise perfectly well that this 15 a very controvermal subject and it poombly should not even be brought up at this present stage of our knowledge but I would add runply that I had a very skeptical attitude about x ray treat ment just an Dr Love did some 5 or 6 years ago It was only when I began to look up our statistics after we started using this 2 million volt machine ·TREATMENT OF PITUITARI ADEXONAS 103 that I realized liat astoundingly foord results ne lind I then thought I should son hot mo hnd accomplished in the past and what the prere accomplishing during this newer pcriol I nas really astounded to find out hor good these resulte lind liecn and I simply pres them on Tho x bole thog, no I am sure you know, 18 a matter of mature judgment plus folloring your cases for long periods This is really all I inve to say and I Apologue for brogog up such a controversial subject QUESTION TO TIE PANEL Do you agree with Dr Horrax concerning our studies as diagnostic tests? De Lore I havo no desire to become knof'n as "The Great Disscatur," get it 18 a fact that over the ycars cnccphalography in the diagnosis of chromophole adenomas of the pituitary body and oren in the detection of small craniopharyngiomas or adamantinomas has not been a great help to me Personally, I would much rather rely on my cstimation of the patient's clinical course and upon the judgment of my associates in ophia thalmology as to the status of the 17310n I have seen a number of patienta over tho years who underwent au studice nith resulta that were considered to be negatre, as were repults of angiograns yet tlicy fiad programare visual loss as demonstrated by Dr Rucher and lus associates. In such ubstancat I have had no hentancy whatever in operating, and I have found space-occupyiag lesions thich mould account for the visual lose. I Bliare Dr Horrax 8 view that any procedure, however simple, is associated with rish lou all know that occasionally a patient des after a hypodermoso mjection. Well suppose you propose to ancathctize a patient and make an encephalogram but you then consider that the patient does not have choked optic disks, and conclude that shaving the head malog a couple of bur holes for ventriculogmphy am not warranted The only method left 19 angiography I think all three of these procedures at times will fail in helping you establish the diagnosis of an intrasellar lesion which is producing pressure on the visual apparatus. DR RAŁ I dont agree with that We rarely resort to air studies but To liave used angiography rather frequently of latt mostly to find out that we could learn from it The distortion can urually be demonstrated brut I ain not sure that it adds materially to the diagnons or to the plan of decision about opriation. QCESTOY What is your opinion regarding the deleterious effects and changes to the bron resulting from radiation therapy ? DR. RAT It is true that in the series I discussed I alluded to one patient wlio had received large amounts of letatron It was given in an effort to destroy the pituitare iwluch is quite another matter from that thich Dr Horrat has been reporting! This patient showed pro- Ariane anterioration and then ple died autope Prealed extcaulic eliangre in the brain due to irradiation.

·101 CLINICAL NEUROSURGERY lle also have in print at the moment though not published, thic account of 2 achromegalic patients ho de eloped all the signs and symptoms of brain tumor and at operntion, loobed as though they had glioblastomas In cach case, thexe changes rere the results of repeated doses of x ray treatment over a period of years. Onc can easily point out that the mistake ras in giving all the x ray, but in each case the series was given by someone who thought he knew what was approprate In each case I think thc dosage totalled somewhere around 10,000 r over a period of years Dr Browder operated on one of these patients and I operated on the other Dr Horrar has already said what the dosage should be and I hope he will sav, when he has a chance to discuss this what he feels about repeated doxes of ray I would also like to ask him what attitude he tahes when there is no improvement in 1910n—if he assumes that it 15 a folure or 18 he content to accept it as all one can accomplish in the treatment of this paticnt? I have a purpote in asking this question because I think I have enough experience to lead me to beliere that many patients whose 178100 18 not improred by a rar cubsequently get a rery stnking improvement from operation. Also I think that what is one man's opinion of dangerous progreasion of the tumor, is not what the opinion of another man would be Some might regard loss of vioon to 20/50 or even up to 20/100-as still witlun the safe range of trying ray treatment. I would be alarmed at that much loss of 17000 and I am fronk to say that I am much more enthunastic about operation than I am about x ray It seems to me that in the last fett i car with very fets exceptions the patients who have been coming to me for operation have alrcady had the limut of treatment by I ray I have never used the argument homen er that i ray treatment maher subrequent operation korte I do not believe that 18 tho cage at all QUESTION Comment on the mechanism of headache in pituitary tumors and its relationship to the various types of adenomas. DR. Rar I agree with what Dr Penfield bas said. I dont think we knot for sure why a patient with a pituitary adenoma has headacheo It can early be reasoned that there are pain Bensory structures in the aren The diapbragus cella is painful and the carotd wluch lies im mediately adjacent 18 cty renenture to pain At least thote structures might gne rise to headache I think that probably all or many of us have Ecen patients with hemorrhage into an adenoma then there 18 an acute type of beadache wluch leaves very little doubt that it is associated with that cpisode I rupect that in the majority of patients with pituitarr tumors the headache exite on rome other mechapim and I wont in to explain what The acromegalıcs trere much more inclined to complain ·105 THEATWENT OF PITUITARI ADENOVAS of headache than the chromophobe types One might explain that the licadache 18 in keeping rith other pains which occur in the body, probably due to somatic overgron th partially involving thic penosteum and other pain sensitive touco Onc haa to be sory cautious in anticipating bencfit from an operation in a patient with nny type of pituitary tumor whose associated fiendnches constitutc the reason for operation QUESTION Doce the fixed cluasi citr neccesitate section of one optic neret DR. RAY I supposc what 18 ncant fixed chinon 18 gliort optio neries or the very prominent tuberculum sclla or both in either, the space anterior to the chuiasm is narrower than one would prefer In our last 100 cars I think there have linen 4. In 1 or 2 patients I found at operation that this space mas 40 narrow that I could not work conveniently or mafely, therefore I had to remove the tuberculum sedla Tlus is a perfectly feasible procedure but it takes time Maybe I am impatient, but it takes me an extra bolf hour there is also the possibility of opening snto the sphenoid sinus and of a subsequent spital furd lenk. In one patrent the visual loss occurred as the result of a fracture which passed into the optic foramen when I drove the cinecl into the bone to mahe the first opening, so there are diffirullica of that kind In the answer to the specific question, does onc optio nene sometimes have to be divided, I would say that the answer to that is Do One nuust make the midline exposure thich I point out 19 a very necessary part of thun particular operative techniquc Tic brain retractor must hug the falx. The surgeon's line of 1310n must be directly down along the falx, in which case the pituitary stalk 18 in full victs If thic cxposure is compromised by & more lateral approach the nght optic nerie obscures the stall and must be retracted with a risk of damaging it. Deliberate division of the right optat perve does not neem justifiable unless, of counc, the patient 18 blind in the aght ege QUESTIOS Are you approaching your pituitary tumors from the mid hoc rather than from the ade? DR. RAT What I described 18 the method used 13 reinovog the pituitars in hypophy sectomy This is still a very nice ray to approach the pituitary tumor or meningioma or any other legon in that region I must confess, though that if the frontal nouses are very large or if the patient might object strongly of the olfactory sense should be lost I rould be inclined to moie a little interalls, where the frontal ainus could be avoided in the tradiotony and There one could better capeet to preserve the olfactory norte QUESTIO Ar you concerned about opening into the frontal spuses? Dr. Rar lo but it is a potential risk and also, it takes a little uime to deal with an open sinus then opening and closing the found.

·104 CLINICAL NEUROSURGERT TVc also havo in print at the moment, though not published, the account of 2 achromnegalic patients who developed all the signs and symptoms of brain tumor and, at operntion, looked as though they had glioblastoma. In cach case, these changes were the results of repeated doses of x ray treatment over a period of years One can canly point out that the inistake ras in giving all the x ray, but in each case the series was given by somcono tho thought he knew what was appropriate In each case, I think the dosage totalled somewhere around 10,000 r over a period of ycan. Dr Browder operated on one of these patients and I operated on the other Dr Hortax has alrcady and what the dosage should be apd I hope ho will say, when ho has a chance to discuss this what he feels about repeated doses of x My I would also libc to ask him what attitude hc takes when there is no improvement in 17910n-if he assume that it 18 a failure or is he content to accept it as all one can accomplish to the treatment of this patient? I have a purpose in asking this question becauso I think I have enough expericucc to Icad me to believe that many patients whose vision 18 not improved by x ray subsequently get a very stnking improvement from operation Also, I think that that is one man 8 opinion of dangerous progression of the tumor not that the opinion of another man would be Some might regard loss of vision to 20/50—or men up to 20/100-as still within the safe range of trying x ray treatment I would be alarmed at that much loss of 11810n and I am franb to say that I am much more enthusiastic about operation than I am about x ray It becms to mo that in the last few years with very fet cxceptions, the patients who have been coming to me for operation havo alrcady had the limit of trcatment by 1 ray I have noter used the argument however that I ray treatment makes subsequent operation worse I do not believe that 19 the case at all QUESTION Comment on the mechanism of headache in pituitary tumors and its relationship to the various types of adenomas DR. RAY I agree with what Dr Penfield has said I don't think the know for sure why a patient with a pituitary adenoma has headaches It can easily be reasoned that there are pain sensory structures in the Area The diaphragm o sella is painful and the carotid much lieu im mediately adjacent is very sensitive to pain. At least those structures muglit give rise to headache I think that probably all or many of us have Gecn patients with hemorrhage into an adenoma then there is an acute type of headache which leare very little doubt that it is associated with that episode I spect that in the majority of patients with pituton tumor the headache exists on some other mechanian and I not to to explain what Tho acromegalies were much more inclined to complain ·TBEATNET OF TITT IT IRI DELOLA 102 of headache than the chromopliolx tume One might explain that thic headache 18 to keeping with other pain #luch occur in the body, probably duo to somatic or crgronth partially involving the penosteum nnd other pain sensitive tistuer One has to be sen cautious in anticipating benefit from an operation in a patient mrith no trpee of pituitar tumor hose Asociated headachet constitute the renson for operation QUESTION Docs the fixed cluasın ci cr neccretatc section of onc optic nerte? DR. Ray I suppose that is meant lui fixed cluasm is sliort optic nench or the very prominent tuberculum sella or both In either, the space antenor to the cluasm is parton er than one would prefer In our last 100 cases I think there have been 4 In 1 or 2 patients I found at operation that thus space was so narrow that I could not work convcnicntly or tafely, therefore I had to remoic thic tuberculum sella This is a perfectly feasible procedure, but it takes time Maybe I am impatient, but it takes me an extra half-hour, there 18 algo the possibility of opening into the phenoid sinus and of a subrequent spinal fluid leah. In onc patient the visual loss occurred as the result of a fracture which passed into the optic foramen when I drove the chisel into the bone to inake the first opening, 80 there are difficulties of that kind. In the answer to the specific question, does one optic nerve sometimes have to be divided I would say that the answer to that is, no One must make the midline exposure, which I point out is a very necessary part of this particular operative technique The brain retractor must hug the falı, The surgeon's line of rison must be directly down along the falx in which case the pituitary stalk is in full vien If the exposure 18 compromised by a more lateral approach the right optic nere obecures the stalh and must be retracted with a risk of damaging it. Deliberate division of tho right optic nerve does not seem justifiable unless, of course the patient 18 blind in the right eye QUESTIOP Are you approaching your pituitary tumors from the mid- 1100 rather than from the odc? DR. Ray What I described is the method used in renoving the pituitary m hypophysectomy This 18 still a very nice way to approach the pitwtary tumor or meningoma or any other lesion in that region I must confcos, though that if the frontal einuses are very large or if the patient might object strongly of the olfactory rense should be lost, I would be inclined to move a little laterally where the frontal minus could be aroided in the craniotomy and where one could better expect to presenc thc olfactory nerve QUESTIOT Are you concerned about opening into the frontal sinur? DR. RAi do but it is a potential nsh and alvo it takes a little time to deal with an open sinus when opening and closing the found.

·CHAPTER VIT Hypophysectomy for Cancer of the Breast BROVSOV S RAY, MD The trial use of lypophyrectomy in the treatment of malignancy has been used in patients with carcinoma of the breast. I assume that you are Atrare that carcinoms of the breast is the coinmoncst ncoplasm in mankind. In aperimental animals mammary carcinoma can be hormonally induced. In humans for many years there has been direct and indirect evidence of the bormonal influence on the grourth of breast carcinoma. It seems a natural scquence then that the effects of ablation of the pituitary should be investigated after me have learned that may be accomplished by ablating the ovaries and then the adrenals, and then tre hero ACTH and cortisone for substitution therapy after remoral of the pituitary This report deals with the results thus far in the progress of testing the benefits of hy pophy sectomy in the management of Advanced carcinoma of the breast in tromen. This work has been done in collaboration wth Dr O Pearson who will speak to you shortly, and, of course, with the assist ance of many peoplo on our clinical and laboratory staffs in the New Jork Hospital and the Vicmonal Center In the 242 ycar perod between Varch, 1954 and September 1 1958 110 hypophy sectomies rere performed on 109 women, and the present evaluation 18 based on the follon up (of from 1 to 30 months) on these 110 hypophyrectomice Hypophysectomy has also been employed in a rarcts of otliet neoplasms and to date our total expcnence with the opera tion has been with about 175 patients The results in treatment of malig nancies other than brcast carcinoma and possibly prostatic carcinoma bere been very disappointing. In fact re have seen no beneficial effects on other tumors NDICATIO\ FOR I POPIIRECTOMI The indications that we have come to employ in recommending and performing hypophy octomics on women with carcinoma of the brcast are that there should be palpable or visible lesions endencing metasta 18 or there should be x ray cidence of metastasia to lungs or lone or pleural effusion contanding identifiable malignant cells Somc patients rith clcletal metastases alco lave alteration in calcium balance (hypercalcemie adil lly percalcuuma) In fact in choosing patients on nhom to perford the 100 ·llyTorill SECTOWY FOR CA\CHR OF THE BREAST 107 operation, we did not choose any also have not shown cuidence of metastatic circam in progresil\cncuits llith patients a ho hnic recently been treated by some other means, with enerogeny or androgeas or X-ray or cortisone, we have waited until the effect of this incatoicnt kind wom off, of indeed thiore liad leon an effect and when RC were oure that we were dealing mesth an active procene Other ist, me should linie hnd nothing with sluch we could make companson after the lipopluscctomy lle bare found no evidence of correlation sa our resulte mith the type of tumor of thic breast, aith the age of the patient or the duration of the direase, that is the interval ltnccn the dicotery of the discane or mastectomy and the unic of in popli ectomy Patients with intracranial metastast czdenced by sncreased intracranial pressure puisies aphasia or confused mental states laiclxen escluded! Patients with enous impair meat of their vital capaciti ns the result of inetastases to the lung hato been found to be unsuitable This does not mean, lorcier, tlint patients are excluded mlio lavt respiratory difficulty froin pleural effusion, if thu symptom 19 or crcomc by draining the fud Oftea pleural metastases appear to benefit from lry poplıyoctomy and pleural fud docs not reaccumulate after operation. Also, it has secuned that paticats with extenarse hver metastases, those riuch would product a very large liver, jaundice or some measurable deficiency in Iner function do poorly after hypophyrectomy But often, as it must be obvious to you, the decision has to be arbitrary and dopende pretty much on that itongblı factor clinical judg ment. On the whole the patients of this serice have liad advanced meta Matic discase and many of them have been brously ill A BATISFACTORY BURGICAL TECHNIQUE After an initial period of trial god crror with the surgical techniques, me arrived at a satisfactory method in March 1964. The patients who are evaluated in this present report were operated on after that date and by the same method (ercept for a fer minor ramations in technique) I performed all the operations If there is time later a film of the operature procedure can be shown, but I should like to go on bere to discuss the results of operation shich are more important at the moment. Dr Pearson wll discuss with you so more detas} the various endocrinc spects of the problem. Ia tuc 18 hours before operation patients were Biren 300 mg of cortione, in divided doses, intramuscularly, on the mornmg of operation 100 mg, of cortisone were given by mouth and following the operation cortisone ras continued intramuscularly for 24 hours in 50- me doces giren et cry 4 hours. Thereafter for the following wech the dosage of cortisone fas gradually diminished to the marintenance dose of about 25 mg. twice in 24 hours The matter of controlling diabetes insipidus ·108 CLINICAL VEUROSURGERY thyroid deficiency and other occasional postoperative endocrino problem will be discused by Dr Pearson Perhaps we cannot tall trith complete certainty about how many patients have had incomplete hypophy occtomy but my estimate is that in this group of 110 operations there are 6 known incompleto hypophyeee tomics In the patients who have died there is an autopsy rate of about per cent Serial sectioning on the region of the sella turcica has not been made in all tho patients that have come to autopoy It 18 an cxpensie and time consuming procedure and it has not been practical to perform senal sections on every autopsy specimen In thosc patients who in clinica testovere belicted to have residual gland, there was residual glandulaj tuouc, evident on gross inspection In those bello ed to have bad total hypoplysectomy on the basis of endocrine studies, residual glandulor tissue was not present on genal sections, with one possible cxception The first slıdc (Table 6) shows you the postoperative marbidity and mortality rates Among tho 109 patients there were 8 deaths within the first 30 days after operation Three of these are cstimated to be the direct result of the surgical procedure One patient believed to have a postoperative remission of her disease had gone home but dicd of a pulmonary embolism on the 26th day One patient died before the skin iDCHOD could be com plcted, probably as a result of unrecognized pericardial metastases There wero 3 patients who died in this 30-day period of the progression of their discase barang been unbenefited by the hypophymectomy Therefore, tho over all mortality (that 18, death wthin the first 30 days after operation), 19 about 7 per cent The mortality rectly attrbutable to peration 13 nearer to 3 per cent, it might be as low as 2 per cent and certainly 18 not more than 5 per cent. The morbidity 18 listed as follows 2 patients sustained important visual Jose One of these patients lost 1700n completely in one cye but up the Tanz 8 Ruks of llypophyrectomy in 110 Operations Mortality (30 days postopentive) Direct rural Pulmonary embolus (28th day) Anesthers Progrexon of disease 3 1 1 3 2 Jorbidity (13 patients) Serious val lo Field defocus Veurologcal complications Lotncral clot 6 3 3 ·10 119TORIIS SECTOYS FOR CANCER OF TF NRELST Xhet ETC she bos cpoucli virion left for useful purpose The other patient Dad considerable unpainuent in liotli ftclla ol ynrion but returned to her job u hairdrerer Su others had field defects hich were identifical only on careful virual field studies or were recognizel in pntients as very minor quadrantic dcfcets Three are listral ne having neurological complications, mostly lemparisie, but onc patient liad apilaria much we have found difficult to understand since she was night handal Recovery mod enougl in these 3 go that readunls ncre not iniportant Thirce had postoperatie ntracranial clots that required re-operation, but in thic lart 30 or 40 cascs thus complication lias not recurred, for reasons vluch I shall mention later To this morbidity list should perhnjy be added 2 thingsode is that about 5 to 10 per cent of patients have lind convuleic attachs, sometime in the first freek after the operation. To minimic the likeliliood of the occurring, WE DOT administer Drlantın reteral dave llorc operation and continue at for 10 daye to 3 n cehs afterward The other thing that should be mentioned is that at least half of the patients lose smell functions for it does not seem possible always to avoid damage to both olfactorr nemes. Fifty per cent 18 an estuoats, because it has beemtd beter not to draw attention to the possibility of the loss of smell Soric of those that have lost oncli function are well aware of it, others are not or ignore it or accept it as something ununportant The next olide (Table 6) lists the criteria for evaluating remission of the metastatic disease by hypophycectomy We have kept definitely and rigidly to objective agus of remission and disregard fubjectire improvement alone as rewable evdence of remungon. Patients are regarded as having developed retu18910n when enther artert of the disease or regression of the disease har occurred An arrest has occurred if there 18 no progress of the previous legion or if there » disappearance of hypercalcemia and hypercalciune or uprovement in myelophthusic anemua accompanying extennie skeleta] metastases. Evidence of regresnon includes 1) Recalafication of body Iceions that is by x ras 2) Diminution in size of any viable or palpable TALE 6 Cniona for Ernluating RemWROR Arrat To progress of PTETIOLLE lexons Duappeamace of hypercaleems and hypertalcuns Improvement in myelophthunc ADET JA Regreanon Reralefication of bone lessons Dimaution mir of any Leon \o De Imone ·110 CLINICAL NEUBOSURGERY 1 rai Fio VII 1A lemon and, at the same time no now lesion Remission is counted as having ended when any old lesions become progres11e on new ones appear It i only fair to say that relief of pain in patients with bony metastaser har often been dramatic I almost hesitate to report that when some patiente Take up they are completely relic ed of the evero pain they suffordd before It peems a little too dramatic but such 18 the case Occasionally there has been relief of pain when it was not possible objectively to establish regression of the skeletal lemon. Tho following blides Bhor a few examples of objectne remix9ion The first (Fig VII-1a) in a preopemtne picture of an ulcerating lesion of the breast in a 42 year old woman In 1952 sho had bxcn castrated for liat Fas conndered to be an inoperablc tumor mastectomy was not performed ·111 HYPOCITYSECTORY FOR CANCER OF THE DREAST - 1 Pio VII 1b Enghteen months ago bypophysectomy was performed and the photograph (Fig. VII-1b), inade 11 months after operation, shows the resolu tion of the tumor The remission of her discaso continues now 18 months following hypophybrctomy The next case (F1g VII-2) 18 that of a 72 ycar-old woman who had an extensive tumor extending well up in the supraclavicular region, Lalla, arm, across the other ndc and down toward the abdomen circling a good part of the chest. She had no other metastases and she had no other treatment Tho postoperative picture (Fig V11-2b) taken one year later shong the complete subsdance of her extensive lesions Her remission ended shortly after tlu picture was taken about a y car after hypophysectomy but xhc 18 still living more than 2 ycan after hypophyrectomy The local recurrence has been olon and has responded rather well to x-ray trcatment And she has not da eloped any other metastases The next slide 18 of roentgenograms before and after operation (Fig 171-3) of n 34-1 car old premenopausal woman who had a radical mastectomy and local s my trentment 2 cars before lypophy actomy She had developed pulmonary mymptoms 2 inonthis before she came to the hospital with the motonin matandnes no 11.. 1..- 1

·ܢ
Fia VII-21
Fio VII-26
11n

·IN ROPITINECTORY FOR CANCER OF THE BREAKT FIO VII-3 roentgenogram. The second roentgenogram was made just 3 Techs after operation and shos the rapid disappearance of the pulmonary Icons It 18 not 18 months sinco operation and her disceso 18 still in full remission She is a good looking school teacher and is teaclung school and Icading just as active a life as acr I emphasue the fact that she 18 good-looking to briog out the point that patients after hypophyæctomy do not have a change in feature. Thoy do not look like patients with hypopituitarum And they nrc spared the changes in appearance that accompany androgen therapy or large doses of cortisone The next slide shore pre- and postoperative films (Fig. VII-4) of a 42 ycar-old woman who had a radical marteotomy 249 years before. One year before hypophysectony she had castration for metastasis to the lungs, And had a favorable result from that for about 6 months The first tim Fre V4 ·114 CLINICAL NEUROSURGERY Fia. VII-5 abows the exten ervo recurrent pulmonary motastases and aloo pericardial effusion duo to pericardial metastases The postoperativo film 4 months later shows the remarkable subsidance of the lesions Full remission ended about 10 months after operation The next slide shove pre- and posthypophyscotomy films of skeletal metastases (Fig VII-5) in a 44-year old woman who had a radical mas tectomy 4 years before Skeletal motastases vero known to exist during the 18 months boforo hypophyecctomy The striking improvement in the appearance of the skeletal motastases after an interval of about 6 months 10 ocen in tho postoperative film Remission ended some months after that, but the temporary effect was qute dramatic RESULTS OF HIPOPITYSECTMIY K VALVARY CARCIKORIA To have tended to compare our results with those of Luft and Olivecrona Luft recently brought their statistics up to date in & paper presented beforo the American Cancer Society in New York. Ho reported remission of disease after hypophysectomy in 54 per cent of 52 patients with mam mary carcinoma. Our results have been quite comparable and our opinions are not at significant vanance with one posable aception They mako a ·115 InTorill SECTOR FOR CANCER OF THE BREAST THE Results of Memenomul Ilyporhyerclomy (caca) tom of diens (2 al 5 months) Argeon of disco (7 4+ 17+ months) No bencfit 2 3 3 point that hy noplyectomy king little or no bencfit in older wonics and that has not been our experience nt all lou linie seen the dramatic improrchcnt in a 72 ycar-old woman, and in otlicry over 10 years of ago thero laro buen comparable bencats All the 61408 of Luſt and Oliccrona were of painiary lygoply-sectomy, that 18 ther patients had not had previous castration or adrenalectomy A third or more of our patients harc had hvpophy sectomy after they have had contration, or castration and adrenalectomy and it 18 possible thereforo to point out that additional benefits can be attained from liypophysectomy after castration and adrenalectomy The following slides mall show the results in scicral groups harjag a different endocrinc status Eight patients were in the premenopausal penod and still menstruating (Table 7) Tro of the 8 had an arrest of from 2 to 5 months after hypophysectomy and 3 others had regression of their duease of the 3 patients trhose discaso regressed after bypophy sectomy, 2 are still in a state of regression 4 and 17 months later, while one has had reactivation of the disease 7 months after hypophysectomy The pext slide (Table 8) classifies the results so 25 patients who had tlctapeutic costration either surgically or by x may before bypophyaec tomy Of these 25 patients 14 had remulsions 9 failed to improve, and 7 connot yet be craluated. An obeervation of additional interest and importanco w that the 7 patients who had a temporary remission of their disease from castration haro a ner remission following hypophysectomy lo 1 of 5 patients who had failed to benefit from castration & reinikon Occurred from hypophyecctomy It 18 very likely, therefore that any patient who benefits from ablation of the overies can be espected to benefit also TAJLE 8 Results of Hypophymrlom7 12 28 ccm kulk Previous Therapeuta Contratton 0 To benefit Returion of duce Tot related Reponse to contratos 6 lo refpodia toration 13 1 am Aluated rattration 7 Herponre to hooporrectomy 1 Response to hutopliy sectomy O tour to hrpophrectady ·118 CLINICAL NEUROSURGERY TABLE 9 Results of Typophyrectomy m 18 Cares with Prorrows Therapeutic Castration and Adrenaloclomy No benefit Arrogt of disease (for 2 to 3 months) Repronion of dies (for 7 months) 8 3 1 from hypophysectomy and that occasionally patients who do not benefit from onstration may benefit from hypophysectomy Thero there 13 patients in whom the results after castration could not be adequatoly evaluated, half of those patients obtained a rudission from hypophysectomy The Dext chart (Tablo 9) is of a group of 12 patients who had had oophorectomy and adrenalcotomy Three patients had arrest of the dis ease for short periode, (2 to 3 months) and 1 patient had had a regression of the disease lasting for 7 months. This is definito evidence that something more un accomplished by bypophysectomy than 18 accomplished by a com bination of oopherectomy and adrenalcctomy It might be reasoned that those who benefited did so as a result of suppression of function of acces sory adrenal tissue but it dove not seem likely that this would be truc for as many as 4 of 12 patients. The nert olido (Tablo 10) pertains to patiento in postmcnopausal phases Of the 56 patients thoro were 28 who had remissions, 24 who failed to bcnefit and 4 who have not yet boen ovaluated Thirty cight bad had spontancous menopause and 18 induced menopauso prior to developing carcinoma of the breast. There doce not seem to be any sigorficant dif ference in the results of hypophydectomy in the ttro groups The final slide, (Table 11) summanses the results of 110 hypophyseo tomics in 109 patients oy cr a 24 year period Fifty-onc patients had reminion of their discan (10 were arrests and 41 vero repressions) Thero were 44 failurce and 8 deaths. The results in 6 patients have not yet been determined. The average duration of the objectivo remission go far is 76 months the shortest period of remission being 2 months and the longest to date being 27 months (in a patient who shots no signs of recurrence of tho disco8C) It is of course cncouraging to add that 23 of tho 51 patients TARE 10 Renvlu ol Pou menopausal Hypophyrdomy tn 58 Caxs No benefit Remton of de Mot onluated 21 28 4 ·IITPOPITILECTOVI FOR CANCER OF THE DREAST TAME 11 Results of Hypophy clomy in 103 Caxs of Broat Carcinonta 117 ho benefit Deaths Arrest of ducare Region of diamo Mot on aluated H 8 101 Average duration romutton (to date) 11/07 0 • Extrema ? to 27+ months, 23 of 81 still in remigon 7 6 months are still in remission and the average duration of remission will increase As time passes Luft reports an average period of remission of 17 months It 18 gratifying to show objective improvements for a while in patients, but the question inevitably ashed us ' are fo prolonging lifo and doing it 80 for the comfort of the patient? In attempting to draw some conolusion regarding the survival time we found that the average period of survival following lypophysectomy in patients who had not bencfited by the peration (not counting the postoperative deaths in the first 30 days) has een 5 months and but a few of the patients in that group are still liting. gainst that the can compare the survival thus far in the patients who ac been benefited by operation and already it is better than twice as ng. That is, the survival period 1. 10 months or better, with half the pamts still in remission and still living. Of course the termination of remisin is not synonymous with the termination of life There is some suggestion too that in some patients the diveasc 18 mild and slot in its reourrence and that the beneficial influence of hypophysectomy continues OTHER TECHNIQUES FOR HOLISHING THE PITUITARI AXD ITS FUNCTIOY I am sure that you are woll aware that others have tried and are trying different techniques for abolishing the pituitary or its function. Thcso other techniques include section of the pituitary stalk sithout removal of the gland and intracranial approaches for the cxcision of the gland different from the one I have shown Transantral Scisions have been tred and are being tred again. Tho insertion of radioactive matcral by way of intra cranial exposure or transantrally is being investigated in some places. Then there is irradiation of the pituitary either by betatron or, as more recently reported by Dr John Larrence, by use of a proton beam produced by unenr accelerator There methods are designed to avoid the hazards of intracranial hypophymectomi but for of them consistcntly attain total excision of the gland or abolition of pituitary hormonco Our cfforts have been directed ·118 CLINICAL NEUROSURGERY toward finding out first of all what can be accomplished by total ablation by intracranial escision of the pituitary Against this caperence vo con evaluate the efficacy of other methods 12 VINUTE TECHNICOLOR 18-BL. FILL OF THE BURGICAL TECHNIQUE OF TYPOPHTISECTOLIY More Comment Tho incision formerly employed Tas right frontal with one limb pasang vertically through the mid-forchead, but I havo given tlus up in favor of a coronal incision just behind the hairline. A conccaled SCAT 18 much appreciated by these women who have already had to suffer a grcat deal Anesthesia 18 induced by Pentothal Bodium and maintained by cndotracheal ether Hypotension induced with Arfonad usually 10 started beforo the skin incision is made and 18 continued until the closing skin sutures are in place. The patient lies in the supine position sometimes with the head dropped back and often mth the table tilted with the foot dotyn in order to facilitate the effect of lıypotension The systolic blood presourc 18 maintained somerhere around 70 mm of mercury A free bono plate is removed from the right frontal area A transverse incision through the temporal fascia near its attachment is done in such & way that the fascia and muscle can then be sutured back in placo at the time of closure That does away with the unsghtly depression in the temporal region. One of 4 preliminary openings in the akull is low in tho undline of the forehead made with a trophine The removal of a bone but ton liere not only inakes it possible to replace it in closing and thus avoid dımpling but also it often bery ct to hold in place saling material Gelfoam or a piece of the ponostcum or some otlier material againgt an open frontal mous of tho frontal minus has been opened madvertently or deliberately I have learned not to compromise the exposure by altering the portion of this bur liolo and the sacut through the brot even if the frontal oinutes are large. If the frontal sinus 18 large it is often possible to push bach tho mucosa and preserve it so that there is no opening into the cavity of the snus. If the einus is opened it 19 temporarily packed off during the opera tion and at closure it can be sealed off by any one of a variety of methods If the opening in the sinus 18 large I turn a flap of the penostcum dort over tho margin and anchor it to the dure. If the opening 18 mall usually Gelfoam held in position by the replacement of the bonc plate and the bone button 18 sufficient Rarely have he encountered temporary cerebrospinal fud runorrhea and thus far have had no important infections, After thc bonc plate 18 removed and tho dural opening started spinal fluid 18 removed through a needle which has been placed at the beginning of the operation. This 18 an intradumi approach and I am sorry I did not ·JIYPOPIII SECTOWI FOR CANCER OF THE BREAST 110 sec Dr Lotes picture yesterday about nhich I have heard ouch fine com ments. I understand he made a point of staying outsido tho dura as far as possible, but I have lund no reason to feel that we wero in any difficulty in using thu intradural type of approach It is most important to stay up close to the fals. The surgeon s line of vision must be dircotly down tho line of the falı so that it 18 possible to scc betn een tho optic nerves The olfactory nerve on the night is divided The rcason why patients sometimes lose smell function is that the nerve on the loft will tear when the the brain is retracted After the mathdrawal of all the spinal fluid one can expect to get a VICTS of the liypophyseal stalk and adjacent structure. Tho only exceptions aro when the tuberculum sella 18 prominent or the nerves are relatively short The stalk in this case is coagulated to diminish bleeding when it 18 out and also to destroy any anterior lobe cells that may extend into it I am satisfied not that coagulation is not a wise procedure since the inci dence of permanent diabetes insipidus 18 much less of the stalk is sharply divided at the level of the diaphragm sellae without previous coagulation or clipping. After tho stalk has been divided the maneuver is to plunge the blunt end of a book through the opening in the diaphragm and tear the diaphragm in a cruciate fashion to the margins of the circular anus. Ring cu retter of several sies and shapes some sharp and some semi-sharp, are used to clean out the cavity of the della turcica systematically The gland 18 usually removed in several large pieces and then small remaining fragments aro obliterated by systematio currettement abrasive stabbing, suc tion and finally exposure to Zenker's solution. or principal concern, I find is deliberato interruption or accidental tearing of large veins that run into the saggital sinus Thu 18 likely to lead to venous congestion subpial or even subcortical hemorrhage When it comcs timo to close the wound if the tip of the frontal lobe looks as though it has been jeopardised by the interruption of the veins tho tip of the lobe should be resected Complications leading to postoperativo deaths in 3 patients ocurred 18 a result of failure to follow this procedure Application of Zenker s solution to the walls of the sello is accomplished by placing in the cavity a small rubber sponge into tho center of which has been implanted the end of a polythene tube A small pledget of cotton 18 packed under the chism to plug the subarachnoid space to protect against any possiblo epıllage of Zenker's into the basal cisterns Actually there has been no difficulty or complication from tlus mancuyer but one can never get careless It is lees important how much Zenher B rolution 1x used for irrigation than the time during which the cavity of the alla ** cipo-ed to the solution usuallı ten minutes coporure leaves a gray roagulated lining of the sella. Before taking the sponge out it is neccrear ·120 CLINICAL NEUROBURGERY to run saline through it to remove tho Zenker s solution and thus protect the optic nerves as the sponge 16 removed. On closing the round the spinal flud need not be replaced Tho dura has always been approximated tightly, particulary if there has been an opening in the frontal onus. There has been no trouble with cdema of tho brain and thicro 18 no need for a decompression REFERENCES Lurt R. AND H. OLITECHOXA Hypophymectomy in Alun Expertencer in Metustatic Cancer of the Breast Cancer March and April 8, 201 No 2, 1955 LUTT RAD I OUTOCROSA Hypophymectomy n tho Treatment of Malipant Tumore, Cancer (In Prero) Presented at the Scientific Semon of the American Canett Soaety Now York, October 1850 ) Questions and Answery QUESTIOY What are the results of transection of the pitwtary stal, as compared to hypophyscctomy in the treatment of metastatic carcinoma? DE RAT It has been my impression that it is virtually imposible to drat any conclusions from the results of the proceduro, but perhaps I am not up to-dato on tho matter I know that the operation was performed on the basis of work done by Harris and others in England It may be that this will turn out to be a useful procedure, but on the information we have in hand at the present, I don't see hot that can como about Certainly, in our operations for removing the pituitary we cut the stalk-there is no question about that We know that if there is any agnificant part of tho pituitary gland left there 18 otill identifiable anterior lobo function If that u not dono atay thicre 18 still identifiablo anterior lobe function. We shall have to change our whole attitude, if it turns out that we can get clinical benefit by amply dinding the stalk and still have evidence of pituitary activity I would not be inclined to expect much from stall section but I would Icep en open mind ·CHAPTER VIII Physiological Effects of Hypophysectomy OLF H PEARSOY, 11.D When Dr Ray and I first discussed hypophy sectomy we were of course, sonoerned about what Fould happen to the patient after removal of tho pituitary This was at a time when cortisone was available for replace ment therapy t'e had had experience with the use of cortisone in patients mith Addison's diseasо and with removal of the adrenal glands and to were quite confident that, as far as adrenal function was concerned these patients could be quite adequately maintained. Also patients with panhypopituitarism could be maintained in a good state of health with ade quate adrenal and thyroid replacement ADRENAL FUNCTION I would like to discuss first the effects of removal of the pituitary gland on adrenal function (1) The adrenal glands are most important as far as hfe maintenance 18 concerned Following bypophysectomy there is a profound cessation of function of the adrenal glands comparable to that of surgical removal at least as far as lifo maintenance is concerned. The hormoncs of the adrenal glando, as we know them now, consist primarily of hydrocortisone which is the bſe maintaining hormone In addition to hydrocortisone there is the salt hormone known as aldosterone As I mill demonstrate following hypophyteotomy thu function of the adrenal zland 18 apparently not impared so that maintenance of salt balanco u mot a problem after hypophycectomy as it 18 after adrenalectomy In addition to hydrocortisone and aldosterone the adrenal gland produces androgenic and estrogenjo steroids One of the purposes of hypophysectomy 18 to suppress the production of these steroids since they may be important in tho gronth of breast cancer Figure VIII-1 illustrates some of the things that happen to an adrena lectomucd patient on withdrawal of cortisone The patient as being maintained on 50 mg, of cortisone a day given in divided doses of 25 mg every 12 hours plus an adequate salt intahe then cortisone was withdrawn, the patient noted malajee anorexia and lassitude mithin 24 hours. There- * There #udies were Ripported in part by prants from the Tational Cancer Instr tute of the \ational Insututes of Health United States Public Health Service the loited States Atomie Egeres Communion the American Cancer Society Inc and the Damon Runvon Alemonal Fund 121 ·122 CLINICAL XEUROSURGERY WC a trustett CORTISORE 0 /doy 100L ALDOSTERON 900 M om SERUH SOYU MEAL 1351 125L 120 SYSTOLIC 100 mmHg DIASTOUC 103 TUITERATURE 101 Degrons F 97! 2 3 DAYS Fio VIII-1 Effects of withdrawal of cortisone in an adrenalectomired petiont on body temperature blood pressure and serum sodium after muscular aching postural hypotension Dausen, and profound work ness ensued. At 36 hours tho patient had an ashen gray appearance, was hyperpyrudo add hypotensyo and appeared critically ill Replacement with cortionc brought the patient back to normal within 12 to 24 hours Similar changes occur in the hypophysectomized patient when cortisono 18 withdrawn In the adrenalectomised patient, the scrum sodium frequently falls although this is not insanablo After hypophyoctomy this 18 lcs likely to occur becaus, wo think there has been damage to the partneri osa system producing a mild diabetes insipidus. Figure VIII-2 demonstrates that the hypophysectomized patient can maintain a normal salt balance on a lof salt intake This patient was maintained on desiccated thyroid 2 grains a day, and 50 mg, of cortisode daily The sodium intake was decrcard from 144 to 10 mEq per day ·123 PITY8IOLOGICAL EFFECTS OF HYTOPIIRECTOIT D$ 143316 CA. BREAST HR DESKCCATED THYROHO 20 VARR oc COTONE ACETATE BOL wto/L SERUM SODIU 1905 140 LEO/Z4 HR 72 URINARY SODIUM 48 OF 46 72 120 BODY WEICHT O MEO KON $. 83 3 B 7 3 DAY PERIODS Fra V111-1 Wilocts of alteruou o sodium intake on the bodrum balance of an hyponk rectomised patient. The sodium intake u plotted daratand from the sero line and the local and unnary wodium output w plotted aphard from the intako ime Sodium balance tras attained by the sixth day The serum sodium remained normal and the patient ſelt tell This response is ami}ar to that of a normal individual It has been dergonstrated that thc hypophyrectomized patient dont icrete aldosterone in the unido and that the amount in- CTCase Flien the sodium intake is reduced Figur VIII-3 illustrated the eiiccts of salt mthdrawal in a patient with Addison 8 discasc When the bodmn intake was lowered to 10 mEq per da) sodium balance nins pot achened after a period of 16 days At this imme the patient developed makness and anorexin mhich disappeared promptly when the salt intake was restond. TUITROID FUNCTION Inpoplyncetona induces a marked suppression of thyroid function resulting in elsnical manifeftations of lipothyroidism mthin 4 to 8 vecko ·124 CLINICAL NEUROSURGERY LY.BIZ 403 4 1001SOMS DISEASE VON ME O CORTISOL ACETATE 30 140 tart SENUU SOOLUM BS WEO4 HR 7t URIRATY SOONUN 24 0 24 40 ZA 72 10 LO 14 15 BODY WEIOHT J 5 R 7 J DAY PERIODS Fra VI-3. Elects of ruutions in sodium mteho on the sodrum balance of an Addisonnin patient. (2) Yo have aroided giving thyroid replacement therapy for several weeks after operation because tro felt that evaluation of thyroid function might provide information concerning the completeness of hypophy occ tomy Figure VIII4 presents the changes in borum protein bound 1odine in a group of patients before and after hypophysctomy It will be noted that the values fall to myxedema les els within 2 reeks after operation Figure VII-5 demonstrates the uptake of radioactive iodine by the thy roid gland in the same group of patients Hypophysectomy markedly impaired the ability of the thyroid gland to accumulate radioactivo iodine If hypophysectomy bas been grossly incomplete, theso parameters of thy roid function may shot an initial decline but usually return to normal Tithin 3 to 4 weeks after operation. Thus, measurements of thyroid function provide a valuable ck on the completeness of hy tomy but do not necessanly guarantee that a 100 per cent removal of the pituitary gland has been obtained. Tho rerum cholesterol 1808 very slowly after hypophysectomy and the increase is relatively minor averaging 60 mg/100 co.

·PITIBIOLOGICAL EFFECTS OP HYPOPITYSECTOUI 10 125 SERUI PROTEIN BOUND 10DINE VALUES BEFORE AND AFTER HYPOPHYSECTOWY (23 SUBJECTS) 8 6 99001ONT • Before After 2 2 2 4 8 10 WEEKS Fro VIIH Effect of hypophy octomy on serum protein-bound Jodie From J Clin. Endocrinol Metab., 15 1232 1933 8 Tho length of time for the development of clinical lypothyroidism 18 quite variable occasionally taking 4 to 6 months but usually being evident within 1 to 2 months Earliest signs of hypothyroidism have been dryness of the shin and obesity Subsequent appearance of the classical clinical manifestations of myxedema such as cold intolerance constipation las oitude thickening of the ship and delayed relaxation phase of deep tendon refletet hare been observed when thyroid 18 withheld Restoration to the cuthyroid state has been easily accomplished with 120 to 180 mg. of desic cated thyroid daily GOVADAL FUNCTIO In menstruating women function of the orary appears to ccase after -pophyuctoms When the operation tras donc carly in the menstrual ·120 OLINICAL NEUROSURGERY THYROID I UPTAKE VALUES BEFORE AND AFTER HYPOPHY SECTOMY (28 SUBJECTS) 40 +30 • Botore After 20 % Uptaka 10 2 2 4 6 16 18 20 WEEKS Fra VII-5 Efeet of hypophrectomy in the 48-hour pa uplato be the thyroid gland. From J Clin Endocrinol & Motab., 15, 1231 1958 cycle, no further menstrual periods occurred. If the operation took place dunng the progestational phase, there was one subsequent mensis The vaginal omears show a postmenopausal picture one week after hypophysec tomy and a completely atrophic scar is obtained in 2 to 4 weeke, Pituitary gonadotrophin wzorction in the unne has been measured as another index of the completeness of hypophysectomy In the majority of CABEH A complete hypophysectomy Tas accompanied by disappearance of gonadotropluns 2 to 3 weeks after operation. A few patients wlio vero subsequently proved to have had complete removal of tho pituitary gland have exhibited persistence of urinary gonadotrophins for periods of 2 to 3 months before the titer dropped to an immeasurable level Nooo of the premenopausal patients suffered definite postmenopausal symptome after hypophysectomy 'Two patients had transiont peculiar sensations simulatiog vasomotor phenomena but secro hot flushes' As may occur following ovanectomy have not beca cncountered. There 18 & marked decrease in growth of axillary and pubic hair wluch may becomo quite sparge Scalp hair appear to grow normally and rotain its previous texture Female patients have noted a definite decrease in libido following hypophysectomy Our obser ations of tho effects of hypophysectomy in males with intact ·PITIBIOLOGICAL EFFECTS OF JIITON SEOTOLIY testes have been limited In two paticnts, the testes becamo small and soft mtlun 4 to 8 weehs after operation Atrophy of tho bcx organs oo curred and the pationts trere impotent A testioular biopsy obtained o treeks post-hypophysectomy slowed considerablo ntroply of tho tubulce. 127 OTTER PITUITARI FACTORS The hypoplysectomized patient who is maintained with cortisono and thyroid rotains a normal appearance and, in particular, the color and texture of tho skin docs not rcioal any obvious change Pallor of the type seen in the untreated hypopitutory patient has not beon encountered. Our patients tan normally when exposed to sunlight and do not appear to have any unduo sensitivity to such exposuro. Thus, the presumed absence of melanophore-stimulating hormono docs not produce any gross changes m the skin. Observations on carbohydrate motabolism trere made as a possible reficction of the lack of growth hormone Alterations in carbohydrate metabolism following hypophy sectomy have been minimal No instance of symptomatio hypoglycemia has been encountered with cortisone main tenance the fasting blood sugar is either unchanged or shows a minimal drop (10 to 15 mg./100 cc) The oral glucose tolerance test is either normal or may show a slight exaggeration of the late hypoglycemic phase When the hypophyseotomued patient is maintained tith cortisone inpulin tolerance appears to bo somewhat reduced although hypoglycemia responsiveness 10 normal. We tested our patients following hypophysectomy with ono-third or one-half the usual does of insulin and obtained normal insulin toleranco curves, which were comparable to insulin toleranco curves obtained bofore hypophysectomy using the the standard insulin dosage (01 units per kg) Tho cancer patients with diabetes mellitus trho required moderate amounts of insulin did not require insulin after hypophy vectomy These observatins suggest that hypophyscotomy induces minor changes in carbohydrate metabolismu possibly related to tho presumed absonce of growth hormone Tho hypophysectomized patient 18 able to gain weight without the addition of gonadal steroids. Positive nitrogen balance may occur in the abance of gronth hormone or androgens Pathological obesity has not been encountered. Repair of bone can occur after hypophy actomy as evidenced by the appearance of callus in osteolytic lessons and pathological fractures In patients wlioxo cancer remained quescent no evidence of ancmia developed after periods up to 2 years after hypophy sectomy In 2 cares myclophthino anemia due to cancer regressed after hypophy sectomy, 60 that bone marrot can restore itself to normal in the absence of hormones other than cortisone and thyroid Androgens exert their typical anabolic ·128 CLINICAL NEUROSURGERY affects in these patients Estrogens will induco vaginal comification and endometrial proliferation, as evidenced by withdrawal bleeding, DLABETES INSIPIDUS Then the hypophyseal stalh 18 cut and the pituitary gland removed, I major portion of the pars ncryosa has been destroyed. If the stalk 13 sectioned below the diaphragma sellae, 86 is done in transsphenoidal hypophysectomy (3), permanent diabetcs insipidus Tas not encountered. TVhen the pituitary stalk as sectioned and cauterized above the dia phragma sellac, more than 20 per cent of the patients developed varying degrees of diabetes insipidus In this discussion, diabetes inapidus is defined as that state characterized by a decrcased renal concentrating ability without reference to polyuria although polyuria is usually present. It 19 our belief that at equal soluto loads the forenty of the diabetes insipidus depends on the level of stalk section and the preservation of a variable portion of the pars nervosa. Following transfrontal hypophysectony, polyuria may appear thin e few hours to a let days (4) Within a period of about 2 teoko postoperatively the water exchange usually stabiliscs at a les cl wluch persists indefinitely thereafter In como patients the daily water exchango may be only twice tho preoperative les cl, although the soluto load is unchanged There 18 & range from these mild cases to those patients who have daily unne outputs of 9 to 10 liters per day In the mild cases, dehydration may 1oduco considerablo concentration of the unino whereas in the BoyCrO CASCH there may be little or no ability to concentrate the urine. As indicated abore, it is believed that the degree of severity of the diabetes insipidus 18 dependent upon the remainder of the pars nervosa which remains intact The presence or absence of the anterior lobe of the pitutary doce not appear to be a dotermining factor in the degree of diabetes insipidus which develops Withdraal of cortisono in the hypophysectomued patient with polyure usually results in a decreased urinary output. It has been shown that this decrease in polyure results from the decreased solute load presented to the kidney due to the associated anorexia and that there 18 essentially no increase in the concentration of the urine Vanations in the doses of thyroid and cortisone replacement lave produced no og nificant changes in real concentrating ability in patients with diabetes inopidus In patients who have mild polyuna moderato restriction of salt in take may be sufficient to bring the frater exchange within the limits of comfort. For more severe cases of polyuria most patients prefer the use of posterior pituitary powder (Armour) by pasal insufflation 3 or 4 times daily for relief Pitrean tandato-in-oul (Parhe Davis) giu ca intramuscu ·Pin BIOLOGICAL EFFECTS OF NITOPIN BETON 120 laris in docce of 5 units cicry 2 to 4 days will also proindc cffectivo relief of thic dinlctcr insipidus In conclusion, it can be stated that replacement thernps 16 adqunte for maintenance of normal l;ſc after total hypophyrectomy in man RIFFAF\CES 1 LrSETT MB. NEXT CD. MACLES JPAXD Parmax O I Adrenal function after hytophrectomi in man J Can Endocrinol, 17, 386 1057 L JIC RALL, JE VICLES JP, LITRETT NI B, RAT B AND PEx O H Thyroid function following hypophorectomy m mann J Clm Endocrinol, 15, 12, 1835 3 Pzt 0 H., Rar D FLAREOLA, C C. West C D, LAC MOLLY J P, 1.7D LOETT JI B Lyrophrectomy in the treatmrat of advanced cancer Tr Adu PhyuqoQ: 68, 101 1955 4. LirecTT BIB BACLAX SP, West CD, LA M C AND PLAY O H An analyts of the polyunn ioduced by hypophorectoas in inan. J Clio Endocrinol., 16, 183 1056 Questions and Answers QUESTIOY TO DR. LOVE Do you select cortisode Over ACTH so psturtary tumor CASCh and would not the patient be better off with ACTA? DE LOVE 18 you havo already licard, cortisone 18 tho klo-Bustaning substance or hormone of the adrenal gland. ACTH on the other land, 15 a stimulant to the adrenal gland. We administer cortisode intramuscularly JD 200-mg doses, and we do this to assure the patient of a store of this substance which mill fortify him against the stress and strain of both the anesthesia and the surgical procedure that 18 anticipated. ACTH of course will stimulate the adrenal glands to produce the natural product cortisone I believe it u generally accepted that cortisone protects the patient better m such a circumstance than would ACTB I am not, honerer, an endo criologist, and I think the answer to the second part of tho question ongist dot to come from me QUESTIOT TO DR Ras Please comment on the last question and would you reiterate the pre- and post-operative endocrine AERIALAnts that you usc. DR. RAF I agree with Dr Love that cortisode is the more practical means of heodkng the shortcomings of the ndrcgals because it docent do any good to whip a tured horec There is little way of knowing where you Hanul if you rely on ACTH during the strea period of an operation or imrudiately thereafter You are 10 a much better position if you uro rortimone Furthermore, if the patient is to take one or the othor of these drugs for any length of tine cortisone by mouth 18 much more readily araslable to the patient than ACTH injection. With regard to aldosteronc 23 Dr Pearson reported to you the aldosterone production is not dependent on the pitustary gland It might then easily be assumed that te don t harc ·180 OL INTOL NEUROSURGIJIRY any dificulty with salt balance after hypophysectomy and are not con fronted with salt losing syndrome after operation in patients with pituitary tumors. That does not always seem to be the case and many surgeons are DOW Award of the diffioulty in controlling the low salt syndrome that occa gonally develops in the post-operative management of pituitary opern tions, this problem needs a great deal of investigation. The chances are that in addition to the aldosterone hormone, there is a central mechanism that also controls salt balance, and if your patient does poorly in the post operative period in spite of your careful administration of cortisone, you had better malo very suro about the olectrolyte otuation. If the Bodrum chlorido 18 lors, just accept that for what it 18 and deal with it as needed. You may not be able to explain it as yet, but the fact remains that I think that in the past some of the deaths in the post-operative period, had been the result of insufficient salt In the patients with carcinoma of the breast, of course there may be unsuspected mctastars to the adrenals and in that caso the aldosterone produotion could be affected. QUESTION TO DR. Ray Will you summanse the post-operativo tests and your critera for assuming that the hypophysectomy has been completo, Also, what treatment you would use afterwards? DE RAY I am not an endoorinologist but I have learned somo of their lingo and I have given careful attention to the tests that have been employed in our series of patients. The routine tests have been the malus tion of the thyroid function by the iodine studies (principally the I 131 uptake with the protein bound 10dine determinations) We believe that tho raluo 18 reduced to a lor level permanently if the pituitary has been com pletely removed. If there aro cxceptions to this they must be quite raro and as yet need explanation. That is one may wo expect to determine how complete the hypophysectomy 18 Another test 18 the study of thc FSH production which has to do with the gonadotropio hormone and which should disappear completely aftor hypophyecctomy Howe er sometimes in an incomplete remor al of the pitutary both in animals and in man tho jodido determinations and FSH determinations fall to zero yet thero may still bo some functioning gland. In erperimental progressive destruction of the pituitary tho gon adotropic hormono and the follicle stimulating hormono aro abolibed first, whereas the ACTU (the adrcootrophio hormone) is the last to disappear A little residual gland will be crough to continue produotion of the adrcnotrophic hormone Finally if you want to test your patient, tabe him off cortisone and watch lum carcfully If he lius any ruudual functioning gland he 17]} be ablo to go along for many days if not continually without cortzone if he has total removal of the gland he will very soon let you know Within ·PILAIOLOGICAL EFFECTS OF HITOPIN SECTOX 131 not more than a wech's timc, lie will probably dc clop Addisonian crisis and will not be ablo to 17thstand the permanent withdrawal of cortisonc. There are thic tests on which we have relied in determining completences of hypoplyuctony However, the accuracy may be open to question and some have questioned it Dr Pearson, whose ability and opinion I have come to regard highly, 18 very much satisficd with it Our treatment, as I outlined to you in chapter VII, is to fortify the patient with 300 mg. of cortisone in the 18 hours before surgery, add about 200 mg on the dar of operation, and gradually (10 a week's time) diminish thic amount to a maintenance dose of 25 mig. twice a day--that 9, 50 mg in a 24-hour period, which he must take thereafter If lie misses a dose, or tno nothing bad is going to happen It isn't quite lihc insulin. But if lic mig«es several days dosage, he will certainly get into trouble DR. LOVE Thero 18 one point I forgot to mention and since no one else has mentioned it, I shall claborate on it llc have indicated that if the patient is doing satufactorily, tre ccave to administer cortisone a fer dars after removal of a pituitary tumor But if some untoward sign or symptom Anues, such as manifestations of a clot or the necessity for opening the Found or an emergency situation such as acute appendicitus or renal colic we would of course trish to fortify the patient This we can do notr, As you probably knor, by means of hydrocortisone, thich can be ad ministered intravenously Morcoi er if a patient is encountered who ex hibits the signs of hemorrhage into an adenoma and an emergency operation is required at once it is not necessary to delay surgical intervention until the patient has been prepared with cortisone administered intramuscularly The operation can be conducted immediately and the hormone can be administered while the operation w in progress trith adequate protection to the patient QUESTIOT TO DR. Rar Is it not true that some anterior lobe must be present for the der elopment of diabetes insipidus? DR. Rar Thus of course was the attitude for many years based on experimental trork in animals but the believe that it 18 crroneous Me believe that diabetes insipidus is entirely dependent on degeneration of the Apraoptic and para entrcular nuclei and its occurrence 18 no criterion as to whether there 18 or 18 not any anterior lobe present QUESTIOT TO De Rui What company puts out Pitressin powder? DR. Rar I am a little uncertain but I think it is Armour I am surprised that more people dont know about this but it is a very convenient method The powder is in a little capsule and an atomizer is provided with it The end of the capoule 18 perforated with a pin and the atomizer simply blotre the potrder out of the capsule ·Congress of Neurological Surgeons, Inc. MEMBERSHIP ROSTER January 1, 1957 LI ONORARY 29 1962 Olivecrons, Horbert, Proforyor of Neurosurgery Banfirmerloerotto & Karo- Lingle Institute Stockholm Esedon 1953 Jeffction, Bir Geoffrey Emeritus Profemor of Neurosurgery Director of the Neurological Univeræty of Manchestor Manchester England 1851-B1oKenne Kenneth G Profesor of Surgery Unirernt of Toronto Toronto Canada 1955–-Rand, Carl Clinical Professor of Neurological Bury University of South California, Los Angeles, California 1056-Penfield Wilder G, Director Montreal Neurological Institute Montreal Quem boo, Canada 1 Abbott, Kenneth H, 850 East Broad Street, Columbur 18 Ohio 2 Abbott Walter D. 900 Deo Momos Building, Deo Bloines, Iowa 3 Ablin, George 7741 H Street, Bakerfield California 4 Adamets John H, Donaghoy Building Lattle Roch, Arkansas 5 Alf Robert C814 Citizens Bailam Tampa Florida 6 Allen, LcRor 309 Woodburn Road Cameron Village Raleigh North Carolina 7 Amador Lu V, 0723 North Drake Arente Lincolanood Illinom 8 Amerongen Frodonck, 4418 mcland Avenue Hollywood California 9 Armorman, Harvey , 2025 Ey. Stroet NTT Tashington DC 10 Amyer, 414 North Camden Dave Bos erly Hills Calfomnia 11 Anderson, Robert L Suite 815 Talcott Building Rockford, Illinom 12 Andier Dierwell BI JE 414 North Cauden Drive Berorts Hills California 13 Andy Orlando J, c/o Unnaty of Mindapp Medical Ceptor Jackson, Mio soppi 14 Angelo Martin A 091 Delawaro Arenue Bufalo 2 ler York 18 Amold, James, 11 East Chase Street Baltimore 2 Diaryland 10 Ashenasy B 910 Medical Towe, Houston 5 Tems 1" Austin Georgo di 3100 Spruco Street, Philadelphie Pennsylvan 18 Bard, William C 000 Becond National Bank Building, Akron Ohio 19 Baker Robert L. 403.5 Jenkins Arcado Building Pittsburgh Peanriranja 20 Balody John T 000 Der Momco Building Des Moines, LOTTA 21 Baldwin, Dimtrand National Institute of Neurology NLA Bethesda, Biursland 2 Barun, Charles, 404 Sherland Building, South Bend 1 IpduADO 23 Bartett, J 443 444 Ingraham Building Miami Florida 24 Berringer Floyd 9 701 lorth Fint Street Springfield Illinou 25 Batkin Stanley 150 Alordall Street, Syncumo Na York 20 Becker Leon, Century Medical Center 205 Meridian Rond, San Joy Caluoma 77 Bellar Aaron J Madarah Unirerety Hospital, Jeruumicm Israel 28. Bellons Roland T, 1019 King Dore Charlotte North Carolina 132 ·WOUDLRSIP ROSTETI » Beltran latndo Central Quirurgic lartrras 0-103 dicxico DF Metico 30 Bichert Donalds 8,710 Prachtrre Street \Atlanta Georgin 31 Bond C Wohlm 413 Saint Jaines Burleſing Jacksonville Flonda 32 Bitop Edward J. 1003 Ilannn Building Clci cland 15 Ohio 33 Blake Paul S., 1837 Valieal Ints Building Minneapolis, Microta 31 Blanchard George C., Doctor Building hings Dnie Charlotte 7 North Caro- 133 35 Bochm Walter E. 101 Intentatc Building Chattanoogn Tenneske 36 Boland Cirant L 1123 Valien! Arts Building Dallas Texas 5 Booth Crorge T, 100 frror Hotel Toledo Ohio 33 Bortwich Jackmon l. 501 Bell Buudmg Montgomery Alalama 39 Boyd Hart R, 2302 E. Dartmouth Englewood Colorado 10 Brackett Charles F.., 4320 ll cut 70th Stret harms City hanas 41 Brougham Milton F 412 Beacon Street Boston Vasachusetts 42. Brown, Carroll 1., 809 Badgerow Building Sioux Cits Iown 43 Brown Al Hunter 1033 Gayley Aicnuc Il est rood Vlage Los Angeleh, Cali forama 41 Brrutowict Richard, 277 Alexander Street Rochceter lek Tork 5 Cannon, Bland 1 1092 Maduon luonuc Memphus 3 Tennessee 8. Carlin Blaunco P., 2708 Blagowan Dore Santa Rosa Calfomia Carmichael, Francis A, Jr 170 Plaza Timc Building, 411 Michols Rd., kanas City Alumouri Carton Charles A Pontefiore Hospital 210th Street Ver Tork 67 som lork Caudill C A., 803 Atlas Building Charleston Il cot Virginia Chambert William R 162 Aledical Arts Building Atlanta Georgia Chandy Jacob Christian Aledical College Hospital, 1 ellore South India Sheney Roger H., 23 Vaple Street Springfield Masnachusetts herry Glenn R., 009 Medical Arts Building Dallas, Texas of Christoferson LOA 135 Delendroco Building Fargo North Dakota 55 Clary Warren U 12 11 est Jones Street, Savannah, Georgia 50 Cloieland David 231 East Wiscongn Avenue Afilmaukee 1l aconan 57 Cluff J W, 1007 Bledical Dental Building 125 W Georgia Street Vancouver в с 68 Cobb Cully A landerbilt Unni craty Hospital dantiville Tennenec 50 Cohn George 8., 993 Delaware Avenge Buffalo 9 Mor lork 00 Colclough John A 1001 Manon Blanche Buldmg New Orleans 18 LOULADA OL Cooper Inmg 8, 477 Fint Arenue New York, lox lork Cooper Jack R Brothorhood Buildmy kansas City hansus a Coppola, Armando R., 2814 West Avenue Newport News Virginia 61 Corcoran, Charles E 7839 South Western Arenue Chicago 43 Illinois 5 Corridmi Ex erott W., 109 Walnut Street Elmira Net Jork 00 Color Howard 8., 908 Government Street Mobile Alabama 67 Croe, Glen O 400 Post Street San FrapaXO 2 Cabromia 88 Cube Henry a 11 Samat Sta. Mesa Heights Quoron City Philippines o Culbreth George 207 Hartlome Lane Charlotte North Carolma To Cummmg henneth L., 2032 Seventeenth Street Bakersfield California I Cure Charles T, 206 Hume Mansur Building, Indianapolis 4 Indiana 2 Duanel, Jame T, 813 Park Avenue Ness lort 21 der Vork 3 Duru Courtland Jr., Borman Gray School of Medirme Ilmston-Salem Morth Carolina ·131 CLINICAL YEUROSURGERY 74 Darbon, Ralph E, 1021 Mott Building, Flint, Michigan 75 Dol Cueto Ramon Palenque 581 Blexico DF Blerico 76 de Blartines-6 Junn Dept of Neurological Surgery Univerraty of Virginia Hot pital, Charlottesville Virginia 77 DeSaussure, Richard L., Soite 525 Phyacans & Surgeons Bids Memphx, Tcn Doc 78 Dovanney Joha TY, 108 TYilliam Howard Taft Road Cincinnatti 19 Obio 79 Dodgo Henry TV Jr., Blayo Clinio Rochester Minnesota 80 Dormen Charles E. 1415 Patahtreo Street NE Atlanta 5 Georg 81 Drake Charles George 489 Tatorloo Street, London Canada 8 Duffy Jamas J. 1791 West Homerd Street Chicago Ilmous 8 Duggor Gordon 8, North Carolina Hospital, Chapel Hill, North Carolina 84. Dunnare Rembrandt 85 Jefferpon Street, Hartford, Connocticut 85 Earnest, Franklm III 200 Bell Bailding 709 Madison Avenuo Toledo Oblo 88 Ebm Judah L 816 Odd Fellow Building South Bend 1 Indians 87 Edolman, Joseph M., Tho Commerce Building 333 Laurol Street Baton Rouge Louiana 88 Elcabeus, John A, Lou Grunow Memonal Hospital 9.20 E. McDowell Road Phoenix, Arizona 80 Elkins, Charles T 1013 North Tucson Boulevard, Tucson Arrana 20 Epetoin Joseph 230 Alton Avenue Hempstead Blodical Center Hompetend Now lori 01 Espey Frank F Brooke Army Hospital, Annex 4 Fort Sam Houston Houston, Tomas 123 Mallard Btreet, Greenville South Carolina 92 Evans, Tvilum G., 1910 Knoxvillo Btreet, Labbock, Temas 93 Farmon, David Jual 1360 Buenos Aires Argentina 91 Farles A W., Jr 1803 North Michigan Arenuo Saginaw Michigan 05 Fausot C Baal, 2901 North Moridian Street Indianapolis & Induna 06 Fcferman Martm E., 510 Sberland Baking South Bend Indiada 07 Fisher Robert Goorgo Hitchcock Clinic, Hanover Now Hampaburo 98 Foneca, Juan E 1013 North Tucoom Boulevard, Tucson Anrode 09 Forman Oliver Duane Buito 200 101 St. Ferdmand Street Baton Rouge Louta no 100 Fortythe Robert Y., 411 Nichols Road Kansas City ? 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Hiljard Raymond W1, 1007 Delamaro Arcaue Wilmington, Delaware 141. Hincher Thomas P R 1101 Beacon Street Brookline Mamachinetta 145 Holbster Methaniel R, 1120 Reibold Brulding, Davton Obto 140 Hopple, Theron Secor Hotel, Toledo Obuo 187 Homning E Douglas, 18 West Franklin Street, Baltimore Varyland 10 Horarth J Corall, 22 North Atun Street Orlando Flonda 149 Huf Thomas , 216 Medico-Dental Baldrag Stockton California 150 Hugh Robert 312 Eastmin Buiding Boise Idaho UL. Horches, Orren Floyd, zo Highland Arenue, Birmingham Alaboma 153 Humpbreyr, Storer P 201 Beacon Street, Boston Makachusetts 163 Hunt, Wiliana Edoard 1776 Olentang Rue Road Columbur Oho 62. Hunter Currood A, 500 Oak Street, Ciannatı 19 Ohto 155 Lurton, William A 1819 Van Vusz Boulevard lap luyt California 10 Imler Robert L., Jr, Sute 107 Ulica Square Medical Center Tulsa, Oklahoma 157 loguer Roman Arana Convenciou 128 Blontendeo Uruguay 158 Jackson Ina 3 University of Teras, Medical Beach Galveston Terus 19 Jaeter Robert Al 1746 Llen Bureet Aleptow Pennsylvanus 160 Jettreyr Everett 705-08 O'Hanlon Building Winston-Salem lorth Carolina 101 Jobmon | Beaumont II 123 8 Michigan Avenue Chicago IMBOLS 12 Johnson Alexander C bfedical Irte Building Great Falle Voalans 16. Johnson, Donald A 1200 Cathedral Armur IT llastungton DC 164 Johanon, Herbert C. 30 lorth Fifth Street Reading Pennsylvann 143 dollar Fleming, 715 Dortora Building 1-8 Peachtree Street, VE, Alanu Georgia ·130 CLINICAL NEUROSURGERY 166. 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Building Portland Oregon 185 Lalonde Albert A, 806 Capital Bank Building Austin Terus 180 Lamberta Auntio E, 68 Reorom Avenue NE, Grand Rapids, Michigan 187 Lander Howard 820 MIcClellan Street, Spokane Washington 188 Landry Christopher L. 620 Commonwealth, Boston 15 Blossachuetto 189 Lemmen Lloyd Jean Gargul Settico Veterans Adminstration Hospital Uns vetate Drive Pittsburgh Pennsylvania 190 Lovin Julcs D, 161 If Finanan Ascout Blilwaukee laudan 191 Low, Rovic C 411 Michols Rond, huneus City Mom 180 Liste a C, Jr., 1200 North Walker Street Oklahoma 3 Ollahoma 193 Lut Carl F., Suite 203 833 lako Dove SE Grand Rapida, Afichigan 191 Llewellyn, RC, 3.503 Prytanu Street, Net Orlando, LOWANA 195 Lowery John J, Tho Clinic Bapiolan 8t & Thomas 69 Honolulu 14 Haru 196 McAthens Homard J. 401 Profcational Building, Springfield, Dildouri 197 DicCulill, Dansel 521 Doylo Put Dare Santa Rom California 148 McClintock, Homor Glenn 1800 East 18th Street, Dearer Colondo 100 McClure Chrotopher C, Jr 1918 Haron Street, Mashalie Tengeteo 200 McClure Claude 899 Misduon Arenue Memphis, Tendence 201 DicCoy Archibald D, 08 North Chicago Btreet, Joliet, Ilinoin 202 BicDonnell Robert R, 67 Trumbull Street, New Haren 6 Connecticut 203. 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W., 005 Congrer Street Palo Alto California 225 Mhiller Leroy J. 717 Enero Place Albuquerque le Mexico 2 Alorgan Clmton W, Jr., 215 Oak Street, MF Albuquerque Tex Mexico 2 Blorley Thomas P., 007 Bledical Irts Building Toronto Canada 23 Blomberg William H., Jr., 11 East Chase Street Baltimore 2 Maryland 229 Blount Harry T R 276 Elgin Street Ottawa Ontario Canada 20 Aluchlig Wilbur d., Mlediral Arts Buildmg, Omaha 2 Nebraska 331 Sluíron Joacph A., 759 Worth Dilwaukee Street Alltrauheo 2 11 sscongn 22 Munalow Ralph d, 1233 A Profesonal Buildmg, 414 Naruto St., San Antonio Teras 23 diurtagh Fredenck 5603 Grecne Street Philadelphia Pennn liania 234 \ash Tom M., 730 Aledical Arts Building, Dallas, Texas 235 Mell Robert G., 320 Worth Main Stret Orlando Flonda 238. 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Doctor Building Charlotte Torth Carolina 259 Polero John L 1005 Theatland freage Lancaster Pennyluanie ·138 CLINICAL NEUROSURGERY 200 Pollard Claude Jr 411 Herinena Professional Building Houston 6 Tewas 281 Polmetoer Frank A., 4835 Van Nuya Bouleverd, Shorman Oaks, California 202 Price Pliny A.883 East Broad Street Coimbus 15 Ohio 283 Price Richard D. 1233 Nix Profeodal Bldg, 114 Navarro St San Antonio Texu 261, Rafes Earl H., Beaumont Neurologic Contor 676 Fifth Street, Beaumont Tags 205 Ralkon Bruce L 120 Center Drye Bethesda, Maryland 206 Rancy Aidan A., 2010 Wilshire Boulovard Los Angeles 67 California 207 Ransohoff Joveph 710 West 108th Stroot, Yonkers, New York 208 Raskind Robert, 130 Diaduron Avenue Memphis, Tenneneco 200 Rood, H. Lester 315 Fincastle Building Louimille 2 Kentucky 270 Rchfoldt, Frederick C, 1001 Pennsylvania Avenue Fort Worth Tamu 271 Reilly Francis G, 85 Jefferma Street, Hartford Connecticut 272 Rettor Richard 350 East Broad Street Columbus 15 Ohio 273 Reronde Nilson % M A. Coelbo 301 Central Avenue Hackenrock New Jerney 274 Runoli, Hugo 1160 Connectiout Avenue, NW Washington DC 278 Robinson, Franklm 114 Bhorman Street New Haven, Connecticut 276 Romcn, Harold Jacob St. John General Hospital 8t John N B Canada 277 Roth David B 1005 Third National Bank Building Dayton Ohio 278 Rupell John, 3884 Ruch lo Street, Indianapolis 8 Indiana 279 Rutledge Robert, 1200 North Talkor Btreet, Oulahoma City OLLaboma 280 Sayers, Martin P, Nmo Butter Avenue Columbus 8 Ohio 281 Schaerer Jacques P, 307 Handy Circlo El Paso Tartu 282 Schoíbort, Charles Dard Kennedy Veterado Hospital, Blempbla, Tenneco 283 Schonerman, Walter G 210 West Blato Street, Trenton New Jersey 284 Schneder Richard C 6169 Out Patient Buildmg, 1313 E Adn Bt, Ann Arbor Dlich. 285 Schult Elmor C., 899 Bladison Arenue Memphis, Teonesco 280 Schwab John E, Bluefield Sanitarium PO Box 600 Bluefield West Virginia 287 Schweinfurth, James Paul, 3244 E Douglas Strect, Wichita, Kandus 288 Schwdde Jon T Suito 102 1231 North 90th Stroot, Billings, Blontana 289 Bcott Thomas E 136 Broadway Daytona Beach Fionda 290 Boara, Robert A Docton Building Atlanta, Georgia 291 Secrest Roy J., Nine Battes Avenue Columbus 8, Ohio 22 Sererberg, Ludwig H 406 Hey bam Building Lowyıllo Kentucky 283 Selotr Emil 405 North Bedford Drive Boverly Hills, California 291 Selverstone Bertram, Pratt Diagnostic Clinio Harrioton & Bennett 8 Boston Manchusotto 205 Sengotaken Robert T 520 Franklin Street Garden City New York 230 Shafor William A, 600 Sanfras Street, Ene Penney Irina 207 Sheldon Kotb W. 910 Hanna Building, Cleveland 18 Ohio 238 Shepard John W, 1854 Northorn Boulevard, Manbasot, New York 290 Shuer Bernard B 338 Vest Toodroll Street, Toledo Ohio 300 Brefort, H Jack 100 29th Stroot, Oakland D California 901 8.lier Maunco 102 Waterman Street, Providence Rhodo Island 302 Bimpoon, Jama R, 300 High Street, Hamilton Ohio 303 Skultety F Mulo, Uniroraty Hospital, loma City lowo 304 Slade Harry 3000 EAUX Road, develand Heights, Clercland Ohio 305 Slemmer Robert E 2007 Union Central Building Cincinnat > Ohio 308 Sepun, Alexander 959 Lalayotto Arenue Viagara Falls, der York ·NEUBERSHIP ROSTFR 130 307 Smilos Gordon L. 14 Ridlgorool Rond Louisillo 2 hentucky 303. Smith George Ildham Sioux Falls Cunic Building Sioux Falls South Dalola 300 Smith | Edron 20 llct II:ll Stret, hnorrille Terneut 310 Smolib Edmund 1 3720 Wartungton Bouleiard St. Louis, Mimoun 311 Somaberg Harold V 31 Lincoln Park Newark Nem Jcroog 312 Speigel I Joshua 55 Fast llashington Street Chicago 2 Illinois 313 Speace William T., 1150 Conncrucut MII Taslungton DC 314 Stafford Donald E, 002 Boren Arcouc, Seattle Washington 316 Starr Harry Fifth Street Beaumont Teens 316 Steelman Ham, F., 550 Thomas Road Phoenix Arizona 317 Stoll Julu Jr., 270 Benefit Street Providence Rhosle Irlanıl 318. Storcu Acrill, 1181 South Peora Avenue Tulsa, OLlaloma 319 Strain Richard E, 401 Coral llar Coral Gables, Flonda 230 Stratomeyer Winslor P 316 Rose Lane El Paso Texas 231 Strewler Gordon J., 412 Medical Arts Building Duluth 2 Bfinncrota 37. Sturman, Robert H. Len Vyt Road Toolbury Connecticut 32. Buckle Henry 110 East Main Streot, Mladwon 3 llisconga 821 Sullivan Benjamin H., 736 Sixth Street South St. Petersburg Flonda 325 Sullivan E J., 316 Greenlcar Building Jachronville Florida 326 Brien, Hendrick J., Mayo Clinic Rochester Minnesota 27 Sweeney Donald B, 2205 Higliland Avenue Bircamgham Alabama 3:28. Taberi % E. 511 Center Avenue Bay City Michigan 329 Taylor Charles TT 410 Greyhound Buildmg Calgary Alberta Canada 330 Thelon Emil P., U 8 Naval Hospital #3923 %FPO San Francisco California 331 Thompeon, John Brorgan 3133 Richard Ann Arbor Michigan 132 Thompson Raymond h, 11 Eart Chame Street Baltimore 2 Diary land 333 Tico William 203 Carlton Terrace Building Roanoke Virginia 31 Titrud Leonard 920 Modical Arts Bulding Minneapolu 2 Minnesota 335 Torer Richard C 3017 West Oth Street, Topeka Kansus 338 Turpin, William R, 413 South Revena Boulor ard, Ann Arbor Blichigan 337 Tyrer A. Roy 2 Morth Blanas, Aſomphus Tennemece 338 van Buren John, 10223 Capitol Vior Road Silver Spring afar land 339 van der Noort, Gordon 1830 Chestnut Stroot, Philadelphia 3 Pennrylvania 310 Van Hom, Philip R 411 Thirtieth Street Dalland California 311 Van Landingham John H., 321 West State Street, Rockford Naois 312 Velasco-Suarez Manuel Tonala 18 Mexico DF biexico 313 Ter Brugghen, Adrien 12 South Michigan Areaue Chicago 3 Ilinou 314 Toru, Harold C 30 North Michigan Avenue Chicago 2 Minous 315 Walker Exum The Mourocimic 133 Docton Building, Atlanta Georgin 316 Wallet Jamce C 412 Beacon Street, Boston 16 Massachusetts 317 Wallman Letter J Man Fletcher Hospital, Burlmglon, Vermont 3-48 leadon Preston 8., 211 Bronson Blodical Center Kalamazoo Bichigan 319 Wcaret Edgar A., 31" Carlton Terraco Building Roanoke Virginia 350 Webb J Hugh 200 Bell Building 709 Bladıxon Avenue Tolodo Ohio 351 Webster John E 810 Whitney Building Detroit, Blichigan 352 erford, Edward C, 320 Wat 17th Street, hansus City Alumnouri 353 Il moberger Laurence A1, 900 Second National Buildmg Akron 8 Ohio 351 Hertharen Peter landet 6233 Hohman Arcade Hammond Indiana 3.55 Imand Robert C 411 Thirtieth Street, Oakland o Calfornia 356 lito y LaRue 109 Park Avenuo Rocherter 10 ler lork ·140 CLINICAL NEUROSURGERY 387 Williams, James R., kennedy VA Hospital Memphu 18 Tendenco 368 Willems, John R. 833 Lako Dave Grand Rapids Michigan 859 Wilson Archer A, 803 Atas Building, Charleston 1 et Virginia 360 Wilson, Charles, Docton Building 3707 Gugton Avonue Dallas, Teams 301 inokur Gerald L, Medical Arts Boldmg 8-12 Culton Place Jerkey City 4 NJ 362 Vitt, Joseph A. U 8 Naval Hospital Oakland California 363 Woods, Robert P, The Planunger Foundation, 3817 West Bth 8t, Topele KIDAI 384 Tu William. 314 Doctors Buildmg, 3rd & Holmes Bt. Kaows City Alimoun 306 Yuhl, Enc T, 10062 Le Conte Avenue Los Angeles 14, Califorut 300 Zealer David Scofield 1308 Olvo drenue Fremo Callbornja 307 Zinker Leonard L., VA Hospital Cenandaigua Now York 209 Zoll John G., 131 Linwood Arenue Buffalo 9 Met York ·Index Adrenal function effect of hypophyme toms of 121 Bitcmporal deprcanon 42 52 and central cotoma 54 Bitemporal hemianopos xo Hemianopea bitemporal Bitemporal scotomas ko Scotoma bi temporal Brain, effect of x-ray therapy on 118 Breast cancer hypophysectomy for 104 cffect on thyroid function 123 effect on various functions 127 oraluating remon, 107 for breast cancer 101 indications for 101 operatire nat of 108 pbyxological effects, 121 rerilts in breast cancer 112 Argical technique 100 116 Cerebellar tumor Cabang erosion of pot terior clinoid process and solla 07 Craniopharyngioma, calcified produmng focal tomon of posterior cimord procencs 07 Illusions, auditory H mterpretire of prenent experience 25 of familianty seat of m brain, 27 of four 26 tual, 24 reat of m brain 20 Ivalon sponges, 87 Diabetes mapidus, effect of hypophy Rectomy on 128 Epilepas due to birth mjurica, 32 Membership roster Congress of Neurological Surgeons Inc, 132 Bleniere om denne virtual and motor llung ons during attacks, 33 Janglionic memory recordmg meche nism of 33 fogadal function effect of hypophy vectomy on, 125 Ocular manifestations, of pitutary tumor 34 Ocular muncler paralysis of in piutary tumor 31 Optie chiarn anatomical structure 3-4 course of fibers through facing p 31 effect of pituitary tumors on 35 lenons of differential diagnoos of 38 Optic nerve heade, oppearance of in pi tutary tumor 49 lucinations, experiential a adaeben, in patients with pituitars tumor 07 119 nuanoptu bitcmparal, 38 8.5 after operation, 18 ompleto 37 Artual 39 incongruous homonymous, 44 incongruou nght lower quadrant homonimon, 18 Hippocrates, facts and fiction regardmg hum 11 Hypophtartom effect on adrrual func tron 121 cffect on diabetes inamdur 128 offert on gonadal function 125 mert on rum proton-hormd iodme 123 und Penfield Wilder G., bibliography of 2 biographical sketch 1 Perceptional illusons 2 Perimeter in dotermining naal field defects 38 Physeal reepons are in temporal lobe 24 Pineal shult, amificance of in rolla turcica lenons, 73 Patuitary techniques for abolwhing it aod its functions 115 gland indieations for operations on 70 operatire approach 75 11 ·142 INDEX tumor Ar tudies, Talve of 102 appearance of optic nerie heads in, 19 effect on optio chua 35 effect on vuon of operations for 57 emergency operation for 78 headaches in patients th 07 110 uradiation treatment early 88 ocular manifcetations 34 paralysis of ocular muscles in 01 renults of irradiation trentment, 12 13 results of real treatment 94 rurgical and irradiation treatment, 88 underlying optic nerves, 50 von logt due to restortion 78 Ir therapy opmron on 85 Porchical response Areas in temporal corter 29 focal erogon m lesions about roentgenologie a pocts of 61 pormal nations in, 61 partenor clinord proceres cum of eronon of 65 Agnificance of double contour of floor of 72 acreo opic lateral yiora, 03 tuberculum of medlnoma enging from Benmory arcu ia tcmporal cortes 77 Serum protein-bound rodine cffect of hypophymectomy OD 125 9Lull, rostero-antorior 107-degree projection of ahowing changes in molla turca 68 stereoscopic Latoral roentgenogrumi, dhoming diangco in rella turcica, 61 Scotomas bilateral centml, 14 bitemporal, 40 55 in field of left eyo 41 rclatio in Belds of both eyes, 43 Bella turama, caure of erosion of clinoids and dorsum with increand prepare 73 changes in, rocntogenographic recog nition 02 circular expansion and dealification of cauumed by primary intruxellar pitur tar) tumor 68 produced by nght tomporal lobo tumor 08 destruction of posterior portion caused by lymphocpithelioma of phepoid Anus 0.9 difficulty of recognizing changes in 61 eronon of duo to cerebellar tumor 67 Tempoml corta function of theorico ou 21 psychical response areas in 20 en or areas in, 27 Tomporal lobe physical responro Arena in, 24 meinuncs, percepual llocs 23 Thyroid function effect of hypophyrectomy on 123 Vion, lost due to pitutary tumor me tortron of 78 Vipal field defects 34 metruments for dotermining, 316 recording, 38 studies, dimusnon on difficulty od getting 58