MENTAL SYMPTOMS IN PHYSICAL DISEASE: Being an Abridgement of the Bradshaw Lecture delivered before the Royal College of Physicians of London
Authors: M. Craig
Journal: BMJ (1922)

rMED CALT ERAs 841 a trephine at these corners.The discs of bone so removed are placed under the portions of the scalp around the flap and so kept until the termination of thle operation.Thle four trepliine openings are now united with a Gigli's saw, the cuts being niaae obliquely upwards and outwards so that the bony flap is larger externally than internally.The whole flap is now elevated and turned outwards.The dura is gently raised from the roof of the orbit until the posterior edge of the lesser wing of the sphenoid is exposed.By this means the greater part of the retraction of thle brain is performed with the dura still intact and is tihus preserved from harm.When the lesser wing is exposed the dura is opened and very little further retraction will expose the olfactory tract, the optic nerve, chiasma, and thle pituitary tumour.Gentle dissection with a Watson Chevne dissector will usually determine the size and motility of thje tumour, and as a general rule this can be elevated from the pituitary fossa and entirely freed and removed.Haemorrhage is not excessive and in no case lhave I found it necessary to ligature any vessels.If a cyst be present it may be necessary to aspirate it before dissecting out the cyst wall.The tutmiour having been removed the brain and dura are allowed to drop back into place, the dura is sutured, the bone flap replaced, tlhe four trephine circles are removed from beneath the scalp and put back into place, and tlhe soft tissues are sutured.The operation differs from that of Frazier in that the supra-orbital ridge is untouched, and it is found that by elevating the dura sufficient retraction is obtained to give a perfect view of the pituitary fossa.The trephine circles of bone are replaced at the end of the operation, for if tlis is riot carried out an unsightly depression maypersist in the forehead immediately above the root of the nose. RESULTS OF OPERATION.My experience includes the following cases: CASE I. I. J., female, aged 14, was brought to me on June 14th, 1915, with a history of having had hea(lache for two years, fits for eighteen months, anid blindness for seven weeks.She was extremely fat; there were no secondary sexual characteristics.Operationi.-Righlt frontal approach; orbital ridge divided ; cyst with cholesterin fluid drainel.Result.-Little improvement only.The fits returned, and she died in ten months.CASE II. S. B.. female, aged 55; seen on October 23rd, 1915.She suffered from severe headache, had bitemporal hemianopsia, occasional diplopia, and later left blindness.Oper-ationi.-Frontalflap; left optic nerve divided ; tumour and pituitary removed entirely.The patholoaist's report stated the tumour to be a solid acinious carcinoma of the pituitary.Result.-Six years later the patient was doing well.She regards herself as a marvellous recovery, and is able to do all her work.Vision in right eye good.CASE III.M. S., female, aged 50; first seen July 17th, 1916.Symptoms: Headache, vomiting, vertigo, drowsiness, increase of fat; she had bitem'poral hemianopsia.Ophvatio)i.-Left frontal flap; pituitayy and tumour easily removed.Pathologist's report: Excess of acinous tissue containing secretion; probable adenoma.Result.-Collapse followed the operation, and the patient died the next day.CASE IV.S. S., female, aged 42, came to me on January 12th, 1918, with a history of having had changes of vision for seven years; she had bitemporal hemianopsia passing on to blindness, and suffered from vomiting and headacbe.Operation.-Rightfrontal flap; tumour removed, apparently completely.The pathologist's report stated that the tumour was a cuboidal-celled carcinoma.Resutlts.-Thepatient collapsed the same evening and died.The :post-mnortem examination revealed the fact that removal of the tumour was incomplete.CASE V.