Maurice Craig

MENTAL SYMPTOMS IN PHYSICAL DISEASE: Being an Abridgement of the Bradshaw Lecture delivered before the Royal College of Physicians of London.

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 Giglis 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 supraorbital 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.