133 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from TUMOURS OF THE FRONTAL By GEOFFREY JEFFERSON, M.S., F.R.C.S., F.R.C.P., F.R.S. Professor of , University of Manchester General Considerations centre, or Broca's area, comes within the The difficulties in diagnosing frontal tumours anatomist's definition of the frontal lobe, so that have been well recognized, not only by all writers difficulties in the exteriorization of speech might on the subject, but by all clinicians whether they well be found with a frontal tumour far enough have contributed to the written word or not. The back to involve these mechanisms. We must not reasons for this are not hard to find, and centre be unduly impressed with the importance of the chiefly round the fact that large though the frontal of the cortex at the posterior end of lobes are they contain no structure whose destruc- the left third frontal convolution. Tumours, and tion must necessarily cause an obvious alteration for- that matter other lesions as well, more com- in the patient, an alteration that could not have monly produce their effects by interference with been produced by a lesion elsewhere. Objections the white matter, by cutting deep association and to this statement come to mind, for it will be re- projection fibres, than by destruction of the layers membered that the motor area and the pre-motor of cells in the cortex. It is more probable that area both lie within the frontal lobe. They de- defects of speech are due to damage to these deep marcate, however, its extreme posterior border and fibres than to loss of cells with a special function it is clear that unless a tumour is so far back in the in the cortex. This belief has led in more recent frontal lobe that it almost ceases to be a pure years to speech defects being referred to damage of frontal tumour no disturbance of motion will ' the region of the insula ' (island of Reil), a brain Protected by copyright. result. On the left side the so-called motor speech area that belongs as much to the as http://pmj.bmj.com/ on September 28, 2021 by guest.

Sketch of a right frontal lobectomy showing the bare floor of the anterior fossa falx and left anterior cerebral . 134 POSTGRADUATE MEDICAL JOURNAL March 1950 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from to the frontal. Tumours have a way of trans- tumours which have been made during the past gressing the anatomical boundaries of tradition; a 30 years a certain uniformity of description has tumour may be temporal as well as frontal, tem- emerged. Writers differ in the emphasis which poral as well as parietal, occipital as well as both they place on this or that symptom or sign; such temporal and parietal. When, therefore, one emphasis tends to be individualistic and what has wishes to speak of the signs of a tumour in any helped one observer may be thought unimportant area it is best to confine the examples to lesions by another, even though he agrees that the observa- which are entirely local. Hence frontal tumours of tion is correct. However desirable it may be for classical description will only slightly, if at all, en- teaching purposes to produce a syndrome, a croach on the motor area, nor will all of those even formula, something which shall represent the on the left side lead to deficiency in speech. Is photographic likeness of a disease entity, we know there then within the frontal lobe no other struc- very well that in practice the resemblance will be ture, is it an unbroken mass of white matter with a family rather than an exact one. It is exceed- the usual grey matter covering it ? There lies ingly rare for any case to show every sign which within it the and the front end of the closest scrutiny of a large number of cases has the lateral ventricle. It may be that the tremor to proved to be a possibility. Only too often but one which Grainger Stewart first drew in or two of the theoretically possible diagnostic I906 and has since been noticed by many as a critical points are all there is to work on. peculiarity of frontal tumours, is due to partial We will begin with a list of symptoms and signs, involvement of the caudate nucleus and basal and first amongst them we must place those of that ganglia. The anterior horn of the lateral ventricle rise in intracranial pressure which is the general could have no neurological significance, but it is rule in intracranial tumours. important that the foramen of Monro lies within x. Signs of raised intracranial pressure: head- the frontal lobe and if a tumour is so situated that ache, choking of the optic nerve heads, vomiting,Protected by copyright. it could block it, a great rise in intracranial paralysis of at a distance, usually pressure must follow. Otherwise the pressure the abducens, and (in later stages) drowsiness. within the skull tends to be low with anteriorly 2. due to interference with placed tumours, as Stopford first pointed out the brain mass of the frontal lobes: though not for the reason that he adduced (absence (a) Epileptic fits. of pressure on the vein of Galen). (b) defects, personality changes, in- In this review of the neural structures of the continence, inertia, loss of powers of concentra- frontal lobe, in the search for areas whose destruc- tion and of introspection, facetiousness, un- tion might lead to outspoken signs or symptoms, warranted good (Witzelsucht, euphoria). no mention has been made as yet of intellectual (c) Weakness of the contralateral limbs, per- processes. Are not the frontal lobes the ' organs haps a ' grasp reflex.' of the mind,' the organizers of personality, the (d) ' Motor ' , if the lesion is left- censors of conduct, almost one might say the seat sided in a right-handed person. http://pmj.bmj.com/ of the soul ? Is there no recognizable anatomical (e) Tremor of the arms, often ipsilateral. cortical area which houses the mind ? Although (f) Pseudo-cerebellar signs-dizziness, ataxia, the frontal lobes are concerned in these things, and nystagmus. probably more concerned than any other part of (g) Electro-encephalographic evidence of a the brain, all the evidence points to these qualities focal or general disturbance of cortical activity. being more diffusely spread throughout the brain 3. Neighbourhood signs, due to compression of than was thought as recently as 20 years ago. It nearby structures: is more possible for a patient to have a large frontal (a) , uni- or bilateral. on September 28, 2021 by guest. lesion without alteration in his memory or per- (b) Optic atrophy, especially when it is uni- sonality or moral . Sometimes of course lateral. Central scotomata. Foster Kennedy these things are disturbed, but much less com- -Paton syndrome. monly than would be the case if the frontal cortex 4. X-ray evidence of: was an exceedingly highly specialized mosaic (a) Calcification in the benign frontal gliomas. where the whole of our intellectual and (for want (b) Hyperostosis of the floor of the anterior of a better word) spiritual potentialities or achieve- fossa or of the vault, associated with some, but ment were lodged. This fascinating subject will not all, meningiomas. be dealt with a little more fully below. (c) Increased local diploic vascularity. Symptoms and Signs of Frontal Lobe Discussion Tumours If all the signs mentioned above occurred always As the result of the analysis of frontal lobe we should have a very clear picture indeed, unless March 1950 JEFFERSON: Tumours of the Frontal Lobe 135 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from

ANALYSIS OF THE SYMPTOMS OF 50 FRONTAL LOBE TUMOURS 20 Cases of 30 Cases of Meningioma Glioma Per cent. Per cent. i. Pressure signs: Headache, vomiting, visual disturbances, etc...... 90 77 2. Symptoms and signs attributable to the frontal lobe: (a) Epileptic attacks: Generalized ...... 20 50 Localized ...... 0 27 Minor ...... 5 I 3 (b) Contralateral pareses ...... 20 27 (c) Other pyramidal signs ...... 25 23 (d) Early apathy, loss of concentration, memory defects, euphoria, personality changes ...... 30 20 (e) Grasp reflex ...... 3 (f) Aphasia ...... 25 I0 (g) Hypersomnia ...... 3 3. Pseudo-cerebellar signs: (a) Ataxia ...... 25 0 (b) Tremor o...... I0 7 (c) Vertigo ...... 25 20 (d) Nystagmus ...... 5 3 4. Neighbourhood signs: (a) Anosmia ...... 25 7 (b) Optic atrophy, and Foster Kennedy-Paton syndrome ...... 25 7

5. X-ray evidences: Protected by copyright. Calcification, hyperostosis ...... 40 33 the cerebellar signs were also outspoken. There ' tumour conscious' and ready to suspect a brain might then be a conflict in the observer's mind as to lesion on little evidence. The last ten years has which signs were the more reliable. It is better shown a remarkable improvement in this direction not to get involved in that problem at this stage, in this country, for which praise must be given to so we will go back to the signs of raised pressure. him to whom it is due, the family doctor. Unless these are insistent the idea of a tumour i. Generalpressure signs. There is nothing very being present is scarcely likely to arise. This is, noteworthy about the headaches from which these alas, only too true and many a patient with a patients suffer. They are often not very severe, frontal tumour has been thought to be a hysteric but they are continuous and progressive. They or to be at fault in some system other than the do not have the paroxysmal qualities of the pain nervous. It is a good working rule to attribute produced by some tumours in the posterior fossa. http://pmj.bmj.com/ nervous symptoms to the nervous system. The The pain may be unilateral, and then it is generally practitioner is not always so ready to do so as he on the same side as the tumour. It has to be should be. Headaches are often dismissed as differentiated from migraine in which the pain is bilious or migrainous, vomiting as due to gastric commonly unilateral, may be accompanied by or other sub-diaphragmatic disorder, and the fleeting visual disturbances (teichopsia) and by symptoms otherwise generally attributed, if sex vomiting, but it dates back commonly over years, and age make that possible, to menopausal dis- is well spaced in time, and periodical. It does not turbances. Unless the patient has a fit or the have the continuously worrying character of on September 28, 2021 by guest. doctor an ophthalmoscope things may drag on tumour headache. Some patients with tumour, indefinitely in this way until the tumour is in- and even with very high pressure, have no head- operable. A fatality at this late stage may con- ache at all, but thanks to the work of Pickering in firm the doctor's impression that brain tumours are England and of Harold Wolff and his collaborators very risky things and that most patients die of in New York it appears probable that headache is them. Although there must of course be a sub- caused by distortion of brain-meningeal relation- stratum of truth in such an opinion, otherwise it ships. The only structures within the skull in would not have arisen, the more conscientious which pain can be experimentally induced are the would more properly wonder whether the picture basal dura, the great vessels and the cranial would not be different if tumours were diagnosed nerves; pain cannot be caused by stimulating the when they were small. They never will be recog- brain itself. It appears therefore that a tumour nized at that stage unless the practitioners to whom causes headache by slight rotations or drags such the -patients first go with their complaints are as distort the relationship of the brain to the pain- 136 POSTGRADUATE MEDICAL JOURNAL March 1950 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from sensitive structures mentioned. When a patient cases. If the tumour spreads far back towards the has no headache and yet has a tumour we assume motor area the myoclonic movements may pre- that insufficient disturbance of intradural relation- ponderate in the contralateral limbs and may rarely ships has occurred. be Jacksonian. Most often the convulsions come Changes in the optic discs, papilloedema and without warning or with an uninformative aura. congestion of the nerve-heads are present in most The importance of this apparently idiopathic cases. It is undoubtedly possible for a tumour in characteristic is that the fits may be the only sign of the anterior fossa to attain some size before any a tumour for months or years. How are we to pressuresigns arise. The brain does not so tightly fill distinguish fits of this kind from the idiopathic ? its membranes and bony capsule that the slightest Only by general inference and by auxiliary tests. encroachment on the intracranial space leads to The vast majority of idiopathic epilepsies begin clearly recognizable cerebral embarrassment. A before the patient is 20 years old. As age advances small tumour in the posterior fossa will cause true idiopathic epilepsy becomes rarer, and it is trouble much earlier than one in the prefrontal our duty to search most carefully for a cause in all region because it will interfere with the circulation patients in whom it starts during the third, fourth, of the cerebrospinal fluid. In that case the mass of fifth and later decades of life. The fact that the fluid in the dilated ventricles must be added to fit begins with turning of the head to the opposite that of the tumour itself if we wish to compare side is not diagnostic, because a great many tumour sizes with tumour effects. Equally a small youthful epileptics do that. James Collier (1929) meningioma springing from the sphenoidal wing, thought that point important, but something else burying itself in the brain and hindering the out- that he observed seems to the writer much more flow of cerebrospinal fluid from the lateral ven- so-the tendency of these fits to be multiple, to tricle will, in the end, cause more disturbance than approach or to attain ' status epilepticus,' if there a much larger tumour at the frontal pole. The is a tumour in the frontal lobe. This has certainlyProtected by copyright. outflow of cerebrospinal fluid may be interfered been so in some of my own cases. If, therefore, with by the crebral oedema which is so common a man or woman in the forties, let us say, begins to an accompaniment of the gliomas, and which have generalized fits and at the same time head- itself adds to the bulk of the tumour proper. It is ache and some unaccountable falling off in working less common in meningiomas (though it can occur powers we ought certainly to suspect that a frontal with these as well) and thus it comes about that a tumour is present. If there is as yet no papil- frontal tumour springing from the meninges of the loedema the best plan will be to examine the convexity may attain a considerable size over a cerebro-spinal fluid for pressure and for raised number of years before its bulk is comparable with albumen content, and to make pneumograms or a glioma. Some of the gliomas, to be sure, are electro-encephalograms. very slow growing and it is not so rare as might (b) Loss of memory for recent events, some be imagined to have a five-year, a ten-year or subtle alteration in personality, loss of application even longer history with tumours of this sort. at work and failure to recognize that duties must http://pmj.bmj.com/ Nearly all of these are astrocytomas. And since be completed, loss of reticence and decency, are this tumour tends to weave itself amongst the frequently encountered in patients with frontal normal neural structures, and even to push them tumours. Complete moral breakdown so that the on one side, disturbances of function are not patient becomes delinquent or liable to imprison- nearly so obvious or so early as they are with the ment for his acts is in the writer's experience very malignant types of glioma (especially the dreaded uncommon (one case only). Much more common spongioblastoma multiforme, still, in spite of is it to find the patient good humoured and docile, radiotherapy, an incurable lesion). Vomiting is a though given at times to periods of unreasonable- on September 28, 2021 by guest. rare and always a late symptom, as will be deduced ness impenetrable to persuasion or argument. from the foregoing considerations, for it requires Few of my frontal tumour series have realized the for its production involvement of centres either in seriousness of their condition, few have been the region of the third ventricle, the hypothalamus worried at the prospects of an operation, which to or the posterior fossa. the lay mind is particularly dangerous, few have 2. Signs and symptoms due to interference with been bothered about money matters, the expense local brain mechanism. (a) Tremor has already been or duration of their illness has brought no anxieties mentioned and is rarely an outstanding sign or or questionings. They have a certain amount of complaint. Much more important are epileptic insight, for they may be brought to understand fits. These occur in about 50 per cent. of frontal perfectly what is the matter with them, but even tumours, and they are often almost, or even quite, then they seem to be spared anxieties of a really indistinguishable from the idiopathic variety. worrying kind. They are commoner in glioma than in meningioma There is no doubt whatever that all of the mental March 1950 JEFFERSON: Tumours of the Frontal Lobe 137 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from troubles so firmly linked in our minds until re- the lesion, interfering as it does with the actions cently with tumours of the frontal lobes also occur of the brain as a whole, is capable of causing great with tumours elsewhere. As the result of ex- changes in alertness and in thought, and examples periences in the unilateral removal of the frontal could be brought forward of a clear frontal lobe lobes in man the writer has been driven to the syndrome when the tumour was later proved to conclusion that although the frontal lobes have be elsewhere. We must therefore be wary of much to do with the workings of the intellect, and accepting mental peculiarities as incontrovertible of all the faculties subsidiary to it, that they are not evidence of a frontal lesion. If these changes are its one and only seat. Nor can any differences be present in a person with no signs of high pressure detected whether it be the right lobe or the left that would be better evidence. that is excised. If a frontal lobe is removed the Incontinence. In the highly compressed, drowsy patient is left quantitively with less neural tissue or stuporous patient incontinence is common than he had before to carry on his life and thought, wherever the lesion is. Normally few individuals to direct his conduct. So much is obvious. But past infancy micturate at the first feeling of desire what could not have been foretold is that the to do so, they have acquired inhibition. The deprivation makes remarkablv little difference to drowsy patient reverts to childhood's state and him. It is clear that thought processes are not so may wet the bed like the sleepy child. But for an intensively cultivated in the frontal cortex that adult to do so whilst awake is always a positive removal of a part leads to permanent loss of such sign, usually of a frontal lesion-it is as positive a and such a faculty of the mind. It would have piece of evidence as papilloedema or a positive been very interesting if it were so, for a careful Babinski. Some patients are greatly disturbed by correlation study of pathological material and of such events but explain that the bladder empties the observed clinical facts would have led to the before they can prevent it, as if their powers of establishment of individual human faculties in inhibition have vanished. We believe that theProtected by copyright. different areas of the cortex. Some might have cortical inhibitory pathways to the bladder are been in the right lobe, some in the left. Such an chiefly subfrontal, linking the frontal lobes to arrangement would have completely justified the centres in the hypothalamus. Incontinence is a phrenologists, Gall and Spurzheim, the first common happening after the deep bifrontal localizers of function. transactions of complete leucotomy, rare after The facts are, of course, quite otherwise. limited dorsal frontal cuts. But although there Function is diffusely sown in the brain, though is probably an anatomical basis in fibre-tract dis- no one would deny that it is heavily concentrated connections in frontal tumours, the thoughtful in certain parts. The greatest mental defects are may be interested to pursue their own reflections caused by bilateral frontal lesions or by tumours of on the subject of inhibition of micturition and the the , which by cutting corn- effects that sleepiness alone might exercise upon it. missural fibres impair the activities of both lobes. But it cannot too often be repeated that incon-

Mesially placed frontal tumours are very apt to tinence during wakefulness is a sign with localizing http://pmj.bmj.com/ invade the corpus callosum. Severe symptoms will value. In the highly compressed, drowsy or always, therefore, suggest callosal involvement. stuporous patient this calls for no special comment. Mental power, in Foster Kennedy's (I91 i) words, But it is another matter if it occurs when the depends on the exquisite integration of the entire patient is conscious. It is then strongly suggestive brain. Disturbances of commissural fibres and of a frontal lesion. In the analvtical table of 50 tracts leads to an upset in this integration far more frontal tumours it will be observed that mental and than does cortical damage, which is in human memory defects occur as an early sign in less than pathology rarely diffuse. It is worth making the one-third of the patients. As a late sign there are on September 28, 2021 by guest. generalization that the kind of mental alteration few patients who do not show some alteration for which brain tumours bring are , the they must all eventually become drowsy and in- detailed patterns of which depend on the previous continent. These alterations are due to high education and personality of the sufferers. But pressure and are very similar whatever part of the generally they take the form of loss of previous brain the tumour affects. abilities. Schizophrenic characters do not occur (c, d) Better still would be the additional -and would not except in those who are already presence of an aphasia, a difficulty in saying what schizophrenes. Noisiness and restlessness are the patient wishes though he declares that he is most seen in folk who are noisy and restless by perfectly clear headed. This can only occur when nature and this is true of head injuries as well. the tumour is on the left side (with the usual Remarkable disturbances of personality some- reservation of right handedness) and far back. times follow left temporal lesions, neoplastic or Similarly slight pyramidal signs, absent abdominal otherwise. High intracranial pressure, wherever reflexes, may suggest the side of the tumour if not I38 POSTGRADUATE MEDICAL JOURNAL March 1950 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from its site. Sachs has stressed particularly weakness anterior basal meningiomas, 1938). Also one of the face on the opposite side; this certainly must beware of being deceived by an atrophy occurs but it is as frequent with temporal tumours. consecutive to severe choking of the discs which None the less Sachs' studies of frontal tumours are has become more complete on one side than the important; he regards fits, mental changes, and other. nystagmus as most important signs. A grasp re- 4. No special comment is required by the X-ray flex may be present, that reflex action by which evidences except to say that a number of the the patient will always clench hold of anything benign gliomas calcify and that the patterns of these which so touches his palm. It has been admirably calcifications need an expert eye to recognize. described by Adie and Macdonald Critchley They may be very faint and easily overlooked. (1927). Weakness of the leg is rare in frontal Of recent years angiography has proved of great tumour patients, because the motor area slants use in the final diagnosis of brain tumours, its forward offering the face area most readily to the advantage being that it will often enough give tumour. evidence not only whether a tumour is present (e) The cerebellar signs shown by some frontal and where it is, but will also indicate its nature. tumours will best be dealt with in the differential It is particularly successful with the meningiomas diagnosis. because their self-contained fine capillary shadow 3. Neighbourhood signs. The olfactory tracts makes a well-defined mass in the X-ray film. are so closely applied to the under surface of the Equally -it may demonstrate an unsuspected frontal lobes that their compression by sub- angioma or the wild vascular pattern of a malignant frontal tumours is well imaginable. Complete glioma. anosmia, on one or both sides, is rare unless the olfactory bulbs are disorganized, as happens Differential Diagnosis chiefly when there is an olfactory groove men- We will assume that the fits and mental changesProtected by copyright. ingioma. Elsberg has introduced more delicate from which our hypothetical patient could suffer tests for estimating depression of the sense of have been proved non-syphilitic by a negative smell short of complete loss. Special, even though Wassermann reaction. The chief differentiation simple apparatus, is necessary and outside hospital necessary will be between either temporal or it will suffice if the clinician tests the sense of cerebellar tumours. Temporal tumours equally smell with whatever easily identifiable odours he produce raised pressure (only more early because can find to hand. These tests must be remem- they tend to compress the third ventricle), facial bered, for especially if the loss is unilateral, the weakness and fits. There are two points peculiar patient may be unaware and does not mention it. to temporal lobe tumours-uncinate fits and When it is bilateral (in the absence of nasal disease) homonymous visual field defects. If neither of it is always important, always organic, though it these is present, differential diagnosis can only be can be a false localizing sign (Cushing, I9I6). arrived at by mechanical means. of Unilateral optic atrophy caused by the pressure The possibility cerebellar signs in frontal http://pmj.bmj.com/ of a frontal tumour bearing heavily on the nerve tumours has already been mentioned once or twice. of the same side is an extremely important sign. This possibility of confusion is brought about by It was first given diagnostic significance by Leslie the important pathways which leave the frontal Paton, and worked up with illustrative cases in an lobes and run to the pontine nuclei, there to be important paper by Foster Kennedy, whose relayed to the cerebellum and labyrinthine name is usually attached to the syndrome of apparatus. But it can be said at once that a full- atrophy of the optic nerve on the side of the fledged cerebellar picture is never given by tumour, papilloedema in the uncompressed nerve frontal tumours. The symptoms and signs are on September 28, 2021 by guest. of the opposite side. Of recent years the signifi- suggestive and no more. Why then should diffi- cance of unilateral optic atrophy has more and culties ever arise? The reason is that cerebellar more impressed itself on ophthalmologists and tumours themselves frequently give rise to symp- neurologists. It is an organic sign of the first toms and signs which are scarcely more obtrusive order, and never more so than when the opposite or classical. The clinical picture which Gordon disc is oedematous. Its presence means exactly Holmes (1922) has made so well known is best seen what the facts indicate. (The present writer has in injuries or vascular insults of the cerebellum. It published a study of compression of the optic can, of course, occur in patients with tumours, too, chiasma by gliomas and discussed this syndrome but not so often as might be thought. Even fully, Doyne Lecture, Trans. Ophth. Soc., 45, nystagmus itself may, if rarely, be minimal or I945.) The optic atrophy can be as well pro- absent in cerebellar lesions. It is quite certain duced by a temporal tumour as-by a frontal (see that the coarse, unmistakable nystagmus of some Fig. I24 in W. R. Henderson's essay on the cerebellar tumnours never occurs with frontal. March 1950 JEFFERSON: Tumours of the Frontal Lobe 139 Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from Before having recourse to angiography or of the ventricle it will be wiser to break off the ventriculography the cortical potentials should be operation before more harm is done and try again studied electronically. Sometimes extremely ac- under local anaesthesia alone later. Supposing curate localization can be given by these means by that the dura can be safely opened this is next alterations of potentials, phase reversals and so done, cutting it below, in front and behind. The forth as Grey Walter, Denis Williams and George cortex is now inspected for evidence of tumour, Dawson have shown. Electro-encephalography which may be very clear. If not it will be found has become an essential exploration of organic by puncture. The recognition of the presence of a cerebral lesions. Further information can be tumour, of its extent and especially of its nature obtained by angiography or ventriculography. needs considerable culture. It is on this vital point that the general surgeon was so constantly defeated. If excision of the frontal lobe is decided Operations on Frontal Tumours upon the cortical veins entering the superior In general the attack on a frontal tumour follows longitudinal sinus are first coagulated so that the the lines generally adopted in neurosurgery. It is falx is clear. This necessitates a bone incision assumed that the aim is the removal of the tumour. exactly on the mid-line. A half- or one-inch over- This can sometimes be effected by enucleation, in hang will greatly hamper the securing of these other cases the extent and position of the tumour veins. When clearly seen they are easily dia- make the sacrifice of the lobe unavoidable. The thermized and divided. The line of cortical in- lobe may have to be excised to give access to a cision is-next planned on the surface of the brain, tumour beneath it. The steps of the operation are the veins to be cut coagulated and the as follows. An incision is made in the mid-line occluded with silver clips. The line of this section backwards from a point just above the glabella to will commence below, as a rule, at the junction of one inside the hair line. The cosmetic result is the anterior and middle fossae. The incision into Protected by copyright. superior if the incision is very accurately placed in the brain is best made with a narrow blunt the mid-line. Having reached the higher point the dissector, which allows the recognition of deep incision curves over the scalp to fall vertically vessels. The anterior horn of the lateral ventricle towards the ear which it should reach. The scalp may be cut across if the tumour has not pushed it flap should be first marked out with iodine and too far back. This does not matter. The only then with a scratch. Novocaine-adrenalin solution difficulty may be the clipping of the anterior (i per cent.) is then injected along the proposed cerebral artery on the mesial surface deep in. line of section. The whole scalp flap is dissected After the orbital surface of the brain has been downwards and forwards, free from the bone. cut through, the whole lobe is lifted out. All Great care must be taken by finger compression to bleeding points are secured, the large cavity filled keep the blood-loss during the cutting of the scalp with Ringer's solution and the dura closed. A flap down to a few cubic centimetres. Suitable small drain can be left in between bone and dura points are now chosen for making drill holes, for 24 hours, but it is certain that daily aspirations http://pmj.bmj.com/ avoiding the frontal air sinus. The bone dust of fluid will have to be made during the next week obtained in making the holes is saved for replace- or ten days. The dead space eventually settles ment at the close of the operation. The holes are down, it may permanently communicate with the most safely made by brace and perforator and burr ventricle. worked by hand. After separation of the dura Lobectomy gives the patient the best chance of mater from the bone the holes are connected with long survival and obeys the surgical maxim of the Gigli saw. The base of the bone flap in the block removal of non-enucleable tumours. In temporal fossa may be narrowed with de Vilbiss none of the writer's cases has there been any on September 28, 2021 by guest. forceps; it is then broken down, hinged on the important mental, moral or-other disability as the temporal muscle. The bleeding from the exposed result of it. dura is usually negligible, and is well controllable The prognosis depends on the nature of the with wet cotton or lintine. If bleeding is severe tumour. It is excellent in the meningiomas and either there is a meningioma beneath the dura with angiomas, hopeless in the malignant gliomas and a wide attachment to it, or the anaesthetic is intermediate in the more benign gliomas (astro- wrong or the airway imperfect. It is a great cytomas). The writer has had several patients handicap to good surgery to have a high intra- with astrocytomas who have survived five years cranial pressure, hence the need for early diagnosis. and a few who lived usefully for over ten years The patient's chances of recovery are greatly en- after frontal lobectomy. The great advantage of dangered if the brain tends to bulge irresistibly the operation is that it leaves so large an ' internal through a dural incision. If the pressure cannot decompression' that given a very slowly growing be lowered by puncture of an intracerebral cyst or tumour the space serves them well. 140 PENNYBACKER: Pituitary, Pineal and Third Ventricle Tumours March I950' Postgrad Med J: first published as 10.1136/pgmj.26.293.133 on 1 March 1950. Downloaded from

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