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389 Tumours of the Pituitary Region manifested them- selves in two ways. Function was disturbed, with changes in the skeleton, in other glandular functions, producing such conditions as hairlessness, and pressure produced intolerable headaches with failing vision. It was for the latter symptoms that, in the present state of our knowledge, the skill of the surgeon was sought. These tumours fell into two divisions. 1. Simple adenomata of the pars anterior excavated the sella, and also pushed up the optic chiasma, but in invading the cranial cavity they remained encap- suled. It was with these types of tumour that the glandular disturbances might occur ; and one must bear in mind that such patients bore operations badly. 2. The other division was composed of suprapituitary tumours: (a) meningeal tumours of the interpeduncular space, (b) tumours or cysts of complex structure probably arising from the infundi- bulum. With these the glandular changes are not remarked. Either type may be approached (1) by the temporal route used by Horsley 20 years ago, (2) from below through the sphenoidal sinus as advocated by Cushing, (3) by means of a frontal osteo-plastic flap as devised by Frazier. The speaker preferred the last method. The prognosis was best with adenomata ; with improvement in technique the proportion of satisfactory results was quite gratifying. Supra- pituitary tumours were less satisfactory to deal with. Some were cystic, and contained cholesterin ; with these there seemed bo be a risk of death from toxaemia following the liberation of the fluid. Cerebello-pontine Tumours were usually neuro- fibromata of the auditory nerve. Others were cholesteatomata, or " pearl tumours." The former were usually firm, solid, encapsuled tumours, but might be soft or even cystic. They enlarged the internal auditory meatus, sometimes to a remarkable degree this could be demonstrated by skiagraphy. Deafness and tinnitus might by the only symptoms for years. Loss of function of the vestibular part of the nerve was early demonstrable. Loss of the corneal reflex of the same side was also frequent. Later, the classical signs of tumour, headache, vomiting, and papilloedema appeared. By this time operation had become a more difficult, as well as a more hazardous, procedure. The tumours should not be removed en masse ; this could be done, but the resulting disturbance to the vascular supply of the medulla commonly induced death ; the tumour should be removed intracapsularly bymorcellement. This method had given the speaker a mortality of 3 only in 19 cases. Decompres- sion might be done if piecemeal removal was not thought advisable, but the results were not nearly so satisfactory. The group of e-izdotlzeliomatct was histological rather than regional, though the tumours were meningeal and tended to be superficial. They cupped but did not infiltrate the brain, and probably arose from the arachnoid tufts which formed the Pacchionian bodies and so tended to be found about the longitudinal sinus. Growing very slowly, they might attain very large size before giving rise to symptoms. These tumours might often be diagnosed and localised with certainty before signs of general pressure appeared. This was a great advantage as an osteo-plastic flap could be employed. A two-stage operation was not advised; the patient might die between the two operations. These tumours formed only a small proportion of the whole class of tumours of the cere- brum and were rare in the cerebellum. The glioma of an infiltrating type was the common tumour. For these, decompression and partial removal gave some relief, and it seemed that gliomata were tumours favourable for the action of radium buried in their substance. In any case, where there was a high degree of intracranial pressure, any operation was fraught with difficulty and danger; the classical signs of tumour should be regarded rather as danger signals or even portents of impending death. Early and accurate diagnosis were the points of - essential importance. Spinal Tumours, he said, provided some of the most gratifying results of operation on the central nervous system. A large proportion were benign extra- medullary growths, and in all these there must be some stage where operation afforded prospect of complete removal at very small risk. In addition to neurological means of diagnosis and lumbar puncture, skiagraphy after injection of lipiodol through the occipito-atlantoid ligament afforded valuable means of localising the tumour. ABERDEEN MEDICO-CHIRURGICAL SOCIETY. i A MEETING of this Society was held recently, Dr. PETER HOWIE, the President, in the chair, when Dr. A. G. ANDERSON read a paper on Encephalitis Lethargica. Dr. Anderson’s experience of the disease extended to some 20 cases, and he outlined the various points of interest which had emerged from the study of these cases. After describing the original appearance of encephalitis lethargica in 1917 and its spread in different countries, and stating that the descriptions of " lethargic " was now inapplicable to many of the recent cases, Dr. Anderson recounted the details of the first case he had seen on March 17th, 1920, in a- woman of 37, who presented the typical features of fever, ocular disturbance, and lethargy which lasted for seven or eight days. The most interesting feature was that in a few days the mask-like facies developed,. and by the end of May the typically stiff gait like a- case of paralysis agitans had appeared. During the next two or three years the residual phenomena noted were the mask-like face, the stiff hesitating move- ments of the limbs-the arms being held in the characteristic mid-brain attitude. Fortunately, the Parkinsonism was not progressive, and during the past year the patient had emigrated and was able to do active work. Dr. Anderson then discussed the development of the mid-brain syndrome, and indicated that this was now regarded as one of the commonest sequelae of encephalitis lethargica, the time of its appearance being extremely variable. In the description of further cases of the series Dr. Anderson dealt fully with the various charac- teristic symptoms and signs which had appeared, and discussed their features especially as regards period of onset and diagnostic and prognostic import. Such were Parkinsonism, lethargy, muscular and mental passivity, the running gait, akinesia paradoxica, disorders of speech, tremors, emaciation, excito- motor phenomena, pain, myoclonus, chorea, athetosis, spasmodic tics and automatic movements, facial paralysis, and signs simulating meningitis. One patient had a pregnancy after the onset of the encephalitis, a healthy child being born ; the case illustrated the facts that encephalitis does not neces- sarily lead to premature labour, that the child need not be infected, and that pregnancy seems to have a definite effect in aggravating an existing Parkinsonian syndrome. In connexion with the choreic type of case Dr. Anderson described fully two cases : one, a boy of 14, who had attacks nightly lasting about four hours, when he went through a series of " antics "-coughing, snorting, jumping in and out of bed, and so on, till he fell asleep exhausted. The other case, also a boy of 14, had similar restless attacks with very marked insomnia, the wakefulness persisting till 4 or 5 A.M. ; one period of insomnia lasted for 48 hours. This boy also had attacks of marked respiratory disturbance. The mental and moral changes in the disease were next discussed, and their problems indicated. In conclusion, Dr. Anderson dealt with the theories of the infective nature of the disease, referring to cases which might lend clinical support to the idea. He also briefly referred to the necessity of a complete examination of the cerebro-spinal fluid in all cases, not so much for the possible positive findings as for
