Lumbar puncture, frequently repeated, has also been practised for the relief of tension in inoperable cases, but it is not free of danger and is not to be looked upon as a substitute for a decompression operation.
When surgical treatment is contra-indicated, all that can be done is to palliate the symptoms by bromides, opium, phenacetin, caffein, and other drugs.
Tumours of the Pituitary Body or Hypophysis Cerebri.—The tumours most frequently met with in the pituitary body are of the nature of adenoma with hyperplasia and cystic degeneration; carcinoma and sarcoma also occur. They develop slowly and give rise to comparatively slight increase in the intra-cranial tension. When the anterior lobe is implicated and there is a pathological increase in the functional activity of the gland (hyperpituitarism), signs of acromegaly may ensue. Diminution of function (hypopituitarism) is attended with infantilism, a rapid deposition of fat in the subcutaneous tissue, and a decrease or loss of the genital functions. In women, amenorrhœa is an early and constant symptom. Intense drowsiness is a marked feature in some cases.
From their position close to the back of the optic chiasma these growths affect the fibres passing to the nasal half of each retina, and so give rise to bilateral temporal hemianopsia, and although there is no choked disc, the optic nerves undergo primary atrophy from pressure, and there is failure of sight.
Marked temporary benefit has followed the administration of thyreoid extract. Operative treatment has been successful in a number of cases, but as the anterior lobe is essential to life, the operation is merely directed towards the relief of pressure on the optic chiasma with a view to preventing loss of vision. We have seen marked relief follow a temporal decompression operation.
Epilepsy.—The surgical aspects of Jacksonian epilepsy following head injuries have already been considered ([p. 358]). For the cure of those forms of epilepsy in which there is no gross lesion of the brain, numerous surgical procedures have been suggested, but from none of these have the results been encouraging.
Hernia Cerebri.—This term is applied to a protrusion of brain substance through an acquired opening in the skull and dura mater, such as may result from a compound fracture or a gun-shot wound. The protrusion is due to increased intra-cranial tension, and is almost invariably associated with infection of the brain and its membranes, and with the presence of a foreign body or fragments of bone. Other things being equal, a hernia is more likely to occur through a small than through a large opening in the skull.
So long as the extruded portion of brain matter is small, it pulsates, but as it increases in size and is pressed upon by the edges of the opening through which it escapes, the pulsation ceases, and the herniated portion may become strangulated and undergo necrosis.
In cases of compound fracture, and in other conditions associated with necrosis of bone, masses of redundant granulation tissue growing from the soft parts outside the skull may simulate a hernia cerebri.
The treatment consists in counteracting the septic infection by purifying the protruding mass, and if necessary by enlarging the opening in the skull with rongeur forceps to admit of the removal of foreign bodies or bone fragments and to relieve the inter-cranial tension. Steps must also be taken to prevent meningitis, which, if it occurs, is usually fatal. Pressure over the hernia, with the object of returning it to the skull, is to be avoided, and the herniated portion should not be cut away unless it is sloughing, or has become pedunculated. It may be got rid of by painting it with 40 per cent. formalin, which causes a dry, horny crust to form on the surface; this is picked off, and the formalin re-applied.