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✓ The author documents the development of the Medical School at Washington University since 1891, when the St. Louis Medical College was first included as part of the University. In 1909, Robert Brookings, President of the Corporation of Washington University, acquired a large endowment and moved the clinical and hospital facilities to a new location, enabled by the estate of Robert Barnes. Harvey Cushing was offered the chair of surgery but eventually decided in favor of Harvard University in 1910. Dr. Ernest Sachs was recruited to Washington University by Dr. Fred Murphy, and in 1919 became the first ever Professor of Neurological Surgery. The history of neurosurgery and those who served it at the Washington University Medical Center and Barnes Hospital is recounted.

✓ Procedures for relief of coronal synostosis and metopic synostosis have resulted in some undesirable sequelae. The authors present combined neurological and plastic surgical modifications to prevent additional synostoses, forehead ridging, and lateral orbital wall step-off. They recommend bifrontal craniotomy with lateral wall osteotomy into the body of the zygoma and self-retaining grafts.

A case of cerebral arteriovenous fistulas with congenital heart disease is presented.Cerebral arteriogram confirmed the presence of the arteriovenous malformation which drained into the vein of Galen. The patient did not improve after the surgical obliteration of the major cerebral arteriovenous fistulas. Cardiac catheterization and angiocardiographic studies revealed the presence of an interatrial septal defect and an anomalous venous connection. Surgical repair of these cardiac malformations was carried out but the patient died during the immediate postoperative period. The case suggests that in a patient with cerebral arteriovenous malformations, one should suspect the presence of an associated cardiac malformation especially if there is no improvement in the cardiovascular status of the patient after successful obliteration of the fistulas.

A multivariate analysis of prognostic variables was performed on a retrospective review of 136 patients with presumed or histologically proven primary lesions of the thalamus and brainstem treated by combined surgery and post-operative irradiation or by irradiation alone from January 1950 through December 1983. Overall survival for all patients at 5 and 10 years was 34.4 and 27.8%, respectively. Follow-up of 33 living patients ranged from 3 to 22 years. Prognostic variables analyzed by univariate analysis and found to be of significance (p less than 0.05) were race, duration of symptoms, extent of surgery (i.e. subtotal excision), and dose of irradiation. Further evaluation by Cox regression analysis revealed these same factors to be of prognostic significance (p less than 0.05). It is of importance to note that age and tumor site were not significant prognostic variables in the multivariate analysis but were significant by univariate analysis. The 5-year overall survival for patients with thalamic tumors was 59.5 and 20.9% for children and adults, respectively (p = 0.006). The 5-year overall survival for patients with pontine lesions was 46.6 and 16.0% for adults and children, respectively (p = 0.01). Only one patient was known to have expired due to a complication of therapy. Neurologic deficits and functional ability was normal or mild in 57.6% of the surviving patients.

Adenoid cystic carcinoma of the lacrimal gland is a rare tumor, although it is the malignancy most frequently arising in the gland. Treatment has been unsuccessful generally, with a 15-year survival of less than 20 percent. Our experience with this tumor in a 61-year-old woman has led to a proposal for therapeutic management based on awareness of the lesion's natural history, an understanding of regional anatomy, and familiarity with therapies reported in the literature. The feasibility of adequate tumor ablation is determined from preoperative evaluation, including CT scan, initial exploratory craniotomy, and frozen-section examination of the cranial nerves transversing the orbit. Once resectability is confirmed, "curative" intracranial and extracranial en bloc resection is performed, including the tumor, the lacrimal gland, and all contiguous structures. The defect is immediately resurfaced with and "ice cream cone" forehead flap in anticipation of adjuvant radiotherapy. An orbital prosthesis is fitted as soon as the radiation reaction subsides, and a postablative CT scan is obtained as the baseline for follow-up. It remains to be seen whether this application of the technology of CT scanning and the techniques of craniofacial surgery will improve the prognosis for adenoid cystic carcinoma arising in the lacrimal gland.

A woman with left atrial myxoma had progressive disturbance of intellectual function, headache, and prominent constitutional symptoms. The absence of stroke is noteworthy. Multiple high-density lesions with contrast enhancement were seen by CT scan, suggesting metastatic neoplasms, hematomas, or hemorrhagic infarcts. Serial study showed progressive enlargement of the lesions. The only cerebral lesion examined histologically proved to be an organizing hematoma, originating most likely from adjacent small arteries found to be plugged by embolic myxoma.

Prognostic factors and results of therapy were analyzed in a retrospective examination of 121 patients with pituitary adenomas treated with surgery and postoperative irradiation (RT) from January 1954 through December 1982 at the Radiation Oncology Center, Mallinckrodt Institute of Radiology. The 10-year overall and disease-free survival for all patients was 85.1 and 89.4%. The expected survival for an age-, gender-, and race-matched population was not significantly distinct at 85.3% (p = 0.72). Follow-up of 94 surviving patients ranged from 3.4 to 29.5 years (mean, 11.7). Statistical analysis was performed for multiple prognostic factors including age, race, gender, disease bulk, visual field symptoms, disease type, surgical approach, and irradiation dose and volume. The only prognostic variable identified by univariate analysis to significantly alter disease-free survival was irradiation dose. Patients receiving 5000-5400 cGy had a tumor control rate of 94.1% (64/68) compared to 85.0% (17/20) for 4000-4999 cGy, 75.0% (18/24) for 3000-3999 cGy, and 28.6% (2/7) for less than 3000 cGy (p = 0.000059). Factors evaluated but established to be insignificant were age, race, gender, disease bulk, visual field symptoms, disease type, surgical approach, and irradiated volume. The 10-year disease-free survival by classification was 93.3% for patients with amenorrhea/galactorrhea, 89.9% for non-functioning adenomas, and 76.4% for acromegaly (p = 0.21). Overall improvement in visual field defects subsequent to treatment occurred in 48.4% (44/91) of those with visual field defects before RT and was significantly correlated with RT dose. The median time to progression of disease was 10.2 years with the last failure occurring at 25 years following the fulfillment of RT. Severe complications related to RT were apparent in 1.7% (2/121). None were known to have endured brain radionecrosis. Serious surgical complications occurred in 9.9% (12/121).

✓ A case of severe tuberculous destruction of the cervical spine treated without bone grafting is described.

Lateral rupture of the cervical intervertebral disks should be considered in the differential diagnosis in a patient with a history of pain or stiffness of the neck, with radiation of pain to the shoulder, arm or hand. In some cases the superficial impression may be that of angina pectoris. Differential diagnosis between cervical rib and scalenus anticus syndrome and cervical disk can usually be made on the basis of the point of reference of pain or numbness. In cases of cervical disk rupture, symptoms and signs are usually referable to the sixth and seventh cervical dermatomes, whereas the other conditions usually involve the eighth dermatome. Roentgenograms of the cervical spine frequently show reversal of the normal curve and narrowing of the suspected interspace.Cervical disks which rupture closer to the midline may produce signs and symptoms of degenerative cord disease, such as amyotrophic lateral sclerosis, or may even cause complete paralysis simulating spinal cord tumor.Because of the great risk ...

Diastematomyelia is a congenital malformation in which a band of fibrous or bony tissue extends dorsoventrally through the spinal canal and between the portions of either a partially duplicated or split spinal cord. According to Bremer (2), this represents one manifestation of a persistent accessory neurenteric canal or dorsal intestinal fistula. These fistulas, which in the embryo extend from the enteric cavity to the neural groove, may persist and present clinically as tubular tracts reaching from some portion of the gastrointestinal tract to the skin (7, 9). Others may form cysts and be mistaken for anterior meningoceles or branchial cysts (2). More commonly the fistula disappears, but according to Bremer its former presence may be manifested by: increased breadth of the vertebral bodies; a circular or oval defect extending through the vertebral bodies; development of the vertebra in two halves, which later fuse to form a median bony or cartilaginous spur projecting into the spinal canal and transfixin...

Hypothermia has proved to be a doubleedge sword, for while protecting the brain against anoxia it threatens the heart with arrhythmia. This undesirable effect has led to attempts to cool the brain profoundly, while lowering the heart temperature only moderately. Several groups 1,12,14,17 have accomplished this by shunting carotid blood through a heat exchanger. Woodhall and collaborators 27 used a circuit whereby jugular blood is oxygenated and cooled and then recirculated through the brain. We were encouraged by the report of Kimoto et al., 12 who cited successful use of an extracorporeal carotid cooling system as an adjunct to open heart surgery in 9 of 11 human cases. The present study was undertaken to gain experience with the new technique of blood-stream cooling, and to enlarge on observations reported by others. We sought specifically to compare surface cerebral temperatures with those in the depths of the cerebrum and cerebellum, and

THE PSYCHOLOGICAL effects of cortical destruction in man have been recognized for many years. Even the effects of damage to an area as extensive as an entire hemisphere had been described decades ago, as Karnosh and Gardner 1 have noted. Over a hundred and fifty years ago, Francis Joseph Gall presented a case report on a man in whom the right hemisphere had been totally destroyed by suppuration and yet the intellectual faculties had remained intact up to the time of the death. Much of our knowledge of the effects of decortication has come from animal operations, for example, Kellogg's 2 long-time studies at Indiana University. Even earlier, Karplus and Kreidl 3 had accomplished decerebration in animals, including apes. It was not until 1923 that Dandy 4 performed the first hemispherectomy on man. Since his first published report in 1928, a number of articles in the literature have dealt with