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ALIGNANT tumors of the paranasal sinuses account for but a small percentage of human neoplastic disease. This amounts to about 3 % of all cancer of the upper respiratory and alimentary tracts or approximately 0.2 % of all human cancers. TM Watson TM found an incidence of 0.44 % of cancer of the paranasal sinuses in a total of 26,062 patients admitted for malignant disease at Memorial Hospital. Nevertheless, serious study of these patients is merited not only because of the peculiarly unpleasant suffering these patients undergo in the terminal period but because it has been found practical to eradicate the disease in a relatively high proportion of patients. It should be re-emphasized that only histologically malignant tumors are under present consideration. From a statistical point of view, several features suggest that radical therapy should provide a high cure rate. Some 80 % of tumors of the paranasal sinuses are estimated to arise in the maxillary sinus which has long been considered a surgically accessible site. 1 The tumors, appearing as they most commonly do in the fifth to seventh decade, are predominantly carcinomas or adenocarcinomas and frequently of slow-growing type. 8 Certainly one of the greatest difficulties in treatment is diagnosis of the tumor in an early stage. Often, many months of symptomatic treatment is prescribed for the protean symptoms of nasal obstruction, local pain, and epistaxis before a definitive diagnosis of malignancy is made. Despite the late diagnosis, metastases are relatively uncommon. Of 68 patients with cancer of the nasal cavity, MacComb and Martin ~x found that 12 % had metastases on admission and only 17% had metastases later in their course. This incidence is approximately the same as that of Ashley Received for publication July 13, 1967. and Schwartz I who noted at autopsy that only 25 % of maxillary carcinomas spread beyond the local area. Metastases usually appeared in the retropharyngeal and superior cervical lymph nodes if the primary tumor was in the superior and medial portion of the antrum. Tumors involving the floor and lateral wall were more prone to show metastases in the submandibular lymph nodes. Taken together, these features encourage surgical attack upon the local lesion. Unfortunately, hopes of an en bloc resection through a facial approach can only be realized in the cases with very small lesions, since tumors, even if primary in the antrum, seldom remain there. The common extension of tumor into the ethmoidal sinus and the impossibility of removing this sinus en bloc through a facial approach is a particular deterrent to resection, since even as late as 1963, FrazeU and Lewis 6 warned that "the entire cribriform plate can rarely be resected without creating cerebral complications .... "

Clinical neurologists and neurosurgeons are beginning to realize the usefulness of quantitative testing batteries to augment the qualitative measurements of the standard neurological examination in evaluating treatments for neurological diseases. This paper briefly reviews the literature on the subject, defines what is meant by a clinical quantitative neurological test, discusses the advantages of quantitative testing, considers some essential ingredients in constructing a quantitative testing system, and describes the battery of tests which is being used currently by the authors. A sample of patients from a recent study of the efficacy of thalamotomy in Parkinson’s disease is used to develop an example illustrating the usefulness of quantitative testing.

Summary The combined intracranial transfacial approach to the ethmoid, sphenoid, and frontal sinuses has been satisfactory in performing en bloc resection of cancer arising in or involving these anatomic areas. Fifty-four patients have been treated with this procedure, using the combined expertise of the neurosurgeon and the surgeon interested in the head and neck area. Two postoperative deaths have occurred, both attributed to meningitis. The long range postoperative morbidity is negligible, except as it relates to loss of the palate in all but eight patients and the orbital contents in thirty patients. The cumulative five year survival in this series of patients, forty-two of whom had failure of previous treatment, is 56 per cent. If the procedure is carried out with rigid attention to good surgical technic and the principles of en bloc tumor removal, this combined procedure has the following advantages: (1) allows accurate evaluation of the intracranial tumor extension, (2) protects the brain, (3) avoids cerebrospinal fistulization, (4) provides adequate hemostasis, (5) facilitates en bloc tumor resection, and (6) selectively conserves the orbital contents.

A stereotaxic radiotherapy technique that permits accurate delivery of highly localized dose to a small intracranial target has been developed. The technique facilitates precise integration of the diagnostic and therapeutic procedures including target localization, treatment planning, simulation, repetitive patient irradiation, and daily treatment verification. A conventional linear accelerator and computed tomography scanner as well as special diagnostic and therapeutic guides are used. A suitable dosimetric distribution is achieved using arc therapy with small radiation fields and 10-MV x rays.

SUMMARY Four patients with seizures of presumed temporal lobe origin are presented in whom a definite focal ictal onset in the orbitofrontal cortex was revealed during recording, either by chronically implanted electrodes or ECoG. In three cases automatisms occurred concomitantly with orbitofrontal activation without spread of paroxysmal activity into the temporal structures monitored. With eight additional cases of possible orbitofrontal epilepsy found on reviewing the literature, two subgroups emerge: (1) patients with primarily psychomotor-type fits, and (2) patients with loss of consciousness, head and eye deviation, and generalized convulsions. Scalp EEGs, in patients on whom we have available data, manifested bilaterally synchronous, paroxysmal discharges which were bifrontal, frontopolar, or maximal in one anterior quadrant, with or without evidence of additional temporal lobe involvement. On the basis of anatomic and physiological studies, as well as our own electrographic data, it is felt that a posterior orbitofrontal and temporo-limbic, or mesial orbitofrontal and parasagittal-limbic relationship exists, within which autonomous epileptogenic zones may develop, with the ability to discharge directly and independently to subcortical centers, while eliciting similar clinical patterns. RESUME On a etudie 4 malades ayant des crises supposees ďorigine temporale, dans lesquelles un debut critique focal bien precis dans le cortex orbito-frontal etait revele pendant Ľenregistrement, soit par des electrodes implantees chroniques, soit par ECoG. Dans 3 cas, des automatismes se manifestaient simultanement a une activation orbitofrontale, sans que Ľactivite paroxystique s'etende aux structures temporales enregistrees. Avec 8 cas en plus ďeventuelle epilepsie orbitofrontale, decouverts en revoyant la litterature, on peut distinguer 2 sous-groupes: (1) les malades presentant essentiellement des crises temporales (2) et les malades ayant des pertes de conscience, deviation de la tete et des yeux, et convulsions generalisees. Les enregistrements EEG chez les malades pour qui nous avons des donnees valables, montraient des decharges paroxystiques synchrones et bilaterales qui etaient bifrontales, frontopolaires ou maximum dans une region anterieure avec ou sans participation additionnelle evidente du lobe temporal. En se basant sur des etudes anatomiques, et physiologiques aussi bien que sur nos propres donnees electrographiques, on pense qu'il existe une relation entre la region orbitofrontale posterieure et temporale limbique ou orbitofrontale mesiale et limbique parasagittale, dans lesquelles des zones epileptogeniques pourraient se developer, avec la possiblite de decharges directement et independamment vers les centres subcorticaux, en provoquant des manifestations cliniques semblables. RESUMEN Se han presentado 4 pacientes con ataques de presumible origen temporal, en los que se encontro un claro comienzo focal del ataque en la corteza orbitofrontal, durante el registro mediante electrodos implantados permanentemente o electrocorticograma. En tres de estos enfermos los automatismos ocurrieron simultaneamente con activacion orbitofrontal sin propagacion de la actividad paroxistica a los lobulos temporales, tambien monitorizados. Tras el estudio de ocho casos adicionales de posible epilepsia orbito-frontal, registrados en la literatura, se pueden extraer los siguientes subgrupos: (1) enfermos que presentan, princi-palmente, ataques psicomotores, y (2) enfermos con perdida de conocimiento, rotacion de cabeza y ojos y convulsiones generalizadas. En enfermos en los que hemos recogido information, los EEGs habituates mostraron descargas paroxisticas, bilaterales y sincronas de presentation bifrontal, frontopolar o dominando en uno de los cuadrantes anteriores, con o sin evidencia de afectacion adicional de uno de los lobulos temporales. Basandose en los estudios anatomicos y fisiologicos, unidos a nuestra information electroencefalografica, es possible aceptar una relation entre las regiones orbitofrontal posterior y limbico-temporal o entre las regiones orbitofrontal medial y parasagital limbica, con capacidad epileptogenica autonoma en cada una de dichas zonas y la posibilidad de descargar directa e indepen-dientemente sobre centros subcorticales dis-tintos con manifestaciones clfnicas semejantes. jantes. ZUSAMMENFASSUNG Vier Patienten werden besprochen, bei denen Temporallappen-Anfalle vermutet wurden. Die Ableitungen mit chronisch im-plantierten Elektroden bzw. Des Elektro-corticogramms liessen eindeutig den fokalen Anfallsbeginn im orbitofrontalen Cortex erkennen. Bei drei Patienten zeigten sich Auto-matismen gleichzeitig mit der orbitofrontalen Aktivierung, ohne dass eine Ausbreitung der paroxysmalen Aktivitat in die temporalen Strukturen erkennbar war. Unter Beruck-sichtigung von 8 zusatzlichen Patienten mit vermuteter orbitofrontaler Epilepsie aus der Literatur, lassen sich zwei Untergruppen unterscheiden: (1) Patienten mit Anfallen primar vom psychomotorischen Typ und (2) Patienten mit Bewusstseinsverlust, Deviation von Kopf und Augen und generalisierten Krampfen. Soweit Oberflachen-EEGs dieser Patienten verfugbar sind, zeigen sich bilateral synchrone, paroxysmale Entladungen bifrontal, frontopolar oder mit Betonung in einem vorderen Quadranten mit oder ohne Hinweise auf zusatzliche Einbeziehung des Temporallappens. Aufgrund anatomischer und physiologischer Untersuchungen sowie unserer eigenen elektro-graphischen Daten werden hintere orbitofrontale und temporal-limbische oder mesiale orbitofrontale und parasagittal-limbische Ver-bindungen angenommen innerhalb derer auto-nome epileptogene Zonen sich entwickeln konnen. Sie haben die Fahigkeit, direkt und unabhangig nach subcortikalen Zentren sich zu entladen, und dabei ahnliche klinische Muster auszulosen.

Publisher Summary This chapter discusses the thalamocortical mediation of perception and memory in man. The pulvinar nucleus in the left and right lateral thalamus and the ipsilateral cortices co-sponsor naming and recalling verbal memoranda or discriminating and recognizing visual patterns. In a study described in the chapter, stimulation within this system on either side produced a distinct retrograde memory loss. In contrast, stimulation of the cingulum or the cortex of the anterior temporal lobe never elicited dysphasia or perceptual deficits but produced anterograde memory problems. The effects of cortical lesions in the language zone are more severe and disabling. Retrograde memory errors and anomia occurred with left posterior-temporal parietal stimulation. Thus, stimulation upset the primary language system and prevented the subject from being able to name or tag highly familiar objects, which in one sense might be classified as old information, well-established within, the subject's long-term repository. This indicates that in man, recent and remote memory for certain types of information may be served by a common retrieval mechanism situated within the cortical language zone, interacting with the pulvinar nucleus of the thalamus.

✓ This series included five patients who had suffered 8 to 23 years of severe, medically intractable seizures without remission, severe socioeconomic handicaps, and an average of over one seizure a day on hospital observation and by history. All had combinations of partial and general seizures with focal and/or bilaterally synchronous epileptiform activity consistently on multiple electroencephalograms (EEG's). One patient had nearly continuous myoclonic activity. Serum levels of phenytoin, primidone, and phenobarbital were adjusted to therapeutic ranges. Three patients had additional medication (diazepam, ethosuximide). Cerebellar biopsy in three patients showed reduction in Purkinje cells. After implantation of cerebellar stimulators, seizure frequency was evaluated in hospital during three or four admissions for 4- to 6-week periods over the ensuing 15 to 21 months. No slow trends toward improvement or deterioration were noted. No significant differences in seizure frequency were found when comparing intervals of about 7 days of on-and-off stimulation both in the double-blind and unblinded conditions. No changes in EEG or Intelligence or Memory Quotients occurred unaccounted for by variations in serum levels of antiepileptic drugs. Despite the lack of objective improvement, patient and family acceptance of cerebellar stimulation was positive to enthusiastic. A rise in CSF norepinephrine and a fall in gamma aminobutyric acid (GABA) accompanied cerebellar stimulation and may be related to the results.

Intercellular contacts in the subfornical organ (SFO) of kittens 3, 16, and 29 days old were studied in thin sections and by the freeze-etch method. Gap junctions appeared between growing nerve processes and target cells. The junctions were interspersed between immature synapses lacking mitochondria as well as full pre- and postsynaptic membrane specializations. Gap junctions were seen on filopodia as well as on more mature processes. The morphology of these junctions was typical of those described earlier but they were of small size (0.2-0.3 micron). Gap junctions of peculiar form were also seen between ependymal elements in the SFO at 16 days. These were of large size (0.5-0.8 micron) and were often of segmented character. This segmentation consisted of bands 3-4 particles in width with a center-to-center spacing of 90 nm with particle free corridors between corresponding to the width of about two rows of particles. The margin of the group might be circumscribed by a row of particles. Although gap junctions of large size were seen between ependymal cells in thin section, features corresponding to the particle free corridors have not been observed to date.

This study is based on 28 patients with intractable seizures in whom exclusively extratemporal or a combination of temporal and extratemporal electrodes were chronically implanted for the localization of the epileptogenic process and possible surgical treatment. Clinical and electrographic data are briefly summarized, the indications for the use of implanted electrodes are outlined, and the number and position of the electrodes and the findings in each individual case are given. Four illustrative examples are described in greater detail. Mainly on the basis of data derived from this particular technique of investigation, surgical treatment was eventually carried out in 14 patients. It is concluded that the use of implanted electrodes in seizure disorders of probable extratemporal origin can be of real diagnostic benefit in certain specific situations. In most instances, however, this technique simply serves to demonstrate the complexity of an apparently simple case or, of greater clinical consequence, might tend to oversimplify cases that are actually very complex. Indeed, many data in this study raise some doubts about the validity of the classic concepts of “focal” epilepsy.

Lumbar cerebrospinal fluid norepinephrine concentrations were determined by radioenzymatic assay in five epileptic patients receiving double-blind cerebellar stimulation and in three epileptic patients with subdural cerebral surface electrodes. Mean CSF norepinephrine levels were significantly elevated by chronic cerebellar stimulation and significantly depressed after intermittent cerebral cortical stimulation. Lumbar CSF cyclic adenosine monophosphate levels determined by radioimmunoassay were not significantly altered by either cerebellar or cerebral surface stimulation. Our study suggests that (1) electrical stimulation of the anterodorsal cerebellum in man evokes alterations in noradrenergic metabolism. Cerebellar stimulation-induced elevations in norepinephrine may inhibit cerebellar, cerebral, and spinal neuronal activity. In addition, (2) noradrenergic responses to brain surface stimulation may exhibit regional specificity, and (3) noradrenergic alterations evoked by cerebral surface stimulation may not mimic those induced in isolated brain preparations.

A 240-cm thick coarse carbonate sand layer was recovered by piston coring from 4,000 m of water east of the steep (14°-60°), high relief (4-5 km) Bahama Escarpment. Most of the sediment was derived from the adjacent shallow-water Bahama carbonate platform. The deposit consists of four units (from bottom to top): (I) a basal unit (7-8 cm thick) intensely mined with the underlying hemipelagic sediment; (II) a 72-cm thick inversely graded section; (III) a massive, non-graded unit 125 cm thick; and capped by (IV) a normally graded unit 35 cm thick. Contacts between all units are gradational and the top of the deposit is flat and sharp. Units I-III are interpreted to have been deposited by modified grain flow. Interstitial muds are believed to have aided in support of the flow by a ding some matrix strength. The normal grading in unit IV may have resulted from increased turbulence with overlying waters and the transition from grain flow to turbidity current at the top of the flow. This is the first report of a modern modified grain flow deposit from the deep sea.

Mechanisms for perception and memory were probed by electrical stimulation via chronic electrodes in the human thalamus. Stimulation within the left pulvinar nucleus induced transient dysphasia and a retrograde loss in recent memory for verbal memoranda. In contrast, comparable stimulation of the right pulvinar failed to disrupt verbal behavior and, instead, disabled the mechanism for discrimination and recognition of complex visual patterns. The findings suggest that an asymmetry in the functional organization of linguistic and nonverbal processes appears to exist at the level of the lateral thalamus. The hypothesis is advanced that the pulvinar scans incoming sensory traces and searches long-term memory registers for appropriate cues and labels.

In 14 patients operated upon for focal cerebral seizures under local anesthesia, cortical electrical activity was compared with the levels of nicotinamide adenine dinucleotide (NADH) observed fluorometrically. NADH levels fell 3 to 15% in response to 5-second intervals of cortical stimulation in 42 of 70 observations. Although a rough correlation was seen between the quantity of current delivered (milliamperes X seconds) and the NADH decrease, this varied from case to case. The presence of cortical afterdischarge often, but not invariably, corresponded to a greater percentage of change in the NADH levels. Averaging the NADH response to sporadic interictal epileptiform discharges failed to demonstrate concomitant NADH reductions. A similar lack of change was seen in four patients in whom low frequency spike foci were induced by topically applied penicillin in cortex destined for excision. Preliminary studies of the topography of spread of NADH change after cortical stimulation indicate that this is usually asymmetrical in human epileptogenic cortex. Under experimental conditions in cats, it seemed possible to differentiate primary from projected epileptiform activity, in that the projected activity had little or no concomitant fall in the NADH level after the electrographic spike. Pathological examination of the excised sites of NADH recording showed, with one exception, fibrous astrocytic transformation of the central cortex layers.

Cerebellar biopsy specimens were obtained at the time of cerebellar electrode installation in three epileptic patients. Cerebellar autopsy specimens also were examined from four epileptic patients and from five patients without epilepsy or neurologic disease. All specimens from seizure patients showed isomorphic gliosis of the cerebellar cortices. Significantly lower Purkinje cell densities were found in epileptic patients as compared with nonepileptic control patients. Our two epileptic patients showing marked Purkinje cell loss before cerebellar stimualtaion appeared to have better seizure control during stimulation than the patient who had only mild reduction in Purkinje cell density. These data suggest that augmentation of Purkinje cell inhibitory discharges in not the dominant mechanism for seizure suppression during cerebellar stimulation. Comparison of cerebellar specimens obtained during electrode installation with those obtained later during electrode revisions may have been prognostic significance.

The present series of cytoarchitectural plates is intended as a guide to the topographical relationships of the various thalamic nuclei to the commissuralmidline system. Although reproduced at relatively low power, some idea of the cytoarchitecture of the individual nuclei may be gained by careful inspection of the plates with the aid of a hand magnifier.

BECAUSE of its accessibility and the myriad responses induced by its stimulation, the cerebral cortex has intrigued many investigators since Fritsch and Hitzig 1 demonstrated its electrical excitability, in 1870. Spencer's 2 careful work, published in 1894, showed that autonomic, as well as somatic, functions were represented at the cortical level. Since the work of these pioneers much has been added to our knowledge, and this knowledge has increasingly been applied to clinical problems. The present paper is a summary of the results of a series of experiments on dogs, presented with the hope that it may serve as a guide to a better understanding of the mechanism of action of the human cerebral cortex in relation to autonomic functions. The term "feeding pattern" is intended to imply the actions of the most rostral part of the digestive tract during the ingestion of food. Specifically, our observations dealt with tongue

A patient, suffering from syringomyelia for 34 years and syringobulbia for 27 years, has been under our care for the past 10 years. The symptoms and neurological signs were typical, both developed or rapidly became worse after a minor injury. On three occasions the patient was almost completely disable because of sensory and motor dysfunctions; and, without exceptions, his misery was relieved by surgical drainage of the syrinx.

The following 54 cases are presented as montages of drawings including every 100th section through the hemisphere and every 40th section through the thalamus. The nomenclature and methods have been presented and discussed in Chapters 1 and 2. Using the abbreviations of this nomenclature, a summary of the areas of destruction and degeneration is presented at the start of each anatomical description. The conventions used on the drawings to indicate gliosis, neuron change, and demyelination are shown in Fig. 98. Black indicates total destruction of tissue.

The variations of the gross diencephalic and midbrain structures have been prepared using 25 hemispheres for each plane according to the methods given in detail in Chapter 2, Part III of Volume I.

THE PRESENT studies were made on a group of 50 patients studied in collaboration with the Branch of Endocrinology of the National Cancer Institute over a period of approximately two years. Nearly all of the patients were undertaken for the palliation of metastatic breast carcinoma. They were accepted only after oophorectomy in the premenopausal women who had reached their maximum benefit from palliative x-rays and endocrine therapy. In addition, a number of patients had had chemotherapy for their metastatic disease. It became evident rather early in the series that a beneficial response from oophorectomy or endocrine therapy was a rather uncertain indicator of the outcome of the pituitary ablation. Although many patients who had previously responded favorably to the treatment also responded favorably to pituitary ablation, others did not; and, it was soon found that certain patients who had not responded favorably before would respond with remission to pituitary ablation.