Cialis Online Prescription Uk | OVERNIGHT Delivery!

carious procedure. In practically all cases the area of operation can be covered in by healthy scalp, by simple suture or by a plastic operation such as de- scribed below. The use of the U flap of civil sur- gery is advisable in removing a foreign body through an unwounded area and in decompression opera- tions for hernia cerebri. The latter have rarely been attended with success. Depressed fracture. — Every case in which de- pressed fracture of the skull is suspected should be explored without undue delay, whether sepsis is present or not. Delay and waiting for surface wounds to clean too frequently lead to dangerous intracranial developments. If the edge of the wound is much inflamed and infiltrated, treatment with hypertonic saline applications or a paraffin paste usually makes it fit for excision in twenty-four to forty-eight hours. In most cases it is possible so to excise the wounds in both scalp and bone that an aseptic field of operation is left. If sepsis has al- ready penetrated to the depth of the brain, the sooner operation is done the better. The injury comes under one of the following varieties : I. Cases ivithout definite external signs of de- pressed fracture. — Because fracture with displace- ment of the inner table or some other subcranial lesion may be present, it is important that operation 45« MEDICINE AND SURGERY IN THE ARMY AND NAVY. [New Yo«k Medical Journal. should be carried out. When the entrance and exit wounds are separated so far by a bridge of scalp that the line joining them Cialis Online Prescription Uk traverses the bone, or if the jjatient has been stunned at the time of injury, the jjresumplion is that the bone has been damaged. Such wounds and the track between them, as well as single gaping wounds of the scalp, should be excised en masse, including the pericranium. In- jury, even mere bruising, of the periosteum usu- ally means that the bone has suffered. If focal loss of Cialis Online Prescription Uk function, even although evanescent, persistent headache, giddiness, or other more definite signs of cerebral compression are present, especially if optic neuritis coexists, trephining should be done, even in the absence of definite laceration of the perios- teum. If fracture of the outer table without depression is found, Cialis Online Prescription Uk or even if the bone is merely bruised, a small trephine opening in the external table only should be made and the inner Cialis Online Prescription Uk table examined. De- pressed fracture of the inner table may exist with- out any apparent injury to the external table or Cialis Online Prescription Uk any cerebral symptoms, and only the very best skiagrams will show such a fracture. Operation in such cases is practically without danger. ^. Fracture zvith depression but without injury to the dura mater. — The fractured and probably sejJtic bone is excised either by making a very small trephine opening outside the soiled area and com- pleting the removal with a skull cutting forceps, e. g., De Vilbis, just wide of the shattered bone, or by the nibbling method, using a properly devised small gouge forceps. It is better to work Cialis Online Prescription Uk with a small forceps and nibble the bone away in small pieces than to use a large powerful forceps which may cause extensive fissure fracture. The former trephining method is theoretically the better technic, but the latter is simpler, gives equally good results, and does not entail removal of so much bone. It is not necessary to trim the edge of the resultant opening in the bone. It seems likely that bone is thrown out more readily from an untrimmed mar- gin, so that the opening may become greatly re- duced in size. If the dura is apparently normal and the brain pulsates well, the operation can then be comjjleted by suture of the scalp with or Cialis Online Prescription Uk without drainage. If, however, the dura is muddy looking, if there is loss of pulsation and circum.'^cribed loss of elasticity, especially if focal symptoms have been present after the wounil was received, the dura should be opened. This is usually best done by a small crucial incision. Disintegrated brain and blood clot are squeezed out by the vis a tergo. If the jnilpcd material does not come out quite readily, it may be helped out by inserting a small artery for- ceps for a short distance and opening the blades so as to dilate the hole in the dura and underlying mem- branes. Only the useless matter will exude unless the intracranial pressure is high, in which case lumbar puncture is indicated. 5. Injury of dura ivithout foreign body or sepsis. — Fracture with injury to dura mater, when no for- eign body is present and the wound in the brain probably aseptic, occurs frequently. After excision, en masse as before, the scalp wound may Cialis Online Prescription Uk be en- larged in any desired direction in order to procure adequate access. The bone around the fracture is cleared. A trephine opening Cialis Online Prescription Uk is rarely required. The spicules are removed and the skull cut away care- fully with forceps to an extent varying with the injury to tiie dura. A clear margin of one third of an inch of uninjured dura should be exposed. Great care must be exercised to separate the dura from the bone while this is being done. Ragged edges of dura should be excised. Cialis Online Prescription Uk If a track exists in the brain, this should be carefully explored, by the finger if possible, and any collection of pulped brain tissue allowed to escape. Cialis Online Prescription Uk If thought advisable a piece of aponeurosis may be drawn across the opening Cialis Online Prescription Uk in the dura, and the operation completed by suturing the scalp wound. A drain of folded jaconet or small rubber tubing should reach from the opening in the dura through one end of the wound. It should be removed after twenty-four hours. If sepsis as- serts itself, the wound should be freely opened up at once. 4. Injury to the Cialis Online Prescription Uk dura complicated by a foreign body in the brain and by sepsis. — The position of