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Fig. 1. — First stage of plastic opera- tion for closure of an elliptical loss of tissue in the scalp, showing line of for detachment of flap. the fungus is fairly recent, rapid removal of cerebro- spinal fluid may allow infection to spread. The wound should always be exposed for inspec- tion when lumbar puncture is done, because this may cause the herniated brain to sink back to a considerable depth and protective ad- hesions may be torn. If lumbar puncture fails to alleviate the condi- tion, a contralater- al decompression operation may be tried. Spirit dress- ing is usually em- ployed for such cases. Picric acid, 0.5 to one per cent., or some astringent preparation may, with benefit, be added when discharge is free. The free application of "bipp" has been found of great value in many cases. Generic Cialis Tadalafil 2.5mg In most cases of hernia cerebri it will be found that posture has a marked effect, the protrusion being lessened when the patient is propped up in the Fowler position. This position should be adopted Generic Cialis Tadalafil 2.5mg immediately after operation. A smart in- testinal purge is I I T I ?^, \ 1 ^^^'^ sometimes ef- ^ ^ •( ' \ y ' fective. It is not advisable to make lumbar ptmcture in the early stages after a wound of the brain has been caused, unless the dura is intact, or until the exact local conditions have been revealed by operation. I Closure of the scalp. — In the great majority of cases the elliptical wounds resulting from excision can be closed, owing to the mobility of the scalp, if all layer sutures are used v^^ith superficial sutures between. It is well to work from each end in tying the sutures. In cases where complete closure can- not be obtained by this method, one must not hesi- tate to use plastic means, to which the scalp is par- / Generic Cialis Tadalafil 2.5mg ticularly adaptable, t A successful and i widely used method V is by extension of the original incision to form a large U or S flap. The ends of the wounds may be sutured to Fig. 2. — Operation concluded. "\ ) ._ __ I'lG. 3. — Diagram of plastic operation J ~"i , r for triangular defect duce Generic Cialis Tadalafil 2.5mg the amount of plastic necessary (Fig. i). An S incision is Generic Cialis Tadalafil 2.5mg made as indicated by the dotted Generic Cialis Tadalafil 2.5mg line. The end Generic Cialis Tadalafil 2.5mg A should extend well beyond a line drawn at right angles to the main axis of, and through the end of, the raw area. The scalp is undermined completely to any desired extent. This is easily done by thrusting a curved blunt 460 MEDICINE AND SURGERY IN THE ARMY AND NAVY. [New Yo»k :dical Joubna pointed scissors, concavity toward the skull, be- tween the aponeurosis and pericranium, opening the blades and withdrawing. Here and there it may be necessary to cut resistant strands Generic Cialis Tadalafil 2.5mg of tissue. Su- ture at a-a' to see how the flap comes up. Sutures at the base of the tiaj) should be inserted obliquely as at b-b', c-c': when tied they help to remove ten- sion. When fully sutured there should be little tension; if there is much the scalp should be scari- fied ■ repeatedly between the sutures, sufficiently to draw blood. The line of sutures lies frequently completely to one side of the wound in the dura. Thus this method has an advantage over that of turning down a flap, and is no more elaborate. For a triangular defect, proceed as shown in Fig- 3- The operation necessary in the majority of head injuries is a comparatively simple one. If preceded by infiltration of the scalp witli local anesthetic and adrenalin, hemorrhage and shock are obviated to a very great extent and the operation made even more simple. The dangerous hemorrhage which may occur from large flap incisions is entirely prevented by this infiltration of the incision area with adrena-