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the foreign body is ])reviously determined by x rays. At the operation, as in 3, the track through the brain matter can Online Cialis Pharmacy usually be explored by the index finger. It may be necessary to enlarge the wound in the dura slightly. The foreign body having been located, a suitable flat or slightly curved scoop is passed along the finger under the foreign body which is then pressed against the point of the finger, and all three are carefully and gently withdrawn. The greatest delicacy of touch is required during this procedure. The finger, in a flexible manner, must follow the previously formed track, and must not break through uninjured brain Online Cialis Pharmacy Online Cialis Pharmacy substance. Any stiff- ness of the finger must be avoided. Online Cialis Pharmacy The use of a forceps is apt to increase Online Cialis Pharmacy the damage to the brain. A foreign body or piece of bone may often be coaxed out by making very slight flexion movements with the distal phalanx of the examining finger. If the track will not admit the finger, the foreign body can usually be left with safety. A drain should be Online Cialis Pharmacy inserted in all cases, as already described. If defi- nite sepsis is present drains should be inserted in the track, leading straight out through the wound. In the worst cases the scalp wound should not be sutured till all danger has passed. The exploration for foreign bodies by the finger at the primary operation is justified by the follow- ing considerations: i, A track through brain sub- stance is already present ; 2, only very rarely is fur- ther injury to the brain caused by the procedure; 3, an abscess frequently develops if the foreign body is left in the brain ; 4, if the wounds are large, sepsis has almost certainly penetrated along with, or following, the foreign bodies, and, as has been said, the sooner they are dealt with the better. As al- ready indicated, foreign bodies imbedded in the brain, by their direct influence and by their inter- ference with the cerebral circulation, may produce symptoms of focal irritation and of compression or increased intracranial tension. If their removal does not immediately relieve these, and especially Online Cialis Pharmacy ff her- Online Cialis Pharmacy nia cerebri is threatened, lumbar puncture should be resorted to. If this fails to relieve the intra- cranial tension, subtemporal decompression may give relief, but has on the whole proved an unsatis Online Cialis Pharmacy factor)' operation under these septic conditions. March g. 1918.] GRAY: IV AK WOUNDS OF THE BRAIN. 459 5. Fracture with injury to one of the blood si- nuses. — Operation in such cases may be difficult on account of the alarming hemorrhage which may occur during exposure of the sinus. It should not, therefore, be undertaken by an inexperienced opera- tor. The size of the superficial wound of the scalp or skull gives no indication of the extent to which the sinus may Online Cialis Pharmacy be injured. The results of such opera- tions have been very favorable. Three of the pro- cedures recommended for control of Online Cialis Pharmacy such hemor- rhage have Online Cialis Pharmacy practically been given up, namely, lateral application of suture or forceps, plugging with gauze, and ligature. Plugging and ligature espe- cially must be avoided behind the entrance of the parietal lacunae or cerebral veins. It has been found that practically all cases which survive the imme- diate effects of the injury are amenable to treat- ment by the application, under light pressure, of a piece of aponeurosis cut from the edge of the scalp wound or from the fascia lata Online Cialis Pharmacy of the thigh. The procedure is known as the "postage stamp" opera- tion. After free and ra])id exposure of the hole in the sinus, hemorrhage therefrom being controlled by light gauze pressure, the "stamp" should be cut and spread on the palmar surface of the Online Cialis Pharmacy point of the operator's gloved index finger or on a small swab covered with batiste or rubber tissue. The perfora- tion is then blocked by a finger of the other hand. AH blood clot is carefully v/iped away, the con- trolling finger is removed and the "stamp" applied rapidly Online Cialis Pharmacy over the perforation. Fairly firm equable pressure is kept up for a few minutes, when the graft will have adhered to Online Cialis Pharmacy the wall of the sinus. If the tear is a large one. the "postage stamp" and swab may be bandaged in position for twenty min- utes or so while the operator does something else. A hole, measuring three fourths by one half inch, has been closed successfully in this way, and, judg- ing by the ease with which this was done, it should be possible to close even larger ones. The graft should always be covered by scalp at the end of the operation. In these cases it is practically always possible to suture the scalp wound completely, a small soft drain being inserted close to but not on to the graft, and withdrawn in a day or so. Lumbar puncture. — Lumbar puncture has fre- quently been found to give relief in cases of local circulatory disturbance after operation, evidenced, for example, by persistent headache, recurring focal muscular spasms, or slight hernia cerebri. The amount of cerebrospinal fluid withdrawn varies with the pressure of the fluid. It is rarely necessary to remove more than twenty-five c. c. or thereby. UsiJially the withdrawal of a much less quantity suffices. The process may be repeated several times if thought advisable. It ought to be resorted to before any marked signs occur. Certain cases of large fungus cerebri have been cured by this pro- cedure. If fungus is present, however, while it is to be regarded as a symptom of increased intra- cranial tension, it must be remembered that this is frequently due to the presence of foreign bodies or abscess in the brain or to more diffuse encephalitis or meningitis, and suitable remedies must be used for these conditions. If meningitis is present or if b' 1 A