After-treatment.-The shock resulting from the operation must be combated by appropriate measures, care being taken, however, not to employ alcohol. The patient must be kept perfectly quiet in a darkened room, and must not be disturbed by noises or by the visits of friends. Restlessness must be met by injections of morphine or heroin. The dressings should be changed and any packing or drainage tube removed after two or three days. As soon as possible the patient should be propped up in bed with pillows, so as to diminish the congestion of the brain and hinder the escape of cerebro-spinal fluid. Confinement to bed and absolute quiescence will be required for three or four weeks. The bowels must be kept regularly opened and light diet given.

Palliative Operations.-When it is impossible to locate the tumour or

when circumstances render it inadvisable to attempt its removal, relief of the symptoms may be obtained by means of the so-called 'decompression' operations. The object of this operation is to lessen the general intra-cranial tension by the removal of a large portion of the skull. The temporal region is the one generally selected, but in some cases the occipital region may be preferred. These regions are the most suitable, because the thick muscles and dense fascia serve to restrain the result

ing hernia cerebri, while at the same time a sufficient amount of bone can be removed to relieve the intra-cranial pressure efficiently. By operating in these areas also, the functions of the brain are least liable to be affected. The operation should be performed on the same side as the tumour when this is in the cerebrum, and, if necessary, it may be repeated on the opposite side. When operating on the cerebellar region, it is usual to remove the bone on both sides.

Cushing's Temporal operation.-A large flap is marked out proportionate to the amount of bone to be removed (see Fig. 193). The incision involves the skin and subcutaneous tissues only, and the vessels entering the base of the fiap must not be divided. The temporal fascia is then divided in the line of the muscle fibres, and these are separated down to the bone throughout their whole extent. The muscle is raised from the bone by a periosteal detacher, and the

The temporal fascia detached FIG. 194.-CUSHING'S TEMPORAL DECOMPRESSION. and turned down. In Cushing's original operation the fascia was merely incised vertically, but this does not give enough room. When the fascia is detached, as shown above, very good retraction of the muscle fibres can be obtained.

FIG. 195.-CUSHING'S TEMPORAL DECOMPRESSION. The decompression effected. The fibres of the temporal muscle have been pulled apart, the skull opened as widely as possible, and the dura is about to be incised. In these cases the dura should be cut away over an area equal to the opening in the bone.

fibres held aside by retractors. A three-quarter or one inch trephine is applied, and after the circle of bone has been removed, the dura mater is separated all round the opening, which is enlarged by suitable forceps in all directions until enough bone has been taken away. (see Fig. 195). An extensive incision is then made in the dura mater, any bleeding vessels being ligatured or under-run on its outer aspect. The muscle and fascia are sutured in position, and the skin flap is sewn up (see Fig. 196). A thick mass of dressing is firmly bandaged on.

FIG. 196.-CUSHING'S TEMPORAL DECOMPRESSION. Uniting the soft parts over the herniated brain. The fibres of the temporal muscle are united, and then the temporal fascia; finally, the skin is sutured accurately.

The Occipital operation. In this region the muscles and skin flap are turned down together, a curved incision being made along the superior curved line of the occipital bone, extending from the posterior border of one mastoid process to a corresponding point on the other side. The occipital bone is trephined on each side of the middle line; in doing this the positions of the superior longitudinal, lateral, and inferior longitudinal sinuses, must be borne in mind. The portion of bone over the latter sinus may be removed by a Gigli's saw, after careful separation of the sinus from the bone by means of the special introducer kept close to the bone (see Figs 197 and 198). The subsequent steps are the same as in the temporal operation. This region is

FIG. 197.-UCCIPITAL DECOMPRESSION. Exposure of the lobes of the cerebellum. This is also the operation for removal of a cerebellar tumour. Gigli's saw is seen in position to remove the bone between the lateral openings. The introducer and guard shown in Fig. 191 are most valuable in this connection.

longitudinal sinus removed. This has been done by Gigli's saw. The inferior longitudinal sinus has been ligatured in two places and the intervening portion removed.

very vascular, and great pains must be taken to limit the loss of blood by the means described on p. 430.

Results. Some patients are greatly benefited by these palliative operations and life is rendered much more tolerable; on the other hand, a good many cases do not improve.

LUMBAR PUNCTURE IN INJURIES AND DISEASES OF THE CENTRAL NERVOUS SYSTEM AND THE MENINGES.'

BY DR. W. D'ESTE EMERY,

In cases of injuries to the head or spine, in cases of cerebral disease, and especially in persons found unconscious, examination of the cerebrospinal fluid may afford information of the utmost value. The operation is simple and easy, and the examination of the fluid does not, in many cases, require much special knowledge.

The only instrument required is a long and sharp needle. The needle should be at least three inches long, and not too fine, otherwise it may be

broken in the tissues by spasmodic contraction of the muscles. An antitoxin needle will serve, if nothing better is at hand. The author's special needle (see Fig 199) is more convenient, especially if cultures have to be made. It is sterilised by dry heat in a test-tube plugged with cotton-wool.

The operation is best conducted with the patient in a sitting position, with his head bent well forward and his back arched. As this is often impracticable, the patient may be placed on his side with his back well. curved forward. In either position, the laminæ of the lumbar vertebræ are separated as widely as possible, and the introduction of the needle. is greatly facilitated. The point at which the puncture is made is slightly to one side of the middle line, in the interspace between the second and third or the third and fourth lumbar vertebræ, The guide to these points is a line drawn between the highest points of the iliac crests, which crosses the spinous process of the fourth lumbar vertebra. The direction of the puncture is forwards, with a slight

For further details upon this subject the reader should consult a special manual-such as that of Dr. Emery, Clinical Bacteriology and Hæmatology (Lewis, London).