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Operations in the Neighbourhood of the Elbow-joint.— Amputation at elbow. The frequency and meaning of optic neuritis has already been alluded to, p. While headache may be as marked a feature in cerebral or cerebellar abscess as in meningitis, I am inclined to think that in the last of these it is more persistent ; in the later stages of abscess it is not uncommon for the headache to remit. The probable explanation of those cases in which if symptoms have been present for long periods, but in which deafcj has rapidly followed upon the sudden development of braa^ symptoms, is that quoted by Wharton from Flourens. In the remaimi 210 no attempt at removal was made, and only 88 recovered, 122 dying, further analysis shows that, amongst those cases classed as recoveries, dea ultimately took place in 10 at periods varying from three to ten years, and m manv of the patients suffered from such after-effects as vertigo, incapacity 1 physical exertion, loss of sight or hearing, epilepsy, and deteriorated nient powers. 209 The following is an interesting instance of successful operation for the removal of a bullet penetrating the brain. 52 a, 6, Track of bullet and situ of the trepbine-openings. (Fluhrer.) The patient,* aged nineteen, shot himself with a pistol held • very near to the centre of his forehead. The track of the ball through the brain was then examined by a straight Nelaton's probe,t and the *&,ms). If a diagonal line (/.e) is now drawn from the posterior superior to the anterior inferior angle of this space, the line will he over the fissure of Rolando. The upper end is situated 2.2 inches behind the bregma (vide infra). From the very end of the external orbital process, where this rises up to join the temporal crest draw a horizontal line of 2 \ inches, and from the extreme end of this draw a vertical line of a little over 1 inch. 2 1 9 under the frontal bone, but extends backwards under the anterior part of the parietal, the fissure of Rolando, which forms the pos- terior boundary of the frontal lobe, lying from I i to 2 inches be- hind the coronal suture.* Fig. The above view of the brain in situ shows the relations of the surface convo- lutions to the regions of the skull.

Barker thinks that free removal of bone with irrigation and drainage would save many a patient. As to symptoms of meningitis, I fear we have none reliable save involvement of the cranial nerves, and, when we get such evidence as squint, the case has gone beyond interference. Apoplexy is an occasional cause of death, , i is pressure of the foreign body on the venous trunks, inducir: ventricular effusion and consequent compression of the cranii nerves. The foreign boc was removed in 106 cases, 72 recovering, while only 34 died. This procedure was complicated by most profuse haemorrhage from a branch of the anterior cerebral artery, which was finally controlled by small compression-forceps left in situ 10 this arterial bleeding was added a considerable venous flow from the superior longitudinal sinus, which, like the artery, had been cut across by the bullet. Ander* and Makins in a paocr on " Cranio-cerebral Topography {Jou,«. There is then described on the surface of the head a four-sided figure bounded above and below by the lines for the longitudinal fissure and horizontal limb of the fissure of Sylvius respectively, and in front and behind by the two perpendicular fines. infra tit.) di- rections for finding the- fissure of Rolando.

id was (I) £«k,«.-A bram growth on the right ; * aiagn Ufi "p u* destruction of the -mainiug arm-centres in tke 'emo tumour.

, t Vip Patent of softening around was not great, S n l T« ^ « til accurately,^ the brain had under- gone ! The original growth was a glioma, ^pednnder the ^^t^^^^ t) R—p of { ll a Xly physiclogically and pathological, "Ite will well repay most careful perusal; only the chief points can be given here.

Under the above heading such bodies as bullets, knife-points, &c, are included. As to the fatality of wounds of the different portions of tt brain, 5 8 deaths took place out of 1 3 2 cases where the foreig: body entered through the frontal bone ; 5 8 wounds of the parietr showed 2 7 deaths and 3 1 recoveries. (After Eeid.) for cerebral tumour, used the following simple method of expos* the fissure of Rolando in its middle third :— J (1) A line was drawn between the frontal and occipital § tuberances. ' ^ this ^ ^ S3, ^gjitly altered, h M o Lt T Sf n Tw^! PO, Parieto-occipital fissure between the parietal and occipital lobes. (After Turner.) The occipitoparietal or larabdoidal suture, the posterior limit of she parietal bone, will be marked out by a line which starts from \ point 2f inches above the external occipital protuberance, and runs forwards and downwards to its termination, which will be ound on a level with the zygoma, ri inch behind the meatus As the occipital lobe is not limited to the upper portion of the occipital bone, but extends forwards under cover of the posterior )art of the parietal, the parieto-occipital fissure lies about f inch n tront of the apex of the lambdoid suture (Fig. As, however, there was a tender spot on the scalp 2 inches anterior to this, the first opening was made (with a trephine 1 inch in diameter) between the two.* The dura mater was normal ; after a crucial incision was made in it, the brain was thought to bulge abnormally, and to be rather more yellow than usual, otherwise it was healthy.

OPERATIVE INTERFERENCE IN THE CASE OP FOREIGN BODIES IN THE BRAIN. Tht observer found that bullets introduced into different portions | the upper parts of the hemispheres and the cerebellum gradual; penetrated the brain substance, ultimately reaching the basis crami the bullet tracks healing after them (Nancrede, from Wharton). About twelve hours afterwards, when seen by the surgeon, he was semi-conscious, aphasic, with complete loss of motion, without loss of sensation on the right side below the head. Ca Se UDder th bec ° ua ' ™ * 1 ana 2 /» , second temporo-spheuoidal tions. Between P ° mt S ' Pa SSing ratll6r ° bli( * uel y forwards, lies this 'eent S 2? E, Fissure of Eolando, separating the parietal from the frontal lobe. The outlines of the coronal, squamoso-parietal, and larabdoidal sutures are also seen. ™ th C av ^ge^ist7nce in eleven .skulls as »■ ^cas-Champiomuere inch behind the diagonal line, and about 1 4- inch from the median longitudinal line.

It remains for me to acknowledge very gratefully the encourage- ment given me by my reviewers, and a host of correspondents from all parts of the world. I most gladly take this opportunity of acknowledging my good fortune in being able to profit by the facile pencil and the culti- vated knowledge of my old dresser and friend Dr. Before closing the wound the centre of the thumb- area was removed by a free incision* Numerous vessels were out in h tl detail -, I ? Horsley had resolved to carry to p event rf ^ .° f there bein S »° obvious gross organic disease, in order Prevent, as far as possible, recurrence of the epilepsy. A * There had been no fits hand was not quite so good as before. The tumour was composed of dense fibrous dssue with two caseated foci, microscopical examination proving * ^ t X0«- « A^^8 7 )has alsoremoved, lj wlh a fa J result, a tubercular tumour from the nght lobe o TZ cerebellum, Death took place nineteen hours to V*e patient havino- only partially recovered consciousness. The operation was chronic tubercle was found m the viscera . The extreme bulging of the du Inter o;ave evidence of great intracranial pressure, the cortex ST^^^^t* below the If f riboc k a few honrs Ute, fj^Z^t The above case is especially mterestmg fro™ J Be gmann circular matter in the brain with . Time alone 1 tlstay favoar ffi^ of^ — , giving rise to tnberoalar me t^ to -The cation of operation here can bnt no one will operate on a gumma of the bi^iu^ t n f Horslev's paper, said that * Dr.

Coincident also with the formation of ^he herni came fresh symptoms, in the shape ^"^^^ partial anesthesia of one-half of the body. 229 due to the effects of simple pressure, and possibly to the subsequent secondary softening of the conducting fibres caused by it. A man, aged twenty, began, in Januaiy 1884, to have cx^amps in the left thumb and forefinger, these consisting of clonic oppo- sition of the above-named digits, and occurring about twice a day for three months.

The local inflamma- tion of the wound had opened out the parts, and separated the adhesions so as to allow the discharge to percolate into the cranial cavity, but not till three weeks after the operation. It being found that the hemorrhage could be checked by direct pressure, the cavity was packed with 5 p* cent iodoform gauze, not too tightly, as it was assumed that the released brain would contribute additional pressure, and the ends of the strips were allowed, for easy extraction, to protrude from the lower angle of the scalp wound ; the dura was partly united over the gauze by several loose sutures instead of being brought c Lely together, and the scalp wound closed with ca gut sutures a rubber frainage-tube being introduced under the skin up to the skull opening, aid over these sublimated and iodoform pea bags were secured with gauze bandage. Sd., 1888,) has published a most m erestmg case of fibroma, weighiug over three ounces, m ater, which he removed successfully m a patient aged werty seven The growth probably dated to an injury in childhoou ll caused epilepsy, aphasia, complete hemiplegia, neuralgia, deafness, and great impairment of vision J»« the eye" and ear symptoms, all the others had P--d "way slowness of speech and the epilepsy, and the last was m disease. 231 there is good reason to believe that the growths are primary and single (p. The following is one of the most interesting of Prof. The character of the fits was nearly always the same.

The meningitis was due to irritating matter from the interior of the wound flowing downwards between the layers of the arachnoid, and accumulating at the base of the brain. Inspection of the mass showed that the tumour had been entirely removed, and that its probable attachment had been towards the posterior border of the falx; the tumour was a spindle-celled sarcoma, weighing 5 i ounces, measuring 3 i ***** *7 *t™*f\ Wlde ' and being 8* inches at its greater circumference The falx was crowded over towards the left, and the tentorium depressed ; two bleeding points were observed, one being m the region of the straight sinus, although not free enough for that vein, and pro- bably belonging to the pedicle of the growth, while the other was apparently atrial. Then followed a series of remissions of the twitchings, until in August 1885 commenced a series of fits occurring once or twice a week until admission in December 1885.

This delay will, perhaps, be excused when it is remembered what time and trouble are needed for an attempt to bring a book like this up to date, and to make the needful alterations and additions. a Larg G Sarcoma ' causing Hemianopsia, from the Occipital Lobe IXS- • . By further removal of bone the mass to which the dura mater was adherent was completely exposed.

I was unprepared for the rapid sale of the first edition, and the book has consequently been out of print for twelve months. next drawing the finger gently but firmly towards the cranial opening, the tumour was torn nearly completely in two, and its of the V, , 3 ! On June 22, 1886, the seat of the lesion being determined by measurement, the 2 -inch trephine was applied, and on removing the dura mater a tumour came into view.

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THE OPERATIONS OF SURGERY the OPERATIONS OF SURGERY INTENDED ESPECIALLY FOR THE USE OF THOSE RECENTLY APPOINTED ON A HOSPITAL STAFF AND FOR THOSE PREPARING FOR THE HIGHER EXAMINATIONS BY W. Towards the upper part of the opening the brain offered resistance on palpation, lms sensation proceeded from the interior of the brain, in the direction of the paracentral lobule, a layer of brain tissue inter- vening between this more resistant structure and the finger An incision being made through the upper part of the ascending parietal towards this firm structure, about two drachms of grumous md escaped.