. Some points in the surgery of the brain and its membranes . s of the neck, which are subsequentlysutured in layers. Gushing, in this paper, relates cases in which Naturecarried out the decompressive operation in early life by separation of the cranialsutures. There is a curious reluctance on the part of many surgeons to leave bonedefects in the skull. Emphasis must be laid on the fact that in cases of braintumour the defect is desirable. Owing to the inelasticity of the dura the removal ofbone alone does not answer as a palliative measure. The hernia should be establishedover as silent an ar
. Some points in the surgery of the brain and its membranes . s of the neck, which are subsequentlysutured in layers. Gushing, in this paper, relates cases in which Naturecarried out the decompressive operation in early life by separation of the cranialsutures. There is a curious reluctance on the part of many surgeons to leave bonedefects in the skull. Emphasis must be laid on the fact that in cases of braintumour the defect is desirable. Owing to the inelasticity of the dura the removal ofbone alone does not answer as a palliative measure. The hernia should be establishedover as silent an area of the cortex as possible. There is no doubt in my mindthat the dura must be reflected or removed in decompressive operations. Theremoval of even a large area of bone alters very little the volume of the intraduralspace. In an experiment performed with Prof. Sherrington many years ago, it wasfound (in the case of a recently-killed large dog) that only ccm. of fluid enteredthe dural cavity in consequence of the removal of half the vault of the Fig. 77.—Exposure of cerebellum (R. hemisphere) by the usual method.(From a drawing of an operation by the author.) The opening is made behind the vertical and below the horizontal parts of thesigmoid sinus. Gontrast with Harvey Cushings intermuscular method. OF TUMOUR OF THE BRAIN 173 Symptoms and Diagnosis The problem presented to the surgeon whenasked to see a case of suspected cerebral tumouris three-fold. 1. Is there an intra-cranial tumour ? 2. If so, where is it ? 3. What is its nature ? To the first question an answer can often withconfidence be given, to the second much lessfrequently, and to the third rarely. In otherwords, we may usually be sure that a tumour ispresent, but its exact localisation often presentsa perplexing, and possibly at the present timeinsolvable problem. The diagnosis dependsmainly upon a correct interpretation of thesymptoms presented ; radiography, lumbarpuncture, and percussion and auscu
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