A patient (B.J.) is reported who developed severe memory impairment following a penetrating brain injury caused by a snooker cue which entered through his left nostril into the basal regions of the brain. Initially, his memory disorder had the clinical features of a dense amnesic syndrome, with both anterograde and retrograde amnesia, but B.J. subsequently showed significant recovery of memory function. Formal memory testing was carried out 21 months after injury. This demonstrated marked verbal memory impairment, as severe as that seen in patients with the amnesic syndrome. On nonverbal memory tests, his impairment was relatively mild and patchy. His retrograde amnesia had regressed mainly to affect a 6 month period before the injury. On other cognitive tasks, he performed at an average or above average level, and there was no neuropsychological evidence of frontal lobe dysfunction. Neuroradiological investigations at various stages after his injury failed to demonstrate a lesion in any of the thalamic nuclei. Magnetic resonance imaging showed a lesion in the hypothalamus in the region of the mamillary bodies. Our study demonstrates that marked, relatively focal, memory disorder after diencephalic injury can occur without direct pathology to the body of the thalamus. It also indicates that structures in or adjacent to the hypothalamus, such as the mamillary bodies, may play a more important role in human memory functioning than has hitherto been considered.

SUMMARYThe management of 93 patients with craniocerebral gunshot wounds is reviewed. The contrast between the injuries of urban guerilla warfare, conventional warfare and civilian life is outlined. Emphasis is placed on the need for early and adequate transfusion and for immediate airway control to limit cerebral oedema. Principles of wound surgery evolved in other conflicts were followed and developed.CEREBRAL gunshot wounds differ from other types of head injury. The initial damage is often focal; even when both cerebral hemispheres are affected the level of consciousness is often surprisingly light, but spreading cerebral oedema, if unchecked, leads rapidly to severe generalized brain damage.When a bullet strikes the body the effect depends partly on the kinetic energy of the bullet and partly on its size and shape. As kinetic energy is a function of the mass of the bullet and the square of its velocity ( E = +mu2), it follows that even a small high velocity bullet will carry much more energy than a larger one of low velocity. A high velocity bullet travels faster than the speed of sound

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Doubt remains as to the safest surgical approach to the prolapsed thoracic intervertebral disc. Laminectomy, lateral rhachotomy and the transthoracic approach all have their protagonists. Twenty-two patients from the National Hospital for Nervous Diseases, Queen Square, and Atkinson Morley's Hospital have been reviewed. Their clinical presentation is discussed and the ancillary aids to diagnosis assessed. The diagnostic value of disc space calcification is stressed, and the use of air myelography as an adjunct to positive contrast myelography is noted. Fifteen patients were subjected to laminectomy, and seven to lateral rhachotomy. Each group contained patients with a wide range of neurological deficit. Six of the patients who underwent laminectomy were improved, two were unchanged, six deteriorated and one died. Of the patients who had lateral rhachotomy, six were improved, one was unchanged and none deteriorated. The conclusion is drawn that lateral rhachotomy is a safer procedure.

Watchful waiting is one of the options available in the management of acoustic neuromas and this article deals with 13 patients who were so managed. Non-operative management was advised because of age, poor general health, small size of tumour, only hearing ear, or in patients unwilling to undergo surgery for various reasons. This group was followed up at 6-12-monthly intervals and the follow-up period ranged from 1 to 18 years (mean 5.3 years). Ten patients had small tumours and only in 2 of these was increase in tumour size demonstrated on follow-up CT scan. In one this increase was later followed by regression. Two patients required partial removal of tumour because of increasing symptoms after 3 and 7 years of follow-up; one of them died on the twelfth post-operative day. There appears to be a small group of patients for whom delay is worth while rather than to subject all patients with acoustic neuroma to surgery from which full recovery cannot be guaranteed.

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Intrathecal baclofen abolishes spasticity in many patients with neurological diseases but there are few studies on its long-term effectiveness. Since 1986 a manually operated subcutaneous pump has been used to deliver baclofen intrathecally in 21 patients with a follow up of at least one year. Most patients had multiple sclerosis and all were wheelchair-bound. Sixteen patients had a complete and sustained benefit. In four other patients the treatment was effective in the short term but not in the long term. In the remaining patient the pump never worked. Complications included meningitis, pump failure, erosion through the skin, and baclofen overdose. Nevertheless, only three patients have asked to discontinue the treatment. We conclude that intrathecal baclofen, delivered by a manually operated implanted pump, is an effective treatment for severe spasticity in most patients. drugs by mouth at the maximum tolerated doses; (b) leg spasticity or spasms which interfered with everyday life as judged either by the patient or their carer; (c) a good response of the spasticity or spasms to an intrathecal bolus of baclofen; and (di) informed consent of the patient and family. OUTCOME MEASURES Hypertonia, spasms, and the improvement in quality of life as judged by the patient and carers were used as the three main measures of outcome. Tone was measured using the Ashworth scale.3 This is an ordinal scale which grades tone in the muscle between 1 (normal) and 5 (where the limb is fixed). Care was taken to exclude fixed contractures due to muscle shortening. Hip flexion, extension, and abduction, and knee flexion and extension were tested in all patients. The three worst movements from each leg were summed to give the patient's spasticity score. Spasms were scored for each leg: 0 for absent, 1 for movement-induced, 2 for touch-induced, and 3 for spontaneous. The sum of these scores gave the patient's spasm score. We determined the Barthel index and asked patients and carers specific questions about sitting, bathing, toileting, and dressing as we found this more sensitive than complex quality of life scales in measuring ease of care-giving. INTRATHECAL BACLOFEN INJECTIONVarious strengths of baclofen injection ranging from 50 to 3000,ug/ml were prepared in batches by the central pharmaceutical production unit, Royal Victoria Hospital, using baclofen powder obtained from either CibaGeigy or Bufa BV. Where patients required different strengths from those available these were prepared aseptically in the pharmacy department, Royal Victoria Hospital by diluting a more concentrated injection. Most patients were started with an injection of 50 ,ug given at lumbar puncture. Tone and spasms were assessed at three hours and, if the spasticity score was not reduced to between six and 12 or spasms were not completely abolished, the procedure was repeated at intervals of two days using increasing doses of baclofen up to a maximum dose of 300 ,ug. Most patients responded to 200 ,ug or less. The pump delivers a bolus of 0 1 ml when ...