BRAIN ABSCESS

INTRODUCTION:-

• A brain abscess is a collection of pus enclosed in the brain tissue, caused by a

bacterial or fungal infection.

• Brain abscess or (cerebral abscess) is an abscess caused by inflammation and

collection of infected (dental abscess, infection of paranasal sinuses, infection of
the mastoid air cells of the temporal bone, epidural abscess ) or remote (lung,
heart, kidney etc.) infectious sources within the brain tissue.

• A brain abscess is pus filled swelling in the brain it usually occurrence when
bacteria or fungi enter the brain tissue after an infection or severe head injury.

• A brain abscess is a collection of pus that develop it response to an infection or

tune it remains a serious and potential life threatening condition.

DEFINITION:-
“ACCORDING TO ROSS &WILSON”

Brain abscess is defined as purulence and inflammation in one or more localized

regions within the brain parenchyma.

“ACCORDING TO JAVED ANSARI”

Brain abscess is a focal infection (pus collection) of the brain parenchyma case
bacteria fungai or parasites.
 “ACCORDING TO ENCYCLOPEDIA”

A focal intracranial infection that is instated as an area of cerebrates and evolves

in to a collection of pus surrounded by a vascularised capsule.

“ACCORDING TO MEDICAL DICTIONARY”

Brain abscess is a challenge for the neurosurgeon because it is needed good

clinical pharmacological and surgical skill for providing good clinical outcome
and prognosis to brain abscess patient considered infrequent brain infection.

ANATOMY AND PHYSIOLOGY

Brain is the large organ waiting around 1.4 kg in adult various part of
brain include
• Cerebrum
• Thalamus
• Hypothalamus
• Midbrain
• Pons
• Medulla oblongata
• Cerebellum
CEREBRUM:- cerebrum is the largest part of the brain and it
occupies the anterior and middle cranial fossa. Cerebrum is divided by
deep cleft, longitudinal cerebral fissure, into right and left centre brain
hemisphere. Each containing one of the lateral ventricles. Deep within
the brain, the hemisphere are connected by a mass of matter called
corpus callosum. The flax cerebri is formed by Dura meter.

THERE ARE FOUR LOBES WHICH ARE PRESENT IN

THE CEREBRUM

• Frontal lobe
• Parietal lobe
• Temporal lobe
• Occipital lobe
THALAMUS:- the thalamus consists of two mass of grey and white
matter and they are situated within the cerebral area of the brain.
Thalamus is present in just below the corpus callosum, one on each side
of the 3rd ventricles.

HYPOTHALAMUS:- The hypothalamus is small but important is

structure. Hypothalamus consist of number of nuclei. It is situated below
and in front of the thalamus, immediately above the pituitary gland. The
hypothalamus is linked to the posterior lobe of pituitary gland by nerve
fibres.

MIDBRAIN:- The midbrain is the area of brain situated around the

cerebral aqueduct. Between the cerebrum above and the pons below.
Midbrain consist of nuclei and nerve fibres, which connect the cerebrum
with lower part of brain and with the spinal cord. The nuclei act as relay
station for the ascending and descending nerve fibres.

PONS:- The pons is situated in the front of cerebellum, below the

midbrains and above the medulla oblongata. It consists mainly nerve
fibres dad form a bridge between the two hemispheres of the cerebellum,
end of fiber spacing between the higher level of brain and the spinal
cord.

MEDULLA OBLONGATA:- the medulla oblongata or simply the

medulla is the most interior region of the brain steam. Each weight is
about 2.5 centimetres long and lies just within the cranium above the
foramen magnum. Some cells constitute relay for sensory nerve passing
from spinal cord to cerebrum.

CEREBELLUM:- The cerebellum is situated behind the pons and

immediately below the posterior portion of cerebrum. It occupy the
posterior cranial fossa. Cerebellum is ovoid in shape and has two
hemisphere, separated by narrow median strip called vermis , grey
matter form the surface of the cerebellum, and the white matter lies
deeply.
PHYSIOLOGY OF BRAIN :-
• Brain coordinate activities of the body so that mechanism and hormonal
reaction of the body work together.
• Brain receive information end carry nerve impulses from all the
sensory organs of the body.
• Brain correlate the warriors is to millers from different sense organs
and produce appropriate response.
• Brain store information, show that the behaviour of human beings can
be modified according to the past experience.

INCIDENCE:-
• The incidence rate 1.3/100.000 person tear 1.9 in makes and 0.6 in female.
• Incidence of brain abscess is approximately 8%
• Brain abscess has decresed in the united state thought the 20 central a single
center.
• Children incidence and prevalence 0.2 per 100.000 tear brain abscess.

STAGES OF BRAIN ABSCESS:-

STAGE 1:- Early celebrities (Day 1 to 3)

➢ Prevascular infiltration of inflammation cells.

➢ Central core of copulative neurosis
➢ Marked edema surrounds the lesions.
STAGE 2:- Late celebrities (day 4 to 9)
➢ Pus formation ( necrotic center)
➢ Microphages & fibroblasts
➢ Thin capsule (fibroblast & reticular fibers)
➢ Marked edema around the lesions.
 STAGE 3:- Early capsule formation (day 10 to 13)

➢ Capsule formation
➢ Ring enhancing capsule (imaging)

STAGE 4:- Late capsule formation (14 days)

➢ Well formed necrotic center

➢ Dense peripheral collage nous capsule
➢ No cerebral edema

CAUSES AND RISK FACTOR:-

1. Meningitis
2. Head injury
3. Congenital heart disease
4. HIV or AIDS
5. Immunosuppressant drug
6. Chronic sinus or middle ear infection
7. Blood borne infection
8. Fungai bacterial infection

1.) MENINGITIS:- Meningitis is an inflammation of the meninges, the

meninges are the three membranes that cover the brain and spinal cord.
➢ The brain and spinal cord are compeletly surrounded by three layers of
tissue, the meninges.
• Dura mater
• Arachnoid mater
• Pia mater
➢ Meningitis can occur when fluid surrounding meninges become infected.
➢ The most common causes of meningitis are viral and bacterial infection.
2.) HEAD INJURY:- A head injury any short of injury four brain skull or
scalp this can range from a mild bump or bruise.
➢ To a traumatic brain injury common head injury includeds concussions.
➢ Head injury may be either closer or open a close head injury is and injury
that dosesn’t break toy skull on open.
➢ Head injury one in which something break your scalp and skull and enter
your brain.

3.) CONGENITAL HEART DISEASE:- Congenital heart disease is a

heart abnormality present at birth the problems can affect.
➢ There are numerous type of congenital heart defect they can range from
simple condition causes to complex problem that causes severe life
imitating symptoms.

4.) HIV OR AIDS:- HIV Aids is a virus that damage the immune system her
the body fight of infection untreated HIV infects and kill.
➢ CD4 cell which are a type of immune cell t cell over time HIV kill more
CD4 cell.
➢ The body is more likely is get various types of infection and cancer.

5.) IMMUNOSUPPRESSANT DRUG:- Immunosuppressant drug are

used to treat autoimmune disease the immune system attack the body own
tissue because immunosuppressant drug weaken the immune system.

6.) CHRONIC SINUS OR MIDDLE EAR INFECTION:- Chronic

sinus sometime bacteria or allergen can cause to much mucus to from which
blokes the opening of your sinuses sinus cavity leading bacterial or viral
infection most sinus infection are viral infection.
 7.) BLOOD BORNE INFECTION:- The blood stream carries blood borne
infection from another part of body this accounts for between 15 and 30
present of cases.
➢ Blood brain barrier infection entering the brain but barrier and infect the
brain.

8.) FUNGAI BACTERIA INFECTION:- Most common causes of brain

abscess also known as a cerebral abscess is an infection infects a part of the
body causing swelling infected brain cell white blood cell live and dead fungai
bacteria all accumulate in a brain abscess.

ETIOLOGY:-
1. ACQUIRED
2. CONGENITAL
1.ACQUIRED:-
i. Brain tumor
ii. Meningitis
iii. Head injury
iv. Fungai bacteria infection

I. BRAIN TUMOR:- A brain tumor is a localized intracranial lesion which

occupies space within the skull and may cause a rise in intracranial pressure.
➢ A brain tumor is a collection or mass of abnormal cells in brain.
➢ A cancerous or non-cancerous mass or growth of abnormal cells in the
brain.
II. MENINGITIS:- Meningitis is an inflammation of the meningitis, the
meninges are the three membranes that cover the brain and spinal cord.
• Dura mater
• Arachnoid mater
• Pia mater
➢ Meningitis can occur when fluid surrounding meninges become causes of
meningitis are viral and bacterial infection.

III. HEAD INJURY:- A head injury any short of injury four brain skull or
scalp this can range from a mild bump or bruise.
➢ To a traumatic brain injury common head injury includeds concussions.
➢ Head injury may be either closer or open a close head injury is and injury
that dosesn’t break toy skull on open.
➢ Head injury one in which something break your scalp and skull and enter
your brain.

IV. FUNGAI BACTERIA INFECTION:- Most common causes of brain

abscess also known as a cerebral abscess is an infection infects a part of the
body causing swelling infected brain cell white blood cell live and dead
fungai bacteria all accumulate in a brain abscess.

2. CONGENITAL:-
i. Congenital Heart Disease
ii. Meningocel
iii. Meningomyocel
i. CONGENITAL HEART DISEASE:- People with cyanotic congenital
heart disease are at risk of develop brain abscess.
➢ This condition is serious and can lead to death because the abscess causes
abnormal brain function.
➢ Treatment includes antibiotic therapy to kill the bacteria that causes the
infection.

ii. MENINGOCELE:- A birth defect in which a developing baby’s spinal

cord fails to develop properly.
➢ It occurs when a developing baby’s spinal cord fails to develop or close
properly while in the womb.
➢ A protrusion of the meninges through a gap in the spine dur to a congenital
defect.

iii. MENINGOMYOCEL:- Meningomyocel is a neural tube defect in which

the bones of the spine do not completely form.
➢ This result in an incomplete spinal canal.
➢ The spinal cord and meninges protrude from the child’s back.
➢ This condition may affect as 1 out of every 4000 infants.
➢ Meningomyocel occurs due to failure of closure of the neural tube during the
third week of gestation.
➢ Abnormal differentiation of the embryonic neural tube.
 PATHOPHYSIOLOGY
Due to etiology factors

Infection by virus bacteria

Enter to the blood stream

Crosses blood brain barrier

Infection

Spreading of infection to the brain

Collection of infectious materials inside the tissue of brain

Increased intra cranial pressure

Brain abscess occurs

CLINICAL MANIFESTATION
1. Headache
2. Fever and chills
3. Change in mental status
4. Decreased sensation
5. Vomiting
6. Seizure
7. Muscle weakness
8. Coma
9. Vision change
10. Decreased speech
1.) HEADACHE:- Headache most common sign symptom of brain abscess
more than 75% of people of with brain abscess have a dull achy headache for
many people this is the only symptom the pain usually is limited to the side
of the brain.
2.) FEVER AND CHILLS:- A brain abscess from a collection of pus and
dead cell resulting especially when it occurs with fever and chills.
3.) CHANGE IN MENTAL STATUS:- In the part a brain abscess was
almost certainly fetal but tanks to progress in diagnosis and confusion
drossiness and lethargy irritability.
4.) DECREASED SENSATION:- A brain abscess from a collection of pus
and dead cell resulting from infection due to sensation decreased.
5.) VOMITING:- Brain abscess is in abscess caused by combination of
increase intracranial pressure due to space occupying lesion vomiting.
6.) SEIZURE:- A brain abscess is a focal supportive infection in the brain
parenchyma sing of amebic brain abscess including most commonly
meninges sign facial never motor paralysis and seizure.
7.) MUSCLE WEAKNESS:- Brain abscess including symptom diagnosis
and in mental state such as appealing very confused weakness or paralysis on
one site of the body.
8.) COMA:- A brain abscess is a serious medical condition characterized by
the collection of pus in the brain if there is to much intracranial pressure
patient can go into come.
9.) VISION CHANGE:- Brain abscess way almost certainly fetal but
changes in mental status occur as parcent of case of stiff near back or
shoulder blurred double vision.
10.) DECREASED SPEECH:- A Brain abscess was almost certainly fetal
but and treatment have significantly increased the change of one side of the
body speech problem.

DIANOSTIC EVALUATION:-
1. History taking
2. Neurological examination
3. Blood culture
4. Chest X-ray
5. Complete blood count
6. Head CT-Scan
7. Electroencephalogram
8. MRI of Head
9. Needle biopsy
1. HISTORY TAKING:- History taking For diagnosing of brain abscess
and any other type of disease it is necessary to collect data with patient.
2. NEUROLOGICAL EXAMINATION:- Neurological examination is
a evaluation of a person nerves system which the typical neurological
exam will also include general physical examination.
3. BLOOD CULTURE:- A blood test to check for high levels of white
blood cells, which can indicate an infection.
4. CHEST X-RAY:- Chest X-ray is an imaging test that user small amount
of radiation to produce picture of the organ tissue & bone.
5. COMPLETE BLOOD COUNT (CBC):- CBC count should be
obtain evaluation intracranial abscess are uncommon series CBS count
with differential and platelet count.
6. HEAD CT SCAN:- A brain abscess is a pus filled swelling in the brain
usually causes by infection or a severe head injury this involves using a
CT scan guide needle to site of the abscess.
7. ELECTROENCEPHALOGRAM:- A brain abscess is an infection in
the brain that is encapsulated a procedure the records the brain contagious
electrical activity.
8. MRI :- MRI brain abscess if csf is removed the swollen brain can shift
into small opening in the dure and skull.
➢ MRI early cerebritis is characterized as poorly defined hyperintensity
on T2-weighted images and as hypointensity on T1-weighted images.
9. NEEDLE BIOPSY:- A needle biopsy is usually performed to identify
the cause of the infection.
➢ Needle biopsy which involves taking a sample of pus for analysis.
 MANAGEMENT
1. Medical Management
2. Pharmacology Management
3. Surgical Management
4. Dietary Management
5. Nursing Management

1. MEDICAL MANAGEMENT:-
• Blood spectrum antibiotics.
• Measures to decrease intracranial pressure.
• Antifungal medication may also be prescribed if the infection is likely
caused by a fungus.
• Control ICP
• Administration appropriate antibiotics therapy corticosteroids may be used
to treat cerebral edema.
• Poor assess location brain steam.

2. PHARMACOLOGICAL MANAGEMENT:-
ANTIBIOTICS:-
➢ Ceftriaxone - I/V 3-4g/DAY
➢ Metronidalole - I/V 500mg TDS
➢ Amoxcillin - I/V 2g 4 hours ( middle ear source)
➢ Dexamethasone - I/V 4mg Q6hr for decreasing edema.
➢ Manitol - I/V 20% (0.5gm/kg) for decreasing ICP.
➢ Anti epileptics like phenytoin sodium.
3. SURGICAL MANAGEMENT
1. Needle Aspiration
2. Surgical Excision
3. Mastoidectomy Operation
1. NEEDLE ASPIRATION:- Aspiration bedside brain evaluation
surgical drug used palpated and opened with II blade and brain needle
ventricular need was advanced.

2.SURGICAL EXCISION:- Surgical excision once the mainstay of

therapy for brain abscess has been treatment and early diagnosis prompt
surgical removal of pus simultaneous.
3.MASTOIDECTOMY SURGERY:- A mastoidectomy is
surgery to remove cells in the hallow, air filled spaces in the skull behind
the ear within the mastoid bone.
➢ These cells are called mastoid air cells.

4. DIETARY MANAGEMENT
Total Kcal - 2500-3000 kcal

Protein - 120-150 kcal

CHO - 500-550 kcal

Fat - 30-35 kcal

 MENU PLANNING:-

TIME FOOD CHO PROTEIN FAT ENERGY

(KCAL)

BREAK Milk 1 cup 5.0 4.3 6.5 117

FAST Roti – 2 41.6 7.2 1.0 204
Curd 100g 3.0 3.1 4.0 60

MID Fresh fruit 33.0 20.0 0.9 23

MORNING
LUNCH Rice 100g 79.0 6.4 0.4 346
Vegitable 250g 60.6 22.9 1.3 350
Curd 1 cup 3.0 3.1 4.0 60
Dal 35g 20.6 8.7 0.2 123
EVENING Tea 52.4 0.7 10.8 53
TEA Biscuit3-4 73.9 11.0 0.9 348
Sprouted mong 50g 28.2 12.0 0.6 166

DINNER Veg soup 12.1 8.0 1.0 90

Chapati-2 41.6 7.2 1.0 204
Mix veg 1 katori 60.6 22.9 1.3 350

TOTAL 514.6 137.5 33.9 2495

 5. NURSING MANAGEMENT

PRE – OPERATIVE NURSING CARE

1. NURSING DIAGNOSIS:- Deficient knowledge related to disease

condition.
GOAL:- To improve knowledge about their disease condition.
INTERVENTION:-
• To assess the general condition.
• To give health education to the patient.
• To determine clients perception of disease.
• To give comfortable environment to the patient.
• Assess patient’s level of understanding.

2. NURSING DIAGNOSIS:- Fear anxiety related to surgical procedure.

GOAL:- To reduce anxiety of the patient.
INTERVENTION:-
• To Assess the general condition of patient.
• To monitar the vital sign.
• To give psychological support.
• To give comfortable environment to the patient.
3. NURSING DIAGNOSIS:- Acute pain related to disease condition.
GOAL:- To reduce the pain of patient.
INTERVENTION:-
• To Assess the general condition.
• To check the vital sign.
• To give proper position to the patient.
• To give medicine as prescribe by physician order.
4. NURSING DIAGNOSIS:- Hyperthermia related to disease condition.
GOAL:- To maintain body temperature of patient.
INTERVENTION:-
• To Assess the general condition of patient.
• Check the vital sign of patient.
• To give cold sponge to the patient.
• To give medicine according to doctor order.

POST OPERATIVE NURSING CARE

1. NURSING DIAGNOSIS:- Risk for infection due to broken of tissue.

GOAL:- To reduce the risk of tissue infection.
INTERVENTION:-
• Adhere to facility infection control sterilization and aseptic policies and
procedures.
• To Assess the general condition of patient.
• To give health education about personal hygiene.
• To give medicine according to doctor order.
• Review laboratory studies for possibility of systemic infectios.
2. NURSING DIAGNOSIS:- Risk for deficient fluid volume due to loss of
blood during surgery.
GOAL:- To reduce weakness and maintain fluid volume of patient..
INTERVENTION:-
• To Assess the general condition of patient.
• To monitor the output and input.
• To check the vital sign. Of patient.
• To give health education of the patient.
 • To give medicine according to doctor order.
• To give comfortable environment to the patient.

3. NURSING DIAGNOSIS:- Alter body temperature related to infection as

evidence by vital sign.
GOAL:- To maintain body temperature.
INTERVENTION:-
• To Assess the general condition of the patient.
• To monitor vital sign of the patient.
• To give cold sponge to patient.
• To give medicine according to doctor order.
• Cover skin areas outside of operative field.
• To give comfortable environment to the patient.
• To give health education of the patient.

4. NURSING DIAGNOSIS:- Loss of appetite related to surgery as evidence

by patients verbalization.
GOAL:- To increase appetite of patient.
INTERVENTION:-
• To Assess the general condition of the patient.
• To provide proper diet according to patient dietary requirement.
• To give health education about diet and disease.
• To give psychological support.
• To give medicine according to doctor order.
5. NURSING DIAGNOSIS:- Acute pain related to surgery as evidence by
patient verbalization.
GOAL:- To reduce pain of patient.
INTERVENTION:-
• To Assess the general condition of the patient.
• To Assess the level of pain.
• To give comfortable position to patient.
• To give medicine as prescribe by physician order.
• To check the vital sign of patient.

COMPLICATION
1. EARLY
2. LATE
1. EARLY:-
• Speech problem
• Poor orientation
• Unconsciousness
• Semiconscious
• Vision disturbance

i. SPEECH PROBLEM:- Speech problem change in mental state such as

confusion or irritability.
➢ Problem with nerve function such as muscle weakness slurred speech or
paralysis on one side of the body.
ii. POOR ORIENTATION:- Poor orientation is a poor mental focus, poor
responsiveness, slow thought process, coma..
➢ Neurological difficulties affect 50-65 percent of people with brain abscess.
iii. UNCONSCIOUSNESS:- Unconsciousness is when a person is unable
to respond to people and activities.
➢ A temporary loss of brain function typically resulting from a relatively mild
injury to the brain not necessarily associated with unconsciousness.

iv. SEMICONSCIOUS:- Semiconscious is also the complication of brain

abscess.
➢ It is situation which occur when tsvangirai was semiconscious on a blood
stained carpet after the attack.
➢ Semiconscious is the state of a very sick patient who is drifting in and out
of awareness.

v. VISION DISTURBANCE:- Vision disturbance is changes in vision

such as blurring ,graying of vision or double vision due to abscess putting
pressure on the optic nerve.
➢ Visual impairment, also known as vision impairment or vision loss and
decreased ability.

2. LATE:-
• Coma
• Brain death
• Death

i COMA:- Coma is a prolonged state of deep unconsciousness, caused

especially by severe injury or illness.
➢ A period of prolonged unconsciousness brought on by illness or injury.
➢ A coma, sometimes also called persistent vegetative state, is a profound or
deep state of unconsciousness.
➢ Damage to the brain from interruption of it’s blood supply.
➢ Traumatic head injury, stroke, brain tumor.
➢ A coma is a deep state of prolonged unconsciousness in which a person
cannot be awakened fails to respond normally to painful stimuli.

ii BRAIN DEATH:- Brain death also known as brain stem death.

➢ Brain death is defiend as a complete and irreversible cessation of brain

activity.
➢ Brain death is often confused with the state of vegetation.
➢ When a person on an artificial life support machine no longer has any brain
function.
➢ A person who’s brain dead is legally confirmed as dead.

iii DEATH:- Death is also complication of brain abscess.

➢ It occur in very severe cases.

➢ When a person on an artificial life support machine no longer has any brain
function.
➢ A person who’s brain dead is legally confirmed as dead.
➢ A person must be unconscious and fail to respond to outside stimulation.
➢ Brain death diagnosis requires presence of 3 conditions persistent coma,
absence of brainstem reflexes and lack of ability.
PREVENTION
Effective measure of primary prevention strategies for brain
abscess include:-
• Prophylaxis with antibiotics for patients undergoing extensive dental
procedure.
• Suitable treatment of sinusitis.

• Highly active antiretroviral therapy for patient with HIV infection.

• Reduce the risk of developing a brain abscess by getting treated for
infections or health problem that can cause them.

HEALTH EDUCATION
1.) PERSONAL HYGIENE:-
• To give the education that about persona; hygiene.
• To take daily bath.
• To be alert everywhere.
• To wear clean cloth.
• Brush the teeth twice a day.

2.) DIET:-
• To take high protein diet.
• To avoid spicy and oily food.
• To take fresh fruit and vegetables.
• Low saturated fat and cholesterol should be encourage diet.
3.) MEDICATION:-
• To give medicine according to doctor order.
• To check expirey date of medicine .
• Medicine should be taken at proper time.

4.) EXCERCISE:-
• To advice for passive exercise.
• To avoid heavy work.
• To provide medication therapy.

5.) FOLLOW UP CARE:-

• After recovery patient medicating schedule to the doctor to follow by
patient.
• Bring all the document during follow check up.
• Don’t come empty stomach.

SUMMARY:- At the end of my topic “BRAIN ABSCESS” I

have deal with the introduction, definition, anatomy and physiology,
incidence, stages of brain abscess, causes and risk factor, etiology,
pathophysiology, diagnostic evaluation, management, complication,
prevention of Brain Abscess.

CONCLUSION:- The clinical signs of brain abscess are unspecific,

many patients presented without clear signs of infection and diagnosis and
treatment were often delayed.
➢ Decreased GCS, presence of comorbidities and intraventricular rupture of
brain abscess were associated with poor outcome.
 BIBLIOGRAPHY

1. ANSARI JAVED:- A TEXT BOOK OF MEDICAL SURGICAL

NURSING-II; PUBLISHED BY; S. VIKAS & COMPANY
MEDICAL PUBLISHERS; PAGE NO.- 347-348.

2. WILSON & ROSS:- ANATOMY AND PHYSIOLOGY;3RD

EDITION; PUBLISHED BY; ELSEVIER LTD.; PAGE NO.
336-339.

3. SURESH SHARMA:- MANNUAL OF MEDICAL SURGICAL

NURSING 2ND EDITION; PUBLISHED BY;
WOLTERS; PAGE NO.- 300-302

4. B.VENKATESAN:- TEXTBOOK OF MEDICAL SURGICAL

NURSING-II; 3RD EDITION; EMMESS; PAGE NO.-
805-808.

5. SUDDARTH’S & BRUNNER:- “MEDICAL SUGICAL NURSING-II

PUBLISHED BY; WOLTERS; 12TH EDITION; PAGE

NO.- 510-515.