1

states that cerebro-spinal fluid cannot flow from the ear in fractures of the middle fossa unless (1) the line of fracture crosses the internal meatus, (2) unless the prolongation of the membranes into the meatus is torn, (3) unless a communication exists between the internal ear and tympanum, and (4) unless the drum-membrane is torn. Profuse serous discharge may flow from the ear after an injury without fracture when the drum is ruptured, the fluid coming from the cells of the mastoid. It must be understood that fracture of the base may exist when there is no flow of blood or of serous fluid (when the drum is not lacerated). A fracture of the middle fossa is usually compound, made so, even when the drum is not ruptured, by the Eustachian tube. In fracture of the posterior fossa blood accumulates beneath the deep fascia and produces discoloration in the line of the posterior auricular artery (Battle's sign), the discoloration first appearing near the tip of the mastoid. Fractures of the base are apt to be associated with paralysis of cranial nerves. Optic neuritis often arises after the first week. Dr. Keen says that in fractures of the base the temperature is subnormal during the shock, rises to 100° or 101°, falls again to a little below normal, and remains normal or subnormal unless there be inflammation or sepsis.

Treatment. In treating a fracture of the base of the skull, collect any serous discharge and analyze it, and disinfect any cavity involved. In fractures of the middle fossa with ruptured drum, clean the ear mechanically, wash it out with hydrogen peroxide and with a stream of warm corrosivesublimate solution of a strength of 1: 2000 (turn the head toward the affected side, so that the mercurial solution will not run down the Eustachian tube), pack with iodoform gauze, and apply an antiseptic dressing. The naso-pharynx must be cleaned and insufflated with iodoform. In fracture 1 Applied Anatomy.

of the orbit the surgeon must disinfect, and if the fracture is punctured, the roof of the orbit must be trephined or be chiseled to permit of disinfection and drainage. In fractures of the middle and anterior fossæ the naso-pharynx must be cleaned. Wash out these cavities often with hot water, next with peroxide of hydrogen, and finally with boracic-acid solution. Insufflate the naso-pharynx with iodoform, and pack the nose with iodoform gauze (Keen, Dennis). In some cases drainage has been obtained from the anterior fossa by breaking down the cribriform plate and introducing a tube through the nostril (Allis), and from the middle fossa by trephining above and behind the external auditory meatus. In a very extensive fracture of the base, besides use of the methods set forth above, the entire head should be shaved and a plaster cap be applied. Cases of fracture of the base must be put into a quiet and darkened room and be kept upon a low diet, sleep being secured and the bowels and bladder being attended to.

Wounds of the brain are produced by violence and by foreign bodies (knives, bullets, etc.). Except when due to penetration of a fontanelle in a child or of a parietal foramen. in adults, wounds of the brain are accompanied by fracture of the skull. These wounds are very dangerous: foreign bodies (bone, hair, clothing, etc.) are often lodged in the brain, hemorrhage is usually severe, and sepsis is almost inevitable without proper treatment. These cases are very fatal, though some astonishing recoveries are on record.' The symptoms of brain-wounds may be slight and longdeferred or may be immediate and overwhelming; they depend upon the site and extent of the injury. Localizing symptoms may exist, and encephalitis with coma is apt to arise. Abscess not unusually follows. In treating wounds

1 See a most interesting and instructive paper by Dr. Wm. J. Taylor, read before the Academy of Surgery of Philadelphia, and reporting a number of cases.

of the brain, always shave the entire scalp and examine the weapon to see if a piece were broken off. Asepticize, enlarge the wound, trephine, arrest bleeding, elevate any depression, remove foreign bodies, irrigate the wound, suture the dura, drain, and dress.

Gunshot Wounds of the Head.-A penetrating wound is one in which the bullet enters the head, but does not emerge; a perforating wound is one in which the bullet passes through the head and emerges. The wound of entrance is small; the wound of exit is large. At the wound of entrance the inner table is more extensively fractured; at the wound of exit, the outer table. The symptoms of gunshot wounds of the head are similar to those of any other brain-wound, but, as a rule, are more widely diffused.

Treatment. In treating gunshot wounds of the head, shave and asepticize the whole scalp, disinfect the entire track of the ball, and arrest hemorrhage at the wounds of entrance and exit, using the rongeur to expose the bleeding points. The bullet, if retained, is to be sought for. So place the head that the track of the ball will be vertical, then introduce Fluhrer's aluminium probe and let it find its way by gravity. The probe may find the ball near the wound of entrance, in which case extract the ball with forceps; or the probe may find the ball near the opposite side of the head, in which case make a counter-opening through the bone, at a point the probe would touch if it were pushed entirely across. Take a new and clean rubber catheter (No. 9, French), insert a stylet, and carry the catheter through the wound (Keen). Knowing the depth of the ball, it is searched for around the catheter tube as an axis, and when found it is extracted. After extraction, drain the wound by means of a tube. When a counter-opening exists, drain through and through. Girdner's induction-balance may be employed to locate a ball. If the ball cannot be detected,

drain by a tube carried to the depths of the wound. After dressing, always place the head in a position. favorable to drainage.

Fungus cerebri (hernia of the brain) rarely contains true brain-substance. It is in most instances a growth from the neuroglia. Hernia cerebri cannot occur if the dura is not opened; it is rare in any case unless the brain was damaged, and is most frequent after septic wounds. In any brainoperation where the dura is opened, suture it; or, if there be a great gap in the dura, cut off a piece of pericranium from the flap, turn its bone-forming surface upward, and stitch this membrane to the dura (Keen). The evidence of brainhernia is a protruding mass which is soft, lobulated, of a dirtywhite color, pulsating, painless to the touch, often bleeding, and sometimes discharging cerebro-spinal fluid. In treating brain-hernia, employ antiseptic dressings. Skin-grafting benefits some cases. Pressure is dangerous. Excision by the knife or cautery does no good. After healing, a depression marks the site of the hernia.

Traumatic inflammation of the brain and its membranes is divided into encephalitis or cerebritis, inflammation of the cerebrum ; cerebellitis, inflammation of the cerebellum; meningitis, inflammation of the meninges; arachnitis, inflammation of the arachnoid; pachymeningitis, inflammation of the dura; and leptomeningitis, inflammation of the arachnoid and pia.

Pachymeningitis.-Inflammation of the external layer of the dura is rare (pachymeningitis externa). It may arise from tumor, caries, necrosis, middle-ear disease, sunstroke, or traumatism. Syphilis is a not unusual cause. The other membranes may become involved. Suppuration may arise, having extended by contiguity from neighboring parts. The symptoms of pachymeningitis externa are uncertain. They resemble often those of leptomeningitis. Pressure-symptoms

may arise. Paralysis may or may not exist. If pus forms, the ordinary constitutional symptoms of suppuration arise (high temperature and sweats), not the symptoms of abscess in the brain. In a severe case other membranes become involved. The treatment consists in removing the cause (carious bone, pus, middle-ear disease). In pachymeningitis from traumatism, trephine to drain inflammatory products; in a case with localizing symptoms, trephine; in an ordinary case, without pus and with no evidences of traumatism, use wet cups back of the mastoid processes, apply an ice-bag to the head, and purge by means of calomel. Use iodide of potassium in most cases. If sunstroke is the cause, treat accordingly.

Pachymeningitis interna may extend from the pia. The form known as hematoma of the dura mater, or pachymeningitis interna hæmorrhagica, may arise during infectious diseases (typhoid fever and rheumatism), in persons of the hemorrhagic diathesis, in diseases causing atrophy of the brain, and in chronic diseases of the heart and kidneys. Among the exciting causes are traumatism, inflammation in adjacent parts, and, especially, the abuse of alcohol. In this disease blood is extravasated on the inner surface of the dura. Many observers do not class hemorrhagic pachymeningitis as inflammation, but regard the hemorrhage as primary. The symptoms of internal pachymeningitis are very chronic, are not characteristic, and may be absent. They consist usually of persistent headache and apoplectiform attacks with contraction of the pupil, slow pulse, and vomiting. Choked disk is not infrequent, localizing symptoms may be made out, and coma is apt to arise. The treatment is the same as that of external pachymeningitis.

Leptomeningitis is a purulent inflammation of the soft membranes of the brain. The pathological changes can be noted in the pia and in the brain-substance. The brain is