it became known; but in the cases where there has been no compound fracture, no laceration of the soft parts—as I say, those cases are the ones that have always been neglected, and those are the cases which can most easily be saved in many instances, and they are the cases which should be most carefully studied, and which should be dealt with, as the doctor has stated, by relieving intra-cranial pressure.

DR. W. H. EARLES, Milwaukee-Mr. President and Gentlemen of the Society. First of all I wish to endorse every thought expressed by the writer in his paper. I believe it is absolutely sound, and as I have had the pleasure of associating with Dr. Lemon in a great deal of head surgery, I must say that every proposition propounded in that paper is backed by the clinical experience that the writer has himself had.

That we may more fully understand the necessities of the situation where we have injury to the skull, with possible intra-cranial pressure, we must first of all learn to recognize this one fact, which I believe has been clearly demonstrated by such men as Starr, Horsely, McEwen and others, that any injury to the skull sufficiently forcible to produce fracture is also sufficiently forcible to produce severe injury to the brain, its covering or circulation. The second proposition is, that we may have a very pronounced injury of the brain, its circulation or covering, with no surface wound whatever to indicate that the skull had received any injury.

When we learn these two propositions thoroughly and believe in them, it will be an easy matter for us to comprehend all that the writer has said in his paper to-day.

The next thing for us to learn is that where there is any pronounced suspicion of intra-cranial pressure, whether it be blood or serum, it is the duty of the surgeon to relieve it. If you have even a minute injury to the brain and its circulation, you are going to have oozing, and if it becomes sufficiently pronounced, then it is the duty of the surgeon to enter the skull. Why not enter it? We can enter the skull to-day with the same degree of safety that we can the abdominal cavity; and who hesitates to enter the abdominal cavity when he suspects that in the abdomen there is a condition jeopardizing the life of the patient?

It is gratifying to note all along the line, the marked progress of head surgery. At the last meeting of the American Medical Association there was pronounced evidence of it; and in the classical paper we have just listened to, I think we have good, sound surgical principles enunciated which it would be wise for all of us to remember.

I again wish to say that I feel personally indebted to Dr. Lemon for it, and heartily endorse every thought that he has expressed in his paper.

DR. A. H. LEVINGS, Milwaukee-There are some points which should perhaps be brought out, which the doctor has not touched upon. One of these is, that in injuries of the skull not only may the middle meningeal artery be ruptured with a clot of blood between the dura and the skull, but also a branch of the middle cerebral may be ruptured, producing a clot of blood which rests inside of the dura or upon the brain.

It is stated by Phelps in his great work on injuries of the skull, that a traumatism of the head never produces a rupture of the middle cerebral artery or of its branches; and that it can only produce a rupture of the meningeal. This I know to be erroneous from my own experience, which includes three

cases of rupture of the middle cerebral artery from an injury, without fracture of the skull.

Another point I wish to lay special stress upon is this, that in injuries of the head with marked symptoms, the condition is not necessarily due to hemorrhage. The hemorrhage may be extremely slight, insignificant and apparently of no consequence. It should always be borne in mind, however, that contusions of the brain or of the membranes, and more especially lacerations of the brain, are of the greatest importance and demand special consideration in head injuries. Hemorrhage may nearly always be controlled, lacerations of the middle meningeal or middle cerebral artery can practically always be put under control, but a contusion of the brain or a laceration of the brain can never be corrected by operative means. When one is about to operate I think he should have a clear conception of what he is going to operate for, so that he may be able to determine whether the condition can be benefited by operation or not. Of course, in injuries pressure is produced by hemorrhage, depressed bone, inflammatory exudates, or it may be produced, as the writer has stated, by progressive edema, but certainly progressive edema requiring operation is rare. It has only come into the literature lately. In lacerations or contusions of the brain the symptoms are manifested at once.

Pressure from hemorrhage or edema comes, with very rare exceptions, only after some hours. If we consider that there has been a considerable period of consciousness following an injury, and if then unconsciousness supervenes, we have a pressure which often, perhaps nearly always, may be relieved by operative measures; but if coma occurs at once and is unassociated with fracture and depression, the probabilities are that we are dealing with an injury to the brain which cannot be relieved by operative measures.

DR. C. O. THIENHAUS, Milwaukee-I should almost gather from the tenor of the paper that the writer advises operative procedures for all contusions of the skull followed by fissures and fractures and all cases of intracranial hemorrhage. Now, when a man has an apoplectic stroke with hemorrhage into the brain, is it advisable in such cases to operate? Certainly not. Furthermore, when we have to deal with a case of severe contusion of the skull, it is our first duty to define the location of the lesion and make a strict differential diagnosis between concussion and intra-cranial pressure produced by hemorrhage, before resorting to operative procedures. I will at this place not go into the details of differential diagnosis in such cases, but would like to call the attention of the Society at this place to a question of great scientific interest with which I had to contend recently and which belongs into the realm of this paper. You know that oftentimes following births in cases of contracted pelvis, with or without forceps delivery, depressions of that parietal and temporal bone occur, which passes the promontory. Many of these children die, some of them, without question, because of asphyxia produced by the prolonged delivery. But in other cases where this cause of death was not in evidence, one attributed the death to pressure on the brain produced by the depression of the bone. Recent post mortems in such cases, however, have demonstrated that in all cases which died, the death was to be attributed to intra-cranial hemorrhage complicating the depression and not the depression itself. I am not aware that there has been one case cited where such a child was saved by immediate trephining because of the hemorrhage. Another question which, however, does not come under the realm of this paper is: Shall we, when the child lives, immediately raise the depression?

It has been proven that very many of these children live with such a depression without showing any symptoms of pressure or alteration of the brain by this depression, or of idiocy in later years. In other cases later on symptoms may develop which call for surgical interference. Now, if one tries to raise the depression immediately after birth, one can, in some cases, accomplish this by simple pressure on the surrounding parts of the skull, which causes the bone to snap back. In other cases of emergency it is advisable to use a small corkscrew, which, after sterilization, is screwed into the depressed part of the bone. Herewith the depressed bone may slowly be raised without injury to the brain tissue. I show you herewith a picture of a case in which there is an enormous depression produced by a rachitic pelvis. As the conjugate vera measured 7 centimeters I advised Caesarean section out of relative indications. As this was rejected by the patient, I performed version and extraction, giving but little hope for the life of the child. Mother and child are living and well today, three months after confinement.

DR. F. SHIMONEK, Milwaukee-With reference to one point I wish to make a remark or two, and that is in fractures of the middle fossa of the skull. The fracture extends through the petrous portion of the temporal bone and into the vault of the pharynx; there is a direct communication with the external surface, in other words, we have a compound fracture, and in this the great danger of basal fracture exists. The statement was made in the paper (at least I understood it so) that antiseptic injections into the ear were advisable and proper. Now it seems to me that in using injections into the ear we run great risk of forcing septic material from the ear into the brain; and it also seems to me that in spraying the vault of the pharynx we might also force septic material into the brain. The chief danger in those fractures is septic infection of the meninges. I think the proper thing to do is simply to pack the ears with wet antiseptic gauze.

DR. WILLIAM BECKER, Milwaukee-It is true that the surgeon does not as a rule operate on cases of cerebral hemorrhage where symptoms of extreme

intra-cranial pressure are manifest. This lack of active interference is to be deplored. Wherever we have profound coma and where Cheyne-Stokes respiration and other symptoms of intra-cranial pressure appear after cerebral hemorrhage, the surgeon should be called upon to open the skull of the patient. This would certainly relieve the intra-cranial pressure, which is the fatal factor. A very minute exactitude in localizing the site of the hemorrhage is not essential, so long as the hemisphere is diagnosed-an easy proposition. If edema of the brain follows laceration of the brain or its coverings, this edema is not so much due to the immediate local lesion, but, I think, rather to changes diffused therefrom, i. e., changes occasioned by the process of repair. We must also consider the effects of brain lesion on the very sensitive vaso-motor apparatus of the brain. In short, experience in the autopsy room has taught me that the vicinity of a brain bruise, no matter how slight, is always in a condition of hydropic degeneration.

Dr. Lemon had the kindness to show me the case reported. The site of the lesion had been correctly diagnosed. Dr. Lemon's novel and thoughtful operation proved a gratifying success. Successful operations, no matter how new, should be encouraged.

DR. LEMON.—In the scope of a paper to be read in a limited time of 20 minutes, of course, one cannot cover everything, and I had in mind what Dr. Levings suggested about other arteries. Of course, there are quite a number of arteries that might be torn in a fracture of the base of the skull, but I called attention to the middle meningeal because that is the one that we more commonly see.

I was unfortunate, owing to the time limit, in not being able to finish the reading of the essay because had I been able to do so I should have obviated another criticism, and that is, that all contusions of the skull were to be operated upon. Such an idea, of course, I had not in mind at all. There are certain cases of contusion of the brain cited in the paper, especially those cases which are followed by marked edema of the brain with symptoms of unmistakable character, that should be operated upon, and my object was to plead for further operative procedure in the belief that many of these cases that are comparatively frequent could be relieved. The statement that they are rare reminds me of a story about Dr. Mayo, who, when asked how it happened that he had so many more cases of gallstone proportionately than others, said that it was because he made the diagnosis more frequently; and I think if we made the diagnosis of contusion with edema, instead of concussion of the brain with shock or hemorrhage, or something else-pure guess work-in the future many cases would be saved.

With reference to the injection of these cavities: I do not believe any skillful person would inject any solutions into the ear or nose, or any other cavity communicating with the brain, with sufficient force to drive the solutions into the brain; and it is absolutely necessary, in my own experience with ears, that they should have a very thorough scrubbing out and cleansing in all of these cases where we have hemorrhage from the base of the brain through the ear.

REPORT OF A CASE OF TUBERCULOSIS OF THE ADRENALS, WITH PATHOLOGIC SPECIMENS.*

BY JULIUS NOER, M. D.,

STOUGHTON, WIS.

The symptomatology and pathology of disease of the adrenals is as yet in such a hazy condition that I feel that the report of the history and autopsy of even a single case will be of interest to members of this society. Addison gave us a very clear symptomatology of the disease as early as 1855. The fact that his autopsies usually corroborated his ante-mortem diagnosis is very good evidence of his keen powers of observation and good judgment.

B. K., who died on March 22, 1903, came under my care in April, 1893, for tuberculosis of the right sacro-iliac joint. The disease manifested itself at first in the form of an abscess which could be easily demonstrated directly above the right anterior superior spine of the ilium. This abscess was opened, traced to the point of origin, and its tubercular nature ascertained.

The sinuses and tubercular cavity were curetted some five or six times; diseased bone was removed from the ilium a number of times. The wounds were kept saturated with an emulsion of iodo form in glycerin and balsam of peru. During the first two months of treatment the patient was confined to bed and a long plaster cast was applied to the diseased side of the body. There was never any material afternoon fever, the temperature never exceeding 101° or 1011° F. There was some emaciation during the period of confinement to bed, but the patient rapidly regained normal weight after being allowed to go about on crutches. After two months of treatment he was permitted to get up and be about on crutches, a Thomas long posterior splint having been applied to the diseased side of the body and a thick

soled shoe to the well foot.

After one year and a half of treatment the wounds were all completely healed and the patient was dismissed as cured. He very soon got around as well as he ever did, and there were never any signs of a return of the disease at the point of original infection.

Till the autumn of 1901, B. K. never showed any symptoms of disease, but continued to be in perfect health. He became an active, enterprising man of affairs. After the discovery of gold at Nome, Alaska, he became interested with his brother in a mine at that place and spent two summers there.

In the autumn of 1991 he was not as well as usual and for this reason decided to spend the winter in California. While in San Francisco during this winter he was taken very sick, the symptoms being *Read before the Central Wisconsin Medical Society, April 29, 1903,

Beloit, Wis.

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