highly developed areas of the cerebral cortex. Besides, the subtemporal route provides not only an excellent exposure of the middle meningeal artery and that portion of the brain so frequently involved in fractures of the skull, but it affords drainage to the middle fossa of the skull-the chief intracranial cisternat its lowest point at the base of the skull; again, the thinness of the squamous portion of the temporal bone makes the operation a less difficult one technically. The vertical incision (and not the usual curved incision) should be used not only to render the operative hemostasis more effective in that the trunk of the temporal artery is clamped at its lowest point at the very beginning of the operation and therefore there is no bleeding from its branches, but this incision also permits the removal of the underlying squamous bone as far as is possible beneath the temporal muscle-a diameter of three inches—and yet the attachment of the temporal muscle to the parietal crest is left intact so that a firm closure of its separated muscle fibres is assured; this is a most important point in cases of high intracranial pressure as in brain tumor where a cerebral hernia or fungus might result from an imperfect closure of the temporal muscle. The insertion of silver and celluloid plates and other foreign bodies beneath the scalp is to be most strongly condemned.

If the intracranial pressure is so high that the cerebral cortex tends to protrude through the bony opening, it is frequently wiser in selected cases to perform a similar operation upon the opposite side of the head immediately after the first operation; I have been obliged to do this in only five per cent of the patients; they are the ones having a swollen oedematous brain-"waterlogged" as it were, where the drainage of blood and cerebrospinal fluid is slight and not sufficient to cause a marked decrease of the intracranial pressure; in some doubtful cases, it is better judgment to wait for one or two days and even longer, before the second operation is considered advisable. The rubber tissue drains are usually removed on the first or second day post-operative, and the hospital convalescence ordinarily requires at least two weeks. Naturally, these patients should not enter into their former active life for a period of three months and even longer;

a too early return to the strain and stress of modern life predisposes them to many complaints-both subjective and objective; repeated examinations of the fundus of the eye and of the superficial and deep reflexes are here most important in estimating the physical normality of the patient.

The end results of patients having brain injuries with or without a fracture of the skull have been an interesting study. It has become quite a common belief that once a man has had a fracture of the skull and then recovers, he is never the same person again. In 1912, I examined the records of three of the large hospitals of New York City during the decade of 19001910; the mortality of fractures of the skull was 46-68 per cent; the mortality of the patients operated upon was 87 per cent—this high percentage due undoubtedly to the operation being postponed until the extreme stages of medullary compression and oedema, and also to the fact that the operation performed was the "turning down" of a bone flap-a much more formidable procedure than a decompression-and then the bone replaced so that even the benefits of a decompression were prevented; besides, in many cases, the dura was not opened, and as the dura is inelastic in adults, therefore no adequate relief of the pressure could possibly be obtained. Of the patients, however, who were finally discharged as "well" or "cured," I was able to trace only 34 per cent, but of these 34 per cent of the total patients found, 67 per cent of them were still suffering from the effects of the injury-that is, two-thirds of them were not as well as before the injury; the chief complaints were persistent headache, a change of personality of the depressed or of the excitable type and thus emotionally unstable, early fatigue making any prolonged mental or physical effort impossible and thus the inability to work, lapses of memory, spells of dizziness and faintness, and even epileptiform seizures in a small percentage of them. In examining the hospital records of the patients having these post-traumatic conditions, it was most interesting to ascertain that these were the patients-and there were but few exceptions-who regained consciousness gradually after several days and remained in the hospital for a

period of four weeks and longer, whose charts made frequent mention of the severe headache and a low pulse rate of 60 and in some cases below 60-that is, the usual clinical signs of an increased intracranial pressure; an ophthalmoscopic examination had rarely been made. Many of these patients still showed the results of the increased intracranial pressure in their fundi and at lumbar puncture, and these were the ones upon whom a cranial decompression even at this late date caused a marked improvement; the operative findings were always associated with a "wet" swollen oedematous brain; many of the so-called post-traumatic neuroses are in my opinion frequently superimposed upon this definite organic basis as the result of the brain injury.

The treatment, therefore, of brain injuries should not be limited merely to the recovery of the patient as far as life is concerned but it should also be directed toward obtaining a normal individual—approximating as closely as possible the condition of the patient before the injury.

Dr. Sharpe, after the following introduction, demonstrated a brain operation with motion pictures: "I would like to say just a word regarding these pictures. I had been trying for some time to have a moving picture of a cranial operation, particularly of this type of brain injury. This patient was brought into the hospital and the moving picture apparatus was all ready for him. It happened to be a man fifty-four years of age, a cab man, alcoholic, who had fallen from his cab while intoxicated. He was brought into the hospital unconscious, bleeding from both ears and the cerebral spinal fluid, however, coming from the right ear therefore, a basal fracture in that area.

"Upon examination he apparently was in no shock and at the time of the ophthalmoscopic examination no signs of pressure. However, the lumbar puncture by the use of the spinal mercurial manometer revealed blood under high pressure, registered 17 mm. mercury, about twice the normal amount (5-9 mm.); the pulse in this case was 62. Neurologically he had some weakness of the left side of his body, especially the left leg; his

reflexes also were increased on the left side-there being a typical Babinski reflex. A right sub-temporal decompression was advised. No anesthesia was required at first, but upon incising the temporal fascia he came out of his unconsciousness so that ether was obligatory. As is shown in the picture, both a fracture at the underlying squamous bone and a sub-dural hemorrhage were exposed. The patient had an uneventful convalescence in the hospital and has made an excellent recovery." 20 West 50th Street, New York.

The Distribution of Fat in the Appendix and its

Relation to Inflammation.

DR. GEO. M. SMITH, WATERBURY.

(From the Surgical Division of the Waterbury Hospital.)

The accumulation of visible fat in various regions of the body has long been a matter of study; and much clinical and experimental data are now at hand to show the relation of fat to normal and pathological processes. With the exception of the heart and the blood vessels, the solid parenchymatous organs have been of chief interest for their variations in content, distribution and nature of fat. It is only in more recent times, with the renewal of interest in the study of lipoids, caused by the application of improved methods of analysis, that some of the hollow organs of the abdominal cavity have become the object of investigation.

It is a matter of general knowledge, particularly since the researches of Rosenfeld (1), that the visibility of fat in tissues is not necessarily a true index of the entire fat content of the organ; for many of the lipoids found in tissues are held in an invisible combination with other substances, becoming an object of visible demonstration only when chemically liberated from the substances with which they are associated. On the one hand, a kidney showing a marked fatty condition on gross or microscopic examination, when chemically analyzed may show no increase in fat over what is normal. On the other hand, a kidney exhibiting on inspection or by staining methods very little or no fat, may be found to contain an unusually high percentage of fat when chemically examined. For practical purposes, however, any extensive accumulation of visible fat in an organ is regarded as satisfactory evidence of pathologic increase in its content of fat.

Many investigations have been undertaken to explain the process by which an abnormal deposit of fat occurs. In a general