of the cranium." After a blow upon the head, a certain amount of blood may be effused in the orbits, sufficient to produce considerable ecchymosis; as well as a certain degree of epistaxis, even when the nose has not received an injury; and, indeed, there may have been some bleeding from the ear and pharynx where the mucous lining of these cavities has been lacerated, not as the result of direct injury to the part itself, without necessarily involving a fracture. Yet, if any great amount of hemorrhage should occur, and especially from the pharynx and ear, consequent upon a severe blow on a remote part of the head, I think the best authorities will warrant us in pronouncing it the result of fracture of the base of the skull. Mr. Prescott Hewett insists upon the importance of extravasated blood under the ocular conjunctiva as diagnostic of fracture, and says of it, to be of prime value, "we should not be able to trace its limits," that it should extend farther than we are able to see. There may be extravasation in the mastoid region, and lateral regions of the neck, leading to strong suspicions of fracture of the posterior part of the base. The symptoms showing injury to the nerves will indicate not only fracture, but may point out its direction; a strabismus implicates the third or sixth nerve; a paralysis of the face shows that the seventh has suffered; deafness points to the auditory; loss of sensibility of one half the tongue to the third branch of the fifth, and of motion to the ninth; while dysphagia and snoring indicate that the exit of the eighth pair has been infringed upon by the line of fissure; and so we may carry these observations further, as by the absence of paralysis, or other derangements of nervous action, we may assure ourselves that the brain substance has not suffered. The escape of the serous fluid has given rise to much speculation, and even up to the present; I am not prepared to say that it must always be taken as unmistakable evidence of fracture of the base of the skull, nor that its source even when existing in. large quantity, must always be referred to the cerebro-spinal liquor. That in almost all cases where this fluid has been discharged after severe injuries of the head, terminating fatally, it can be satisfactory demonstrated to have proceeded from a rupture of the membrane containing it, there can be no doubt. Yet, Mr. Hewett mentions in his lectures upon this.

subject, at least two cases where no such opening could possibly exist, and, in one of the cases under his immediate eye, when the serum was copious and prolonged, a careful dissection, made by himself and Mr. Henry Gray, revealed that there was no fracture of the petrous bone at all. He says, that in this case, "the only possible explanation is, that it was a secretion of the membrane lining the tympanum and mastoid cells." As Mr. Hewett is perhaps the highest authority of the present day, who takes issue with those who believe this serous discharge to be in all cases the cerebro-spinal fluid, and consequently pathognomonic of fracture of the base of the skull, it may be excusable to copy what he is pleased to call his three classes of cases presenting this watery discharge. "The first is where the fluid from the ear is plentiful and of a decidedly watery character immediately after the accident; in these cases," he says, "we need still be in no doubt as to the nature of the accident. We may safely say that the watery discharge is due to the escape of the cerebrospinal fluid, which can only take place through the petrous bone implicating the internal auditory canal and its membranes.

"The second class, characterized by a copious and prolonged bleeding from the ear, followed by a watery discharge, we may here also safely diagnose a fracture of the petrous bone, but we can not pretend to say that the line of fracture follows any particular course. It is right, however, that we should clearly understand that it is not to this watery discharge that we can in these cases safely trust for our diagnosis, but to the copious and prolonged bleeding which has never as yet led me wrong.

"Thus far, then, there is no difficulty in the diagnosis; not so however in the third class of cases. Here we get at first a discharge of blood only, which is neither copious nor prolonged; then comes the watery discharge, varying as to the time of its appearance. Mark, it may be there within a very few hours after the accident, varying again as to the quantity; it may be profuse also within a very few hours after its appearance. These are the cases," adds Mr. Hewett," in which experience has of late taught us that the diagnosis must be doubtful. Does such a discharge of blood indicate a fracture? certainly not. Does such a discharge of watery fluid indicate a fracture? not for certain. A limpid watery fluid may be discharged within a few hours

after the accident, the quantity of it may even be profuse, and yet there may be no fracture. Up to the present time it has been held that these two characters of early appearance and profuseness, were signs positive, in truth, none more so, of fractared base. Of this idea we must now disabuse ourselves."

It need scarcely be added that we may have a fracture with none of the above indications to govern our opinion, and in their absence we may sometimes shrewdly guess at the true character of the mischief, but are never warranted in pronouncing it so with positiveness. The prognosis in these cases is extremely bad. A few years ago it was believed that all such accidents were fatal. Yet we now know, that although a person may receive an extensive fracture of the base of the skull, we need not necessarily condemn him to death.

There is very little outside of what is called general principles to be said of treatment. Operative interference may be necessary, where a spicula of bone impinges from the orbit, or from a caving in of a portion of the posterior fossæ.

In closing the account of this case, and the rambling comments I have been betrayed into making, I must apologize for introducing the details of treatment for the violent pains which afflicted my patient; but feeling that I stumbled upon what proved a very boon to him, and not then, nor now, being able to offer any solution of the means to ends, I beg that gentlemen will be kind enough to give this part of my paper more than a passing reference.

ART. II.-Cuses of Thoracic Disease. BY H. P. AYRES, M. D., Fort Wayne, Ind.

CASE 1.-PNEUMONIA.-Jas. B. was attacked with pneumonia in the spring of 1844. The inflammation extended to both lungs, but reached a higher degree in the left, and resulted in an entire disorganization of that lung, and change in the locality of the heart. The attack and treatment of the pneumonia had no peculiarities, but the results are unusual, and beautifully illustrate the tenacity sometimes manifested for life, and the resources of nature in supplying any defect in the organism. During the sickness and convalescence there

were no special evidences of decay in the left lung, and the change which occurred can only be accounted for as the. result of absorption. Mr. B. is still living, and his prospects for life are as good as they were twenty years ago, and, for the present, entirely forbid the idea of a post mortem examination.

The ribs on the left side of the chest have fallen in, or flattened, so that the measurement of that side is not more than one third that of the right. Percussion reveals only a solid mass occupying the remaining cavity, and the action or motion of the ribs is entirely wanting. The heart has been pushed entirely into the right side of the chest, and its action may be seen and heard, a little on the inside of the right nipple, while its apex points forward and outwardly. Its motions are quick, but smooth and uniform. The respiration is hurried, but the resonance of the right side, on percussion, indicates a sound lung. Mr. B. possesses a well-developed body, and one free froin any hereditary disease. His appeareance now is slightly stooped, pale and delicate, yet he has sufficient strength to enable him to walk about and give directions respecting his business; but can undergo no great amount of fatigue. The right side of the chest is not materially increased in size, when we remember that it contains the heart and the entire respiratory apparatus of the body. The appetite continues good, and the digestive organs are entirely healthy. The vertebral column has not suffered with this great change in the organism. The stooping mentioned above, probably results from other causes. The man is, undoubtedly, living with only the right lung. The heart has been crowded several inches from its proper position in the thorax.

There are undoubtedly instances in which men have lived with one lung, from hepatization or solidification, but I do not now remember any, where there has been such an entire disorganization of the vital organs. What changes have taken place in the aorta, vena cava, heart and respiratory organs, is, for the present, only a matter of conjecture; and as the subject has lived for twenty-two years, and bids fair for many more, it may never be known.

CASE 2.-EMPYEMA FROM PNEUMONIA.-S. B., aged 35, a stout, vigorous, healthy and temperate man, was attacked

in 1850 with pneumonia. The inflammation occurred in both lungs, but was particularly severe in the left. The treatment was prompt and energetic; but as we write only to record the results of the case, we entirely omit it. Hepatization of the left lung followed in a few hours, while the right gradually assumed its healthy state and function. The patient slowly improved, and in six weeks, was able to visit town-his residence being six miles in the country. The dullness over the lung continued, but hopes were entertained that it would gradu-. ally resume its functions. He continued to visit town every two weeks, but complained of great pain in the diseased side of the chest, and a sensation of a floating or moving substance in that side. The first attack was in August, and in December he had become so emaciated and weak, and felt the weight of the left lung so great, that he gave up all locomotion, and confined himself to a semi-erect position in bed, being compelled to lie continuously on the back. From December to February his sufferings were intense and almost continuous. In February his physician visited him, and fonnd an evident pointing of matter between the third and fourth ribs, which he opened, and over six pints of thick pus escaped within eight hours. So exhausting was it to the patient, that, notwithstanding he had a bandage around him tightly, it became necessary to stop the flow of the pus, until rest and stimulants could restore him. The operation left the patient in a much prostrated condition.

In three weeks, two more pointings appeared between the fourth and fifth ribs, which were opened, and discharged large quantities of matter. Subsequently four openings were made, one near the base, and one at the apex of the heart, the remainder as low down as the seventh rib, but all on the anterior surface of the left breast. During the sixteen years which have elapsed, new fistulæ have formed, and old ones closed. There are generally four running, three occasionally, and one, which is of great interest to me, and really the subject of this paper. This one he is compelled to empty night and morning, or, as he expresses it, "Blow it out." During the sixteen years, he has been confined to the house about one year; the remainder has been devoted to the management of his property; but at no time was he able to undergo any severe labor. His chest is drawn to the left side,