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Some hypothetical conclusions bearing on the evolution of cicatricial tissue can be suggested. The arterial circulation deposits in the wound chemical substances necessary for contraction of the wound and for epithelial proliferation. When the biologic process is not hindered by any special or severe bacterial infection this deposit is as regular as the circulation itself, and enables us to determine in advance the date of cicatrization. It even seems as though when the epidermization process is retarded by a slight infection the substances necessary for epidermization are stored up in the wound, and when the delay due to infection is removed the epithelium finds an accumulation of nutritive substances, and, so to speak, makes up the lost time. Moreover, when an infection entirely or partially stops epidermization, we have observed (Experiments 3, 4, and 5) that after the infection has disappeared the progress of new epidermization is much more rapid than normally; it even passes the calculated curve. The infection apparently destroyed only the epithelium and left in the wound the chemical substances which activate epidermization. The existence of these physical or chemical activating agents has been indicated again by two anatomical clinical facts. In treating a scalp wound in which there had been practically no epidermization for many months, we applied over the entire surface of the sterile wound dermo-epidermic grafts of fetal skin. After apparently taking, the grafts were absorbed and disappeared, but epidermization of the periphery of the wound, which hitherto had not progressed, took place abundantly, almost a hundred times as much as before. We believe that by mathematical measurements we can solve the problem of the action of various organic fluids on the cicatrization of wounds.

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A survey of the time interval between injury and operation in relation to the type of wound healing, whether per primary or secondary intention, reveals that no definite time limit can be demonstrated with regard to primary wound healing. Healing per primary union occurred after debridement carried out 11 and 12 days following injury, even in the presence of a discharging sinus as evidenced by cases 2.1.10 and 2.1.11. In case 2.1.14 the original scalp wound in the left frontal region was closed and already granulating when, six weeks after injury, the wound was re-opened and a frontal abscess evacuated. A soft rubber drain was removed after four days and did not interfere with primary healing of the wound.

If the expression sometimes ascribed to Sir Astley Cooper, that "No injury of the head is too slight to be despised nor too severe to be despaired of," be true, I will need no apology for inviting attention to the subject, except perhaps for the weakness of its presentation. Injuries to the head should possess, for every practitioner, more than ordinary interest, as they entail more than ordinary responsibilities, and when we consider the many and varied conditions met with in this field of surgery, from the slight and apparently trivial scalp wound to the fracture of the base of the skull with its probable accompanying laceration of brain tissue and membranes, and possibly rupture of large blood-vessels, the range of thought necessary to comprehend and combat these conditions becomes apparent. In the contemplation of this class of injuries we may say, in a general way, that the practitioner must

The occurrence of middle meningeal hemorrhage, unless accompanied with severe depressed and compound fractures of the skull, is not so frequent but that the following case may be of interest: History.— About midnight of April 4, 1909, I was called to see a workman who, I was told, was suffering from a scalp wound inflicted by means of a bricklayer's spirit-level, in the hands of a fellow-workman. On arriving at the scene of the trouble about half an hour later, I found the patient lying on the floor in an unconscious condition. His breath had a very strong odor of alcohol. Examination.— There was a contused scalp wound about three inches long in the left temporal and parietal regions, which was bleeding profusely. The pupils were equal and reacted to light. On further examination I concluded that the patient was suffering from concussion of the brain and acute alcoholism. I

Incision and drainage is an accepted and fundamental surgical principle in the treatment of abscesses and of purulent collections in the body cavities. The introduction of penicillin has modified this, so that at present drainage of the purulent material by aspiration and replacement with penicillin in isotonic sodium chloride solution has cured the condition in many instances and obviated the need for surgical intervention. The procedure was first employed in this series at Harlem Hospital, August 1944, in the treatment of a newborn infant in whom numerous discreet nodular infections developed secondary to an infected scalp wound. Although sulfonamide drugs were administered orally for eleven days, the infant's temperature remained elevated, up to 102 F., and new nodules continued to appear. There were many nodules, and they were distributed on the entire back, buttocks, abdomen, thighs and legs. Blood cultures were negative on two occasions. As there was no response

The patient, D. P. M., aged 49, male, married, native American, by occupation a round-house hostler, was referred for X-ray examination by Dr. R. W. Mullen, of Sioux Falls, South Dakota, who supplied the history. The family and personal history was essentially negative. The patient had not been operated upon. On the afternoon of September 16, 1926, six days before the date of the roentgenologic examination, he was found standing in his engine cab with blood on his face. He was irrational, and on being removed from the engine had a convulsion which lasted two minutes. He was known to have been working in the fire-box and the probability is that he became overheated and fell, striking his head. He was removed to the hospital where he had another convulsion lasting two minutes. Physical examination showed a well developed and fairly well nourished man, restless and talking irrationally. The skin was of good color. There was a scalp wound, irregular in shape, 4 cm. in length, directly above the left eye. The ...

The case here reported was diagnosticated before the skiagram was submitted, as it presented no great problem. The one point which ultimately resulted in a favorable outcome, however, was brought out by a study of the skiagram and the measure for relief decided on. History. —C. N., aged 15, was admitted to Harlem Hospital. July 6, 1908, with a history of having fallen from a rapidly moving trolley car. In an effort to save himself he held the right hand forward and the force of the fall was received on the palm. The ambulance surgeon who saw the boy soon after the injury diagnosticated a fracture of the lower end of the radius with lateral displacement. The boy had also sustained a small scalp wound and some minor contusions. The latter were of little import, however, and after an unsuccessful attempt at reduction of the deformity at the forearm the

LACERATIONS of the scalp may end with almost fatal complications. This is especially true if the patient has an unsuspected diabetes. Since the advent of sulfonamides, penicillin and other antibiotics, they may be slightly less serious, but 2 patients, recently admitted to this hospital, illustrate how poor is the outcome when the initial treatment is inadequate. Botterell and Jefferson 1 pointed out that Briesen found, in a review of over five thousand head injuries in Los Angeles, that the longest periods of hospitalization were due to septic wounds of the scalp. Another factor which they call attention to is "that an infected scalp wound makes it impossible to undertake exploratory punctures of the skull and dura as the later progress of the case may demand." In neither of our cases were exploratory punctures necessary, but it remains an important consideration. Case 1. —M. R., a 65 year old Iroquois

Complete rupture of the healthy aorta without external signs of the cause of death is of sufficient rarity to warrant the publication of a synopsis of necropsy which I made recently. A laborer, aged about 40 years, was struck by a large mass of falling earth which gave him a glancing blow on the back and knocked him down, though it covered only his legs. A few seconds later he was picked up dead, and was seen by a medical man in a few minutes who could find no cause externally for the sudden death. I examined the body a few hours later but saw no apparent cause of death. There was a large scalp wound on the forehead down to the bone, but the frontal bone was not fractured. The mouth, nose and ears were free from blood or foreign matter. There was a little frothy mucus in the