intljfCttporimllork College of ^ijpsicians anb ^urgeong Hibrarp Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/traumaticinjurieOOphel TRAUMATIC INJURIES OF THE BRAIN AND ITS MEMBRANES IVITH A SPECIAL STUDY OF PISTOL-SHOT iVOUNDS OF THE HEAD IN THEIR MEDICO-LEGAL AND SURGICAL RELATIONS BY CHARLES PHELPS, M. D. SURGEON TO BELLEVUE AND ST. VINCENT's HOSPITALS %,\ WITH FORTY-NINE ILLUSTRATIONS A. NEW YORK D. APPLETON AND COMPANY 1897 Copyright, iSgy, By D. APPLETON AND COMPANY. 146 PREFACE This work is designed to be a concise and systematic exposition of the injuries which the brain suffers from external violence, a division of brain surgery which has th<5 greatest practical importance and has received the least careful attention. It is believed that it will not only be of interest to surgeons, but will meet the requirements of general practitioners in whose experience such injuries are infrequent, and who in exceptional instances have urgent need of the aid to be derived from a wider clinical obser- vation than their own opportunities have permitted. It has been based essentially, if not exclusively, upon an obser- vation of five hundred consecutive cases of recent oc- currence. These cases are so large in number, and so va- ried in character, and in so many instances are complete in the record of essential historic and necroscopic detail, as in themselves to afford material for a comprehensive history of intracranial traumatism. The picture they rep- resent is incomplete only in the illustration of secondary pyogenic infection involving the brain substance. In view of this clinical deficiency, the consideration given to cere- bral abscess has been supplemented by some account of the conditions of septic invasion and of the degenerative proc- esses which it occasions, abstracted, by permission of the distinguished author, from Macewen's " History of the Pyo- genic Inflammations of the Brain and Spinal Cord." The generalizations which have been made, and the conclusions which have been reached, from clinical obser- vation, have been verified in each instance by necroscopic examination. jy PREFACE. In an appended series, all those cases in which necropsy was had, and a certain number of others which terminated in recovery or in which necropsy was otherwise impracti- cable, have been collated. This course has permitted the preservation of continuity in the text by the omission of interpolated illustrative cases, has afforded a means for the disproval of possible unwarranted or erroneous deductions, and has preserved much material for the use of indepen- dent observers hereafter. They have been classified sim- ply from their relation to cranial fractures, and this, though an imperfect method of classification, is, by reason of the multiplicity of lesions in individual cases, the only one which has seemed practicable. The lesions which attend pistol-shot wounds of the head have been considered apart from general injuries, as a method more clearly presenting their distinctive character- istics. Their complete history has necessitated an abstract of the results of a series of cadaveric experiments, instituted to determine for legal purposes the extent to which the conditions under which they have been inflicted can be predicated from the appearances they present. These observations have been sufficiently extensive to better define not only the positive value, but the limitations, of medical evidence in such cases than has been heretofore possible. This portion of the work which directly concerns medical jurisprudence is especially designed for the use of the legal profession in more precisely estimating the proper weight to be given to expert testimony in cases of this character. The author has much pleasure in acknowledging his in- debtedness to his colleagues of the Fourth Surgical Divi- sion of Bellevue Hospital, Dr. Jno. W. S. Gouley and Dr. Wm. F. Fluhrer, and of the Surgical Service of St. Vin- cent's Hospital, Drs. Stephen Smith, Frederick S. Dennis, and Jos. D. Bryant, through whose courtesy his oppor- tunities for clinical observation have been greatly ex- PREFACE. V tended. He is also under very great obligation to succes- sive house staffs of the same hospitals, and to the medical officers of the Coroner's Office during the past six years for the constant aid and co-operation which have made possible the collection of the great mass of facts which the nature of this work has involved. He has finally to make acknowledgment of the skilled marksmanship and other- wise valuable assistance rendered to him bv Drs. J. H. Titterington, Henry L. Whitener, and Harry L. Hib- bard, late of Bellevue Hospital, and by Drs. John Freeland and Jno, D. Gorman, in the difficult and laborious task of cadaveric experimentation. 34 West Thirty-seventh Street, July, 1897. TABLE OF CONTENTS. PART I. General Traumatic Lesions. a preliminary consideration of cranial fracture. PAGE Classification of Injuries of the Head, ....... i Cranial Fracture, 2 Classification, . . . ........ 2 Fracture of the Cranial Base, ........ 3 Direct and Indirect, ......... 4 Mechanism, . 6 Complications of Cranial Fracture, 11 Symptomatology and Diagnosis, 12 Fractures of the Vault, ......... 12 Fractures of the Base, ......... 13 External Hemorrhages of Cranial or Intracranial Origin ; . .13 their Comparative Frequency in Different Forms of Basic Frac- ture, 14 their Diagnostic Value, . . . . . . . . . iS Escape of Brain Matter, ......... 21 Water}- Discharges, 21 CEdema of the Mastoid Region, ....... 23 Implication of the Cranial Nerves, ...;... 24 Localized Pain, .......... 26 Indirect Symptoms from Intracranial Complication, . ' . .27 Prognosis, ............ 28 Concomitant and Consecutive Complications, . . . .30 Treatment, 32 Shock, ............ 33 Fracture of the Base, ......... 33 Fracture of the Vault, ......... 34 Incision, ............ 35 Elevation of Depressed Bone, ....... 36 Trephination, . . 39 Vlll TABLE OF CONTENTS. CHAPTER I. Pathology. Shock, ty, Exsanguination, and Diminu stic Degeneration Fluid Direct Lesions, Classification, . Hemorrhages, Epidural, . Pial Cortical, . Dangers of Hemorrhages tion of Cranial Capac Terminations in Absorption and Cy Thromboses of Dural Sinuses, Contusion, .... General Contusion of the Brain, Anatomical Conditions, . Duret's Theory of Displacement of the Cerebro-Spinal Concussion and Compression, .... Prescott Hewitt — Observations of Contusion, Von Bergmann's Theory of Concussion and Compression Structural Alteration Attends All Brain Injuries, Limited Contusion of the Brain, Anatomical Conditions, Contusion of the Meninges. Hemorrhage, .... Subarachnoid Serous Effusion, Laceration of the Brain, Anatomical Conditions, . Terminations, . Indirect Lesions — Secondary Inflammations, Due to Accidental Infection of Primary Lesions. External or Distant Origin of Pathogenic Germs Infrequency of Occurrence, .... Macewen's History of Intracranial Infection, Acute Leptomeningitis. . Acute Serous Leptomeningitis, Purulent Leptomeningitis. Red Softening. White Softening, Cerebral Abscess, Secondary Abscess. . Pyogenic Abscess. Necrosis of Cerebral Tissue, Localization of Primary Lesion Determines the Alternati Meningitis or Abscess, ...... Possibility of Intracranial Inflammation without Infection, PAGE 42 of 85 86 TABLE OF CONTEXTS. ix Arachnitis a More Exact Term than Leptomeningitis. Encephalitis Always Pyogenic, .... Cirrhotic Inflammation — Atrophy, .... CHAPTER IL Symptomatology. Direct Lesions, •••........ qi Hemorrhages, ••••....... 92 Unconsciousness, Delirium, 93 95 Condition of the Pupils, ......... 95 Temperature, ........... gy Pulse, gS Respiration — Marked Infrequency from Compression of the Medulla, gg Tabulation of Cases, . 100 Cyanosis and Pulmonarj' CEdema, ....... 103 Psychical Disturbances, ......... 104 Influence of Complications, ........ 104 General Contusion of the Brain, ........ 107 Variability of Symptoms, ........ 108 Severe Cases, ........... 108 Mild Cases, ........... m Cases Complicated by Hemorrhages, 113 Limited Contusion of the Brain, . . . . . . , . 114 Laceration of the Brain, ......... 115 Temperature, ........... 116 Pulse and Respiration, .......... 121 Asymmetrical Radial Pulsation 122 Condition of the Pupils, . 124 Loss of Consciousness, ......... 125 Psychical Disturbances, 126 CHAPTER IIL Symptomatology — Contimced. Symptoms Indicative of the Localization of Lesions, .... 129 Mental Disorders in Cases of Laceration of the Frontal Lobes, . . 129 Differences in Symptomatology as the Right or the Left Frontal Lobe, or as the Superficial or Deeper Portion of the Left Lobe, is Involved — Tabulation of Cases, ...... 130 Illustrated by Histories of Pistol-Shot Wounds, .... 136 Conclusions, ........... 138 TABLE OF CONTENTS. "AGE Derangements of Muscular Action 138 Paralysis. 139 Incoordination, 139 Clonic and Tetanic Spasm 139 S3-mptoms from Lesion of Corpus Striatum, . 141 Optic Thalamus 141 Fornix, ........ 142 Gyrus Fornicatus, ...... 142 Pons 143 Temporal Lobe, 143 Conjugate Deviation 146 Loss of Urinary and Faecal Control. 147 Secondary Inflammations 148 Arachnitis, I4S General Symptoms 150 Abscess 153 Superficial, ..... 153 Deep. 154 Analysis of General Symptoms, 157 Localizing Symptoms 159 161 CHAPTER IV. Diagnosis. Unconsciousness as a General Indication of Traumatic and Idiopathic Characteristics of Opium Narcosis, 165 " Ursemic Coma. . 166 " " Apoplectic Coma, . 166 " Alcoholic Coma, . 166 " " Traumatic Coma, . 167 Diagnosis of Traumatic from Alcoholic Coma, . 168 Coexistence of the Two Conditions, . 169 Temperature, ...... . 170 Delirium, ....... • 171 • 172 Coexistence of the Two Conditions, . 172 • 173 DiflEerentiation of Traumatic Lesions from Each Other, • 174 • 174 Unconsciousness, ..... • 175 Temperature, ...... . 176 Respiration . • 177 Pulse • 177 TABLE OF CONTENTS. xi PAGE Condition of Pupils, -179 Mental Disturbances, ......... 180 Muscular Disorders, . . . . . . . . .i3i Loss of Urinary and Fsecal Control, ...... 182 Aphasia — Not from Hemorrhage . .182 Unconsciousness, Temperature, Pulse, and Respiration, as the Essential Factors in Diagnosis of Intracranial Lesions, . . 185 Secondary Inflam.mations, . . . . . . . . .185 Arachnitis, . 185 Abscess, ............ i88 Diagnosis, when of Early Formation, from Primary Contusion, . . 188 Diagnosis, when of Later Development, from Results of Vascular Le- sions and from Tumor 189 Symptoms Common to All Organic Diseases of the Brain, . . . igo Symptoms Common to Abscess and Tumor igo Diagnosis of Abscess from Tumor, igi CHAPTER V. Prognosis. Direct Lesions, ........ Statistical Results in Five Hundred Original Cases, Relative Danger of Fractures of Cranial Base and Vertex Dependent upon Complications. ...... Relative Danger of Different Intracranial Complications, Analysis of Recovering Cases, ..... Prognostic Indications from Individual Symptoms, Secondary Inflammations, ...... Arachnitis, ........ Abscess 193 193 195 195 198 201 204 204 205 CHAPTER VI. Principles of Treatment. Direct Lesions, ........... 206 Shock, ..... 206 Operation for Intracranial Injuries, • . 208 Epidural Hemorrhage 208 Conditions of Operation. ........ 210 Subdural Lesions, .......... 212 Pial and Cortical Hemorrhages, ....... 212 General Contusion, .......... 214 Laceration of the Brain 215 Arachnitis, ........... 216 Suramar5\ ...'........ 217 Late Pathic Conditions, ......... 219 Dangers of Operation 220 XI 1 TABLE OF CONTENTS. General Conduct of Operation General Treatment, Secondary Inflammations, Arachnitis, Abscess, Superficial, Deep, PAGE . 222 ■ 223 . 227 . 227 . 22S . 22S . 230 PART II. Pistol-Shot Wounds of the Head. CHAPTER VII. Medico-Legal Relations. Observations Made upon the Cadaver, Extracranial Lesions, 0.3S cal.. Head, o. 3S cal.. Bod}-, 0.32 cal.. Head, 0.44 cal. , " 0.22 cal., " Generalization of Results, Modifying Conditions, Characteristics of Cutaneous Wound of Exit, How far Wounds Inflicted during Life Differ from Those Cadaveric Experimentation, ..... Comparative Importance of Different External Conditions in Estimating Range and Calibre, .... Medico-Legal Importance of the Study of These Lesions, cessity of Sufficiently Extended Experimentation, Decisive in only a Limited Number of Cases, Cranial Lesions, ...... Peculiarities Common to all Calibres of Ball, Cranial Penetration, .... 0.44 cal.. Pistol of Most Efficient Type, 0.44 cal.. Pistol of Inferior Type, 0.38 cal., . 0.32 cal., .... 0.22 cal., ; . . . Modifying Conditions, Dimensions of Cranial Wounds, 0.44 cal., .... 0.38 cal 0.32 cal.. .... 0.22 cal., .... Produced in Enumeratec and the Ne 235 239 239 250 254 260 266 276 2 86 289 290 292 295 297 297 298 298 300 302 302 304 306 30S 312 312 312 314 314 TABLE OF CONTENTS. Xlll PAGE Summary, . 314 Cranial Wounds of Exit, 315 Cranial Comminution and Fissuring, 320 0.44 cal., ..... 320 0.38 cal., 322 0.32 cal., ..... 324 0.22 cal., ..... 324 Intracranial Lesions, 326 CHAPTER VIIL Surgical Relations. Symptomatology, .... Profundity of Unconsciousness, Immediate Subjective Symptoms, Diagnosis, .... Fluhrer's Probe, Nelaton's Probe, Girdner's Telephonic Probe, Use of Rontgen Rays, Acupuncture, Diversion of the Bullet, . Examdnation of the Eye and Orbit, Examination of Cervical Region, Treatment, ..... Shock, ..... Several Views as to Further Treatment, Illustrations from Published Cases, Results of Expectant Treatment, Incision of Dura Mater, . Operation with a View to Drainage only. Analysis of Published Cases with Reference to the Results of Reten tion of Bullets within the Cranial Cavity, Conclusions, ...... Analysis of Published Cases with Reference to the Comparative Dan- ger of Retention and Removal of Bullets Deeply Situated within the Cranial Cavity Conclusions, Treatment of Superficial Wounds of Entrance and Exit Exaggerated Estimate of the Danger of Operation, Details of Operation, . . . Counter-Operation, ...... Circumstances Adverse to Counter-Operation, Disinfection and Drainage, ..... Prognosis, ........ Statistics Treatment, . • , • • • • • 334 337 338 342 344 344 345 346 348 349 350 35T 353 353 354 355 356 358 360 360 366 366 370 371 372 375 379 382 384 387 387 390 XIV TABLE OF CONTENTS. The Condensed Histories of Three Hundred Intra- cranial Traumatisms. CASES verified BY NECROPSY. Fractures of the Cranial Base, Fractures of the Cranial Base from Pistol-Shot Wound, Fractures Confined to the Cranial Vertex, ..... Fractures Confined to the Cranial Vertex from Pistol-Shot Wound, Encephalic Injuries without Cranial Fracture PAGE 395 477 493 503 513 CASES unverified BY NECROPSY. L^nclassified 537 Intracranial Lesions from Pistol-Shot Wounds with Recovery, . . 577 INJURIES OF THE BRAIN AND OF ITS MEMBRANES. PART I. GENERAL TRAUMATIC LESIONS. A PRELIMINARY CONSIDERATION OF CRANIAL FRACTURE. Injuries of the head may be topographically classified as superficial or extracranial, cranial, and intracranial. These may occur independently or may variously com- plicate each other. The external injuries may be excluded as of no import- ance in a consideration of intracranial lesions except as aids in diagnosis, and in the case of cutaneous wounds, as a possible means of infection in meningitis or in the course of cerebral abscess. The cranial injuries are contusion and fracture, and of these contusion followed by consequences of moment is in- frequent and has no closer relation to intracranial injury than have contusions of the more superficial parts. Frac- tures so usually complicate, or are complicated by, struc- tural changes in the brain or its meninges ; and are often so directly connected with the pathic results of intracranial lesions, either by osteal hemorrhage or by affording a channel for the invasion of septogenic germs, as to justify some particularity of attention to their peculiarities. 2 injuries of the brain and membranes. Fracture. The classification of fractures of the cranium is prima- rily the same as of fractures of other bones: I. Simple. Compound. Comminuted. Complicated. II. Complete. Incomplete. III. Direct. Indirect. Secondarily or specifically they may be again sub- divided : I. Fractures of the vault. Fractures of the base. II. Linear or fissured. Punctured. Depressed. The last may be either singly or doubly camerated. A much simpler and therefore better classification, which has the additional advantage of a definite relation to diagnosis, prognosis, and treatment, may be derived from the one just presented. PRELIMINARY CONSIDERATIONS. . 3 I. Integral. Complicated. Non- complicated, II. Regional. Fractures of the vault. Fractures of the base. Fractures of either the vault or base may be simple, compound, or comminuted, punctured, linear, or depressed, direct or indirect, though the relative frequency of these subdivisions varies greatly in the two primary forms. Fractures of the base are ordinarily simple and linear, ■while those of the vault are not infrequently compound, comminuted, depressed, or punctured. Both are almost invariably caused by direct violence, and, while both may be either complicated or non-complicated, a complication in fracture of the base is more characteristic and often oc- casions not only differences in prognosis but in methods of diagnosis and requirements of treatment. The presence or absence of a complication is of essential importance, and as its recognition, probable result, and treatment may be influenced by the region of injury, the corresponding divisions of fracture, whether or not they are accepted as a formal basis of classification, must always be those of the greatest practical value. The other distinctions which may be made in the characters of a fracture, if not insig- nificant, are at least of minor importance; whether the osteal wound be simple or compound, linear or depressed, or comminuted, is of little moment in view of the present 4 INJURIES OF THE BRAIN AND MEMBRANES. resources of surgery ; and one is often converted into the other in the course of preliminary examination. All fractures which involve the base, though originat- ing in the vault, are to be regarded as basic, because it is upon the implication of this region that their characteristic conditions depend. In a certain number of cases, violence is inflicted through the eye, nose, or mouth, or inferior temporal region, by bullets or exceptionally by sharp- pointed instruments ; but exclusive of these there are few instances in which a fracture of the skull does not have its beginning in the vault. In the appended series of cases, as verified by necropsic examination, there are 146 frac- tures of the base, of which 18 were from pistol shot and i from another form of violence directly applied to the point of basic lesion ; there are 34 fractures confined to the vault, of which 14 were from pistol shot; in 147 fractures of the vault, therefore, not of pistol-shot origin, the base was im- plicated in 127. There existed in but 12 of the 127 a basic fissure independent of a fracture of the vault, and in sev- eral (6) of these another fissure extended from vault to base. These 12 cases in which force was indirect, that is to say, in which the fracture began and ended in the base, though the force was applied to the vault at a distance and transmitted through parts which maintained their in- tegrity, are instances of what has sometimes been called injury by contrecoup, and similar to what is much more frequently encountered in the brain. In each case by the history as well as by existent wound or contusion, it was proven that the force was primarily exerted upon the vault, nor was there in any one the slightest reason to suspect that the effect of violence had been conveyed through the spinal column. The concurrence of direct PRELIMINARY CONSIDERATIONS. 5 fracture was noted in 6 cases and there was intervening brain laceration in all but 2. The direct force in 6 cases was applied to the parietal region, and in 3 of these was transmitted to an orbital plate or to the crista galli and sphenoid surface ; in 5 it was applied to the occiput, and in 3 of these also was transmitted to the orbital plates ; but in the others the indirect fracture was produced in the middle or posterior fossa or upon the surface of the inter- vening petrous portion. It is evident therefore that it is not always the most fragile portions of the cranium which give way. In 10 of the 12 cases the counterfracture was no more than a fine short fissure, which could have had no influence in the display of symptoms and could be of no real importance in contravening the general statement that fractures of the base are continuations of fissures which have their origin in the vault at the point of injury. In the 2 cases remaining the counterfracture was directly contributive to the death of the patient. In one the fis- sure widely curved through both orbital plates and the fractured edge of each was raised and tilted forward, and on the right side it deeply lacerated the base of the frontal lobe ; the frontal sinus was also opened into the cranial cavity. In the other a smaller osseous lesion was no less disastrous ; the fissure was fine and extended only from the anterior inferior angle of the parietal bone across the squamous portion of the temporal to the petrous junction, but a minute triangular portion of the inner table was de- tached and had lacerated the arteria meningea media at its bifurcation with resulting profuse and fatal hemorrhage. The conditions which govern the character and extent of cranial fractures are the violence of impact, the extent of surface involved, and the physical properties of the era- 6 INJURIES OF THE BRAIN AND MEMBRANES. nium, its elasticity, composite structure, degree of thick- ness or density, and its vaulted form. The concentration of force when the head is struck by an object of limited size and definite outline tends to the production of com- minuted and depressed fractures confined to the region of impact. The diffusion of force when the head itself is the impinging object, as in falls from a distance, equally leads to extended fissures with or without crushing at the point of direct injury. The observation of cases, however, shows that the physical properties of the cranial vault are ordinarily such that even when force is concentrated, if the instrument of violence be other than a pistol shot or some sharp weapon, the effect is much more than likely to be diffused. A great degree and concentration of violence and a tenuity or brittleness of a part undoubtedly favor re- striction of fracture to the site of injury, as wider diffusion of force and the elasticity and average density of the skull account for its more frequent extension by fissure to a dis- tance. The precise mechanism of basic fracture has been ex- perimentally investigated by various surgeons, who have arrived at somewhat different conclusions. The recent summary of the opinions of these experimenters by Ros- well Park, in Dennis' "System of Surgery," precludes the necessity for their repetition. The usual basic fracture unquestionably extends be- tween the region in which primary injury is received and the corresponding basic fossa of the same side ; and the explanation of Aran, that force follows the shortest anatomi- cal route and in the direction in which there is least resistance, seems adequate. If the middle fossae, alone or in contiguity, suffer oftener than the others, it is because PRELIMINARY CONSIDERATIONS. 7 the middle region of the vault is most exposed to violence. If force is too great for its entire expenditure at the point of impact, or resistance too obstinate, it traverses the bone till exhausted ; that it should be propagated in direct lines, modified only by inequalities of resistance, is as plainly in accordance with natural laws as the riving of wood or iron by the wedge. In some instances the force is too great to be restrained by any resistance which it may encounter, and transgresses the limits which may be set by " natural buttresses," or abandons the squamous to folloAV its direct course through the denser petrous portion. The theory of Hare, that the elastic skull, compressed between two poles, like a melon gives way in the middle, and that the fracture extends in both directions, seems far-fetched and not sub- stantiated by appearances which the fissures present when examined for corroboration. The comparison of the exact site of superficial contusion w^ith the commencement of a linear fracture of the vault indicates that not infrequently force may be transmitted through the bone for a certain distance before disruption begins. The limited number of cases in which independent fractures, more or less trivial, occur at the base, with or without a fracture of the vault, are less readily explained by the direct propagation of force through the cranial wall. The brain substance and the bone have each been regarded as the medium of transmission. In the well-known case of the assassination of a president of the United States, in which a pistol-shot fracture of the occiput, with lodgement of the bullet near the corpus striatum, caused comminution of both orbital plates, Mr. Longmore believes that the or- bital fracture was due to " transmitted undulatory strokes or sudden impulse of the brain substance against these 8 INJURIES OF THE BRAIN AND MEMBRANES. bony layers." This may be possible in so thin and fragile laminae as the orbital plates, but it is insufficient to explain the Assuring of bony parts so dense as the petrous portion of the temporal, or the floor of a middle or posterior basic fossa. There are also the special defects in Mr. Long- more 's explanation of the counterfracture in the case quoted, that it ignores the fact that the direction of force was parallel to the orbital surfaces, and that it fails to account for the upward dislocation of the fragments. In simple counterfissure of the base, it would seem more probable that the distant lesion was due to the direct trans- mission of force through the bone. In view of the numer- ous instances in which force is transmitted for a limited distance through the lateral wall of the vault before cleav- age begins, it is not illogical to suppose that in others exceptionally noted its course should have been even longer continued before its eruption. In counterfissures confined to the petrous portion or to the contiguous basic fossae, it is scarcely possible to conceive, though the skull might be compressed to the point of bursting, that the rupture should have occurred in its most rigid if not abso- lutely inelastic portion. The effect of distant violence, in causing not only indirect fracture but limited osteal hyper- aemia and extravasation, is illustrated in Case CXXV. of the appended series and represented in Fig. 44. There are occasional indirect basic fractures which are more readily explicable, or even necessarily dependent, upon the suppo- sition that the skull has been violently compressed. In Case CIV. of the appended series, the circumstances of in- jury and the effects which it produced concur to make this explanation inevitable. The head was struck upon the occiput by a descending elevator and forced forward, with PRELIMINARY CONSIDERATIONS. 9 the chin resting upon an iron railing as an approximately fixed point. Fracture was confined to the anterior basal fossae, and extended from the posterior border of the crib- riform plate upon the right side by a wide sweep outward and forward, and then inward through both orbital plates. The roof of the orbit was elevated and tilted forward, and the frontal sinuses were opened into the cranial cavity. Continued force and resistance acted at the extremities of the occipito-mental diameter, and violent disruption oc- curred in a vulnerable region at its centre. In a recov- ering case, No. CCLIX., in which force was similarly applied, fracture through the anterior and middle fosss into the petrous portion was doubtless produced by the same mechanism. It is impossible to believe that the mechanism of frac- ture is always the same. In a careful necropsic examina- tion of cranial fractures included in the appended series of cases, there are a rather limited number which immedi- ately involve the base, all but one from bullet wound, and a scarcely larger number which may be termed indirect and are of questionable origin. All the others, more than ninety per cent, of the entire number, are the result of violence inflicted upon the vault, and of these more than seventy-eight per cent, extend to the base. If pistol-shot fractures be excluded, the percentage of those which extend from vault to base is increased to eighty -five. The inspection of basic fractures of this predominating class has suggested nothing but an origin at the point of injury. They negative in their appearance Hare's opin- ion that diffuse bloAvs produce their effect at a distance from the point of application, and, as such evidence is entitled to more weight than conclusions, which must be 10 INJURIES OF THE BRAIN AND MEMBRANES. more or less theoretical, derived from experimentation upon the cadaver, these fractures must be regarded as in general the product of direct violence. The very small proportion of basic fissures which are obviously indirect are very likely of variable as well as questionable origin ; apart from such unusual antecedent conditions as severe and demonstrable compression of the head between two fixed points, exemplified in Case CIV., they afi'ord no positive etiological data; whether force is generated by insupportable distortion of the elastic vault, or is trans- mitted like the electric current without change in the osseous structure traversed to its point of discharge in some basic region, or is propagated by undulations in the brain substance, is a problem still confined for its solution to the domain of theory and of individual probability. These indirect fractures have been called contrecoup, since they are developed in a region directly or approximately opposite to that in which violence has been inflicted, and the term may be conveniently and allowably retained with- out involving a theory of their production ; its application to fissures of the base which are continuous with fractures of the vault is unwarranted, A study of the one hundred and eighty cranial fractures in the appended series of original cases which were sub- jected to post-mortem examination discloses many facts concerning the details of their character and mechanism which are of interest and value, but are not essential to the discussion of intracranial lesions. The peculiarities of depressed, comminuted, or perfo- rating forms of cranial fracture are adequately described in general text-books of surgery. Simply as osseous le- sions they have been robbed of their significance by ad- PRELIMINARY CONSIDERATIONS. II vancements in the methods of surgical practice. In their greater liability to intracranial complication they retain their special importance ; a degree of violence sufficient to comminute the bone is likely to extend its effects to the subjacent structures ; depressed fragments become new sources of injury; and perforating fractures almost neces- sarily involve cerebral or dural wound. Their results are more serious and their treatment demands more active intervention than do simple fissures, but it is by reason of the complication rather than by the greater injury Avhich the bone has sustained. The necessity of removing com- minuted or of elevating depressed fragments of bone scarcely increases the gravity of prognosis. The most insignificant fissure may be associated with fatal in- tracranial hemorrhage, while the largest comminution, if uncomplicated, may be devoid of danger. It is the complication and not the fracture which dominates the case. The complications of cranial fracture are cerebral and meningeal, and in either one may be laceration, contusion, hemorrhage, or septic inflammation ; and to these may be added hemorrhage from the osteal vessels. The septic inflammations are rather sequelae than complications, since they are not direct products of the same violence which causes the fracture, but the result of a later infection for which the fracture has afforded opportunity. All these conditions may equally occur in the absence of fracture, as primary and independent lesions, and as such will be given later consideration. Fractures which are practically uncomplicated may occur both in the vault and in the base, though some degree of cerebral contusion will probably attend even the most inconsiderable of simple fissures. If 12 INJURIES OF THE BRAIN AND MEMBRANES. the symptoms of this contusion are trivial and transient, it may be properly disregarded in classification as well as in treatment. Symptomatology and Diagnosis. The very frequent coincidence of fracture with intra- cranial lesion has led to much confusion in symptomatol- ogy and consequent prognosis. Loss of consciousness and variations in pulse, temperature, and respiration, with other undoubted indications of intracranial com- plication, are still enumerated among the symptoms of fracture. These inaccuracies are of consequence, since a lack of well-defined conception of the nature of lesions or of the significance of symptoms begets errors of treatment. The direct effects of fracture are few and usually not difficult to discover. It may be briefly stated that fracture of the vault is to be recogized by tactile or visual sense; that these methods are always practicable ; that no others are defensible; and that there is no justification for the neglect to resort to both when one is insufficient for exact diagnosis. If the fracture be compound, there can be no doubt of its existence, provided the wound be of sufficient size to disclose the osseous surface ; if the wound be too small for thorough exploration, the fracture may be re- garded as essentially of the simple variety. The simple fracture, if depressed, may be often recognized by palpa- tion through the layers of the scalp, but if doubt exists, or if from symptoms of intracranial complication suspicion arises, certainty should be reached by incision and direct inspection. This covers the whole ground of diagnosis — tactile or visual examination, and, if necessary to that PRELIMINARY CONSIDERATIONS. 1 3 purpose, unhesitating and sufficient incision down to the cranial surface. The diagnosis of fracture of the base is sometimes equally direct, but is oftener inferential, and it may be entirely conjectural. If continuous with a fracture of the vault which has attracted attention, it should be incident- ally discovered in the course of the examination necessi- tated at the site of immediate injury, as fissures are readily traceable to a point at which their implication of the base becomes assured. In a very large proportion of cases, however, the basic fracture begins as a simple fissure at the vertex, or upon the lateral aspect of the vault, and with an absence of conditions w^hich suggest direct exploration. The indications of intracranial injury may then afford reasons for inferring the existence of basic fracture, but not with absolute certainty, since the occurrence of inde- pendent traumatic lesions is not infrequent. There is one direct symptom of the fracture which when present may be almost pathognomonic: it is an osteal or intracranial hemorrhage w^hich through some channel becomes visible at or beneath the surface. Its source may be the vessels of the diploe, of the meninges, or of the brain, and its escape may be from the ear, nose, or mouth, or into the subconjunctival or subcutaneous cel- lular tissue. The fracture very generally traverses some portion of the base w^hich permits the appearance of the blood externally in one or the other of these situations. The comparative frequency with which different basic regions are involved, and the significance of various ex- ternal hemorrhages of internal origin, are suggested by a summary of these fractures included in the appended gen- eral series. 14 injuries of the brain and membranes. Fractures of the Base. I. Results. Recovered, . . . . .no Died, 176 II. Necropsies. Fractures continued from vault, . 133 Fractures confined to base, . .13 III. Hemorrhages. Fractures with external hemorrhage, 67 Fractures without external hemor- rhage, 61 IV. Regions of Fraeture and External Site of Hemor- rhage (pistol-shot fractures excluded). 1. Petrous Portion. Hemorrhage from ear, . . 5 No hemorrhage, .... 4 — 9 2. Petrons Portion and Middle Fossa. Hemorrhage from ear, . . 6 Hemorrhage from ear and nose, . 2 Hemorrhage from ear, nose, and mouth, . . . . i No hemorrhage, . . . . 3 — 12 3. Petrous Portion and Posterior Fossa. Hemorrhage from ear, . . 5 Hemorrhage, subcutaneous, mastoid, i Hemorrhage from ear and nose, . 3 No hemorrhage, .... 3 — 12 4. Petrous Portion ; — Middle and Posterior Fosses. Hemorrhage from ear, . . 6 Hemorrhage from nose, . . 3 Hemorrhage from ear and mouth, i PRELIMINARY CONSIDERATIONS. I 5 Hemorrhage from ear, mouth, and nose, . . . • 2 No hemorrhage, . . • • 2 14 5. Petrous Portion; Middle and Anterior Fosses. Hemorrhage from ear, . • i Hemorrhage from ear and nose, . 4 Hemorrhage from ear, nose, and mouth, . • • • ^ Hemorrhage from ear and nose and subconjunctival, • . i Hemorrhage, subconjunctival, . 1—8 6. Both Petrous Portions and All Basic Fosses. Hemorrhage from one ear, . . i Hemorrhage from both ears, nose, and mouth, . • • • ^ ^ 7. Petrous Portion and All Basic Fosscb of the Same Side. Hemorrhage from ear, . • i Hemorrhage from ear, nose, and mouth, . • • • ^ ^ 8. Petrous Portion; Anterior and Middle Fosses; Basilar Process. Hemorrhage from ear, nose, and mouth, . • • • ^ 9.. Anterior Fosscb. Hemorrhage from nose, . • 2 Hemorrhage from nose and mouth, i Hemorrhage, subconjunctival, No hemorrhage, . • • ■ 10. Middle Fosses. Hemorrhage from nose, . • 3 Hemorrhage, subconjunctival, I 5—9 I l6 INJURIES OF THE BRAIN AND MEMBRANES. No hemorrhage, .... 13 — 17 1 1 . Posterior Fosses. No hemorrhage, . . . .21 12. A nterior and Middle Fossee. Hemorrhage from nose, . . 6 Hemorrhage, subconjunctival in both eyes, . . . . i Hemorrhage, subjunctival, in both eyes, nose, and mouth, . . i No hemorrhage, . . . . 5 — 13 1 3 . Posterior and Middle Fossce. Hemorrhage from nose, , . i No hemorrhage, .... 4 — 5 14. Posterior and Anterior Fosses. Hemorrhage, nose, . . . i 1 5 . Anterior, Middle, and Posterior Fosses. Hemorrhage from nose, . . i No hemorrhage, .... i — 2 V. Sununary of External Sources of Hemorrhages. Hemorrhage from ear, . . 26 Hemorrhage from ear and nose, . 9 Hemorrhage from ear and mouth, i Hemorrhage from ear, nose, and mouth, .... 6 Hemorrhage from ear, nose, and subconjunctival, . . . i Hemorrhage from nose, , .17 Hemorrhage from mouth, . . i Hemorrhage from nose, mouth, and subconjunctival, . . i Subconjunctival hemorrhage, . 4 Subcutaneous, mastoid hemorrhage i — 67 PRELIMINARY CONSIDERATIONS. 1 7 This study of hemorrhages has been confined to the first class of basic fractures, those in which fissure extends from a site of injury in some part of the vault. The cases in which fracture originates in the base are almost exclu- sively pistol-shot wounds, and are not often attended by distant hemorrhages and rarely involve a question of re- gional diagnosis. The inferences to be derived from the tabular analyses are so obvious as scarcely to call for explanatory comment. It will be observed that hemorrhage from the ear has oc- curred in more than one-third of the total number of cases, in all of which the petrous portion has been impli- cated; that hemorrhage from the nose has occurred in more than one-fourth of all the cases, and when significant has followed fracture of an anterior fossa or of the ante- rior part of a middle fossa; that there has been subcon- junctival hemorrhage in six cases, in all of which the fracture traversed an anterior fossa; that buccal hemor- rhage has been noted three times, twice in conjunction with epistaxis; and that the subcutaneous hemorrhage resulted from an inclusion of the mastoid process in a fracture through the posterior fossa. The anatomical necessity which absolutely limits these external indications to fracture of positively definite regions is manifest. The causes of their frequent absence in fractures of the same arbitrarily defined basic fossae are not less obvious. If the fracture of the petrous portion does not involve the audi- tory cavities, or that of the middle fossa involve the sphe- noid bone, there can be no escape externally of the blood effused; if the fracture of the anterior fossse does not traverse the ethmoid bone, and the injury to the orbital plates is trivial, the slight hemorrhage which it occasions 1 8 INJURIES OF THE BRAIN AND MEMBRANES. still fails of outlet; the only possible route by which blood extravasated in the posterior fossas can reach the surface is through the fasciae of the neck, except when the mas- toid process is implicated, when it may force its way through the periosteum and be visible subcutaneously be- hind the ear. The amount of hemorrhage from an occip- ital fracture is insufficient often to penetrate the deeper cervical fascias, unless it be from a pistol-shot wound, and its becoming subcutaneous is only a recognizable possi- bility. The occurrence of a visible hemorrhage as an in- dication of simple fracture of the base depends upon the implication of the mastoid or petrous portions of the tem- poral, the ethmoid or sphenoid, or the orbital processes of the frontal bone; and its undoubted value as a symp- tom, positive or negative, is dependent upon the relation, suggested by Aran, which these parts bear to the regions of the vault most exposed to injury. The apparent pro- portion of basic fractures attended by external hemor- rhage is somewhat diminished by the inclusion in the to- tality of cases of a certain number in which the early history was imperfect or absent, and in which the hemor- rhage might have been present but was not assumed. It is possible that these hemorrhages may occur as a coincidence rather than as a result of fracture, though their interpretation in such an event is not likely to be difficult. A hemorrhage from the ear accompanying a pistol-shot wound of the temporal fossa was found in Case CXX XVIII. to have resulted from a rupture of the tympanum by con- cussion, but extremities of violence by blows or falls upon the head, which have shattered the vault or base, have not incidentally produced a similar lesion, nor can such a re- sult be expected under any conceivable circumstances apart PRELIMINARY CONSIDERATIONS. I9 from the shock of an explosive at close contact. A wound of the external meatus may also occasion a moderate hem- orrhage, or blood from a wound of the scalp which has filled this canal may be momentarily deceptive, but such sources of error are eliminated in the preliminary exami- nation. If ordinary care be exercised in excluding these occasional non-essential hemorrhages, this direct symptom may be regarded as fairly pathognomonic. A failure to discover the wound of the tympanum is not material, since when linear it may be closed and invisible after hemor- rhage has ceased, but a lesion of the external meatus can- not be hidden from observation. The amount of blood which escapes from the ear, or the period at which hemorrhage occurs, its continuance, or its relation to serous discharges, while perhaps indicative of the extent of cranial or internal lesion, is not essential to the recognition of a petrous fracture. The simple knowl- edge that the hemorrhage exists, with exclusion of such possibilities of error as have been suggested, should be sufficient to establish the fact that this part has been frac- tured. The promptitude, freedom, and persistence of a hemorrhage from the ear which succeeds an injury to the head merely confirm the opinion which an otherwise in- explicable effusion has justified, and to this extent are fac- tors in the case. The subconjunctival, nasal, and buccal hemorrhages are less frequently positively diagnostic. Direct orbital contusions which involve the eye, or epistaxis from super- ficial injuries of the nose, may be coincident with basic fracture, and the estimate of the clinical value of a hemor- rhage in one of these situations may therefore require careful inquiry into the manner in which injury was re- 20 INJURIES OF THE BRAIN AND MEMBRANES. ceived, and a study of all the attendant symptomatic con- ditions. If the history shows, and the superficial lesions confirm, a limitation of the field of violence to a cranial region, and there is evidence of intracranial complication, the dependence of an ocular or nasal hemorrhage upon fracture can be properly inferred ; while the existence of a contusion of the nose or of an ecchymosis of the face or orbit will render its origin more or less uncertain. There are really few cases in which even this class of hemor- rhages cannot be correctly interpreted. The amount of blood lost or extravasated in this instance is of more im- portance than when the ear is the seat of discharge. An extensive subconjunctival effusion or a profuse flow from the nose at the outset, with perhaps subsequent hsema- temesis, affords a stronger presumption of fracture than trivial loss or discoloration, which might have been caused by trifling injury. After the lapse of twenty-four hours the beginning of a slow oozing from the nose or of a spreading discoloration beneath the subconjunctiva is more significant. The relative proportion of fractures of the base indi- cated by the external appearance of osteal or intracranial hemorrhage is greatly increased when comparison is ex- tended to the whole number of cases observed. In 115 cases in which fracture extended from vault to base, com- prising recoveries as well as deaths in which necropsy was unattainable, 99, or eighty-six per cent., were attended by external or superficial hemorrhage ; when no characteristic hemorrhage was present, diagnosis was made by incision. In the aggregate of this class of fractures, 224 recoveries, and deaths both with and without necropsic examination, 154, or seventy per cent., were associated with a visible PRELIMINARY CONSIDERATIONS. 2 1 hemorrhage which could be considered diagnostic. It is evident that the escape of blood externally, notwithstand- ing its obscurity in some instances and its failure of recog- nition in others, has in itself been sufficient to determine the existence of fractured base in a very large majority of cases included in the appended summary of observations. There are besides hemorrhage direct symptoms, of oc- casional or exceptional occurrence, which may be of great diagnostic value. The escape of brain matter from the ear is absolutely pathognomonic, not only of petrous frac- ture but of cerebral laceration. In one of two cases in the appended series, No. CCLIV., it followed profuse hemor- rhage and was delayed till the second day ; it was an in- termittent oozing for twenty-four hours, amounting to one drachm or more ; it was not followed by serious effects of brain injury, and the patient recovered. In the second case it was accompanied by profuse hemorrhage from the nose and mouth, but by none from the ear; the patient died in a few hours and escaped necropsic examination. It is more frequently observed in fractures of the vault, and very rarely through the nose. Serous discharges from the ear are also infrequent. In the entire series of two hundred and eighty-six cases of deaths and recoveries, there are altogether thirteen in- stances, but in three it was undoubtedly a declining phase of hemorrhage which in each had continued for a week, gradually lessening and becoming serous before its cessa- tion; and in a fourth, an intermittent sero-sanguinolent discharge, which appeared on the eighth or ninth day, was clearly aural and inflammatory. In the nine in which it was an actual symptom, it was primary and independent in two only, Nos. LXXIII., CCXXX., and in one of these 22 INJURIES OF THE BRAIN AND MEMBRANES. was followed by recovery. In the recovering case it began suddenly and very profusely a short time after the pa- tient's fall from a considerable height, and continued for several days ; the development of symptoms of intracranial complication was followed by a late mastoid inflammation, which was relieved by a trephination otherwise barren of result. The second case, in which the discharge was also profuse, proved fatal from pulmonary oedema in a few hours ; the petrous portion was fissured and the brain ex- tensively lacerated subcortically, with only slight arachnoid hemorrhage in the frontal region. The discharge in both instances was probably cerebro-spinal, in view of its pro- fusion and almost immediate occurrence. In the seven cases remaining, the serous fluid, which was abundant and usually clear, was preceded in each by a free hemorrhage lasting from a few hours to the fourth day ; three were fol- lowed by recovery and four by death and necropsy. In two of the necropsic cases, death was caused by purulent meningitis and there had been no intracranial hemorrhage ; in one there was a large arachnoid serous effusion at the base, and in the other a moderate arachnoid effusion with excessive oedema of the brain substance ; in one the pos- terior surface of the petrous portion was comminuted and in the other a fissure traversed its central portion. In the other two necropsic cases, petrous fracture was accompanied by large and firm epidural and arachnoid clots in a con- tiguous basic fossa, and in one of them by thrombosis of the superior longitudinal, lateral, and petrosal sinuses and internal jugular vein, with a localized oedema in the pos- terior cerebral region confined to the meshes of the pia mater. The three recovering cases in which serous dis- charge followed hemorrhage were not of identical charac- PRELIMINARY CONSIDERATIONS. 23 ter ; in one it was coincident with an extrusion of brain matter on the second day and continued twenty-four hours ; in the other two it occurred on the second and fourth days and was of brief duration. All the sources to which these watery fluxes have been ascribed seem to have been exemplified in these few cases. In three it was demonstrably the final phase of hemor- rhage, and in one the outcome of aural inflammation ; in two it was no less positively the cerebro-spinal fluid, and in two an inflammatory arachnoid effusion ; in one at least certainly, and in others presumably, it was the result of the coagulation of blood following an intracranial hemor- rhage. In this way it often happens that exclusive theories are disproved by the results of sufiiciently extended observation. The diagnostic value of watery discharge is very lim- ited ; if it is primary and profuse, it is pathognomonic ; if, as these observations seem to show, it usually follows a hemorrhage, when it occurs at all, it adds nothing to the already assured certainty of fracture. Another and still more infrequent symptom of basic fracture is an oedema of the mastoid region. In the single instance noted, No. LXIL, it accompanied fracture of the posterior fossa which traversed the groove for the lateral sinus, with obstruction of that vessel by a thrombus. The occurrence of such a symptom must necessitate the joint condition of a venous obstruction to cause the oedema and of a fracture to permit its appearance in a cranial region. It could hardly be apparent at any point where the super- ficial tissues are thicker than those which so thinly cover this bony prominence. In one of the instances cited of secondary serous discharge from the ear, it is possible that 24 INJURIES OF THE BRAIN AND MEMBRANES. the same conjunction of thrombosis and fracture may have contributed to the result. The implication of a cranial nerve may discover the existence of a fracture, even if otherwise unsuspected. It must be practicable, however, fairly to determine that functional disturbance or abeyance does not depend upon intracranial lesion before it can be attributed to structural injury of the nerve while within its bony conduit or fora- men. It is possible that any cranial nerve may be crushed or compressed in this manner, though, with the exception of the second and seventh pairs, it is in the highest degree improbable. In the appended series of cases, there are numerous instances in which each in turn has suffered functional loss or disturbance from intracranial lesion, but it is only in case of the second and seventh that similar conditions have been demonstrably due to implication of the nerve in the line of fracture. The frequency with which this complication occurs is probably overestimated. Facial paralysis in connection with head injuries is of con- stant occurrence, and fractures of the petrous portion in- volving the part through which the nerve passes constitute a large proportion of all those extending into the base; yet a cranial rather than an intracranial origin of this con- dition is rarely suspected, and is still more rarely disclosed on necropsic examination. There is in general neither osseous displacement nor retention of coagula to lacerate or compress the nerves, and only one or two examples can be found in the whole of the appended series. The lesion of the optic nerve at the optic foramen by compression from the osseous fragments is less exceptional than the injury to the facial, and is more readily discover- able, not only after death but during life. Callan published PRELIMINARY CONSIDERATIONS. 2$ nine cases and has since increased the number of his obser- vations to seventeen. The appended series of cases in- cludes six, of which four were recognized only upon necropsy, and of these three had died without the recovery of consciousness and the fourth had suffered no loss of vision. In one only was the nerve implicated in the frac- ture. In the two cases in which life was preserved, the patient upon the restoration of intelligent consciousness discovered loss of vision. Ophthalmosopic examination made on the third day in the first was negative, though the pupil did not respond to direct exposure to light ; fifteen days later atrophy of the optic nerve had begun. In the second case the ophthalmoscopic examination was not made till the fourth week ; the pupil was then insensitive to light and atrophy of the nerve was in progress. Entire loss of vision was permanent in both cases. These six probably represent nearly if not quite the whole number of cranial injuries to the optic nerve in the series of two hundred and forty-five basic fractures. The necropsic examinations, when the anterior fossae were involved, were made with a view to the detection of this complication, and if the patient recovered it certainly could not have escaped observation ; if there were others, they must have been confined to the very few instances in which death occurred without previous restoration to con- sciousness, and in which opportunity was not afforded for post-mortem examination. The injuries to the nerve are much fewer even than the implications of the optic fora- men in the line of fracture. Callan gives this description of the lesion and its mani- festations : " It is due to a fracture of the sphenoid bone which compresses the optic nerve as it passes through the 26 INJURIES OF THE BRAIN AND MEMBRANES. optic foramen, and is more likely to happen if the blow is received upon the frontal bone, but may result from a fis- sure which extends from another cranial region. Monocu- lar blindness is immediate and generally with total loss of all light perception. The eyeball protrudes and diverges, and the pupil is enlarged and non-responsive to light. Optic-nerve atrophy begins within two weeks." The two cases cited conform to this description, except that hemorrhage chanced to be insufficient to cause ocular protrusion or divergence. In only one of the necropsic cases did the fracture involve the sphenoid body. The cases in which sight is destroyed by direct wound of the orbit, as from pistol shot or by profuse hemorrhage into the orbit or globus oculi in fracture propagated from the vault, are of less diagnostic interest, because the con- dition is obvious and readily apprehended. There is still another and perhaps final direct symptom of basic fracture which may suggest its existence and loca- tion in the absence of more positive indications. It is an acute localized pain, different from the frontal, occipital, or diffused headache which is common in all forms of in- tracranial lesion. Its limitation and intensity serve to distinguish it from the pain of internal injuries, while it is disproportionate to the amount of superficial contusion. In fracture limited to the posterior fossa, in which other direct symptoms are often wanting, it may afford the only ground for suspicion, and when it involves the mastoid process its import may be confirmed by the later appear- ance of subcutaneous hemorrhage. It has been often noted in the cases appended, and its significance often established in subsequent post-mortem examination. This symptom, which has been generally if not en- PRELIMINARY CONSIDERATIONS. 2/ tirely overlooked, is sufficiently important to deserve attention. The evidences of intracranial complication which have been so often regarded as symptoms of basic fracture are indirectly diagnostic of that lesion, but only in so far as they explain or confirm its direct indications ; they are of themselves insufficient, since all of the intracranial lesions may exist independently, just as fracture may occur with- out complication. The cranial and the intracranial lesions, however, concur in a large majority of cases, and while the direct symptoms are usually adequate to a diagnosis of the fracture, there are still cases in which an element of doubt remains, to be resolved, possibly, by the recognition of an internal injury. A profuse hemorrhage or serous dis- charge from the ear, with certain restrictions as to the conditions under which it occurs, or the extrusion of brain tissue, may render the existence of a petrous fracture cer- tain ; but a nasal hemorrhage or a localized pain, however characteristic, can hardly determine an ethmoid or sphe- noid or a mastoid fracture with equal certainty, and con- firmation is naturally sought in the fact of intracranial complication. The possible error in the use of this means of diagnosis has been in ascribing to it undue importance, and in a consequent depreciation of the value of direct symptoms. Some minor degree of cerebral contusion may exist in any case in which violence has been sufficient to produce fracture, but, if so, its indications are so often slight and transitory, and early histories are so often im- perfect, that this assumption is impossible of verification. The presence therefore of even trivial intracranial injury cannot be regarded as essential and much less as of pri- mary importance in the diagnosis of fracture, which really 28 INJURIES OF THE BRAIN AND MEMBRANES. occurs much oftener without complication than without the evidence of direct symptoms. Fractures of the base were for a long time regarded as shrouded in mystery, and, like the intracranial traumata, as problems to be satisfactorily solved only by necropsic examination. The means afforded for their diagnosis are certainly not unusually restricted ; the possibility of trac- ing the fissure from its origin in the vault, the evidence of external hemorrhages, serous discharges, or extrusions of brain tissue, the localization of pain, and the concurrence of complicating intracranial lesions, suffice in by far the larger number of cases to remove them from the domain of obscurity and conjecture. Prognosis. The prognosis of cranial fracture demands some con- sideration. It concerns repair, the loss of function, and by a possibility the danger to life. The restoration of the bone in simple linear fracture is effected by a definitive callus and is perfect ; even a trace of its existence is eventually discoverable in only the most exceptional instances. At the base, in which fracture is almost invariably of this form when propagated from the vault, and in which frequency of occurrence and of recov- ery would presuppose frequency of disclosure in the dead- house if evidence of closed fissures remained, it is practi- cally unknown as an ancient lesion. A cranium discovered and lost in the morgue of Bellevue Hospital many years ago, by a youth ignorant of its pathological value, exhibited a line of fracture across both middle fossae with slight dis- placement of the posterior segment upward, and with PRELIMINARY CONSIDERATIONS. 29 union long perfected. This specimen was periiaps uniqiie. If the fissure is widely opened and the patient survives the complications with which it is likely to be attended, it will be approximately closed by the elasticity of the skull be- fore repair begins. In any event the process is slow and may extend over many months. An exception to the almost invariable closure of an open fissure occurs in one of the appended cases, in which, with a fracture through the median line of the frontal bone extending into an orbi- tal plate, perceptible separation and mobility of the seg- ments existed five years after a comminution of the vertex. The very unusual instances cited, the displacement of seg- ments of the base and the lack of union in fissure of the vault, are merely curiosities of surgical experience. The established rule as to the absence of displacement and the perfection of union in this class and variety of cranial frac- tures is unaffected. Fracture of the orbital processes of the frontal bone occur under special conditions, and dis- placement of fragments which sometimes directly lacerate the frontal lobes are not uncommon ; they are consequently allied to fractures of the vault rather than of the base. The only dangers directly attributable to linear fracture are essentially confined to the orbital region, and are the laceration of the brain by elevation of an orbital fragment and implication of the optic nerve in its foramen of exit. Displacement elsewhere in the base or in the vault Avithout comminution is practically impossible ; implication of other cranial nerves is very exceptional, and no subsequent harm can come from the simple process of repair. Depressed or displaced, and comminuted, fractures are limited to the vault and orbit, regions in which the bone is comparatively thin, and are often prolonged by simple fissures. If the 30 INJURIES OF THE BRAIN AND MEMBRANES. bone is composed of two tables, depression may be con- fined to either, and if the inner be the one depressed, the outer is usually but not invariably fissured ; and if both are depressed, the inner is likely to be the more exten- sively involved and often comminuted. These simple facts are of common acceptance. If the displaced frag- ments can be restored to their normal position without loss of substance, the lines of fracture only remain and will unite as readily and with as little incidental danger as primitive fissures. If loss of substance results from the displacement and necessary removal of fragments, the un- aided osteogenic properties of the pericranium, diploe, and dura are insufficient to replace the portion which is lost. The dense fibrous structures which then occupy the osse- ous hiatus imperfectly protect the cranial contents from external violence, and this structural weakness is a source of danger proportionate to the extent and situation of the enfeebled part. The detached fragments, when com- pletely separated and depressed, may become the source of additional dangers ; they may be encapsulated in the dura and by irritative pressure lead to remote neuro-psy- chic disturbances, or they may be necrosed and occasion dural or peripheral abscess. The complications of depressed fracture are twofold: there are concomitant intracranial lesions, as general me- ningeal or cerebral contusions or distant lacerations pro- duced simultaneously by the same violence which causes the fracture, and common to all its varieties; and there are superadded the localized wounds inflicted by the dislo- cated fragments. The coincident injuries have no part in the prognosis of fracture ; the consecutive lesions consti- tute whatever elements of danger it possesses. Hence a PRELIMIXARY CONSIDERATIONS. 3 1 seeming paradox. The fissured fracture of the base is often followed by a fatal result, while the depressed and comminuted fractures of the vault generally end in recov- ery. The harmless fissure of the base is likely to be asso- ciated with grave concomitant lesions, and being in bad company is held responsible for the fatalities to which these complications directly lead ; the more dangerous fractures characteristic of the vertex are oftener compli- cated only by the direct and accessible injuries of their own production. The coincident lesions are in a majority of instances beyond remedy, though not equally beyond recovery ; the consecutive injuries are in larger proportion amenable to treatment. In a minority of cases a wound of a dural sinus or of the middle meningeal artery may be irremediable, or a cerebral laceration made by an orbital fragment may be inacccessible, and it is possible that structural disorganization from crushing violence may be irreparable; but ordinarily the hemorrhages and lacera- tions at the site of fracture are manageable and infection is preventible if surgical interference is sufficiently early and complete. It is therefore true that in themselves cranial fractures are important only in exceptional cases. Their prognosis is really the prognosis of their complications. Neither the shock of an uncomplicated fracture nor the hemor- rhage from the osteal vessels is ever fatal. Its methods of repair involve no subsequent dangers, and if it occasions loss of substance which necessarily fails of osteogenetic restoration it can only increase a bare chance of remote disaster from some future exposure to violence. The fatalities which follow in its train are in the vast majority of cases due to concomitant lesions with which it has only 32 INJURIES OF THE BRAIN AND MEMBRANES. an accidental and innocent connection. The consecutive complications for which alone it is responsible are usually amenable to control, and there remains only a residuum of scattered cases beyond the pale of relief to justify its evil reputation. The tabulation of cases of fractured base or vault, with reference to the percentage of recoveries or its relation to the region involved, is useless, except it be to determine the probability of a fatal complication, or its more frequent occurrence in different parts. The fracture is rarely more than an incident. The generalization supposed to be jus- tified by the discovery that in a certain number of cases of fractured base recovery followed in all in which injury was survived for twenty-four hours, is a familiar illustra- tion of the idleness of purely arithmetical conclusions. It is well known that the issue of coincident intracranial le- sions is not usually determined in that length of time. An analysis of the results and conditions of fractures included in the appended series of cases will show a fatality in nearly two-thirds of those which involved the base and about one-third of those which were confined to the vault, but in the total of three hundred and fifty there are less than a score in which the fracture was the determining cause of death. Treatment. The treatment of cranial fracture is essentially local. If the osseous lesion is devoid of intracranial complication, there will be no general indications to meet, and if com- plicated, the general treatment will not be modified by the coexistence of fracture. The initiative of treatment in the presence of grave complication will be constitutional. PRELIMINARY CONSIDERATIONS. 33 Shock is the most urgent primary condition, and until re- action has been established, no local interference is per- missible except it be for the control of hemorrhage by the simplest possible means. If the hemorrhage is serious it may be proper to go farther, even to the extent of invad- ing the cranial cavity, since in emergencies even laws are held in abeyance — but always with discretion. The gen- eral principle that the resort to local measures must await the restoration of nervous and vascular force, except for the relief of hemorrhage by which depression is prolonged, is a fundamental law in surgery. The neglect of this pre- cept is one of the most frequent errors of inexperienced practitioners and hospital assistants, and seems especially to prevail in the case of injuries of the head; that life is often thus jeopardized or sacrificed at the outset is mani- fest not only from observation but in the published his- tories of cases. In the absence of shock or after reaction has been secured, the injury should receive immediate attention. If operative measures prove to be required, early conditions are more favorable than those presented after pathic changes have begun. The principles of sur- gical procedure are precisely the same as with complicated fractures of the extremities : the establishment of reaction and then, if interference be demanded, a resort to primary rather than to secondary operation. Fractures of the base rarely admit of direct interfer- ence, even for exploration. They are usually inaccessible, and of the linear type which neither involves danger nor requires rectification ; it is only incidentally in an exami- nation of a fracture of the vault from which it takes its origin that a basic fissure may be justifiably exposed for inspection. 3 34 INJURIES OF THE BRAIN AND MEMBRANES. If a petrous fracture has been made compound by its implication of the internal auditory passage and a rupture of the tympanum, though the danger of infection may be slight, it should be repelled by careful aseptic protection of the external meatus. A similar external communi- cation of an ethmoid or a sphenoid fracture through the nasal cavities is anatomically less favorably situated for the exercise of aseptic precautions. Fractures of the orbit or of the ethmoid bone, the result of immediate violence, are allied to fractures of the vault not only in character and prognosis but in treatment ; and the replacement or removal of osseous fragments and the observance of asep- tic care in the management of the osseous wound may be- come practicable and, if so, are no less imperative. The requirements of treatment in the case of fracture of the vault are more positive. There are simple uncom- plicated fissures which are often undiscovered and always unimportant, and which are better left without interfer- ence; but complicated fissures and comminuted, depressed, and punctured fractures, even without apparent complica- tion, demand complete exploration, operative reduction to their simplest possible form, and rigid aseptic methods in the immediate and subsequent treatment of the wound. These conditions are absolute, and the particular measures which they necessitate are immaterial, but should be as simple as is compatible with the attainment of the ends in view. It is useless to discuss the propriety of one method of procedure, or the safety of another ; it is the necessity of either to the fulfilment of essential indications which must be brought in question. Everything is proper which is indispensable, and anything is safe which can be pos- sibly required for the better comprehension and treatment PRELIMINARY CONSIDERATIONS. 35 of this very simple form of injury. If therefore the exist- ence of a hidden fracture of the vault can be ascertained by palpation, incision should be practised in order to de- termine its extent and characters; even a doubt in the presence of intracranial complication should be resolved by making direct inspection possible. If the cranial sur- face is precluded from digital examination by a large or well-defined haematoma, incision should still be made, though as yet there may be no indicaton of internal injury. So far diagnosis and treatment coincide. This method is justified not only by the necessity of exploration for the intelligent determination of treatment, but both by theo- retical considerations of safety and by the results of experi- ence. It has no conceivable dangers; the matter of infec- tion is within the control of the surgeon, and the amount of additional shock or hemorrhage involved in an explora- tive incision is inappreciable. This course has been gen- erally pursued in the conduct of cases in the series appended, and the issue has confirmed the opinion ex- pressed as to its propriety. The absence of shock, a fair constitutional condition, and the observance of ordinary precautions; the maintenance of asepsis, the careful re- pression of hemorrhage, and the restriction of the wound to the limits required for its purpose, are always to be assumed. If the incision reveals no fracture, or a fine fissure which is deemed unimportant, the wound can be closed and the patient will be none the worse for the means taken to ascertain the nature and extent of his local injury ; but if a more pretentious fissure or some other form of frac- ture is disclosed, exploration and treatment, still conjoined, must be farther extended. The depressed fracture may 36 INJURIES OF THE BRAIN AND MEMBRANES. be said to include all the others, since it is the possibility of concealed depression which gives importance to cranial comminution or puncture, and removes the first from the class of mere multiple fissure, or the second from the con- dition of a wound left by trephination. It is the continued uncertainty as to the amount of injury done to the internal table which compels further exploration, even at the cost of operation when the external depression may seem un- important. The extensive and entirely disproportionate comminution of the internal table and the frequent serious laceration of the brain by its dislocated fragments, with simple fissure or trivial external depression, have been made notorious by reiteration and illustration in every surgical text-book. These conditions often are suggested by no primar}^ general symptoms of complication, and, if unsought, must remain undiscovered at the peril of the patient. The unfortunate results of such neglected frac- tures have forced themselves upon the attention of every surgeon ; immediate septic infection or remoter effects of cerebral irritation or pressure from completely severed or partially detached osseous fragments resting upon or pene- trating the brain, including dural or cortical abscess, cere- bral necrosis, epileptiform convulsions, and multiform disturbances of functional control, have not yet ceased to be of common occurrence, though with improvement of practice they have notably diminished in frequency. Forty years ago, Dr. James R. Wood, who was often in advance of his time, was the only surgeon of eminence who taught the necessity of elevating depressed bone under all circum- stances when not specifically contraindicated. Since then Roberts, Nancrede, and other still more recent writers have advocated it as a general rule of treatment. The in- PRELIMINARY CONSIDERATIONS. 37 junction to refrain from interference with depressed frac- tures in the absence of complicating symptoms, however, is still widely upheld and respected in the profession, for no better apparent reason than the fact that many patients who are treated upon the expectant plan at least tempo- rarily recover, notwithstanding the recognized dangers to which they are exposed. The influence of tradition and a failure to apprehend the changed conditions of modern surgery often content the general practitioner v/ith the gambler's chance, and the patient takes all the risk. There may be a slightly wider latitude of opinion allow- able when the bone is not obviously depressed, but the probabilities of depression when the vault is comminuted or traversed by an open fissure, or when the fracture is of the punctured variety, are sufficient to warrant a positive solution of the question when it arises. A comminution indicates great violence, limited or diffused, or else struc- tural weakness of the bone, and in either case makes prob- able greater injury of its deeper part than is apparent upon the surface. A punctured fracture almost invariably in- volves concealed injury of which the external lesion affords no means of estimate. The exposure of the inner table in both varieties is essential to safety, and should be made, almost without exception, when the general condition of the patient permits. There are sometimes numerous fine fissures, perhaps radiating from a point of impact, without mobility of the intervening parts, and the case is then to be regarded as one of multiple fissure rather than of com- minution. The proper course to pursue in the case of a fissure may in some instances seem difficult to decide ; it is plain enough when the fissure is insignificant, appar- entlv limited to the outer table, and has been made com- 38 INJURIES OF THE BRAIN AND MEMBRANES. pound only by incision, or, conversely, when it is wide and deep, and exposed by primary injury. The only rule which can be formulated is that hesitation is always to be ended by sufficient exploration to resolve whatever doubt exists. If the fissure is originally compound, its danger is enhanced by the possibility that infection has already occurred, since it is well known that even closed fissures may have been open in their inception. The concurrence of symptoms of intracranial injury gives additional force to the direct indications for deep exploration, by increas- ing the probability that the hurt has been sufficiently severe to comminute the inner table. The exploration and rectification of a fracture, of what- ever character, can ordinarily be effected by very simple operative measures, and by the use of correspondingly simple instruments. Depressed bone in a large propor- tion of cases can be raised by the periosteal elevator, the cranial opening can be sufficiently enlarged by the ron- geur, osseous fragments can be removed by any kind of forceps, and intracranial exploration made by the ordinary probe. If the elevator cannot be inserted, a sufficient opening can often be obtained with the burr drill. The use of the trephine is only occasionally required. Com- minuted fractures may be exposed and fragments removed with equal facility and by the aid of the same instruments. Even punctured wounds of the cranium may sometimes be enlarged by the rongeur. There is no objection to the resort to the trephine in any case in which it better or more conveniently serves the purposes of the opera- tion. The chisel is best adapted to the examination of fissures and can be supplemented by the trephine if reason is found to suspect internal comminution. The PRELIMINARY CONSIDERATIONS. 39 details of procedure are exemplified in text-books of general surgery. Trephination has been voluminously discussed, and large tabulations have been made of cases in which it has been a feature in treatment. Whatever of propriety or necessity may have existed heretofore for the marked attention which has been accorded this simple operative procedure, or whatever question may still exist as to its employment in the treatment of intracranial lesions, there can be no longer reason to give it special prominence or to individualize it among the other expedients utilized in the management of fractures. It is simply an incident in treatment, to be used or avoided as the exigencies of a case may suggest, not dangerous in itself, and no more respon- sible for the outcome than the choice of a knife for mak- ing the incision or of a forceps for the extraction of an osseous fragment. The statistical tables which have de- termined the rate of mortality in cases in which trephina- tion has been employed have also shown the infrequency with which the operation has contributed to the fatal re- sults recorded. It is the complication which kills, not the fracture, nor the means of treatment which the fracture requires. The percentage of deaths for which it is held responsible, three per cent. (Amidon), is, in view of the fallibility of human judgment and the natural errors of inexperience, rather remarkable. It seems probable in the exceptional cases in which operation, whether trephination or some other procedure, and not the lesion, is justly chargeable with the death which follows, that the timidity or recklessness of the operator is likely to be in fault — a timidity which allows the case to drift till the development of symptoms compels interference under unfavorable cir- 40 INJURIES OF THE BRAIN AND MEMBRANES. cumstances, or a recklessness which impels to operation regardless of the constitutional condition of the patient. There is no apparent reason why trephination should in- volve peculiar dangers; it is not an operation in which shock need be excessive, nor in which a general anaes- thetic even need be employed if deemed unadvisable, or in which the danger of infection, whether from exposure of the diploe or of the cranial cavity need be greater than in the making of the external incision, if it need exist at all. The consideration of treatment in general has been advanced to a higher plane than it formerly occupied, and the proper fulfilment of indications has become of greater recognized importance than the selection of means for their accomplishment. It suffices if these are as simple as may be and devoid of unnecessary danger. Greater dis- crimination is also exercised in estimating the results of necessarily fatal injuries, and the effects of possibly un- successful measures taken for their relief. It is now recognized that trephination is in itself neither a formi- dable procedure nor necessarily of radical importance, and it has therefore come to be regarded as a less prominent factor in the prognosis and treatment of injuries of the head. The differentiation of cranial fracture from complicat- ing intracranial lesion defines the limit within which op- erations for its rectification are imdertaken. They may be primarily explorative, but are ultimately prophylactic and not curative. The fracture of the bone is not directly a source of danger, but the lesions of the brain and me- ninges which its dislocated fragments, unless reduced or removed, may produce often lead to immediate or remote disaster. The traditional cases in which, by the elevation PRELIMINARY CONSIDERATIONS. 41 of a depressed fragment of bone and relief of " compres- sion," the patient in the twinkling of an eye springs from profound coma into consciousness and mental activity, seem to be extinct. Instances still occur in which by the opening of the cranial cavity and incidental elevation of encroaching bone for the relief of intracranial hemorrhage and removal of coagula, cerebral function is presently re- stored ; but these operations concern the treatment of con- secutive complication. chapter I. PATHOLOGY. DIRECT LESIONS. The traumatic intracranial lesions, whether they occur independently or as complications or sequelae of cranial fracture, cannot be predicated upon the amount of violence apparently inflicted. Injuries received by falls upon the head from great distances, or from a mere stumble upon the street, may be in either event trivial or disastrous; force in the one case may be so broken in various ways that its final impact is minimized, as in the other it may be fully conserved or even exaggerated by attendant con- ditions. Their exact history is rarely attainable. The effect of a glancing blow differs from that of one which is direct, and the comparative elasticity, thickness, or density of the skull will modify the extent and character of intra- cranial injuries as well as of fracture. The study there- fore of different forms of violence, in the necessary absence of essential data, is of no practical utility. The intracranial traumatic lesions may be classified primarily as: Hemorrhages. Thromboses of sinuses. Contusions. Lacerations. And their sequelae as : Meningeal and parenchymatous inflammations, which are usually, if not invariably, of a septic character; and PATHOLOGY. 43 Atrophy. The primary conditions may occur as isolated lesions or in combination with each other, and the later inflamma- tions which may also coexist develop at any period during the persistence of the direct structural changes upon which they in part depend. The hemorrhages may be epidural, pial, cortical, or parenchymatous, and the contusions and lacerations may either be confined to the brain or meninges or may involve both structures with a predominance in one. As previously stated, when the intracranial lesions occur as complications of fracture they may be coincident or consecutive, and usually dominate the symptomatology, afford the indications for treatment, and determine the prognosis of the case. I. Hemorrhages. Some confusion has arisen in the nomenclature of hem- orrhages as it relates to their nature and location. The use of the term "epidural" is anatomically correct, and as the sources of this hemorrhage are various it would be doubtless difficult or impossible to suggest another which would at the same time denote its origin. The terms "subdural" and "arachnoid" are indefinite as to location, and imply nothing as to source, and are therefore objec- tionable. These deeper hemorrhages are derived from the vessels of the pia mater and from or through the cere- bral cortex, and are always originally situated beneath the visceral arachnoid membrane, though if the extravasation is sufficiently large it will secondarily break through into the arachnoid cavity. This extension has no clinical or 44 INJURIES OF THE BRAIN AND MEMBRANES, Other importance, but to specialize them as subarachnoid rather than as subdural would somewhat more closely de- fine their anatomical position. The designations "pial" and "cortical," as the subarachnoid hemorrhage is of me- ningeal or visceral origin, are topographically exact and pathologically distinctive. If the prefix epidural is invari- ably used to characterize a hemorrhage which separates the dura from the cranial wall, "pial," to characterize a hemorrhage into that membrane from rupture of its ves- sels, and "cortical" to characterize a hemorrhage upon the surface of the brain from laceration of its substance, both the source and location of the hemorrhage will be ex- pressed in a single word with accuracy and conciseness, and the description of cases much shortened and fa- cilitated. a. Epidural hemorrhage, when derived from the diploic vessels, is usually inconsiderable in amount, and may ap- pear externally beneath the pericranium and in the situa- tions noted in connection with basic fractures. If it escape from the cranial cavity, its importancce in this form is mainly diagnostic, and if retained, is insufficient to occa- sion symptoms ; but in exceptional instances of compound fracture of the vertex the loss of blood from this source has been excessive. The implication of the dural vessels increases the extent of hemorrhage in proportion to their size, and in case the arteria meningea media or either of its primary branches is involved the danger to life be- comes imminent. The effusion from these large menin- geal vessels is usually rapid, with early coagulation, and may be as much as six or eight fluid ounces in volume. The lateral aspect of the corresponding cerebrum is some- times converted by compression into an oblique plane, and PATHOLOGY. 45 with the dura may remain for a time after the removal of the clot widely separated from the bone, both laterally and at the base. In one of the appended recovering cases the clot from a smaller meningeal branch in the squamous region measured four fluid ounces, and was one and a half inches in thickness in its central portion. The laceration may be occasioned by a wound inflicted by a fragment of the inner table, by rupture in the line of fracture, or by contrecoup, and may even occur without cranial lesion. These different forms of injury are all exemplified in the two hundred and twenty-five necropsic cases included in the appended series. The dural sinuses are a further vsource of large hemorrhages, possibly from direct rupture of their walls but more generally from wound by an osse- ous fragment. The accumulation of coagula is less than in the meningeal variety, since the fragment which causes the injury so often closes it till disturbed by manipulation. The profuse discharge of dark-colored fluid blood which at once follows the elevation or removal of a portion of bone from the vicinity of a sinus readily indicates the nature of the lesion. The greater longitudinal sinus is the one usually involved and is not infrequently lacerated in fractures of the vertex. The lateral sinus is occasion- ally wounded, but from its situation is somewhat more subject to rupture from transmitted force. The hemor- rhage is less manageable than that from the longitudinal sinus and is a far more serious accident. The wounding or rupture of the other sinuses must be of exceeding rarity except as it occurs in connection with crushing or disorga- nizing injuries in which all the adjacent structures are concerned. The several species of epidural hemorrhage may be 46 INJURIES OF THE BRAIN AND MEMBRANES. variously commingled, but it is likely to be essentially of one distinguishable and predominating character, b. Pial hemorrhage is occasioned by rupture of the vessels of the pia mater and is primarily confined to its meshes. It is one of the results of intracranial contusion and is independent of epidural extravasation. In its sim- plest form it consists of punctate extravasations analogous to those which occur in the brain substance. It more characteristically forms a thin sheet over the vertex ; if it is in larger quantity it breaks into the arachnoid cavity, or less probably dissects the pia mater from the cerebral sur- face. It may be universal or it may occur in patches, pos- sibly a single one of not more than one inch in diameter, or perhaps covering the vertex upon one or both hemis- pheres. The quantity of blood effused is never so great as it may be in epidural hemorrhage, and its clinical im- portance is mainly due to its association with other lesions. There are still cases in which it is large enough not only to occasion symptoms of general and local pressure but to destroy or endanger life. c. Cortical hemorrhage is the direct result of a wound of the brain substance, which may be superficial, or may be subcortical with an access of blood to the surface by rupture of the intervening tissue. It varies in extent from a trivial oozing which scarcely transcends the limits of the wound to an enormous effusion which, as it increases, breaks through the pia mater into the arachnoid cavity and may suffice to spread over the entire vertex and to fill all the basic fossae. If the hemorrhage from a subcortical laceration does not reach the cerebral surface, it differs from an apoplectic effusion only in cause and attendant conditions. PATHOLOGY. 47 These several hemorrhages are all of such common occurrence that their comparative frequency is unimpor- tant. In one hundred and ninety-three necropsic cases appended, exclusive of pistol-shot wounds, there was epi- dural hemorrhage in fifty-four, pial hemorrhage in sixty- nine, and cortical hemorrhage in fifty-eight. Two or more varieties are often coincident, of which one is likely to outrank the others either in extent or in the possible gravity of its results. The epidural blood never penetrates the dura, and never reaches the subarachnoid spaces except that membrane has been ruptured by the violence of the original injury. The pial and cortical effusions may con- cur, and may be localized in different regions, or may be commingled, and in either case may be discriminated by tracing each to its source, unless a profuse cortical hemor- rhage has overflowed the site of a smaller pial extravasa- tion. If no cerebral laceration can be discovered, it is impossible that a hemorrhage should be of cortical origin. In a large proportion of cases hemorrhage is a distinct factor in the production of symptoms, and often the sole cause of a fatal termination. It is questionable if it is ever an absolutely isolated lesion. It is oftener secondary to brain laceration, but, when primary, some degree of general or local contusion or an independent laceration may still coexist. The same violence which is sufficient to separate the dura mater from the bone, or to rupture the vessels of the pia mater, can hardly fail further to be transmitted to the brain and its effect ultimately concen- trated in a limited lesion at a distant point, or diffused in a general contusion of its substance. A hemorrhage is often regarded as uncomplicated, from want of sufficiently careful necropsic examination of the brain throughout its 48 INJURIES OF THE BRAIN AND MEMBRANES. whole extent. There may be no laceration or other obvi- ous local lesion, and general contusion is readily over- looked or unappreciated. This almost universal fact of complication renders the direct effects of hemorrhage diffi- cult of segregation, and has probably led to the misappre- hension of certain symptoms which often follow in its train. The dangers which attend intracranial hemorrhage are due to shock, exsanguination of the patient, and diminu- tion of the cranial capacity. If the effusion reaches the medulla oblongata, as occasionally happens, life is termi- nated by direct compression of the respiratory ganglion ; otherwise the effect of encroachment upon the intracranial space is diffused. That the loss of blood may be directly fat,al is sometimes made obvious when the hemorrhage complicates fracture. In cases in which a dural sinus has been wounded, death has sometimes so promptly followed the removal of an osseous fragment as to make its immedi- ate cause unmistakable ; in other cases in which compound fractures have involved a wound of a larger meningeal artery, fatal collapse has so plainly depended upon cardiac failure as to leave no room for doubt. In the larger class of cases in which the blood extravasated has been retained within the cranial cavity, the hemorrhage though insuffi- cient, even when so profuse as is anatomically possible in that situation, to cause exsanguination, may still render fatal a shock from which recovery had been otherwise not hopeless, or may by producing consecutive asthenia be distinctly contributive to the unfavorable issue of associ- ated lesions. The greater number of deaths in which hemorrhages seem to have been the direct cause are differently occa- PATHOLOGY. 49 sioned and less simply interpreted. They have been gen- erally attributed to a mechanical compression which the brain suffers, the result of the intrusion of additional mat- ter into a cavity with unyielding walls which the viscus exactly fills ; the consequent disturbance of circulation and nutrition, by more or less complete obliteration of the cere- bral capillaries, has been as generally held to be entirely adequate to the explanation of all the characteristic attend- ant symptoms. In this view the effects of hemorrhage, purulent effusion, and bone depressed have been regarded as identical. It has been experimentally demonstrated that when wax, a substance incapable of absorption, is in- jected into the cranial cavity in excess of a maximum amount of 6.5 per cent., distinctive symptoms are pro- duced, and that when the amount reaches one-twelfth or one-sixth of the cranial capacity, as its situation is epidural or subdural, fatal coma results. As the effect is purely mechanical, and without the possibility of direct brain le- sion, there can be no doubt of its dependence upon pressure or compression. The term compression when applied to a solid organ is permissible, since the reduction of its bulk by extrusion of its fluids is no less real than when accom- plished by a change in the density of its solid constituents. That the resultant vascular disturbance leads to deficient nutrition must be conceded. It is equally beyond ques- tion that it is preceded by displacement of the cerebro- spinal fluid into the vertebral canal, which continues until the capacity of that diverticulum is exhausted, and that then circulatory interference begins. As the tension of the cerebro-spinal fluid is augmented under pressure of continued extravasation and by increasing resistance in the vertebral canal, capillary flow is checked and may 50 INJURIES OF THE BRAIN AND MEMBRANES. cease altogether, with complete cerebral anaemia and aboli- tion of all functional control. The intercurrence of oedema from capillary transudation may further increase intracra- nial pressure. If the hemorrhage is epidural, sudden, and profuse, the anaemic condition will be rapidly attained and complete, and its manifestation will be immediate but not instantaneous, and with permanent inhibition of conscious- ness; if the same extravasation is more gradual, cerebral anaemia may never become complete, or not until time has been afforded for relief; if it be of moderate amount as well as gradually effused, it may be capable of absorption without the necessity of interference. The pial and corti- cal hemorrhages are rarely sufficiently copious to produce marked cerebral anaemia, but they are associated with other lesions, which contribute to a fatal result. In all these instances of hemorrhage, the serious interference with vascular supply and the occurrence of answerable inhibitory symptoms are comprehensible. There are other and smaller infringements upon the intracranial space which have been rated as agents of com- pression, but which are quite incapable of exercising that amount of general pressure which would cause even par- tial capillary occlusion. The uncomplicated depression of a fragment of bone, however large, could scarcely diminish the cranial capacity beyond the space gained by practi- cable displacement of the cerebro-spinal fluid, to an extent which would appreciably disturb the general cerebral nu- trition. It might by local pressure cause temporary im- pairment or abrogation of a function controlled by a centre directly involved, but a compression of the entire cere- brum would be inconceivable. The possibility of an epi- dural or other abscess being permitted to attain a bulk PATHOLOGY. 5 i sufficient to cause general compression should be scarcely more conceivable in the present epoch of surgical practice. The general symptoms which attend these inconsiderable curtailments of the intracranial space, whatever their na- ture, must therefore be ascribed to other causes than a general circulatory disturbance occasioned by the contrac- tion of cranial capacity. The almost invariable concur- rence of other intracranial lesions with hemorrhage sug- gests their source. Pressure and compression are mechanical agencies, and not pathological conditions ; the action of one is limited, and of the other diffuse. Hemorrhage causes either pres- sure or compression, as blood is extravasated in small or large amount; depression of bone or the epidural effusion of pus cause pressure. The symptoms of the compression caused by large arachnoid inflammatory effusions are merged in those of the disease in which they mark the final stage. The attempt to combine the symptomatic and pathic conditions of hemorrhages of different grades, depression of bone, and inflammation, like other unwarranted gen- eralizations, has led to confusion, obscurity, and much misapprehension . In cases destined to recovery, the blood extravasated ordinarily disappears by absorption, and such a termina- tion is frequent when the amount is small. It is also ob- served after hemorrhages of considerable extent, when some portion has been removed by the aid of trephination. If after an interval of months the patient dies, its final traces may be sometimes noted as a mere yellow stain above or below the dura. Cystic degeneration is of occa- sional occurrence, and is most likely to be a transformation 52 INJURIES OF THE BRAIN AND MEMBRANES. of an epidural clot complicating depressed fracture. In this way it comes to be encountered from time to time in trephining for traumatic epilepsy. The purulent infection of a clot even in the substance of the brain is not only possible but may exceptionally occur without negligence on the part of the surgeon. 2. Thromboses of Dural Sinuses. The occurrence of thrombi in the dural and basic si- nuses, perhaps extending into the jugular vein, which are neither marasmic nor infective, is occasional and not always susceptible of adequate explanation. This con- dition may affect any one of these canals and is concurrent with other and varying anatomical lesions. The throm- bus may be wholly or partially decolorized, is non-adher- ent, and is likely to extend from the superior longitudinal sinus or torcular Herophili through the lateral and petro- sal sinuses. In one of the appended cases the wall of the posterior part of the superior vSinus was infiltrated with blood at a point immediately below a compound fracture, with laceration of the meninges and extensive epidural, pial, and cortical hemorrhages. As the thrombosis began at the site of injury, it was probably the result of the direct lesion of the sinus wall. In another case, as the thrombus extended from the jugular vein into the torcular Hero- phili and a cranial fissure terminated in the jugular fora- men, there is again probability of direct injury. In a third case there was no fracture or intracranial injury other than a general contusion and thrombosis of the minute cerebral vessels, most pronounced at the base and upon the left side. The thrombus, which was decolorized, occupied both lateral and both petrosal sinuses. These PATHOLOGY. 53 cases, in which the thrombi were all of ante-mortem for- mation, were pathologically independent of each other, and unconnected with pressure or with any inflammatory proc- ess within or without their walls, or with any dyscrasia of the patient. They were non-infective and had no appre- ciable influence in symptomatology. It is conceivable that by closure of the jugular vein they should occasion external symptoms of venous obstruction, and such have been observed in recovering cases in which it was sus- pected. Their clinical value is yet to be discovered, but their occurrence must be recognized as one of the several intracranial traumatic lesions. 3. Contusion. Intracranial contusion may be cerebral or meningeal, and in either structure may be limited or diffuse. a. General Contusion of the Brain. This condition probably exists in some degree in all cases of intracranial injury, and may affect the entire organ or be confined to the cerebrum. It is infrequent as an absolutely isolated lesion, of rather more common occurrence as an essential change, and almost constant in connection with a considerable hemorrhage or laceration. It has often escaped observation, partly by reason of its diffused character and its coexistence with more obvious alterations of structure, and partly from the still general acceptance of a theoretical basis of functional disturbance as an adequate explanation of symptoms. The visible an- atomical changes are : a distention of the parenchymatous vessels, a general formation of minute throm.bi, the pres- ence of punctate extravasations, and a more or less distinct 54 INJURIES OF THE BRAIN AND MEMBRANES. oedema. The punctate extravasations which are character- istic of limited contusion are rarely seen in this general form of the same lesion, and then perhaps only singly and at widely different points. If the hemorrhages are larger, even of the size of a buck shot, they are the result not of contusion but of laceration. It is not an arbitrary distinc- tion, and the line is drawn at punctate extravasations, not only because it is definite but because it is the probable limit at which the effusion ceases to be purely interstitial and becomes destructive of tissue. The minute thrombi are the most characteristic of the several morbid conditions which have been enumerated, since they are almost if not quite unknown after death from idiopathic disorders in which hyperaemia has been excessive. The oedema, which is variable in amount, sometimes appreciable only after some delay and a close inspection upon section, and at other times so profuse that the fluid can be squeezed from the brain by the hand as from a sponge, is notably frequent. All these abnormal conditions, the extravasations, thrombi, and oedema, are simply measures of the general hyperae- mia which immediately preceded death. The primary or intervening transient changes which induced the final vas- cular fluxion can be inferred only from symptoms and an- alogy. It is demonstrated by Boise that general shock is a hyperirritation of the entire sympathetic nervous system, occasioned by some sudden and more or less violent im- pression, and causing contraction of the arterioles by stim- ulation of the vasomotor nerves. The character of its symptoms indicates the deficient vascular supply. The immediate inhibitory symptoms which attend a violent injury of the head would seem to depend upon a similar irritation of the cerebral centres of vascular control with PATHOLOGY. 55 contraction of the cerebral vessels; to this succeed by- continued irritation paralysis and dilatation. The brain is primarily made anaemic ; with the secondary dilatation of its vessels, as hypersemia becomes excessive, it is again anaemic in effect from more or less complete cessation of capillary movement and from oedema. The result of com- pression and of general brain contusion is the same, and it is the frequent coexistence of contusion with the pressure of depressed bone which has led to the confusion of pres- sion with compression. If the cortical centres recover from the shock, the circulation is readjusted. In accepting vascular derangements as the source of symptoms in intracranial contusion, it has been sought by some previous writers to interpose certain physical proc- esses between the application of external violence and the impression made upon the nerve centres. Miles, in an elaborate study of this subject, and as a result of experi- mental and speculative considerations, accepts Buret's theory of the formation of consecutive areas of cranial depression and bulging, causing temporary compression and forcing the fluid of the lateral ventricles into the fourth ventricle and the spinal subarachnoid space: and from overdistention of the fourth ventricle involving rup- ture of its floor and lesions of contiguous parts, including the medulla. A stimulation of the restiform bodies is assumed to follow, and a consequent efferent reflex action which directly occasions the capillary contraction. It may be objected to this explanation that it is unnecessarily complex, since, from the analogy of general shock, the direct transmission of the nervous impression from the external surface is equally conceivable ; and still further that post-mortem examination of cases in which even ex- 56 INJURIES OF THE BRAIN AND MEMBRANES. treme contusion is found to exist does not disclose such localized lesions in the neighborhood of the fourth ven- tricle as were said to result from experimentation. The immediate tetanic effects observed in the experiments upon animals, made both by Miles and by Duret, are also absent in contusion of the human brain, unaccompanied by laceration or hemorrhage. The invention and application of a fanciful term to comprehend all combinations of symptoms and pathic con- ditions, when the brain is not supposed to be compressed, has met with great acceptance. All traumatisms involv- ing brain symptoms, were for many years classified as cases of concussion or of compression. The classification was simple and of easy comprehension. If the intracra- nial space was diminished by the intrusion of bone, serum, extravasated blood, or pus, it was compression; otherwise all symptoms were referred to a hypothetical vibration of the brain within the skull, a merely functional disorder produced by violence. Thirty years ago Prescott Hewitt described several forms of contusion, in which he included lacerations, and questioned the occurrence of concussion as a distinctive pathic condition independent of anatomical change. Previous to this time several observers had noted structural alterations in certain suddenly fatal cases which had presented the symptoms attributed to concussion, but had not recognized the existence of perceptible lesion when life was further prolonged or recovery ensued. Mr. Hewitt, in suggesting that all cases of concussion are at- tended by some appreciable lesion, made a distinct advance in the study of the pathology of cerebral trauma. He did not, however, distinguish contusion from laceration or hemorrhage in the classification of cases. Though a belief PATHOLOGY. 57 in a physical basis for all cerebral symptoms occasioned by injuries of the head became more widely extended, von BeroTnann some vears later in a clinical lecture admitted the existence of both concussion and compression, with an etiological difference, and insisted upon their clinical iden- tity. He attributed concussion to a direct injury from a single impulse, modified by the elasticity of the skull, by which the brain suffered a diffuse disturbance without ap- preciable lesion. He considered it a suspension of cortical activity, followed by a stimulation and eventually by a depression of the medulla. He regarded it as occurring in three degrees : as involving paralysis of the cortex only, as a paralysis of the cortex and a stimulation of the me- dulla, and as a paralysis of both cortex and medulla with a primary brief and unobserved medullary stimulation. Cortical paralysis was indicated by unconsciousness ; med- ullary stimulation by slowness of pulse and increase of arterial tension ; and medullary paralysis by rapidity of pulse and decreased arterial tension. In compression, he regarded the brain condition as identically the same and as manifested by the same symptoms, but as due to change of cranial capacity and not, as in concussion, to change of cranial form. Finally, he considered diagnosis as only possible by the duration of the symptoms. The views of von Ber^mann are of too sfreat weight and authoritv to be lightly questioned; but since the time at which he wrote, further observation has shown that the diffuse disturbance he terms concussion is connected with evident lesion ; and, while the vascular derangements caused by compres- sion of the brain substance may be identical with those due to direct injury, recognition must certainly be given to the presence of the compressing agent within the era- 58 INJURIES OF THE BRAIN AND MEMBRANES. nial cavity by which clinical as well as etiological differ- ences are established. Concussion and compression, hav- ing been consolidated by von Bergmann, should be abolished together, so far as they are terms used to ex- press a pathic condition. The impossibility of accepting a functional disorder as adequate explanation of the group of symptoms which has been collectively known as concussion, resides in the fact that in recovering cases it is purely an assumption which is contradicted by the necropsic appearances ob- served in those which are fatal. Structural alterations have been denied, not only without reason but in despite of positive evidence. In every fatal case, when the clini- cal history has corresponded to that of those which have recovered, a carefully conducted necropsy has revealed organic lesion. In all the instances which have been cited to prove the absence of lesion, not one has been noted with sufficient exactitude to give it the slightest statistical value. There is nothing in analogy to warrant at the present time the assumption that any fatal disorder termi- nates without involving structural change. Even dis- orders of the nervous system, long considered functional, have with closer investigation fallen more and more into line with organic diseases. It may properly be held, both from post-mortem observation and from analogy, that brain injury produces structural alteration wdth the same cer- tainty that it occasions palpable symptoms. If the W'ords concussion and compression be used to indicate a group of symptoms or variations of pathic condition, it is objection- able, both on the score of propriety and of exactitude and as being likely to lead to erroneous diagnosis. If they be discarded, the form of injury the patient has suffered, as PATHOLOGY. 59 laceration, general contusion, or fracture with hemorrhage, is more likely to be accurately determined than if attention be directed solely to a symptomatic condition that may not clearly exist. If the cortical centres recover from the shock to which they have been subjected, the circulation is readjusted, the punctate extravasations and serous transudations are re- absorbed, and it is probable no physical vestige of struc- tural alteration remains. There is a subsequent instability of cerebral nutrition, which has been recognized as a sequel of intracranial injury, and, as it also occurs after all lesions in which contusion is a complication, it is probably due to an increased susceptibility of the vasomotor centres, and a consequent liability from trivial cause to the occur- rence of transient conditions of either anaemia or hyper- aemia. Such persons are often unable to endure serious mental or physical labor, exposure to the sun, moderate alcoholic stimulation, or many other of the fatigues and pleasures incident to ordinary life. This fact was officially recognized in the later part of the war of secession, and men who had recovered from a head injury of any kind were relegated to the invalid corps. b. Limited Contusion of the Brain. This lesion may be confined to the cortex, or may exist subcortically in any region of the organ. It may be said to differ from laceration, as a contusion elsewhere differs from a wound. It is a bruising of the tissue with minute hemorrhages and possible molecular disintegration, and in both particulars is distinguishable from general con- tusion. The hemorrhages are characteristically in punc- tate form and are thickly scattered among the cells and 6o INJURIES OF THE BRAIN AND MEMBRANES. capillary vessels. As it occurs upon the surface in a single area, or perhaps in two or more different regions, it may occcupy a space from a fraction of an inch to one or two inches in diameter, and is a simple bruise. It is slightly depressed and variously discolored from dark red to yel- lowish-gray, and without arachnoid laceration. In the subcortical substance it appears in similar areas as an aggregate of punctate extravasations with or without a yellowish or darker stain of the intervening tissue. In general contusion it may happen that the change is lim- ited to a single hemisphere or to a single lobe, but is still comparatively large, and, as its anatomical peculiarities are different, it is to be regarded rather as a regional form of the general lesion than as a limited contusion. This is the most infrequent form of intracranial injury, and without complication is almost exceptional. It indi- cates the direct transmission of a certain degree of force, in place of its entire diffusion ; that it stops short of lac- eration is because force is possibly minimized, in some instances and in some measure, from the amount of resist- ance which it encounters. If the lesion is superficial, whether it be a laceration or a mere contusion, it is oftener than elsewhere at the base of the brain, and in the anterior or middle fossa. In itself it is unimportant except as it is contributory to the effects of the general injury, and has no distinctive indications. Its relation to subsequent infective changes will demand later consideration. PATHOLOGY. 6l c. Contusion of the Meninges. Meningeal contusion has not been heretofore appreci- ated or described as one of the distinctive lesions in intra- cranial injury. It may be more or less prominent than the cerebral contusion which it accompanies, and while it may be the paramount apparent lesion it is probably no more entirely independent of general cerebral contusion than is a laceration or a hemorrhage. It is incredible that force should be so strictly localized as utterly to expend itself in a structure so thin and delicate as the pia mater, to which meningeal contusion is apparently restricted. Its relation in extent and severity to general cerebral con- tusion is not clearly defined, but they are not always directly proportionate, and either one may be relatively excessive. It may be largely or universally diffused, or may be limited to areas not larger than the localized in- juries of the cortex. It is legitimate inference that the evident vascular derangements are produced, as they are in the brain substance, by the shock impressed upon the vasomotor centres. The same conditions, hyperasmia, oedema, and hemorrhages, are apparent. The punctate extravasations are more numerous and more frequently observed, and moderately profuse hemorrhages, which are unknown in the diffused cerebral lesion, are of common occurrence in patches, in thin sheets spread over the ver- tex, or in quantity sufficient to break into and fill the arachnoid cavity. The difference in the amount of ex- travasation which follows engorgement of the vessels depends upon the anatomical peculiarities of the pial membrane. The vessels are comparatively large, with feeble support from the loose areolar tissue which they 62 INJURIES OF THE BRAIN AND MEMBRANES. traverse, while in the brain substance the circulation is maintained through capillaries and arteries of the smallest size, which are greatly strengthened by the denser struc- ture in which they lie. Even in the largest pial hemor- rhages it is unnecessary to suppose that there has been rupture of the membrane from direct transmission of force. The vessels give way from the lateral pressure of over- distention, and, if the areolae are torn, it results second- arily, from the profuseness of the hemorrhagic effusion. Limited hemorrhages which have infiltrated the pia may be demonstrably without laceration of its areolar struc- ture. Hemorrhage is the usual indication of this meningeal form of contusion, and was observed in sixty-eight of the appended series of necropsies. Its greatest relative fre- quency was in intracranial injuries without fracture, and its least was in connection with fractures of the vertex. This estimate is independent of simple hypersemias and punctate extravasations. The termination of these cases is not unlike that of other intracranial hemorrhages in the circumstances of recovery or death. In place of a hemorrhage, a subarachnoid serous effu- sion is sometimes encountered, as a result of the hyperaemia which follows meningeal contusion. It is not of frequent occurrence and is readily mistaken for an inflammatory process. It may be recognized as a perfectly clear fluid, confined to limited areas, and unaccompanied by arach- noid opacity. It may cover a single lobe, or a space not more than one or two inches in diameter, and like other evidences of contusion these transudations m.ay be single or multiple. Several instances in which the cedematous may be discriminated from the inflammatory effusion are PATHOLOGY. 63 to be found in the appended series of necropsic observa- tions. It is not to be expected that it can be detected dur- ing life, since even when considerable in amount it is still insufficient to occasion symptoms of compression. There is a sequel of meningeal contusion in an inflam- matory process similar to that of the limited visceral lesion, which will be included in the study of secondary traumatic inflammations. 4. Laceration of the Brain. Laceration of the brain is the final expression of limited force in its greatest intensity. It may be cortical or sub- cortical, single or multiple, trivial or important. If less absolutely constant than general contusion, it is even more frequently encountered as an emphasized lesion. In the whole number of necropsies upon which these propositions are based, it occurred in one hundred and twenty-eight, and in ninety-four was evidently the source of symptoms or the cause of death. It is not always possible to deter- mine the extent of the original wound, since so many and so considerable vessels are likely to be ruptured, and the consequent hemorrhage to be so profuse that the brain substance mav be broken down to a great distance and in every direction. It is not unusual for an entire lobe to be excavated and disintegrated, or even the greater part of a hemisphere to be similarly destroyed. These enor- mous subcortical lacerations may break through the cortex, and the extravasated blood spread over the whole surface of the brain ; or they may remain strictly confined to the parenchyma in which they originated, enclosed only in a mere shell of the cortical substance. In other cases they are scarcely larger or more important than the most incon- 64 INJURIES OF THE BRAIN AND MEMBRANES. siderable limited contusion, from which they are dis- tinguishable only by the relatively greater amount of hemorrhage which they involve. Between these extremes they present every gradation of destructive injury. Like fractures and limited contusions, they are oftenest discov- ered in the basic region, and in the majority of instances affect the frontal and temporal lobes. There is no por- tion of the brain, however, which may not be wounded; neither the interior of the cerebellum, pons, medulla, optic thalamus, or corpus striatum, nor the fornix or gj-rus forni- catus; no ganglion or convolution is exempt from this result of violence. In the cases examined, exclusive of the fractures of the vertex in which lesion was produced by the direct application of force, some part had been lacerated in nearly seventy-five per cent., and in by far the larger proportion it was the inferior surface of the frontal or temporal lobes. Lacerations again, like limited contusions and indirect fractures, almost invariably occur at points directly opposite that at which force has been applied. It has been supposed that this fact, as it affects visceral lesions, is to be explained by a sudden displace- ment of the brain, which in its rebound strikes against the cranial wall and is bruised or wounded by its sharp or rug- ged prominences, and that this specially accounts for the greater liability to injury to the inferior surface of the lobes which occupy the anterior and middle fossae. This theory is unsatisfactory, not only because there is no evi- dence that such movements take place within the cranial cavity, but because the local superficial lesions by no means usually correspond to the situation of the bony processes and irregularities, and because it fails to account for the cen- tral lesions. Their production has been also ascribed to PATHOLOGY. 65 the change of form suffered by the skull in virtue of its elasticity when subjected to violence, which causes distor- tion of the brain to the point of rupture. It would seem, if this interpretation were correct, that the brain tissue should give way at one or the other extremity of the lengthened axis, and not so generally in the shortest diam- eter. Another explanation, which is suggested by Miles, is that in the displacement of the cerebro-spinal fluid by the consecutive cranial depression and bulging, which he believes to follow a blow upon the head, a momentary vacuum is formed at either end of the axis of force, and the vessels of the brain and membranes rupture from lack of support. Granting the correctness of the premises, superficial vascular lesions might occur in this manner, but hardly the considerable laceration of tissue, which is often in excess of the injury to vessels. It is still more difficult to conceive of lacerations in the central portions of the brain as being produced by these transient and dis- tant if not trivial fluctuations of the cerebro-spinal fluid, while the immediate and firmer support of the general parenchyma remains intact, and the delicate walls of the pial vessels perhaps remain uninjured. There remains only the possibility of a direct propagation of force from its point of application, in straight lines through the inter- vening parts to the site of local injury, with such diffusion through the yielding cerebral substance as is manifest in the general lesions. There is no greater difficulty in ac- cepting this simple explanation than in admitting the sim- ilar transmission of force through other media. The cortical lacerations are, when recent, merely lace- rated wounds containing more or less blood coagulum, with underlying shreds and granular detritus of brain tissue ; 5 66 INJURIES OF THE BRAIN AND MEMBRANES, their base is usually pultaceous and stained with blood or of a grayish color. The contiguous brain matter may be softened or dotted with miliary extravasations, but is oftener of normal consistence and appearance. The wound may be circular, oval, or irregular in outline, not larger than a pea or perhaps covering the whole extent of the inferior surface of the frontal or temporal lobe. The re- sulting hemorrhage constitutes the cortical extravasation already described. The .subcortical lacerations are usually more or less irregular cavities filled with blood, but after the removal of the clot their walls present the same ragged, discolored appearance, and the adjacent tissue the possible miliary extravasations which characterize the superficial lesions. The subsequent history of these wounds is usually sim- ple. If they are of considerable size, death ensues in a ma- jority of cases before sufficient time has elapsed to permit any change of importance. The end to be hoped for in any wound with loss of tissue is cicatrization. Recoveries are by no means exceptional in which laceration seems to have been verified by symptoms, yet evidences of such a repara- tive process have rarely been discovered in the course of necropsic examinations. It is probable that small cica- trices are difficult of detection, and that large lacerations are not prone to heal. There is warrant, however, for the statement that fibrous cicatricial tissue may be formed, and the late Dr. Alonzo Clark described in detail the re- generation of nerve fibres after the occurrence of intra- cerebral hemorrhage. The formation of cysts, areolar tissue, and adventitious membranes, and various degen- erative changes have been noted as terminations or results. Mr. Hewitt refers to a case in which two large cerebral PATHOLOGY. 6/ lacerations, uncomplicated by cranial fracture, were exam- ined after many years. The surface was excavated and the arachnoid membrane bridged a cavity filled with serum and loose areolar tissue. In a case of gunshot wound, in- cluded in the appended series, the brain track after thir- teen years was converted into a membranous canal. The process of reparation is evidently slow. After the lapse of seven months lacerations have been found to be still distinctly limited, uncontracted, softened, rusty in color, and without apparent inflammatory alteration. The fatalities which immediately follow intracranial injury with laceration, are probably to be ascribed to con- comitant hemorrhage or general contusion ; those in which the laceration is the essential cause of death occur during a period which may be estimated as extending from the end of the first forty-eight hours to six weeks. During the first few days the contained clot becomes darker and more friable; at a later period, when death seems to have been due to laceration the wound has often assumed a sloughy appearance, which, with the antecedent symptoms, points to a septic infection. No inflammatory changes have been discovered in repeated microscopical examina- tions. These several organic lesions represent the whole ex- penditure of the force derived from external violence, upon the cranium and its contents: fractures limited to the point of impact or propagated to a distance, limited or diffused contusions of the pia mater, wounds and bruises of the brain substance, and resulting hemorrhages from the osteo-meningeal and cerebral vessels, with occasional thromboses of the dural sinuses. These traumatic con- ditions are variously complicated with each other; and 68 INJURIES OF THE BRAIN AND MEMBRANES. general cerebral contusion, which is probably a constant factor in all intracranial injuries, may also occur as an iso- lated lesion. Secondary Inflammations. The traumatic intracranial inflammations are secondary to the immediate structural changes which have been de- scribed. They are properly sequelae rather than compli- cations, not only because they are chronologically later, but because the primary lesion comes between them and the receipt of injury. Their development may not be identically the same in all cases, but ordinarily if not in- variably there are involved a structural alteration, the direct result of traumatism, which is essential, and a later infec- tion, which is accidental. These two factors in their pa- thogeny may be considered fundamental. It is always haz- ardous to proclaim generalizations to be without exception, but the universality of the law that some appreciable in- jury of cerebral or meningeal tissue precedes its traumatic inflammation is sustained so far as observation is prac- ticable. There are meningites in which the pia mater is so greatly altered by the secondary processes, and chronic abscesses of the brain in which the original lesion is so completely replaced by the purulent effusion, that the antecedent local conditions can only be inferred from the clinical history or from analogy ; but in both disorders the vestiges of an abnormal pre-inflammatory state are in many cases recognizable after the inflammation has run its course. The strict limitation of a meningitis to the site of a meningeal contusion is often clearly shown in cases in which infection has taken place through a cranial opening, and in which, while the membranes in the vicinage of the PATHOLOGY. 69 wound present a perfectly normal appearance, inflamma- tion has been localized over some part of the opposite hemisphere. In other instances there are two or more widely separated sites of subarachnoid purulent effusion, each not more than an inch in diameter, or with an injury of the vertex, a single one of no greater size in some region of the base. It can hardly be supposed that these multiple or distant seats of inflammation were accidentally determined, but it may be reasonably assumed that their diminished power of resistance exposed them to the attack of predatory germs and hence localized the pathogenic process. There are few recent cases in which traces of meningeal or cerebral contusion do not confirm this as- sumption. The demonstration of the initial lesion in central abscess of the brain is often prevented by the pro- tracted course of the disease, but even after the lapse of months some evidence of the original lesion may be pos- sibly discovered in the minute examination of the wall of the cavity. The position of the abscess is always signifi- cant. If the skull has been fractured, the dura wounded, and the surface of the brain lacerated or contused, infec- tion will be followed by superficial suppuration ; if the dura remains intact, and the cerebral surface uninjured, the pus formation will occur at a deeper point of limited contusion in some line of transmitted force. In neglected pistol-shot wounds pus may form, either in the course of or upon one side or the other of the track of laceration, and even at two or more foci of inflammation. The severe contusion of the adjacent tissue and the abundant supply of infective material, which may be carried to any depth into the intracranial wound, account for the peculiar situa- tion and frequent multiplication of abscess in cases of this 70 INJURIES OF THE BRAIN AND MEMBRANES. character. The lapse of time from the reception of injury to death from consequent abscess is usually so consider- able that not only the indications of primary lesion may have disappeared, but the early history, if it was ever noted, is ordinarily lost. A mathematical demonstration, therefore, that the seat of central abscess of the brain is always the site of an original contusion or laceration, is even more difficult than in case of meningeal inflamma- tion. The circumstances which tend to establish it infer- entially are : its susceptibility of proof whenever satisfac- tory examination is possible ; the confirmation afforded by attainable clinical histories; the fact that it is not directly propagated from the point at which violence has been inflicted; and the greater resistance oft'ered by sound tis- sue to infection, which renders already damaged parts the natural prey of wandering pathogenic germs. The neces- sity of some structural injury as an antecedent condition of the establishment of either meningeal or parenchyma- tous traumatic inflammation seems scarcely in question. Either one of the meningeal lesions, whether limited or diffuse, seems to be adequate, but whether diffuse con- tusion always precedes diffuse inflammation is uncertain. The antecedent visceral lesions are subcortical laceration and limited contusion ; general contusion with a local in- tensification may possibly be included. The cortical le- sions lead to superficial abscess only when directly exposed to infection ; those produced upon the side of the brain opposite to the site of injury, and those which occur with- out cranial fracture, are thus exempt from pyogenic change. The immediate dependence of these inflammations upon microbic infection, an immigration of pathogenic \ \ PATHOLOGY. 7 1 germs from without or from some other part of the body, has been proven in repeated instance by cultures of the affected tissue — in so many instances in fact that the only question which still remains is whether they ever originate without foreign intervention. The acceptance of the prop- osition that traumatic intracranial suppuration is even gen- erally due to microbic invasion was at one time made unnecessarily difficult by the further averment that trau- matic brain abscess never occurs without external wound. This is an error and is disproved by rather more than ex- ceptional cases :■ two are reported by the author in a previ- ous reference to the subject. The knowledge that patho- genic germs may reach the brain from more distant points through its vascular supply renders it at least conceivable that any cerebral abscess -may be infective. It must be conceded that in by far the greater number of intracranial inflammations of traumatic origin, whatever structure may be implicated, there has been wound of the soft parts which invest the cranium. The external lesion may be confined to the tegumentary coverings of the bone, but must necessarily involve the periosteum. Simple subperi- osteal exposure of the osseous surface, erosion or wound of the bone, punctured, linear, or depressed fracture, in the presence of pathogenic organisms may each lead to intra- cranial infection. One of these injuries may be more probably succeeded by infection than another, as the microbia are more or less deeply implanted, or otherwise more or less inaccessible to germicidal treatment. In the majority of instances, danger is synonymous with neglect. The osseous surface exposed, eroded, or wounded, or the edges of a compound linear fracture, can be made aseptic even if it require the use of a chisel, and the elevation of 72 INJURIES OF THE BRAIN AND MEMBRANES. a depressed fracture affords opportunity for the destruction or removal of lurking elements of disease. Fissures of the petrous portion, most frequent of all compound cranial fractures, can be made absolutely aseptic by careful occlu- sion of the ear. The punctured fracture may be attended by the direct introduction of pathogenic germs into the cranial cavity, or even into the brain substance, which are quite beyond the reach of aggressive measures; but the most thorough practicable removal of tangible foreign sub- stances or fragments of bone and cleansing of the wound, and the most vigorous aseptic care, reduces the danger of infection to exceedingly narrow limits ; the greatly dimin- ished frequency of septic inflammations after pistol-shot intracranial wounds, since the wider recognition of the necessity of such a plan of treatment, clearly demonstrates how much can be accomplished by the use of aseptic and antiseptic methods, even under unfavorable circumstances. The most inaccessible osseous lesions, and consequently when infected the most intractable, are fractures through the ethmoid or sphenoid body, or of the occipital basilar process, with wound of the nasopharyngeal mucous mem- brane. It is not only impossible to subject them to effi- cient aseptic treatment, but they are peculiarly exposed to septic influences from their direct communication with both the digestive and respiratory tracts. In the usual instance of fracture through the ethmoid or sphenoid cells, derived from the vault, the nasopharyngeal membrane, if wounded, after a certain amount of hemorrhage is likely to be closed by primary union and danger obviated ; but in gunshot wounds through the mouth, if the patient sur- vives, the probability of infection is greatly increased. Notwithstanding the various possibilities of infection. PATHOLOGY. 73 and the imperfection of aseptic methods as they are ordi- narily employed, the actual occurrence of traumatic inflam- mation of either the meninges or the parenchyma of the brain is comparatively infrequent. In the appended se- ries of five hundred cases of intracranial injury of diversi- fied character there are included but three central abscesses and one of the cerebral surface. The last was developed after fracture in the frontal region and in the absence of any surgical supervision, and one of the others had run its course prior to admission to the hospital in which its his- tory was finally recorded ; there remain but two which are fairly chargeable to this collection. The puffy tumor of Pott, the once so often observed cranial necrosis with underlying abscess, the late result of neglected and in- fected superficial wound, and now an almost extinct sur- gical phenomenon, is unrepresented. The instances of arachnitis are somewhat more numerous, but in some of these an infective origin was not demonstrable upon post- mortem examination ; and in others it would seem that infection should have been prevented. The immediate treatment of these cases was for the most part in the hands of hospital assistants of varying degrees of capacity and experience, and aseptic methods, while employed with per- haps more than average care, were not always ideal. The infrequency of infective inflammation, therefore, is not to be ascribed to any exceptional rigor in aseptic manage- ment. It is a possibility that in traumatic inflammation the pathogenic organisms should reach the cranial cavity through other channels which they are known to traverse in idiopathic cases, as through the tonsil, or Eustachian tube, and middle ear, or in the general circulation; but 74 INJURIES OF THE BRAIN AND MEMBRANES. this would be so purely a coincidence, and so unusual, as to require no special consideration. There is no reason to suppose that the nature of the invading germ determines the site of infection. Ingress having been obtained, the morbid process may be extended in continuity from without, or may be established at a more distant point which has been made vulnerable by the primary injury. In this relation, the views of Macewen, the most recent writer of authority upon the subject of intracranial inflammation, have been abstracted or con- densed so far as they concern the conditions of septic in- vasion and the degenerative processes by which they are followed. " In a ofiven case in which a cause of infective infiamma- tion exists on the outside of the skull, from which the in- terior becomes affected, the alternative, whether meningitis or brain abscess results, depends partly on the anatomical arrangement of the structures and partly on the intensity and rapidity of the inflammatory action; which again may be dependent upon the micro-organism and the virulence of its action. One — or more — of several intracranial con- ditions, pachymeningitis, leptomeningitis, ulceration of the brain, abscess of the brain, and necrosis of the cere- bral tissue, besides the involvement of the intracranial sinuses with disintegrating thrombosis, may result there- from. " TJic various intracranial lesions ii ^^3° ^^^ io2°-|-. The complications in four were extensive; a relatively large extravasation into the pons, a deep laceration of the frontal lobe, and a large cortical hemorrhage, in one; cortical laceration of the frontal and a wide and deep laceration of the temporal lobe in the second ; pial hemor- 142 INJURIES OF THE BRAIN AND MEMBRANES. rhage in the third ; and an excessive cerebral oedema in the fourth. In the case last mentioned there were a notice- able weakness of the muscles of the trunk, post-cervical muscular rigidity as well as general convulsions, loss of fsecal and urinary control, and marked mental decadence, though there were no hemorrhages and no lacerations. The fifth case was remarkable, both from the severity of the lesions of the thalami and from the fact of their comparative isolation. The left thalamus was much contused in the anterior portion of its inner sur- face, and the right thalamus extensively lacerated upon its superior surface. There were contusion of the fornix an- teriorly with punctate extravasations, a small clot not larger than a filbert in the centre of the left cerebellum, and a moderate general contusion. The disorders of muscular action were confined to the left side ; there were temporary rigidity upon admission, which was relieved by the eleva- tion of a depressed osseous fragment, violent unilateral convulsions on the second day, continuing for three hours, and later permanent rigidity. The temperature in the last twenty-four hours of life ranged from i05°-|- to 107°. There were two instances of laceration of the fornix, one in its anterior and the other in its posterior portion, neither of which was of great extent. In the first, which complicated frontal laceration and general contusion,, the prominent symptoms were delirium and mental enfeeble- ment, with high temperatures. In the second, in which copious subarachnoid, ventricular, and parenchymatous serous effusions were notable complications, the unusual feature in the case was the extraordinary variations in both axillary and rectal temperatures. Lacerations of the gyrus fornicatus occurred in three SYMPTOMATOLOGY. I43 cases, in one of which it was trivial; in a second, implicat- ing its anterior portion and incidental to severe laceration of the left frontal lobe, there was temporary anaesthesia of the right upper extremity; and in the third, which was in- dependent and situated in the middle third of the convolu- tion, general sensation was markedly diminished on the fourth and last day of life. There were five cases in which laceration with extrava- sation occurred in the substance of the pons. The lesion in each was limited, the largest clot not exceeding the size of a pea. There were no disturbances of muscular action, except in one previously mentioned as complicat- ing thalamic laceration, and death was occasioned by cortical or meningeal hemorrhage. This series of limited lesions of the deeper portions of the brain is too restricted in number, and the complica- tions are too serious, to justify any inferences as to the existence of distinctive topical symptoms. The injuries of the corpora striata and optic thalami seemed to be attended in almost every instance by some muscular disorder and an elevation of temperature, which in case of the optic thalami was pronounced ; and lacerations of the fornix by a diminu- tion of ordinary sensibility ; but these indications even if invariable still fail of a definite localizing value. There is still a pathic condition to be considered, which is at once indicative of the existence of laceration and of its situation. Sensory aphasia has been satisfactorily de- termined by neurologists to depend, in idiopathic disease, upon lesion of the lower parietal and upper temporal re- gions, or, more definitely, of the first temporal and supra- marginal convolutions and angular gyrus. The traumatic destruction of the same parts must necessarily lead to the 144 INJURIES OF THE BRAIN AND MEMBRANES. same results. It is somewhat remarkable that, while the disturbances of speech have not been infrequent in the re- covering cases, the appended series has afforded but a single example among those which were fatal. In this one instance, which was characteristic, the first left tem- poral convolution was lacerated through the whole thick- ness of the cortex, for a length of one and a half inches, which included the second and part of its third fifths, esti- mated from its anterior extremity, and in its middle por- tion the laceration involved the second convolution. This injury was limited to the exact width of the two convolu- tions, and was covered by the unruptured arachnoid mem- brane. Smaller lacerations existed at the tip and upon the inferior surface of this lobe, and at the tip of the right lobe. In the remaining cases, seventy-five or more in number, in which the temporal lobes were lacerated, there were twenty-five in which the external surface, which in- cludes centres of speech, was affected ; in fourteen of these, primary and permanent unconsciousness precluded the recognition of possible impairments of this faculty in any of its elements; in ten in which the retention or the re- turn of consciousness permitted the exercise of speech, the position and extent of the lesion in each was thus deter- mined : 1. External border — small — left. 2. External surface — small — left. 3. Middle of first convolution — right. 4. Middle of second convolution — left. 5. Anterior one-fourth of second convolution — left. 6. Posterior part of third convolution — small — left. 7. Posterior one-third of first and second convolution — riofht. SYMPTOMATOLOGY. 145 8. Anterior extremity of first and second and middle of first convolutions — left, 9. Nearly the whole of second and third, and a little of first convolutions — atrophy and induration of the whole lobe — right. 10. Complete subcortical excavation — left. There were in addition two cases of limited contusion. 1 . Posterior part of first, second, and third convolutions, covering an area of one square inch — yellowish in color and studded with hard punctate extravasations — right. 2. Middle portion of first convolution and adjacent parietal region — dark cortical discoloration and punctate extravasations — left. There were no aphasic conditions in any of these lacer- ations or contusions, which in view of exceptional cases include those of the right as well as of . the left side. It would seem from these instances that absolute destruction of tissue within the whole of an exactly limited area is essential to specific impairments of speech ; and that sub- cortical disintegration, however complete in, extent or de^ gree, or alteration of cortical structure by limited contusion,, however exact in its conformation to the limits of the centre of control, is insufficient. The comparative fre,- quency of some form of aphasia in recovering cases is a probable result of general rather than of local lesion. An examination of the history of such cases will usually point to the existence of general contusion, and the often early as well as perfect restoration of function indicates cirr culatory disturbance rather than structural alteration. There was no appreciable default or disorder of the special senses in any of the temporal lacerations, though the supposed auditory, olfactory, and gustatory centres 146 INJURIES OF THE BRAIN AND MEMBRANES. were sometimes involved. In certain recovering cases there seemed reason to believe that occasional defects of hearing, smell, or taste were due to central lesion. The occipital visual area was rarely the seat of limited injury. The conjugate deviation of the head and eyes, or of the eyes alone, when observed in traumatic cases is not in- dicative of a lesion such as might naturally be expected from the result of experimentation ; nor has it been asso- ciated with the conditions which have been recognized in idiopathic disease. The experimental destruction of the posterior portion of a frontal lobe occasions temporary de- viation to the corresponding side, and its irritation a devia- tion in the opposite direction. In cases of acccidental in- jury in which this symptom has occurred the lesions have been varied, but in no instance have included posterior frontal laceration. Idiopathically it occurs in connection with epileptic seizures; and, when paralytic, with more general paralysis caused by hemorrhage. In the com- paratively few instances in which it was noted in the ap- pended series, no other considerable paralysis existed, and when death resulted, as it usually did, the lesion was found to be indifferently a general contusion with oedema, lacera- tion, meningitis, or some form or degree of hemorrhage; and almost invariably different lesions were so complicated with each other as to render impossible the identification of either one as the direct cause of the symptom. The exact manner of implication of the nerve nucleus is not evident. The prominent associated condition was a pro- found unconsciousness, and the essential lesion was oftener general than limited. In a minor number of cases re- covery ensued, and in them consciousness was not lost. The enumeration of symptoms may be ended with one SYMPTOMATOLOGY. I47 of the most important of the general indications, the loss of control over the action of the bladder and rectum. It is impossible to estimate its numerical frequency, for, if these receptacles are empty at the time the brain injury is inflicted, and if, as often happens in recorded cases, life is afterward measured by hours or perhaps by minutes, this diagnostic point is necessarily lost. If such explicable cases are excluded, it may be said to be very generally ob- served as a symptom of laceration. It has been as often noted in the absence of any form of paralysis as other- wise, and when consciousness has been retained; and though some form of mental impairment may have always coexisted, the same loss or aberration of mental power when due to other lesions has not been characterized by this particular functional incapacity. The lacerations have been both cortical and subcortical, and have involved all the lobes and all regions of the brain, so that the direct cause of this lack of control would seem to be any wound of the cerebral parenchyma, whether or not it may be ulti- mately traced to some special centre. The direct symptoms of intracranial traumatism have been described as they occur in fatal cases, and as they have been verified by necropsic examination; they have been in the main disregarded as they are manifest in recov- ering cases, in which positive evidence of the pathogenic conditions upon which they depend is usually want- ing. It is probable that no esential differences in symp- tomatology exist, except in degree, and in many instances the early progress of the case is not at all indicative of the final result. There is no symptom which occurs in fatal cases which may not be noted in those destined to a more 148 INJURIES OF THE BRAIN AND MEMBRANES. favorable termination, unless it may be the infrequency of respiration which follows compression of the medulla, and none less characteristically present, except an extreme elevation of temperature. Even in temperature the dis- tinction is not absolute; not only in the beginning but for many days it may be higher in a recovering case than in one which is to end in death, but in general its range is less, and it has rarely attained and never exceeded a limit of 105°, as it has been observed in the series of five hun- dred cases upon which these conclusions have been based. The direct results of lesion in all cases, whatever the final issue, are shock, circulatory disturbance, and possible sep- sis; and their manifestations will present no more radical differences than obtain in other types of disease. In illustration of those cases in which the significance of symptoms has not been demonstrated by a later inspec- tion of pathogenic lesions, the histories of a certain num- ber have been condensed and added to the appended series of those in which death was followed by necropsy. These instances have been selected with the intent of showing with recovery all the symptoms and pathic conditions which in another class have been connected with the causative structural alterations. Secondary Inflammations. I. Arachnitis. The inflammatory sequela of meningeal contusion is usually known as meningitis or leptomeningitis. The exception suggested in the previous study of pathology to the ordinary classification of intracranial hemorrhages, that the terms are not sufficiently distinctive, is to be taken to these designations. The occasional implication of the SYMPTOMATOLOGY. 149 dura mater in a suppurative process extending from a neglected external wound through a cranial fracture, or its farther extension to the deeper structures, constituting a general meningitis, is distinct from this other and not always infective process which originates in the parts to which it is confined ; nor is this a dual affection of the pial and arachnoid membranes, to be called, for some fantastic reason, leptoid, but a simple arachnoid inflammation or arachnitis. Its phenomena, as previously explained, are manifested in the substance of the pia mater, and not upon the arachnoid surface, as in other serous inflammations, by reason of an exceptional looseness of the subserous at- tachment. The exudations in pleurisy or peritonitis occur within the pleural or peritoneal cavity, rather than upon the visceral or the parietal surface, because it is in the di- rection of least resistance. It is difficult to estimate the frequency of the occur- rence of traumatic arachnitis. There are many instances in which some localized point of contusion becomes the seat of an equally limited inflammation which can have no appreciable influence either on the course of symptoms or on the termination of the case ; and there are many others in which it is of somewhat larger extent, but in which the influence it has exerted is at least doubtful. There are others still in which, though the serous effusion is abun- dant and the membrane even more or less opaque, the fact that death came before the establishment of reaction nega- tives the possibility of an inflammatory origin. If cases be disregarded in which the existence of meningeal in- flammation is questionable or apparently unimportant, there are but eighteen in the appended general series in which the lesion was positive and at the same time suffi- 150 INJURIES OF THE BRAIN AND MEMBRANES. ciently extensive to be influential in compassing the final result. There are nine in which the effusion was purulent or sero-purulent, and nine in which it was sero-fibrinous. In several there was neither external wound nor cranial fracture. They are too few in number for wide generaliza- tion in symptomatology, but the results obtained from their analysis are so generally confirmed by comparison with such facts as may be gleaned from the general field of traumatic arachnitis that they may be considered typical. The invasion is uncertain as to time and character, and the subsequent course of symptoms is irregular. The antecedent and coexistent lesions, with the exception of the meningeal contusion upon which it directly depends, have no obvious relation to the development of the in- flammatory process. It is probable that infection when it occurs will be early, but not of necessity primary; and that non-infective cases will be oftener late, and in the usual course of idiopathic secondary serous inflammations in prolonged disease, with the added predisposition derived from the antecedent contusion. The invasion of a trau- matic arachnitis is often immediate and is sometimes de- ferred till the third or fourth week, but is more frequent from the second to the fourteenth days. The initial symp- toms, when the inflammation is of low grade, are occasion- ally so insidious as to fail of recognition, but in general are sharply defined. In the larger number of cases, those ■which may be considered typical, the course of symptoms referable to antecedent and complicating lesions is inter- rupted by a distinct and somewhat sudden rise in tempera- ture, accompanied by an evident change in the general condition of the patient, who becomes irritable, restless, delirious, or somnolent. Active delirium, when not al- SYMPTOMATOLOGY. 151 ready existent as the result of cerebral contusion, is usu- ally the first general manifestation of the access of menin- geal inflammation. The occurrence of an invasive chill is exceptional, and when it occurs it is not necessarily indica- tive of an effusion of purulent character. The subsequent course of temperature is erratic. It is often marked by irregular variations from day to day and from hour to hour, not usual in case of other intracranial lesions. The irregularity and extent of the thermal changes, which may exceed 4° within each twenty-four hours, are characteristic. The dependence of these fluctuations upon a secondary implication of thermotaxic centres situated in the cerebral cortex, as has been suggested, may be worthy of considera- tion when the existence of such centres has been better established. In rapidly progressive cases of marked in- tensity, the recessions do not occur. The rise in tempera- ture which indicates the supervention of an arachnitis in a case of intracranial injury is usually distinct and some- times abrupt, it may be to the extent of 4° or 5° or even 6° in a few hours. The average temperature, notwith- standing its recessions, is afterward high, attaining eleva- tions of 103° to 107°-!- and in articulo mortis ranging from io5°-|- to 109°. The association of other grave structural alterations is so constant that it is difficult to demonstrate the exact relations of temperature, but the sudden primary rise is unmistakable, and the observation of both fatal and recovering cases in which minimum complications existed has made the subsequent range and the often character- istic irregular variations sufficiently well assured. The occasional excessive final temperature is probably always to be ascribed, at least in part, to concomitant laceration. After the invasion, and aside from peculiarities of tern- 152 INJURIES OF THE BRAIN AND MEMBRANES. perature, the progress of the disease is especially char- acterized by continued manifestations of cortical irritation. Some grade of delirium persists in almost every case, and restlessness, irritability, or extreme sensitiveness to ex- ternal impressions is often marked long after consciousness has been finally lost. General or post-cervical muscular rigidity, muscular twitching, limited or slight general con- vulsive movements, are further indications of nervous ex- citation. The occurrence of chill, which is an unusual invasive symptom, is not frequent at a later period. Head- ache is always in evidence, w^hen the mental condition of the patient wnll permit its recognition. Additional symp- toms have little value. The pupils are oftener normal than otherwise, and the pulse and respiration fail to reflect in the larger proportion of cases the existing inflammatory process. In many instances the want of correspondence between the pulse or respiration and the temperature may be ascribed to the influence of complicating lesions, but it is equally observed in others in which only a moderate cerebral contusion and no laceration exist, and in which the inflammation is of the highest grade. It cannot be said that in a majority of cases there is any sharp contrast in symptoms which indicates the character of the effusion. A copious purulent formation may be indicated by high pulse and temperature and active delirium without an in- vasive chill, or may be preceded by a chill and accompanied by asthenic symptoms ; it may be insidious in its progress, as an essentially serous effusion may be distinctly evident and of easy recognition. In a minor number of cases the symptoms are commensurate with the character of the in- flammation. The duration of the disease, like its period of invasion, is uncertain, and may be for days or weeks. Its SYMPTOMATOLOGY. 1 53 termination, when fatal, is in asthenia rather than in coma as the result of pressure. It is unfortunate that the greater number of the cases of traumatic arachnitis which have been reported fail in the detail essential to useful generalization. It has been pos- sible, however, to supplement the eighteen cases included in the appended series of intracranial lesions by another collection of eight heretofore unpublished cases, all of purulent and infective character, though not all of trau- matic origin. These exhibit the same irregular fluctua- tions of temperature and varied manifestations of cortical irritation which have been described. The results which have been obtained from the aggregation of the two series afford sufficient evidence to warrant the conclusion that these peculiarities, together with a more or less decided change in symptomatology at its inception, indicate the intercurrence of arachnoid inflammation in a case of in- tracranial injuy. 2. Abscess. Intracranial or cerebral abscess has been described as of two varieties, as it occurs upon the surface or deep in the substance of the brain. The lirst, which follows neglected compound fracture, may be properly excluded from consideration. It affords no question of diagnosis, since the pyogenic process involves alike the cerebral sur- face, the membranes, and the cutaneous wound; and if not open to direct visual inspection, or manifest through the existence of a fistulous canal, it will be necessarily disclosed in the exploration of the infected external parts. It is an almost impossible condition when the wound has received sufficiently early and intelligent aseptic care. 154 INJURIES OP THE BRAIN AND MEMBRANES. In the great majority of cases in which abscess is encoun- tered by the surgeon it has received no previous attention by reason of the stupidity of the patient and his friends, who in the absence of primary general symptoms have re- garded the injury as trivial. The concurrent evidence of local and systemic infection clearly indicates the nature of the complication. The history of traumatic suppurative inflammation of the deeper portions of the cerebral parenchyma is not only relatively but absolutely difficult to trace. There are no positive external indications, and no pathognomonic symp- toms. The initial symptoms are lost in those of the pri- -mary lesions, which it complicates as well as follows, and those of later development may be equally impossible of segregation and correct interpretation. Such abscesses, which have existed for months and have attained large size, have often escaped recognition, even by diagnosticians skilled in the knowledge of intracranial disease. The idiopathic cases, which have been made typical, present fewer difficulties, since they ordinarily originate in a single well-defined form of extracranial disorder, and pursue their course uncomplicated by other intracranial affections. They occur from traumatic cause with scarcely greater fre- quency than do the unavoidable suppurations involving the cortical surface, and are, except in pistol-shot cases, seldom attributable to neglect. The infrequency of traumatic central abscess of the brain is exemplified in the appended series of five hundred cases, in which it occcurs but four times; twice in the frontal, once in the fronto-parietal, and once in the parieto-occipital region ; only one of these at- tained a considerable size. It has been of most frequent occurrence in connection with pistol-shot wounds, in which SYMPTOMATOLOGY. 155 an ultraconservative treatment has been adopted. In one hundred and twelve cases reported in English, Colonial, and American journals, from 1879 to 1895, mainly treated without effort to remove the bullet or fragments of bone which penetrated the brain, and often even without their removal from the external wound, central abscess resulted in eleven cases, or nearly ten per cent., in addition to many purulent infections of the cerebral surface. The his- tories of abscesses formed in this way should be of great value in the study of symptomatology from the uniformity of the antecedent lesion and from the absence of other complication, but inaccuracy of observation and careless- ness of record have very generally minimized their im- portance. The moment at which the inflammatory process begins in the contused cerebral tissue is impossible even ap- proximately to determine. As purulent infection of the normal parenchyma from pneumonia and other distant in- fective diseases may remain unsuspected until long after the pus accumulation has become large, it is not to be sup- posed that its very beginning will be always or even usu- ally manifest when the part is already damaged and the lesion indicated by perhaps multifarious and to some ex- tent similar symptoms. In the most frequent form of cerebral abscess, that from otitis media, in which the ex- tension of inflammation is perhaps abrupt and the previous symptoms have been local and not of a nature to obscure thoise which supervene, it is possible to have a recogniza- ble initiatory stage. Pain of an altered character, rigors, vomiting, and a distinct elevation of temperature may unquestionably mark the access of a secondary process within the cranium. In traumatic cases the sudden acces- 156 INJURIES OF THE BRAIN AND MEMBRANES. sion of new symptoms may be followed by death and the post-mortem discovery of cerebral abscess; but they will probably indicate some crisis in its progress, some in- cidental cerebral or meningeal change, some increase in its size which has made it no longer tolerable, and not the inception of the pyogenic process. The existence of exceptional instances must be admitted. Thus, in one of the four appended cases, the pus formation was at- tended by distinctive symptoms in its incipience, which were recognized, and the abscess was evacuated at a very early stage. There are doubtless invasive symptoms in every case, though impossible of recognition — an elevation of temperature included in that of the an- tecedent contusion ; pain, which is masked by the continued stupor or delirium of the patient ; or circulatory and respira- tory derangements which are equally inappreciable in the existent general disorder of the system. It may be as- sumed that retrogressive changes begin in the contused or wounded cerebral tissue immediately after the occurrence of injury, and that with or without the invasion of an in- fective organism, at a variable period, at once or soon after- ward, they are followed by those of a pyogenic character. If the pyogenetic action is intense and the cumulation of pus is rapid, its symptoms are at once evident, despite the continuance of those of the primitive lesions; if the in- flammation is of low grade and the pus formation slow, the presence of abscess may be indicated only at a much later period, possibly long after the disappearance of the primary symptoms. At some period, early or late, the continued growth of the abscess, and its interference with the nutrition or func- tion of surrounding parts, will usually occasion recogniz- SYMPTOMATOLOGY. 1 57 able symptoms, whicli may be characterized as general, and as localizing or dependent upon disturbance of special centres of control. They are neither numerous nor indi- vidually distinctive. The occurrence of chill or rigors, which is regarded by Macewen as one of the most constant of early symptoms in the idiopathic cases which he describes, is less frequent in the traumatic form. The fact that the arachnoid mem- brane is not implicated, the usually lower grade of inflam- mation, and the different constitutional and nervous con- dition of the patient, may serve to explain this distinction. The temperature, as is usual in cerebral lesions, is of importance. In general, it is elevated during the pri- mary period in w^hich the symptoms of the antecedent con- dition predominate, normal during a subsequent interval of quiescence, and normal or subnormal after the develop- ment of the abscess has been sufficient to occasion direct manifestations of its existence. This generalization is by no means absolute. In those cases in which progress is rapid, and the pyogenic process begins before the subsi- dence of the disturbance occasioned by the primitive cere- bral lesion, the temperature will remain continuously high till the end; the sudden onset of late symptoms may be attended by an elevation from normal to 102° or 103° ; and even in the more insidious cases a temperature of ioo°-|- is not an extraordinary occurrence. After operative evacuation of the abscess cavity, an immediate and signal advance occurs, which is soon folloAved by a recession to a point but little above the normal standard. Some degree of pain in the head is an almost constant symptom. If it occurs early in the case, it is indistinguish- able from that which attends contusion ; at a later period, 158 INJURIES OF THE BRAIN AND MEMBRANES. especially when, after an interval comparatively devoid of morbid indications, it is an incident in the inception of new symptoms, it becomes characteristic. It may then recur suddenly and with great intensity, or, in the more insidi- ous cases, with less severity, it may be of remarkable per- sistency. It is oftener in the frontal region than elsewhere, even in the case of cerebellar abscess; and, when the mental condition of the patient permits, it may be aggra- vated or even detected, though otherwise inappreciable, by percussion ; but only if made upon the corresponding side (Mace wen). The pulse is characteristically slow, as it is in other lesions of the cerebral substance — not much above or be- low 60 in the greater number of cases, occasionally even slower, and in a minority of cases moderately accelerated. After evacuation of the abscess it increases in frequency with the rise in temperature, and also near a fatal termi- nation. The respiration, like the pulse, is diminished in fre- quency and like the pulse condition represents a usual effect of uncomplicated cerebral lesion. It is also at times irreg- ular, with intervals of retardation and acceleration, or late in the progress of the disease may have the Cheyne-Stokes peculiarities. Thus neither the pulse nor the respiration reflects the special character of the structural alteration. The mental condition, again, is characteristic but not peculiar. It is indistinguishable from that which often re- sults from cerebral laceration, and sometimes from con- tusion, in which the activity of cerebral function is les- sened. There are apathy, slowness and dulness of the mental faculties, insensibility to pain, somnolence, and in- creasing stupor. In the cases in which the pus formation SYMPTOMATOLOGY. 1 59 immediately succeeds the primary contusion and its ad- vance is rapid, these evidences of decadence may be re- placed or preceded by restlessness, irritability, and delir- ium, which terminate as before in stupor and coma. Prostration and emaciation are disproportionate to the amount of febrile action as indicated by the pulse and temperature, and are excessive in relation to other atten- dant symptoms. Vomiting or vertigo may be, either one, a prominent in- cident in individual cases, and, though they are not specific symptoms in abscess formation generally, are undoubtedly very significant in the particular instances in which they occur. Convulsions and muscular rigidity are of more frequent occurrence, and the suppurative process is then so generally located in the temporal or frontal lobe that they may be regarded as in some degree localizing symptoms. Constipation is in no sense an indication of suppuration, but is common to many morbid cerebral conditions ; and retention of urine when it exists is to be in no greater de- gree attributed to the special character of the lesion. The loss of faecal and urinary control in the terminal stage signifies only the destructive character of the lesion . An enlargement of the posterior cervical glands after the cicatrization of an external wound in one of the ap- pended cases, and before the occurrence of symptoms of an abscess beneath the angular gyrus, attracted attention. It is possible that further observation may show this condi- tion to have some symptomatic importance. The second class of symptoms depends upon the direct or indirect implication of cerebral centres of control. In eleven of an accessible series of twenty traumatic abscesses, l6o INJURIES OF THE BRAIN AND MEMBRANES. motor paralysis, anaesthesia, aphasia, disturbed reflexes, optic neuritis, hemianopsia, or abnormal conditions of the pupils, singly or in combination, were observed. The fact that nutritive disturbances extend for a considerable dis- tance from the abscess formation lessens the significance of these functional or other disorders in localizing its situa- tion ; but they still have an approximate value. In con- nection with other and more general symptoms, they have great corroborative diagnostic importance. The paralyses are of most frequent occurrence, since the abscess is in the larger proportion of cases situated in the frontal or tem- poral lobe in the vicinity of the motor areas, and for the same reason the reflexes are often exaggerated or dimin- ished. These functional disorders, together with aphasia and anaesthesia as results of local pressure or of adjacent structural alterations, invite no special comment. The existence of a lateral hemianopsia in like manner may result from the implication of a visual area in the event of an abscess occurring in the parieto-occipital region. Pupillary phenomena are not infrequently manifest when abscess is seated in the temporo- sphenoidal or frontal lobe. The pupil on the corresponding side is then either myotic or mydriatic, with some degree of fixation, as the abscess is small and causes iritation, or as it is large and exercises pressure. ^lyosis may give place to mydriasis as a small abscess increases in bulk. Occasionally the only pupillary change is the sluggishness of one pupil to both light and accommodation. If the abscess is large, the pres- sure upon the third nerve, which occasions mydriasis, may at the same time cause ptosis and external strabismus (Macewen). SYMPTOMATOLOGY. l6l The occurrence of an optic neuritis after an abscess has attained moderate size is not infrequent, and while it is a local manifestation, so far as it is a consecutive disease of a special part, it is not a localizing indication, and might perhaps have been more properly included in the enumera- tion of general symptoms. It is due to an increase of in- tracranial pressure without reference to the site of the abscess, and is the most characteristic of all the abscess symptoms, in the sense that it is occasioned by a smaller number of lesions than any other. It may exist upon one side or both ; when double it will not always be of greatest extent upon the corresponding side, and when single may be of the opposite nerve. The atrophic stage is seldom reached before the culmination of the primary disease. Analytical examination and enumeration of these varied possible symptoms are easier than their synthetical rearrangement to form a typical case. It may be said that while in the greater number of instances the pyogenic process may be continuous with the degenerative changes which immediately follow the primary cerebral contusion, there will be an interval in which the progress of symp- toms is unnoted. This is neither a period of incubation nor of intermission, but of remission, during which it is not unusual for the patient to follow his ordinary voca- tions, and if unobservant of himself to be unaware that he is really ill. This interval may extend over many months, but in time, suddenly or insidiously, more urgent symp- toms will be developed; either an intense pain in the head, vomiting, and vertigo, or a convulsion, or muscular rigidity, with great prostration, followed by stupor and coma, may precede an early fatal termination ; or pain persistent rather l62 INJURIES OF THE BRAIN AND MEMBRANES. than severe, gradual prostration and comparatively rapid emaciation, with slow pulse and respiration and possibly a slightly subnormal temperature, slowly failing sight, mental and physical lethargy, increasing somnolence and stupor lapsing into final coma, may extend over many days or even weeks. Intercurrent muscular weakness or paralysis, anaesthesia, aphasia, or pupillary changes may emphasize its progress. It often happens that many of these symptoms are wanting, and that others are indefinite or but faintly suggestive of the nature of the cerebral lesion. The usual end of all cases, whether their indications have been decisive or obscure, is death from coma in a previ- ously existent asthenic condition. In the comparatively few instances in which abscess is acute, suppuration is dif- fuse and pya^mic infection follows; in the vast majority of chronic abscesses, capsulation is an efficient protection from rupture and a consequent diffuse infective inflamma- tion. It is possible that the capsule may give way, and the pus reach the cerebral surface, or that it may break through into the ventricles, but these terminations, if they occur at all, must be of great infrequency. There is more probability that an extension of the inflammatory area about the abscess will involve the arachnoid mem- brane. If an atachnitis supervenes, either from rupture of the abscess and an access of pus to the cerebral surface, or from simple extension of the peripheral inflammation, there will be sudden increase in the severity and urgency of symptoms ; there will be an abrupt rise in temperature, rapid pulse, hurried respiration, and other indications of the new pathic condition. In the event of a purulent in- vasion of the ventricles, the transition of symptoms will be still more violent, and with even less premonition. SYMPTOMATOLOGY. 163 The face becomes livid, the pupils are widely dilated, the respiration is insufficient and perhaps stertorous, the pulse frequent and oppressed, and the temperature greatly ex- alted; the muscles are convulsed, coma is immediate, and death soon ensues. Chapter IV. DIAGNOSIS. DIRECT LESIONS. The differential diagnosis of intracranial lesions is usually practicable if symptoms are accurately noted and are subjected to careful analysis. They are first to be dis- tinguished from all other morbid conditions, especially from those involving loss of consciousness or delirium, and, secondly, they are to be discriminated from each other. The existence of an encephalic injury is often patent from numerous and manifest indications, and from a knowledge of the immediate history of a case ; but its recognition when symptoms are obscure or perhaps mainly negative, and no historical data are attainable, may require the exer- cise of great circumspection and exact discrimination. The frequent instances in which, after a survival of the patient for many days, extensive cerebral wounds are unsuspected till disclosed upon necropsic examination, evince the ne- cessity of care, if not the difficulty in diagnosis which may be encountered. The case of an unknown man found un- conscious in the street, taken to a hospital, retained in a medical ward, and first discovered in the dead-house to have been the victim of accident or violence, is not excep- tional. The primary symptom which undoubtedly overshadows all others, in all forms of intracranial injur}', is coma or some decree of unconsciousness, which at the same time is DIAGNOSIS. 165 the most striking symptom in various other morbid condi- tions. It is natural that this identity should be, as it is, the most fruitful source of error in diagnosis. The num- ber of idiopathic diseases in which coma is characteristic is large, possibly twenty and more. In case of the greater part of these, as in malignant fever, facial erysipelas, or diabetes, the danger of confusion with the effects of trau- matism is too remote to necessitate any reference to their distinctive signs; in others, as in epilepsy or sunstroke, the distinction is so readily made that their consideration may be omitted with equal propriety; but in apoplexy, uraemia, alcoholism, and opium narcosis diagnostic dif- ficulties are sometimes so great and erroneous conclusions so often reached as to demand some comparison of their symptoms with those which follow intracranial traumatism. The occurrence of delirium, which sometimes replaces or accompanies the coma of alcoholism or of uraemia, may be a special source of embarrassment when these diseases are brought in question. In the coma of opium poisoning the pupils are strongly, immovably, and symmetrically contracted ; the face, at first pale, becomes swollen, flushed, and livid; the breath may have the odor of opium ; the skin is warm and moist or perspiring; the patient can be aroused, and the mental condition is then found to be normal and the articulation unaffected ; the repsiration is markedly and progressively diminished in frequency, and is slow, it may be with stertor, and with a pause between inspiration and expira- tion; the pulse is at first slow and full, and later is feeble and rapid; the temperature is slightly subnormal; and the reflexes are absent without the occurrence of other disorders of muscular function. l66 INJURIES OF THE BRAIN AND MEMBRANES. In urasmic coma the pupils are dilated, and sluggish or irresponsive to light; the face is white, and the surface cedematous; the breath has a sweetish odor; the patient can rarely be aroused; the respiration is frequent and irregular, the inspiration hissing and the expiration some- times noisy; the pulse is irregular, incompressible, and usually rapid; the temperature is normal, the muscular function and reflexes are unaffected, and the urine is albuminous. In apoplexy the pupils are dilated, except in hemor- rhage into the pons, and are immovable; the eyes are glassy and there may be strabismus ; the face is pale or darkly flushed, the surface is cold and moist, the odor of the breath is natural, the patient cannot be aroused; the respiration is slow, irregular, and stertorous, and the lips are covered with frothy saliva; the pulse is variable, at first small and infrequent, and later full, hard, and fre- quent; the superficial arteries are often rigid; the tem- perature, at first subnormal, becomes and remains normal in cases destined to recovery, but in those which are fatal it continues to rise and attains a high degree ; there may be unilateral paralysis of the face or extremities with ex- aggerated reflexes on the paralyzed side, and the urine is often retained. In acoholic coma the pupils are not characteristically changed, and are usually normal; the face is likely to be flushed, and the surface is cold; the breath is alcoholic; the patient can be aroused unless coma is profound, and he is then irritable and incoherent, and the articulation is indistinct ; the respiration is regular and without stertor, may be slow or hurried, and expiration is quickened ; the pulse is frequent and weak, but becomes slow as coma in- DIAGNOSIS. 167 creases ; the temperature is normal in some instances, but when the comatose condition is profound is markedly sub- normal ; and the urine may contain alcohol. The symptoms detailed as occurring in these several forms of coma are variously modified, and many of theni perhaps absent altogether, in individual cases; but the picture as presented is representative and substantially correct. The symptoms occasioned by intracranial lesions have been sufficiently described ; it remains to indicate their diagnostic relations. The fact of some intracranial injury having been received will be at once suggested by the ex- istence of wound or contusion of the scalp or of demon- strable fracture of the cranium. It will of itself establish the diagnosis in a large majority of cases in which the origin of coma is in doubt, since the instances are ex- ceptional in which the extracranial lesion and the intra- cranial disorder are independent of each other, and are scarcely more numerous in which a traumatic intracranial lesion is not attended by some superficial or cranial injury. It is possible that a drunken man, or an epileptic, or one falling in an apoplectic attack, should wound or contuse his scalp or fracture his skull, either with or without receiv- ing further cerebral hurt, and that subsequent coma or delirium, which might be fairly attributable either to the traumatism or to the antecedent morbid condition, would be difficult of interpretation. The immediate history of a case, if attainable, is of first importance in establishing a prima facie probability of the presence or absence of en- cephalic lesion ; but, as often happens when patients have been found unconscious in the street, the positive or nega- tive evidence derived from external examination must take l68 INJURIES OF THE BRAIN AND MEMBRANES. its place. This must be thorough to be of absolute value; the head may have to be shaved to discover contusions or haematomata, or incision made to permit tactile or visual detection of linear fracture ; and the occurrence of pathog- nomonic external hemorrhages of internal origin must be recognized and appreciated. Such an inspection might be sufficient to determine the probable traumatic or idiopathic nature of an initial lesion, but, even with the aid of an ex- act history, would be a manifestly unsafe reliance without the confirmation afforded by general symptoms. The crit- ical study of the various features of a case will ordinarily serve to determine not only the etiological character of its lesions but also the occasional coexistence of traumatism and antecedent disease. In this scrutiny the symptomatic peculiarities of the several forms of coma must be con- sidered and contrasted, or reconciled with the actual conditions presented, and the diagnosis perhaps finally established by the predominant importance of a single symptom. The disease or morbid condition with which intra- cranial injury is most frequently confounded is alcoholic coma. It is scarcely possible to overestimate the import- ance of the correct differentiation of these two forms of coma, of such diverse origin and significance. Error in diagnosis not only inflicts great unnecessary suffering, ad- ditional danger, and possible disgrace upon the patient, but places corresponding responsibility, both moral and professional, upon the surgeon. The number of instances in which the indications of most serious intracranial injury have been mistaken for the results of simple alcoholic ex- cess is inexcusably great, and justifies more than casual reference. This misconception of the significance of DIAGNOSIS. 169 symptoms is even oftener the result of negligence tlian of incompetence. It is often apparently forgotten that while there may be a fair presumption that a man found uncon- scious in the street, or delirious in a police station, is simply drunk, it is no warrant for the neglect of ordi- nary physical examination or disregard of obvious indica- tions. The appended .series of cases includes many in which fractured skull or lacerated brain, plainly evident when suspected and sought, has been unnoted in a hastily formed theory of alcoholic coma; others, in which the patient has been left by the ambulance surgeon to die in the police cells, or sent from the police court to a term of imprisonment ; and very many in which he has been de- tained in the alcoholic wards of a hospital or even trans- ferred to an asylum for the insane. These flagrant scan- dals still occur, and with increased discredit to hospital administration, since increased experience has shown the necessity of special provisions to avert the possibility of their occurrence. It is primarily essential, in approaching the diagnosis of a case of apparent aloholic coma, to divest the mind of all preconceptions and to realize that an un- conscious man with a scalp wound is not necessarily drunk, and that even a drunken man may be so seriously injured as to require hospital treatment. Unconsciousness and the existence of superficial injury of the head should in any case arrest attention, and awaken suspicion of brain lesion. Coma ought not to be ascribed to alcohol, except by the strictest process of exclusion. Symptoms which are most likely to characterize different forms of head injury should be sought seriatim, and their absence, not less than their presence, noted. It should be remembered, finally, that even if the patient be intoxicated, this circumstance should I/O INJURIES OF THE BRAIN AND MEMBRANES. Strengthen rather than allay suspicion of traumatism. It follows that the flushed face and sodden features, the al- coholic breath, which mark habitual inebriety, the inco- herence and thickened articulation when the patient can be aroused, are nothing to the purpose till the fact of cere- bral traumatism has been excluded. The observance of temperature will afford an almost absolute means of diagnosis. In alcoholic coma, when profound, the temperature is subnormal, often not above 96°; and when less complete, not above the normal stand- ard; its depression is likely to be proportionate to the depth of unconsciousness. These generalizations are founded upon a sufficient number of observations to justify the assumption that they are essentially correct. The rule that in cases of intracranial injury the temperature is elevated is equally positive, and when the lesion is sub- stantially cerebral, the one in which the general condition most closely resembles that of alcoholism, the contrast in temperature is most decided. In a majority of instances in which cerebral lesion exists, the temperature is charac- teristic from the first, but in a certain number it is prima- rily depressed, either from general shock or from the fact of a concomitant alcoholic condition ; and in this event, if other symptoms are not conclusive, some delay must oc- cur in arriving at a positive opinion. If the comatose condition has resulted purely from alcoholic excess, the temperature will in a few hours become normal with the re- storation of consciousness; if some intracranial injury has coexisted, the temperature, after the same interval, whether or not consciousness is regained, will rise above its normal degree to an extent dependent upon the nature of the lesion. In the cases in which primary temperature is de- DIAGNOSIS. 171 pressed by general shock, that condition will be recognized by its tis-iial symptoms, and after reaction has been estab- lished the elevation of temperature will be no less char- aracteristic. Even if intracranial hemorrhage has been the essential lesion, and the subsequent range of tempera- ture is less than in cerebral trauma, it is still distinctive. In the comparatively exceptional instances of primary subnormal temperature, in connection with traumatic in- tracranial lesions, the immediate recognition of structural injury is ordinarily practicable from an examination of the other symptoms presented. The indications of alcoholic insensibility, aside from those of inebriety, are mainly negative; neither the pupils, pulse, nor respiration, are characteristic; there is no paralysis, and the patient, except in extreme cases, can be aroused. If intracranial lesion exists, it can hardly fail that some one or more of its dis- tinctive symptoms can be detected — unequal or dilated pupils, muscular paralysis or rigidity, unsymmetrical radial pulsations at the two wrists, abnormal relation of pulse, respiration, and temperature, or some other positive indica- tion of organic change, which will be manifest while tem- perature is yet depressed. The active delirium which may occur in the period im- mediately succeeding the reception of a brain injury is sometimes very difficult to distinguish from that which re- sults from alcoholic excess. The difficulty may be further increased by the fact that the subject is of known intem- perate habits, and was very likely intoxicated when first ^brought under observation. In those cases in which de- lirium is the first symptom noted, and probably replaces unconsciousness, the condition is made very deceptive. In this instance we are not aided by the temperature, which 172 INJURIES OF THE BRAIN AND MEMBRANES. is usually elevated in alcoholic delirium, and the elevation may be, and often is, very great. There may be no posi- tive means by which such a case, if alcoholic, can be diag- nosticated from one of cerebral contusion ; but few cases of laceration will be encountered in which at least one or two characteristic symptoms cannot be detected, and there are differences even in the character of the delirium which may be recognized, though not easily formulated. In the differentiation of the coma of apoplexy from that of encephalic injury the temperature is again of paramount importance. The observations of Bourneville, confirmed by others of more recent date, show that in apoplexy the primary temperature is subnormal, and that it subsequently rises scarcely above the normal standard except when death ensues. In an accessible series of twenty-three cases, with a mortality of seven, the highest temperature in twenty- one was ioo°-|-; in two, which were fatal, it reached 102° -104°. This is in marked contrast to what happens in cases in which the lesion is traumatic, and in which from a possible depression the rise is immediate, whether re- covery or death impends, and is practically continuous while the result remains in abeyance. The distinctive peculiarities of temperature in alcoholism, cerebral trau- matism, and apoplexy are thus well marked. There are no other individual symptoms in apoplexy which are in any degree pathognomonic, or which may not be reproduced from a traumatic lesion ; in their ensemble they may ac- quire a more positive diagnostic value. It may happen that a patient, seized with an attack of cerebral hemorrhage, falls and suffers a consecutive in- tracranial injury. Two such instances occur in the ap- pended series of cases, in each of which a cerebellar lac- DIAGNOSIS. 173 eration was produced. In the absence of history, such a concurrence of lesions would probably be impossible of detection. The diagnosis of traumatic from opium or ursemic coma presents fewer difficulties. In the second, the strongly contracted pupils and excessively slow respira- tion, the fact that when unconsciousness is not absolute the patient can be aroused and that his mental condition is then clear, the often swollen and livid face, and perhaps the odor of the drug upon his breath, with a practically normal temperature and the absence of all traumatic in- dications, make the pathic condition clear. In the third, the facies, general symptoms of renal disease, and albumi- nous urine, even without the contrast of the special expres- sions of different cerebral lesions, are equally convincing. The only probable danger of confounding either one of these two forms of coma with that which results from in- tracranial injury will arise from inattention rather than from any essential difficulty in their discrimination. These questions of diagnosis, as it concerns different forms of coma, have been considered upon the supposition that no previous history of a case is attainable, and that the fact of traumatism, even, is unknown, except as it may be indicated by some discoverable superficial or cranial lesion. It is fortunate that the immediate ante- cedent circumstances can usually be learned; and, with symptoms which can then have no equivocal meaning, no doubt need remain that some sort of intracranial injury has been sustained. The fact that an intracranial injury has been received having been determined, the designation of the special form it has assumed is fraught with difficulties, which 174 INJURIES OF THE BRAIN AND MEMBRANES. sometimes prove insuperable. The lesions are likely to be multiple, and many of the symptoms to be equally ref- erable to either one of their number; the manifestations of a circumscribed lesion are often lost in those of one of a diffuse character; and similar results constantly ensue from different causes ; but a diagnosis of sufficient if not absolute exactitude is ordinarily possible. It is essen- tial to determine not only the character but the location of a lesion, with a view both to prognosis and to possible operative interference. In cases which are obscure, diagnosis must rest primarily upon the recognition of in- dividual symptoms, and secondarily upon a study of their relations of time and circumstance and upon a knowledge of what has been established as to the dependence of each upon definite structural alterations. Every existent symp- tom must be appreciated and estimated in a quest for one which is either pathognomonic or characteristic, and this, when detected, must be reconciled with others apparently inconsistent, though it may necessitate the assumption of multiple rather than of single lesion. The method of de- velopment, not less than the existence of symptoms, the period of their occurrence, and the changes which they suffer, must be accurately noted, and a provisional diag- nosis often left to time to confirm or disprove. The differentiation of the several primary lesions has been already indicated, either directly or by implication, in the enumeration and delineation of individual symptoms ; but the more extended study of comparative symptoma- tology, in which the modified significance of the external manifestations of these internal injuries is to be estimated in view of their period of development, length of continu- ance, and mutual relations, is usually requisite to either DIAGNOSIS. 175 certainty or exactitude of diagnosis. It is practicable to make the consideration of specific diagnostic methods scarcely more than suggestive ; the possible variations in the nature and relation of coexisting or consecutive symp- toms are too multitudinous to admit of systematic or detailed description and analysis. The examination which may be instituted to determine the character of an intracranial injury naturally begins with the condition of unconsciousness, at once the most notable and the most constant of all primary symptoms. If by chance consciousness has been retained, inquiry will then be at first directed to the proper interpretation in the light of attendant conditions of whatever other symptom may be most prominent. The loss of consciousness which im- mediately succeeds a cephalic injury is always the result of diffuse cerebral contusion; if unconsciousness is pre- ceded by a conscious interval, however brief, or if after restoration of consciousness its privation recurs, it is occa- sioned by some form of intracranial hemorrhage. These distinctions are theoretically simple, and in practice readily made. If, however, primary unconsciousness is permanent or greatly prolonged, its continuance may be due either to the severity of cerebral lesion or to a complicating hemor- rhage ; and whether the one has persisted from the begin- ning or has been at any time replaced by the other, or whether both exist together, can be determined, if at all, only by a study of all the symptoms presented. The pulse, temperature, and respiration must be systematically recorded in every case from the first opportunity afforded for observation until its end, and the accuracy of this rec- ord, not only from day to day, but sometimes from hour to hour, may be of the utmost diagnostic importance ; of 176 INJURIES OF THE BRAIN AND MEMBRANES. these, the temperature in its course and variations will afford in the greater number of cases the most distinctive indication of the nature of the lesion. The primary temperature is above the normal standard in all forms of intracranial lesion, when it has not been depressed by general shock or the effect of alcoholic ex- cess. In cases of comparativel}' uncomplicated hemor- rhage, it will range from 98.5° to 99.5°, and will not sub- sequently exceed 100°, unless general cerebral contusion is well pronounced, when it may reach 101° or even ioi°-|-. If the essential lesion is a cerebral contusion, the primary temperature is but slightly higher, but will rise progress- ively, and in a certain proportion of cases will be marked by recessions which do not attend hemorrhages. Cere- bral lacerations are characterized by a still higher initial temperature, and when severe by an early and rapidly pro- gressive increase with only brief and unimportant reces- sions, and if fatal by an often excessive final elevation. These generalizations result from an analytical study of the appended series of cases. If then, after the lapse of hours, consciousness still remains in abeyance, a stationar}'' temperature but one or two degrees above the normal standard will indicate a hemorrhage of some profusion without serious cerebral injury; but a higher elevation which constantly increases, with possible recessions, will point to a visceral lesion. If this increasing temperature does not exceed moderate limits and its advance is slow, it will suggest contusion alone, or with laceration of small extent ; a still higher early temperature, advancing rapidly and uninterruptedly or without important recessions, is an almost pathognomonic indication of laceration; and a resultant cortical or a coincident other form of hemor- DIAGNOSIS. ' 177 rlaage can be recognized only by the coexistence of some characteristic symptom of a different nature. In occa- sional instances of cerebral contusion the temperature may as rapidly attain a high degree as with laceration, and diagnosis must again depend upon the other symptoms. The cases in which consciousness after a brief restoration is again lost, permanently or for a lengthened period, have the same relations to temperature as those in which un- consciousness has been uninterrupted. It will be recalled that the recurrence of unconsciousness after an early in- terval of sensibility is indicative of an increase or super- vention of hemorrhage, and that at a later period more or less conscious intervals in a generally unconscious condi- tion result from a temporary lessening from time to time of the hyperemia or oedema of a diffuse cerebral contusion. The question of hemorrhage could scarcely be mooted in the last instance, but the temperature still conforms to established rule. The diagnostic characters of the pulse and respiration can be less definitely formulated. In uncomplicated hemorrhages the pulse is oftener frequent than otherwise, and in cases which are to some extent complicated it is usually normal; but the exceptions to the rule are so nu- merous in either case that it has little practical importance. The conditions of the pulse are more uniform in epidural hemorrhages than in others, and slowness and fulness are so generally noted that they may be considered fairly characteristic. The respiration when hemorrhage is pro- fuse and practically uncomplicated is only exceptionally of normal character; but its disturbances are without recog- nizable relation to the form of the extravasation or. in Sfeneral. to its situation. Increased or diminished fre- 178 INJURIES OF THE BRAIN AND MEMBRANES. quency, with or without stertor, occur alike whether the effusion is epidural, pial, or cortical, or whether it is at the base or vertex ; but infrequency and stertor, like slowness and fulness of the pulse, are more nearly characteristic of epidural than of other forms of hemorrhage. If the ex- travasated blood compresses the medulla, the fact of hemorrhage, its position and its source in the pial or cor- tical vessels, are all absolutely demonstrated by extreme respiratory infrequency; this certainty, with the prob- ability of an epidural form of hemorrhage, when the respiration is stertorous and moderately infrequent, sum- marize the information to be derived from a study of this function in connection with intracranial vascular lesions. In diffuse cerebral contusion it is impossible to dis- cover any variations from the normal pulse and respiration which occur with sufficient uniformity to afford assistance in diagnosis in individual cases. Neither the proportion of cases in which they are not sensibly affected, nor of those in which they are increased or are diminished in fre- quency, is sufficiently large to justify positive inference, though both incline to acceleration. In case of the cerebral lesions in which laceration is an essential part, a more uniform condition of pulse and respiration can be predicated. After recovery from shock and unless meningeal inflammation supervenes, the fre- quency of the pulse upon early examination does not often exceed 90, nor the respiration 26. In the majority of cases the pulse is full and slow and not more frequent than from 60 to 70, and is sometimes but 40 in the minute. If the respiration departs from its normal standard, it is more likely to be slightly accelerated than retarded. These conditions are maintained till recovery, or, if the case is DIAGNOSIS. 179 destined to a fatal termination, until the patient becomes asthenic. The contrast so often presented by a nearly- normal and unaccelerated pulse and respiration, with a high temperature and general symptoms of perhaps great severity, is not only striking, but is of great value in diag- nosis. There is also a frequent want of correspondence in their changes, which is characteristic when they suffer more notable disturbance, the pulse becoming slower as the respiration is accelerated. The irregular rhythm of respiration which sometimes occurs with severe cerebral lesion is not observed in the case of hemorrhages, except as a symptom of coincident contusion. The asymmetrical radial pulsations upon opposite sides of the body, which are so conclusive of the existence of some form of intra- cranial injury, afford no clew to the nature of the lesion. Dyspnoea and resulting cyanosis are not referable to compression of the medulla, but of the intracranial portion of the pneumogastric nerve. An importance has been attributed to indications afforded by the pupils which is not warranted by an an- alysis of cases. They are so often normal, and when ab- normal present so many variations in dilatation and contrac- tion, that their observation cannot as a rule materially aid in diagnosis. The paralysis or spastic contraction of muscular fibres, upon which their changes depend, results from cerebral injury, and, as they occur in a much larger percentage of hemorrhages than of the essentially visceral lesions, it would appear that the cortex, which is coinci- dently involved, is specially connected with their control. This muscular derangement occurs, however, with lesion of every part of the brain, whether limited or diffuse, and with or without the concurrence of hemorrhage ; but the l80 INJURIES OF THE BRAIN AND MEMBRANES. organic conditions which determine its presence or ab- sence or the nature of its manifestation are unknown. There is a single exception to be made to this statement of the pathology and of the diagnostic value of pupillary change. The dilatation of the corresponding pupil with an epidural hemorrhage is due not to cerebral injury, but to direct pressure of the extravasated blood upon the third cranial nerve, and, having a definite origin, it is a distinc- tive S5'mptom. Still it is neither constant nor pathog- nomonic; there are many epidural hemorrhages, even those occasioned by rupture of the middle meningeal artery, in which no pressure is exerted upon the nerve and no change in the pupil exists; and there are many in- stances of epidural hemorrhage with dilatation of the opposite pupil from some coincident cerebral lesion. The mental disturbances which may replace or imme- diately succeed unconsciousness, or in some form occur at a later period, are all indicative of visceral lesion. De- lirium is always the result of circulatory disturbance, and as an early symptom must be distinguished from the effect of alcoholism, and later from the same condition as pro- duced by sepsis or by meningeal inflammation. If promi- nent and convincing evidence of hemorrhage or of lacera- tion exists, it is to be attributed not to those lesions but to a complicating cortical contusion. Irritability, restless- ness, or other sensory disturbances are to be ascribed to the same cause. There is no mental disorder, aside from loss of consciousness, which results from hemorrhage. The derangements of the intellectual faculties which are not incidental to delirium, as delusions, loss of memory, defective judgment, and mental decadence, indicate in the great majority of cases laceration, and this has been de- DIAGNOSIS. l8l monstrated by conjoinea clinical and necropsic observation to involve the left frontal lobe. The dependence of such symptoms upon general contusion is possible but it is exceptional. Loss or disorder of muscular action may occur with each of the traumatic intracranial lesions, but either is an infrequent result of uncomplicated contusion. Paralysis is especially characteristic of hemorrhages, and irregular muscular action of laceration. The paralyses, which may be either complete or incomplete, local or general, are due in the case of hemorrhage to compression, and in lacera- tion to disruption of recognized motor tracts or areas. General or local convulsions, muscular twitchings, and muscular rigidity are occasioned by compression and irri- tation of the cortex in hemorrhage, or by irritation of the contiguous cerebral substance in laceration. The cause of these several motor disturbances, as they occur in indi- vidual cases, may be to some extent assumed from their known relative frequency from different lesions. This is notably true of convulsions which are so generally the result of laceration. The indication of hemorrhage or laceration afforded by a study of symptoms collectively is however, more directly diagnostic, and the relation of the pathic motor condition to special associated symptoms has great significance. The temperature which precedes the convulsive paroxysms is distinctly higher if the causative lesion is a laceration than if it is a hemorrhage ; the im- mediate subsequent temperature has no corresponding value. The convulsions which result from hemorrhage, which is usually pial, are likely to be preceded or accom- panied by paralysis, which is improbable if they are due to laceration. The precedence or coincidence of certain l82 INJURIES OF THE BRAIN AND MEMBRANES. mental derangements known to be usually connected with frontal lesion will greatly add to the probability which so generally exists that any convulsion is due to laceration of the temporo-frontal region. The loss of faecal and urinary control is a nearly pathog- nomonic symptom of laceration. It is fairly constant when life is prolonged for a number of hours, and it is of rare occurrence when cerebral injury is confined to hemor- rhage or contusion. It is unaffected by the region of brain involved, and is independent of paralysis or the loss of consciousness. The retention of urine which sometimes occurs in cases of hemorrhage, on the contrary, is not indicative of the nature of the lesion, but is merely a result of the unconscious state, however produced. The several pathic conditions which have been enumer- ated possess different diagnostic values. Some of them, like secondary unconsciousness or loss of faecal and urinary control, indicate merely the nature of the lesion; others, like special forms of paralysis, indicate its situation; and others still, like certain mental disorders or an extreme infrequency of respiration, indicate both its nature and its exact or approximate situation. There are certain other symptoms which might be possibly encountered and in- terpreted in the light of physiological investigation as ap- plied to cerebral localization. It might be supposed that traumatic lesion of the occipital visual centre, or of the temporo-sphenoidal auditory or gustatory centres, if such exist, would be attended by default or aberration of the corresponding special senses. If these effects have been recognized, they have been unrecorded — at least so far as taste or hearing are concerned. The lesions of the speech centres in the frontal and DIAGNOSIS. 183 temporal lobes are not infrequently indicated in recovering cases by the existence of motor or sensory aphasia. The very general coincidence of an unconscious or delirious condition renders it exceptional as a recognizable symptom in those which are fatal. It has been assumed that com- pression from hemorrhage, as well as destructive injury of its centres of control, is an effective cause of the loss or disturbance of the faculty of speech. This assumption is opposed to the results of observation and not less to gen- eral anatomical and pathological considerations. The compression, if exerted by a small amount of blood, must be direct and accurately applied; if it be by a hemor- rhage large enough to include these small spaces in the wide expanse of cerebral surface through which we are brought in contact with the world without, the individual fault is lost in the general obscuration of all the faculties which attends the grosser injury. A pial hemorrhage from meningeal contusion in this region is likely to be scant and diffused; a cortical hemorrhage, if small and confined to either area in which the control of speech resides, is derived from laceration of the part itself, to which as the primary and more potent lesion the result must be at- tributed; an epidural hemorrhage while yet in moderate amount acts directly and inadequately upon the temporal or lower frontal region through the dura, which serves as an efficient shield. In the case of wounds of the middle meningeal artery, in which the effusion of blood may in time become excessive, the loss of consciousness which then ensues abrogates speech with all the other manifesta- tions of intellectual life. In the large number of hemor- rhages included in the appended series of cases, none of pial or cortical origin have suggested an interference 184 INJURIES OF THE BRAIN AND MEMBRANES, with the integrity of speech, and in none in which con- sciousness has been retained or restored has blood de- scended from the vertex in sufficient quantity to produce such a result by compression of the frontal or temporal lobe. They include instances of large epidural hemor- rhage in which consciousness was gradually lost before death or relief by operation, but none in which aphasic symptoms were recognized at any time during their prog- ress. There is a case reported in which motor aphasia is attributed to hemorrage. The effusion was small; the patient was trephined, and some power of speech regained as well as some improvement made in an impaired mental condition. It has been demonstrated from extensive ob- servations that intellectual and emotional impairment is not occasioned by traumatic hemorrhage. There were evidences of both in this case which the amount of blood discovered and removed was certainly insufficient to ex- plain. It is necessary to assume laceration in order to ac- count for their existence, and it seems more probable that the same lesion was the cause of the aphasia, which might readily have escaped notice in the comparatively small opening of operation, especially if it were entirely subcor- tical within the visual area. The patient after the lapse of some years was still aphasic. It may be added that it by no means followed that hemorrhage was the cause of symptoms because immediate improvement succeeded operation. The removal of a small portion of bone by the trephine not infrequently relieves morbid cerebral condi- tions, though the lesion remains undiscovered. Examples of successful results from operative failure in cranial sur- gery are as varied as the conditions which demand inter- ference ; one such may be cited from the appended series DIAGNOSIS. 185 of cases, in which traumatic convulsions of several days' continuance were immediately and permanently controlled by trephining both in the region of direct injury and at the supposed point of contrecoup, though nothing abnormal was discovered and nothing more was done. It is evident from this rehearsal and alignment of in- dications that the primary factors in the diagnosis of trau- matic intracranial lesions are the absolute and relative characters of the pulse, temperature, and respiration, and the varied phases of unconsciousness. The other pathic conditions presented are accidental in the sense of incon- stancy, but the existence of one or more of them may be probably assumed in the majority of cases. The consider- ation which has been given to the history and progression of symptoms demonstrates their" constantly varying indi- vidual significance in either class, and the necessity for their accurate observation and careful comparison in each particular instance. It may happen in the end that it is still impossible to arrive at certainty, and a conclusion must be based upon a just estimate of probabilities, in forming which the experience and sagacity of the surgeon may become conspicuous. SECONDARY INFLAMMATIONS. I. Arachnitis. The diagnosis of acute arachnitis is probably impossible at the outset, if its invasion immediately succeeds the pri- mary injury. Its indications then are not only illy de- fined, but are hidden by those of the original contusion and possibly by those of coincident lesions. If its invasion is also insidious, diagnosis may be no more than conject- 1 86 IN-JURIES OF THE BRAIN AND MEMBRANES. ural even at a later period. If again the inflammatory process is acute as well as immediate, its onset will be ap- parent by the occurrence of a sthenic constitutional reac- tion, of which the symptoms will be consistent with each other. The chill will probably be absent, and the tem- perature be no higher than is common with simple lacera- tions ; but the respiration will be hurried and frequent, and the pulse full and strong as well as rapid, in contrast with the nearly normal or retarded pulse and respiration which characterize cerebral lesions with a high temperature. The delirium too will be more active, the heat of surface greater, and vomiting more likely to occur. In the more frequent instances in which an arachnitis of greater or less intensity is developd some days after the reception of meningeal injury, its invasion is marked by an abrupt change in the condition of the patient which is character- istic. The course of symptoms referable to the primary lesion is interrupted by a somewhat sudden rise in temper- ature, and by the manifestation of mental and sensory dis- turbances. The temperature, whatever may be its course in idiopathic cases, is subject to irregular and sometimes very marked daily recessions. The irritability, restless- ness, delirium, or somnolence, which are persistent as well as invasive symptoms, are often in distinct contrast to the conditions which had previously existed. The sudden rise and often notable subsequent fluctuations of temperature, and the varied manifestations of cortical irritation, are in general the only direct means of recognizing the menin- geal inflammatory process, whether it results from infec- tion or from a continuance of the original structural changes. The occurrence of post-cervical or general mus- cular rigidity is confined to cases which secondarily in- DIAGNOSIS. 187 volve the spinal membranes, as disordered function from implication of the cranial nerves exists only when the dis- ease extends to the basilar region. In the cases in which the inflammation is wholly or mainly limited to the vertex, and which perhaps constitute the majority, such localizing symptoms are almost impossible. Paralyses involving the extremities are not to be expected, since the disease usu- ally terminates in fatal asthenia before the effusion is sufficiently large to interfere by pressure with either con- sciousness or muscular action. In the larger number of cases, whatever the period of their development and whatever the grade of inflammation, the pulse and respira- tion are not affected to a degree which challenges atten- tion. There are no symptoms which, in themselves and apart from attendant circumstances, are either pathogno- monic or even characteristic. The character of the effusion cannot be inferred with any certainty from a study of symptoms. The occurrence of chill, with a pulse, temperature, and respiration denoting a sthenic constitutional reaction, and with active delirium, may properly be taken to indicate the formation of pus ; but the chill may be absent when suppuration is profuse, or present when the effusion is wholly serous or sero-fibri- nous, and it is probably rather the measure of the suscepti- bility of the patient's nervous system to irritation than of the height of the inflammatory process. In like manner the invasion and progress of the inflammation may be ex- tremely insidious though the event is suppurative, or the constitutional reaction may be severe when the exudation is simply serous. If the inflammation is known to be in- fective, the purulent character of the effusion can hardly be in doubt, though the symptoms may be ambiguous. A 1 88 INJURIES OF THE BRAIN AND MEMBRANES. traumatic arachnitis in young subjects sometimes assumes a tuberculous character; this may be suspected from the successive implication of cranial and spinal nerves, which indicates its basal situation, and from the sluggish prog- ress and great prolongation of the disease. 2. Abscess. Parenchymatous, like meningeal inflammation, when traumatic, is probably always a continuance of structural changes which begin in an original contusion, and, with or without the intervention of an infective organism, ter- minate in the leucocytal migration. It differs from menin- geal inflammation in the fact of invariable defeat of the leucocytes and formation of pus. If this process is vig- orous and rapid, its diagnosis may come in question before the disappearance of the symptoms of the primary lesion, and while the liability to the development of an arachnoid inflammation still exists. It oftener happens that the in- dications of abscess begin to be evident only after the lapse of weeks or months, and perhaps not till the occurrence of an original injury has been forgotten. If in the interval the patient has been unobservant of himself and has not deviated from his usual habits of life, the symptoms which finally compel attention may seem very obscure. The exceptional instance of what may be termed a primary cerebral abscess must be diagnosticated from its still existent source, cerebral contusion or laceration, and from arachnoid inflammation. It is doubtful if the earliest constitutional reaction from the local inflammation can be distinguished from that which attends an arachnitis. Such differences as exist are not greater than those which may occur in individual instances of either disease. It is DIAGNOSIS. 189 only as they progress further that their symptoms diverge ; greater cortical irritation, fluctuating and increasing tem- perature, and possibly an implication of the cranial nerves, in arachnitis ; decreasing temperature, more rapid and ex- tensive nutritive changes, and more notable disturbances of functional control from pressure, in abscess. The dif- ferentiation from the antecedent and concurrent visceral lesion, if practicable, is made, as in arachnitis, by the pre- dominance of the constitutional evidences of an inflam- matory process over those of a simply destructive local change. After the initial symptoms have given place to those of an existent body of pus, the conditions do not differ from those of the more usual chronic abscess, ex- cept that there is available a continuous history and con- sequently the means for a more facile interpretation of the phenomena presented. The abscess of more lengthened and insidious development may manifest itself after weeks or months of apparent quiescence, either abruptly or by the gradually increasing gravity of symptoms which have flnally come to challenge attention. In the first case, diagnosis is to be made from sudden vascular lesion, and in the second, from the results of an older vascular lesion and from tumor. It may also happen that one condition may be engrafted upon the other ; persistent symptoms of more or less urgency then terminate in some distinct crisis, but without raising new issues in diagnosis. In a large proportion of late abscesses of traumatic origin it is possi- ble to discover or to surmise the antecedent cranial injury; this in otherwise obscure cases may be an essential factor in determining the nature of the lesion. The fact that an injury of the head has been sustained, even without a his- tory of cerebral implication, is entitled to great weight in 1 90 INJURIES OF THE BRAIN AND MEMBRANES. the final summary of indications, as in other cases of abscess is the presence of an otitis media or other evident source of possible infection. If the occurrence of the primary cerebral contusion or laceration is undoubted, there will be little difficulty in interpreting the symptoms of its inflammatory sequel. It would be improbable, at least, that cerebral softening from thrombosis or embo- lism, or that a morbid growth should occur at this time. There are certain broad distinctions, however, indepen- dent of a history of traumatism or of a discoverable source of purulent infection, in the symptomatology of cerebral softening, abscess, and tumor, which will ordinarily serve for their differentiation. Structural change in the brain tissue from vascular ob- struction is so much more frequent than the formation of abscess or tumor that it is naturally first suspected in cases in which paralyses occur with progressive mental deca- dence. These conditions, with some impairment of the general health, are common to all organic diseases of the brain, and together with anaesthesia, aphasia, and hemi- anopsia are also localizing symptoms, but not diagnostic of the nature of the lesion ; they simply serve to narrow the field of inquiry. If the radial arteries are rigid, if the cardiac valves are thickened, or if the patient is ad- vanced in life, or if, younger, he has been contaminated b)'- syphilis, the probability of a simple cerebral softening is increased. The absence of symptoms which are directly characteristic of abscess or tumor renders this probability as near an approach to certainty as can be attained. There are certain additional symptoms \Nhich are in- dicative of both abscess and tumor, but not of softening; these are the result of increased intracranial pressure, and DIAGNOSIS. 191 are: headache, vertigo, slow pulse and respiration, con- vulsions, optic neuritis, dilatation of the pupil, and a sub- normal temperature. There is a still further indication noted by Dr. J. F. Eskridge. He has been led to con- clude from a number of observations that in irritative lesions a sustained temperature from ^° to 1° higher on the paralyzed side, several weeks after paralysis has be- come manifest, is characteristic. A bilateral variation of axillary temperatures may be occasionally observed in cases of cerebral softening, but it is not sustained and not uni- form. Extreme variations have been noted also in some of the appended histories of intracranial injuries, but they were ephemeral, and inconstant in their relation to the site of the lesion. This point in diagnosis seems worthy of more extended observation. The final analytic process by which abscess is to be differentiated from tumor requires not only the recogni- tion of its positively distinctive symptoms, if such exist, but an estimation of the comparative value of those com- mon to both diseases as they occur in either one, and a continuous regard for suggestive facts in the history of the patient. It is questionable if any symptom is pathogno- monic, unless it be the occasional escape of pus through a cerebral sinus, though the continued rigidity of more or less paralyzed muscles for days at a time has been regarded by Eskridge as positive evidence in cases of abscess in which tumor is the alternative. In general, the emacia- tion and prostration of the patient are more marked and more rapidly progressive than occur in connection with the growth of tumors, and the temperature is more fre- quently, persistently, and distinctly subnormal. The changes in the optic discs, on the contrary, are less fre- 192 INJURIES OF THE BRAIN AND MEMBRANES. quent and less pronounced in the formation of abscess. These differences, while not absolutely determinate of the nature of the lesion, are sufficiently characteristic to be- come important factors in diagnosis. It is still to be re- membered that a subnormal temperature, choked discs, or marked failure of the general nutrition, may exceptionally attend even vascular occlusion. Variations in the size or stability of the pupils, and headaches of different degrees of severity and persistency, are equally observed in tumor and in abscess, and under similar conditions. The ab- sence of such coincidents as syphilitic or tuberculous infec- tion, or of the cancerous cachexia and their local manifesta- tions in other parts of the body, and following the exclusion of predispositions to embolism or thrombosis, will of course add to the probability which exists that symptoms common to both are due to abscess in a given case rather than to tumor. In every case of manifest disease of the brain substance, the distinctive character of the lesion is to be sought in the study of its etiology ; this quest if successful will furnish the key to the correct interpretation of symptoms other- wise obscure. Chapter V. PROGNOSIS. A.— DIRECT LESIONS. The chances of recovery from intracranial injury may be estimated in part from the results which have been ob- served in large numbers of cases. Conclusions formed upon a purely statistical basis are generally to be dis- trusted, but the cases which have served for the present study of these lesions have been so many, and the methods employed for their diagnosis have been so uniform and so fully detailed, that their tabulation will have some special value. The method of treatment adopted may determine the issue in individual instances, but will exert no sen- sible influence upon general results when the aggregate number of observations is large, and may be assumed to be immaterial. The five hundred cases, upon the observation of which this consideration of intracranial injuries has been based, may be classified primarily in reference to their general mortality. I. Fractures Involving the Base of the Cranium. Recovered, . . . . .no Died, 176—286 Number of necropsies, . . . 146 13 194 INJURIES OF THE BRAIN AND MEMBRANES. 11. Fractures ConJi)icd to the Vertex of the Cranium. Recovered, . . . . .75 Died, ...... 41 — 116 Number of necropsies, . . .34 III. Encephalic Injuries not Accompanied by Fracture of the Cranium. Recovered, . . . . -41 Died 57 — 98 Number of necropsies, . . -45 Summary. Total number of recoveries, . . 226 Total number of deaths, . . . 274 Total number of necropsies, . .225 This classification, which is not directly one of intra- cranial injuries, is essentially such, since fractures of the cranium necessarily involve at least a cerebral contusion, and are usually more seriously complicated. The percentage of recoveries is much greater than might have been expected in view of the fact that en- cephalic lesions, and especially those which complicate fractures of the cranial base, have been long regarded as of exceptionally fatal character. The proportion of recover- ies from intracranial injury is indeed even larger than is indicated by the numerical percentage in the present series of cases. These were of more than average severity, and the least urgent were sufficiently important to demand hospital relief. They also include a considerable number of pistol-shot wounds, in which the fatality markedly ex- ceeds that of the general class of intracranial traumatisms. It is to be further noted that in many instances death was almost immediate, and that these largely outnumber those PROGNOSIS. 195 whicli proved to be relatively unimportant. If, therefore, regard were had only to those cases in which the evidence of lesion is distinct but in which time suffices for prognosis and treatment, and pistol-shot wounds were excluded, the average of recovery would be, not somewhat less, but considerably more than fifty per cent, of their whole number. The very different percentages of recovery, as the cranial base or vertex may be fractured, only indicate the greater liability of the one to dangerous intracranial com- plication as compared with the other. The proportion of deaths to recoveries, when intracranial injury is unaccom- panied by cranial wound, is only of statistical interest. The value of these deductions when made is entirely apart from the question of prognosis in individual cases. In general it may be said that the danger from encephalic lesion, when force is solely exerted through the bone at and about its point of impact upon the cranial vertex, is scarcely more than one-half that which attends when it is also transmitted through the cranial base ; and that when force is entirely expended upon the intracranial contents, as it was in nearly twenty per cent of the series of five hundred cases, danger is somewhat less than when the cranial base is implicated. This difference is probably due to the exclusion of epidural hemorrhages, which occur in serious amount only as a complication of fracture. It is difficult to estimate the comparative danger of the several lesions, from the fact that they are so generally multiple, and all together conspire to bring about a fatal result. It is also true that the severity rather than the form of lesion is to be made the basis of prognosis. It may be impossible therefore to infer their relative danger 196 INJURIES OF THE BRAIN AND MEMBRANES. from the mere frequency with which different lesions have been found to exist in fatal cases ; but an opinion may be approximated by the tabulation of those which have oc- curred, separately or in conjunction, and in degree ap- parently sufficient to occasion distinct symptoms, omitting reference to those which are obviously trivial and probably void of effect. This course has been pursued in an ex- amination of the two hundred and twenty-five appended cases which were subjected to necropsy. The resulting tables which follow are as nearly accurate as the com- plexity of the subject will allow. General contusion is unmentioned in connection with lacerations, though it al- ways exists in greater or less degree, and is often the es- sential cause of death. I. Fractures of the Crania! Base. Laceration and more or less consequent cortical hemorrhage. Laceration and meningeal contusion, Laceration and epidural hemorrhage, Meningeal contusion. General cerebral contusion. Meningeal and general cerebral con tusion, ..... Epidural hemorrhage. Epidural hemorrhage and general cerebral contusion, Abscess, ..... n. Fractures of the Cranial Vertex. Laceration and more or less consequent cortical hemorrhage. Laceration and epidural hemorrhage, . 74 13 10 1 1 9 5 12 10 2- 28 I • 146 PROGNOSIS. 197 10 10 3 5 I Meningeal contusion, ... 2 Meningeal and general cerebral con- tusion, ...... I Epidural hemorrhage, . . . 2 — 34 III. Encephalic Injuries- without Cranial Fractures. Laceration and more or less consequent cortical hemorrhage, Laceration and meningeal contusion, . Meningeal contusion, .... General cerebral contusion, Meningeal and general cerebral con- tusion, ...... Epidural hemorrhage, Epidural hemorrhage and general con- tusion, ..... . 2 — 45 Summary. Laceration and cortical hemorrhage, Laceration and meningeal contusion, Laceration and epidural hemorrhage, Meningeal contusion, . ' General contusion, Meningeal and general contusion, Epidural hemorrhage. Epidural hemorrhage and general con tusion, ...... 12 Abscess, 2—225 Arachnitis resulted from meningeal contusion in fifteen cases ; eight of these were in conjunction with fractured base, two with fractured vertex, and five were independent of cranial injury. In each case of abscess it chanced that the cranial base was fractured. 1 12 23 1 1 16 14 20 15 igS INJURIES OF THE BRAIN AND MEMBRANES. The relative importance of the cerebral wound, its re- sultant hemorrhage, and its attendant general contusion, are too often impossible to estimate with precision to permit a further subdivision of the cases in which laceration is a prominent lesion. It sometimes happens that a cerebral wound comparatively trivial in extent occasions an enor- mous hemorrhage, or that with great destruction of cere- bral tissue but little blood is lost, or that the concomitant general contusion is obviously serious or is insignificant; it then becomes easy to apportion or to limit the responsibil- ity for the fatal result. In the majority of cases, if the primary shock of general contusion is surmounted, it is probable that when laceration is of much extent it is to be accounted the essential cause of death ; cortical hemorrhage is but an incident of the cerebral wound. If another form of hemorrhage, or an inflammatory sequel coexist, the lac- eration may perhaps be held a less influential factor in compassing the final issue. An analysis of recovering cases, with a view to the de- termination in each, of the existing lesions, as the comple- ment of the similar examination of those which are fatal, affords results which are less definite because incapable of verification. Errors in diagnosis are to some extent in- evitable ; and yet in a very large proportion of cases the nature of the dominant lesion can be established with a fair approach to certainty. The diagnosis in each of the two hundred and twenty-six cases of recovery in the present series of intracranial injuries was made after careful study, and, conceding its correctness, justifies the appended sum- mary of the lesions which were paramount. In twenty of these, a fracture of the base or vertex was so nearly un- complicated that the trivial cerebral contusion, which may PROGNOSIS. 199 be assumed to have existed, has been disregarded and the case omitted from the tabulation. I. Fracture of the Cranial Base. General contusion, Laceration, .... General contusion and hemorrhage, Epidural hemorrhage, II. Fracture of Cranial Vertex. General contusion, Laceration, .... Meningeal contusion, . Epidural hemorrhage. Superficial abscess, Central abscess, . III. Encephalic Injuries without Fracture. General contusion, .... Laceration, ..... Epidural hemorrhage, Epidural hemorrhage and general contusion, ..... Summary. General contusion, .... Laceration, ..... Epidural hemorrhage, Meningeal contusion, , . . General contusion and epidural hem- orrhage, ...... Superficial abscess, . . . • Central abscess, . . The preponderance assigned to general contusion as the direct cause of death is perhaps not entirely warranted. 57 24 9 3— 93 57 12 2 5 I I- 78 14 17 3 I— 35 128 53 1 1 2 10 I I- -206 200 INJURIES OF THE BRAIN AND MEMBRANES. In many instances in which doubt might fairly exist whether the brain lesion included laceration, it was rated as simple contusion in the absence of positive evidence of the fur- ther injury. It is not improbable that in this way lacera- tion of moderate extent has been sometimes unnoted and its frequency in recovering cases somewhat underrated. In other instances contusion has been inferred from the simple character or brief duration of the symptoms; this is proper ground for diagnosis, but it occasionally happens that lacerations are discovered after death which have been unsuspected from a history of w'hich all the details were well known. If full allowance be made for such errors in classification, there will still remain sufficient clinical evidence that general contusion is the essential, if not the sole lesion in as large a majority of recovering cases as is laceration in those which are fatal. Menin- geal contusion is but twice mentioned as a recognized lesion when recovery ensued, and in each instance was manifest by the direct exposure of the oedematous sub- arachnoid tissue. It can hardly be doubted from its fre- quent occurrence in fatal injuries that this change must constitute a part of many of the general contusions which have a favorable issue. It is also possible that symptoms ascribed to a general contusion with epidural hemorrhage may be often due to a pial hemorrhage from meningeal implication, but in the absence of direct knowledge the more conservative course has been taken of assuming the general condition. The diagnosis in many instances was more precise than would appear from the tabulations which have been made, but the less specific statements are safer and sufficient for the present purpose. The comparison of summaries in the fatal and recovering PROGNOSIS. 201 cases seems to indicate that laceration, with its incidental hemorrhage, is at once the most frequent and the most dangerous of all lesions in cases of severity, and that general contusion is by far the most frequent in those cases which are of milder type. It affords no means of estimating the absolute danger of epidural hemorrhage or of meningeal contusion, which must depend in either one upon the amount and situation of the extravasation, and in case of meningeal contusion upon the possible occurrence of a subsequent inflammatory process. The probability of the existence of particular lesions in cases of indeterminate character, based upon their known frequency and the estimation of their relative danger from previous observations, will have a certain prognostic value. The result to be expected in individual instances will di- rectly depend upon the symptoms presented, as indicating the extent rather than the nature of the injury which has been sustained. The uncertainty which attends the issue of an intracranial traumatism is great, not only at the be- ginning, but at a later period when recovery is apparently assured. The immediate danger is to be measured by the profundity of shock, the depression of temperature, and the enfeeblement of pulse, and in some instances by the ex- tent of visible injury ; but reaction is still possible under conditions which seem to be hopeless. The question of prognosis which more seriously involves the judgment of the surgeon arises with the passing of this initiatory stage. It will suffice to indicate some of the more characteristic symptomatic phenomena which presage the impending course and termination of these cases of encephalic injury. Neither depth nor prolongation of primary unconscious- ness is in itself a measure of danger. It is not unusual for 202 INJURIES OF THE BRAIN AND MEMBRANES. complete loss of consciousness to continue for some days without concomitant or subsequent symptoms of special severity. If, however, during this time pulse, tempera- ture, or other sj^mptoms maintain or assume an unfavora- ble character, the mental default with which they are asso- ciated may then be regarded as further increasing the gravity of prognosis. The loss of consciousness which occurs at a later stage of the case is always of grave im- port ; it is then a manifestation of an increase of cerebral oedema, a meningeal inflammatory effusion, septic infec- tion, or of the asthenic condition of the patient. The temperature from first to last in prognosis, as in diagnosis, transcends in importance all the other sympto- matic indications. It gauges by its depression and by its persistence the danger from primary shock, and, a little later, the amount of a hemorrhage which may be other- wise known to exist. At a somewhat later period its rapid and progressive rise will denote the magnitude or severity of a meningeal or cerebral lesion. It has never exceeded 105° in any one of the appended series of five hundred cases which terminated in recovery, and it has only exception- ally attained to that degree. This may be regarded as the practical if not the absolute limit of temperature, in this class of injuries, consistent with the recovery of the patient. A sudden rise in temperature late in the progress of a case, or a continued subnormal temperature at any time after reaction from primary shock, is always reason for appre- hension. The pulse and respiration have less significance as re- gards the result. A failure of cardiac force when it occurs is neither more nor less threatening in this than in other forms of disease or traumatism. In general, the normal. PROGNOSIS. 203 or full and moderately infrequent pulse, is equally charac- teristic in fatal as in recovering cases, and the want of symmetry in opposite radial pulsations has no evident bearing upon prognosis. The respiration does not usually reflect the degree of danger, except in primary shock and toward the close of the case, when it corresponds with the acceleration of the pulse. An irregularity of respiratory rhythm indicates a dangerous intracranial pressure, and an extreme infrequency of the respiratory act makes probable a fatal compression of the medulla. Aside from pulse and temperature, symptoms become prognostic only as they determine the nature and extent of the lesions from which they result. In this way they are indirectly indicative of the degree of danger which im- pends. A high temperature or a rapid and feeble pulse is in itself alarming, whatever its specific intracranial cause, but the occurrence of convulsions or the loss of faecal or urinary control is of grave import only so far as it can be connected with a lesion of dangerous extent or situation. The prognosis, like the diagnosis, thus becomes largely dependent upon the massing of symptoms and the study of their mutual relations; and this again, as was said of diagnosis, is rather a matter of surgical sagacity and ex- perience than of formal rule. There is no class of injuries in which the issue is at all times so uncertain, and often so surprising. The cases which in their earlier days pre- sent the mildest symptoms, and seem most surely destined to unobstructed recovery, may at some later period as- sume a threatening or alarming character and perhaps prove fatal in the end ; as others, in which the combination of symptoms long justifies the gravest apprehension, may eventually terminate not only with the preservation of life 204 INJURIES OF THE BRAIN AND MEMBRANES. but with perfect restoration of long disordered or sus- pended function. There are evident lesions so extensive, or it may be symptoms so clearly decisive, that a fatal event is unquestionable ; but no conditions can be so favor- able as to assure recovery. The prognosis must be in general not only guarded, but subject to revision from day to day, until all direct symptoms have disappeared, and temperature has been for a length of time practically normal. SECONDARY INFLAMMATIONS. I. Arachnitis. The tabulation of recovering cases includes no in- stance of arachnitis. It is not meant to assume that none existed, but that none could be diagnosticated with that degree of certainty which is essential for statistical infer- ence. There were cases in which some degree of menin- geal inflammation was more than suspected, and in which the possibility of its confirmation was fortunately avoided. It may be be held as a correct generalization that in arachnitis the certainty of an unfavorable result is pro- portionate to the certainty of diagnosis. The acute or pyogenic arachnoid inflammations, whether simple or in- fectious, have probably an always fatal issue; the sub- acute inflammations, in which the effusion is serous or sero-fibrinous, may as probably be sometimes arrested in their course, but usually at an early period, while the in- dications are still of doubtful significance. Under such circumstances the comparative danger of the disease as it affects the base or vertex is scarcely of importance. PROGNOSIS. 205 2. Abscess. The termination of central abscess of the brain in death, unless avoided by operative interference, which is a recognized necessity of idiopathic cases, is no less inevi- table in those which follow violence. The meagre chances of recovery after the absess has been discovered and evac- uated are certainly not increased by the fact of a traumatic origin. The limited superficial suppuration which results from the neglect and infection of an external wound, and from the extension of the suppurative process to the cerebral surface, is amenable to control unless relief has been too long delayed. The three cases of central and one of superficial suppuration included in the appended general series of cases suggest no modification of these axiomatic state- ments. chapter VI. PRINCIPLES OF TREATMENT. DIRECT LESIONS. The manner of treatment is of importance in only a minority of cases, since many subjects of intracranial in- jury are fated to die whatever measures may be adopted for their relief, and a still greater number are destined to recover though left entirely to the resources of nature. In those which remain the result will often directly de- pend upon the assiduity or discretion of the surgeon. It is probable that in by far the larger proportion of cases in which the issue is determined by treatment it is met in the initial stage, and by insuring restoration from pri- mary shock. For the accomplishment of this purpose the exercise of assiduous care is especially demanded ; the methods and agents of procedure are not peculiar, and are too authoritatively prescribed to permit the use of any extraordinary discretion. At a later period, the question of operation may require for its determination the exer- cise not only of the highest surgical discretion but also of the nicest diagnostic discrimination. The collapse from general shock may be nearly com- plete, but such a condition is never to be regarded as so far hopeless as to justify the neglect of restorative meas- ures, unless the visible evidences of a fatal crushing injury are .so positive as to afford no possible room for doubt. PRI>XIPLES OF TREATMENT. 20/ The rapid ambulance system which has been so generally established, and the hypodermic use not only of alcohol but also of the concentrated cardiac stimulants, have made possible such immediate and efficient general stimulation in cases of urgent necessity as materially to reduce the early mortality in this as well as in all other forms of dangerous traumatism. In doing this these agencies have bettered the apparent numerical prognosis of intracranial injuries, since concurrent general shock has so often proved fatal when the essential lesion was far from irremediable. It is scarcely necessary in a work of this character to refer in detail to the means employed to establish reaction. The}^ include the usual medicinal agents for cardiac stimulation, as digi- talis, glonoin, and strychnine, and when the lesion is largely destructive or much blood has been lost their use may be necessitated for an indefinite time after nervous force has been restored. The resort to these reactive measures, when indicated, will take precedence of others for the direct relief of the intracranial injury. There are instances, however, in which the persistence of external, or even of intracranial hemorrhage, or of some other acces- sible pathic conditions, prolongs or intensifies existing shock, and may require concurrent treatment. General reaction and the re-establishment of a compar- atively normal pulse and temperature should be followed by the earliest possible attention to cranial and intracranial lesions. The first step to be taken, in all but the obviously trivial cases, is the shaving of the head, as a measure at once diagnostic and therapeutic. Its importance in diag- nosis as a means of ascertaining the presence or absence of fracture, or the existence of otherwise inappreciable contusions, has been previously noted; its value in the 208 INJURIES OF THE BRAIN AND MEMBRANES. treatment of intracranial injuries will be considered later. The propriety of incision, if further necessary to the abso- lute determination of the question of fracture, has also been made evident ; and the principles which govern the man- agement of the cranial wound, and the details of their ap- plication to particular cases, have been formulated in a previous chapter. It is in cases of intracranial lesion with- out implication of the cranial wall that new problems of treatment arise, and that the advisability of operative in- terference must be reconsidered in the presence of new conditions. An operation then ceases to be confined to the possible removal of already detached or depressed cranial frag- ments, or to be made only in fulfilment of an obvious indication in treatment. It is always an invasion of a heretofore unbroken osseous barrier, in pursuance of the dictates of a judgment which can never be infallible, and is therefore to be less lightly undertaken. It is not like the incision of the scalp, justifiable as a purely explorative procedure, which at the worst is nugatory if the result proves it to have been unnecessary. If in some degree ex- plorative, it must still have sufficient logical basis to justify the risk attendant upon any operative interference at the time and under the circumstances which will exist when it is most likely to be brought in question. The one in- tracranial lesion for the relief of which, when clearly diagnosticated, it is fully conceded that operation may be justified or demanded, is epidural hemorrhage. The time of election for interference will be after the establishment of full or of partial reaction, as the extravasation is be- lieved to have ceased, or to be still in progress after an interval limited in duration by the judgment of the sur- PRINCIPLES OF TREATMENT. 2O9 geon. The judicious resort to operation in the treatment of this form of hemorrhage is vindicated both by results and by the observation of cases and necropsies in which it has been neglected. Success will be commensurate with accuracy of diagnosis and with justness of appreciation of the time and conditions when interference is demanded. It is fortunate that the diagnostic indications are often most distinct in this one of the intracranial lesions best fitted for operative relief. It is the form of hemorrhage in which, with or without primary unconsciousness, an in- terval of consciousness most frequently precedes its later loss. It is also the one in which the dilatation of the cor- responding pupil is most characteristic, especially in the absence of the temperature and other conditions of general contusion ; and the one in which gradually and perceptibly increasing paralysis of the extremities, and more or less rapidly progressive stupor ending in coma, are most often observed. The moderately increased or diminished tem- perature, the contusion or haematoma, or the cranial fissure in the vicinage of the larger middle meningeal branches, and other symptoms which in themselves or in connection with others mentioned may be considered diagnostic, it is needless to recapitulate. The diagnosis ought to be usually practicable in cases sufficiently uncomplicated to warrant the contemplation of a possible operation. The decision as to the necessity or futility of operative interference, which may be one of the most difficult ques- tions in intracranial surgery to decide, will often require the exercise of great discretion, inspired by much knowl- edge derived from experience and directed by the soundest judgment. Three considerations will present themselves: the contraindications which may exist in the influence of 14 2IO INJURIES OF THE BRAIN AND MEMBRANES. allied lesions ; the probable necessity for intervention ; and the exact time at which operation should be done. If other intracranial injuries have been sustained which are obviously or presumably of immediately fatal charac- ter, operation will probably hasten rather than retard the catastrophe, though it may confirm the diagnosis. The indications of severe diffuse contusion or of extensive laceration of the brain, added to the evidence of hemor- rhage in sufficient amount to suggest an exploration of the cranial cavity, constitute a general condition which, if not absolutely hopeless, is ill calculated to withstand the in- fliction of further injury. The slender chances of recovery will be better conserved by inaction. It is only when symptoms point clearly to hemorrhage as the essential if not the exclusive lesion that operation for its relief will afford legitimate hope of success. If the existence of a comparatively uncomplicated epi- dural hemorrhage of considerable extent seems to have been established by the study of symptoms, the necessity or propriety of attempting its removal by operative means will consecutively demand consideration. The questions involved are theoretically simple: whether the constitu- tional condition of the patient will permit interference; and whether the amount of extravasation and its inhibitory effect upon cerebral function are so far limited as to render its eventual disappearance by absorption possible or even probable. The solution of these problems is often easily reached ; reaction may never occur, or, after it has become complete, the persistence or increasing gravity of pressure symptoms may positively indicate the danger of a con- tinued expectancy in treatment. There are still other cases, in which reaction is in some degree unsatisfactory, PRINCIPLES OF TREATMENT. 211 or in which the value of symptoms is indeterminate; a decision must then in each instance rest solely upon the discretion of the sugeon ; no formal rules can be prescribed which should control his judgment or guide his action. If operation is to be done, the time which is chosen for its performance may practically determine its result. Hasty and ill-considered action, or a lack of promptitude at the opportune moment, may end in equal disaster. The cases in Avhich reaction entirely fails, or in -which pulse, temperature, and external warmth are perfectly restored, while with the lapse of time pressure symptoms deepen or remain profound, can hardly occasion doubt as to the direction in which duty lies ; but when with imperfect reaction these symptoms are still progressive, opportunity must be seized when the tide is at its full, when reaction has reached its limit, and before recession of strength be- gins, in order to profit by whatever slender chance there may be for a favorable issue. Success may be doubtful at the best, but any waste of vital force invites certain failure. It will not often happen that the fundamental rule in sur- gery, that operation should always be deferred till after reaction has been fully established, should be violated; never in this instance by reason of the gravity of pathic indications, or when reaction fails almost at its beginning; but only when, after a time, with some fair degree of strength, coma deepens and the pulse grows weaker, as hemorrhage still goes on. In the exceptional case, opera- tion must always be early, as it always will be by choice, if done when hemorrhage has ceased and reaction has be- come complete; but the patient sometimes escapes obser- vation till some days have passed and operative conditions may yet remain propitious. 212 INJURIES OF THE BRAIN AND MEMBRANES. The resort to operation in other forms of direct intra- cranial lesion is of very limited utility. Definite indica- tions which can be met by operative measures are usually wanting, and in their absence an invasion of the cranial cavity must be empirical and without justification. The conditions which when recognized might be supposed to encourage this procedure are usually complicated by oth- ers which render it futile. The occurrence of subdural hemorrhage or of serous effusion from meningeal contusion occasions dangerous cerebral compression, and operation might be considered practicable and efficacious, as it is in epidural extravasation; and a pial, mistaken for an epi- dural, hemorrhage has in some instances been successfully treated in this manner. Such an operation, however, when premeditated, is without adequate reason and can afford no just expectation of success. The epidural clot is usually of limited area, and can be wholly removed, or in sufficient degree to avert danger until the remainder has suffered absorption. The pial or cortical hemorrhage, if in recognizable amount, will be widely diffused, and so en- tangled in the meshes of the pia that little can escape or be withdrawn through the cranial opening. The dropsical effusion which follows the meningeal lesion, if its exist- ence could be positively known or reasonably inferred, might doubtless be drained through this perforation. The further and fundamental fact which contraindicates and makes fruitless the attempt to afford relief by the removal of these subdural accumulations is that the essential lesion remains unaffected. The pial hemorrhage or serous effu- sion which results from a meningeal contusion will prob- ably be associated with a like condition of the entire brain substance, and the cortical hemorrhage will be no more PRINCIPLES OF TREATMENT. 213 than an incident of the laceration from which it is de- rived. The added traumatism of the operation will thus be uncompensated by any possible betterment of conditions which depend upon the more important structural altera- tions produced by the original injury. The shock which attends any operative procedure, and which under favor- able conditions may be unimportant when the cranial wall is alone involved, is always of more serious concern when the dura mater is incised and the cerebral surface exposed. If, as in the cases considered, nutritive changes in the intracranial tissues already exist, this danger is still further exaggerated, and must be taken clearly into account when- ever under such circumstances so radical a measure may be contemplated. In the history of one of the appended cases there is a record of a result obtained by trephination, suggesting a possible indication for operation, which may be stated with some reserve. In this instance, in which an apoplectic effusion was followed by a traumatic cerebellar laceration, the patient was paralyzed, anaesthetic, and profoundly un- conscious. He was trephined and a large amount of serous fluid drained from the surface of the brain. His temperature fell in six hours from 103.4° to 98.6°. He became conscious, could articulate, spoke rationally and intelligently, gave his name and address, again lapsed into unconsciousness, and fourteen hours later died. The transient return to consciousness was in this case wholly unimportant, but it involves possibilities of startling medico- legal interest. It is not unusual for the victim of a homi- cidal assault to remain unconscious till his death, and that the criminal escapes in the absence of any witness of his crime. If such a coma can be reasonably ascribed to a 2 14 INJURIES OF THE BRAIN AND MEMBRANES. fluid compressing the brain, even though complicated by fatal lesion of its parenchyma, trephination, it is evident, may at least by a possibility temporarily restore conscious- ness, intelligence, and speech, to the furtherance of the ends of justice. The prospect of realizing this success would certainly be not altogether chimerical, for in the instance cited just such a hypothetical result was absolutely attained. The question of operation is not to be decided upon any ground foreign to the welfare of the patient ; but when death seems inevitable and doubt exists as to the propriety of interference, medico-legal considerations are recognized as having a certain degree of weight. It has sometimes happened, when homicidal injury has proved fatal, that the attempt has been made to transfer responsi- bility from the murderer to the surgeon, who in his discre- tion has resorted to operation, or perhaps even found occa- sion for the administration of narcotics. This hazard, and the necessity of self-protection which it involves, are very properly held in view when professional duty permits; the acceptance of the same principle may equally justify, if occasion arises, a due regard for the interests of justice, within the limits established by conscience and sound judgment. The contingency is remote, but it is still pos- sible. There can be no advantage from operation when the urgent symptoms are the result of a general cerebral contu- sion. As an underlying condition of minor importance contusion may not contraindicate an operation otherwise made necessary; but in itself, or as it approximates a para- mount lesion, it is obviously beyond the scope of any measure of mechanical relief. It is scarcely necessary to point out its impossible application to cases of this char- PRINCIPLES OF TREATMENT, 21 5 acter, in which existent pressure is intracerebral and diffuse, and incapable of mitigation by any practicable re- moval of the cranial wall; and in which, moreover, the morbid state is essentially one of nutritive change in which interstitial pressure is merely incidental. The operative treatment of brain lacerations, as they occur at points remote from the seat of fracture of the cranial vertex, might have the pathological warrant which in the general lesion is lacking, if its employment were practicable. Superficial lacerations of the vertex in con- nection with fracture are accessible, and, when drained and maintained in an aseptic condition, are usually cicatrized without serious danger to the patient. There is no evi- dent reason why cerebral wounds which occur without cranial injury should not be as amenable to local treat- ment, if they could be reached; but they are often central, and, if superficial, very likely to be situated in some inac- cessible region of the base. The impossibility of accurate localization of the lesion, in the vast majority of cases, by any known diagnostic methods is additionally a bar to any justifiable attempt at topical treatment by operative means. It is still a question, beyond that of feasibility, how far operation if made possible might increase the chances of recovery. In general, laceration as disclosed in post- mortem examination, except when enormous excavation has been produced by the attendant hemorrhage, is com- plicated by diffuse cerebral contusion which is largely re- sponsible for the fatal result. In a minorit}'' of cases the cerebral wounds may be found to be in a septic condition, and it is in these, if their exact position could have been determined and exposed, that a possible danger might have been averted. Altogether there seems little to be 2l6 INJURIES OF THE BRAIN AND MEMBRANES. hoped for in these cases, now or prospectively, from any operative interference. It has been proposed to treat arachnitis by perforation of the cranial wall, and withdrawal of the inflammatory effusion ; and this method of treatment, it has been claimed, has been followed by good results. It is difficult to understand what permanent advantage can be derived from the removal of an effect while the cause remains operative. The elevation of depressed bone is a radical measure of relief, because with the removal of the source of symptoms, the possibility of their continuance or recur- rence is removed ; and the extraction of an epidural clot is made effective by the ligation, if necessary, of the ruptured vessel ; but the mere drainage of an inflammatory arachnoid effusion will by no means prevent its return. There is no reason to believe that a diminution of the pressure exerted by a serous exudation will lead to the cessation of the pathic processes upon which it depends; it is not conso- nant with what is observed elsewhere when no obstacle exists to the escape of inflammatory exudations. In trau- matic cases, at least, it is not the increase of intracranial pressure which proves fatal, but the direct irritant and de- pressing effect of the tissue changes which characterize the inflammatory process. So far as the effusion is plastic or purulent, drainage will be impossible or very imperfect, whether it be attempted from the Sylvian or post-erior cer. vical region, or elsewhere, and no semblance of advantage can be expected to accrue. The views of Gross, which have been held to favor trephination and drainage in cases of traumatic arachnitis, are evidently founded upon the observance of limited purulent accumulations in the arach- noid cavity, and resulting from a now infrequent form of PRINCIPLES OF TREATMENT. 217 pachymeningitis ; they have no reference to a true arach- nitis in which the effusions are subarachnoid and diffuse, and which is meant to be understood when the term men- ingitis is employed. Macewen's instances of recovery from purulent basilar meningitis after operation were secondary to inflammation of the middle ear, and were apparently recognized by him as limited. The advocacy by Ruth of this method of treatment is not supported by a record of answerable cases. It is doubtful if any properly authenti- cated instance can be adduced in which a diffuse inflam- matory subarachnoid exudation has been drained with sub- stantial benefit to the patient. It seems probable that in some cases subarachnoid oedema has been mistaken for a product of inflammation. A case reported by McCosh was undoubtedly one of arachnitis, possibly diffuse, and though recovery was regarded as nearly complete in the third month, the patient was then the subject of a forming cere- bral abscess, from which he died some time subsequent to an operation for its relief. The record of necropsy does not make clear the relation which existed between the super- ficial and deep inflammatory lesions, but it is probable, from the conditions observed when the abscess was evacuated, that they were connected. This case was brilliant in diag. nosis and operation in both its early and later stages, but it is at least not conclusive as to the extent of cure of the arachnitis. The justifiable use of operation in head injuries is thus seen to be very limited. It may be summarized as prop- erly general in depressed cranial fractures, frequent in comparatively uncomplicated epidural hemorrhages, and exceptional in subdural lesions whether of the brain or of the pio-arachnoid membrane. The resort to operative 2l8 INJURIES OF THE BRAIN AND MEMBRANES. measures, which is essential under favorable constitutional conditions in abscess of the brain and in intracranial gun- shot wounds, will be given consideration in the later study of those conditions. If in the general class of intracranial injuries operation is to be but infrequently done, the ques- tion of operation will be often raised and decision as to the course to be pursued will then entail grave responsi- bility, since error in judgment may deprive the patient of a chance for life by increasing the danger of an already criti- cal condition. Action or inaction at the wrong moment has invited disaster on either hand ; but instances of too early or unwarranted operative interference by inexperi- enced surgeons outnumber those in which the ultra-con- servatism of their elders has led to a perhaps fatal neglect. The acceptance or rejection of operation as a method of treatment, when encephalic lesions are independent of accessible cranial fracture, is to be decided in each instance upon specific and tenable grounds. Operation is not to be done as a so-called last resource, and because the patient is likely or sure to die without it, as he is with it unless some blind chance interposes where reason affords no room for hope. Intracranial exploration will be defensible or indefensible as it is made with or without sufficient cause, and not as it may conform to an opinion deducible from a wide generalization of results that it is a good or a bad procedure. Unless general rules can be made absolute, the obligation to determine in each instance the treatment to be pursued in accordance with the indications which it pre- sents remains unimpaired, and the contention that more lives are lost by operative interference which is unneces- sary than by its neglect when it is required has no relation to the exigencies of particular cases. The failure to recog- PRINCIPLES OF TREATMENT. 219 nize the truth of these apparently simple propositions ac- counts for the widely divergent practice which has obtained in different countries at corresponding or at different times. The record of ten years in which only four trephi- nations were reported in France, while during the same period one hundred and fifty-seven were reported in Eng- land (Dennis) , is scarcely explicable except upon the sup- position that treatment was ordered in accordance with conventional general rules, and not with a regard to special indications. The character of the discussion which is still maintained as to the merits of trephination necessitates the placing of some emphasis upon this phase of the subject. There are late results of intracranial traumatism in which the indications for treatment are to be considered as those of a separate class of cases, distinct from recent in- juries. These include paralyses and convulsions which are often due to the imperfect absorption of surface hemor- rhages, or to superficial or ventricular effusion from an original contusion. The case of drainage of a lateral ven- tricle with subsequent recovery of the patient, reported by McCosh, was probably of this nature ; the historical details and the absence of superficial effusion seem to disprove the inflammatory character of the disease, in which the subarachnoid and interstitial oedema of a general menin- geal and cerebral contusion might have readily disap- peared, while the ventricular serous accummulation re- mained and increased. One of the cases reported by Ruth seems as probably to have been an instance of superficial serous transudation from meningeal contusion. A purely explorative examination of the cranial contents is not only justified but demanded when such permanent functional 220 INJURIES OF THE BRAIN AND MEMBRANES. derangements succeed the primary effects of intracranial injury. The hazard of operation is minimized at this time, and if the hope of success is not realized even though an evident lesion is discovered, the patient's condition is not likely to be made worse. The possibility of danger in the procedure may or may not be a factor to be considered in deciding upon the advisability of operation. No such question can arise in connection with the elevation of depressed bone ; and in the removal of foreign bodies from the brain, or of an epidural clot from the cranial cavity less danger is in- curred than is involved in the continuance of the morbid condition which it is sought to remedy. It is in the treatment of the subdural lesions, in which advantage is most problematical, that the operation is in itself the source of new and serious peril. It is usually a question of secondary interference, when conditions are always unfavorable, and the brain, which is necessarily exposed and in which morbid structural changes are in progress, is especially prone to resent disturbance. The prospect of success in meeting the indication is in general remote ; and the danger to be incurred is so considerable and so immi- nent that ordinarily it may well suffice to negative any measure of this character. If at the outset, with urgent symptoms of hemorrhage, the cranial cavity is opened and the extravasation is found to be pial, and perhaps involv- ing the arachnoid cavity, the conditions will approximate those of epidural hemorrhage, for which it has been pos- sibly mistaken, and the prognosis will not be materially worse than with the more superficial lesion. The cases in which operation may be indicated for the relief of symp- toms existing at the end of weeks or months are not anal- PRINCIPLES OF TREATMENT. 221 ogous to others which have been considered, and have been already placed in a distinct category. These are not more properly secondary than they are primary operations, as those terms are employed, but in this sense are entirely disconnected with the original injury ; and, even though the brain substance is invaded, the danger of interference is less to be dreaded than when it is more closely related in time to the application of violence. If, however, atten- tion be confined to the traumatisms of the subarachnoid structures, in which after the lapse of hours or days the in- crease in the severity of symptoms and the growing hope- lessness of non-operative means of relief incite the surgeon to attempt an operation, the danger it entails as contrasted with the meagre promise it offers, cannot well be ignored. The field of operation is restricted, but the indications for interference when they exist are positive, and what- ever degree of danger must be encountered is to be mini- mized by the most scrupulous care exercised in the choice of time and circumstance and of technical detail. The necessity of awaiting complete reaction in primary opera- tions has been stated fully, but its reiteration cannot be made too frequent. The single exception, when imperfect reaction is followed by indications of continued epidural hemorrhage, need not obscure the vital importance of the general rule. The neglect of this fundamental law in the management of all traumatisms, whatever may be its ex- planation, is probably at once the most frequent and the most fatal error of the inexperienced surgeon. If reaction has been fully established and the indications for opera- tion are clear, promptitude of action becomes as imperative as was previous delay. In all operative cases there is some degree of diffuse cerebral contusion, and with the occur- 222 INJURIES OF THE BRAIN AND MEMBRANES. rence of considerable hemorrhage some external cerebral compression. There results an obstruction to cerebral capillary circulation which renders the administration of anaesthetics especially hazardous. It is better, therefore, in case of marked intracranial lesion to avoid their use when practicable, and, if indispensable, to restrict it as far as possible. When the immediate issue is fatal, the an- aesthetic is often largely responsible for the result. The general conduct of operation, and the management of its details are adequately described in the more recent text-books of general surgery. The maintenance of asep- tic conditions is not less an absolute necessity than in ab- dominal section, and presents no unusual difficulties un- less the exigencies of a case compel immediate interference under circumstances in which ordinary appliances are un- attainable. The loss of blood, which, from the conditions of cerebral circulation is badly borne, must be restricted to the smallest possible amount by the exercise of unremit- ting care. The immediate purpose of operation in cases without cranial fracture -is to obtain access to the cranial cavity ; and the use of the trephine affords in general the most convenient means to that end. The further employment of the rongeur, chisel, or saw, will be in like manner a matter of convenience, and with the situation and size of one or more openings, the reimplantation of bone, and other practical details, concerns a phase of the subject, as before stated, sufficiently considered in the general text- books. The extent to which exploration should be carried may be predetermined by the object for which operation has been instituted, or it may require decision at the moment in view of conditions disclosed in its progress. PRINCIPLES OF TREATMENT. 223 In recent cases it will not often be designed to expose the subdural structures ; but if, with or without epidural lesion, there are discoloration, distention, or absence of pulsation of the dura mater, that membrane should be incised. If the removal of foreign bodies be excepted, it is only in the treatment of the later results of cerebral lesions that the brain itself may be invaded, as it becomes necessary for the relief of ventricular distention or for the evacuation of abscess. The general management of primary intracranial in- juries is limited to the fulfilment of such indications as are directly afforded by symptoms. The necessity for the con- tinuance of general and specific cardiac stimulants for a length of time after the establishment of reaction has been mentioned in correlation with the treatment of primary shock. The character of the pulse is the sole guide in de- termining the period of their administration, to which ac- tive delirium, heat of surface, or muscular strength, is no more a contraindication than in morbid processes of a different nature. Even in recovering cases these remedies may be requisite for days or weeks during- the employment of more directly curative measures, to which they afford essential support, or through a prolonged convalescence. The shaving of the head, which has been advised as a means of facilitating diagnosis, is at the same time a meas- ure of treatment. The weight and thickness of the hair, with which the patient is often favored, increases the de- gree of local heat as it also prevents its dissipation, and its removal in some degree aids in the reduction of tempera- ture. The essential advantage, however, to be derived from this procedure is that it permits the effective applica- tion of the ice-cap, which next to trephination, under 224 INJURIES OF THE BRAIN AND MEMBRANES. indicated conditions, is most nearly a directly curative resource. The topical use of cold in this manner is ser- viceable in those cases in which cerebral hyperaemia or meningeal inflammation is manifested by pain, high tem- perature, and active ~ delirium. It is contraindicated in hemorrhages and cerebral lacerations when uncomplicated by serious contusion ; but, as those lesions are constantly thus complicated, it may be held a proper resort when such symptoms are manifest, without regard to exact diagnosis. The constringence of congested internal vessels by the in- fluence of cold exerted through the tegumentary coverings of the cavities of the body is fully recognized. It is evi- dent in this class of cases from the usual subsidence of the symptoms for the relief of which it has been employed; and in many instances the nutritive changes inaugurated by the diffuse lesion seem to have been arrested, and the integrity of the parts restored. There is the history of a case, among those appended, which ended in recovery, in which the mind was clear and the temperature approxi- mately normal whenever the ice-cap was applied, and in which the temperature rose markedly and delirium recurred whenever it was removed. These interchangeable condi- tions were made the subject of frequent observation for several days. The use of a mild form of mechanical restraint is often required for keeping the patient in bed. It has an inci- dental value in quieting nervous excitement and husband- ing physical strength, which is of even greater importance than the fulfilment of what is usually regarded as its pri- mary indication. It is oftener applied in consequence of extreme restlessness or persistent efforts to rise from the bed than of violent delirium. The patient rarely objects PRINCIPLES OFTREATMENT. 22$ to the confinement, and his struggles cease almost at once, not from terror, but because his mental condition is such that he is easily diverted from efforts which he finds to be ineffectual. The waste of both nervous and physical force is thus better prevented than it could be by the adminis- tration of medicinal sedatives and stimulants. Leather bracelets and a strap to control the wrists and an arrange- ment of sheets will suffice for the purpose. The control of nervous irritation and the maintenance of strength are the paramount indications in general treat- ment. If the ice-cap and mechanical restraint are insuffi- cient to afford rest and necessary sleep, or are unsuited to the conditions of the case, the hypodermic administration of morphine is likely to be the most efficient of sedative medicinal remedies, and, judiciously employed, is appar- ently without subsequent ill effect. The bromides, which are administered to this end and for their supposed action in diminishing cerebral congestion, seem to be void of effect even when carried to their physiological limit. The nutrition of the patient in every serious case, what- ever its nature, whether of accident or disease, requires careful attention. In severe brain lesions which are not immediately fatal the restorative processes, if they occur at all, are usually slow, and the issue to some extent may de- pend upon the support which is given to the natural powers of endurance. Alimentation is not often attended with much difficulty in the earlier stages of treatment, or while recovery may still seem hopeful or possible. It is of essen- tial importance that it should be systematic and not too long deferred. The injunction to be mindful of the action of the bowels and of the evacuation of the bladder, which is so generally coupled with that of careful nutrition, may 15 226 INJURIES OF THE BRAIN AND MEMBRANES. have special significance in relation to these injuries of the brain. In a considerable proportion of cases, the lack of urinary and fascal control may render it superfluous; but when unconsciousness is profound retention of urine oc- casionally occurs, and in all pathic cerebral conditions the importance of the revulsive effect of free intestinal action is well understood. These several admonitions to caution, though trite, are not to be regarded as purely perfunctory ; their observance is of absolute importance, and their neg- lect invites disaster. There are certain other measures of treatment, some- times adopted, which are of at least doubtful expediency. There may exist conditions which seem to indicate deple- tion, and the application of a leech behind the ear has been followed by mitigation of urgent symptoms; but it is doubtful if the gain is ever permanent, and, failing this, it is certain that the collapse of the patient will be acceler- ated. The alcohol bath will cause a temporary reduction of several degrees in high temperatures, and, though it sometimes may be more than once repeated, the tempera- ture each time regains its former height. This is appar- ently an invariable rule when the danger limit of heat has been exceeded ; and, if so, there can be no sufficient reason for this resort, since moderate elevations will not require so radical a measure. The iodide of potassium is still much in use in the treatment of brain injuries, without regard to their special nature. The results of extended observation fail to show that it is efficacious, either in re- lieving circulatory obstruction or in the absorption of pial effusions or of cerebral oedema. PRINCIPLES OF TREATMENT. 22/ SECONDARY INFLAMMATIONS. I. Arachnitis. The treatment of traumatic arachnitis is not essen- tially different from that of the idiopathic form of the dis- ease; it will demand therefore but brief consideration. If serious complication of hemorrhage or cerebral lesion exist, and the mixed nature of the lesions is recognizable, very little can be added to the means which have been adopted to meet the earlier indications. Cold to the head, if not previously applied, is the one depressant which may be tol- erated; blistering is not only useless, but harmful, as it increases existing general irritation. If the exudation is distinctly purulent, or the result of pyogenic infection, whether or not there may be complicating injuries of the brain, it is recognized as distinctly fatal, unless there may be hope in operative interference by which effective drain- age can be established. That resort has already been given consideration. The cases in which recovery seems pos- sible are those in which arachnoid inflammation is the direct result of contusion, without serous intracranial com- plication and without subsequent infection, and in which the exudation is mainly of a serous character. It is not always possible during life to determine whether the in- flammatory product is either in part or wholly purulent, or whether it has resulted from infection ; but in view of treatment it should be assumed, pendente lite, to be serous or sero-fibrinous. The treatment of idiopathic arachnitis suggested by the late Dr. Alonzo Clark, is not less appli- cable to the traumatic form of the disease; it is rational, it has been at least quite as successful as any other, and still retains favor. It consists essentially in the use of counter- 228 INJURIES OF THE BRAIN AND MEMBRANES. irritation to resolve inflammation and of diuretics to effect the removal of its serous product by absorption. The agencies he employed were blisters and the iodide of po- tassium. If the symptoms are acute, the blistering may be preceded by the application of ice or ice water to the head; or, if the condition of the patient is asthenic, both blisters and the cold appliances may be discarded. Local depletion may be indicated in individual instances, but with great infrequenc3^ The strength of the patient must be carefully maintained and the use of stimulants may be required from the beginning. 2. Abscess. The superficial abscess, which is nearly ahvays of epi- dural origin, may come to involve the cerebral surface. It is no longer of common occurrence, and, if it exists at all, is an incident of neglected cranial fracture. Its treat- ment has been already intimated in a former reference to its symptomatology. In the examination of such a case, which will be suggested by the general indications of septic infection, or of localized cerebral disturbance, the cranial fracture will be necessarily exposed and the cranial cavity opened. If the pyogenic process has extended from without inward, the abscess will be at once disclosed. In the possible contingency that the pus formation is limited to the arachnoid cavity and subarachnoid space, the ap- pearance of the dural surface will unquestionably indicate the necessity for its incision. The foundation of treatment and its operative measures are thus included in the methods of exact diagnosis. If the pus is thoroughly removed, the w^ound disinfected, drainage provided, and absolute aseptic conditions are maintained, it only remains to give such at- PRINCIPLES OF TREATMENT. 229 tention to the nutrition, stimulation, and general constitu- tional management as may be required for primary lesions. It is scarcely conceivable that, with the exercise of care in the earlier treatment of the fracture and external wound, such a complication should result. The formation of a superficial intracranial abscess, without cranial fracture or external wound, once frequently encountered, has almost if not entirely disappeared from modern hospital practice. The bone was contused, became inflamed, and was subsequently necrosed, with concurrent periostitis and pachymeningitis. Pus formed between the bone and pericranium, and between the bone and the dura mater, and might later extend to, or involve the cerebral surface. Its external manifestation was a swelling known as Pott's puffy tumor of the scalp. The history of local in- jury, the existence of tumor, and the coincidence of symp- toms of septic infection and cerebral disturbance, confirmed the diagnosis. The local and the general treatment were thereafter the same as when the original injury had in- volved a compound fracture, rather than a simple contusion, of the bone. The hernia cerebri, which is allied to superficial cerebral abscess, is another accident of cranial injury with dural implication which is no longer frequent. It is a tumor of variable size, in some part composed of brain elements, but in larger proportion of inflammatory products, which protrudes through a perforation of the cranial wall. It presupposes a cranial opening, whether from accident or operation, a wound of the dura mater and an inflammation of the cerebral surface with or without a pyogenic process which softens its structure and permits its extrusion by the force derived from the pulsation of the cerebral vessels. 230 INJURIES OF THE BRAIN AND MEMBRANES. It is of impossible occurrence unless the road has been opened and the brain substance has been at the same time sufficiently altered by inflammatory changes. Aseptic methods have so prevented or limited such degenerations of cerebral tissue that this complication has not only ceased to be a menace, but is no longer a source of great danger in the exceptional instances in which it occurs. If, with considerable loss of cranial and dural support, correspond- ing injury of the cerebral surface has been inflicted, some protrusion of the brain substance may be inevitable ; but if the wound has been aseptically treated the tumor will con- tain but a small proportion of inflammatory products, and will usually be amenable to a continuance of aseptic treat- ment, in conjunction with moderate pressure equably sus- tained. It is still possible that the tumor, from neglect of early treatment, will eventually require excision, but this procedure will no longer entail the danger with which it was formerly attended. The septic conditions which al- ready exist will by present methods be diminished rather than increased by operation. Deep Abscess. The traumatic central abscess of the brain, unlike the superficial inflammations just described, is often deter- mined by unknown circumstances in which neglect has had no obvious part. The fact of its only exceptional occur- rence, even before the necessity of surgical cleanliness was recognized, the possibility that external wound may be wantinof, and the usual tenor of such histories as can be obtained, do not seem to indicate either its uniform or its habitual origin in superficial injury. There is therefore less stress to be laid upon the efficacy of a preventive treat- PRINCIPLES OF TREATMENT. 23 1 ment, though from this, as from every point ot view, the observance of rigid aseptic precautions is to be enjoined in the management of all injuries of the head. There can be no special treatment in the formative stage of the abscess ; as there are no recognizable s^^mptoms, there can be no direct indications. Treatment can begin only when the abscess has attained such size that it can be recognized, or at least reasonably suspected ; and then if deemed justi- fiable must be purely operative. There is no diversity of opinion, and hence can be no discussion as to the almost certain fatality of even encapsulated purulent accumula- tions in the brain substance when undisturbed ; nor as to the possibility of their successful evacuation by operation under favorable, and sometimes under unfavorable, cir- cumstances. If the progress of a case has led to a well- founded conviction that abscess exists, and the general condition of the patient promises safety in case of opera- tive failure, exploration should be made ; or if action has been delayed till diagnosis is practically certain, or till a sudden irruption of symptoms unexpectedly discloses the nature of the lesion, and it is accessible, operation should be essayed, though only a forlorn hope of a successful issue remains. The situation of the cyst will be determined, so far as its determination is practicable, by the general con- sideration of symptoms upon which the fact of its existence was predicated, aided incidentally perhaps by a knowledge of the external seat of original injury. The spontaneous discharge of pus through a cranial wound, if such was originally inflicted, or through natural passages, is too im- probable to be made the basis of speculation or of reliance. It is possible, especially in case of gunshot wounds, but even then indicates operative interference. These formu- 232 INJURIES OF THE BRAIN AND MEMBRANES. lated statements are believed to be in accordance with the views of surgeons generally and of writers upon the sub- ject. The choice of site for operation, the details of proce- dure, the disinfection of the abscess cavity, and the question of drainage have been thoroughly discussed by ]\Iacewen and others. The appended series of fatal and recovering cases in- cludes but five, or one per cent, of the whole number, which involved a pyogenic process of the parenchyma. One of these was a diffuse inflammation resulting from the use of an infected drainage tube ; three of the four abscesses followed early neglect and a late admission to the hospital, and were probably preventible. There were two recoveries, both after operation ; one in case of a cor- tical, and the other of a central suppuration. In one of the two fatalities a small abscess was evacuated, and in the other an operation was not deemed practicable in the con- dition of the patient. These cases are included in the series appended. PART II. PISTOL-SHOT WOUNDS OF THE HEAD. Chapter VII. MEDICO-LEGAL RELATIONS. The increasing frequency of pistol - shot wounds, whether accidental, suicidal, or homicidal, has added to their recognized importance as a distinctive class of general injuries. The pistol is essentially the weapon of modern life ; hionest men carry it for defence, other men use it for defence or offence as occasion serves; it is accessible as well as congenial to the temperament of the time, and so suits the suicidal purpose ; the results of ordinary careless- ness render it additionally the fruitful source of accident. The countless wounds which it occasions are inflicted upon the head with disproportionate frequency as compared with other regions of the body, and have then peculiarities which demand special consideration in a comprehensive view of intracranial lesions. Pistol-shot wounds of the head are of importance in two distinct relations : as they concern medico-legal inquiries, and in their purely surgical aspect as a subdivision of the class of encephalic injuries. Gunshot wounds have been carefully studied at differ- ent epochs, and the effects of different arms and projectiles 234 INJURIES OF THE BRAIN AND MEMBRANES. at long range have been determined with some accuracy both by observation and by direct experimentation. The close of each great conflict of arms in modern times has been followed by such additions to the literature of the subject as have been necessitated by the attainment of suc- cessive increments of destructive power. The observations of John Hunter were made from 1760 through various Continental wars, and were terminated only with his death toward the end of the century. From that time till the conclusion of the Franco-Prussian war, a period crowded with historic military operations of great extent, not only in Europe but in the East and in this country, progressive improvements in arms and projectiles have been constantly paralleled by equal advances in the knowledge of the in- juries which they inflict, and facts established by experi- ence in the field have been supplemented by the later ex- perimental observations of Bruns, Chaumel, and Nimier, and of many others, and very recently by those of La Garde under the direction of the Ordnance and vSurgeon-General's departments of the United States Army. The results thus obtained may be held to be limited to wounds inflicted at long range. The pistol plays so small a part in actual war- fare that it would be as useless as it is impossible to dis- criminate the occasional wounds it has produced from the incomparably greater number due to other small arms in habitual military use. The experiments on the cadaver, furthermore, which have been conducted by military sur- geons have never included studies of the special character- istics of pistol-shot wound. Their history must be sought in civil life, to which their ravages have been largely con- fined and in which their interest mainly centres. medico- legal relations. 235 The Medico-Legal Relations of Pistol-Shot Wounds of the Head. The medico-legal significance of pistol-shot wounds of the head is in great part dependent upon the character of the injuries suffered by the soft parts and by the cranium. The question of homicide or suicide may depend exclu- sively for its solution upon the possibility of thus determin- ing the distance at which a fatal shot was fired, its direc- tion, or its calibre. The intracranial wound may afford corroboration of the inferences derived from an examina- tion of the external appearances, but in this regard its value is relatively slight. The surgical importance of head injuries of this class, on the contrary, will rest in great part upon the damage sustained by the intracranial con- tents. Generalizations founded upon clinical observation have a basis too narrow to make them of use in the interpreta- tion of facts pertinent to medico-legal investigation. The number of instances for comparison, made necessary by the diversity of attendant circumstances, is too great to be compassed within the limit of individual experience, even when favored by exceptional opportunity. In other varieties of gunshot injury examples may be at times in- definitely aggregated, as will happen in the course of mili- tary operations. There is the further difficulty encoun- tered that the conditions under which the wound has been inflicted can rarely be determined with precision. The calibre of the ball, the distance from which it has been pro- jected, its direction, and even the nature of the explosive, may be positively known, if at all, only from the state- ment of the homicidal or suicidal victim, who is not often 236 INJURIES OF THE BRAIN AND MEMBRANES. in a mental or physical state to afford definite information. In gunshot wounds inflicted upon the field of battle, dis- tances are estimated at hundreds of yards, and with other essential conditions are predetermined and definitely for- mulated. In pistol-shot wounds, distances are usually cal- culated upon a scale of feet or inches, and distinctions must necessarily be more minutely drawn. There are no established data from which deductions can be made, and perhaps no other witness with knowledge of explanatory facts than the suicide or murderer, whose lips, as already said, are sealed by mental or physical disability, or by the instinct of self-preservation. Another source of inexacti- tude or failure in generalization exists in the alteration or destruction of evidences impressed upon the external sur- face of the body. The wound may have been enlarged or distorted, unburned grains of powder may have been removed, or smoke stains may have been washed away. As a result of these several causes of uncertainty, the limitation of individual experience, the lack of positive knowledge of all the circumstances under which the injury has been received, and the changes to which the external wound and the adjacent cutaneous surface have been pos- sibly subjected, there are but few opportunities afforded for satisfactory clinical observation of the results of pistol shots under exactly specified conditions of weapon, missile, distance, and direction. It would be difficult to find even an exceptional instance in which one or more elements necessary to comparison were not wanting. In order to determine the effects produced by balls of different calibres, fired at different distances and under varied conditions, it is necessary to resort to experimen- tation upon the cadaver. Results obtained in this manner, MEDICO-LEGAL RELATIONS. 237 ■when confined to lesions and disfigurements of the scalp and cranium, if not identical with those observed in the case of similar injuries inflicted upon the living subject, are sufficiently approximate to have weight in the forma- tion of medico-legal conclusions. The allowances which are to be made for the physical changes which have oc- curred in those parts in the quite recent post-mortem con- dition are scarcely greater than those required for the vari- ations in individual clinical cases. Such experiments have been undertaken from time to time, but they have been heretofore desultory in character, limited in scope, impo- tent in conclusion, and infrequently or inexactly recorded. A very great number of observations systematically made is essential to the formulation of rules which govern the infliction and reception of this type of gunshot wound. The calibre of the ball, its angle of incidence, and the dis- tance which it traverses must not only be considered, but, additionally, the length of the Aveapon, the character of the explosive, the density and thickness of the individual cranium, and the special cranial region which is involved. It is of course impossible experimentally to fix the exact value of each one of these elements through all its con- ceivable permutations. If experiments be confined to the effects of balls of the four sizes in most frequent use, fired from a single variety of pistol, and at distances varying from contact to the limit at which penetration of bone is possible for each calibre, the number demanded will even then be very large. If each observation be repeated suffi- ciently often to discriminate occasional or uncertain effects from those which are invariable, their total number will be enormously increased. In a series of experiments made upon the cadaver dur- 238 INJURIES OF THE BRAIN AND MEMBRANES. ing the past three years, the author has proceeded in the manner which seems essential to the formation of definite conclusions. The calibres selected were 0.22, 0.32, 0.38, and 0.44. The cartridges, like the pistols primarily used, were of a single manufacture, and the distances were the same for each calibre, varying from absolute contact of the weapon's muzzle with the skin to the limit of practicable observation, which was fixed at one hundred feet. For further comparison a limited number of additional obser- vations was made with pistols and cartridges from other makers, and also with the smokeless in place of the black powder. The trials were made upon entire subjects re- cently dead, in which cadaveric rigidity did not exist and in which decomposition was not appreciably advanced. In such heads the physical properties of the cranium may be considered as unaltered, and changes in the superficial soft parts as insufficient materially to afi^ect results. The influence of regional variations, and of differences in the thickness or density of individual crania, upon the amount and character of injury wrought by the missile was inci- dentally apparent in the course of observations of a more general character. The effects of pistol shots upon the head which were especially studied were lesions of the tegumentary cov- erings and of the cranium ; intracranial injuries were regarded as of less certain value on account of possible modifications from changes incident to the post-mortem condition in so soft a tissue as the brain substance. The specific effects noted and subjected to comparison were, for the external soft parts, the characteristics of the external wound of entrance, the burning of the skin or hair, the staining of the skin by smoke, and the deposit of MEDICO-LEGAL RELATIONS. 239 unburned grains of powder upon the surface or in the sub- stance of the skin or subjacent wounded tissues ; and for the cranium, the peculiarities of the osseous wounds of entrance and of exit, and the resulting fractures of the vault or base. To these were added an examination of the brain track for the detection of powder traces or of bony fragments. Extracranial Lesions. 0.38 calibre. Length of barrel, 3%". Diameter of ball, 0.430". Weight of lead, 146-150 grs. Weight of powder, 15-19 grs. Number of observations made upon the head, io8. Number of observations made upon the body, 132. The effects of balls of this calibre were given earliest consideration and in some sort made standards of com- parison for those occasioned by others of larger or smaller size, since they are not only more commonly encountered but also present greater uniformity of character. The wound of entrance is at all ranges smaller than the ball, circular except for an occasional minute tear, and from -^'^ to 3^" in diameter. The margin is sometimes slightly inverted, or may be finely serrated, and when the range is greater than 3" is often stained with lead. Exceptions. — {a) If the ball strikes upon a cranial curve, the cutaneous wound may be lacerated and its size in- creased to a moderate extent. {b) At contact of the weapon, and occasionally even when the range is Y^" , the 240 INJURIES OF THE BRAIN AND MEMBRANES. wound is much larger than the ball, and the subcutaneous tissues are disclosed, torn, and burned, or blackened by powder and smoke. The wound is then usually linear, from i" to 2" in length, and often made secondarily trian- gular by the rupture of one of the cutaneous edges. It may possibly be quadrilateral, or even circular, but is always comparatively large, though in that event smaller than the ball. Disintegrated brain matter may be forced through the wound of entrance at all ranges, and this will occur in the larger proportion of cases. It may simply bulge from the wound, lie upon the adjacent surface, be entangled in the hair, or be ejected to a considerable distance, as far even as fifteen or twenty feet. The amount varies from a bit not larger than a robin shot to as much as one or two drachms. As the extrusion of brain matter occurs at all ranges, and its quantity and force of ejection depend in part upon other circumstances, it has no value in determining the distance through which the ball has been projected. Smoke stain upon the skin does not occur at firm contact, but when contact is imperfect, and at a range less than 6" it is nearly constant. The exceptions are in certain cases in which the wound is made in a portion of the head covered with thick hair, and in the rarer cases in which at a range of ^" the wound is lacerated and the subcutaneous tissues are widely disclosed. At a range from 6" to one foot it is again nearly constant ; from one foot to two feet it is of more uncertain occurrence. At a range of more than two feet it is always absent as a distinct area, though it may be perhaps detected with a damp cloth. The smoke-stained area is usually circular and dark, with an extension of lighter hue, which may be either symmetrical, irregular, or i6 242 INJURIES OF THE BRAIN AND MEMBRANES. prolonged upon one aspect of the wound, and possibly with smudges upon neighboring prominences or depressions, as upon the ear or nose or in the orbital fossae. These areas are, approximately: at ranges of less than i", from i^/^" to 2%" diam. ; at ranges of i" to 3", from 3" to 5" diam. ; at ranges of 6", from 2^" to 4" diam.; and at ranges from one foot to two feet either very small, not more than i" in diam., or, as usually happens, very largely and faintly diffused over an irregular space of from 5" to 6". At a range of ^" to 3" there is ordinarily a deeply blackened circular area from %" to ^ " in diameter, surrounding the wound, which is the combined result of smoke, burn, and infiltration of the skin with finely divided grains of powder. With imperfect contact of the weapon a double smoke ring may be formed with a clear interval between the two, hav- ing an entire diameter of two inches. The density of the smoke deposit, the probability of its occurrence at the uncertain ranges, and its extension to more distant surfaces will be influenced by atmospheric conditions. Each will be notably as well as naturally favored by an excess of dampness, but the accuracy of the conclusions stated will not be further affected. Burning or scorching of the skin occurs only at a range of less than one foot. At contact or at a range of %" it is confined to the edge of the cutaneous wound, as it is when with a range of yi" or less the soft parts are lacer- ated. At a range from yi" to 6" inclusive there is usually a circular blackened area yi" to 3^" in diameter, due in part to burn, as previously described. In a single instance it exceeded this limit ; it is invariable if not prevented by the thickness of the hair at the point of injury. At a range from i" to 6" inclusive the skin may be additionally 244 INJURIES OF THE BRAIN AND MEMBRANES. scorched, either over a circular area of i" to i^" alto- gether, or upon one aspect of the wound. At any of these ranges, the hair, if interposed, will be burned or singed over an area from i" to 2jj" in extent, and may or may not prevent burning or other characteristic lesions of the skin. At a range of 7" to 10" the blackened area is not formed, and burning is again limited to the edge of the cutaneous wound, or to a slight singeing of the hair, or it may be entirely absent. Burning is not constant at any range. Unburned grains of powder may lie upon the surface of the skin or be more or less completely embedded in its substance. At contact or at a range of y^" no such indica- tion exists, but in its place there is a powder infiltration of the exposed subcutaneous tissues, and a distribution of un- burned grains upon the detached surface of the temporal fascia or of the fronto-occipital aponeurosis. The skin is ingrained with powder at ranges from ^" to four feet in- clusive, but at three feet the ingraining ceases to be invari- able. At ^ " or I " it is confined to the blackened area of yi " to 3^" diam. At 3" it is extended to an area of i^" to 2^"; at 6", to an area of 2^" to 4", which is not much increased up to a range of one foot, though the average becomes con- stantly greater. At ranges of one foot and two feet it in- cludes an area of 4" to 6", and in the case of wound^ involving the anterior temporal region covers the whole side of the face, neck, and ear. At three and one half and four feet, in half the observations made, no grains, and in the others not more than two or three, were embedded. These areas represent extreme measurements, but the greater part of the implantations were made within somewhat narrower limits, and as the range increased they were more widely ^m 246 INJURIES OF THE BRAIN AND MEMBRANES. separated from each other. The number is difficult to es- timate; at a range from 3" to two feet it is probably from 200 to 400 or even more ; at three feet they may be counted, and the total number will probably not exceed 25 to 50, and may be not more than 3 or 4, and at four feet there will be 2 or 3 or none at all. At six feet they no longer exist. Unburned grains which are free upon the cutaneous surface are not distinguishable when the range is less than 6", though they may be seen upon the underlying cloth. There are more grains free at a range of lo", and still more at one foot, but those which are fixed in the skin .still preponderate. At a range of two feet the proportion is variable ; at three feet the greater part are free ; and at four feet only an occasional grain is embedded ; at ranges of six feet and upward whatever grains escape combustion are free upon the surface of the adjacent parts or else- where. The grains are many at six feet, but at eight or nine feet and up to a range of not much short of thirty feet there are rarely more than six or eight, oftener one or two, and in many instances none at all. At and beyond a range of thirty feet not even a single grain has been found in any of the observations made. Within the limit in which fixed and free grains exist together their area is commensurate. At a range of from one foot to six feet the whole side of the face and neck and the ear is likely to be included. At the longer ranges in which there is but a grain or two, or at most but five or six, they are found or- dinarily at a distance from the wound, even as far as the hip, though if it be but a single grain it may have made its lodgement almost upon the margin of entrance. In general the number of free grains increases relatively as that of the s ^ 248 INJURIES OF THE BRAIN AND MEMBRANES. fixed grains diminishes, and as the range is increased both are more sparsely scattered. If a white cloth be placed under the head and shoulders of the subject, unburned grains will often be detected when they fail to appear upon the surface of the head or face, but none when the range exceeds the already determined distance of thirty feet. Lesions of the subcutaneous tissues occur from a dis- charge of the weapon at contact to a range of one foot in- clusive. At contact these tissues are lacerated, burned, smoked, and infiltrated with powder, and the blackened surface is disclosed through the cutaneous wound. In ex- ceptional cases these conditions may be produced in a wound inflicted at a range of y^" . At a range of %" to 3" the superficial tissues are usually separated from the temporal fascia or occipito-frontal aponeurosis, which is powder stained over an area of %" to 2". At a range of 6" or more, if any stain exists it is not likely to extend beyond the track of the ball, though grains of powder may be ex- ceptionally discovered at one foot. At a distance of 3" or less in range the contiguous surfaces of the cranium and dura mater may be powder stained over an area of yi " to 2", or the margin of the osseous wound upon its outer sur- face may be similarly stained for a variable distance. The occurrence of fragments or particles of lead in the tissues, especially in the muscle, or of a lead stain of the bone or pericranium, is frequent when the range is 3" or more, and almost invariable at the longer distances. Unburned powder is carried through the whole length of the brain track when the ball is discharged at contact or when the range is not greater than }4". At a range of i" it may not be detected beyond the median fissure ; at 3" it ceases to be invariable, and the quantity is much dimin- Fig. =.— 0.38 Cal. Range, i ft. Trace of Smoke, Free and Embedded Powder Grains 250 INJURIES OF THE BRAIN AND MEMBRANES. ished; at 6" it apparently no longer penetrates the cranial opening. At greater distances the brain substance is oc- casionally stained with lead. Fragments of bone more or less finely comminuted may be driven into or through the brain at whatever range the ball has been projected. Their number and size, and the depth to which they are carried, will de- pend rather upon the physical properties of particular crania and upon the point or angle of incidence, than upon the distance which the ball has traversed. They have therefore no significance in the determination of ranges. These results have been corroborated in certain par- ticulars by observations made upon other parts of the body. The characters of the wound of entrance or of the subcu- taneous lesions might conceivably differ, by reason of different relations of bone and superincumbent tissues, as the wound is inflicted upon the head or upon the trunk or extremities; but the results of imperfect combustion of powder and the effects of flame, the area of smoke stain, the distribution of unburned grains, the burning of the skin, ought to be approximately the same in the two classes of cases. In one hundred and thirty-two corroborative observations of this kind comparison has been restricted to those incidents. At absolute contact, not only upon the thigh and thorax, but over the skin or sternum where the relation of skin to subjacent bone is more exactly comparable to that which exists in the head, the deposit of smoke is not limited to the subcutaneous tissues but also occurs upon the surface over an area of from }^" to i". At a range of i" and less the cutaneous smoke area is larger than upon the head, but \ - '^•■f f;f^' Fig. 6.— 0.38 Cal. Range, 2 ft. Free Powder Grains, only Seven Embedded. 2 52 INJURIES OF THE BRAIN AND MEMBRANES. at 3", 6", and one foot it is very nearly the same, and at all these ranges it is constant. From one foot to two feet it is uncertain, and subject to similar variations, and at two feet it is no longer visible even in exceptional cases. Hence the only point of difference noted is in the extent of the smoke stain at a range of i" or less. As upon the head, burning or scorching of the skin at contact is limited to the cutaneous edge. At ranges of less than one foot it has about the same extent and char- acters as was found to exist at corresponding distances in head cases, and as in them it never occurs when the range reaches or exceeds one foot. The correspondence in results obtained in the two classes of cases is extended to the distribution of powder grains which escape combustion. At contact under the exceptional condition which permits the staining of the skin with smoke, some grains may be embedded in its area. The narrow blackened margin, due to burn, smoke, and infiltration of finely divided grains of powder, which at ranges of yi" and i" or more was found to environ the wound as it occurs in the head, is reproduced in those of the body, and to it is equally confined the deposit of un- burned grains. At ranges extending from 3" to four feet the areas of embedded grain do not materially differ from those previously established ; and at greater distances, though no longer embedded, they may as before be detected lying free upon the cutaneous surface, or upon the white cloth which underlies the body. At ranges greater than four feet, as before, the number of free grains is at once greatly diminished ; their presence very soon becomes un- certain, and at some point just short of thirty feet they disappear altogether. 254 INJURIES OF THE BRAIN AND MEMBRANES. • 0.32 cal. Length of barrel, 3%". Diameter of ball, 0.319". Weight of ball, 88 grs. Weight of powder, 10 grs. Number of observations made, 82. The results of observation do not differ widely from those obtained when the ball is of 0.38 cal. The wound of entrance is still found to be smaller than the ball, with the same exceptions, that is, at contact, or in the occasional instances in which it is lacerated by im- pact of the ball upon a cranial curve. Its diameter will vary between the same limit of yY' and j^", and the aver- age is not perceptibly less. At contact, however, the wound, which is still usually linear, is shorter, not often exceeding i" in length, and is more likely to show its original circular outline with the tear on either side which has made it linear. It is less likely to be further compli- cated by a secondary tear upon one of its linear edges, which in the use of the ball of 0.38 cal. so often makes it triangular. In a single instance the circular outline was preserved without modification and the diameter remained smaller than that of the ball. Disintegrated brain matter is extruded from the wound of entrance in two cases out of three in the aggregate number taken at all ranges. At contact, it is of excep- tional occurrence. In these particulars, as in variations of amount and of force of projection, the facts observed are the same as in the use of the ball of larger calibre. The smoke stain upon the skin is constant at a range of 8' or less, is present in a minority of cases when it is from 256 INJURIES OF THE BRAIN AND MEMBRANES. one foot to two feet, and is never formed when it exceeds that distance. The limit of range is therefore the same as in case of the ball of 0.38 cal. At contact there is usually a trivial staining of the surface which was exceptional in the former instance. At a range of i" or less there is a distinctly defined smoke area from i^/^" to 2j4" in diame- ter with possible prolongations or more distant smudges ; at 3" the area is from 1^2" to 2}^" in diameter with some- times an additional trace to an equal extent; at 6" to 8" the area, which is from 2" to 2}^ in diameter, is sharply limited; at one foot, the area is reduced to i}4" in diam- eter ; and at two feet there is no longer an area and only ex- ceptionally an indefinite trace. In general, at the lesser dis- tances the traces of smoke upon the surface may be further extended, while at the longer ranges the area is more con- tracted and more sharply defined than with the larger ball. Burns of the hair or skin occur within a range of 6". At contact the burning of the cutaneous edge is limited to the central portion of the woimd which is directly tra- versed by the ball. In the one case observed in which the wound maintained its circular outline there was a scorched as well as a smoked area of }^" as there would have been in a similar wound inflicted at a perceptible range. The hair when exposed may be slightly singed immediately at the point of entrance either at its ends or at its roots. At a range from 14" to 3" the black area is from }i" to }(" with a possible additional scorched area from }i" to i". At 3" or 6" burning is not invariable, and at 6" it is limited to the cutaneous edge or to the hair ; at 7" it ceases altogether. The presence of unburned grains, either fixed in the skin or free upon its surface, is noted from contact to a range of 17 258 IN7URIES OF THE BRAIN AND MEMBRANES. three and one-half feet inclusive. The deposit of free grains may be detected upon the surface of the skin or upon the un- derlying white cloth at any range less than thirty feet. These limits seem to be absolute. At contact the ingraining of the skin is exceptional, and is then limited to the margin of the wound. At a range of 1 " and less it is confined to the black area of less than ^" in diameter, with possibly a very few isolated grains just beyond its border; at 3" and 6" it is limited to the extreme smoke area of i3/^" to 6", at one foot it is mainly within a space of 2;2", but is extended to a distance of 4" and even 6"; at two feet there is less in- graining in the immediate vicinity of the wound, but the whole area is not smaller. At three and at three and one- half feet the number of grains embedded is very small, per- haps not more than two or three, and these at a distance from the wound. At ranges from 3" to two feet, the number is very great, and probably not less than when the ball is of 0.38 cal. The unburned grains which remain free at ranges less than 3" can usually be detected only upon the underlying cloth; at ranges of 3" and 6" they can be noted in the smoke area with those which are em- bedded but in much smaller number. At ranges from one foot to three feet they are numerous, and beyond that limit they are few and at a distance from the wound. The range at which unburned powder may be embedded in the skin is thus somewhat less than with ball of 0.38 cal., as is the area of smoke stain or of burning, but the number of grains and the area which they cover are not essentially different, nor is either the range, number, or area of those grains which are left free upon the surface. The lesions of the subcutaneous tissues at contact, or at ranges of 1" and less, are indistinguishable in nature and Fig. io. — 0.32 Cal. Range, 3". Smoke Area and Scorching of Skin; Powder Grains Apparently all Embedded. 260 INJURIES OF THE BRAIN AND MEMBRANES. extent from those produced by the ball of 0.38 cal. At 3" there are less staining and separation of the scalp layers, and at 6" traces of powder are no longer evident. Frag- ments or particles of lead and lead stains, as with the larger calibre, occur at all ranges and with equal certainty at the longer distances. Powder grains within the cranial cavity can be detected at ranges of less than i", and at contact — often upon the contiguous surfaces of the calvarium and dura mater, invari- ably in the brain track, and sometimes in the cutaneous wound of exit. At 3" the}' can be usually recognized, but at 6" it is probably never possible to discover them by simple visual inspection. A lead stain can be occasionally distin- guished in the brain substance, either with or without the presence of grains of powder. There is nothing in the extent of intracranial staining which indicates the calibre of ball. Fragments of bone more or less finely comminuted may be carried into the brain to all distances at all ranges, and this result of pistol-shot fracture of the cranium has no special characteristics with balls of this calibre 0.44 cal. {(i) Length of barrel, 6)4". (/;) Length of barrel, 2}(''. vSame cartridge. Diameter of ball, 0.429. Weight of ball, 236 grs. Weight of powder. 23 grs. Total number of observations, 90. The difference in penetrative power and consequent 262 INJURIES OF THE BRAIN AND MEMBRANES. effectiveness of different weapons of this calibre is so great that two were selected as types, and observations made independently for each. The results proved that corre- sponding or appreciable differences did not exist in the lesions of soft parts nor in other superficial conditions, and conclusions have been formulated from the consolidation of the two series. The wound of entrance, while exceptionally as minute (ye") as any observed from balls of the smallest calibre, is ordinarily from ^" to j-\", and occasionally i<(" in diameter. At contact, the wound, though it may be as large as ^" when circular and symmetrical, does not exceed in length when linear those inflicted with a ball of 0.38 cal. In the use of the inferior type of weapon, in which penetration of bone often fails, the size of the wound is not usually in- creased. A lead stain of the cutaneous edge is of frequent occurrence, as it is with the use of balls of other calibres. The extrusion of disintegrated brain matter through the external wound with more or less force occurs in some- what more than half of the whole number of cases, and is observed at contact or at one hundred feet as well as at the intermediate ranges. A smoke stain upon the skin, of variable extent, is perceptible in a minority of cases at contact, but it is al- ways faint. At 3" and less it is dense, and invariable, with an extent of 2" to 2}4", and a possible increase to 4". At 6" it has the same density and area, but ceases to be invariable. At one foot it is again faint and of still more uncertain occurrence. At two feet it has disappeared. The hair or skin is burned at contact or at a range of 15" or less. At contact, only the hair, or the margin of the wound to an extent not exceeding yi ", will be involved. 264 INJURIES OF THE BRAIX AND MEMBRANES. At a range from ^2" to 3' inclusive, a black area of y." may be formed, or the skin scorched upon one aspect of the wound or concentrically ^" to iX "> or the hair burned over an area of 2 " or less. At a range of 6" the skin is scorched in a majority of cases, unless protected by the hair, and at 7" it is possible, but was not positive in any of the obser- vations made. At one foot the hair may be slightly singed, and at 15" it is of only exceptional occurrence. Powder is ingrained or remains free upon the surface in an area which varies to some extent in the use of the two types of pistol of this calibre. The differences are not great and might disappear if the observations were suffi- ciently extended. At contact with the inferior weapon, some free grains were found upon the underlying cloth in each instance, and in one a black area was formed about the wound of entrance ; while with the better weapon no unburned grains, superficial or embedded, were perceptible in either of the observations made. At a range of >^'^ there was a black area of >^" or less with the first weapon, and there were only a few free grains upon the cloth with the second. At a range of i" many grains were embedded in an area of i" to 1^2 " with the first weapon ; and only a black area of Yz", or an area of larger embedded grains of i", was formed with the second. At a range of 3" the area of embedded grains was the same, i>4" to \i/i" in both. At a range of 6" the area of embedded grains was again the same in both weapons, but was from 2" to 2>^" in diameter. At a range of one foot, while the area of embedded grains might extend to 4"+, it was mainly limited to 3"X2". The free grains were the more numerous when the inferior weapon was employed. At a range of two feet, with the better weapon, the grains were still embedded in the larger ^ Fig. 13.— 0.32 Cal. Range, 2 ft. Free Powder Grains, Twelve Embedded. 266 INJURIES OF THE BRAIN AND MEMBRANES. proportion, and the area was extended to five inches. At a range of three feet the grains, which were about one-half embedded and somewhat less numerous, covered the whole side of the face. At a range of five feet few appreciable grains were imconsumed, of which not more than ten or twelve were likely to be embedded. At six feet no grains were embedded and few remained free upon the surface. At ten feet, and longer ranges, a few scattered grains upon the face or underlying cloth were of uncertain occurrence, and at twenty-five feet they had disappeared altogether. The subcutaneous lesions produced at contact with the more efficient pistol of 0.44 cal. are more extensive than with weapons of smaller size in proportion to the more extensive cutaneous wound which it inflicts. The pistol of this calibre of inferior type has no greater destructive effect than has those of the lesser calibres. At ranges of from one to three inches no more extended staining of the tissues or separation of the layers of the scalp is observed than has been found to exist with the use of 0.38 cal., nor is the range longer in which they occur. Powder grains are carried into the intracranial cavity and are appreciable at the same ranges and in the same proportion of cases as with 0.32 or 0.38 cal. The comminuted bone is driven into the brain at all ran- ges as with other calibres, and in somewhat greater amount. 0.22 cal. Length of barrel, 3". Diameter of ball, 0.230". Weight of ball, 45 grs. Weight of powder, 1 5 grs. Number of observations, 200. ,,^ Fig. 14.— 0.32 Cal. Range, 3 ft. Free Powder Grains. 268 INJURIES OF THE BRAIN AND MEMBRANES. The superficial conditions presented in wounds inflicted by this smaller missile are much more variable than when the ball has been of either of the larger calibres previously considered ; but the variations are within definite and com- paratively narrow limits. The wound of entrance, while still circular and smaller than the ball, save in the exceptional instances noted for the larger calibres, is of relatively and often of absolutely greater diameter than the average ascertained for balls of 0.32 or even 0.38 cal. The diameter, which is within the same limits of ^" to -^", is perhaps oftener as large as yi" than in them. At contact the wound ceases to have char- acteristics which when the ball was larger habitually dis- tinguished it from those inflicted at perceptible ranges. In fifteen out of eighteen cases the wound was small and circular, and from -^" to i" in diameter; in the three re- maining it was linear and patulous, i" in length in two of them, and /4"X}i" with lacerated and everted edge in the other. Subcutaneous laceration occurred in but a single one, though blackening of some plane of tissue was invariable. Disintegrated brain matter is extruded from the wound of entrance with much less frequency than in the use of balls of larger calibre, and never with the same violence which with them has been sometimes noted at moderate ranges. The smoke stain upon the skin, which was rarely ob- served at ordinarily firm contact in the use of balls of 0.32 or 0.38 cal., is present in three cases out of four when the ball is of 0.22 cal. In three-fourths of these again it covers an area >4" in diameter, and in the remainder its extent varies from }i" to }^". At imperfect contact it 270 INJURIES OF THE BRAIN AND MEMBRANES. often happens that a dense smoke area of Yz" and a clear interval of the same or somewhat greater extent are in- cluded in a more or less distinct or complete outer ring of smoke, with an aggregate diameter of i>^" to 3". At a range of i" the smoke area extends from i"to4" in its longest diameter, but is usually from lYz" to 2>^". At 3" and at 6" its average remains the same, but its density is less, with perhaps no definite area. At a range of one foot, as in case of 0.32 cal., there is but a faint trace of smoke or none at all, and beyond that limit it is absent altogether. Burning or scorching of the skin and hair occurs at contact and is limited to a range of 3". At contact in fifteen out of sixteen cases the margin of the wound was burned or the skin was scorched over a circular area of y(^" to y^," or in some instances upon one side only. At I " the skin was scorched over an area of ■^" to i", or the hair was burned. At 3" the skin was occasion- ally scorched for similar distances, or, as more frequently happened, the hair was singed, and in many instances no burn of any kind or degree existed. At greater distances not even the edge of the wound was burned, though it was often lead stained. The existence of unburned grains of powder, whether embedded in the skin or lying free upon its surface, is not absolutely constant at any range; and in any case the grains are comparatively few in number. KX. contact, as occurs with the larger calibres, they are practically absent, and this even though the wound of entrance is usually contracted. In a single instance one or two grains were found far away upon the surface. At i" in a major- ity of cases a moderate number of grains are embedded 0) t* bo a> ■a "u 5| > H K c «i-i ^ C4 ■Jl 4) 1) < 272 INJURIES OF THE BRAIN AND MEMBRANES. in an area of %" to i"; in other cases from six to ten grains or even fewer may be sparsely scattered somewhat farther away from the wound; and in others still there are no grains embedded and none upon the surface. At 3" the unburned grains are all embedded in an area of ^" to 1%", and in one case no grains remained unconsumed. At 6" the area of implantation is extended to i" or 2" in half the cases, and in the other half there may be not more than five or six grains altogether at un- certain distances from the wound. At these ranges, from contact to six inches, appreciable unburned grains free upon the surface are exceptional; such as have es- caped combustion, if not fixed in the skin, are too few and too distant to be distinguishable. At one foot and two feet there were a very limited number of embedded grains in half the cases examined, but in all save one there were free unburned grains within an area of 3" or less. At three feet and more no grains are embedded, and the few lying upon the surface are widely scattered, often over the whole side of the face and forehead. At twenty-five feet or more, unburned grains are no longer discoverable either upon the surface of the head or face or upon the underlying cloth. The subcutaneous lesions are practically confined to a range of i " and less. At contact the blackened area may be either upon or beneath the temporal fascia, and measure from %," to 2" in diameter. The muscular tissue is often additionally powder stained and smoked through its substance, and the osseous surface similarly discolored, but laceration is infrequent. At i" the muscle is stained in three-fourths of the cases examined, but the more super- ficial layers are unaffected. At 3" there is ordinarily 274 INJURIES OF THE BRAIN AND MEMBRANES. nothing more than a discoloration of the ball track, though grains of powder may be sometimes detected in its course or upon the osseous margin, and a lead stain upon the temporal fascia is possible. At 6" and more there are no evidences of the passage of the ball through the exter- nal parts outside its track, except for the not infrequent presence of particles or fragments of lead. Grains of powder in the intracranial cavity are de- monstrable at a range of i" or less, and may be excep- tionally noted even at 6". The amount of powder carried into the brain substance is small, and it penetrates the contiguous cerebral lobe only to a moderate distance. In one case at a range of 6" only three grains were dis- tinguishable. At contact the contiguous surfaces of cal- varium and dura may be dotted with grains of powder over an area of i" or more, as in observations made with larger calibres of ball. The detection of more or less finely comminuted frag- ments of bone in the course of the ball through the brain is possible at all ranges, but as the osseous wound is smaller the number is necessarily less than when the calibre is greater. It can probably not be recognized be- yond the median cerebral fissure. In formulating so great a number of experimental re- sults, it has been thought unadvisable to present each observation in detail, since a procedure so laborious and a record so voluminous would be attended by no corre- sponding advantage. The individual differences for each point to be determined have been inconsiderable; and by noting and recording the limits of variation in repeated instances needless repetition has been avoided. The notation of corroborative experiments upon the 2/6 INJURIES OF THE BRAIN AND MEMBRANES. trunk and extremities was discontinued beyond those made with balls of 0.38 caL, as peculiarities in effect, though slight, still existed, and conclusions as to the head might be open to just criticism if based upon them. The results obtained from these observations of pistol- shot wounds of the head, made at corresponding ranges with balls of different calibres, have been so far con- densed that no necessity exists for further generalization ; but for convenience of comparison they may be somewhat abbreviated and differently formulated. The wound of entrance, with all calibres of ball and at all ranges, except at contact or in certain instances in which impact is made upon a cranial curve, is smaller than the ball. Its diameter varies from yL.'' to -^^" , and its average is the same for each calibre except 0.44, for which it is perceptibly larger and for which a maximum of ]^" may be attained. Disintegrated brain matter may be forced into the wound of entrance, or may be extruded from it with more or less violence, at all ranges with all calibres of ball. It occurs in rather more than half the cases in the use of 0.32, 0.38, or 0.44 cal., and in rather less than half the number with 0.22 cal. The staining of the skin by smoke at different ranges varies in its occurrence and extent with the use of differ- ent calibres of ball. {a) 0.38 cal. A smoke stain upon the skin never oc- curs at firm contact; is invariable at a range of 6" or less — except possibly when intercepted by thick hair, or when in rare instances a lacerated wound is inflicted at a range slightly beyond contact; is of uncertain presence at a range of from one foot to two feet ; and is absent at greater 278 INJURIES OF THE BRAIN AND MEMBRANES. distances. At a range of 1" and less it covers an area of i}(" to 2^2", and at a range of 3'' an area from 3" to 5' in diameter, and at both ranges includes a black area which is the result of smoke, burn, and the ingraining of finely divided grains of powder. At a range of 6" it covers an area of 2^4" to 4", and at a range of from one foot to two feet either covers a well-defined area of 1" or is faintly diffused over a space of $" to 6". (d) 0.32 cal. A smoke stain is usually perceptible at contact, forms a distinct area from 1%" to 2)4" in extent at any range less than 6", infrequently occurs and forms an area of 1)4" at one foot, and is only occasionally present as a mere trace at two feet. (c) 0.44 cal. A smoke stain occurs at contact and at ranges less than two feet. At contact and at one foot it is faint and inconstant. At 3" and less it is dense, covers an area from 2" to 2 j4" in diameter and is invariable. At 6" it has the same density and area, but ceases to be invariable. (d) 0.22 cal. A smoke stain covers an area of ^" to }(" in diameter in 75 per cent, of cases at contact ; may form a double ring of i>^" to 3" aggregate diameter at imper- fect contact ; extends over a space from i " to 4" in diam- eter at a range of i" to 6"; exists only as a faint trace at one foot, and is absent altogether at greater distances. Burning of the hair or skin occurs at contact with all calibres and is limited: with 0.44 cal. to a range of 15", with 0.38 cal. to a range of 10", with 0.32 cal. to a range of 6", and with 0.22 cal. to a range of 3". At the extreme limits it is confined to the edge of the wound or to the hair, and at intermediate ranges it additionally includes the burning, which is a factor in the production of the black area, or a still more extended scorching of the skin. Fig. -.--.44 Ca,. Range, . ft. Area of Powder Grains, Mainly Embedded. 28o INJURIES OF THE BRAIN AND MEMBRANES. The black area which is formed at a range of Yz" to 6" with the 0.38 cal., or of Yz" to 3" with the 0.32 cal,, is from y%" to y^" in diameter. The scorching of the skin in the use of the 0.38 cal. occurs in an area of i" to i^", and of the 0.32 cal. in an area of y%" to i". In a suicidal case reported in the accompanying series the burned and scorched area extended to a distance of nearly 2" (0.32 cal.). The black area with 0.22 or 0.44 cal. is limited to y%" and the scorching of the skin to i" and \y^" re- spectively. Embedded grains of powder when the cartridge is of 0.38 cal. may be detected at ranges from Yz" to four feet, and unburned grains upon the surface at ranges from 6" to just within thirty feet. The embedded grains may be confined to the composite black area, or cover a space of 6", and at the longer ranges, from three to four feet, there may be none, or the number may vary from one or two to forty. The superficial free grains are numerous at ranges of from one to six feet and may cover the whole side of the face and neck ; at longer ranges they may be absent, or may be not more than one or two in number. The em- bedded grains outnumber those which are free upon the surface at ranges less than two feet, are in variable pro- portion at that limit, and are fewer, if thej^ exist at all, at longer ranges. When the cartridge used is of 0.32 cal. grains of powder are embedded at ranges from contact to three and one-half feet inclusive, and are left free upon the surface at ranges from 3" to twenty-five feet. At a range of less than 3" free grains may be sometimes discovered in the hair or upon the underlying cloth. The number of unburned grains is not generally less than with the o. 38 cal. , and the areas which thev cover and their relative numeri- 0f ' ..' wC' - ^Pr Fig. 21.— 0.44 Cal. Range, 3 ft. Free and Embedded Powder Grains. 282 INJURIES OF THE BRAIN AND MEMBRANES. cal proportions are the same. When the cartridge is of 0.44 cal. the areas and relative numbers of embedded and superficial grains vary slightly with the type of pistol used. The ranges at which the}^ are ingrained extend from yi" to five feet, and the ranges at which they are de- posited upon the surface of the skin or upon neighboring objects from contact to twenty-five feet. At ranges of less than 3" the proportion of embedded grains is greater with the inferior weapon, and at ranges of more than 6" is greater when the weapon is of the more efficient type. The areas covered by unburned grains are: at ranges of 3" and less, Yi" to lYz" \ at a range of 6", i}^" to 3"; at a range of one foot, 2>4" to 4"; and at ranges of three to five feet they include the whole side of the face. When the cartridge is of 0.22 cal. the unburned grains are fewer in number and inconstant at all ranges. They may be observed from contact to a range somewhat less than three feet for those which are embedded, and some- what less than twent3'-six feet for those which are free. The embedded grains are found in an area of less than 2", and those upon the surface within an area of less than 3". At ranges of more than three feet the superficial grains may be sparsely scattered over the whole side of the face and forehead. The subcutaneous lesions with all calibres, at con- tact, include laceration of the tissues from the explosive effect of the bullet, and their blackening by smoke, burn- ing, and power infiltration, together with some separation of the layers of the scalp, which usually occurs at the level of the temporal fascia. The laceration involves an area of 1" to 3". At ranges of 1" to 3", lesions are confined to blackening of the tissues below the occipito-frontal apo- 284 INJURIES OF THE KRAIX AND MEMBRANES, neurosis or temporal fascia, or of the margin of the osseous entrance, over an area of %" to 2. At or beyond ranges of 3" there is only an exceptional staining of the tissues outside the track of the ball. The extreme limit of range at which these changes occur is for 0.38 cal. of ball 6", though possibly a few grains of powder may be carried into the temporal muscle at one foot; for 0.32 cal., not to exceed 3"; for 0.44 cal, 6"; and for 0.22 cal. not ex- ceeding i". Fragments of lead and lead stains are fre- quent at all ranges and with all calibres of ball. Grains of powder appreciable upon simple visual in- spection may be carried through the osseous wound into the intracranial cavity with all calibres at contact and within a possible range of 6". At contact they may be invariably detected, and perhaps with equal certainty at a range of i". At a range of 3" their detection becomes doubtful, and at 6" only exceptionally possible. At con- tact they may be found upon the contiguous surfaces of the calvarium and dura, and in large number through the whole length of the cerebral track and perhaps even through the external wound of exit. At a range of i" they are likely to be confined to the track through the contiguous cerebral lobe; and at 3" or 6", if they exist at all, they are few and isolated and near the osseous woimd of entrance. Their number seems to be independent of the calibre of the ball, except at contact, when the corre- spondence is direct. Fragments or particles of bone more or less fineh' comminuted are carried into the brain track with all calibres and at all ranges. The differences observed have no essential or diagnostic importance. These generalizations have been made sufficiently 286 INJURIES OF THE BRAIN AND MEMBRANES. comprehensive to include conceivable variations in the effects of different weapons and cartridges upon different subjects under ordinary circumstances. They directly summarize the average results obtained from the use of factory-filled cartridges of the usual type at specified ranges. There are differences to be reckoned with in indi- vidual cartridges and in individual weapons, as there are in individual subjects and in attendant conditions. Car- tridges and pistols of the same calibre vary in their eff'ects, not onh^ as they are the product of different makers, but as they are of different types and lengths, and each may have even individual peculiarities. Atmos- •pheric conditions may aff'ect cutaneous indications, as may accidental conditions of the surface, or as may physical properties dependent upon age, sex, or congenital confor- mation. Smoke will not be so densely deposited upon the surface in dry as in damp weather; the hair which is wet or smooth will not be so readily burned as will the hair which is dry and fluffy; the skin which is tough and re- sistant, or which is covered by thick hair, will not be so closely ingrained with powder as skin which is of softer texture or which is unprotected ; and the pistol of antique fashion or the cartridge which is old or made of inferior powder will not have the same penetrative pov.-er, or oc- casion an external wound having the same characters, as will the products of most recent manufacture. It is not to be expected, therefore, that a ball of given calibre dis- charged at a given range will in every instance and under all circumstances produce exactly the same super- ficial lesions, or occasion precisely the same extent of cutaneous change from more or less perfect combustion of the explosive; but these variations are still com- 288 INJURIES OF THE BRAIN AND MEMBRANES. paratively slight, and can be estimated with sufficient exactitude. The averages which have been reached in the measure- ment of the degree and extent of superficial lesions were established primarily for pistols and cartridges of the highest grade in use for other than target purposes; but in the instance of each calibre a sufficient number of sub- stitutions was made to demonstrate resulting variations in effect at practicable ranges. vSuch variations were gen- erally trivial. The influence exerted by natural or accidental differences in the physical properties of the external parts, while often appreciable and sometimes considerable, was, in the great number of observations made, still insufficient materially to modify the general conclusions as originally formulated. In all essential par- ticulars these may be regarded as established truths, so far as absolute general laws may be deduced from an aggregation of individual instances. The characteristics of the external wound of exit are in general too well defined to demand formal or extended consideration. This wound is usually larger and more extensively lacerated, and contains a greater amount of disintegrated cerebral and subcutaneous tissue, than that of entrance. Its margin is everted, and everted osseous fragments may often be detected before or after its enlargement for more thorough examination. The ad- jacent cutaneous surface is devoid of marks of flame, smoke, or powder. These conditions are largely indepen- dent of range or calibre, but if calibre is large and range approximates contact, the destructive effects of the ball at exit will be emphasized, and unburned powder which has been driven through the brain may be found through and 19 290 INJURIES OF THE BRAIN AND MEMBRANES. even at the surface of the wound. If in any case doubt may conceivably exist, it may be resolved by comparison with the wound of entrance or by examination of the osseous lesion. The question is pertinent as to how far lesions and indications produced in the post-mortem state correspond with those which are incident to traumatisms in the liv- ing subject. Differences undoubtedly exist, but they are manifest rather in the extent of such changes than in the range at which they occur. In a case of suicide, Xo. CXXXIX. of the annexed series of histories, in which the true skin was charred through its entire thickness, not only the degree but the superficial extent of burn was greater than in any of the cadaveric observations made, but it was still within the determined limit of distance from the wound. In general, burning of the skin occurs within the same limit of range, and is confined to the same area, upon the living as upon the dead subject; but while upon the cadaver it is no more than a mere staining of the surface, or possibly a destruction of the epidermis, during life the true skin may be involved and the whole structure be desiccated and hardened. The number of grains of powder embedded in the skin might very con- ceivably differ with the varying conditions of life and death, but the number of grains deposited upon the sur- face, or the occurrence of smoke stain, which depend solely upon the perfection of combustion within given ranges, should be the same in either event. An exact appreciation of such differences would demand the clinical study of a vast number of cases in which the antecedent conditions of injury could be accurately determined; and which, if it were possible, would obviate the necessity for 292 INJURIES OF THE BRAIN AND MEMBRANES. post-mortem experimentation. The instances of gunshot wounds of the head included in the accompanying series of intracranial injuries suggest no greater discrepancies in superficial appearances than have been indicated when such wounds are inflicted after death. The enumerated alterations suffered by the external soft parts, in structure, or appearance, are not equally con- stant factors in the estimation of calibres or ranges. The more or less forcible extrusion of brain substance through the external wound, or the projection of bone fragments through the cerebral track of the ball, have in this regard no diagnostic value, since they are possible at all ranges with balls of all calibres. The deposition of unburned grains of powder upon the skin or surrounding surfaces, though of great importance when observed, is probably in the great majority of instances in which it has occurred imavailable as a means of determining either of those points in diagnosis. They are so readily displaced and lost upon the surface of the earth or elsewhere, and the body is so certain to have been disturbed before expert examination can be made, that their recognition can be scarcely more than fortuitous, even in the cases in which they have been most abundantly precipitated. So, too, the powder grains which have been driven into the cerebral substance by the force of the explosion, and are readily recognizable in cadaveric experimentation, are so concealed by intracerebral hemorrhage that they are more than likely to escape detection. The smoke stain is very generally washed away, either by external hemorrhage or by the application of water in a sometimes misguided effort to render the appearance of the wounded man pre- sentable upon the arrival of the surgeon or of the under- 294 INJURIES OF THE BRAIN AND MEMBRANES. taker. The original characters of the external wound, finally, are not infrequently changed in an early attempt at exploration and their significance is lost. Notwithstand- ing the slender probability that certain characteristic conditions of pistol-shot wounds which have been specified can be utilized for determining the circumstances under which they have been produced, it may well happen in any case that some one of them may remain sufficiently in evidence to make clear an otherwise doubtful history. Other conditions of such wounds and attendant lesions of the skin which have been subjected to experimental inves- tigation in the cadaver may be reasonably expected to afford, in every instance, either positive or negative evidence of the size of the ball, or of its range. The superficial wound of entrance, though liable to surgical interference and alteration prior to observance of its original characteristics, is oftener left intact for proper medico-legal examination; or, as it may chance, the pecu- liarities of the primary wound may be discerned through the secondary changes which have been made in its ex- tent and conformation. The burning of the hair or skin involves structural changes, and, however trivial it may be, its traces can hardly disappear before opportunity is afforded for their discovery. The grains of powder which are fully embedded in the skin can be removed only with difficulty and by direct design, and their presence or ab- sence must have a definite value in the estimate of every case which demands investigation. The subcutaneous lesions of the scalp, if they exist outside of the track of the ball, involve structural changes which cannot be alto- gether obscured, even by inexpert examination or explora- tion of the wound. MEDICO-LEGAL RELATIONS. 295 It must not be expected that typical cases of pistol-shot wound will be often encountered in which there will be a complete and symmetrical presentation of all the possible superficial alterations which indicate the range at which they were inflicted or the calibre of the ball. Conclu- sions must be reached here as on other lines of surgical inquiry, from the study not of complete pictures, but of fragments, and may be as positive as the much-quoted results which have been similarly attained in the field of comparative anatomy. A single indication may be all that is necessary. The fact that the skin has been scorched is sufficient evidence that, whatever the calibre of the ball, the range of fire has been not more than six inches, just as the ingraining of the skin with powder is that it has not been more than five feet. Confirmation is probable through the presence or absence of some other indication, but without it the single fact, uncontroverted, remains sufficient. Indications of range and calibre may exist which are of apparently contradictory import. Their reconciliation is probably always possible and involves the recognition of the established limits within which their variations may legitimately occur, and, it may be, some experience in their observation. The difficulties which such cases present are not insuperable, and not usually greater than those incident to the solution of other medico-legal problems. It is scarcely possible to overestimate the medico-legal importance which attaches to these anatomical considera- tions connected with the infliction of pistol-shot wounds of the head. The instances in which the ball has passed quite through both cranium and soft parts, and been absolutely lost, or in which the distance it has traversed 296 INJURIES OF THE BRAIN AND MEMBRANES. can be gauged only by the nature of the wound which it has inflicted, or by the traces it has left upon the surface, are of great frequency. Its size or its range, thus indi- rectly determined, may perhaps solve the question of accident, suicide, or homicide ; and the vindication of in- nocence or the punishment of guilt may rest solely upon the possibility of fixing with precision the nature and extent of the superficial lesions, and upon the correct interpretation of the indications which they afford. The grave responsibility incurred by the expression of expert opinion in cases of known or suspected homi- cide can be justifiably assumed only after rigorous inves- tigation and careful consideration of all the anatomical facts and their comparison with established data. Ca- daveric observations, if practicable, might well be made with the pistol which has been the instrument of death, and with cartridges similar to the one it carried ; but it is not certain that more definite ground for opinion will be found in special and, it may be assumed, limited experi- mentation than in the comprehensive series of observations which have been here collated, though its results might conform more closely to the technicalities of judicial re- quirement. If such special experiments are to be under- taken for the elucidation of a particular case, an adequate number of heads should be assured, the use of which may be economized by accepting data already acquired in order to limit the field of special inquiry. The effects of balls upon paper targets are not admissible in evidence, as they are not comparable with those which are observed upon the human skin, and body shots at the same range are not precisely the same in their characters as those in- flicted upon the head. As in no case except with balls of MEDICO-LEGAL RELATIONS. 297 the smallest calibre can more than two or three observa- tions be made upon the same head, and if the ball is of large calibre and is fired at short range probably not more than a single one, and as observations must be largely multiplied to justify positive conclusions, it follows that unless ana- tomical material is fully at command, it is ordinaril}- safer to interpret the phenomena presented in a given case by a comparison with the aggregate results of previous clinical and experimental experience. In case of wounds inflicted by weapons which are now^ of unusual calibre, as 0.30 or 0.25, it will be safe to make the ascertained effects of the approximate standard calibre the basis of comparison. The range at which with a ball of 0.30 cal. the skin ceases to be burned, or at which powder grains are no longer em- bedded, w'ill be less than with one of 0.32 cal., and with a ball of 0.25 cal. the range within which these effects are possible will be somewhat greater than with one of 0.22 cal. The problem to be solved is usually that of the pos- sibility of suicide in cases in which homicide is suspected, and as in homicide the range is usually Avithin that in which suicide is practicable, and Avithin which superficial effects are not essentially diff'erent for approximate calibres, sufficient accuracy will be assured. The number of instances in Avhich cadaveric observa- tion can be made decisive in determining the exact condi- tions under which wounds have been inflicted during life is by no means large, but this restriction cannot be taken as a measure of its value. The absolute certainty that there is no range within which a suicidal bullet wound might not have been homicidal, and that in the vast ma- jority of cases no evidence afforded by necropsy can discrim- inate the one from the other, is in its application to indi- 298 IN'JURIES OF THE BRAIN AND MEMBRANES. vidual cases no less important as a negative conclusion than the positive fact that in certain exceptional cases the wound is necessarily homicidal. It is only by largely extended experimentation that the line which separates these two classes of cases can be accurately defined. Cranial Lesions. The osseous wounds of entrance and exit present certain peculiarities which are invariable, whatever may be the calibre of the ball which has produced them or the range at which they have been inflicted. There are in- stances, not infrequent, in which the cranial lesions may determine both range and calibre, but in general they have few characteristics absolutely indicative of either. The characters which they have in common are an osseous opening larger than the ball and an unequal com- minution of the osseous tables, which has a definite rela- tion to its direction. The wound of entrance is usually not very much larger than the ball, and may thus abso- lutely determine its calibre. The diameter of a circular perforation of the bone made by a ball of 0.22 cal. may be smaller than that of the ball itself of any of the larger calibres; and the diameter of a similar perforation when made by a ball of 0.44 cal. may be larger than any which has been observed with balls of smaller size. Irregular or even circular openings when made by balls of 0.32 or 0.38 cal. are individually indistinguishable from each other, as they may be even from those of 0.22 or 0.44 cal. The direct osseous wound is u.sually made by a fine comminu- tion, but instances are observed in which a circular piece is punched out of the bone and perhaps remains attached to 300 INJURIES OF THE BRAIN AND MEMBRANES. the dura. The wound of exit, in which comminution is more extensive and involves larger fragments, can hardly afford in any case a clew to the calibre of the ball. The unequal comminution of the two tables is not only observed at all ranges and with all calibres, but occurs in all regions of the cranium where two osseous tables exist. At the site of entrance the edge of the external table is sharp and clean cut. while the margin of the internal table, to an extent of }b " more or less, is eroded by fine commi- nution. This erosion of the margin of the inner table has the appearance of having been produced by the gnawing of small teeth or by the use of a fine rongeur, and is very characteristic. At the site of exit, when the bone is not too extensively comminuted for observation, these condi- tions are reversed ; the margin of the inner table is clean cut, and that of the external table eroded. The exact diagnostic value to be attributed to other circumstances of cranial injury may be best appreciated by a study of the results of observation arranged in statis- tical form. I . Cranial Poictration. (a) 0.44 cal. Pistol of most eificient type. 41 observations. 40 penetrations — 40 exits. I non-penetration at range of 30 ft., with the point of incidence just above the supraorbital ridge and with one fragment of the ball wnthin the ex- ternal table. I exit not cutaneous. Ranges, from contact to too ft., inclusive, in frontal, temporal, parietal, and occipital regions. * 302 INJURIES OF THE BRAIN AND MEMBRANES. {b) 0.44 cal. Pistol of inferior type. 34 observations. 19 penetrations. 6 exits, and 4 cases in which without exit the bone was fractured and the ball fell back into the brain, at ranges of contact, 6", 5 ft., and 20 ft. 15 non-penetrations: I at range of i in. i at range of 10 ft. 1 " " " 6 " 3 30 " 2 " " " I ft. I " " " 40 " I " " " 3 " I " " " 50 " I " " " 5 " 3, range not noted. These involved all regions of the cranium. The ranges at which exit occurred were : At contact, i. At 50 ft., i. 3 in- I- " 75 ft., I. 20 ft., I. " 100 ft. I The ranges at which penetration occurred without exit were from contact to 50 ft. inclusive. {c) 0.38 cal. 1 14 observations. 106 penetrations — 75 exits. 8 non-penetrations. Xon-exits: o at contact with 10 observ 2 at range of >^ to i in. with 17 observations. , " " " 3 " 8 " " " 6 " 2 " " " I ft. ations. / 16 304 INJURIES OF THE BRAIN AND MEMBRANES. 2 at range of 2 ft. with 6 observations. 3 " " " 3 ' 8 2 " " " 4 ' 4 2 " " " 6 ' 3 4 " " " 10 ' G " " " 15 ' ' " 2 " " " 20 ' ' " I " " " 25 ' i i* ^ " " " 30 ' * ** 1 3 " 35 " 6 I " " " 40 ' I " u . ^Q . I I " " " 100 ' Non-penetrations. I at range of 2 ft. in parietal region. I " u g ' in occipital " I " " " 10 ' upon temporal ridge. I " " 20 ' in fronto-parietal region. 2 " " " 40 ' in occipital region. I " " 40 ' in parietal I " " 40 ' upon frontal curve. ((if) 0.32 cal. 126 observations. 115 penetrations — 33 exits. 1 1 non-penetrations. Xon-exits: I at contact with 2 observations. 15 at range of >2 in. with 19 ob.servations. 3Q6 IxMJUKIES OF THE BRAIN AND MEMBRANES. 14 at range of 6 in. with 18 observations. 1 1 4 6 I tt. 17 2 " " 12 3 " 6 3/3" " 2 4 " ** .) 5 8 6 " 7 10 " 3 15 " " 2 20 " " o 25 " 5 A large proportion of the exits were not cutaneous. Non-penetrations : I at range of 3 in. in mid-frontal region. 6 " " I ft. " I 3 ' 4 ' 4 ' 5 ' 6 ' mastoid region. " inferior occipital region. tt tt tt tt upon temporal ridge, in mid-temporal region. " posterior parietal region. It will be observed that failure of penetration with this, as with 0.38 cal. usually occurred in regions in which the resistance offered by the cranial wall is greatest, or upon curves which favor the deflection of the ball. * (r) 0.22 cal. 163 observations. 3o8 INJURIES OF THE BRAIN AND MEMBRANES. In a first series of 30 observations there were but 1 1 penetrations, and in 6 of these the dura mater was unin- jured. As all cartridges of 0.22 cal. are rim fire and deteriorate with age, it is probable that those used in this instance were old and in bad condition. In a second series comprising 133 observations, there were 100 penetrations. Both series were at ranges from contact to 25 feet, inclu- sive, and involved the frontal, temporal, and occipital regions, as did the previous observations made with other calibres. In the second series there were : At a range of contact, 5 penetrations in 7 observations. 14 21 15 16 15 12 2 12 15 2 I I There were no exits, and only one instance in which the opposite surface of bone was fractured. The fact of cranial penetration or non -penetration depends not only upon range and calibre but upon con- comitant circumstances of even greater importance. There are pistols of inferior grade with which penetration is always uncertain if not improbable; many of those of 0.22 cal. are of this character, and the cheaper varieties of I m.. 12 3 " 15 6 " 14 I ft.. 13 '■ 1 1 3 " 8 4 " 2 6 " 6 10 " 10 15 " 2 20 " I 25 " I 3 TO INJURIES OF THE BRAIN AND MEMBRANES. 0.44 cal. are scarcely more efficient. In observations made with what is termed an " American bulldog" of 0.44 cal. penetration occurred in but little more than 50 per cent, at all ranges, while in those made with a pistol of the same calibre of the highest grade it failed in but a single instance. It is necessary therefore to found such conclusions as may seem justifiable only upon the results attained in the use of weapons of standard type. The physical characters of the crania assailed, J>cr co/itrci, may be such as abnormally to increase their power of resist- ance. Their density not less than their comparative thickness, and the absence of diploic structure, often ren- der them impenetrable even to balls of large size at short range. The impact of a ball upon a cranial curve, or at an angle of great obliquity, may determine its deflection from the surface. These several considerations make it difficult to formulate any exact rules which may govern penetration for balls of given calibres at stated distances. In general, the larger the calibre of the ball, other condi- tions being the same, the greater the probability of pene- tration. The truth of this proposition is evident from the present series of tabulated results. The influence of range can be less positively stated. It is probable that with any pistol, except it be one of 0.22 cal., penetration rarely fails at contact; that with a pistol of 0.44 cal., of the better type, it always occurs at a range of one foot or less, except in rare instances in which cranial peculiarities or the angle of incidence afford obvious explanation ; and that with a pistol of 0.32 calibre it is practically certain ; but the conditions are too complicated for mathematical expression. The ball has invariably made exit at all ranges when of the best type of 0.44 cal., and never at any range 312 INJURIES OF THE BRAIN AND MEMBRANES. when of 0.22 cal. Exit, like penetration, with balls of 0.32 or 0.38 cal., is influenced by accidental conditions and made to some extent uncertain. The average number of exits with balls of 0.38 cal. is 70 per cent, or more, and with those of 0.32 cal. less than 35 per cent. 2. The Dimensions of Cranial Wounds. Measurements were made of the cranial wounds of en- trance and exit in 308 observations. The wound of entrance was apparently unaffected in size or form by length of range. It was circular in 123. 0.44 cal. — 45 observations. Range, from contact to 100 feet: In 14 obs., diam. \ in. In i obs., diam. V^ in- 4 T6 I n " I " " 5/^ " - I " "I " Total, 22. In the 23 observations remaining, the diameters varied from r XiV'toi" Xi^". 0.38 cal. — 75 observations. Range, from contact to 100 feet: In 18 obs., diam. a^ in. In 2 obs., diam. % in. " 4 " " i " " 3 " " T^ to I in. Total, 2-]. In the 48 observations remaining, the diameters varied from i)i" y. >^" to i3^"x y%". 314 IN'JURIES OF THE BRAIN AND MEMBRANES. 0.32 cal. — 96 observations. Range, from contact to 30 feet : In 16 obs., diam. 3^ in. In i obs., diam. i in. 5 " " i " " 3 '' " ^ 4 " " % " " 3 " — 5_ " 1 6 7 " T6 " I " " ^ " " I " Total, 34. In the 62 observations remaining, the diameter varied from si" X V ^o Ys" X %". 0.22 calibre — 92 observations. Range, from contact to 20 feet: In 24 obs., diam. i in. In 7 obs., diam. ->8 in. a _ (< u 5 <( u T " "7 " 3 T¥ * T6" " 3 " " T% " Total. 40. In the 52 observations remaining, tlie diameter varied from i" X 3//" to Y X Yq" . The number of wounds of entrance which are circular is thus much more than one-third of all those subjected to measurement; those of the remainder which are nearly so add materially to the percentage and do not affect the average of diameters. These circular wounds may be proper!}' regarded as characteristic of the several calibres, while those of irregular form indicate secondary com- minution. In the case of balls of 0.44 cal. the diameter of more than '75 per cent, of circular osseous wounds of entrance is i", or a trifle less; in the case of those of 0.38 cal. it is }i" in 66 per cent.; in the case of those of 0.32 cal. it is also 4^" in nearly 50 per cent.; and in 3i6 INJURIES OF THE BRAIN AND MEMBRANES. the case of balls of 0.22 cal. it is y, or a trifle more, in nearly 75 per cent. The osseous wounds when cir- cular are the result of a fine comminution of bone by the ball in its progress — so line that no part, or an incon- siderable part of it, may be detected in the intracranial cavity. Even if the wound is more than double the diameter of the bullet, no osseous particle of appreci- able size may exist either within or without the cranial opening. In occasional instances, in place of this species of disintegration, a single circular fragment may be punched out and remain attached to the dura mater. It is not impossible that in every case the bone may be suffi- ciently compressible to permit some further enlargement of the wound. The size of cranial wounds of exit is difficult to de- scribe, as they are irregular in outline and as there is no means of discriminating, what may be termed direct from attendant or complicating comminution. The only prac- ticable method of limitation seems to be to regard only those fragments as constituting a part of the wound which are of small size and in immediate relation with the course of the ball. In the 308 observations there are 43 exits, of which the longest diameters are tabulated : a. 0.44. cal. In I obs.. diam. 2 in. X I 2 " X 3 2 " X I iy2 " X I ^y " X 4 '><" X m, i^ " 3i8 INJURIES OF THE BRAIN AND MEMBRANES, In 3 obs., diam. i m. X X J m. 3/ " Total, 17. /; 0.38 cal. In I obs., d iam. 2 in. X ly ir (( I It tt 134 " X -^" u I I (( It i>^" 15^ " X X ^y- " I t< " ly^ " X I " " 5 «t n i>^" X I " It 2 ti ♦' i>^ " X I^ " <( I It a i/^ " X 3/" " I " n ly,- X I " (< I I a tt ly " I X X I " I " Total, 16. c. 0.32 cal. In I obs., diam. 2 in. X H in u 1 " i>^ " X ^y^ n 2 11 i>^ " X I '• a I ti ly " X y << 2 ii 15^" X 1 (( I ti I X I " << 2 " I X y " Total, 10. d. 0.22 cal. No exits occur; in only a single instance the bone was fissured by the impact of the ball at a point opposite its entrance. MEDICO-LEGAL RELATIONS. 319 The size of the osseous wound of exit is not materially influenced by the length of range, and while its average Pig. 38.— OU4 Cal. Range, 6". Osseous Wound of Entrance through External Table is somewhat increased with the calibre, the differences are insufficient to be of value in the determination of doubtful cases. 320 INJURIES OF THE BRAIN AND MEMBRANES. 3. Cranial Coinniinutioti and Fissuring. Comminution or fissuring of the skull may occur either at entrance or at exit, or at both points at once. The com- minution of the wound of entrance usually consists, where the bone is thin, as in the temporal fossa or squamous region, in a limited and unimportant breaking down of the immediately contiguous part; and where the bone is thicker in a slight scaling of the external table. The de- struction of bone at the exit is likely to be much more considerable. The fissures which are produced may be quite as extensive when beginning at the point of entrance as at the point of exit. The minute fissures which may radiate for a little distance from either wound, of scarcely more than capillary size, are not reckoned in the tabula- tion. 0.44 cal. Range, from contact to i " : Entrance, 8 observations, 5 fissured. Exit, 7 " 3 " 3 comminuted. Range, from 3" to 6" : Entrance, 5 observations, i fissured, 2 comminuted. Exit, 5 " I " I Range, from i foot to 6 feet: Entrance, 9 observations, 5 fissured. Exit, 7 " 5 " I comminuted. Range, 10 feet: Entrance, 2 observations, 2 fissured. Exit, 2 " I " 322 INJURIES OF THE BRAIN AND MEMBRANES. Range, from 15 feet to 30 feet: Entrance, 8 observations, 7 fissured. Exit, 6 observations, 2 fissured, 2 fiss'd and com'd. Range, 40 feet: Entrance, i observation, no fissure or comminution. Exit, same observation, fissured. Range, from 50 feet to 100 feet: Entrance, 3 observations. 2 fissured. 3 comminuted. Exit, 3 " 1 " 2 " 0.38 cal. Range, from contact to i": Entrance, 17 observations, 4 fissured, 4 comminuted. Exit, 14 " 4 " Range, from 3" to 6": Entrance, 14 observations, 6 fissured, 1 comminuted. Exit, 10 obs., 2 com'd, i fiss'd and com'd. Range, from i foot to 6 feet : Entrance, 19 observations, 12 fissured. Exit, 12 " 4 " 3 comminuted. Range, 10 feet: Entrance, 4 observations, 3 fissured. Exit, 10 " 1 Range, from 15 feet to 30 feet: Entrance, 5 observations, 4 fissured, i comminuted. Exit, 4 observations, i fissured, i fiss'd and com'd. 324 INJURIES OF THE BRAIN AND MEMBRANES. Range, 40 feet : Entrance, i observation, i fissured. Exit, same observation, fissured. Range, from 50 feet to 100 feet: Entrance, 4 obs., i fiss'd, i fiss'd and com'd. Exit, 2 " (at 50 ft. and 100 ft.), both com'd. 0.32 cal. Range, from contact to 1": Entrance, 22 observations, 5 fissured, 4 comminuted. Exit, 5 " I " I Range, from 3" to 6": Entrance, 18 observations, 4 fissured, 3 comminuted. Exit, 9 " 4 " I Range, from i foot to 6 feet: Entrance, 43 observations, 10 fissured, 8 com'd. Exit, 18 " 2> '' 7 '' Range, 10 feet: Entrance, 5 observations, o fissured, 2 comminuted. Exit, 3 " 2 " o " Range, from 15 feet to 20 feet: Entrance, 8 observations, 4 fissured, i comminuted. Exit, 3 " 2 " o " Range, from 25 feet to 30 feet: Entrance, 5 observations, 1 fissured, 2 comminuted. Exit, 2 " 2 " 0.22 cal. Range, from contact to i": Entrance, 14 observations, 3 comminuted. ^ 326 INJURIES OF THE BRAIN AND MEMBRANES. Range, from 3" to 6": Entrance, 25 observations, no fissure, no com'n. Range, from i foot to 6 feet: Entrance, 42 observations, 10 comminuted. Range, from 9 feet to 10 feet. Entrance, 8 observations, 3 comminuted. Range, from 15 feet to 20 feet. Entrance, 12 observations, no fissure, no com'n. In wounds of entrance made by balls of 0.22 cal. it will be noted that there is no fissuring of the bone, and that comminution is absolutely or relatively small. In case of other calibres of ball, fissuring is only exception- ally extensive at either entrance or exit, and unless at contact is governed rather by the physical properties of the crania than by range. The amount of positive information to be derived from the observation of cranial lesions is limited, but may be important, both intrinsically and as confirmatory of that afforded by the changes wrought in the superficial struc- tures. The further inferences which they may warrant, though not authoritative in elucidating the history of doubtful cases, may so materially strengthen probabilities already established by external examination as to give to them the semblance of certainty. Intracranial Lesions. In the investigation of the conditions under which pis- tol-shot wounds involving the cranial cavity have been produced, cadaveric observation is of only confirmatory MEDICO-LEGAL RELATIONS. 327 value. It is impossible to determine how far post-mortem changes in the brain structure or in its membranes may modify the characters of injuries experimentally produced, and this uncertainty is sufficient to vitiate any conclusions they might otherwise suggest. The cadaveric changes in the brain are undoubtedly rapidly destructive and attended by marked alteration in its physical properties. Its power of resistance is lessened by a process of softening and dis- integration, and at the same time the elasticity of its fibrous covering is probably lost, as it is known to be in other dead tissues of similar character. The first prop- osition may be assumed from common observation, and the second is illustrated by the course of balls of 0.22 cal., which in the living subject so often penetrate the cranium and traverse a considerable distance beween it and the un- injured dura mater, and in the cadaver, having penetrated the bone, rarely fail to enter the brain. The course of the ball through the living structures, therefore, cannot be in- ferred with even reasonable certainty from post-mortem experimentation under analogous conditions. Fortunately it is practicable to determine the characteristics of intra- cranial pistol-shot lesions from their necropsic inspection when inflicted during life, since the possibility of acci- dental disturbance or alteration %Yhich attaches to the pe- culiarities of the external wound is averted in consequence of their inaccessible situation. The number of recorded instances in w^hich attention has been directed to this class of intracranial lesions is not large, and these have been in great part scattered through the history of criminal proceedings. The records of the coroner's office in New York, which ought to afford a vast amount of surgical information of this nature, register only 328 INJURIES OF THE BRAIN AND MEMBRANES, the simple fact of death from pistol-shot wound of the head. The present collection of cases of intracranial injury includes forty of pistol-shot origin, which is perhaps an adequate number for the purpose of medico-legal, if not of clinical conclusions. The three points which it may be of medico-legal im- portance to determine in case of pistol-shot wounds are the calibre, range, and direction of the ball. The calibre of a ball inaccessibly located in the cranial cavity during life, or lost upon exit whether before or after death, must in general be inferred or demonstrated, if at all, from conditions of the external and osseous wounds- which have been already indicated. The lacera- tion of the brain substance produced by the passage of the ball presents no differences in character or extent which serve to measure its size with any useful degree of pre- cision. In general, the larger the ball the wider the area of laceration which attends its course, but as it may be driven forward either with or without change in its axis^ its track may approximate in width either its transverse or its longitudinal diameter and the value of this distinction be lost. In a minority of cases in which the ball is excep- tionally large or small, the greater or lesser extent of lac- eration may be sufficient in itself to determine positively the question of calibre. The cerebral track of a ball of 0.22 cal. may be, and usually is, too minute to have been conceivably made by one of any larger size; the corre- . spending track of a ball of 0.44 cal. may be too wide to have been possibly made by one of 0.22 cal., and, range and attendant conditions of the cranial and external wounds taken into consideration, too wide to have been MEDICO-LEGAL RELATIONS. 329 probably made by one of intermediate size ; but with balls of 0.32 or 0.38 cal., in regard to which, by reason of more general and almost equally frequent usage the distinction becomes most important, it is impossible to make. • . The absolute extent of brain laceration greatly varies. The wound made by a ball of 0.22 cal. may be of such te- nuity that it is difficult to trace beyond the beginning of its course, and in necropsic examinations it may become necessary to abandon the effort and to locate the position of the ball except by minute dissection of the entire organ. If the ball has been one of larger calibre, the area of laceration is from 33" to i" in diameter, the brain tissue is disintegrated and mingled with minute coagula, or the cavity which has been formed is more rarely filled with a single coagulum through its whole extent. Its width can be most accurately appreciated by incising' the brain at right angles to the plane of its general direction. If in- cision be made through its long axis, a gaping wound is displayed of deceptive size, which becomes larger with every • disturbance of the parts. Along its margin the punctate extravasations and local discoloration of the lim- ited form of contusion may be often noted. The concomi- tant lesions, the general oedema and hypersemia of general contusion which is characteristic, and the several forms of hemorrhage which are accidental have no significance in this relation, and no inferences can be derived from the depth to which the ball may penetrate. The range or the distance traversed by the ball from the point of discharge from the weapon to the point of impact cannot be estimated even approximately from an examina- tion of the cranial contents. One or two exceptions may be made to this general statement. At contact, or within 330 INJURIES OF THE BRAIN AND MEMBRANES. a range which approximates it, the dura may be torn or destroyed, and the contiguous brain substance irregularly lacerated to an extent which is not observed at greater dis- tances. It has been stated in a previous section that in wounds inflicted upon the cadaver, at ranges of six inches or less, grains of powder may be detected upon the con- tiguous surfaces of the cranium and dura or in the course of the cerebral laceration ; but it has been also noted that in wounds inflicted during life hemorrhage is sufficient to make the appreciation of this indication improbable. Aside from these exceptional instances, in which external appear- ances are corroborated by some circumstance of internal injury, there are no conditions of the intracranial wound which help to establish even a probability in estimating length of range. At all distances, from contact to limit of observation, the ball may traverse the whole extent of the brain in any of its diameters. The thickness or density of the skull, the point of impact, or the angle of incidence are much more influential than range in determining not only the depth of penetration but also the amount and character of laceration. The direction in which the ball has been projected is readily determined in those cases in w-hich after penetrating the cranium it has overcome the elasticity of the dura and entered the brain. The resistance offered by the bone does not deflect it from its course, and the passing of a probe through the superficial and cranial wounds into the beginning of the cerebral track establishes a line which in its continuation is the one which the ball has traversed. If the bone has not been penetrated, or the dura has re- mained uninjured, it is impossible to ascertain with either certainty or precision the course the ball has taken. MEDICO-LEGAL RELATIONS. 33 I At ranges short enough to afford marks of smoke, fiame, or powder upon the surface, their limitation in some in- stances to a single aspect of the wound may indicate in a general way, as may subcutaneous fragments of lead car- ried beyond the osseous entrance, the side from which the ball has been discharged. At longer ranges no infer- ences as to direction can be made unless a cerebral track exists. The general study of pistol-shot wounds of the head, by means of extended experimentation upon the cadaver, has afforded a definite amount of positive information. It has been equally fruitful of negative results of no less positive value. The certainty that a questionable medico-legal fact cannot be determined by the presence or absence of given post-mortem conditions may be quite as important as the demonstrably necessary dependence of the same conditions upon some other circumstance of injury. It may be of even greater importance to recognize fully the impossibility of solving a question of suicide or homicide than to be able positively to infer the calibre of the ball or its approximate range. The uncertainty which, in the absence of previous investigation, has existed as to just how far the circumstances under which a wound has been inflicted can be legitimately inferred from post-mortem phenomena, has led to the expression of dogmatic opin- ions which have been altogether unwarranted. Conclu- sions, largely theoretical, and more or less based upon un- due generalizations from scanty observation, and exploited as demonstrated facts, are not rare in the records of crim- inal procedure. The preceding observations will be of use, therefore, not only as they indicate just what post- mortem appearances can fix calibre, range, or direction, 332 INJURIES OF THE BRAIN AND MEMBRANES. with that absolute certainty necessary to criminal investi- gation, but also as they serve to fix the limit at which knowledge ends and conjecture begins. The practical combination of positive and negative indications for the interpretation of particular cases, the reconciliation of ap- parent discrepancies in certain instances, the utilization of the material collected, properly concerns the formal writer upon medical jurisprudence. It is the present purpose to aggregate, compare, and generalize the facts noted, rather than to direct their application. The total number of observations made upon the cada- ver in this study of pistol-shot wounds of the head is slightly in excess of one thousand, exclusive of those made upon the body and extremities. Many of these in- dividually included an examination of all the extracranial, cranial, and intracranial lesions; others were limited to such larger or smaller proportion of their number as cir- cumstances might permit; and some did not extend beyond the observation of an isolated fact. A single head could sometimes be utilized for a number of shots if the ball was of small calibre or if the range was long, or it might be serviceable for not more than a single one if the calibre was large and the destructive effects were great. The illustrations which accompany the text are of life size and are from photographs taken immediately after the wounds were inflicted. They are, therefore, exact repro- ductions of what was observed in these specified instances. Those of them which concern the external parts are con- fined to short ranges, since at greater distances there are no other superficial lesions than the cutaneous opening, which is not characteristic. The osseous wounds which are represented were selected nearly at random from those MEDICO-LEGAL RELATIONS. 333 in calvaria collected from this series of observations and now in the Wood Museum of Bellevue Hospital, and are intended to show the characters of such injuries in both the external and internal tables, at entrance and exit, in- dependent of range or calibre. Chapter VIII. SURGICAL RELATIONS. SYMPTOMATOLOGY, The surgical history of pistol-shot wounds of the head is largely included in that of the general class of intra- cranial injuries to which they belong. It involves the same lesions: fractures of the cranial base and vault, gen- eral contusions and lacerations of the brain, and epidural, meningeal, and cortical hemorrhages, which are peculiar only in the fact that they are always direct, and never the result of indirect violence. It presents essentially the same symptoms, general and localizing, which are pro- duced by other traumatisms affecting the same parts. Its questions of diagnosis, prognosis, and treatment are to be solved in accordance with the significance of symptoms upon lines already established, and differ only as they are modified by the lodgement of a foreign body in a perhaps unknown and inaccessible part of the brain or cranial cavity. It is sufficient therefore in the special considera- tion of this form of intracranial traumatism to regard simply such points of difference as may obtain in conse- quence of the introduction of this additional element in the case. * The number of such wounds included in the present SURGICAL RELATIONS. 335 series of intracranial injuries is limited, and in but few in- stances has life been sufficiently prolonged to necessitate raising a question of either localization or treatment. From 1879 to 1S95 inclusive there have been recorded in more or less detail in the British, Colonial, and American journals and transactions of societies, one hundred and forty-five cases in which patients have survived the pri- mary shock of pistol-shot injury involving the cranial cav- ity, of which one hundred and ten have been accessible for comparison. The aggregate number of these pub- lished cases, with the addition of those in the appended series in which death was not immediate or was not too early to permit the notation of symptoms, or the consider- ation of prognosis or treatment, is one hundred and thirty- six, and it is believed affords a sufficient basis for general- ization and to warrant the conclusions formulated in the present study of the subject. The tabulated collections of pistol-shot or other gunshot intracranial wounds which have been previously made in skeleton form for statistical purposes are so wanting in essential elements of compari- son as to be practically valueless for the solution of prob- lems in diagnosis or treatment. Pistol-shot wounds of the head, unlike those produced by arms of longer range or greater power, rarely occasion serious injuries without having penetrated the cranium. Fragments of shell, spent rifle balls, and various missiles, by which gunshot wounds are otherwise inflicted, may fracture the cranium or lacerate the brain without so much even as breaking the skin : the lesions are then not differ- ent from those occasioned by other means of violence, and their svmptoms and termination are in no wise peculiar. A pistol ball, on the contrary, never causes a simple frac- S3^ INJURIES OF THE BRAIN AND MEMBRANES. ture, and rarely a compound fracture which is more than nominal, unless the bone is also penetrated. If the ball is of 0.2 2 cal. it may even penetrate to the dura without cerebral lesion; if it is of a larger calibre, there is no reason to believe that its simple impact upon the bone has ever been attended by intracranial complications. In only exceptional instances a compound fracture without penetration has entailed consequences of a serious character. In a case reported by Mr. Butcher, remarkable in various particulars, a compound depressed fracture of the frontal bone and a subsequent osteogenic process, oc- casioned by the discharge of a pistol loaded only with powder and hard wadding, produced epilepsy and absolute imbecility through a circulatory disturbance. The same effects might legitimately follow in any case in which a bullet had penetrated only the outer table and depressed the inner one, if remedial treatment were not employed. It is always possible also that a non-penetrating compound fracture, even though a simple fissure, in the absence of aseptic precautions whether from neglect or from an inac- cessibility of position, should afford a channel for intra- cranial septic infection. This accident will hardly occur in fractures of the cranial vault, but is not unknown at the base in regions where the bone is thicker and its vascular spaces are larger, or where the peculiarity of its situation prevents discovery or effective approach. There is a re- corded instance of such an intracranial infection from pistol-shot wound, in which a suppurative arachnitis re- sulted from the lodgment of a bullet in the petrous por- tion. There is a similar case in which two rifle balls were embedded in the basilar process and led to gangrene of the dura mater, epidural abscess, and suppurative meningitis. SURGICAL RELATIONS. 337 It may be fairly stated that in a pistol-shot wound confined to the soft parts and cranial vault this complication can occur only through a neglect of the most ordinary aseptic care. If the bullet, of whatsoever calibre it may be, pene- trates the brain, the lesions it causes are still contusion, laceration, and hemorrhage, and the general symptoms are still those which pertain to such conditions, however they may have been induced. The characteristic initial symptom of this variety of intracranial injury is in the serious cases likely to be espe- cially prominent. The unconsciousness, which is never absent in those which are immediately fatal, is of a re- markable profundity. It is in part explicable by the gen- eral contusion which is a factor in the production of pri- mary unconsciousness in all cerebral lacerations, and is continued and deepened by the often profuse immediate cortical hemorrhage. An additional cause of this condi- tion, and a possible explanation of its depth, may be found in a cerebral shock due to the directness and magnitude of the destruction of the nerve centres. This is apart from material change or the intervention of the sympathetic or spinal ganglia, and is rather akin to the effect of emotional shock as exemplified in the sudden and entire abolition of consciousness from an extremity of grief or horror. This distinction is in a measure recognized by Dana, who, hav- ing defined shock as a "sudden depression of the vital functions due to nervous exhaustion following an injury or a sudden violent emotion," divides it accordingly into "corporeal" and /'psychic." In this instance the injury is corporeal, but it is inflicted directly upon the cerebral ganglia, and its effect is manifested without the impulse 338 INJURIES OF THE BRAIN AND MEMBRANES. having been transmitted to the sympathetic system, the irritation of which, as shown by Boise, is the immediate cause of the contracted arterioles, pallid skin, and rapid pulse which characterize the shock of bodily injury. If the profound unconsciousness is to be ascribed solely to the general cerebral contusion, or, as that lesion is inter- preted by Von Bergmann, to the suspension of general cortical activity from circulatory disturbance, it presup- poses a greater derangement of cortical circulation than results from other forms of violence or is indicated by necropsic examination. In this state of unconsciousness, death may ensue almost if not quite instantaneously, or after an interval of hours or even minutes. Aside from an abundant hemorrhage which issues from the external wound and is of frequent occurrence, and the changes in pulse, temperature, and respiration, this is the entire clinical history of a large majority of cases. If the pulse is primarily diminished in frequency, the change in this direction is so transitory that it is a necessarily inappre- ciable symptom. In those cases in which consciousness has not been in- stantaneously abolished, it is not often possible to ascertain the immediate subjective symptoms. Suicidal subjects are indisposed to speak of the circumstances which at- tended the infliction of their injury, and in many in- stances acute mania, alcoholism, or innate stupidity has prevented its appreciation, but it has been occasionally chronicled. In the case of a man who shot himself in the vertex and lacerated the longitudinal sinus without impli- cating the brain, it was described by him as a sensation like an electric shock followed by paraplegia and a brief period of unconsciousness. A woman who shot herself in SURGICAL RELATIONS. 339 the mastoid process without penetrating the cranial cavity experienced excruciating pain. A youth whose right frontal lobe had been traversed by a bullet found his imme- diate sensations to be those of pain in the ear and vertigo. Another man, in whose right frontal lobe the bullet was deeply embedded, felt at the instant of pulling the trigger a sense of general numbness and then of deep-seated pain in both ears. In still another case of pistol-shot wound of the frontal region, in which both lobes had suffered exten- sive laceration, the suicidal person was enabled long after- ward not only to analyze his thoughts at the moment the injury was inflicted, but to recall the impression upon his mind of the almost simultaneous shriek of his mother from an adjacent room. He was suffering from melan- cholia with a feeling of oppression in his head, which was the immediate incentive to self-destruction. The act was deliberate, and, while he was not unmindful of his family, the discomfort he felt in the top of his head was, as he ex- pressed it, "uppermost in his mind." He remembered his mother's cry at the report of the pistol, but had no further definite recollection of what occurred till he " awoke" twenty-three days later in the infirmary to which he had been removed ; and yet for the first two weeks he was apparently rational and in full possession of all his intellectual faculties. After a subsequent period of mental disorder with delusions and paroxysms of acute mania he was apparently quite recovered at the end of the fifth month (Sloane). This case, which was recorded with unusual care by his medical attendant, demonstrates that even with ex- tensive destruction of the psychical centres neither the perceptional nor the ideational powers are necessarily 340 INJURIES OF THE BRAIN AND MEMBRANES. suspended for the minutest conceivable measure of time. The cry was heard and its source recognized, which in- volved a reasoning process, in the time required for sound to traverse twice the distance between two adjacent rooms ; for, as instinct is even quicker than thought, no appreci- able interval could have intervened between the mother's perception of the report of the pistol and her instinctive response. This history parenthetically illustrates the unsuspected enfeeblement of will and incapacity of judgment which may really exist in a case of apparently simple melan- cholia, and in this instance permitted the man to believe that an absurdly trivial ill so far transcended all the obli- gations and interests of life as to make it not worth the living, and left him powerless to restrain his suicidal im- pulse. His later mental condition was in one respect anomalous. In the period immediately succeeding the injury it was believed to be absolutely normal. After a consecutive longer period of acute mania and apparently settled aberration, his mind was permanently restored, ex- cept that his memory was wanting so far as it concerned the previous rational interval. It is usually the remem- brance of events directly connected with the infliction of a grave cerebral injury that is temporarily or permanently lost, and subsequent events, if forgotten for a time, are re- called before the reparative stage is ended. In the case of this patient, memory was perfect for everything that had been felt or done until an instant after the wound was in- flicted, and partially retained for occurrences during the maniacal episode, but a hiatus was complete as to the rational period which intervened between the condition of melancholia and the access of mania. How far his aber- SURGICAL RELATIONS. 341 rations depended upon traumatism and how far upon the progress of his prior mental infirmity, it is of course im- possible to decide. These phenomena scarcely belong to the consideration of the primary symptoms of pistol-shot wounds of the brain, but are not altogether impertinent, in view of the relation which so frequently subsists between such wounds and mental disorder. If the first effects of injury be survived, there is no es- sential variation in the course of symptoms as it has been noted in the general class of brain lacerations. Conscious- ness is perhaps less frequently retained, vomiting of rather more frequent occurrence, and pain in the head more severe. Death may result from the continuance of intracranial hemorrhage, or from the direct inhibitory action of laceration and attendant general contusion upon the vital cerebral functions. In a much smaller propor- tion of cases these dangers are safely passed only to give place to others, scarcely less formidable, which attend retrograde nutritive changes in the cerebral tissue. Soft- ening and abscess with paralysis, mental deterioration, and epilepsy may follow in the course of time, with their usual symptoms in no degree modified by the nature of the original traumatism. The localizing symptoms which may be at any time manifested, in consequence either of limited lesions in the track of injury or of the presence of the ball at the point at which it is lodged, equally conform, to rule as established in the general symptomatology of intracranial injuries. 342 injuries of the brain and membranes. Diagnosis. The problem of diagnosis distinctively concerns but a single point, the location of the bullet when it still re- mains within the cranial cavity. The nature of the trau- matism, the circumstances under which the wound has been inflicted, the point at which the cranium has been penetrated, and the direction which the missile has taken, have all been elucidated so far as it has been possible, in the study which has been made of the external wound in its medico-legal relations, and are independent of intra- cranial conditions. The character and extent of the lesions produced by the bullet in its passage through the brain and appendages can be determined by no different means than have heretofore served for the estimation of similar lesions of different origin. As they have been manifested by the same symptoms in either case, they must be recognized, if at all, by giving these symptoms an identical interpretation. The location of a bullet which has failed of exit alone demands special diagnostic consid- eration, and involves the employment of special methods of investigation. It is sometimes easily accomplished, oftener with difficulty, and oftener still it is impossible. Any effort directed to this end is necessarily deferred un- til the immediate safety of the patient is assured. If, after the partial restoration of consciousness, localizing symp- toms become apparent which can be disassociated from lesions caused by the bullet while still in motion, they are practically pathognomonic. The occurrence of limited paralysis upon the side of the body corresponding to a wound of entrance, for example, in the temporal region, with the corroboration which might be afforded by the SURGICAL RELATIONS. 343 axis of the cerebral wound, would point with great cer- tainty to the lodgement of the bullet in a designated part of the motor area. In like manner the existence of motor or sensory aphasia, or at a later period the occurrence of certain disorders of vision, might equally indicate its loca- tion in a definite part of a speech or visual area. The in- stances in which dependence may be placed upon cerebral localization are after all comparatively infrequent. The extent of cortical area which as yet must be regarded as latent or of indeterminate function is so great, and the further probability that the bullet will rest in some sub- cortical region is so strong, that such aid is hardly to be expected. In another small proportion of cases a clew to the position of the bullet may be had in a discoverable in- jury to the opposite wall of the cranium. This may be more or -less evident ; the scalp may be contused above it or the bone obviously elevated, or there may be only a tender spot, beneath which after incision some fine fissures may be detected. The shaving of the head, which is prac- tised as a part of the routine of treatment in all intra- cranial injuries, permits careful examination, and will probably insure the discovery of any lesion which in- cludes the external table. The main reliance of the surgeon in this investigation must be upon the use of the probe, by which it is sought to trace the bullet from its osseous entrance to its point of lodgement. This method of exploration of gunshot wounds as they affect important visceral cavities has been much and properly criticised, but the procedure is in itself proper, and the limitations to which it is subject concern the consideration of treatment rather than of diagnosis. The instrument is variously adapted to its purpose; the 344 INJURIES OF THE BRAIN AND MEMBRANES. ordinary one of silver which is employed for general sur- gical exploration is supplemented by those of Fluhrer, Nelaton, and Girdner, Fluhrer's probe, like the one in more common use, is designed for general exploration, but is differently constructed. Nelaton 's and Girdner's are both intended not only to detect the presence of a foreign body in the tissues but to determine its metallic character. Fluhrer's probe is so fashioned as to obviate some of the disadvantages which are found to attach to the use of the commoner instrument. It is of large size, tapering toward two bulbous extremities ; it is twelve inches long, and in diameters one-eighth of an inch at its middle, and one-fourth and one-eighth of an inch respectively in its larger and smaller terminal bulbs. Its shaft is rigid, and its weight is lightened by the use of tempered aluminium in place of silver. The ends are made large in order to diminish the danger of wounding the tissues and of making false passages ; the shaft is made rigid in order that its relation to the bulbous ends shall be fixed ; and its weight is made light in order to transmit without loss delicate vibrations to the hand. The probe of Nelaton, by reason of its capability of re- ceiving and retaining a lead stain, has been long used to determine the fact that a foreign body is a leaden bullet. It is a simple ball of unglazed porcelain at the end of a flexible silver stem ; it may be of any size, but is usually of about one-eighth of an inch in diameter. It acts as an ordinary probe in detecting the foreign substance, and specifically determines its nature by acquiring or escaping the peculiar stain of lead as the two substances are firmly pressed or rubbed together. The porcelain will be stained always if actual contact can be obtained ; but the practical SURGICAL RELATIONS. 345 difficulty and possible source of error lies in the fact that this contact cannot be positively assured. It is found in practice that the surface of the bullet may be so protected by blood and shreds of tissue, and the surface of the por- celain so smeared by the fluids of the part, that while the impact upon a hard body may be evident the character- istic stain may be wanting. The positive evidence which it affords is unquestionable, but its failure to demonstrate the presence of lead does not equally prove that the hard body felt is not a bullet. Girdner's telephonic probe, which is of comparatively recent introduction, like that of Nelaton, acts as an ordi- nary probe, and at the same time, when the foreign body embedded in the tissues is a bullet, demonstrates its metal- lic nature by the grating sound produced from the inter- ruptions of an electric current established through it, the circuit being formed by tlje probe in the hand of the oper- ator, a battery, and a bulb in the mouth of the patient. Every precaution of course must be taken to insure the continuity of the current except as it is broken upon the surface of the concealed object when the end of the instru- ment passes over its inequalities. The receiver is held to the ear with one hand, while the probe is guided with the other. This instrument is now sufficiently well known to require no more detailed description. If contact be made with the alien substance, it cannot fail positively to deter- mine whether or not it be the bullet, and in this has mani- fest advantage over the device of Nelaton. There can be no doubt of its value in gunshot wounds of other regions of the body, as in the extremities or in the neighorhood of the spinal column, when to decide this question is to de- cide the question of operation. It has less practical im- 346 IN'JURIES OF THE BRAIN AND MEMBRANES. portance in case of brain wounds, in which a fragment of bone carried into the substance of the organ may be as much a menace to life as is the bullet itself. In the nu- merous instances in which the position of a foreign body cannot be determined it can be of no avail, because contact is an essential condition. Its usefulness is limited, there- fore, not only since it does not necessarily make the sur- geon's position clearer as regards the propriety of opera- tion, but as it fails of even the possibility of very general application. In wounds of the basilar and mastoid proc- esses, and of the petrous portion, or when the bullet has lodged in the basic fossae without having penetrated the dura, or in the orbit, it may be of the greatest service. If it were possible for the electric current to make manifest the vicinage of a bullet to which it could not quite be made to reach, it might more nearly solve one of the still difficult problems in surgery. It has been sought to deter- mine in this way the location of bullets in the brain, as well as elsewhere, by means of an instrument known as the induction balance. In the opinion of Dr. Girdner, who has given it much attention, this mechanism is so delicate in construction and so easily deranged that it can be made effective only in the hands of a professional electrician. It would seem, therefore, that it must take its place with other surgical appliances of theoretical value which are too complex for practical general use. If the cerebral wound be large, and especially if not too deep, the finger, when confined within the limit of lacera- tion, may prove the best instrument of exploration. The use of the Rontgen rays for determining the posi- tion of a bullet within the cranial cavity has thus far been attended with little success. Two cases have been re- SURGICAL RELATIONS. 347 ported by Dr. A. Eulenberg during the past year (1896), in which by a new process of Dr. Buka, of Charlottenburg, the location of the missile seems to have been demonstrated. In both instances a wound had been inflicted in the right temporal region by a pistol shot of small calibre. In one of them exposure to the rays was made a few weeks after injury, and in the other not till after the lapse of ten years. In one, symptoms indicated lesion of the right side of the brain, and in the other no such localizing indica- tions existed. The only apparently successful instance of the employment of this process for the detection of a bullet in the brain, which has been reported in America, is one occurring in the service of Dr. Willy Meyer in the Ger- man Hospital of New York. The patient, whose early history is recorded in Case CCC. of the appended series, was some time after his discharge from Bellevue Hospital, and at a date later than that of Eulenberg's cases, sub- jected by Dr. Meyer to the Rontgen test, with the dis- covery of three minute objects in the frontal lobes, and in line with each other, two of which were believed by him to be fragments of the bullet. In neither of the cases re- ported by Eulenberg or Meyer was the result verified by subsequent operation or necropsic examination. The subject of the case last mentioned again became a patient in Bellevue Hospital, but was for various reasons deemed unfit for operative interference. It is not improbable that the development of this form of photography may in the future add greatly to the cer- tainty with which intracranial foreign bodies can be dis- covered and their position accurately determined ; it seems less certain that by thus increasing the possibility of posi- tive diagnosis it will equally add to the resources and sue- 348 INJURIES OF THE BRAIN AND MEMBRANES. cess of treatment. Increased perfection of method and apparatus will tend to remove it still farther from the uses of private practice, except in cases in which recovery has been had from the immediate effects of injury. In hos- pitals, where it might otherwise be available, the condition of the patient will be likely to preclude its employment at the outset, w^hen operation, if not imperative, will at least afford the best prospect of a successful issue. If the mis- sile or fragment of bone is superficially situated, it should be discovered and removed at once without the necessity of resort to other than ordinary means; if more deeply embedded, and undiscovered at the time when exposure to the light rays has become practicable, success in the dis- closure of the bullet will still leave special operative diffi- culties to be encountered. The original cerebral wound will probably have been closed, and after the exact loca- tion of the bullet has been fixed at the intersection of dif- ferent planes of view, it may be far from easy to utilize this conception in the mind of the operator for making a new and lengthened incision with the precision which is essential for the justification of so serious a procedure. It is idle, however, to speculate upon the practical applica- tion of as yet unattained results in scientific progress ; new conditions may conceivably involve the use of more facile and widely applicable instrumentalities, but at the pres- ent time no demonstrated advantage has accrued in this department of surgery from the Rontgen process of pho- tography. A final diagnostic method consists in thrusting a sharp needle into the cerebral tissue, not quite at random, but in directions which there may be reason to suppose the bullet has taken. If perfect asepsis has been secured, this SURGICAL RELATIONS. 349 may ordinarily be done with safety and the bullet possi- bly discovered. It is a legitimate procedure, recognized in general cerebral surgery, but should be resorted to advisedly and with great discretion. If the bullet cannot be reached through the cerebral wound, and there are at the same time localizing general symptoms or other indi- cations which point to its approximate position, it may be properly sought in this manner, but reckless punctures of the brain which are uninspired by some intelligently directed purpose are scarcely justified by the slender chance of their accidental success. These several methods of search, guided by the obser- vation of existing localizing symptoms or of indications of injury to the opposite cranial wall, are the only means available for the discovery of the bullet. Their successful use requires not only manual skill, but quickness of percep- tion and sagacity of interpretation in the study of the often obscure attendant conditions. It has been assumed that the bullet in its passage through the brain is likely to be diverted from its direct course by trivial obstacles, as is known to be the case in the extremities or in certain regions of the trunk. This con- tingency is in fact less to be expected within the cranial cavity than elsewhere. The density of the brain substance is very much the same from one surface to another, and it is found in both ante-mortem and cadaveric wounds that the reflections of the dura mater are usually penetrated without the direction of the bullet having been changed. There are not wanting instances in which it has been de- flected by the falx cerebri, or in which, having entered a dural sinus, it has traversed it to the end, but these are exceptional. It is nevertheless the fact that in a consider- 350 INJURIES OF THE BRAIN AND MEMBRANES. able proportion of cases the bullet which fails of exit is turned aside from its direct course. The change im- pressed upon its direction is due, not to deep intracranial obstruction, but to the resistance offered by the cranial wall and dura mater at its entrance, or by the same structures upon which it may impinge at a point upon the opposite side of the head. A bullet, especially if of small size, with or without penetration of the dura mater, is often at once deflected at a right angle, or if of larger size, after travers- ing the brain and having insufficient force to penetrate the opposite dural wall, falls back into the track and is diverted perhaps to a considerable distance in some new direction. It may be that it drops directly downward through the cortex or immediately subjacent tissue toward the base, or it may quite as probably take some un- discoverable course which leads to inaccessible cerebral depths. In any attempt at exploration of a cerebral wound to discover the location of the bullet, it should be borne in mind that it is not in the central part of the brain that it is most likely to go astray. If the wound can be traced directly inward for an inch or more, while it is still possi- ble than an elusive pistol ball may have been deflected by a dural reflection, or have stopped short from exhausted force at any point just out of reach, it is more probable that it has gone straight onward at least as far as the op- posite dural wall, and that further search must involve a new departure. The larger the ball the more likely is this generalization to prove true in an individual case. In a wound involving the anterior temporal region espe- cial heed should be given in doubtful cases to the condition of the eye and to the orbit. Sight may have been de- stroyed by an injury of the optic nerve at the optic fora- SURGICAL RELATIONS. 35 I men, and, in the absence of ocular hemorrhage or other apparent ocular or orbital changes, escape discovery unless the parts are subjected to systematic examination. The lack of attention to these local indications, in one case at least, has permitted the resort to serious operation in the vain search of the brain for a bullet, the presence of which in the orbit was evident, but ignored because it failed to respond to the electric test. Considerable hemorrhage in the post-orbital region, causing discoloration of the lids and protrusion of the eye, is not to be lightly disregarded ; and the suspicion which they engender may be strength- ened by the direction which the bullet may be found to have taken from the point at which it entered the brain. It is also possible that the bullet should escape from the cranial cavity in some region of the base which is beyond the possibility of direct examination. This may be de- tected in rare instances, as it was in Case CCXCIX., by passing the probe through the whole length of the cere- bral wound and through the osseous exit. Such a lodge- ment of the ball can ordinarily only be suspected, and con- firmation can be had only in the recovery of the patient. It is sufficient to recognize the possibility of this issue to give perhaps a new significance to apparently trivial signs and symptoms, and sometimes to make easy the interpre- tation of an otherwise inexplicable case. Pain or swelling in some cervical region, or functional disability of the muscles there or in the pharynx, with some dysphagia or dyspnoea, without apparent cause, together with unex- pectedly inconsiderable or improving cerebral symptoms following a wound, perhaps in the mastoid or inferior tem- poral region, through which the ball has passed in an an- 352 INJURIES OF THE BRAIN AND MEMBRANES. swerable direction, make up a picture distinct enough if it be but seen in proper focus. The antithetical case in which the bullet passes through the mouth or neck or even through the eye to penetrate the cranial base is occasionally difficult of diagnosis. Or- dinarily in such a wound, its evident nature, or the imme- diate occurrence of characteristic symptoms, so plainly mark the intracranial complication that the diagnostic problem is solved before it has really challenged thought. In the exceptional case it may be impossible to follow the track of the ball or even to surmise its course, while the general condition of the patient may cause vague suspicion of some hidden lesion ; or after an interval devoid of S5''mptoms some decided change occurs, a notable and con- tinued rise in temperature it may be, for which the closest scrutiny of accessible regions affords no adequate expla- nation. There are no formal rules to follow in the examination of the doubtful cases in which the bullet may have escaped from the cranial cavity into inaccessible adjacent parts, or in which from primary wounds of those parts the bullet may have terminated its course within the cranial walls. It is necessary for the surgeon to be at once alert and sus- picious in the presence of symptoms of uncertain signifi- cance, to bear well in mind all the possibilities connected with the whereabouts of vagrant bullets, and to be wary in the formation of opinions while premises are not yet posi- tively settled. surgical relations. 353 Treatment. The consideration of treatment may properly precede that of prognosis, and may be essentially limited to that division of the subject which concerns the question of in- terference or non-interference with the bullet when re- tained within the cranial cavity. The management of the lesions which the bullet has produced involves no new principles, and is not different from that which has been prescribed for the same cerebral conditions when they have resulted from ordinary forms of violence ; it is there- fore unnecessary in the present connection to reconsider its details. The inception of any treatment comes in question in only a minority of cases ; passing those in which death has been nearly or quite instantaneous, and those in which it is so obviously imminent that there is room only for the simple offices of humanity, but few remain in which the surgeon is called upon to treat primary shock and hemor- rhage. The recumbent position, the application of exter- nal heat, the hypodermic exhibition of cardiac stimulants, the use of hot saline enemata, or the resort to transfusion, and at the same time, if it be possible, the repression of hemorrhage, are here as elsewhere the means at his dis- posal. Until the establishment of reaction nothing more remains to be done. Thus far the procedure is the same as it would be for other surgical injuries ; the general treat- ment of shock is scarcely modified by the nature or loca- tion of a wound ; and the necessity of postponing surgical interference, except for the control of hemorrhage, until after the restoration of nervous force, must be regarded as a fundamental law in surgery. Usually if hemorrhage is 23 354 INJURIES OF THE BRAIN AND MEMBRANES. sufficient to be matter of serious concern it will be uncon- trollable, but it may be derived in some or even greater part from the vessels of the scalp, which may be then easily secured by ligature. There are perhaps cases in which intracranial hemorrhage, though moderate, is persistent, and in which temporary plugging of the intracranial wound with aseptic gauze is justifiable, as it is in operative wounds inflicted upon the brain. If resort is to be made to this means of hsemostasis, great care should be exercised to prevent the further escape of blood from the cerebral wound into the arachnoid and epidural spaces. At the same time that restorative measures are being employed, and as opportunity is afforded, external lesions should be scrutinized, both for medico-legal reasons and for guidance in subsequent surgical procedure. The smoke stain, the unburned grains of powder upon the sur- face, and slight traces of flame are so easily lost that when present they should be noted at the earliest possible moment. The original characteristics of the external wound are liable to alteration and therefore should also receive immediate attention. The further treatment of these cases has been the sub- ject of varied opinion, and is still based upon widely dif- ferent views of surgical propriety. It has been held: First, that the wound should be left absolutely undis- turbed, and intrusted to the simplest form of external aseptic dressing, since the dangers of interference out- weigh any which may result from the direct cerebral in- jury or from the retention of a foreign body. This may be regarded as an ultra-conservative and traditional judg- ment unmodified by changed conditions of surgical prac- tice. Second, that while operative interference may be- SURGICAL RELATIONS. 355 come a necessity, its only justification -will exist in the establishment of drainage, and that the removal of the bullet is of minor or no importance, since it is in itself harmless, having accomplished all the mischief of which it is capable in the infliction of the wound. This is a semi-recognition of the fact that aseptic methods are de- manded for the successful management not only of wounds of the surface but of the cavities and viscera of the body. Third, that the condition of the superficial, cranial, dural, and cerebral wounds should be subjected to thorough ex- amination, fragments of bone removed, drainage insured when necessary, and the bullet, if possible, extracted. This course of procedure is in accordance with general surgical practice at the present time, and is founded upon a belief that asepsis demands absolute cleanliness, and that its laws are of universal application and are to be enforced in their integrity. These several views of the proper plan of treatment of cerebral wounds of this character have been clearly as- serted, and the results of their practical application fully illustrated in the reports of cases published during the past sixteen years. Such a series of clinical observations affords the only ground for opinion, aside from theoretical considerations based upon the general principles of sur- gery. The one hundred and thirty-six cases collected represent the almost entire published experience of Eng- lish, Colonial, and American practitioners since the adop- tion of thorough aseptic methods in surgery, and include twenty-six taken from the personal records which so largely form the basis for the present study of general intracra- nial lesions. The principles of surgical practice are so well estab- 356 INJURIES OF THE BRAIN AND MEMBRANES. lished that it would seem scarcely necessary to insist upon the propriety of exploration of the external and cranial wounds, and the removal thence of fragments of bone and other foreign bodies, if some of the most recently reported cases had not shown that this simple procedure is still often neglected. There is no reason a priori why these partic- ular wounds should be made exceptions to accepted gen- eral rules of treatment, and the only conceivable justifica- tion, if any existed, would have to be found in the results obtained in actual practice. An examination of this entire series of cases faills to disclose any instance in which a conformity to rule in this respect has inured to the preju- dice of the patient, but evidently its neglect has often entailed a fatal result. Death occurred in forty-two out of seventy cases in which no operation was performed. In ten of these re- action was never sufficiently established to justify interfer- ence ; and in five the history is not sufficiently detailed to determine whether operation was done, and, if not, whether its omission was responsible for the result. In at least seven of the remaining twenty-seven cases, death can be directly traced to the want of exploration and of thor- ough aseptic treatment of the osseous and superficial cere- bral wound. The necropsic conditions were : Case I. — A mass of bone piercing the dura and brain, with a superficial cavity containing the bullet and pus, and a nearby abscess in the frontal lobe. Case II.. — Many osseous fragments embedded in the brain and a wound of the middle meningeal artery, v;hich was the direct cause of death twelve hours later. Case III. — Operation on the forty-seventh day and the SURGICAL RELATIONS. 357 removal of small osseous fragments from the frontal region with discharge of a purulent fluid. The bullet on necrop- sic examination was found to be encysted in the cere- bellum. Case IV. — Superficial caAdty containing the bullet, fragments of bone, and a sero-purulent fluid. Case V. — Large fragments, composed of both osse- ous tables, driven into the brain, and contiguous ab- scess. No cerebral change at the site of the distant bullet. Case VI. — Large fragments of bone removed by oper- ation in the eighth month. Necropsy six days later; sub- cutaneous suppuration and localized meningitis; large abscess in subjacent temporal lobe. Case VII. — A depressed dural cicatrix, containing os- seous fragments and a piece of lead. The remainder of the bullet was subcutaneous. In another case, classed among the fatalities following early operation, an osseous fragment was removed on the eighth day with a considerable discharge of pus. Death occurred from sepsis some time afterward. In two instances there was apparent recovery before the development of the fatal symptoms. These cases are perhaps not to be regarded as statisti- cally denoting the fatality which results from the neglect of this simplest form of operative interference ; the pro- portion of reported cases to the whole number of pistol- shot wounds of the cranial contents is too small. They are quite sufficient to establish the fact that osseous frag- ments resting upon the cerebral surface or penetrating the cerebral cortex may be more dangerous than the bullet itself; that there is no safety in the absence of early symp- 358 INJURIES OF THE BRAIN AND MEMBRANES, toms of irritation ; and that instances are not infrequent in which these fragments constitute not only the most immi- nent but the sole source of danger. They make it no less clear that the bullet may rest scarcely below the cranial wall, removable by the simplest possible operative means, but left undisturbed as surely leading on to death as though buried deep in the cerebral substance. They can leave no question that the continuance of removable for- eign bodies in accessible tissues, the neglect to provide a channel for natural drainage, and a wilful ignorance of the conditions of a wound, in defiance of the canons of surgi- cal law, are no more to be tolerated here than in other regions where the proper course to pursue has been long unquestioned. The incision of the dura mater is a more serious pro- cedure than exposing and enlarging the osseous wound. There are instances of brain implication in which the dura is intact or has suffered no more than trivial injury ; in these some natural hesitation in resorting to deeper explora- tion may be felt. If the dura mater is bulging with or without pulsation, or is bruised, or even discolored, the necessity of exposing the cerebral surface is not to be doubted. In one of the more recently reported cases, dural incision gave exit to a small amount of blood and cerebral debris, and was followed by immediate relief of profound coma and the recovery of the patient, the bullet having been previously removed from the external wound. The dura mater Avas here bulging, though apparently unin- jured. In another case, also of recent date, in which the bullet was impacted in the cranial wound, the uninjured dura, which maintained its normal relation to the subjacent cerebral surface, was not incised and death ensued. On SURGICAL RELATIONS. 359 necropsic examination a small superficial clot was found in the midst of a mass of softened and disintegrated cere- bral tissue. In a third case, the inner table of bone, though not apparently broken through, was fractured and driven back into the cranial cavity. After removal of the osseous fragments, the dura mater, which was bulging and had been slightly wounded by a spiculum of bone, was, evi- dently against the better judgment of the surgeon, neither incised nor sutured. A week later death resulted from an extensive purulent meningitis. The external wound had been drained and aseptically treated. These instances constitute a sufficient argument from experience to demonstrate the danger which may lurk be- hind a dura mater which the bullet has left untouched, and which can be estimated and possibly surmounted only by inspection of the parts beneath. If the appearance of the membrane is abnormal, decision should be no less easy than action prompt. It is the cases in which the dura mater itself affords no clew which occasion doubt and hesi- tation. It may be assumed that cortical contusion does not often exist without some dural indication ; but, as this is possible, the question still remains whether or not it is safer in every case to arrive at certainty. When the bullet is of large or medium calibre, and the amount of cranial injury indicates much force of impact, the probability of cerebral lesion would seem not only to justify but to de- mand this measure of prevention. If the bullet is not of larger calibre than 0.22, the inner table of bone not com- minuted, and the dura not affected, it may be well to fore- go subdural exploration. In any case in which doubt fairly arises preference should be given to the aggressive course, and with adequate aseptic care no harm will come 360 INJURIES OF THE BRAIN AND MEMBRANES. from simple exploration, though the event should prove suspicion to have been unfounded. The second proposition in regard to the proper objects, demands, and limits of operative treatment recognizes the necessity of superficial exploration and removal of foreign bodies, and extends similar methods to deeper parts of the brain and intracranial cavity, but holds their utility to exist only in the establishment of aseptic conditions. It denies the irritative effect of foreign bodies in the brain tissue, and asserts the harmlessness of a bullet after its lodgement has been effected. A modified view admits dan- ger from its retention, but regards this as less than that which attends an attempt at its removal. As this proposition involves the question of manage- ment of the bullet, in regard to which there has been not only great diversity of opinion but of practice, it demands careful scrutiny in the light of experience as it has been disclosed in recent years. First, it is claimed that the innocence of stranded bul- lets has been established by the subsequent history of per- sons who have survived the immediate effects of injury. There have been forty-one recorded cases in the series of one hundred and thirty-six, the greater part of which, in the opinion of their chroniclers, may be placed in this category. Of these, at least twenty-five should be dis- carded as of questionable character, or as unverified by a sufficient lapse of time. In four of the twenty-five the penetration of the cranial cavity was doubtful, in one of which in fact the failure was demonstrated ; in a second the bullet could not be traced through the orbital wall ; and in a third, though a wound of the occipital lobe was made certain by the presence of brain matter in the SURGICAL RELATIONS. 36 1 hair, the absence of any sort of primary symptoms made it more probable that the missile had fallen back and escaped externally through the wound of entrance. The fourth case is that of a man who is said to have carried in his brain for sixty-five years a bullet received at the battle of Waterloo. There is no medical evi- dence that the cranial cavity was penetrated, no necropsic examination was made, and no S3'mptom is noted, except " a feeling at the back and lower part of his head, such as would be expected to arise from a bullet which had de- stroyed his eye and traversed the brain but had not effected its escape. " To those who have not experienced this " feel- ing" the corroboration of this story of \Yaterloo is not entirely sufficient to remove it from the doubtful class. In six of the remaining twenty-one cases the final observation was made within one month ; in ten within six months; and in five within eight to eleven months. In some of them at such time there were no s3^mptoms ; and in others there were continued indications, more or less important, of cranial injury. From an examination of the sixteen cases which remain from the forty-one, though in some instances their duration was brief, it is possible to derive some information as to the alleged innocuousness of the bullet when retained with- in the cranial cavity. (i) Purulent discharge from a wound of the left parie- tal lobe, which continued till the seventeenth day, when the bullet was removed, with some osseous fragments, from a cavity just beneath the cerebral cortex. Subse- quent recovery. (2) Wound of right frontal lobe, which healed. Symp- toms of mental decadence continued till death on the thir- 362 INJURIES OF THE BRAIN AND MEMBRANES. tieth day. Bullet lodged in a cavity in opposite frontal lobe, surrounded by clot and disintegrated brain tissue. (3) Wound of right parietal lobe. Death on the thirty- sixth day; bullet in necrotic tissue beneath median sur- face of same lobe. {4) Bullet of 0.22 cal. lodged in petrous partion; puru- lent discharge till death from sepsis on forty-first day. (5) Wound of left frontal lobe; purulent discharge from wound till death at the end of six months. Bullet found post mortem with osseous fragments in a superficial abscess cavity. (6) Wound of right frontal lobe; purulent discharge till removal of bullet from just within the osseous wound in the seventh month, followed by hernia cerebri and- ulti- mate recovery. (7) Wound of left frontal lobe ; purulent discharge till death at a period not stated. Bullet with osseous frag- ments found in a superficial abscess cavity. (8) Bullet of large calibre, lodged in an undescribed part of the brain, caused epileptic convulsions after the lapse of several months; ceased at some undefined later period. (9) Both frontal lobes traversed by a bullet of 0.22 cal. At a later period patient became irritable and quarrel- some. (10) Mid-frontal region penetrated by a bullet of 0.22 cal. without cerebral injury. No symptoms eighteen months later. (11) Wound of left frontal lobe followed by epileptic convulsions, which continued till removal of osseous frag- ments after thirteen months. No symptoms six months later, except improving right hemiplegia. (12) Necropsy in case of a demented criminal two years SURGICAL RELATIONS. 363 after injury. Earlier mental condition not stated; cere- bral convolutions atropliied ; bullet encapsulated upon sur- face of occipital lobe ; bullet track subdural but not travers- ing the brain. (13) Wound in right parietal region; brain not pene- trated ; toy pistol ; four years later, only symptom dilata- tion of right pupil. (14) Wound through ear; petrous portion fissured at its base ; bullet discharged six years later from an abscess in the throat. (15) Wound of frontal lobe by a Minie ball; begin- ning of epileptic convulsions at the end of fifteen years, which became very frequent and severe. Bullet then re- moved from just within cranial cavity. Entire subsequent recovery. (16) Wound of left frontal lobe; bullet of 0.22 cal. ; epileptic convulsions four years later, becoming frequent at the end of thirteen years ; trephination and removal of a fragment of bone and a piece of lead; convulsions not con- trolled. Death one year later from cerebral laceration, the result of a fall during a paroxysm. Bullet found in left trunk area, projecting through the cortex near the median fissure at the end of a membranous canal. There are other cases of similar import in which recov- ery was not claimed. {a) Bullet of small calibre made entrance through the chin. Death twenty days later. A canal extended through left frontal lobe, which was obstructed by reparative prod- ucts ; bullet in pus cavity at its farther extremity. {b) Bullet traversed both hemispheres; death five months afterward. Bullet then found resting upon the dura mater covering the basilar process, having fallen 364 INJURIES OF THE BRAIN AND MEMBRANES. downward from an abscess cavity in the parietal lobe, at the end of its original course. (f) Wound of left frontal lobe and death in twentj'-two months; bullet and osseous fragments contained in a pus cavity beneath a depressed dural cicatrix. {(i) Wound in right frontal region and bullet removed after counter-trephination from abscess cavity in occipital lobe on twentieth da}- ; death ten days later. U) Wound in mastoid region : unsuccessful operation on eleventh day after pyaemic chill; bullet found post mortem partly within lateral sinus. In twelve cases of this series of twenty-one there was sepsis from abscess or necrosis of the cerebral tissue which was directly related to the retention of foreign bodies. In two the nature of the lesion was discovered by operation and the patient recovered ; in ten death resulted, usually at an early period and without attempt at operative relief. In three of the fatalities, and in one of the recoveries, the bullet was contained in a superficial abscess cavity and was associated with osseous fragments ; in seven of the fatalities, and in one of the recoveries, the cerebral lesion, whether abscess or simple necrosis of tissue, was dependent solely upon the presence of the bullet, which with one exception was at a distance from the wound of entrance. In all, S3^mptoms persisted from the time of injury. In another group of four cases, though the bullet re- mained in the cranial cavity, the brain was uninjured and there were no symptoms while the patient continued under observation, a period of from one and one-half to six years. In the one instance in which death is known to have oc- curred later, it was due to intercurrent disease two years after injury, and the bullet was encapsulated. SURGICAL RELATIONS. 365 In Still another group, also of four cases, after a length- ened interval in which no symptoms were noted, epilepsy occurred : in one, after several months, in one after thir- teen months, in one after four years, and in the last after fifteen years. In three of them the attacks ceased: in one after the removal of the bullet, in one after the re- moval of osseous fragments, and in one without operation. In the fourth case the convulsions continued from the fourth to the fourteenth year, when death resulted from accident. The final case of this series must be omitted from con- sideration, since the mental disturbance which followed was due to the laceration of the frontal lobe in the passage of the bullet and not to changes at the point of lodge- ment. There are scattered cases of earlier date in which life has been said to have long continued despite the pres- ence of a bullet in the brain. These histories are usually indefinite, but in some instances it seems probable that there were no important attendant symptoms. It is evident that the retained bullet has proven a menace to life not only when associated with osseous frag- ments but of itself, and it is remarkable that an opposite opinion, supposed to be founded upon actual experience, should have become prevalent. There is probably no authenticated case of recent Anglo-American record in which a bullet left in the brain substance has failed to work mischief, nor has the evil been often long procras- tinated. There have been occasional instances in which it has remained harmless for a number of years in the cranial cavity, but the brain has not been penetrated. The fact that epilepsy has developed so late as fifteen years after 366 INJURIES OF THE BRAIN AND MEMBRANES. injury must make even apparently exceptional cases doubt- ful. It may be justly concluded from these actual observa- tions, that: 1. The bullet left by necessity or choice within the cranial cavity is usually septic ; and necrotic changes ensue with constitutional infection. 2. The bullet when aseptic may become encysted and may then be harmless, or, more probably, may be the source of dural or cerebral irritation at a perhaps distant period. Second : it has been thought that while it may be safer to resort to operative measures, if necessary, for the exploration and disinfection of the superficial cerebral wound, the peril of the patient is augmented rather than diminished by an effort to extract the bullet from deeper parts. This belief, also, has been credited to the teach- ings of experience. In the forty-nine cases which constitute the sum of this experience, as it has been made known in English and American record during the present surgical epoch, death occurred in one before deep exploration had been begun, and m another from anaesthesia before the beginning of operation. In fifteen cases operation was confined to the cranial wall or to the surface of the brain. There remain thirty-two cases in which the removal of the bullet from a distant point of lodgement was made or attempted. Of this number of cases, eighteen ended in recovery; in twelve of which measures instituted for the removal of the bullet suc- ceeded, and in six failed. In fourteen fatal cases removal was effected in seven, and in seven failed. In the nine- teen cases in which the removal of the bullet was success- SURGICAL RELATIONS. 367 fully accomplished, it was withdrawn from the wound of entrance in but three, of which two ended in recovery. In sixteen cases in which it was removed through the oposite cranial wall, counter-trephination or its equivalent Avas done in six in which no counter-fracture existed, twice with recovery and four times w^ith the subsequent death of the patient ; in three other cases, all ending in recovery, serious operation was required ; in the final eight, three of which were fatal, the bullet after simple external incision was removed from the bone or cerebral cortex. In the fourteen cases of failure to discover or extract the bullet, recoveries and fatalities were in equal number. In the fourteen cases which proved fatal, whether or not the effort to remove the bullet was successful, death was due to septic infection in eleven, to age and shock of operation in two, and to shock alone in one. The salient points in their histories may be briefly stated : (i) Trephination in left frontal and counter-trephina- tion in right parietal region on the first day, and removal of bullet of 0.32 cal. from subcortical tissue after incision of the dura mater. Death twenty-four hours later from shock, due to age and unfavorable conditions, including extensive cerebral laceration at wound of entrance. (2) Trephination in left frontal and counter-trephina- tion in left occipital region, and removal of bullet of 0.22 cal. from one and one-half inches below point of counter- operation ; drainage of both wounds, followed by small fungus cerebri in each wound with other symptoms of cerebral necrosis. Death in twelve days. No ne- cropsy. (3) Counter-trephination in left posterior cranial region twenty days after a wound mflicted through right malar 368 INJURIES OF THE BRAIN AND MEMBRANES. bone, and removal of bullet of 0.32 cal. from a pus cavity. Death ten days after operation. (4) Trephination in left frontal, and counter-trephina- tion in right frontal region on the fourth day; bullet not discovered , drainage tube through the brain. Death seven days later; purulent meningitis, and left frontal diffuse abscess. (Bullet in right orbit.) (5) Trephination in right frontal region on the first day, osseous fragments removed, but bullet not discov- ered. Death on the twelfth day. Necropsic conditions: Pus in the subcutaneous cellular tissue; purulent meningitis, and cerebral necrosis; osse- ous fragments found in the brain substance, and bullet of less than 0.22 cal. lodged in the right frontal lobe, three inches from the surface. (6) Trephination of right mastoid on the eleventh day; previous pyaemic chill. Death on the sixteenth da}', and bullet of 0.22 cal. found partly within the lateral sinus. (7) Trephination in the right frontal region on the ninth day; large cavity, filled with blood and necrosed brain tissue, drained ; bullet not discovered. Death on the fourteenth day, and the cavity found to extend to the oc- cipital lobe; fragment of bullet near lateral ventricle. (8) Trephination in right parietal region on the second day; bullet not discovered. Re-examination in another hospital on the thirtieth day; external wound infected; large cerebral cavity containing necrotic tissue and having firm walls. Death on the thirty-sixth day, and bullet found to have been deflected by falx cerebri one inch backward from the cavity previously recognized. (9) Bullet removed from right petrous portion on the fourth day by finger and elevator after incision. Death SURGICAL RELATIONS. 369 two days later; fissure found in petrous portion; pur- ulent meningitis. (10) Incision over counter-fracture in posterior tem- poral region on the fourth, day, and bullet of 0.32 cal. re- moved from cerebral cortex; drainage tube. Death on the ninth day ; drainage tube found to contain pus and its exterior covered with necrotic brain tissue. (11) Incision over counter- fracture in right frontal region and removal of the bullet on the fourth day. Death in fourteen hours from "exhaustion." (12) Removal of bullet from pharynx on the second day; the patient, aged eighty, then unconscious, with irregular respiration. Death in sixty hours. (13) Probing to depth of two inches on the eighth day; pus and osseous fragments removed ; bullet not discovered. Death from septic infection on the thirty-eighth day. No necropsy. (14) Probing deeply through right frontal lobe on the second day; bullet not discovered; wound of entrance afterward healed. Death on the thirtieth day; bullet found surrounded by necrotic tissue in the left island of Reil. It is apparent that in the greater part of these fatalities interference was deferred until septic changes had already occurred, with or without symptoms of general infection. Operation was primary in but three cases, and in four of the others indications of the constitutional disorder were already manifest. In the forty-two deaths which occurred in non-operative cases, inclusive of those already consid- ered in relation to retention of the bullet and osseous frag- ments in the superficial cerebral wound, and exclusive of the ten in which it was a primary result of shock and 24 370 INJURIES OF THE BRAIN AND MEMBRANES. hemorrhage, all but four were occasioned by septic infec- tion following a local lesion, abscess, meningitis, or cere- bral necrosis. The ultimate result, therefore, of a critical analysis of all the available records of practical experience, the court of last resort in matters of scientific opinion, is that the cause of death has been ordinarily the same, whether or not operative interference has been made; and that the percentage of recovery has been greater when operation has been performed. If allowance were made for the number of cases in which sepsis was declared prior to operation, or in which other antecedent conditions made interference practically hopeless, the statistical advantage of operation would become very decided. The series of cases collated is practically complete with- in its limits of time and place. It has not included reports of cases from Continental sources, as their examination if made with equal care would have entailed an almost impossible amount of labor. The statistical results which have been obtained have been only incidental to an exact determination of what have been the real teachings of experience. Their value in this relation is not to be questioned ; they demonstrate the accordance of the facts of observation with general laws of surgery. The pathogenic germs are not less prev- alent in the surroundings and instrumentalities of treat- ment of cerebral wounds than elsewhere, and it would be inconceivable that their preventive control or destruction should be less indispensable. The propriety of operation having been established, its methods and limitations, and the details of treatment, are still to be considered. SURGICAL RELATIONS. 37 1 When the general condition of the patient has so far improved that it has ceased to occasion immediate anxiety, the superficial and osseous wounds should receive more thorough attention. The surface should be cleansed and shaven, and search should be made for embedded grains of powder or remaining, traces of smoke and flame, the cutaneous wound enlarged by incision, the extent of sub- cutaneous lesion determined, and the superficial soft parts made surgically clean. If there has been large comminu- tion, the fragments of bone may require elevation, though in such cases the subjects rarely survive the immediate shock of injury. If, as is more probable, the fracture has been a simple perforation with possibly a fine marginal comminu- tion, the osseous wound should be adequately enlarged by the rongeur, the dura incised, and whatever small detached fragments and foreign substances can be detected removed from the accessible part of the cerebral laceration. In those cases in which the bullet has made exit, the second wound in its superficial and deeper portions is to be pri- marily treated like the wound of entrance, and both wounds are to be closed with the usual aseptic precautions. It may happen that the bullet is lodged just within the cranial wound of entrance, or of exit, and may be readily removable. This fact is to be borne in mind in the pre- liminary examination. The necessity of securing and maintaining the most perfect attainable asepsis is so well recognized as the in- exorable law in all surgical procedures that it may be assumed to be enforced in wh'atever dressings, explora- tions, or operative interferences may be deemed proper, though its specific mention may be sometimes omitted. It is at this point that differences of opinion have led to 372 INJURIES OF THE BRAIN AND MEMBRANES. differences in practice. These affect not only the attempt at removal of the bullet and foreign substances from deeper parts through the wound of entrance, and the re- sort to counter-trephination, but also the use of the probe and the extent to which mechanical drainage may be em- ployed. The obligation of exploration, and of operation if practicable, can no longer be evaded when answerable conditions exist in the individual case. The analytic study of the results obtained in actual practice, and the disclosures of necropsic examination, leave no justification, and the authority of the general principles of surgery affords no warrant, for inaction. The opinion that the bullet is harmless while at rest, or if not harmless is less harmful than the effort to determine its position or to effect its removal, is disproved by the experience from which it claims to be derived. The evidence is conclusive that bullets when retained in the brain, even though en- capsulated or unproductive of symptoms for a length of time, eventually lead to death, while their removal not infrequently permits recovery. The baneful influence exerted by osseous fragments, when left in contact with the dura mater or embedded in the cerebral substance, is even less likely than that of the bullet to be delayed by encapsulation or by the exceptional tolerance of a sensitive tissue; and the imperative necessity for their removal is even less an admissible question, as the record of cases has made evident. An exaggerated estimate of the danger of necessary and reasonably skilful mechanical treatment of brain wounds was naturally made in the early days of aseptic methods before the mental focus had been adjusted to new conditions, and while men's minds were still dominated SURGICAL RELATIONS. 373 by their earlier experience. It is more difficult to com- prehend how it should prevail to some extent at the pres- ent time, when greater familiarity with aseptic laws has brought a juster appreciation of the widened limits within which surgical interference may still be conservative. The imminent danger of sepsis which once attended oper- ative invasions of the great cavities of the body has been precluded, or at least made possible only by neglect; the real source of this danger is from within, where it is abso- lute, and not from without, where it is only contingent. The peculiar peril of such operations arises from the oc- currence of shock, when they are too extensive, too san- guinary, or too much prolonged. The brain tissue is not especially tolerant of mechanical injury, but the procedures taken to discover or extract a bullet need never be made a test of its endurance. The proper use of the probe is confined to the existent wound, so that contact is made only with already disintegrated tissue which is no longer capable of irritation ; the penetration of adjacent uninjured parts is not contemplated and is indefensible. This with- drawal of a foreign body from along the track which it has followed will, if it be deeply situated, probably involve additional laceration. The extent of visceral injury nec- essary to the extirpation of a clearly diagnosticated and accessible brain tumor of moderate size has not prevented its acceptance as a justifiable operation in surgery. The bullet, rendered accessible by the wound which it has made and traversed, its situation clearly defined by the probe, its size necessarily small but its capacity for mischief un- limited, can be ordinarily extracted with less injury or destruction of tissue, and with less hemorrhage or expen- diture of time, than the smallest conceivable tumor. The 374 INJURIES OF THE BRAIN AND MEMBRANES. simple fact that some additional brain laceration must be involved in the withdrawal of a bullet is evidently insuffi- cient reason to forbid the attempt, though its probable extent may be a sufficient contraindication in individual cases. The possible capacity or technical skill of the sur- geon cannot be ignored in such a review of the subject, but its adequacy must be assumed in a general discussion of surgical propriet)'. In view of these several facts and inferences, it may be regarded as established that if the bullet remains within the cranial cavity an effort should be made to determine its location, and if detected that the advisability of an attempt to effect its removal should at once be brought in question. It may be so readily approachable, and its re- moval so evidently practicable, as to leave no room for hesitation ; or its situation may be so uncertain or so inac- cessible that to attempt operation, or to refrain, may seem fraught with equal danger, and the decision will then re- quire the exercise of great discretion as well as of careful and perhaps prolonged examination. The advantage of the earliest possible interference, in view of the patient's general condition, if it is to be made at all, is as positive here as it is in amputation for trauma involving the ex- tremities. The comparative tolerance exhibited by the recently wounded brain to further injury by operation should be given much weight as an element in the consid- eration of all very recent cases in which doubt exists in de- ciding upon a policy of action or inaction. The imminence of septic infection from the earliest moment, and in its face the probable futility of a deferred operation, are still more potent reasons for quickness of decision and for promptitude in whatever action is to be taken. The data SURGICAL RELATIONS. 375 and conclusions of writers of a somewhat earlier period are no longer of authority. The fact that the missile of which they wrote was the musket or rifle and not the pistol ball, is perhaps of no great importance, nor even the changes which have been made in its weight, form, and velocit}'', if lodgement has been once effected; but the methods of surgery have so radically changed with more exact knowledge of pathology that the propriety of opera- tions generally must be reconsidered and new rules of pro- cedure formulated. The first step in the attempted removal of the bullet, the exploration of the cerebral wound with a view to local- ization, is not only a diagnostic method but an incident of treatment. The necessity of some explorative invasion of the cranial cavity is always involved ; for, even though the bullet rest in the external wound, more dangerous osseous fragments may yet lurk beneath the cranial opening. The extent to which it may be properly carried and the manner of its pursuance still require consideration. The funda- mental law which should govern the surgeon in his choice and use of the means of exploration is that the least pos- sible additional laceration, compatible with the attainment of the information sought, should be inflicted. It is desir- able that a single instrument should be selected, preferabl)' that of Fluhrer or of Girdner as best suited to the purpose, and that no substitution of one instrument for another should be subsequently made except for sufficient and well-defined reason. If the probe first employed should have a bulb too large, or be otherwise unsuited to follow the path which the bullet has opened, it should at least indicate with precision the character of the one which should take its place. The utmost caution should be ex- 3/6 INJURIES OF THE BRAIN AND MEMBRANES. ercised to keep within the wound, since false passages are as readily made and, when made, as embarrassing to fur- ther exploration as those which follow the reckless use of the urethral sound. It has been held that when the probe ceases to advance without the exercise of force, the limit of persistence has been reached. This is approximately rather than exactly true. The probe does not fall by its own weight into the depths of the cerebral wound. The channel which the bullet has left behind it is not likely to be open, but filled with coagula and disintegrated tissue, and some force, gentle as it may be, is required to pene- trate this pulpy mass, and some manipulation alone can guide the instrument past obstructing osseous fragments or through an intracerebral dural opening. The judg- ment of the surgeon must decide what measure of force is excessive, as the acuteness of his perception must indicate when the bulb impinges upon the denser but still tender wall of normal structure. The work of exploration may be tedious, but time is of minor importance, while caution is imperative. The bullet, if not at once deflected, ordinarily holds a straight course into the opposite hemisphere ; it is better, therefore, if the track can be followed deeply but without result, to resume the search from the opposite cerebral surface. If the track be lost near its outset, the osseous wound should be further enlarged and the brain incised to reach and follow its new departure. The manipulation of the probe should be not only gentle and cautious but always directed by a settled purpose, and, this accom- plished, should be at once abandoned. When the surgeon, disappointed and impatient at failure in his quest, thrusts the instrument into the brain recklessly and at random, SURGICAL RELATIONS. 377 or nervously again and again explores a channel which the first examination shows to lead to nothing tangible, in the hope that some chance may disclose to him what his intel- ligence has been unable to discover, no good and much harm may come from it. Every misdirected or superflu- ous insertion of this small instrument may increase al- ready dangerous laceration and hemorrhage, and invite already imminent necrosis of tissue and subsequent gen- eral sepsis. These rules of conduct in the employment of the probe are simple, and may seem too obvious for much insistence, but their neglect and its known results have excited a popular prejudice against its proper and neces- sary use, which has in turn sometimes engendered too much timidity on the part of the surgeon. The instru- ment first chosen, if unfit or if it has served its pur- pose, should be unhesitatingly changed ; investigation should be thorough, but nothing should be done with- out reason ; force should never take the place of art, and no dependence should be had upon the aid of accident. If the bullet cannot be detected by the probe, there may be circumstances which invite the use of the needle. A resistance may be felt which the blunt instrument fails directly to reach ; there may be reason to believe that the missile lies near the cerebral surface while an angle in its track prevents direct pursuit without incision ; a deeper wound may be too tortuous to follow ; or localizing symp- toms may have been developed ; any one of which condi- tions might justify this resort. The wound made is so minute that hemorrhage is inconsiderable, and laceration can be scarcely said to be produced. The experience gained in the use of this sort of puncture in cerebral oper- 378 INJURIES OF THE BRAIN AND MEMBRANES. ations which have not been necessitated by traumatism confirms its comparative if not absolute safety. There may be other indications which the exigencies of a case will suggest, but, while even occasional instances of fatality from this seemingly harmless method of investigation are recorded, its purely empirical employment should not be recommended. In those cases in which from shortness of range or pro- fuseness of hemorrhage, or at a later period from neglect, there may be much laceration or disintegration of brain substance, the finger may well supersede any other me- dium of exploration. It is more sensitive than metal and is in immediate in place of indirect communication with the guiding intelligence, and, as room is already provided without new destruction of tissue, there is nothing to counterbalance the positive advantage which it offers. This gives no warrant, however, for its introduction in or- dinary cases in which the track is comparatively narrow, and in which the violent invasion of an organic structure heretofore intact must necessarily add a new element of danger. There are exceptional cases in which there may be sufficient reason to believe that the bullet has escaped from the cranial cavity to justify an abandonment of cerebral search, even though the point of exit may not be discerni- ble. Its course may be so manifestly toward the orbit, or subbasic or suboccipital region, that, in the absence of serious cerebral symptoms and after fruitless exploration of the cerebral wound, it may be judicious to assume this extracranial lodgement and to await the possible develop- ment of local confirmatory symptoms. It may even hap- pen, as in several of the accompanying series of cases, SURGICAL RELATIONS. 379 that the osseous exit into the base or orbit may be dis- covered. The bullet having been recognized in an accessible region of the brain, the same care, gentleness, and avoid- ance of cerebral laceration which are essential in the de- termination of its position should be observed in the use of instruments for its removal. The particular instrument employed, if adapted to its purpose, is of less importance than the manner of its use. The operation is often diffi- cult and may be sometimes judiciously abandoned; the bullet, already deeply situated, may with every effort at extraction sink deeper into the yielding tissue in which it is embedded and in a direction inaccessible for counter- operation, or until its removal, if finally accomplished, would involve lesion of the brain substance so extensive as to entail greater danger than would result from leaving it undisturbed. If pursuit be abandoned from the rear, there remains the resort of attacking it from in front. The bullet may have originally occupied, or been forced into, a position in which it is in evident close contiguity to the superior orbital plate. If the effort to withdraw it through the wound of entrance seems hopeless without too greatly destructive laceration of brain structure, success may attend approach through the orbit. An incision may be made which will permit the enucleation of the eye and its appendages en masse, and their replacement without subsequent deformity or injury to vision. The bullet is then reached through the orbital wall at the point indi- cated by the probe passed through the cerebral wound. The same method is applicable when the original lodgement of the bullet is effected within the orbit. If vision has been destroyed by intracranial or orbital injury, or by 380 INJURIES OF THE BRAIN AND MEMBRANES. lesion of the optic nerve as it passes through the optic foramen, operation will be simplified by the necessary removal of the eye. The equivalent of the operation through the orbital plate is found in counter-trephination through the opposite wall of the calvarium which has remained intact. It is indicated in a case in which the bullet has been discovered deep in the substance of the brain, perhaps across the median line, the attempt to withdraw it having been fore- gone as fruitless or desperate and with no hope of reach- ing it through the orbit; or when, the bullet having been traced far inward, its track has been utterly lost, and no clew exists to its place of lodgement. There is no alterna- tive, except the chance of recovery with the bullet left un- disturbed or this single operative resort. It is a dilemma in which inaction, the easier course, seems to have been the oftener chosen in the few instances in which, as it would seem, such an operation might have been undertaken with fair prospect of success. The early successful cases of Larry and Charles Bell are familiar. In recent years but five others have been recorded, of which four proved fatal. Fluhrer's case in 1884, followed by recovery, has at- tracted much and deserved attention. The bullet of 0.22 cal. penetrated the mid-frontal region, and was followed by the probe for six inches through the left frontal lobe and falx cerebri into the opposite hemisphere. The cranial wall on the right side was trephined three-fourths of an inch be- low the point at which the instrument if projected would emerge, and the dura was incised. Following a trail of blood and later of brain matter, the bone was cut away and the dura further incised till a wound in thepia was discovered, through which the bullet was removed from one-half inch SURGICAL RELATIONS. 38 1 below the cerebral surface. The only reported case of re- moval of the bullet frora the brain through the orbital wall, Case CCXCIV. in the accompanying series, is practically of the same character, though the chisel was used in place of the trephine. Operation was done on the second day, with a rectal temperature of 104°. The wound of entrance in the right temporal fossa was enlarged by the trephine, frag- ments of bone were removed, and the bullet was discovered near the optic foramen. The eye, which was distended with blood, was removed ; the superior orbital plate, which was much comminuted by fissures, but not broken through, was perforated by the chisel; the dura was incised, and the bullet removed from the cerebral cortex. The patient eventually recovered. The necropsic examinations included in the series of published cases disclose occasional instances in which the directness of the bullet's course, and its lodge- ment near the cerebral surface in an accessible region, would have made such operations anatomically possible, and which the histories show would have been clinically proper. Their number, after an eliminative process by death before reaction, by extraction of the bullet through the wound of entrance, or by an obvious impropriety of further interference, is necessarily very limited. The justification of counter-operation through the un- injured cranial wall in properly selected cases is based upon the same considerations which justify the use of the probe for localization and, under suitable conditions, the effort to withdraw the bullet through the original wound. The avoidance of sepsis, and the conduct of operation in such manner as to limit shock, are no less under the con- trol of the surgeon, but, as additional and more considera- ble injury is to be inflicted upon the brain, still greater 382 INJURIES OF THE BRAIN AND MEMBRANES. caution, if not more conservatism, in estimating the rela- tive danger of an aggressive and of an expectant policy will be required. The circumstances adverse to this operation are : First, a bad general condition of the patient succeeding primary shock, a high temperature, a feeble and frequent pulse, and other indications of an inability to sustain the shock of further cerebral injury ; second, extensive cerebral lac- eration about the wound of entrance from the explosive effect of a large bullet at close range, or a suggestion of wide destruction in its track from the severity and diver- sity of localizing symptoms; third, great uncertainty as to the course of the ball, or its direction toward an inaccessi- ble cranial region; fourth, the fact that its course has in- volved the base of the brain; and fifth, the bullet having been of 0.22 cal. or less. The fact that the bullet has taken its course upon or near the basilar surface is to be regarded as a contraindication, because it is more than likely to be deflected near the median line into a central region of the brain by resistance offered by some part of the ethmoid or sphenoid, or by the basilar process of the occipital bone. The fact that the bullet is of 0.22 cal. or less is a contraindication, because its course is usually erratic and its track minute, and because its momentum is so comparatively slight that it rarely reaches an accessible part of the opposite cerebrum. No one of these contra- indications of course is an absolute bar to operation. If, on the contrary, the constitutional condition is good and the laceration is confined to a narrow track, if a bullet of 0.32 cal. or larger has been driven through the central or upper regions of the brain toward some part of the vault, if its track can be traced deep into the opposite hemi- SURGICAL RELATIONS. 383 Sphere, and more especially if the patient has the advan- tage of youth, it will be judicious, after the exhaustion of other means, to resort to this ultimate method of relief. If the counter-operation be resolved upon, it is well to regard it in the first instance as simply explorative. The cerebral surface having been exposed, and the area of ex- posure having been increased at discretion without per- ceptible evidence of lesion, the operation may be properly terminated at this point, unless the bullet can be discov- ered by palpation, or unless its position has been ascer- tained by the exploration of the original wound to be of easy access through the new incision. This amount of ad- ditional or secondary injury, confined essentially to the scalp and cranium, can be inflicted with almost absolute safety, provided sufficient care is taken to control hemorrhage. If, however, a trail of blood or of particles of brain matter can be traced to a wound in the cerebral cortex, or if the color and consistency of the surface indicate subjacent lacera- tion, the operation should be continued with a view to extraction of the bullet, and no harm can come from inci- sion of the already lacerated tissue. If the patient be en- feebled by age or be in ill condition, and much blood be lost in the incisions of the scalp and dura, or if the unin- jured brain be too freely wounded in exploration, the operation may readily lead to disaster. Such methods of treatment as have been outlined are in consonance with present views of the proper utilization of the surgical resources at command for the management of lesions of the great cavities. Ideas are no less conser- vative than formerly, but conservatism is more intelligent. Ten years and more ago it was the fashion to abstain from interference with gunshot wounds of the brain, to the ex- 384 INJURIES OF THE BRAIN AND MEMBRANES. tent of leaving the bullet or fragments of bone at the very entrance of the cerebral track or even beneath the skin at the point of exit. It was considered proper to depend wholly upon aseptic treatment as represented by covering the external wound with a single layer of carbolized lint. The principles of asepsis were recognized, but their appli- cations were primitive and inefficient, and the journals of the period contain many histories of this kind with an- swerable results of septic inflammation and death. It is characteristic of the present epoch to employ available in- strumentalities to their full extent, and to pursue to a logical and practical result whatever advantage they may offer. The later consideration of prognosis as affected by the removal or retention of the bullet will demonstrate the conservatism of what under imperfectly appreciated con- ditions were regarded as radical measures. The final point in treatment, in regard to which differ- ence of opinion may exist, concerns the methods of disin- fection and drainage of the cerebral wound. The bullet, whether it has pierced the opposite cranial wall, or been removed by counter-trephination, or has been withdrawn through the track by which it entered, has necessarily left an area of disintegrated and dead tissue which may become the source of subsequent general infection. This danger, which was noted as attendant upon cases of ordinary brain laceration without external injury, is, of course, more im- minent in gunshot cases, in which sepsis is not only possi- ble from original contamination by foreign substances, but from continued exposure to atmospheric influences. The advantage to be derived from drainage and disinfection is beyond question; the extent to which it maybe justifia- ble or profitable to subject the brain tissues to mechanical SURGICAL RELATIONS. 385 interference in the pursuit of these objects is still a matter of somewhat varied opinion and practice. It must not be forgotten that the brain is permeable to fluids, and that less sensitive structures suffer from the irritation of drain- age tubes when too freely used or too long continued in the wound. The irrigation of the brain and the insertion of drainage tubes into and through its substance should be practised with great reserve, lest their good results be more than counterbalanced by the structural injury which they inflict. The cases in which neither bullet nor other foreign body has been found in the deeper wound, and in which the track is narrow, will be more safely treated if aseptic fluids are confined to the external parts and to the cerebral cortex, and the removal of the more inaccessible coagula and debris of tissue is trusted to absorption and natural drainage. The other cases, in which greater and more widespread damage has been done to the central regions of the brain by the extraction of the bullet or of large fragments of bone, or by complete perforation by missiles of large calibre, demand more active interference. In the irrigation which may then become advisable the prompt return of the antiseptic fluid should be insured by a dependent position of the external wound, by the use of a double catheter or by other adequate means, and its flow should not be unnecessarily profuse. The drainage tube, if used at all, should be withdrawn and abandoned at a very early period, usually on the second day. If drain- age is to be maintained for a longer time, horsehairs or threads of chromicized catgut may replace the tube, and their number be reduced from day to day. Certain ob- jections made to the drainage tube by Hunt in the Australasian-Intercolonial Medical Congress of 1892 are 386 INJURIES OF THE BRAIN AND MEMBRANES. worthy of especial consideration in relation to deep cere- bral wounds: (i) That it is an irritant foreign body. (2) That it is likely to become filled with clot, and then act as a plug rather than as a drain. (3) That it is a medium for the deep implantation of septic elements when the surface has become infected. If the preparation of the tube and the treatment of the wound do not absolutely preclude the possibility of the development of septogenic germs, it is liable to become a no less deadly weapon than the pistol itself. The reiterated injunctions to observe aseptic care which garnish all modern discourse upon surgical proce- dure doubtless grow wearisome ; but like admonitions to virtue they are always in season, and are nowhere of more vital importance than when they concern operations within the cranial cavity. The arachnoid is more sensitive than the peritoneum, and the brain less tolerant of disturbance than the abdominal visera ; septic infection is even more prone to follow errors in technique, and its results are more disastrous than in abdominal operations. In explo- ration, therefore, not less than in operation, and in the general treatment of intracranial wounds, the most rig- orous exactitude is demanded in every detail of aseptic precaution. The responsibility may then be justifiably assumed by the surgeon of using such methods of exami- nation as are necessary to an intelligent apprehension of the conditions of a case and to the subsequent adoption of the course of procedure most likely to insure the eventual safety of the patient. surgical relations. 387 Prog^^osis. The general prognosis of intracranial pistol-shot wounds is absolutely bad ; worse probably than in any other class of bodily injuries. Its numerical expression, while not to be altogether discarded, is of comparatively little value. In the series of reported cases collected for the present study of such injuries, the fatalities are only slightly in excess of the recoveries ; these cases, however, have been exclusively those which have surviA'ed primary shock and hemorrhage, and in many instances they have been avow- edly or presumably reported because they were recoveries, and of special interest on that account. In Bradford's tables, again, deaths are recorded in more than half the total number of ninety-one cases ; in twenty-two of these, a group comprising all those in which the patient lived to reach the Boston City Hospital, but five survived. In Wharton's tables the comparative secondary mortality is practically the same. Bryant's tables were compiled largely from cases not of pistol-shot origin, and are therefore not pertinent to the present inquiry. In the annexed series of personal observations death occurred at once or within the first hour in fifteen cases, within twelve hours in seven cases, and in from fifteen hours to forty days in ten cases. Apparent recovery followed in but eight cases. This last showing of comparative results is still fallacious, as only a small proportion of the immediately fatal cases is brought under professional observation, even at the morgue. As likely to afford upon a scale of sufficient magnitude the most exact knowledge possible of the great fatality of pistol-shot wounds of the brain, a record was made of all such cases reported in the New York Herald, as occurring 388 INJURIES OF THE BRAIN AND MEMBRANES. in New York and its immediate neighborhood, during the year ending December 31, 1896. This summary comprises accidents, suicides, and homicides, in which wounds were inflicted by weapons of all calibres and under all conceivable circumstances. In a total of one hundred and thirty-seven cases, the subject was found dead or death occurred at once in ninety-nine ; twenty-one others were known to have proved fatal at some later period, from a few hours to one or two days; and in eleven the probable result is not indi- cated. In six cases only recovery was assured or can be reasonably inferred from the circumstances noted. This comprehensive notation of a circumscribed class of pistol- shot wounds permits a much more precise estimate of gen- eral prognosis than could be made from clinical observation. It is doubtful if statistical researches are of real importance except for the expression of such elementary facts. They may sufficiently determine, as in this instance, the question of general prognosis, expressed in numerical terms, since life and death are alone involved with no conditions be- yond the causation and location of the wound. Death is the result in so large a gross proportion of cases that it is obvious concomitant circumstances are not largely influential in prognosis. In .suicide the range of fire must always be within the limit in which necropsic observations have shown that it does not materially modify effects, and accidental and homicidal wounds are usually inflicted within scarcely greater distances. At these ranges, a bullet, whether of large or medium calibre, has sufficient momentum to penetrate the cranium, whatever its density or thickness, and to occasion equally extensive cerebral injury. Bullets of 0.22 cal., however, must be excepted from these general statements formulated for SURGICAL RELATIONS. 389 missiles of larger size. It has been noted in cadaveric ex- perimentation that with this calibre penetration is less cer- tain ; it may fail if the cranium be both thick and dense, even at contact or at short ranges, unless the ^veapon be of the best type and the explosive of the best quality. The difference in extent of cerebral laceration as produced by bullets of 0.32, 0.38, and 0.44 cal., though sometimes manifest, is not sufficient to be of practical importance; but with a bullet of 0.22 cal. it is distinctively less, enough so to diminish the primary danger from shock un- less some large meningeal vessel has been wounded. It is noticeable on a recurrence to published cases, in which immediate danger was surmounted, how frequently the calibre when mentioned was 0.22 or less; and wounds of the head when made by bullets of these small calibres have been generally regarded as involving a minimum amount of danger. The proportion of absolute recoveries is doubtless greater than with the larger calibres, not only from more frequent lack of penetration and from lesser cerebral laceration, but from the smaller number and minuter size of the osseous fragments which are driven into the brain substance, and which experience has shown to be the most active agents of septic infection. The re- coveries are still comparatively few ; the most vulnerable point for cranial penetration is usually though ignorantly selected in suicides, which constitute by far the largest class of these cases ; and if an immediately fatal hemor- rhage from division of some large meningeal vessel is evaded, the smallness of the bullet permits it to traverse long distances through the brain, with corresponding lia- bility of realizing conditions of immediate danger; and though it reaches some distant point, in which it is lodged 390 INJURIES OF THE BRAIN AND MEMBRANES. without having directly brought life in question, there still remains the peril of changes in organic structure from sepsis or irritation which may make death its inevitable sequel though long deferred. The one important element of special prognosis is to be found in treatment. The several causes of death are shock, hemorrhage, sepsis, and irritation of the cerebral tissue from the presence of a foreign body. If shock is suflBcient to endanger life, there is not often time for in- terference, and the source of hemorrhage is likely to be beyond the reach of haemostatics ; but so far as treatment is possible, there can be little question as to its methods and none which can modify prognosis. The occurrence of septic infection, which is an imminent danger in all cases, and to which the majority succumb, may be amena- ble to both prophylactic and curative means, and the early extraction of the bullet and osseous fragments, when prac- ticable, obviates the later danger from cerebral irritation. The resort to judicious measures, therefore, for the pre- vention or control of septic infection, and for the removal of causes of cerebral irritation on the one hand, or the abstention from their use on the other, must necessarily influence the result in individual cases and become a factor in its prediction. The better chances of recovery when the necessary means are employed for thorough exploration of the wound for the removal of septic foreign bodies, and for the main- tenance of aseptic conditions, is evident from analysis of the practically complete series of published cases. A study of this character to determine general principles is apart from mere statistical tabulation, in which incongru- ous cases are collated, and in which from the omission of SURGICAL RELATIONS. 39I necessary elements of comparison untrustworthy conclu- sions are deduced. The established facts that in the case of patients surviving the immediate effects of injury a majority die either at once from sepsis, the result of the retention of foreign bodies within the cranial cavity and a concomitant lack of disinfection, or at a later period from the irritation which they occasion, and that present surgi- cal resources are adequate to avert danger of primary or added septic infection from operative interference itself, make the conclusion irresistible that exploration and if possible the removal of the bullet and other alien sub- stances increase the prospects of recovery, whatever may be the attendant conditions. The cases which have collec- tively afforded these basic facts have been sufficently ana- lyzed and summarized in the previous consideration of treatment. The choice of means, of instrumentalities to be em- ployed in the application of the general principle, has not been similarly determined, though various authors have tabulated results with this purpose in view. They have failed in showing either that essential conditions were comparable or that proper discretion was exercised by the surgeon. Elaborate computations of the number of cases probed, trephined, or subjected to no interference what- ever, and made with sole reference to the death or recov- ery of the patient, or enumeration of the results of wounds of the several cerebral lobes inflicted under diverse condi- tions, simply add to that constantly growing fund of use- less knowledge to which the most of us are misguided if not guilty contributors. The bald fact that death followed the use of the probe or of the trephine in a certain number of cases and recovery in a certain number of others, while 392 INJURIES OF THE BRAIN AND MEMBRANES. neither the necessity for its use nor the manner of it, neither the previous hopeless or hopeful condition of the patient nor his subsequent treatment, is in evidence or is given consideration, is not only unimportant, but when stated with the formality of a statistical result is likely to be positively mischievous as leading to unjustifiable infer- ence. In like manner, the formulated fact that in a limited number of cases with imperfect histories a greater num- ber of deaths occurred with or without resort to operative measures can have no legitimate value as a basis for con- clusion or practice. The opinion which has obtained, and is reflected in the histories of cases, that a bullet once within the cranial walls is tapu, and which has more than once permitted a patient to die from septic infection with- out examination of his wound, and with a bullet or osseous fragments lying almost upon the cerebral surface, has had its origin in a fatuous belief that numerical statements are infallible and that treatment is to be conducted in accord- ance with inflexible rules. The general method of treat- ment is to be deduced from the general laws of surgical procedure and confirmed by the results of observation ; but its details in their application to individual cases involve so complex and unstable conditions that they must be de- termined in each instance by the judgment of the surgeon. The thorough exploration of the wound, and if possible the extraction of foreign bodies, are prescriptive; the practicability of operation, and the means for its accom- plishment, lie within his discretion. THE CONDENSED HISTORIES OF THREE HUNDRED INTRACRANIAL TRAUMATISMS SELECTED FROM A SERIES OF FIVE HUNDRED ORIGINAL CASES I. CASES VERIFIED BY NECROPSY. Fractures of the Cranial Base. Case I. Symptoms. — Wound in left posterior parietal region; hemorrhage from left ear; wild delirium; high temperature ; coma. Death in forty-eight hours. Lesions. — Fracture of left temporal bone, with sep- aration of its constituent parts — squamous, petrous, and mastoid. Laceration of both parietal and right temporal lobes. Case II. Symptoms. — Delirium, which was considered alcoholic ; walking case ; treatment refused ; suicide by drowning on the following day. Lesions. — Fracture extending from left parietal emi- nence to foramen magnum. General cerebral and menin- geal contusion, and cortical laceration of right temporal lobe. Case III. Symptoms. — Wound in right superior pos- terior parietal region ; hemorrhage from right ear and later from right nostril. Coma; stertor; general muscular rigidity; dilatation of left pupil; left hemiplegia after twelve hours, and recurrence of hemorrhage from the ear, with disappearance of stertor and muscular rigidity ; urine not controlled; consciousness not regained. Death in six days. Lesions. — Fracture extending from point of injury through right petrous portion and middle fossa. Lacera- tion of inferior and external surfaces of left frontal and right temporal lobes; corresponding cortical hemorrhages, thinning toward base and vertex; excessive general hyper- semia. 396 INJURIES OF THE BRAIN AND MEMBRANES. Case IV. Symptoms. — Compound depressed fracture, external to right parietal eminence ; found on trephination to be confined to external table, with fissures extend- ing into middle fossa. Semi-consciousness, mild delirium, imperfect articulation, with slow and irregular respiration, which continued for three days ; paralysis of right upper extremity and of right upper and lower face, differing in degree at different times; mental condition varying from normal to one of noisy delirium ; patient usually restless, and during last two days unconscious. Temperature on admission, 101°; during first week, 100°; in second week, 99° -|- ; and rose steadily from 103° to 109° through last two days. Death in forty-five days. Lesions. — Subarachnoid serous effusion ; subcortical cav- ity beneath the point of osseous depression, of large size, containing a reddish semifluid material and brown detri- tus ; cortex not wounded ; excessive general hyperaemia. Case V. Symptoms. — Stupor; gradual unconscious- ness; delirium requiring mechanical restraint. Temper- ature on admission, 102°; ten hours later, 105°; declined to 101.8°, and then rose steadily to 106.6°. Death in twenty-nine hours. Lesions. — Wound over occipital tuber, and extravasa- tion of blood over whole calvarium ; no fracture of vertex, but a fine fissure along posterior border of right petrous portion. Pial hemorrhage over superior surface of both hemispheres; laceration of left frontal, and both temporal lobes, and of inner border of right frontal lobe. Case VI. Symptoms. — Stupor; incoherence; dilatation of left pupil ; slight deviation of eyes to the right ; later, delusions, delirium, muscular tremor, irregular pupils, frequent and intermittent pulse. Temperature on admis- sion, 103°; five hours later, 102°; and rose to 106.2°. Death in twenty-four hours. Lesions. — Wound in right parietal region; linear frac- ture extending through whole length of right parietal and occipital bones, and through petrous portion into middle CASES VERIFIED BY NECROPSY. 397 fossa; considerable laceration of inferior surface of left frontal and of left temporal lobes. Case VII. Symptoms. — Patient fell upon the sidewalk, and was admitted to the hospital twenty-four hours later. CEdema of the scalp under and about an old cicatrix be- hind the right ear, and beneath this an extensive commi- nuted fracture; two fragments of bone were removed, and one was elevated, and a large epidural clot extracted as far as possible. Stupor; hemorrhage from right ear; ir- regular pupils; general muscular rigidity; ataxic gait: diminished sensibility, and loss .of urinary control. On the fourth day temperature normal, mind clear, and mus- cular rigidity lessened ; copious serous discharge from right ear and right facial paralysis; on the fifth day in- creased muscular rigidity and recurrence of stupor; on the sixth day, unconsciousness and frequent general convul- sions. Temperature on admission, twenty-four hours after injury 99° -{- ; on the fourth day, normal ; on the fifth day, 100° -|- ; on the seventh day, 105°. Death on the seventh day. Lesions. — The whole central portion of the occipital bone from the foramen magnum upward, and posterior por- tion of both parietal and right temporal bones, forming an ir- regular circle from two inches and a half to three inches in diameter, were broken into large fragments, two of which had been removed during life. The mastoid and outer part of the petrous portion of the right temporal bone could be removed by the fingers with the use of very little force. This line of fracture ran through the tympanic cavity, so that after removal of the outer fragment the carotid canal and aqueductus Fallopii, filled with coagula, could be seen in the section. A large epidural clot was sit- uated beneath the occipital fracture, extending half an inch beyond its margin. A large subdural clot filled the right inferior occipital fossa, extending to the foramen magnum. The cavity of the posterior part of the great longitudinal sinus was occupied by a thrombus, and its 398 INJURIES OF THE BRAIN AND MEMBRANES. walls were infiltrated with blood. There was a large par- tially decomposed thrombus in the torcular Herophili, ex- tending through the right lateral into the petrosal sinus and internal jugular vein. The whole internal surface of the dura beneath the seat of the external hemorrhage was lined by a firmly coagulated clot with an inflammatory ex- udation around it. A portion of the surface of the right occipital lobe posteriorly was softened, showed minute hemorrhages, and was torn away in the removal of the dura. The meshes of the pia mater over a large part of the parietal and occipital lobes posteriorly were dis- tended with slightly turbid serum. There was a small laceration on the under surface of each frontal lobe and a larger one, three-quarters of an inch in diameter, in the right cerebellum at a point corresponding to the site of the thickest part of the subdural hem- orrhage. Case VIII. Symptoms. — CEdema of scalp in right pa- rietal region, and fracture discovered by incision. Coma, stertor, general muscular rigidity most marked on the right side, and strong contraction of both pupils most marked in the left; no change in general condition till death fifty-four hours later. Temperature on admission, 100.4°, rising progressively to 103.8°, with immediate post-mortem recession. Lesiojis. — Fracture extending from posterior and infe- rior part of right parietal bone to right jugular foramen, and then turning backward to foramen magnum. Lacera- tion of anterior border of left temporo-sphenoidal lobe and of the anterior and internal borders of both frontal lobes; cortical hemorrhage covering the whole base of the brain ; subcortical laceration with clot occupying the whole inte- rior of the left frontal and temporo-sphenoidal lobes, and filling with blood both lateral ventricles and both occipital lobes ; slight epidural hemorrhage at point where fracture began in right inferior and posterior parietal region ; slight subarachnoid serous effusion ; thrombus extending from CASES VERIFIED BY NECROPSY. 399 torcular Herophili through right occipital and inferior petrosal sinuses into the jugular vein. Case IX. Symptoms. — Partial unconsciousness for twenty-four hours; became complete; hemorrhage from both nostrils and from right ear; delirium on the fifth day with post-cervical muscular rigidity, restlessness, and retraction of the abdomen ; Cheyne-Stokes respiration and death. Temperature for three days, 99.2°; on the fourth day, 103.2°; on the fifth day, 104.8°. Lesions. — Contusion over right mastoid revealed on raising the scalp. Fracture at base in three fissures, ex- tending from this point; two (fine) across petrous portion, and a third connecting these posteriorly across occipital bone. Deep linear laceration, extending across inferior surface of right cerebellum, near outer border. Cortical hemorrhage over whole left cerebrum, superiorly and lat- erally; most copious in middle lateral region. Laceration of antero-inferior border of left frontal lobe. White sub- stance of left cerebrum much congested, and with punc- tate extravasations throughout its extent. Case X. Symptoms. — Semi-consciousness and left hemiplegia, followed by irritability; hemorrhage from left nostril ; depressed fracture involving left frontal emi- nence; bone elevated. Death in twenty-four hours. Lesions. — Coronal suture separated on right side; multiple fissures, one extending through bod}' of sphe- noid bone into left middle fossa, and others through right middle and anterior fossae, external to orbital plate. Epidural hemorrhage in left temporal region; laceration of right frontal and right temporal lobes, and of left tem- poral lobe. Case XI. Symptoms. — Coma, stertor, dilatation of left and contraction of right pupil, paraplegia, hemorrhage from left ear and nose and under left conjunctiva, and contusion over left eye. Death in five minutes after ad- mission. Lesions. — Linear fracture extending downward and for- 400 INJURIES OF THE BRAIN AND MEMBRANES. ward from behind left parietal eminence, across petrous portion, through middle fossa, transversely across anterior fossa, and terminating in right lesser wing of sphenoid bone. Epidural hemorrhage, blood still fluid ; slight lacerations of inferior surface of left frontal and temporal lobes and trivial cortical hemorrhage; excessive general hyperaemia. Case XII. Symptonis. — Contusion in right parietal re- gion, hemorrhage from left ear and nose, loss of faecal and urinary control, right hemiplegia; temperature on admis- sion, 99.4°. Death in two days. Lesions. — Fracture extending from right parietal emi- nence to foramen magnum, of right petrous portion through its whole length, and of left petrous portion for two inches. Laceration of left parietal lobe, and cortical hemorrhage. Case XIII. Symptoms. — Coma, stertor; normal pulse, respiration, and pupils. Death in five days. Lesions. — Fracture extending from beneath a contusion near right parietal eminence downward and forward, anterior to petrous portion, through middle fossa and sella turcica. Pial hemorrhage over both hemispheres; lacera- tion of inferior surface of left temporal lobe. Case XIV. Symptoms. — Patient knocked down by a blow in the face ; momentarily unconscious, then walked to the hospital, and afterward walked home. Severe pain in head for three hours, gradual supervention of coma, which became complete in four hours. Death in eight hours. Lesions. — Wound of lip and contusion of forehead. Linear fracture of external table extending from right inferior occipital fossa across petrous portion. Slight epi- dural hemorrhage beneath the fracture ; large pial hemor- rhage over external aspect of left frontal and parietal lobes, with some extravasations into the pia mater; slight limited contusions of brain substance. Case XV. Symptoms. — Coma; dilatation of right and contraction of left pupil ; right hemiplegia ; pulse became CASES VERIFIED BY NECROPSY. 4OI slower, ana respiration more labored. Death in nine and one-half hours. Lesions. — Contusion in left parietal region, and fracture extending from that point by two fissures through pa- rietal bone into anterior and middle fossae. Large epi- dural hemorrhage from rupture of left middle meningeal artery ; slight laceration of left parietal lobe at point where fracture began and another upon lateral border of left temporal lobe. Case XVI. Symptoms. — Loss of consciousness followed by stupor, slight but increasing dilatation of left pupil, slight hemorrhage from left ear, slight rigidity of left side, and labored respiration ; temperature 99° ; left hemiplegia first affecting lower extremity ; temperature 101.2°. Death in twenty-one hours. Lesions. — Contusion of scalp in left occipito-parietal re- gion; stellate fracture in centre of left parietal bone: fis- sures which extended toward median line, into inferior occipital fossa, and along upper border of petrous por- tion into middle fossa. Recent laceration of inferior and lateral surfaces of right temporal lobe, and of inferior surface of both frontal lobes along median fissure ; old laceration of inferior surface of left temporal lobe ; deep and irregular in outline, lined with a grayish-yellow Yiscid substance, surrounded b}' an area of 3'ellow softening, and about one inch in its several diameters ; smaller old lacera- tions, presenting similar characters, of inferior surface of left frontal lobe. The recent right temporal lacera- tion Avas of large extent. Extensive cortical hemorrhage over right cerebrum, and well-marked general hyperemia of brain. Case XVIL Symptoms. — Loss of consciousness, dilata- tion of right and contraction of left pupil, right hemiple- gia, full and slow respiration ; pulse, 66. Death in eleven hours. Lesions. — Contusion of left parietal region, from the site of which one fissure extended into the anterior and 26 402 INJURIES OF THE BRAIN AND MEMBRANES. another into the posterior fossae. Large epidural hemor- rhage from rupture of left middle meningeal artery; gen- eral hyperaemia with minute coagula and punctate extra- vasations. Case XVIII. Symptoms. — Loss of consciousness for thirty minutes, subsequent irritability when disturbed; temperature, 98°; pulse, 78 and intermittent; depressed fracture below right temporal ridge, and hemorrhage from right ear. Second day: depressed bone elevated, and three fissures disclosed — one running backward, one for- ward, and one downward^ dura incised; temperature, 101.8°. Third day: somnolence and irritability, loss of urinary control; temperature, 102°. Fourth day: delirium and progressive rise of temperature to 105.4°. Fifth day: moderate dilatation of pupils, restlessness, hyperaesthesia, increase of surface heat, followed by deep coma. The temperature from this time varied each day from 104°-]- in the morning to io5°-j- in the evening till death on the eighth day, and was then 106°. Lesions. — Skull thin. No pus in the wound or in the small brain cavity which had been disclosed by the ante- mortem operation when the depressed bone was elevated. Subdural hemorrhage in the opposite (left) occipito-parie- tal region. An effusion of thick green pus beneath the arachnoid membrane covered the lateral and superior sur- faces of the right occipital and parietal lobes, but did not extend forward to within an inch of the cranial opening left by operation. A subdural effusion of similar thick green pus was coextensive with the whole right inferior occipital fossa. There was a deep laceration, one inch in diameter, upon the lateral border of the left temporo- sphenoidal lobe, which involved the subcortical tissue. At a point directly beneath the opening left by the removal of the depressed bone there was a cavity in the brain substance as large as a hickory nut, which opened by its whole extent upon the cerebral surface. (As this surface v/as intact at time of operation, the cavity must be ascribed CASES VERIFIED BY NECROPSY. 403 to a direct contusion, subcortical, not involving superficial laceration, and to a subsequent giving way of the cerebral cortex under the influence of arterial pulsation, and in the absence of normal repressive force exerted by the skull and dura mater. The whole brain substance and menin- geal vessels were intensely hyperaemic, and there w^ere numerous minute extravasations from general contusion. There was no meningeal or ventricular serous effusion. A fissure extended from the central point of fracture through the petrous portion of the temporal and inferior occipital fossa to the foramen magnum. Case XIX. Symptoms. — Permanent unconsciousness; irritability when disturbed ; dilatation of both pupils, es- pecially marked in right; profuse hemorrhage from left ear, which continued for tw-enty-four hours, and was then followed by serous discharge; general convulsive move- ments, most pronounced in right leg; temperature, 100°; pulse, 80; single general convulsion, most violent on left side on second day, and repeated on third day; tempera- ture rose steadily to 107.2°. Death in three days and six hours. Lesions. — Large hsematoma in substance of left tem- poral muscle. Fracture extended from left squamous por- tion into middle fossa, and by an open fissure along an- terior border of petrous portion to the sella turcica. Large epidural clot in left middle fossa; large and deep lacera- tion of lateral surface of left temporo-sphenoidal, and of lateral and inferior surfaces of right temporo-sphenoidal lobes ; small and deep laceration at right parieto-occipital junction; large cortical clot in left middle fossa; thin cor- tical coagulum over right cerebrum. Case XX. Symptoms. — Contusion of left parietal re- gion and of both eyes. Loss of consciousness, and mutter- ing incoherence when disturbed; subconjunctival hemor- rhage at outer part of left eye ; slight temporary rigidity of right arm; restlessness and irritability; little change till death, in seven days ten hours. Temperature on ad- 404 INJURIES OF THE BRAIN AND MEMBRANES. mission, 101°; in two days rose to 104.8°; declined from fourth to sixth days to ioi°-f- to i02°4-> and then rose progressively to 107° +. Lesions. — Skull thin ; fracture of left anterior and mid- dle fossae, apparently beginning with a comminution of orbital plate of left frontal bone about its centre. At this point two or three small fragments were displaced upward, with fine fissures extending in different directions. One fi-ssure ran outward and upward into left squamous portion of the temporal bone ; another ran backward from the crista galli through the bodies of the ethmoid and sphenoid bones, through the optic foramen, and along the anterior border of the petrous portion ; and the third ran through the right optic foramen into the squamous portion of the right temporal bone. The optic nerves were uninjured. There was a little blood extra vasated over right occipital, and lower part of right parietal lobes. The left frontal lobe was completely excavated by a laceration, which was bounded everywhere by a thin layer of unaltered cortex, except inferiorly, near the anterior border, where it was covered in only by the meninges. It was separated from the ventricle by a thin septum of brain substance. This cavity contained commingled blood, clot, and brain detri- tus. There was also a laceration of the anterior two-thirds of the external lateral border of the right cerebellum, and an extravasation of the size of a robin shot in the centre of the right corpus striatum. There was no clot anywhere at the base of the brain and no other lesions. Case XXI. Symptoms. — Patient while in an alcoholic condition fell seventeen feet into the hold of a vessel. Thirty minutes later when examined he was unconscious, bleeding from the mouth and nose, and said to have been in the interval violent and abusive. He was three times in the course of the ensuing twelve hours refused surgical aid by ambulance surgeons, who decided that he was suf- fering from simple alcoholic intoxication. He was then taken to a police court conscious, apparently rational, but CASES VERIFIED BY NECROPSY. 405 unable to stand or walk, and sentenced to imprisonment for drunkenness. As an afterthought he was sent to the alcoholic ward of Bellevue Hospital, and later transferred to a surgical division. There was then severe contusion of the face and eyes, and a depressed fracture was readily detected in the right frontal region; there was subcon- junctival hemorrhage in both eyes, muscular rigidity of both arms, slow pulse, and labored respiration, soon fol- lowed by restlessness, muttering delirium, loss of urinary control, and Cheyne-Stokes respiration. Temperature, 104.8° to 106°. Death in twenty-four hours after injury. Lesions. — Linear fracture of the temporal bone extend- ing three inches upward and backward from its anterior border; stellate fracture with depression above the right supra-orbital ridge, which on the inner surface extended across both orbital plates, through the ethmoid and the body of the sphenoid bone, and on the left side through the middle fossa nearly to the petrous portion ; nasal bones comminuted. There was no considerable intracranial hemorrhage ; laceration of superior surface of both frontal and both parietal lobes. Case XXII. Symptoms. — Coma, stertor, full pulse, hemorrhage from the right ear, and pulmonary oedema for which he had been bled from the arm by a ship's surgeon before admission. Death in two hours. Lesions. — Hasmatoma over the whole right side of the head. Multiple fissures of the base (six in number), involv- ing both sides and all the fossae. The primary fissure, of five which were connected, began as a wide fissure behind and a little to the left of the foramen magnum, and narrowed to a hair's breadth as it ran forward to the right supercili- ary ridge. A sixth and entirely independent fissure ran backward from the crista galli on the left side through the optic foramen to the sella turcica. There were slight lacer- ations of the under surface of both frontal and right temporo- sphenoidal lobes, which occasioned slight cortical hemor- rhage; an epidural hemorrhage upon the upper and lateral 406 INJURIES OF THE BRAIN AND MEMBRANES. surfaces of the hemispheres, especially the left, and at the base, in the inferior occipital fossae. Case XXIII. Symptoms. — Patient found at foot of cel- lar stairs, unconscious and restless, with a large lacerated scalp wound, which had bled freely, and several wounds of the face. Admitted to the alcoholic ward on the diag- nosis of ambulance surgeon of another hospital, still un- conscious. The scalp wound was in the parieto-occipital re- gion, to the right of the median line, and the most extensive face wound was over the right malar bone. As he did not " clear up," he was transferred to a surgical ward four days afterward. He was then nearly comatose, quiet unless disturbed ; his pupils were normal, and respiration was slow and regular. Temperature, 102.2°; pulse, 96. Tempera- ture next day was 104.6°, 103.6°, and 106°; and on the morning after it was 105° and 107°, when he died without further symptoms, five days and a half after reception of injury. Lesions. — Fracture at base, through petrous portion of left temporal bone, extending to foramen magnum. Lacer- ation of left temporal and frontal lobes, with cortical hemorrhage. Case XXIV. Symptoms. — A woman, aged thirty-eight ; habitual criminal ; jumped from the third tier of the Tombs Prison to the flagging below, thirty feet or more; punc- tured wound in left occipito-parietal region; unconscious; hemorrhage from left ear; pupils moderately dilated, more especially the left; and vomiting persistent. Temper- ature, 98.9°. The next morning the patient was con- scious, rational, and the hemorrhage had nearly ceased. In the evening she was slightly delirious, and the follow- ing day required mechanical restraint till quieted by seda- tives. Both pupils became widely dilated, the left still continuing more dilated than the right, and they were only slightly responsive to strong artificial light. This ocular condition continued till her death. The abdomen was painful and swollen. Her mind remained clear but CASES VERIFIED BY NECROPSY. 407 apathetic till the sixth day, when she fell into a stupor. On the same day all the extremities became paretic and partially ansesthetic. Up to this time the muscular power had been normal. The paresis and aucesthesia were most marked on the right side. The pulse was rapid, quick, and feeble. A day later the left foot and right hand were less paretic, and her mind was clear but the senses were blunted. She answered questions slowl}^ and after an interval, and complained of pain in the head. On the eighth day she was restless and irritable, and had some right facial paral- 3'sis, while power in the left foot and right hand was still further improved. On the ninth day she was delirious and unconscious. On the eleventh day she no longer moved or spoke, and paid no attention to an explorative incision. On the fifteenth day she died from asthenia. The temperature remained below 100° till the close of the fourth day, when it rose to 103°. After that it va- ried from 100° to i02°-j-; usually was 101°-)- till the twelfth day, when it rose to 104° F., and was afterward from 103° to 104.5° till she died. Lesions. — Head large and unsymmetrical, and skull thick. No lesion of the scalp or of the bone was discovered before removing the calvarium. The occiput was dispro- portionately large, and the right occipital fossae were much larger than the left. The left middle and anterior fossse were rather larger than the right. A fissure began at a point in the squamous portion of the left temporal bone, beneath the external wound, and, passing through the an- terior surface of the petrous portion, terminated in the optic foramen. This fissure was not open, but the frag- ments were quite movable. There was no epidural hemor- rhage, but pressure was made upon the facial nerve by interosseous hemorrhage as a result of the fracture. There was no arachnitis and scarcely the usual amount of serum in the meshes of the pia. There were slight lacerations upon the under surface of the right temporo-sphenoidal lobe, and one somewhat larger upon its external border. 408 INJURIES OF THE BRAIN AND MEMBRANES. from which a moderate amount of blood had spread up- ward over the occipital lobe, barely reaching the parietal. Upon section, the cerebral vessels were found to be dis- tended with blood, which flowed from the puncta vascu- losa. The veins could be seen in congeries and filled with coagula. The brain substance was softened and cedema- tous, so that serum followed the knife. The ventricles were distended with serum. Subsequent microscopic ex- amination of the brain tissue in the recent state disclosed no inflammatory changes. There was an extravasation of blood behind the peritoneum on the right side, but no vis- ceral injury, and there were no chronic visceral lesions. Case XXV. Symptouis. — vStupor; hemorrhage from right ear ; lack of control of urine and faeces ; condition alcoholic; second day, active delirium, muscular tremor, delusions, and intervals of unconsciousness; sixth day, coma, stertor, muttering delirium, general muscular rigid- ity, slight contraction of right pupil, and slight right facial paralysis; eighth day, two slight convulsions involving arms, face, and eyes, followed by paralysis of right arm and face, and elevation of surface temperature of left side ; right side normal; left side, 102°, Death on the eighth day. Temperature till fourth day, 100° to 102°; afterward 103° to 104° till eighth day, when it rose to 105.6° and de- clined to 104.8°, with post-mortem elevation to 106°. Lesions. — Thin layer of pial hemorrhage, covering both parietal and both occipital lobes, and meningeal hyper- semia; large subarachnoid serous effusion ; general oedema of brain substance and minute vessels filled with coagula ; fluid blood in anterior cornu of left lateral ventricle ; small lacerations of superior and external surface of right fron- tal and of left occipital lobes and on either side of median fissure of cerebellum. Neither laceration was larger than a walnut, and neither involved a rupture of the pia mater. A linear fracture was confined to the right petrous portion. Case XXVI. Symptoms. — Vertigo and feeling of ill- ness; wound in right temporal region. On admission to CASES VERIFIED BY NECROPSY. 409 hospital, entire consciousness and mental control; hem- orrhage from right ear; temperature, 100°; soon afterward profuse hsematemesis, coma, and stertor. Death in four hours. Lesions. — Depressed fracture of right frontal bone one inch from median line and just anterior to coronal suture, triangular in form, with apex extending to superciliary ridge. One fissure, originating in this depression, ran through, right orbital plate, and greater and lesser wings of sphenoid, into middle fossa; another ran through squa- mous into petrous portion of temporal bone, terminating upon its anterior surface. There was an epidural clot ex- tending over lateral aspect of right frontal lobe into the middle fossa. This portion of the frontal lobe was much flattened and compressed. There was no subdural hemor- rhage and no superficial laceration of the brain. There was a small effusion of blood in the meshes of the pia on either side of the medulla, behind the pons, parallel to the anterior columns. The whole brain was hypersemic with a multitude of punctate extravasations, and the minute vessels were filled with coagula. Upon section a number of extravasations were found in the substance of the pons, mainly in the transverse fibres, but some in the longitudi- nal fibres of the crura. The smaller ones were of the size of a robin shot. The largest one was one-half inch long by one-fourth of an inch wide, and was just below the surface on the right external border of its inferior surface. Case XXVII. Symptoms. — Permanent and primary unconsciousness; haematoma at vertex; ecchymosis at base, right side ; slight hemorrhage from right nostril ; stertor; pulse, 130, irregular and weak; temperature, 94°; rose to 102° some hours later; both eyes protruded and both pupils were dilated, left pupil most markedly so; some rigidity of right side. Death in eight to ten hours after admission into the hospital. Lesions. — Fracture extending from right posterior fossa through petrous portion into middle fossa. Epidural hem- 4IO INJURIES OF THE BRAIN AND MEMBRANES. orrhage in posterior fossa; small laceration of inferior sur- face of left prefrontal lobe ; thin cortical hemorrhage over superior surface of both frontal lobes. Fracture confined to base. Case XXVIII. Symptoms. — Wound in right parietal region; temperature, 98.8°; in twenty minutes left lower extremity became paretic. On the fourth day temperature suddenly rose from 99°+ to 102°. On the fifth day, de- lirium and temperature of io5.2°-io6°. Death. Lesions. — Fracture extending from right squamous por- tion through both anterior fossae, involving right greater sphenoid wing and both orbital plates. Laceration of in- ferior surface of left temporal lobe, and consequent corti- cal hemorrhage filling left middle fossa. Case XXIX. Symptoms. — Wound in left inferior tem- poral region, fracture of left malar bone, and contusions of face. Coma, moist bronchial rales, dilatation of right pupil, left invisible from ecch3'mosis, anaesthesia fol- lowed by paralysis of right upper extremity ; temperature, 101.6'^. Three hours later, patient apparently mori- bund. Second day: mental condition normal; motor and sensory functions restored, urinary control lost; pupils normal; temperature, 99°+. Fifth day: temperature had gradually increased to 103° and some subconjunctival hemorrhage had become evident. Sixth and seventh days: mental condition apathetic, and subconjunctival hemorrhage increased; temperature had declined to 100°. Eighth day: sudden loss of consciousness; tempera- ture, 104.8° with decline in two hours to 102.8°, gradual decreasing strength. Death on the ninth day ; temperature, 106°, with immediate post-mortem recession. Lesions. — An open fissure, through both tables of bone, extended from a point just to the left of the occipital tuber to the left foramen lacerum posterius. Moderate subarach- noid serous effusion ; subcortical lacerations, which disinte- grated and filled with clot the whole interior of both frontal lobes. On the left side the median surface was CASES VERIFIED BY NECROPSY. 4II ruptured through the arm centre and gyrus fornicatus, and the lateral ventricle was invaded ; the clot was very solid and the external layers of fibrin on its inferior aspect were partially decolorized. On the right side the clot was of equal size, but had not broken through the cortex or into the lateral ventricle. There was no cortical hemorrhage, though the posterior border of the left cerebellar lobe was deeply lacerated. The brain substance was softened and reddened in patches of limited contusion. Case XXX. Symptoms. — Small wound in left posterior parietal region. Permanent unconsciousness ; slight hem- orrhage from both nostrils; left pupil dilated, right pupil contracted; loss of faecal and urinary control; face flushed. Temperature, ioi°, and on the second day ioi°-l-; then rose progressively to 106.8° at death, in three and one- half days, with post-mortem increase to 109"^. On the last day general sensation obviously diminished. Lesions. — Fine fissure extended from left of occipital protuberance through posterior fossa and petrous portion to foramen ovale. Laceration excavating inferior surface of right frontal, and extending into right temporal lobe; laceration of middle portion of left gyrus fornicatus, one- half inch in diameter; wide and deep laceration across inferior surface of left cerebellar lobe. The laceration of the gyrus fornicatus involved the cortex. Cortical hem- orrhages; clot, three fluid ounces by measurement, in anterior fossse; hemorrhage slight in right posterior fossa, and in moderate amount over lateral surface of right frontal lobe; all resulted from these several lacer- ations. General contusion of both hemispheres, most marked posteriorly. Case XXXI. Symptoms. — Brief unconsciousness, which recurred in the ambulance ; in the interval no evidence of serious injury. On admission to the hospital, pupils con- tracted, sudden cyanosis, and death in twenty-five min- utes. Lesions. — Haematoma in left occipital region ; blood still 412 INJURIES OF THE BRAIN AND MEMBRANES. fluid. Stellate fracture, with centre in left upper occipital region, and with fissures running downward into foramen maofnum, forward and downward into middle fossa, and upward and laterally. Epidural clot in left occipital re- gion ; pial hemorrhage in inferior occipital fossae over pons and medulla; and cortical hemorrhage over both frontal and both temporal lobes from laceration of their inferior surfaces. Case XXXII, Symptoms. — Patient injured by the fall of a brick from the fourth story of a building ; admitted to / / Fig. 42.— External Surface of Calvarium at Point of Fracture. A, Trephine opening; B. portion of lambdoid suture; C, masto-parietal suture. the hospital on the second day ; mind clear ; hemorrhage from the right ear; compound comminuted, depressed, fracture in the right supramastoid region ; trephination and elevation of bone ; dura mater uninjured ; primary union of wound, and cicatrization of drainage exit without CASES VERIFIED BY NECROPSY. 413 formation of pus. Hemorrhage from ear ceased, and during first week no general symptoms; temperature fall- ing from 100.4° to normal. On the eighth day, tem- perature rose to 101.4°, and an enlarged and painful lymphatic gland was discovered in right posterior cer- vical triangle. On the seventeenth day, no symptoms, general or local; temperature normal. On the twentieth L r' Fig. 43. — Internal Surface of Calvariuin at Point of Fracture. A^ Trephine opening; B^ C, portions of internal table slightly depressed. day, some malaise and headache, the apparent result of a surreptitious bottle of red wine. On the twenty-third day, severe frontal headache, delirium, somnolence, and left hemiplegia. On the twenty-fourth day, complete left hemi- plegia and hemiansesthesia, continued somnolence, and sluggish movement of the pupils; left eye injected; tem- perature, 98.5°; pulse, 6(i; cicatrix uninflamed. On the twenty-fifth day, increasing stupor and loss of faecal and 414 INJURIES OF THE BRAIN AND MEMBRANES. urinary control; temperature, 100.2°. The wound was then reopened, and the dura, which was pulsating, was incised ; the cerebral surface was of normal consistence and had been uninjured. A subcortical abscess was dis- covered by exploration at the first insertion of the probe, from which one to two drachms of reddish pus and dis- integrated brain tissue were evacuated. During the oper- FlG. 44. — Section of the Brain Showing Abscess Cavity and Area of Softening. A, Abscess cavity; B, area of softening gradually disappearing at E , C, section of convulution of central lobe (island of Reil); D, section of lateral ventricle. ation respiration failed, and was restored only by trache- otomy; reaction was complete. Temperature rose to 108°, and death occurred sixteen hours later. Lesions. — The fracture involved the right parietal and occipital bones ; the disc which had been elevated was two inches by one and one-half inches in its principal diameters, included the outer half of the lambdoid suture, and was continuous with a fissure which was prolonged through the whole anterior surface of the petrous portion. There was no intracranial hemorrhage, no subarachnoid effusion or arachnoid opacity, and no superficial contusion or lacer- ation. The dura mater and pia mater were adherent to each other over a small area in the posterior and inferior part of the parietal lobe on the right side corresponding in sit- uation to the site of fracture. In this area the meshes of the pia mater were infiltrated with blood, and beneath it CASES VERIFIED BY NECROPSY. 415 was an area of softening which extended forward for about two and one-fourth inches. The brain was hardened in alcohol, and an oblique longitudinal section then made in a plane passing downward and inward, which intersected the abscess cavity ; this was found to communicate, through a canal made by the passage of the probe during life, with the surface at the point where the adhesions be- tween the membranes were firmest. At this point the ab- scess cavity Avas most superficial, but was at least three- eighths of an inch distant from the surface. The abscess had a well-defined wall, and broadened as it extended forward and inward toward the median line for a distance of about seven-eighths of an inch. It was surrounded by a wide area of softening, which in the part lying be- tween it and the surface at the site of the meningeal adhesions was slightly hemorrhagic and seemed to date from an earlier period than elsewhere. In front of the abscess cavity the softening extended above and below the convolutions of the island of Reil, and cut the motor and sensory fibres both before and after their passage through the internal capsule. Case XXXIII. Symptoms. — Unconsciousness, which continued till death ; hemorrhage from left ear ; dilatation of both pupils, and subsequent contraction of right; muscular relaxation, followed by later rigidity; temper- ature on admission, 99.6°; afterward, 99.6° to 100.4°; on© hour post mortem, 101.2°. Death in twelve hours. Lesions. — Wound in left posterior parietal region. Semicircular fracture of squamous portion of left temporal bone, with fissure extending into anterior surface of pe- trous portion ; deep, :well-defined laceration, laterally and posteriorly, of left temporo-sphenoidal lobe, from which a thick clot extended over occipital region ; brain in all its parts excessively hyperasmic; on section, the surface was repeatedly bathed in blood as it was each time wiped away; no punctate extravasation or coagula in minute vessels. 4l6 INJURIES OF THE BRAIN AND MEMBRANES. Case XXXIV. Symptoms. — Coma; stertor; loss of urinary control; hemorrhage from nose and later haema- temesis; pulse, 96 and full; respiration, 18; tem- perature, 100°, rising gradually to 102.6° some time before death, in fourteen hours after admission to the hospital. Lesions. — Small epidural hemorrhage at site of fracture; rupture of dura mater; corresponding laceration in anterior inferior parietal region ; laceration of anterior half of right middle temporal convolution ; small laceration in centre of left cerebellum filled with fluid blood; general hyperaemia, most marked on left side posteriorly. Wound in right occipito-parietal region, and linear fracture in right parie- tal bone extending through greater wing of sphenoid bone into middle fossa. Case XXXV. Symptoms. — Unconsciousness: contrac- tion of both pupils; rigidity of both lower and of right upper extremities; pulse and respiration too rapid to be counted; temperature, 101°, and /;/ articulo mortis 100.4°. Death in two hours. Temperature two hours post mor- tem, 99°+. Lesions. — Extravasation of blood over whole left parie- tal region, not evident during life; separation of left coro- nal suture beginning in its middle portion, with a continu- ous fissure, which in left middle fossa bifurcated and terminated in greater wing of the sphenoid and at petro-mastoid junction. No epidural hemorrhage, and no superficial laceration. Pial hemorrhage over left frontal and parietal lobes upon their superior and lateral surfaces, and about the region of right occipito-parietal junction ; small central laceration of left corpus striatum at junction of middle and posterior thirds; excessive general hyper- aemia. Case XXXVI. Symptoms. — Coma; stertor; alcoholic condition; no superficial injury ; muscular relaxation ; face flushed; pupils slightly contracted; vomiting; temper- ature, 97°, continuing subnormal; pulse, 60; respira- CASES VERIFIED BY NECROPSY. 417 tion, 16; one general convulsion just before death, at the end of eight hours and a half. Lesions. — Fracture through left occipital, parietal, and squamous portion of temporal bone to margin of petrous portion ; laceration of inferior surface of right frontal lobe and of both temporo-sphenoidal lobes; pial hemorrhage over whole right parietal region. Case XXXVII. Symptoms. — Patient in alcoholic con- dition at the time of injury. Primary and permanent un- consciousness ; stertor ; left radial pulsations fuller and stronger than right; compound linear fracture in left parietal region, through which blood oozed in large amount at each cardiac contraction. On admission to hos- pital, temperature, 98°; pulse, 100; respiration, 32. One and one-half hours later, temperature, 96°; pulse, iio; respiration, 40. Death in three hours. Lesions. — Fracture extending from left parietal emi- nence into left middle fossa, and terminating just be- hind foramen spinosum ; epidural hemorrhage along the course of the fracture; small pial hemorrhage over left hemisphere ; general cerebral hyperasmia. The epidural hemorrhage was derived from the posterior branch of the middle meningeal artery and the blood in great part es- caped through the external wound during life. Case XXXVIII. Symptoms. — The patient, after hav- ing passed through three hospitals, with three discharges and two transfers, and after having wandered about the streets and suffered much exposure, was finally received and allowed to remain in an asylum for the insane on the eighth day after a fall from the stoop of her house. She had then delusions and other symptoms of mental derange- ment, left facial paralysis, left subconjunctival hemor- rhage, and hemorrhage from both ears. She died on the twenty-fourth day from the reception of the injury. Lesions. — Transverse fracture of the base, extending through both petrous portions and left orbital plate ; lac- eration of inferior surface of left frontal lobe ; small sub- 27 41 8 INJURIES OF THE BRAIN AND MEMBRANES. cortical laceration of left parietal lobe ; cortical liemor- rhasfe at base and over external surface of both hemi- spheres; general contusion. Case XXXIX. Symptoms. — Profound coma, which continued till death; stertor; pulse, 70, full and strong; temperature, 99.4°. Death in seven hours. Lesions. — Linear fracture through right side of oc- cipital bone to jugular foramen; pial hemorrhage over both occipital lobes and posterior portion of left parietal lobe ; excessive general hyperaemia. Case XL. Symptoms. — Contusion of left parietal re- gion; primary unconsciousness; epistaxis; delirium, which continued till admission to hospital two days later; uncon- sciousness at that time ; pupils normal ; pulse rapid and weak; respiration, 21 ; temperature, 101.4°, rising to 102°-}-; consciousness not restored. Death in four days. Lesions. — Linear fracture of occipital bone from tuber to right jugular foramen ; also fissure of left orbital plate; thrombosis of lateral sinuses; clot firm, but not decolorized ; general cerebral hyperaemia, with a few minute coagula. Case XLL Symptoms. — Unconsciousness succeeding an injury received on the preceding day; admission to hospital after twenty-four hours ; right pupil slightly di- lated; temperature, 99.8°; pulse, 96; respiration, 24; tem- perature rose to 100,2°. Death in about thirty hours from time of injury. Lesions. — Linear fracture running nearly transversely through left parietal bone into right coronal suture ; also V-shaped indirect fracture in right middle fossa; epidural hemorrhage over right frontal lobe from vertex to base; laceration of middle two-fourths of second right temporal convolution, with cortical hemorrhage extending over pa- rietal lobe; general hyperaemia with minute coagula in all parts of the brain. Case XLIL Symptoms. — Shock; consciousness re- tained; temperature, 96°; pulse, 78; respiration, 21; sud- CASES VERIFIED BY NECROPSY. 419 den cyanosis, with extreme dyspnoea, and loss of conscious- ness, which lasted for only three or four minutes, followed by numbness of both arms; no further dyspnoea; deliri- um fourteen hours later, and death four hours later still, preceded by a single convulsive movement and without respiratory disturbance. Lesions. — Occipital contusion and wound behind right ear; bifurcated linear fracture in right inferior occipital fossa; pial hemorrhage beneath tentorium, extending around lateral borders of cerebellum and covering the pons; moderate general hyperaemia. Case XLIII. Symptoms. — Scalp wounds in left parietal, and large haematoma in right parietal region ; compound linear left parietal fracture; no known loss of conscious- ness ; shock ; dilatation of both pupils ; pulse feeble ; res- piration shallow; temperature after four hours, 96.4°. Death in nine hours and a half. Lesions. — Parietal fissure extended nearly across greater wing of sphenoid ; considerable subarachnoid serous effu- sion ; general hypersemia and thrombosis of minute ves- sels, most marked posteriorly. Case XLIV. Symptoms. — Unconsciousness till death ; pupils normal; muscular twitchings over whole right side of body; temperature on admission, 98°; in six hours, 103.6°; in seven hours, 104.4°; in nine hours, 106.6°; pulse, 80 to 145; respiration, 15 to 34, Death in nine hours and a half. Lesions. — Calvarium crushed ; large wound in the skull at the vertex involving the median line, two by three inches in its diameters; on the left side the osseous fragments rested upon the dura mater, on the right they deeply pen- etrated the brain; a fissure extended into the right orbital plate; epidural clot on the left side, in which the parietal fragments were embedded ; on the right side, disintegrated brain tissue, bone, and membranes were commingled ; an- terior part of both lateral ventricles contained blood ; cor- tical hemorrhage extended beneath the tentorium ; general 420 INJURIES OF THE BRAIN AND MEMBRANES. hyperasmia and vessels even of the larger size filled with thrombi. Case XLV. Symptoms. — Scalp wound in left frontal region ; left pupil dilated ; consciousness only partially lost; temperature on admission, 98°; fell in four hours to 97.6°; pulse, 90; respiration, 24. Death in four hours and a half. Lesions. — Slight depression at left external angular process of frontal bone, and fissure extending thence through both orbital plates and intervening ethmoid body ; deep laceration of frontal lobes on either side of inferior median fissure ; smaller laceration of posterior border of cerebellum, near median line, from which a cortical hem- orrhage extended over both its superior and inferior sur- faces; general hyperaemia and minute coagula. Case XLVI. Symptoms. — Haematoma over whole ver- tex, and small wound of scalp; unconsciousness, which continued till death ; dilatation of left pupil ; general con- vulsions, beginning in hands, with marked opisthoto- nos; temperature six hours after reception of injury, 98.6° ; pulse, 84; respiration, 28; extent of fracture determined by incision. Death in nine hours. Lesions. — Disjunction of coronal suture, multiple fis- sure of frontal bone, and fissure through right parietal and occipital bones, with branch into posterior fossa ; lacer- ation of right frontal, parietal, and occipital lobes, and wound of dura mater permitting escape of brain tissue through osseous parietal opening. Case XLVI I. Symptoms. — Contusions of left side of head and face, and tactile evidence of simple fractures; unconsciousness, which continued till death ; epistaxis and hsematemesis ; temperature on admission, 99°; pulse, 96; two hours later, temperature, 96.4°; pulse, 140; respiration, 53; five hours later, temperature, 95.6°; pulse and res- piration as before. Second day, deglutition became possi- ble and sensitiveness to external impressions was regained; pupils slightly dilated ; temperature, 103° to 103.6°; pulse, CASES VERIFIED BY NECROPSY. 42 1 168 to 196; respiration, 48 to 58. Death in thirty-four hours. (In this, the case of a child four years and a half of age, the brain weighed forty-eight ounces, and was in all respects symmetrical ; the skull was of normal thick- ness.) Lesions. — Separation of the coronal and of the bifrontal suture to nasal bones, which were fractured ; fracture con- tinuous into ethmoid body, with complete detachment of the crista galli and cribriform plate ; fissure of right parie- tal bone and depressed fracture of left frontal above orbital ridge ; slight epidural hemorrhage over vertex ; lacer- ation of frontal lobes in the space corresponding to the site of cribriform plate ; general hypersemia with minute coagula, most marked in cerebellum and occipital lobes. Case XLVIII. Symptoms. — None discovered, and ad- mission to hospital refused two days after a fall in the street; found dead two hours later a block away ; wound over left eye. Lesions. — Pneumonia involving lower lobe of right lung, and large flabby heart ; fracture extending through left supra-orbital ridge and orbital plate into greater wing of sphenoid bone ; general hypersemia and thrombosis. Case XLIX. Symptoms. — Large hsematoma over right eye; profuse hemorrhage from mouth, nose, and right ear; unconsciousness; rapid and feeble pulse and respiration ; dilatation of both pupils, especially the left. Death in fif- teen minutes. (Caesarean section at six months and a half ; child lived forty-five minutes.) Lesions. — Separation of right sutura additamentum lamb- doidalis and fissure continued, through petrous portion and middle fossa, into body of sphenoid bone ; large pial hem- orrhage over left parieto-occipital region. Case L. Symptoms. — Wound over left eye and at occiput; shock; unconsciousness; hemorrhage from ears, nose, and mouth; restlessness, and utterance of short, sharp cries; pulse frequent, weak, and symmetrical; respi- ration slow, irregular, and sighing; right pupil dilated, and 422 INJURIES OF THE BRAIN AND MEMBRANES. left invisible from ecchymosis, twitching of right side of face, followed by general convulsions, preceded death at end of twelve hours. Lesions, discovered by incisions: In left temporal region fissures ran into temporal fossa, and squamous suture was partially disrupted; in occipital region open fissure ran into right petrous portion and lambdoid suture was sepa- rated; arachnoid hemorrhage in right occipito-parietal region. Case LI. Symptoms. — Scalp wounds in parietal regions; mobility and crepitation of calvarium; shock; unconsciousness, which continued till death ; slight epis- taxis and profuse haematemesis ; both pupils dilated, and after three hours and a half the right more so than the left ; one radial pulse fuller and stronger than the other ; temperature on admission, ioi°; in one hour, 102°; in two hours, 106°; in four hours, 106.8°; pulse, 70, no, 160, 170; respiration in two hours, 48. Death in four hours and a half. Lesions. — Fissure, beginning just above left internal angular process, running across middle of parietal bones, and nearly circumscribing calvarium ; another detached its posterior portion, and others still extended from primary line of fracture to base; arachnoid hemorrhage on left side; further examination refused. Case LII. Symptoms. — Contusion in left frontal region and ecchymosis of left eye; consciousness retained; hem- orrhage from right ear and from nose and mouth; de- lirium, becoming violent later in the day and during the night. On the second day, the patient formed a fixed delu- sion that he had fallen from a mulberry tree. He de- scribed with circumstantiality all the details of his imagi- nary accident. He had no recollection of the manner in which his injury had really occurred, and would give no credence to facts as they were presented to him ; he had other and transitory delusions, but this one remained un- alterable. Both pupils were moderately and symmetrically CASES VERIFIED BY NECROPSY. 423 dilated. His mind became remarkably alert, and his con- versation was logical and coherent. Nine days later hem- orrhage from the right ear recurred; subconjunctival hemorrhage, which had been previously noted, increased, and the left eye became prominent. Mechanical restraint was still necessary to keep him in bed. On the twelfth day, hemorrhage from the ear ceased, and subconjunctival hemorrhage diminished ; a scarcely perceptible facial paralysis existed. His mind seemed clearer; he could recollect the street and neighborhood in which he lived, but not the number of his house ; only the one delusion persisted. Later, a frontal headache from which he had constantly suffered became less urgent ; but his general condition was not materially changed till two days before his death, when he became progressively asthenic from an intercurrent diarrhoea. His mind remained clear with occasional transient delusions, his conversation coherent, and his belief in the mulberry tree unshaken to the last. Temperature on admission was 98.6°; one hour later, 100°; and five hours later, 104.7°; for the two days following it was 103° to 103.8°; and during the fourth and fifth days, 101° to 99°+ ; it varied till the twentieth day from 99.8° to 101.8°, only twice exceeding 100°. The pulse on ad- mission was 85, and the respiration 20, with no considera- ble subsequent changes till near the close of life. Thirty- six hours ante mortem temperature rose to 102.4°, a-^id twelve hours later to 105°; in another twelve hours it de- clined to 97.5°, and immediately before death rose again to 100°, with pulse of 140, and respiration of 42. Death on the twenty-fourth day. Lesions. — Depressed fracture above left supra-orbital ridge, with fissure extending across both orbital plates and intervening cribriform plate, through right middle fossa, external to greater wing of sphenoid, through outer part of petrous portion of temporal into posterior fossa, and returning upon itself across petrous portion and through body of sphenoid and ethmoid finally to terminate in itself 424 INJURIES OF THE BRAIN AND MEMBRANES. anteriorly. A second fissure crossed left orbital plate into left middle fossa. Small epidural hemorrhage beneath de- pressed part of fracture ; laceration of under surface of both frontal lobes, mainly subcortical, crossing median line obliquely from centre of left lobe to line of right an- terior cerebral artery. This laceration was one inch and one fourth wide by one inch in depth at its commencement on the left side, and on the right side was five-eighths of an inch in width by half an inch in depth. In removing the brain the arachnoid was torn and the difiluent contents of the cavity escaped; its margin and the overhanging cor- tical tissue were dark and sloughy ; its deeper portion was yellow and ragged; it was separated anteriorly on the left side from the median fissure by a single convolution. There were general hj'peraemia and minute thromboses, most marked posteriorly. Case LIII. Symptoms. — Haematoma in left parietal region ; coma ; stertor ; no response to external irritation ; pupils widely dilated; pulse full, slow, and strong; tem- perature on admission, 99°, and rose steadily to 107.8°; respiration, 32, 46, 14; pulse, 62, 70, 126. Death in four hours and three-quarters. Lesions. — Coronal suture separated and fracture contin- ued into anterior part of middle fossa on both sides; gen- eral hypersemia with well-marked but not excessive oedema, and some punctate extravasations. Case LIV. Symptoms. — Consciousness lost, but par- tially restored on arrival of ambulance ; large haematoma in right posterior occipital region; slight epistaxis; pupils moderately contracted ; respiration shallow ; right radial pulse after two hours more frequent than the left — 84 and 74, 114 and no; temperature on admission, 96''; in two hours, 95°; in six hours normal, rising to 100.4° before death in nine hours. Lesions. — Separation of coronal suture on left side and fracture continued through middle fossa, sella turcica, right middle fossa, right petrous portion, and posterior CASES VERIFIED BY NECROPSY. 425 fossa, to foramen magnum ; large epidural clot in left temporal region ; slight cerebral oedema ; old meningeal adhesions, and small white nodules in the pia mater. Case LV. Symptoms.- — Consciousness retained for fif- teen minutes after admission ; then delirious four hours ; afterward consciousness lost; contusion of right side of head; hemorrhage from left ear and nose, and ha^ma- temesis ; slight dilatation of right pupil ; temperature on admission, 101°, rising to 103°; pulse, 90 to 108; respi- ration, 22, 24. Death in ten hours. Lesions. — Linear fracture extended from right squa- mous portion through body of sphenoid and both middle fossse into left petrous portion ; a second fissure extended from sphenoid into cribriform plate ; large epidural clot in left middle fossa; marked general hyperaemia. Case LVI. Symptoms. — Delirium, which continued till final unconsciousness at close of life ; wound in left temporal region ; hemorrhage from right ear; second day, paralysis of left arm ; fourth day, loss of control of urine and faeces; death in three days and eight hours. Tem- perature on admission, 99°-)-; rose to 103.2°, declined to 101°, and rose to 106.6° shortly before death; pulse, 90 to 114; respiration, 18 to 28. Lesions. — Linear fracture extending from outer part of right petrous portion, through body of sphenoid bone into its left lesser wing; epidural hemorrhage in left middle fossa; large pial hemorrhage over right temporal and parietal lobes, especially profuse near the vertex; general hyperaemia with minute coagula ; thrombus in each lateral sinus. Case LVII. Symptoms. — Consciousness lost, partially recovered after admission; articulation imperfect; alco- holic condition ; small wound in right occipital region ; active delirium a few hours later; alternations of delirium and stupor till death, sixteen days afterward; temperature, pulse, and respiration normal from second to fourth day; temperature varied from 99.4° to 104.8', and was 103° at 426 INJURIES OF THE BRAIN AND MEMBRANES. time of last observation; pulse, 112 to 144; respiration, 26 to 44. Lesions. — Fracture extending from right of foramen magnum, three inches and a half, into left inferior oc- cipital fossa ; laceration of inferior surface of both frontal and left temporo-sphenoidal lobes; pial hemorrhage over right occipital lobe; general subarachnoid serous effusion. Case LVIII. Symptoms. — Coma, which lasted for a few hours ; wound in occipital region ; no general symp- toms noted till seventh day, when sudden recurrence of coma was followed by death. Temperature second, third, and fourth days, 100.4° to 99.4°; after second coma, 104;° pulse and respiration normal. Lesions. — Fracture through right middle fossa, involv- ing petrous portion ; laceration of inferior surface of right frontal and temporo-sphenoidal lobes; cortical hemor- rhage over almost entire surface of right cerebrum ; clot in substance of right centrum ovale. Case LIX. Symptoms. — Momentary unconsciousness; contusion of left eye and wound of left frontal region ; epistaxis without perceptible injury of the nose ; second day, delirium at intervals, becoming constant through the night; third day, somnolence, restlessness, and deliriiim characterized by delusions ; at close of the fourth day delir- ium became muttering and respiration stertorous. Death in four days and a half. Temperature on admission, 99.8°; on the second day, 104.8°, 102°, 100°, 103°, 101.8°; on the third day, 103.6°, 103.4°; on the fourth day, i03°-[-, 106.6°; on the fifth day, 107°, 108.2°. Pulse till end of fourth day, 82, 56, 90, 106; respiration, 19, 34, 24, 40. Lesions. — Fracture beginning at left external angular process of frontal bone, comminuting orbital plate, extend- ing into body of sphenoid, and, after bifurcation, terminat- ing in cribriform plate and in squamous portion of right temporal bone ; two lacerations of inferior surface of left frontal lobe — one near its centre as large as a hickory nut, containing disintegrated clot and brain tissue, the CASES VERIFIED BY NECROPSY. 427 other smaller and more superficial, encroaching upon middle portion of Sylvian fissure ; two other slight lacerations upon inner border of right occipital lobe ; slight subarachnoid serous effusion upon upper surface of cere- bellum ; general hyperasmia with some minute coagula. Case LX. Symptoms. — Consciousness not lost, but delirium continued from time of injury till final coma; contusion behind left ear; very slight dilatation of pupils; delirium became violent. At the end of two or three hours the patient became aphasic; he could utter single words correctly, or a number of words in succession, each correct in itself, but strung together without sense or logical se- quence, as "water — father — when," or "Jesus — now — who." He also connected fragments of words with each other, as "en — is — other," meaning when is mother; or "J — mother," for Jesus, mother; or "J — ter," for Jesus, water; sometimes "ter — J," for water, Jesus. The clew to these fragmentary words and sentences was found in the words he constantly used singly. The aberrations of speech, like the delirium, continued till final coma, and were constant. On the second day his head was extended, but without cervical rigidit}'; he was restless and irritable; the pupils were still normal ; urine was retained ; coma and stertor supervened, and death occurred thirty-seven hours and a half after admission. The temperature on admission was 100.2°, rose progressively in twenty hours to 105.2°, remained stationary for twelve hours, and again rose progressively to 108.6'. One hour post mortem it was 110°. The pulse constantly increased in frequency from 90 to 190. The respiration did not exceed 24 for thirty- two hours, after which it was from 40 to 50. Lesions. — Fracture extending from left superior occipital fossa, through posterior condyloid foramen, into foramen magnum; epidural hemorrhage, slight over occipital lobes and more abundant in inferior occipital fossae; cortical hemorrhage in central part of an- terior fossae and over sella turcica; thrombi in left lateral 428 INJURIES OF THE BRAIN AND MEMBRANES. and superior petrosal sinuses; posterior meningeal veins, including those of larger size, greatly distended ; some opacity of arachnoid membrane and subarachnoid serous effusion over right occipital lobe. Lacerations con- fined to base, except in case of left temporo-sphenoidal lobe. The first left temporal convolution was lacerated through the whole thickness of its cortex for a length of one inch and a half, which included the second and part of its third fifths, estimated from its anterior extremity, and its middle portion involved the second convolution. This laceration was limited to the exact width of the two convo- lutions and was covered by the unruptured arachnoid. A small and deep laceration existed upon the inferior surface of this lobe, and another, small and shallower, was situ- ated at its tip, involving all three of its convolutions. A similar slight laceration occurred at the anterior extremity of the right temporo-sphenoidal lobe, including the second and third convolutions. There was an extensive lacera- tion of the under surface of the left frontal lobe, extend- ing from its anterior border to the optic chiasm and from the median line outward through the first and second into the third orbital convolution ; it disintegrated the cortex and the subcortex to a considerable depth, and the resul- tant hemorrhage had broken through into the arachnoid cavity. There was, fi.nally, a small contusion about the centre of the inferior surface of the right frontal lobe. The brain substance was generally hypersemic with minute thromboses, and a small amount of reddish serum occupied the lateral ventricles. Case LXI. Symptoms. — No evidence of brain lesion on admission, twenty-four hours after injury, except right radial pulsation was fuller and stronger than the left ; fol- lowed by delirium, with delusions, after sixteen hours, which, with the unsymmetrical pulse^ persisted for five days. On the sixth day, mind clear, memory restored, general headache; later, delirium at intervals, aimless inclination to get out of bed, increasing difficulty of articu- CASES VERIFIED BY NECROPSY. 429 lation, progressive mental impairment; control of bladder and rectum lost. On the twenty-fifth day, patient quiet, weaker, picking at the bedclothes. Twenty-sixth and twenty-seventh days, delirium, irritability, great sensitive- ness to external disturbances, unconsciousness. Death occurred on the twenty-eighth day. Temperature on ad- mission, 102°; second and third days, 103°, 104.4°; from this time it was usually 99° to 99°+, sometimes normal, occasionally loo^ until the last eighteen hours, when it suddenly rose to 105", and, with slight recessions, finally reached 108°. Pulse, 84 to 54, till the last four days, when it exceeded 100 ; but in the last twelve hours, with the highest temperature, it ranged from 70 to 54. Respira- tion was accelerated on the second and third days, but at other times was normal till within a few hours of death. Right axillary temperature the day before death was from 0.2° to 1.2° higher than the left. Temperature one hour post mortem, 108°. Lesions. — An open fissure extended from beneath the torcular Herophili, downward and slightly outward, to a point near the left m.argin of the foramen magnum, where it subdivided to enclose a quadrangular depression of bone three-quarters of an inch by half an inch in its diameters ; it was then continued between the posterior border of the petrous portion and the basilar process of the occipital bone, where it terminated. No external evidences of in- jury; small epidural hemorrhage on either side of median line at commencement of fracture; two thin laminar spots of epidural clot, each about half an inch in diameter, firmly attached to dura over anterior part of left frontal lobe, from indirect violence ; corresponding blood stains upon surface of bone, but under surface of dura not discol- ored; large subarachnoid serous effusion over vertex; meningeal hyperaemia, but none of cerebral surface. Four lacerations of antero-superior surface of left pre- frontal lobe, with contusion of intermediate cortex, the whole covering a space one inch and a half in diam.eter ; 430 INJURIES OF THE BRAIN AND MEMBRANES. another laceration of small size a short distance be- hind them; small laceration upon anterior part of ex- ternal surface of right frontal lobe ; these lacerations all extended into the subcortical substance and were partially filled with necrotic tissue ; the adjacent brain substance was unaltered. Marked general oedema and hyperaemia, with moderate number of punctate extravasa- tions and minute thrombi; brain of normal consistence. Immediate microscopic examination afforded no evi- dence of inflammatory action, except in contiguity to the necrotic tissue. The quadrangular osseous depression was firmly fixed, but there was no osseous deposit. Case LXII. Symptoms. — No history; walking case; semiconsciousness, but without speech or comprehension of speech then or afterward; hemorrhage from left ear, and oedema of left mastoid region; pupils normal; early delirium ; sensitiveness to external irritation ; reten- tion of urine. Second day, entire unconsciousness; con- vulsive movements of limbs; Cheyne-Stokes respira- tion ; accumulation of mucus in trachea and bronchi, and death in forty-two hours. Temperature on admission, 101.6°; in twenty-four hours, 103.2°; in twenty-seven hours and till death, 108.6°; one hour post mortem, 108°. Pulse, 64 to 50; second day, 140 to 168. Respiration, nor- mal, 24, 16, 20. Lesions. — Haematoma in left occipital region ; linear fracture through left occipital bone, from median line and along groove for lateral sinus, across petrous portion by a wide fissure, and separating dorsum ephip- pii from sphenoid bone ; thrombus in left lateral sinus; complete disintegration of right frontal lobe to within half an inch of fissure of Sylvius and quite to anterior border of corpus striatum; deep laceration of greater part of inferior surface of left temporo- sphenoidal and a smaller laceration in centre of in- ferior surface of right temporo-sphenoidal lobe ; cor- tical hemorrhao^e from the frontal laceration filled all the CASES VERIFIED BY NECROPSY. 431 basic fossae except the outer part of the left anterior, and one clot m the median line anteriorly was as large as a mandarin orange ; it also covered with a thin coagtilum the superior and lateral surfaces of the whole right and the greater part of the left hemispheres, and extended over the superior surface of the cerebellum ; general hyper- asmia, with a few minute thrombi ; minute extavasations in centre of pons, the largest of which was of about the size of a robin shot. Case LXIII. Symptoms. — Primary unconsciousness, followed by mental hebetude and mild delirium, which continued till death ; occasional dysphagia in second week, sometimes extreme. Temperature on admission, 99.2°, rose in two hours to 102°, and was afterward 99° to 100° and loi'. Pulse on admission, 50; below 90 for eight days; afterward exceeded 100. Respiration normal. Death occurred in fourteen days, and was immediately preceded by extreme dyspnoea and dysphagia. Lesions. — Fracture through left occipital, from median line to petrous portion of temporal bone ; extensive lacera- tion of antero-superior and inferior surfaces of left frontal lobe ; cortical hemorrhage covered with a thin clot the entire left hemisphere and the posterior half of the right, and filled all the basic fossae. Case LXIV. Symptoms. — Contusion in occipital re- gion, and recurrent hemorrhage from left ear; violent delirium after thirty-six hours ; right radial pulse fuller and stronger than the left on the third and fourth days. Temperature on admission, 98.4°, rose in twelve hours to 102°, and afterward varied from 98.5° to 100°-]- in the morning, and from 99.5^ to 100.8° in the evening; last observation, six hours ante mortem, 101.6°. Pulse and respiration were practically normal. Death in ten days. Lesions. — Fracture through posterior part of left parie- tal, into petrous portion of temporal bone; transverse lac- eration across inferior surface of right frontal lobe at junc- 432 INJURIES OF THE BRAIN AND MEMBRANES. tion of its anterior and middle thirds, which was subcortical except at outer extremity, where hemorrhage had broken through the surface; small laceration of anterior fourth of second right temporal convolution, mainly subcortical; cortical hemorrhage in right middle and posterior fossae, and to a small amount in right anterior fossa; moderate general hyperasmia, with a few minute coagula. Case LXV. Symptoms. — Consciousness lost and par- tially restored; persistent occipital pain; admission to hospital four days later; stupor merging in final uncon- sciousness ; loss of control of bladder and rectum ; right radial pulse fuller and stronger than the left, but difference not strongly marked; pupils normal. Temperature on ad- mission ioo°; normal, with exception of eight hours on the seventh day, when it was from 99.2'' to 99.4°, till ten hours ante mortem; final temperatures, 99.2° to 103.8°; pulse, 45 to 80; respiration, 14 to 18. Death in ten days. Lesions. — Hsematoma in left occipital region; biparietal and left parieto-occipital sutures loosened but not sepa- rated ; small laceration on under surface of right frontal lobe anteriorly; cortical hemorrhage covered the whole lateral and superior surfaces of both hemispheres, except in left lower parietal region, extended into median fissure and beneath tentorium over superior surface of cerebellum, and occupied both anterior and both middle fossae. The effusion was thin, except at the base and over the frontal lobes, where the clot was thick, firm, black, and closely adherent to the cortex, and could be traced into the frontal laceration from which it originated. A still smaller lacer- ation existed upon the inferior surface of the right temporo- sphenoidal lobe. The brain was moderately hyperasmic and very oedematous in its cerebral portion. There were no punctate extravasations, few minute thrombi, and no in- flammatory products. Case LXVI. Symptoms. — Complete unconsciousness, which continued till death; hemorrhage from nose and mouth; pupils contracted and immovable, but in a few CASES VERIFIED BY NECROPSY. 433 hours left became dilated; some convulsive movements of right arm; retention of urine; second day, ecchy- mosis of both eyes and subconjunctival hemorrhage in right; continued dilatation of left pupil; right normal. Temperature on admission 101°; in four hours, 102"; in sixteen hours, 105°, and in twenty-four hours, 106°; pulse and respiration frequent throughout. Death in twenty- six hours. Lesions. — Extravasation of blood into substance of left temporal muscle disclosed by incision ; open fissure extended from squamous portion of right temporal bone across both orbital plates and intervening cribriform plate of ethmoid, broke off left lesser wing of sphenoid, crossed left middle fossa and petrous portion, and terminated in left margin of foramen magnum ; epidural clot occupied the whole right anterior fossa, and another of smaller size the left middle fossa ; a thrombus filled the posterior part of the superior longitudinal sinus ; cortical hemorrhage over superior surface of the cerebellum, derived from a small laceration of its lateral border; small pial hemor- rhages over left parietal and temporo-sphenoidal lobes, and a larger one over right parietal lobe ; large subcortical lacer- ation of left temporo-sphenoidal lobe, excavating its sub- stance beneath second and third convolutions and anterior portion of the first convolution, which did not reach the surface; moderate general hyperaemia, more marked in pons and cerebellum. Case LXVII. Symptoms. — Patient walked two miles to the hospital gate and was carried unconscious to the ward ; ecchymosis of right eye and wide dilatation of right pupil ; slight contraction of the left ; no motor or sensory disturbances; left brachial pulsation full and strong, the right very small and weak ; same conditions existed in the radial arteries, but the contrast somewhat obscured by contusion of the left wrist. Temperature on admission , 98° ; four hours later, 104.6°; immediately after death, 105°; one-half hour post mortem, 105.4°; pulse, 40 to 64; respira- 28 434 INJURIES OF THE BRAIN AND MEMBRANES. tion, 32 to 2,^; cyanosis just before death, at the end of five hours. Lesions. — Contusion of scalp, disclosed by incision, ex- tending from coronal suture backward above temporal ridge; fracture in right middle fossa, involving both squa- mous portion of temporal and greater wing of sphenoid bone ; firm epidural clot from laceration of anterior branch of arteria meningea media, measuring three fluid ounces, which filled right middle fossa and flattened temporal lobe laterally and inferiorly. When the clot was re- moved the brain retained its position, widely separated from the base, and leaving the anterior petrous surface and the adjacent middle fossa exposed. The smaller superficial veins and arterioles of the brain were congested, and the surface between them, at first pale, was soon uni- formly reddened. There was a small laceration of the posterior part of the third left temporal convolution ; an- other, somewhat smaller than a buckshot, was found in the anterior part of the pons at the apposition of the trans- verse and longitudinal fibres. The brain substance was generally hyperaemic, especially in the left hemisphere, but without minute extravasations or thrombi. The sur- faces of section soon became deeply reddened and bathed in watery effusion. Case LXYIII. Symptovis. — Partial unconciousness; recurrent hemorrhage from right ear, succeeded by a flow of serous fluid ; vomiting; dilatation of both pupils ; reten- tion of urine ; greater fulness and strength of the left radial pulse than of the right; mental condition normal; inter- current bronchitis on the third day, which ran its usual course ; from the second day a peculiar dusky and swollen appearance of the face, which continued till within two or three days of death ; no other indications of cerebral in- jury till the fourteenth day, when there was occipital pain, which became general headache, and a little later there were somnolence and occasional irritabilit3\ On the eighteenth day, the fifth of this epoch, posterior cervical rigidity ; delir- CASES VERIFIED BY NECROPSY. 435 ium ; temperature at its maximum ; tenderness along the course of the larger nerves of the left lower extremity from the twentieth to the twenty-fifth days; delirium more active, lucid intervals less frequent, somnolence more continuous, and sense of hearing impaired ; deafness progressive till complete ; power of articulation gradually lost, and finally communication possible only by gesture ; dysphagia occurred more suddenly and a little later. The mental condition varied from normal to that of stupor or delirium ; emaciation was progressive ; paralysis and hy- perassthesia of the left lower extremity were of late occur- rence ; recurrence of posterior cervical rigidity was once noted, but was transitory; toward the end, control of urine and faeces was lost ; during the last twelve hours uncon- sciousness was complete, and respiration rapid, insufficient, and entirely nasal. Death occurred on the thirty-first day. The temperature on admission was 97°, became normal in four hours, and was afterward 99° till the invasion of bronchitis, on the third day, when it rose to 103°, and subsided with recovery from the comi plication. On the tenth day it again rose with the recurrence of intracranial symptoms to 103.4°, and afterward varied from 100° to 104°, and was not often less than 101° +. The post- mortem temperature receded in one-half hour from 103.4° to 103°. The axillary temperatures, carefully recorded from the sixth day, were symmetrical in nearly half the observations, and in the others usually varied two-tenths of a degree, and were rather more frequently higher on the right side. The pulse was usually from 64 to 90. The respiration, always frequent, was rarely less than 30 in the minute from the time of admission. Lesions. — No external injury ; linear fracture extending from squamous, through petrous portion of right temporal bone; simple thrombosis of lateral sinuses from torcular Herophili into jugular veins; punctate extravasations in pia mater; large occipital veins distended; no serous effu- sion at vertex, but patches of false membrane, mainly 436 INJURIES OF THE BRAIN AND MEMBRANES. upon left frontal lobe, and upon either side of median fissure. Several ounces of turbid serous effusion at base, and a large amount in lateral ventricles; fibri- nous exudation covering pons, medulla, and inferior surface of cerebellum, one to two millimetres in thick- ness, and in Sylvian fissures; limited contusion of posterior part of surface of right temporo-sphenoidal lobe, covering a space one inch square, which was of a yellowish color and studded with hard miliary hemor- rhages; fornix much softened, and brain substance gen- erally hyperaemic and oedematous. Immediate microscopic examination showed the mem- branous effusion to be crowded with small round cells which extended for some distance in diminishing quantity into the substance of the underlying cerebellum. Other portions of the brain tissue were unchanged. The Strep- tococcus pyogenes was developed from cultures of the exuda- tion. Case LXIX. Syuiptoms. — Consciousness lost, but re- stored at time of admission ; haematoma over right frontal region ; vomiting ; severe frontal headache ; face flushed ; pupils normal; temperature, 95° ; pulse, 90; respiration, 20. One hour later, wide dilatation of right pupil, and right cornea more sensitive than left; sudden uncon- sciousness, followed by rigidity of left side, and con- vulsive movements of right. At the end of an hour and a half, temperature, 97°; pulse, 85; and Cheyne- Stokes respiration. Death in three hours from time of injury. Lesions. — Linear fracture in squamous portion of right temporal bone, continued through anterior part of middle fossa and terminating in body of sphenoid bone; large epidural hemorrhage over lateral surface of right hemisphere nearly to median fissure ; blood partially coagulated and derived from posterior division of ar- teria meningea media; surface of right temporal and anterior part of right occipital lobe somewhat flat- CASES VERIFIED BY NECROPSY. 437 tened; slight contusion of left second temporal convolu- tion ; brain moderately hyperaemic and oedematous. Case LXX. Symptoms. — Patient admitted to the hos- pital without history, wholly unconscious and with Cheyne- Stokes respiration ; scalp wound in right occipital region ; pupils equally dilated ; right radial pulsations fuller and more compressible than the left; temperature, 97.6°. In thirty minutes the right pupil became normal, and in four hours also the left pupil, and the temperature rose to 98.4°; the respiration was 16, and the pulse, previously 130, was reduced to 92; unconsciousness continued. In eight hours the temperature was 102°, the pulse 128, and the respiration 40; the patient could articulate, and an- swered " Yes" to all questions. In eleven hours, temper- ature, 103.2°; pulse, 140; respiration, 42; and in twelve hours death ensued. Temperature, thirty minutes post mortem, 104.6°. Lesions. — Linear fracture from right occipital tuber, to left petrous portion. Epidural hemorrhage in left pos- terior fossae ; cortical hemorrhage over both hemispheres ; slight lacerations of inferior surface of both frontal and both temporal lobes ; brain substance markedly hyperaemic. Case LXXI. Symptoms. — Coma; stertor; pulse strong and irregular; respiration slow; slight dilatation of both pupils, which were insensitive; slight twitching of both arms; extremities cold; no external evidence of injury; temperature, 94.2° to 101.2°; respiration, 24, 20, 14; pulse, 42 to 52. Death in eleven hours. Lesions. — Linear fracture extended from just above and behind right ear into posterior inferior fossa; enormous epidural hemorrhage, derived from posterior division of middle meningeal artery, which compressed right hemi- sphere; slight laceration of the right parietal lobe, pos- terior to fissure of Rolando. Case LXXII. Symptojns. — Unconsciousness, which continued till death ; contusions and superficial wounds of left side of face and temporal region ; dilatation of both 438 INJURIES OF THE BRAIN AND MEMBRANES. pupils, of the right more than of the left; hemorrhage from mouth, nose, and right ear; relaxed muscles, and imperceptible pulse at wrist. Death occurred five minutes after admission, and in about an hour after reception of injury. Lesions. — Hasmatoma over left temporal, both parietal, and right occipital regions, from rupture of intracra- nial vessels ; calvarium crushed on left side anteriorly, and its fragments deeply depressed and distorted; zygoma and both orbital plates comminuted; body of sphenoid bone disintegrated, and base of skull extensively fissured; thin pial hemorrhage covered entire brain, possibly aug- mented by some cortical effusion at base ; limited contu- sions confined to cortex about right parieto-frontal junction and along right side of median fissure; cortical lacera- tions upon inferior surface of left frontal lobe and at tip of left temporo-sphenoidal lobe; brain substance generally hyperaemic and oedematous, with a few punctate extrava- sations. Case LXXIII. Symptoms. — Patient was found in the early morning, sitting in a chair, in which he was said to have passed the night. He would not reply to questions, from seeming lack of comprehension. He could walk, though he had little control over his limbs ; his face was pale and showed traces of vomiting. On admission, there were partial consciousness, right hemiplegia, and hemi- anaesthesia; dilatation of left pupil and contraction of the right; loss of control of urine and faeces; profuse serous discharge from both ears, and slight oedema of lungs. Two hours later coma was complete and oedema of the lungs had increased. Death occurred in ten hours. Tem- perature on admission, 99.2°; in two hours, 101.2°; in four hours, 103°; in six hours, 103.4°; in nine hours, 103.8°; in ten hours, when m articiilo mortis, 104°; thirty minutes post mortem, 106°. The right axillary temperature was 0.2° higher than the left at each observation. Pulse, 90 to 108; respiration, 36, 30, 38. CASES VERIFIED BY NECROPSY. 439 Lesions. — Slight hsematoma over right parietal region disclosed by incision ; fracture extending from right of occipital tuber, across petrous portion, into greater Aving of sphenoid; opacity of arachnoid in right frontal and an- terior parietal regions; small cortical hemorrhage over frontal lobes; extensive laceration of frontal, temporal, and inferior portion of parietal lobes on left side ; these parts were excavated and filled with a dark solid clot, which was extruded in large quantity through a long tear made in the process of removal of the brain from the cranial cavity ; slight ante-mortem cortical rupture through which a little blood had escaped into the middle fossa and ascended upon the frontal region, and another into the posterior cornu of the lateral ventricle, through which the choroid plexus was infiltrated ; small, deep laceration upon the anterior border of the left cerebellum; moderate general hyperaemia and marked oedema, with a few punc- tate extravasations; thrombi in the superior longitudinal and lateral sinuses. Case LXXIV. Syuiptoms. — Patient received a scalp wound two days previously, and Avas found unconscious. On admission to the hospital, mental condition dazed but rational; temperature, 100°; pulse, 68; respiration, 20. Temperature rose on second day to 102° and receded on the third to 98.8°, with normal pulse and respiration. On the fourth day a general convulsion occurred, rather sud- denly, and was followed by four others between morning and night. Temperature remained from 99" to 98' — , and on the fifth and sixth days was from 98.4'' to 97' — . On the seventh day stupor with loss of faecal and urinary control, and on the eighth day coma. Temperature, 97" to 98.8^ in the morning, and 101.2° to 100.2° in the evening. Pulse,. 66, 138, 66, 102. Respiration, 18, 36, 21. On the ninth day, coma continued with contracted pupils and progres- sive anaemia. Temperature, 100.6" to loi"'; pulse, 152 to 146; respiration, 48, 54. Death occurred on the tenth day. Temperature then, iqi° ; and one hour post mortem, 100.8°. 440 INJURIES OF THE BRAIN AND MEMBRANES. Lesions. — Slight separation of anterior portion of bi- parietal suture, continued as an open fissure through me- dian line to centre of frontal bone, and thence as a fine closed fissure through supra-orbital ridge into left orbital plate. Slight epidural hemorrhage beneath the biparie- tal suture. Large pial hemorrhage over left hemisphere, with thick clot in posterior parietal region, and extend- ing over right frontal lobe into anterior and middle fossae; slight cortical contusion upon inferior surface of right temporal lobe. Arachnoid opacity along margin of su- perior median fissure. Brain substance hyperaemic and oedematous. Case LXXV. Symptoms. — Fell down a flight of stairs ; still unconscious on admission; wound in left occipito- parietal region; hemorrhage from left ear; right pupil irresponsive and widely dilated, left pupil moderately dilated ; muscular system relaxed ; temperature on admis- sion, 95°, and in one hour normal; rose progressively to 104.2°; right axillary temperature uniformly from 0.2° to 0.4° higher than the left till the last observation, when the difference was 2°; respiration, 22 to 24; pulse on ad- mission, 72, irregular and intermittent, and afterward 78 to 86 till immediately before death, which occurred in eight and one-half hours. Lesions. — Fracture, which extended from left inferior occipital curved line through petrous portion into sella turcica; laceration, two inches long by an inch wide, of inferior surface of left temporo-sphenoidal lobe ; another, half an inch in diameter, at anterior extremity of first left temporal convolution; and a third upon inferior surface of riofht frontal lobe, which involved its anterior half; cortical hemorrhage filled right anterior and both middle fossae, covered right hemisphere laterally, and extended as a thick clot over right frontal lobe and along corpus callosum quite to cerebellum ; some small extravasations in substance of pons; general hyperaemia and punctate extravasations in anterior and posterior portions of brain. CASES VERIFIED BY NECROPSY. 44 1 Case LXXVI. Symptoms. — Coma; stertor; left pupil dilated; small wound and larger hasmatoma in left parietal region ; sensation diminished in both lower extremities and muscular twitching in right; vomiting; pulse, 52. After trephination a soft epidural clot was discovered and a considerable loss of blood ensued. Using as a guide a fissure which extended through the squamous and petrous portions into the middle fossa, the bone was chiselled and the posterior division of the middle meningeal artery, which was found to be the source of hemorrhage, was clamped. The pulse increased in frequency from 72 to 104; the pupils became normal, but consciousness was not restored, and death occurred a few hours later. Lesions as above. Case LXXVII. Symptoms. — Unconsciousness and death immediately after admission. Lesions. — Skull crushed and flattened on right side; fragments very movable ; comminuted on left side ; ex- tensive laceration of brain posteriorly in left hemisphere; only small superficial wounds of scalp. Case LXXVIII. Symptoms. — Coma; stertor; hemor- rhage from left ear; contusion of left parietal region; pupils dilated; pulse full and slow; temperature on admis- sion, 98°, and rising progressively to 103.6° at time of death in four hours; no decrease for one hour post mortem; respiration, 18 to 26; pulse on admission, 70, rising to 90. Lesions. — Fissure extended from left parietal eminence, through squamous and petrous portions into middle fossa ; deep laceration of inferior surface of right temporo-sphe- noidal lobe and of lateral border of right cerebellum ; cor- tical hemorrhage filled right middle fossa ; hyperaemia of right side of brain. Case LXXIX. Symptoms. — Consciousness lost and not regained ; coma grew more profound ; slight oedema of scalp in right temporal region ; pupils slightly dilated ; great restlessness and irritability ; lack of urinary control ; 442 INJURIES OF THE BRAIN AND MEMBRANES. temperature on admission, 100.4°, and rising to 108°, with only two or three brief fractional recessions; pulse, 94, 58, 80; respiration, 28 to 24. Death in forty-three hours. Lesions. — Haematoma over whole right side of head; linear fracture from right frontal through parietal bone into inferior occipital fossa; large epidural clot over whole base on right side, extending upward over lateral surface of brain ; laceration of inferior surface of both temporo- sphenoidal and both occipital lobes; laceration of inferior surface of both frontal lobes in their anterior portion, very extensive on left side; cortical hemorrhage over posterior border of cerebellum; extensive general hyperae- mia with punctate extravasations. Case LXXX, Symptoms. — Immediate unconsciousness. On admission to the hospital pupils unequal, left dilated, right contracted, neither sensitive to light; urine retained. Temperature, 102.8°; pulse, 96; respiration, 20; eighteen hours later, temperature, 103°; pulse, 80; respiration 24 ; no change in general s3^mptoms. Operation done and an epidural clot of five ounces removed from temporo-parie- tal region, and clear fluid from arachnoid cavity. Tem- perature rose in four hours to 104.8°, pulse to 145, and respi- ration to 32 ; after sponge bath, temperature, 102.4°; pulse, 120; respiration, 32, No change in pupils at any time pre- vious to death. On the following day delirium, continued retention of urine, and convulsive movements of both eyes. Temperature, 102.4°, 103°, 101.8°; pulse, 145, 128; respira- tion, 30 to 32. On the third day, temperature, 103.6°, 102.6°, 104.4°, reduced by sponge bath to 102.4°; pulse, 148 to 140; respiration, 36 to 28. Urinary control lost. On the fourth day temperature was again reduced from 104.4° to 102° -f- by sponge bath. Patient restless and delirious at times, and complained much of pain in his head. The pupils were responsive to light ; clot protruded from cranial opening. The temperature subsequently varied from 102.6° to 100.2° on the sixth day, when it rose pro- gressively to 106°, and was again reduced to 102.2° by the CASES VERIFIED BY NECROPSY. 443 sponge batli. Death occurred two and one-half hours later, or five days and fourteen hours from time of ad- mission. Temperature thirty minutes post mortem, 105°. Delirium increased during the last day. Lesions. — Haematoma in left parietal region. Linear fracture beginning in anterior and inferior part of left frontal, running upward to middle of parietal, and then downward to anterior border of petrous bone in middle fossa. A second fissure extended from the first, at the fronto-parietal junction to the sella turcica, crossing the groove for the anterior branch of the middle meningeal artery. Large epidural clots compressed the left hemi- sphere ; one weighed three and one-half ounces. Lacera- tion, one-half by one-fourth inch in diameters, of inferior surface of left temporal lobe anteriorly, and one still smaller of inferior surface of left frontal lobe. Cortical hemorrhage over left fissure of Rolando. Lateral ventricles distended with serous fluid ; also third ventricle ; iter e tertio ad quar- tum ventriculum as large as a goose quill ; and small hemor- rhage in floor of fourth ventricle, clot one-eighth inch in dia- meter at base of calamus scriptorius. Moderate general cerebral hyperaemia. Case LXXXI. Symptoms. — Large haematoma over left frontal region ; epistaxis and hasmatemesis ; simple fissure from left frontal eminence into orbital plate, dis- closed by incision. On the sixth day muscular twitch- ing of whole right side, including extremities, but not the face, which ceased entirely in fourteen hours and was followed by left hemiplegia and hemiansesthesia. On the seventh day a convulsion, confined for thirty minutes to the right side but afterward becoming general, occurred two hours before death. Temperature on admission was 100.2°, rose to 104.4° on the same day, and to 105.6° on the next, with recessions, and afterward varied from 102° to 105.2°, with no observation for six hours ante mortem. Pulse on admission was 120, and subsequently 130 to 152. Respiration, 26 on admission, and later 44 to 58. 444 INJURIES OF THE BRAIN AND MEMBRANES. Lesions. — Fracture extended from the orbit through posterior part of ethmoid, and the body and right lesser wing of sphenoid into floor of right middle fossa: gen- eral subarachnoid purulent effusion, most marked in left frontal region below site of fracture. Case LXXXII. Symptoms. — Conscious on admission; Cheyne-Stokes respiration ; dilatation of left pupil ; right radial pulse fuller and stronger than the left ; haematoma on right side of the head anterior to occipital junction, and small lacerated wounds over both frontal eminences; muscular contractions of left side, and later of both sides of body. On admission, temperature, 99.3°; pulse, 104; respiration, 19. Lesions. — Multiple fracture; fissure across frontal bone above orbits, extending on either side through parietal bone to median line of vertex on both sides, thence to occiput, and on right side behind ear to within an inch of foramen magnum ; another fissure on left side ex- tended through orbital plate of frontal and lesser wing of sphenoid into middle fossa. Dura and pia mater were lacerated from right mastoid region to a point just beyond median line. Right motor area extensively lacerated, and right optic thalamus and corpus striatum to lesser extent. Left hemisphere was uninjured. Case LXXXIII. Symptoms. — Patient came home in a dazed as well as intoxicated condition, and said he had been assaulted and robbed. He was afterward weak and his mind wandered ; three days later he was found uncon- scious and sent to the hospital. On admission he was un- conscious, muttered incoherently when roused, and the right eye was contused and the pupil contracted; right arm and leg slightly rigid. Death occurred in fourteen hours. Temperature rose progessively from 104° to 106°, pulse from 108 to 204, respiration from 22 to 68. Lesions. — Haematoma of right temporo-occipital region; stellate fracture above right ear with fissures running through sella turcica into left middle fossa; trivial epi- CASES VERIFIED BY NECROPSY. 445 dural hemorrliage from diploic vessels at point of fracture ; slight pial hemorrhage upon under surface of right frontal lobe; limited subarachnoid sero-purulent effusion upon posterior border of left cerebellum in an area not more than one inch in diameter. Excessive hypersemia and moderate oedema of brain. Case LXXXIY. Symptoms. — Patient found uncon- scious in the street. On admission to the hospital, pupils symmetrical but irresponsive to light. Temperature, 98°; pulse, 100; respiration, 30. Death occurred suddenly in one hour. Respiration had dropped to 4 or 5 per minute. Lesions. — ^Wound in median line of occiput; linear fracture extending from a point just to right of occipital median line, forvard and upward into right squamous portion and downward through both occipital fossae nearly to foramen magnum ; slight epidural hemorrhage at ver- tex along line of fracture ; cortical hemorrhage over left temporal and parietal lobes laterally, and in somewhat larger amount over inferior surface of left frontal lobe anteriorly ; pial hemorrhage over whole left side of base of brain, covering pons at its posterior border, and form- ing a large clot upon posterior surface of medulla ; superficial lacerations of inferior surface of left frontal lobe, one situated along median fissure and another near external border; right cerebellar lobe completely exca- vated b}^ subcortical laceration, and filled with clot; both lateral ventricles, and the fourth ventricle, distended with clot and serum derived from contusion of choroid plex- uses ; brain substance moderately hyperaemic and exces- sively oedematous. Some subarachnoid effusion and opacity of arachnoid membrane over posterior parietal and anterior occipital regions probably preceded injury. Case LXXXV. Symptoms. — Primary and permanent unconsciousness ; wound above right superciliary ridge ; ecchymosis of both eyes; stertor; hemorrhage from mouth, nose, and both ears; left pupil dilated, right con- 44^ INJURIES OF THE BRAIN AND MEMBRANES. traded, and both insensitive ; fibrillar twitching of right chest muscles. No paralysis or muscular rigidity. The temperature on admission was 99.4°; pulse, 120, full and strong; respiration, 13; the temperature rose to 99.6°, and the respiration was reduced to 4. Death occurred in twenty minutes ; immediate post-mortem decline in tem- perature. Lesions. — An extensive comminuted fracture of frontal bone and both frontal plates extended through the middle fossae into the petrous portions ; the left optic nerve was crushed by a fragment of bone in the optic foramen. The inferior surface of both frontal lobes was deeply lacerated over its whole extent, and a cortical hemorrhage, still fluid, occupied all the basic fossae, and covered the pons and medulla. Case LXXXVI. Symptoms. — Primary and permanent complete unconsciousness ; hemorrhage from left nostril ; dilatation of both pupils ; no convulsions or muscular rigidity; respiration not more than four to five in the minute at any time after the receipt of injury and finally not more than one ; pulse continued full, strong, and of normal frequency for some moments after respiration ceased. Death in forty-five minutes. Lesions. — Fracture extending through left side of base into middle fossa; moderate pial hemorrhage covering whole surface of brain, vertex, and base, and also me- dulla ; marked general hyperaemia and oedema ; contusion of under surface of left temporo-sphenoidal and frontal lobes. Case LXXXVII. Symptoms. — Primary and permanent unconsciousness ; stertor ; dilatation of pupils ; loss of urinary and faecal control, and pulmonary oedema; left radial pulsation fuller and stronger than right; no ex- ternal injury. Temperature, 104° to 104.8°; pulse, 120 to 166; respiration, 24 to 52. Death in four hours and a half. Lesions. — Fracture extending into both occipital fossae, CASES VERIFIED BY NECROPSY. 447 and a fissure from indirect violence in right middle fossa ; large indirect epidural hemorrhage over right frontal region; complete excavation of right frontal lobe with rupture of inferior cortex and consequent cortical hemor- rhage over superior surface of whole right hemisphere and left frontal lobe; contusion of third left temporo- sphenoidal convolution and small extravasation into cen- tre of pons ; general hyperaemia. Case LXXXVIII. Syviptoms. — Patient found uncon- scious in the street. Pupils slightly contracted, urine retained ; ecchymosis in left mastoid region, which in- creased. Temperature, 105°, and pulse frequent. Con- dition remained unchanged and death occurred in fourteen hours. Lesions. — Hasmatoma covering Avhole occipital region. Linear fracture extending through both inferior occipital fossae into petrous portions of temporal bones. Thick epidural clot in the course of the fracture. Cortical hem- orrhage ; clot over both frontal lobes, more complete on left side, and extending into all basic fossae. Laceration of inferior surface of left frontal lobe, extending subcorti- cally into anterior cornu of left lateral ventricle, also cross- ing median line superficially and then extending subcorti- cally backward to a point opposite to posterior part of the right corpus striatum. This laceration largely excavated both frontal lobes. A small laceration existed upon the inferior surface of the left temporal lobe anteriorly. The brain substance was generally hypersmic, with many patches in which the vessels were filled with minute co- agula. Case LXXXIX. Symptoms. — Patient found in deep coma; stertor; left pupil slightly dilated. On admission to the hospital scalp wound in right parietal region with linear fracture ; hemorrhage from both nostrils ; and both pupils slightly dilated and irresponsive. Temperature, 97.4°; pulse, 96; respiration, 20. Coma continued, with Cheyne-Stokes respiration. Temperature, 99.8°; pulse, 44^ INJURIES OF THE BRAIN AND MEMBRANES. no; respiration, 24. Death forty-five minutes later and six hours after admission. Lesions. — Linear fracture extended from middle portion of right parietal bone through groove for middle menin- geal artery into middle fossa. Large epidural hemor- rhage greatly compressed right hemisphere. Case XC. Symptoms. — Patient, after having fallen into the hold of a vessel, walked about a block and then fell, but though stupid was able to rise and to walk a little farther; then became slightly delirious. On admission to the hospital, mental condition irritable and speech inco- herent, right pupil dilated and irresponsive to light. Temperature, 98.4°; pulse, 64; respiration, 16. Two hours later there was a unilateral convulsion, beginning in the left leg and extending to the arm, which was followed by coma continuing till death four hours after admission. In the interval there were six similar convulsions. Tem- perature at time of first convulsive seizure, 99°; pulse, 86; respiration, 20; temperature just before death, 99.2°; pulse, 122; respiration, 22. Lesions. — Contusion of scalp about left parieto-occipital junction; linear fracture extending from this point to within one-half inch of foramen magnum ; superficial lac- eration of inferior surface of left occipital lobe, one inch in length and corresponding cortical clot not larger than a half-dollar; very moderate cerebral hyperasmia. The previous history of this patient was unknown. Case XCI. Symptoms. — Patient while in an alcoholic condition fell a distance of five stories, striking upon his head ; primary and permanent unconsciousness ; severe hemorrhage from left ear, nose, and mouth, which con- tinued till death thirty minutes afterward. Lesions. — Ecchymosis of both eyes and extensive haema- toma of scalp ; depressed fracture of right parietal bone near median line with multiple fissures extending to base and involving middle and posterior fossas on both sides and left petrous portion. Two fissures completely in- CASES VERIFIED BY NECROPSY. 449 eluded the calvariiim, and another passed through the body of the sphenoid bone. An independent fissure from indirect violence ran backward from the foramen mag- num. Small epidural hemorrhage beneath depression at vertex; pial hemorrhage from meningeal contusion over right hemisphere ; superficial laceration of inferior surface of left temporal lobe with a small consequent cortical hemorrhage in middle fossa ; both lateral ventricles blood stained, and the left communicating with a small lacera- tion in occipital lobe. The ventricular hemorrhage was apparently from contusion of the choroid plexuses. The brain substance was moderately hyperaemic, with thrombi in the minute vessels. Case XCII. Symptoms. — Patient found unconscious in the street, but delirious when admitted to the hospital one hour later; pupils slightly dilated, and afterward irregular; urine, at first voided naturally, was afterward retained. Temperature on admission, 98°; rose to 100.4°, and on the third day to 103°, and receded to 102.6° before death, at the end of three and one-half da3's; pulse, 100 to 130; respiration, 20 to 26. Lesions. — Linear fracture extending from right occipital region to petrous portion on either side. Laceration of inferior surface of left temporal lobe, and of left fron- tal lobe near inner border. Extensive contusion of pos- terior border of left occipital lobe, involving cortex and subcortex to a depth of one inch, and the tissue softened, grayish, and filled with dark punctate extravasations. Cortical hemorrhage over left hemisphere at both base and vertex. Case XCIIL Symptoms. — Patient after a fall of thirty-two feet found unconscious w4th profuse hemor- rhage from the right ear; on admission to the hospital, stupid ; unable to give any account of his accident then or afterward ; profuse hemorrhage from the ear continued ; deviation of eyes to the right; vomiting, restlessness, and general muscular twitchings through the day; no other 29 450 INJURIES OF THE BRAIN AND MEMBRANES. symptoms except some frontal headache. On the third day the hemorrhage from the ear was replaced by a pro- fuse serous discharge which continued till death. The mental condition was dull, but rational, with frontal head- ache and occasional restlessness; no disturbance of speech. On the fourth day slight delirium, which was afterward continuous and became muttering, and was later active in character. On the fifth day there were dry tongue and picking at the bedclothes, and on the sixth day the skin was clammy and there were large bronchial rales. On the seventh day the pupils, which had been normal, were very slightly dilated, the conjunctival reflex was absent in the right eye, and the lids did not respond to irritation ; the left lid and conjunctiva were very sensitive. Restless- ness continued till death. The temperature on admission was 98°, rising to 102.8° on the second day, to 103.8° on the third, to 104° on the fourth, to 105° on the fifth, to 106° on the sixth and seventh, with unimportant re- cessions. The pulse did not exceed 108 in frequency, and the respiration was from 20 to 28 till death on the sev- enth day. Lesions. — No injury of the scalp; linear fracture begin- ning in the right squamous portion of the temporal bone at a point just above the petrous portion, to Vv'hich it ex- tended in two fissures, one running along its anterior sur- face, and the other crossing its superior border and poste- rior surface and extending to foramen magnum. The posterior petrous surface was comminuted, and one small fragment was quite detached and clinging to the dura. There were moderate subarachnoid serous effusion and arachnoid opacity in the right parietal region. Purulent effusion existed in moderate amount upon the anterior border of the pons and upon the posterior border and con- tiguous portion of the inferior surface of the cerebellum. There was also a full drachm of laudable yellow pus in the median line between the reflections of the arachnoid mem- brane upon the cerebellar lobes. No effusion upon the CASES VERIFIED BY NECROPSY. 45 1 medulla or cervical portion of the spinal cord. There were a slight cortical contusion of the right parietal lobe and a large cortical contusion, three by two and a half inches in diameters, involving the middle portion of the first left temporal convolution and the contiguous parietal surface, marked by dark discoloration and punctate extravasations ; no laceration. The brain substance was excessively hy- peraemic and oedematous, but without thrombi. The right lateral ventricle was filled with clear serous effusion, and the left contained a lesser amount. Case XCIV. Symptoms. — Patient found unconscious; pupils slightly contracted; hemorrhage from the nose. On admission to the hospital, pupils normal, small haema- toma in left posterior temporal region, and a cessation of nasal hemorrhage. Eight hours later pupils dilated, muscular twitchings in both arms, and ecchymosis of left anterior frontal region. . Profound unconsciousness with- out change in symptoms continued till death fifteen hours after admission. Temperature, 97.6°; rose progressively to 103°, and immediately receded post mortem. Pulse, 70 to 100; respiration, 24 to 27. Lesions. — Three fissures radiated from the occipital tuberosity ; one extended forward above the right petrous portion into the middle fossa, another to the right side of the foramen magnum, and a third ended in the left infe- rior occipital fossa. Cortical hemorrhage, in moderate amount, covered the inferior surface of both frontal lobes, filled both Sylvian fissures, and extended backward in the central region of the brain from a point just in front of the optic chiasm across the crura cerebri to the anterior border of the pons, and also reached the lateral surface of each temporal lobe. A small pial hemorrhage was found upon the superior surface of the cerebellum, and in the median fissure. Laceration of inferior surface of left frontal lobe, upon its anterior and external border, and excavating its subcortical substance to a moderate extent. Subcorti- cal contusion of anterior part of right optic thalamus, with 452 INJURIES OF THE BRAIN AND MEMBRANES. punctate extravasations. Subcortical laceration of pons in- volving its transverse fibres, filled with clot, one-half inch in diameter. Very moderate hypersemia of the brain with no oedema. Case XCV. Symptoms. — Patient transferred from al- coholic ward without history ; general convulsions, stupor, and loss of urinary control ; right radial pulsations weaker than the left; subconjunctival hemorrhage in both eyes, right pupil dilated ; both pupils irresponsive to light, and both eyes protruding. On the second day occasional rest- lessness, picking at the bedclothes; other conditions un- changed. On the third day loss of fsecal control, want of symmetry in radial pulsations less noticeable but obvious, restlessness and efforts to get out of bed ; pupils as before. On the fourth day coma and death, which occurred in three days and six hours. Temperature, 99° on admission to ward, rising progressively with slight recessions to 105.2°; pulse, 120 to 140; respiration, 24 to 48. Lesions. — Slight haematoma in left temporal muscle. Linear fracture extending across both lesser wings of sphenoid bone into middle fossae. Slight epidural hem- orrhage, about one and one-half drachms. Cortical hemorrhage over right temporal and parietal lobes. Lac- eration of right temporal lobe, one by one and a half inches in diameter, and confined to cortex ; beneath it punctate extravasations. Brain exceedingly hypersemic and oedematous. Serous fluid to amount of two drachms in each lateral ventricle. Basic arteries atheromatous. Case XCVL Symptoms. — Patient fell eight or ten steps, striking upon his head. On immediate admission to the hospital: surface cold and moist; semi-consciousness; pain in the head ; hemorrhage from both nostrils ; respira- tion rapid and irregular, becoming deeper and slower upon disturbance ; pupils moderately dilated and irresponsive to light, and facial paralysis with ptosis, which was ascertained to have existed previous to the injury. Incision through a haematoma on the right side of the head, anterior to the CASES VERIFIED BY NECROPSY. 453 occipital tuberosity, disclosed a depressed and fissured fracture; and a loose fragment of bone, two inches by one inch in diameters, was removed. Through the day the pupils were symmetrically contracted, the pulse was intermittent, respiration irregular, and patient very rest- less and irrational, with loss of urinary control. On the second day restlessness continued, with muscular twitch- ings in both upper and lower extremities. Death occurred at the beginning of the third day without change in symp- toms. Temperature on admission, 97.2°, rising progres- sively through the day to 105.2°. In the morning of the second day, temperature, 102.6"; rose progressively to 106.8", and with one recession to 105.2° again rose to 106.8° at the time of death, with an immediate post-mortem decline. Pulse, 96, 148, 120, 180; respiration, 26, 48, 24, 44. Lesions. — Haematoma over right side of head and occi- put; skull crushed and flattened with radiating fissures involving base; epidural hemorrhage over left occip- ital and posterior part of left parietal lobes ; pial hemor- rhage over both occipital regions. The hemorrhages were of moderate amount. Laceration of inferior surface of both frontal lobes anteriorly, confined to cortex, and of left temporal lobe ; slight contusion of inner border of left parietal lobe; slight cortical hemorrhage at base; brain substance throughout very hypersmic and oedema- tous. Case XCA'^II. Symptoms. — Loss of consciousness, dila- tation of left pupil and contusion of left palpebral region, hemorrhage from both nostrils, and clammy skin. Tem- perature, 98°; pulse, 148; and respiration, 63. Hemor- rhage from left nostril continued after admission to the hospital, and temperature rose progressively to 103.2° at death six hours afterward, with post-mortem increase to 103.4°. Lesions. — Slight contusion of scalp in left parietal region ; fracture of sphenoid bone, extending from crista 454 INJURIES OF THE BRAIN AND MEMBRANES. galli through sella turcica into its left lesser wing; lacera- tion of inferior surface of left frontal lobe, two and one- half inches long and one-half inch in depth; slight gen- eral hyperaemia of brain ; no hemorrhages. Case XCVIII. Symptoms. — Patient thrown from a cable car and struck upon the back of his head ; conscious and rational, with hemorrhage from left ear and nose, Avhen reached by ambulance surgeon. Pupils and muscu- lar action normal, and radial pulsations symmetrical. On admission to the hospital pain in left occipital region and continued hemorrhage from ear with haematemesis, which was frequently repeated during the day and night. The pain in the head was continued till stupor supervened (ten hours), which lapsed into coma (fifteen hours), with loss of urinary control, slight muscular twitchings upon the right side, and slight dilatation of the pupils. Death occurred in twenty-seven hours. Temperature on admission, 98°; rose progressively to 104°, with a single recession of 0.7°, and one hour post mortem was 105°. Pulse, 64 to 80; respiration, 20 to 38. Lesions. — Linear fracture extending from left parieto- squamous suture anteriorly to eminence for semicircular canal upon anterior surface of petrous portion. Slight hem- orrhage into substance of temporal muscle, but none upon surface of dura mater. Cortical hemorrhage over whole superior surface of left hemisphere, and in large amount, in both posterior and both middle fossae. Deep laceration crossing posterior part of superior surface of left occipital lobe. Entire disintegration of whole inferior surface of right frontal, and of anterior half of left frontal lobe, in- cluding cortex and subcortex, to a depth of three-fourths of an inch. On the right side the laceration reached sub- cortically quite to the anterior border of the corpus stria- tum, and on the left to within one-half inch of the same plane. Hemorrhage into centre of pons with clot one-half by three-fourths of an inch in diameters. Moderate gen- eral hyperaemia and oedema of brain. CASES VERIFIED BY NECROPSY. 455 Case XCIX. Symptoms. — Primary and permanent unconsciousness after a fall of six feet. Right pupil di- lated, left contracted, both irresponsive to light; pulse full and slo\v, and radial pulsations symmetrical at the wrists ; rigidity of entire body, which continued till death ; hemor- rhage from left ear, and in slight amount from nose. Small scalp wound in left occipital region. Later, stertor, Cheyne-Stokes respiration, and lack of urinary control. Death occurred in nine hours. Temperature on admis- sion, 98.4°; in three hours, 103.2°; in six hours, 106.2°, and at death, 109.2°; thirty minutes post mortem, 109.2°. Pulse, 60 to 108, six hours after admission; respiration, 34 to 37. Lesions. — Linear fracture extending from a point one inch above left petrous portion of temporal, through its anterior surface into sphenoid bone; some extravasation of blood into temporal muscle. Cortical hemorrhage, in considerable amount and partially fluid, covering right hemisphere superiorl)', and right temporal and occipi- tal lobes inferiorly, derived from superficial lacera- tion of whole lateral surface of right temporal lobe. General hypersemia and oedema of brain not very marked. Case C. Symptoms. — Primary and permanent uncon- sciousness from a fall of fifteen feet upon left side of head; hasmatoma over left fronto-parietal region; no hemorrhages; stertor; right pupil slightly dilated ; rigid- ity of both sides of body, more marked upon left. On admission to the hospital, temperature, 101°; pulse, 86; respiration, 20; right side very rigid till death two hours later. Temperature then 101°, and one-half hour post mortem, 102.1°. Lesions. — Linear fracture extending from frontal emi- nence to middle of left petrous portion. Epidural hemor- rhage over an area of three inches about fronto-parietal junction ; laceration of first and second left temporal con- volutions, one and one-fourth inches long, three-fourths of 456 INJURIES OF THE BRAIN AND MEMBRANES. an inch wide, and three-eighths of an inch deep ; cortical hemorrhage over lateral surface of lobe. Case CI. Syjnptoms. — Primary unconsciousness from a fall of twenty feet; slight wounds of face and a fracture of femur; pupils symmetrically dilated; hemorrhage from left nostril; and twitching of right side. After admis- sion to the hospital, patient remained in a semiconscious, restless condition, with loss of urinary control. Second day, same conditions continued, with dysphagia, slight twitching of the right side, great weakness, and profuse perspiration, till death at the end of thirty-seven hours. Temperature on admission, 98°; later, 102°+, 101° + for ten hours, and then progressive rise to 107.2° with imme- diate post-mortem recession; pulse, 104 to 160; respira- tion, 24, 20, 60. Lesions. — Open fissure in left inferior occipital fossa running into groove for lateral sinus ; no epidural hemor- rhage ; opacity of arachnoid on left side ; slight cortical hemorrhage over left temporal lobe posteriorly ; lacera- tion of inferior surface of same lobe, one inch by three- eighths of an inch in size, confined to cortex; another laceration of the same dimensions upon inferior surface of left occipital lobe ; marked general hypersemia and oedema of brain substance. Case CII. Symptouis. — Patient admitted to the hospi- tal after having fallen to the ground in a convulsion ; wound in right parietal region, with a diffuse hsematoma; no hemorrhages ; pupils symmetrically dilated ; primary and permanent unconsciousness ; no muscular symptoms ; several convulsions occurred before death six hours later. Temperature, 100.6° to 107°, and one hour post mortem, 108°; pulse, 1 10; respiration, 30. Lesions. — An open fissure extended from squamous su- ture into petrous portion ; laceration of inferior surface of right temporal lobe, one inch in length ; cortical hemor- rhage over fissure of Sylvius and island of Reil ; pia mater intensely congested with subarachnoid serous effusion ; CASES VERIFIED BY NECROPSY. 457 h3'per^mia and oedema of the brain substance. A small gumma, one-half by one-fourth inch in size, was situated in the left frontal region. Case CIII. Symptoms.' — Patient, aged four years, fell one story, striking his head upon the pavement. Haema- toma over right parietal eminence ; hemorrhage from right ear; primary and permanent unconsciousness; vomiting; no muscular symptoms, except loss of reflexes on the right side. On admission to the hospital, temperature, 97.6"^; pulse, 144; respiration, 28. A series of right uni- lateral convulsions, each beginning in the forehead and involving the intercostal muscles, occurred soon afterward; each paroxysm was violent and lasted five minutes, fol- lowed by repeated attacks of vomiting, and by paroxysms of hiccough which alternated with stertor ; loss of fsecal and urinary control. The right leg remained in tonic spasm. Four hours after admission, temperature was 103.4°; pulse, 120; respiration, 40; convulsions upon the right side had ceased, and were followed by constant twitchings of the left side of the mouth and of the left leg ; pulmonary oedema supervened, and death occurred at the end of eighteen hours. The temperature fell in four hours from 103.4° to 100°, and then rose progressively to 109°, with immediate post-mortem recession. The pulse rose from no to 150, and the respiration declined from 40 to 30. Lesions.- — ^Subperiosteal haematoma; simple depressed fracture involving central portion of right squamous su- ture, from which extended two fissures, both open and filled with blood clot — one through petrous portion to fora- men ovale, and the other through posterior part of squa- mous portion to within one-half inch of parietal angle; cortical hemorrhage in middle and posterior fossae from an extensive direct laceration of lateral surface of temporal lobe involving both dura and pia mater. Case CIV. Symptoms. — The patient's head was struck in the occipital region by a descending elevator and forced 458 INJURIES OF THE BRAIN AND MEMBRANES. forward upon a railing ; scalp wound of the occiput eight inches long; fracture of nasal bones and contusion of both eyes ; hemorrhage from both nostrils ; no loss of consciousness ; no muscular symptoms ; pupils slightly di- lated, afterward unchanged. On admission to the hos- pital, vomiting of blood and partly digested food, fol- lowed by chill, and a little later by delirium ; loss of urinary control, which was permanent; and restlessness through the night. Second day, patient rational, soon becoming stupid, restless, and at night suffering severe pain in the head but quiet and sleepless. Third day, de- lirious, restless, and sleepless, with some post-cervical rigidity, and twitching of fingers of both hands. There were at one time alternating convulsive movements of the lower limbs, flexion of one at the knee and hip being coincident with extension of the other. These movements were about twenty in the minute. Death occurred at the end of the third day. The temperature on admission was ioo°, rose in four hours to 104.4°, fell two hours later to 102.4°, ranged from 102° to 102° -j- till end of second day, and afterward from 104° to 105.4°, with post-mortem ele- vation to 105.6°. The pulse varied from 75 to 116, and the respiration from 18 to 32. Lesions. — Fracture, confined to anterior fossae and ex- tending from posterior border of cribriform plate on the right side by a wide curve forward and outward, and then inward through both orbital plates to a corresponding point on the left side. The roof of the orbits was elevated and tilted forward, and the frontal sinuses were made continuous with the cranial cavity. Blood clots extended from a moderate epidural hemorrhage upon the floor of the anterior fossae into the orbits. Laceration of central portion of right frontal lobe, one and one-half inches by three-eighths of an inch, confined to the cortex, and caused by a ragged projection in the displaced orbital fragment. The membranes upon the posterior half of the vertex on either side were excessively hyperaemic, CASES VERIFIED BY NECROPSY. 459 while upon the anterior half they were of a dirty yel- low color, oedematous, and elevated by a sero-purulent subarachnoid exudation; the subjacent convolutions were flattened, and their sulci obliterated. The line of demar- cation was well defined. In the posterior segment was a pial hemorrhage. The whole base of the brain was cov- ered with a purulent effusion. The brain substance was excessively hyperasmic and oedematous. Case CV. Symptoms. — Primary and permanent un- consciousness ; manner of injury unknown ; wound in right occipito-parietal region, right pupil dilated, transient left hemiplegia. Temperature, 100°; pulse, 90; respira- tion slightly increased in frequency and stertorous. Ec- chymosis over right mastoid process after three days. Right unilateral convulsions began on the fifth day, and continued with increasing severity and frequency till death on the ninth day. Final temperature, 103°. Lesions. — Fracture of right occipital bone, extending from point of external injury into foramen magnum ; no epidural hemorrhage ; laceration of right parietal lobe at vertex with consequent cortical hemorrhage. Case CVI. Symptoms. — Patient was knocked down and struck the back of his head upon the sidewalk. On admission to the hospital thirty minutes later, contusion of scalp above and to the left of the occipital tuber, stupor from which patient could be roused to answer simple ques- tions, nearly normal pupils, and no hemorrhages or mus- cular symptoms ; profound coma, with pupils contracted to a pin's point and entirely irresponsive, at the end of twenty-four hours. In thirty-five hours, slight general convulsion ; pupils became widely dilated ; pulse rose from 60 to 160, temperature unchanged; thirty minutes later respiration suddenly dropped to four in the minute, and death occurred thirty-five minutes afterward. Tempera- ture on admission was 98°, and did not at any time exceed 102.4°; pulse, 60 to 80, till second day; respiration, i8 to 28. 460 INJURIES OF THE BRAIN AND MEMBRANES. Lesions. — Linear fracture extended from site of exter- nal injury through right parietal and temporal bones to floor of middle fossa ; also small independent fracture in right orbital plate ; epidural hemorrhage on the right side extending to the base ; pial hypersemia with minute hem- orrhages over same area ; laceration of right temporal lobe one and three-fourths inches long, by one inch wide, and three-fourths of an inch deep, and filled with clot, involv- ing posterior part of first and second convolutions; super- ficial laceration of outer half of inferior surface of right frontal lobe ; laceration in centre of right optic thalamus, of the size of a hazelnut, with punctate extravasations near its margin ; several minute hemorrhages in floor of fourth ventricle ; cortical hemorrhage, covering right pa- rietal region and base, extended over medulla. General hyperasmia of brain substance. Case CVII. Symptoms. — Patient, aged three years, fell forty feet, striking the right side of his head upon the pavement ; primary and permanent unconsciousness ; hsematoma over whole lateral parieto-occipital region ; subconjunctival hemorrhage in right eye ; pupils normal ; left radial pulse stronger than the right; several convul- sions while in the ambulance. On admission to the hospi- tal the convulsions continued, being confined to the right side, and involving pectoralis major, deltoid, and supra- spinatus and infraspinatus muscles of the shoulder, and the adductors of the hip and extensors, causing rotatory move- ments of the arm and pounding of the heel at every contraction ; each paroxysm began in the arm. Loss of urinary control, and Cheyne-Stokes respiration for two hours before death, which occurred in twenty-four hours. Temperature on admission, 97.6°; rose to 105.2°, with im- mediate post-mortem recession ; pulse, 102 to 150; respira- tion, 64, 44, 60. Lesions. — Compound, comminuted, depressed fracture of right parietal bone, with fissures radiating to coronal and lambdoid sutures, and separation of sagittal and lamb- CASES VERIFIED BY NECROPSY. 46 1 doid sutures; a fissure extending into middle fossa; rup- ture of dura mater ; epidural hemorrhage over right ver- tex; laceration of parietal and temporal lobes, three inches by one-half inch in extent, filled with clot, and crossing fissure of Rolando; moderate cerebral hyper- semia, most marked in the left hemisphere. Case CVIII. Symptoms. — Patient fell from a mail wagon to the ground, striking upon his head; primary and permanent unconsciousness; wound and hsematoma in right occipito-parietal region ; hemorrhage from right ear and nostril; right pupil dilated, left contracted; radial pulsations symmetrical; muscular twitching of both arms and to a slight extent in left leg. Temperature, 99°; pulse, 68; respiration, 15. No change in symptoms. Death in forty minutes. Temperature, 98.4°, with imme- diate post-mortem recession. Lesions. — Linear fracture extending from right occip- ital bone through petrous portion; epidural hemorrhage covering right hemisphere and forming a thick clot ; no lacerations ; contusion of inferior surface of right temporal lobe. General cerebral hyperaemia and cedema; some fluid in lateral ventricles. Case CIX. Symptoms. — Patient fell from his chair, and was said to have been in a convulsion ; primary and permanent unconsciousness ; profuse hemorrhage from the right ear; right pupil markedly contracted, the left di- lated; rigidity of left arm followed by twitching of the muscles. On admission to the hospital, temperature, 97.2°; pulse, 60; respiration, 22; four general convul- sions occurred at considerable intervals, in the last of which the patient died, twelve hours after admission. Both pupils had become equally dilated. Temperature rose to 106.8°, with immediate post-mortem recession. Pulse, 60 to 96; respiration, 22 to 40. Lesions. — No external injury, except small effusion of blood over right mastoid process. Linear fracture ex- tended from occipital tuber through junction of middle 462 INJURIES OF THE BRAIN AND MEMBRANES. and anterior thirds of the right petrous portion into mid- dle fossa; an independent fracture, linear in the outer table, extended from the anterior inferior angle of the left parietal bone to a point in the squamous portion opposite the petrous junction ; a small triangular bit of the inner table was raised upward and by its sharp point lacerated the m.iddle meningeal artery at its bifurcation ; a conse- quent epidural hemorrhage compressed the left hemi- sphere laterally, and filled all the basic fossas upon that side ; no pial hemorrhage ; small cortical hemorrhage, derived from a small and deep laceration of the external border of the right frontal lobe, covered both frontal and the left parietal lobes; contusion, one inch square, of left occipital lobe about the angular gyrus ; contusion of whole inferior surface of left temporal lobe, and another of the anterior two-thirds of the inferior surface of left frontal lobe; punctate extravasations in the pons ; moderate gen- eral hyperaemia and oedema. Case CX. Symptoms. — Patient during a street alter- cation was jabbed in the right eye with the end of an um- brella; in an alcoholic condition when admitted to the hospital on the following day. Cornea opaque and pupil immovable, subconjunctival hemorrhage, and constant pain in the eye. Temperature, 98.6°; pulse, 80; respira- tion, 20. He became delirious on the third day, and from that time some grade of delirium, with restlessness and occasional pain in the head, persisted till his death on the forty-fifth day. On the forty-second day he became stupid, and there was a discharge of pus from the orbit, followed by final coma and loss of urinary control. There were at no time localizing symptoms. The eye was removed by Dr. Callan on the eighteenth day. The temperature on the third day was 100° to 102°; on the fourth day 101° to 104°; and till the forty-first day was usually from 98°-|- to 102°, and once on the twenty-second day again rose to 104°. From the forty-first to the forty-fifth day it was from 104° to 107.2°, and was without immediate post- CASES VERIFIED BY NECROPSY. 463 mortem change. The pulse usually ranged from 68 to 100, and the respiration Avas only moderately increased in frequency, till near the end of life. Lesiojis. — Only a fine fissure of orbital wall; purulent subarachnoid effusion at base, most marked on left side and upon cerebellum, and extending over whole lateral aspect of left hemisphere ; a moderate amount of muddy- looking fluid in right lateral Yentricle and a somewhat smaller amount in left; left choroid plexus infiltrated with pus and lymph. Xo other lesions. Simple general hy- peraemia. Case CXI. Symptouis. — Patient struck upon the head by a piece of chalk, weighing twenty pounds, which had fallen twenty feet; loss of consciousness for five minutes. Hsematoma in left supra-orbital region, extending into the eyelid ; profuse hemorrhage from left ear and from both nostrils; free haematemesis ; right radial pulsa- tions stronger than left ; pupils normal. On admission to the hospital, temperature, 98"; pulse, 68; respiration, 24; parietal fracture disclosed b}' incision ; restlessness and irritability after restoration to consciousness. Second day, restlessness and twitching of the right arm alter- nating with somnolence; the left radial pulsations had become fuller than the right, and this condition was after- ward unchanged. Third to fifth days, profuse serous dis- charge from the left ear; severe pain in the left side of the head; delirium and struggling to get out of bed at night; delusions ; loss of consciousness ; and finally progressive asthenia, irregular and labored respiration, dilatation of the left pupil and contraction of the right. Death in four days and fourteen hours. The temperature did not exceed 100° till within the last twenty-four hours, when it rose to 106.6°, and receded to 104.4°, v'ith immediate further post- mortem recession. The pulse did not exceed 84 till a few hours before death; respiration, 24 to 42. Lesions. — Linear and open fissures, which were con- fined to left side, of which two were parallel and extended 464 INJURIES OF THE BRAIN AND MEMBRANES. from orbital plate through vertex ; coronal suture opened ; three other fissures intersected these at right angles. An independent fracture (indirect) extended from left fora- men ovale to tympanic cavity. Laceration, one and one- half inches by three-fourths of an inch in extent, filled with clot, upon inferior surface of left frontal lobe, due to angu- lar elevation of orbital plate ; contiguous subjacent brain substance yellow and slightly indurated ; adjacent cortex the seat of punctate extravasations, and of small hemor- rhages; slight epidural hemorrhage over left frontal lobe; cortical hemorrhage at base of brain, about four ounces of a brownish-red fluid ; purulent subarachnoid effusion at base and extending into spinal canal ; convolutions at base flattened, cedematous, and yellow in color; lateral ventri- cles filled with a sanious fluid. Case CXII. Symptoms. — Patient fell down one flight of stairs. On admission to the hospital hemorrhage from mouth, nOvSe, and left ear, and subconjunctival in both eyes ; partial loss of consciousness, which became complete ; temperature, 99.6° to 103°; pulse, 78; respiration, 20; became stertorous. Death occurred in seventeen hours. Lesions. — Fracture involving both orbital plates of frontal, left greater wing of sphenoid, left petrous por- tion, and basilar process of occipital bone; skull thin and brittle; patient, aged fifty-five years; laceration of in- ferior surface of cerebellar lobes. Case CXIII. Symptoms. — Patient found unconscious in the street. On admission to the hospital, profound coma ; large haematoma in right occipito-parietal region ; no hemorrhages; no muscular disorders, but marked re- laxation; retention of urine and loss of faecal control; pupils symmetrical and moderately dilated ; temperature 97.6°, with progressive increase to 107° at time of death fifteen hours after admission, and no immediate post- mortem change; pulse, 49 to 160; respiration, 38 to 60. Lesions. — Fracture extending from right of occipital tuber into occipito-temporal suture ; laceration, one and one- CASES VERIFIED BY NECROPSY. 465 half by two and one-half inches in extent, of inferior surface of right occipital lobe, filled with clot and debris of brain tissue; contusion of both frontal lobes. Case CXIV. Symptoms. — Patient fell twelve feet, striking upon the left side of his head ; three scalp wounds; hemorrhage from left ear; primary and perma- nent unconsciousness ; slight dilatation of right and slight contraction of left pupil. Death in four minutes after admission to the hospital. Lesions. — Compound stellate fracture of left squamous portion and contiguous occipital bone, with open fissures running through middle and posterior fossse, and left petrous portion ; epidural hemorrhage in left occipital region, about two ounces; pial hemorrhage over both hemispheres and cerebellum ; blood coagulated ; no lacer- ation ; independent pial hemorrhage over superior cere- bellar surface; clot in right lateral ventricle ; not much general hyperaemia and no oedema. Case CXV. Symptoms. — Patient fell in the street while intoxicated ; rather profuse hemorrhage from left ear; no loss of consciousness; pain in the head; stupor; in the opinion of the family mental condition different from that usual to the patient when drunk ; restlessness, headache, and stiffness of the neck; and after two days admission to the hospital. There was then no external injury of the head, but there were stupor, somnolence, and a disposition to resist every disturbance ; a few hours later mechanical restraint became necessary and delirium was accompanied by delusions; hemorrhage from left ear recurred; temperature, which on admission was 99.2°, rose to 102°; pulse, 50; respiration, 30. The hemorrhage from the ear and the delirium continued through the next day, and temperature rose progressively to 105°, and was then reduced by an alcohol bath. The hemorrhage from the ear ceased, delirium diminished, and the temperature did not exceed 103°-]-, on the following day. Stupor after- ward alternated with delirium, the temperature of five 30 466 INJURIES OF THE BRAIN AND MEMBRANES. days ranged from 102° to i02°-|-, and the pulse from 60 to 112; coma supervened and death resulted from asthenia on the ninth day. The final temperature was 103.6°, with post-mortem increase to 106.8°. Lesions. — Separation of lambdoid suture for about one inch, and linear fracture extending from it through left posterior fossa and petrous portion ; laceration of inferior surfaces of both frontal and both temporal lobes ; exten- sive and deep in the left frontal and left temporal lobe ; large cortical hemorrhage in all the basic fossae, espe- cially in the left anterior and middle ; moderate subarach- noid purulent effusion, stained with blood, mainly at the base. General cerebral hyperaemia. Case CXVI. Symptovis. — Patient fell down stairs two days previous to admission to the hospital ; ecchymosis of right eye ; stupor and restlessness ; retention of urine ; right pupil dilated and only partially responsive to light ; plantar, patellar, and cremasteric reflexes absent. Second day, stupor increased progressively, right radial pulsations stronger than the left, loss of urinary control, respiration irregular; and before death, which occurred in forty-seven hours, the pupils became more nearly symmetrical, the eyes were turned to the right, the head was somewhat- extended, and there was commencing pulmonary oedema. The temperature was in the first twxnty-four hours, 103°, 100°, 104°; and in the second, 104.2° to 107.2°, with no immediate post-mortem change. The pulse was 100 to 138, and the respiration, 18 to 60. Lesions. — Linear fracture extending from anterior part of right temporal ridge through middle fossa into horizon- tal plate of ethmoid bone ; small epidural clot in middle fossa, and a corresponding pial hemorrhage of not much larger size ; moderately large subarachnoid serous effu- sion ; general cerebral hyperaemia and oedema ; no lacera- tion or evidence of arachnitis. Case CXVII. Syviptouis. — The patient in a collision was throwm from his bicycle, and was primarily uncon- CASES VERIFIED BY NECROPSY. 467 scious. He was taken to his house, where he had a con- vulsion, and was then removed to a hospital, where he remained forty days; no record of his condition during this time is obtainable. He was afterward treated by an oculist for exophthalmos ; he resumed his professional oc- cupation, and was said to have been in good physical health, but a distinct mental change was observed by his family. His temper was irritable and his conversation, which had been hitherto irreproachable, became remark- ably obscene without any apparent appreciation on his part of its impropriety. One week before his admission to St. Vincent's Hospital, and six months after the reception of the injury, he became suddenly apathetic, and soon fell into a stupor, with loss of faecal and urinary control and the accession of a febrile movement. When admitted to the hospital he gave no response to questions and lay motionless without indication of intelligence ; a faint cica- trix was visible across the forehead; the odor of the breath was peculiar ; the left pupil was much dilated and entirely irresponsive, and the right eye protruded ; there were no muscular symptoms, and the radial pulsations were sym- metrical. The temperature was 102°; pulse, 120; res- piration, 20. Second day, low delirium, incoherence, and at times deep flushing of the face. Third day, gen- eral condition unchanged. Fourth day, more restless and actively delirious ; enema given and boAvels moved for the first time. An examination of the eyes showed a descending neuritis of right optic nerve ; and an exoph- thalmos of the right eye, increase of tension, and oedema of the retinoid area, probably the result of venous obstruc- tion in the optic foramen (Gallon). Nourishment and medication were at all times difficult. Fifth day, restless- ness and delirium increased ; the pulse grew weaker and the respiration more frequent; the face became dusky, and death occurred. The temperature was increased on the third day from ioi°-|- to i03°-io5°, on the fourth day reached 106°, and on the fifth day was held at 101.8° 468 INJURIES OF THE BRAIN AND MEMBRANES. to 103.8° by alcohol baths; final temperature 105.4°. The pulse ranged from 130 to 146, and respiration from 24 to 42. Lesions. — The line of a consolidated fracture extended from the left temporal fossa across the forehead, three- fourths of an inch above the supra-orbital ridges, to a point three- fourths of an inch internal to the right exter- nal angular process, and then with a curve passed upward and inward to the median point of the coronal suture. The line of former fracture was very faint and showed no displacement of the fragments; on the inner surface of the bone it was rather more distinct ; no evidence of fis- sures leading to the base. The inner half of the left orbi- tal process of the frontal and the left lesser wing of the sphenoid had disappeared ; the free edge of bone was rounded, and the remainder of the process was white and of natural appearance. The horizontal plate of the eth- moid, and superior surface of the sphenoid body, had also disappeared from the crista galli to the dorsum ephippii ; the exposed cellular spaces below were blackened and in- filtrated with pus. A cyst projecting from the right frontal lobe with the investing cerebral membranes rested in this central cavity of bone. Both frontal lobes were much softened, yellowish in color, and adherent to the dura mater. The anterior inferior portion of these lobes was too much softened for examination ; their superior surfaces were of normal character. The cyst contained from three to four ounces of greenish-yellow pus, which was subsequently found to contain the Staphylococcus py- ogenes aureus ; it was confined to the right lobe but pro- jected across the median line. There was no evidence of former hemorrhages and no general hyperaemia ; but there was much subarachnoid fluid beneath the cerebellum, and the brain substance was very oedematous. Case CXVIII. Symptoms. — Patient fell eight feet and was found unconscious ; he was transferred to Bellevue from another hospital ten days later, and was then in vio- lent delirium. Traces of hemorrhage from the left ear CASES VERIFIED BY NECROPSY. 469 and of a wound of the left side of the head were still visi- ble ; the mouth was drawn to the right, the reflexes were generally absent, the pupils were widely dilated and in- sensitive, and the radial pulsations were symmetrical. He died thirty-three hours afterward. The temperature on admission was 104.2°, fell to 102.8°, and at death was 107°, with immediate post-mortem recession; pulse, no, 84, 150; respiration, 34, 30, 46. Lesions. — Three fissures originated in the left squamous portion, one of which was open and traversed the whole length of the anterior surface of the petrous portion, divid- ing in the middle portion into two branches, one terminat- ing in the sphenoidal fissure, and the other in the pos- terior fossa ; skull thin ; epidural clot in temporal region ; moderate pial hemorrhage over lateral aspect and base of left temporal region ; laceration of second right temporal convolution ; small cloudy subarachnoid serous effusion ; general hypersemia of the brain substance with minute thrombi, and excessive oedema, which involved the pons, medulla, and basal ganglia; two or three punctate extrav- asations in the centrum ovale. Case CXIX. Symptoms. — Patient fell six stories through an elevator shaft ; extreme shock. Primary and permanent unconsciousness ; hemorrhage from right nos- tril and mouth ; large haematoma in right frontal region ; pupils contracted, the left more completely than the right. Temperature on admission to the hospital, 97.2°, and rose progressively to 102.2° with immediate post-mortem in- crease to 102.5°. Death occurred soon after examination and dressing of the wounds. Lesions. — Wound of elbow-joint and compound fracture of leg; open fissure of right frontal, extending through orbital process into bod}' of sphenoid bone ; no epidural hemorrhage ; no laceration ; general pial hyperaemia and oedema, and pial hemorrhage posteriorly ; limited contu- sion, in an area of one and one-half inches in diameter, of right frontal lobe laterally. 4/0 INJURIES OF THE BRAIN AND MEMBRANES. Case CXX. Symptouis. — Patient fell thirty-five feet to the ground; extreme shock. Transient unconscious- ness ; pupils contracted ; respiration frequent, and became stertorous and flagging in the ambulance. On admission to the hospital consciousness again lost ; large hsematoma in each parieto-occipital region ; no hemorrhages ; right facial paralysis; right forearm strongly flexed, rigid, and fingers twitching; left forearm slightly rigid and flexed; within the first hour convulsive movements ever}' ten minutes, in which the left arm was drawn in toward the chest, and both legs were rigid and extended; patellar reflexes increased ; right pupil dilated, and the left con- contracted; face cyanotic; respiration became of the Cheyne-Stokes character; stertor and moist bronchial rales. Temperature, 96.4°, rising progressively to 100° at time of death twelve hours after admission; pulse, 62, 60; respiration, 32, 20, 28 ; one large unconscious urinary evac- uation. Zrj-z'b edition. Translated and edited by George f leminp, C. B., LL. D., F. R. C. Y. 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