A Clinico-Pathological Study 
of Injuries of the Head, 
with Special Reference 
to Lesions of the 
Brain Substance. 
CHAKLES PHELPS, M. D., 
SURGEON TO BELLEVUE AND ST. VINCENT’S HOSF1TALS. 
BY 
REPRINTED PROM 
Cije Neto Yotfc ftietrtcal $euinal 
for January 1J+, 21, and 28, 1898. Reprinted from the Neic York Medical Journal. 
A CLINICO-PATIIOLOGICAL STUDY OF 
INJURIES OF TI1E HEAD, 
WITH SPECIAL REFERENCE TO 
LESIONS OF THE BRAIN SUBSTANCE* 
By CHARLES PHELPS, M. D., 
SURGEON TO BELLEVUE AND ST. VINCENT’S HOSPITALS. 
Two years ago I read before this association, in the 
course of a general discussion upon cerebral surgery, a 
very brief paper upon cerebral contusion. Since that time a 
very considerable number of cases of serious injuries of the 
head, almost all of which have involved lesion of the brain 
substance, have come under my observation. They pre- 
sent so many points of interest and importance that I have 
ventured to ask renewed attention to an extension of the 
same subject. In no department of surgery are more 
problems yet unsolved, and in no department are the re- 
sults of careful study likely to be of more absorbing interest 
or of greater professional value. 
Attention has been largely directed to cerebral localiza- 
tion, and to certain surgical procedures founded upon the 
* Read before the New York State Medical Association, November 
16, 1892. 
Copyright, 1893, by D. Appleton and Company. 2 
A CLINTCO-PATHOLOGICAL STUDY OF 
indications it has afforded. Such operations upon the 
brain have been conspicuously successful, and have been 
justly reckoned among the triumphs of modern surgery. 
When guided by the disclosures of physiological experi- 
ment and aided by the application of recognized aseptic 
laws, operations upon the brain have been devised and suc- 
cessfully executed which in the immediate past would have 
been not only impossible but incredible. It is equally 
true that these operations are still limited in number and 
application. The instances in which brain lesions can be ac- 
curately defined and located and afterward made subject of 
operation with reasonable prospect of success are compara- 
tively infrequent. The lesions which are of such nature, so 
well defined in outline, or so situated, in view of demon- 
strated localization of brain function, that their diagnosis can 
be made with reasonable certainty, are few enough in the 
first instance; those which are within reach of the surgeon’s 
knife are fewer still; and those in which the patient ulti- 
mately survives constitute but a small proportion of the 
originally scanty number. It is not strange, however, that 
operations which invade the very penetralia of the human 
organism should fascinate by their audacity, and that, when 
successful, they should dazzle the modest workers in more 
prosaic fields of labor. It is also possible that the ardor with 
which the diagnosis and relief of local lesions of the brain 
have been pursued, in the light of functional localization, 
may tend to distract attention from those general patho- 
logical conditions which are of so much greater frequency. 
The study of cerebral topography, moreover, has been so 
much more effectively prosecuted by the physiologist than 
by the pathologist, that perhaps the results of clinical and 
pathological work have been practically if not theoretically 
underrated. It is certainly proper at the present time to 
more generously supplement physiological experimentation INJURIES OF THE HEAD. 
3 
by both ante-mortem and post-mortem observations made 
upon the human subject. For this purpose, cerebral trau- 
matism, which this series of cases illustrates, affords pecul- 
iar advantages, since death results from the establishment 
of lesions in a previously healthy brain, and since it pre- 
sents itself with sufficient frequency for purposes of com- 
parison. 
The cases which I propose to subject to analysis are one 
hundred and twenty-four in number, and, with two or three 
exceptions, have been previously unreported. They have 
occurred mainly in my service in two hospitals, and in the 
last two years. They include all cases of injuries of the 
head which I have seen during the time specified, and if 
they are preponderatingly of one character, they are proba- 
bly still representative of the whole class to which they be- 
long. Wounds of the scalp have not been included because 
they are not only surgically insignificant, but have no ne- 
cessary relation to the deeper-seated injuries which it is 
proposed to consider. In a previous paper upon a subject of 
an entirely different character, I found it convenient to ab- 
stract the histories of the several cases upon which it was 
based. I pursue the same course in the present instance 
in order to afford a means of verification of such conclu- 
sions and generalizations as I may establish, and at the 
same time to make record of a large amount of material 
which may be of service hereafter to students of the same 
class of injuries. 1 shall not attempt a reading of these 
histories, but shall leave them to appear in the archives of 
the association for future consultation. They are arranged 
in accordance with the nature and result of the primary 
injury. 
FKACTURES AT THE BASE. 
Case I.—Male, aged forty-five; fell in the street; admitted 
to alcoholic ward; wild delirium, requiring mechanical re- 4 
A CLINICO-PATHOLOGICAL STUDY OF 
straint; haemorrhage from left ear; wound in posterior parietal 
region; high temperature; coma; death in forty-eight hours. 
Necropsy.—Fracture at the base, with complete separation 
of the left temporal bone into its constituent parts—squamous, 
petrous, and mastoid. Slight laceration of left parietal lobe at 
a point corresponding to seat of external injury. At a corre- 
sponding point upon opposite parietal lobe there was extensive 
laceration 3’5 inches x 1‘5 inch in diameter. 
Case If.—Male, aged forty; said to have fallen from his 
truck; no superficial injury; delirium, which was considered 
alcoholic; refused treatment; delirium continued next day, and 
he committed suicide by drowning. 
Necropsy.—Fracture at base extending from left parietal 
eminence to foramen magnum. Superficial laceration of right 
temporo-sphenoidal lobe by contre-coup. 
These two cases have been previously reported. 
Case III.—Male, aged fifty; fell from steps to sidewalk; 
scalp wound in right posterior superior parietal region; haem- 
orrhage from right ear, and later from right nostril; coma; 
stertor ; rigidity of all the limbs; left pupil dilated. In twelve 
hours complete left hemiplegia supervened, and haemorrhage 
from right ear renewed. Stertor and rigidity disappeared, and 
left pupil became normal. Unconsciousness and incontinence 
of urine continued from time of admission till death from as- 
thenia at the end of six days. 
Necropsy. — Fracture at base, beginning at point of injury 
and extending through right petrous portion and middle fossa 
to apex of opposite petrous. Lacerations of left frontal and 
right temporo-sphenoidal lohes interiorly and laterally. Thick 
clot over left frontal and temporal lobes laterally, growing 
thinner as it extended toward base and vertex. Whole brain 
intensely hyperaemic 
Case IV.—Male, aged twenty-two; cause of injury un- 
known; compound depressed fracture external to right parietal 
eminence; semi-comatose, irrational, articulation indistinct; 
respiration continued slow and irregular for three days. The 
depression was found on trephination to be of the external table 
only. Two days after admission, complete paralysis of ex- INJURIES OF THE HEAD. 
5 
tensors of right hand, paresis of right arm, and right facial 
paralysis, involving both mouth and eyelid. All these paralyses 
afterward varied in degree from time to time, and the mental 
condition varied from rationality to noisy delirium. He was 
usually restless, and became unconscious for two days before 
death. Temperature on admission, 101°, and remained above 
100° for a week. Then declined to 99°+ during another 
week. Two days before death it rose steadily from 103° to 
109°. Died in forty-five days. 
Necropsy.—Fissure extending from point of depression into 
right middle fossa. Subacute arachnitis and excessive cerebral 
by persemia; surface of brain at point of fracture unchanged, but 
beneath it was a large cavity containing reddish semi-fluid ma- 
terial, and brown detritus from subcortical laceration. 
Case V.—Male, aged thirty-five; cause of injury unknown ; 
scalp wound over occipital protuberance; patient under influ- 
ence of drink; would not answer questions; grew stupid, and 
in three hours became unconscious; mechanical restraint neces- 
sary. Temperature soon after admission was 102°, and in ten 
hours became 105°, receded to 101*8°, and then rose steadily to 
10f)'6°. He died twenty-nine hours after admission. 
Necropsy.—Haematoma covered whole calvarium. No frac- 
ture of vertex, but a slight fissure existed along the posterior 
border of the right petrous portion of temporal bone from contre- 
coup. Thin coagulum and fluid blood covered upper surface 
of both cerebra (meningeal contusion). Lacerations of under 
surface of left frontal (large) and temporo-sphenoidal, of inner 
border of right frontal, and of under surface of right temporo- 
sphenoidal lobes. The last was as large as a hickory nut. 
Case VI.—Male, aged thirty-eight; knocked down by a blow 
upon the head from a club; scalp wound in right parietal re- 
gion. He was stupid, and could not answer questions coher- 
ently. Left pupil slightly dilated and eyes directed slightly to 
the right. Next day incoherent, delirious, and had delusions 
and muscular tremor, pupils irregular, pulse frequent and inter- 
mittent. Temperature on admission 103°, five hours later 102°, 
rose to 106'2°. Died in twenty-four hours. 
Necropsy.—Linear fracture through whole length of right 6 
A CLINICO-PATHOLOGICAL STUDY OF 
parietal, right occipital, and petrous portion of temporal bone 
into middle fossa. Considerable laceration of under surface of 
left frontal and temporo-spbenoidal lobes. 
Case VII.—Male, aged forty-five; fell upon the sidewalk, 
striking the back of the bead. Admitted after twenty-four 
hours. (Edema under and about an old cicatrix behind the 
right ear, and underneath this an extensive comminuted frac- 
ture. Two pieces of bone were removed and one elevated, and 
a large, firm epidural clot extracted as far as possible. The 
patient was in a condition of stupor; pupils irregularly dilated ; 
articulation difficult; muscles generally rigid; gait ataxic when 
he attempted to walk; sensibility diminished; and urine incon- 
tinent. His condition improved for four days after operation; 
temperature decreased, mental condition became clearer, and 
muscular rigidity lessened. There was copious serous discharge 
from the right ear, followed by right facial paralysis. On the 
fifth day temperature rose from normal, muscular rigidity again 
increased, and he again became stupid. The next day he be- 
came unconscious, and in an hour’s time he had eighteen general 
convulsions, and died the following morning. His temperature 
did not exceed 99‘8° till the fifth day. On the morning of his 
death it was 105°. 
Necropsy.—Fracture at the base. The whole central portion 
of the occipital, from the foramen magnum upward, and poste- 
rior portion of both parietal and right temporal bones, forming 
an irregular circle 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 
could be seen in the section filled with coagula. A large epi- 
dural clot was situated 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 mag- 
num. The cavity of the posterior part of the great longitudinal 
sinus was occupied by a thrombus, and its walls were infiltrated INJURIES OF THE HEAD. 
7 
with blood. There was a large, partially decomposed thrombus 
in the torcular Herophili, extending 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 
haemorrhage was lined by a firmly coagulated clot, with an in- 
flammatory exudation around it. A portion of the surface of 
the right occipital lobe posteriorly was softened, showed minute 
haemorrhages, 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 distended with slightly tur- 
bid 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, existed in the right cerebellum at a point cor- 
re-ponding to the site of the thickest part of the subdural 
haemorrhage. 
Case VIII.—Male, aged seventy-six ; cause of injury un- 
known ; admitted to alcoholic ward, and transferred to surgical 
service same day. Patient unconscious from the time he was 
found in the street. Stertor ; muscles rigid on both sides; both 
pupils very strongly contracted, the left one the more so. Scalp 
oed9matous in right parietal region. Fissure, extending from 
posterior and inferior part of right parietal into occipital bone, 
discovered by incision. There was no change in the general 
symptoms up to the time of death, two days and six hours after 
admission. The left pupil continued to be the more strongly 
contracted, and muscular rigidity continued to be more strongly 
marked on the right side. Consciousness was not regained. 
Temperature on admission, 100-4°; rose steadily to 103'8° ; post 
mortem, 102°. 
Necropsy.—Fracture at base extended to right jugular fora- 
men, and then turned backward to foramen magnum. Slight 
epidural and considerable subdural haemorrhage at point where 
fracture began. Slight serous effusion into pia. Thrombus in 
torcular Herophili, extending into right occipital sinus and 
through petrosal sinus into jugular vein. The whole inferior 
surface of the brain covered with blood. Superficial laceration 
along the anterior border of left temporo-sphenoidal lobe from 
median line outward. Large clot could be seen bulging out- 8 
A CLIXICO-PATHOLOGICAL STUDY OF 
ward, behind a thin cortical layer, along the whole length of 
external border of left frontal lobe. Well-marked lacerations 
upon anterior border of both frontal lobes, and also upon their 
inferior surfaces along the longitudinal fissure. Optic chiasm 
surrounded by a clot, which extended backward as far as ante- 
rior border of the pons Yarolii. Upon section along external 
border of left frontal lobe, a clot of great size was disclosed, 
which occupied almost the whole substance of the left frontal 
and temporo-sphenoidal lobes, from the third frontal convolu- 
tion backward. This haemorrhage had broken through into the 
lateral ventricles and thence into the occipital lobes, which were 
also filled with great pools of fluid blood. 
Case IX.—Male, aged forty ; fell into the hold of a vessel; 
semi-conscious when found; haemorrhage from both nostrils 
and from right ear; regained consciousness next day ; four days 
later delirious and irritable; back of neck rigid; abdomen re- 
tracted ; death at end of five days. Cheyne-Stokes respiration 
supervened. Temperature for seventy-two hours, 99'2° to 99-8° ; 
fourth day, 103*2°; fifth day, 104‘8°. 
Necropsy.—Contusion over right mastoid revealed on raising 
the scalp. Fracture at base in three fissures; extending from 
this point, two (fine) across petrous portion, and a third con- 
necting them posteriorly across occipital bone. Deep linear 
laceration, extending across inferior surface of right cerebellum, 
near outer border. Subdural haemorrhage over whole left cere- 
brum, superiorly and laterally; most copious in middle lateral 
region. Laceration of antero-inferior border of left frontal 
lobe. White substance of left cerebrum much congested, and 
with punctate extravasations throughout its extent. 
Case X.—Female, aged eight; fell two stories; partially un- 
conscious; left hemiplegia, and haemorrhage from left nostril; 
depressed fracture over left frontal eminence. Patient became 
irritable, and the hone was elevated an hour later. Died with- 
in twenty-four hours. 
Necropsy.—Coronal suture separated on the right side. A 
fissure extended through right parietal eminence and another 
through frontal bone. Base fractured across body of sphenoid 
into left middle fossa. Other fissures through right middle and INJURIES OF THE HEAD. 
9 
anterior fossae, external to orbital plate. Epidural haemorrhage 
on left side anteriorly and in temporal region. Lacerations in 
right frontal lobe and in right fissure of Rolando and in left 
temporo sphenoidal lobe. 
Case XI.—Male, aged twenty nine; fell fifteen feet into 
the hold of a vessel and struck on his head. Coma, stertor; 
left pupil markedly dilated and right pupil contracted; para- 
plegia, haemorrhage from left ear and nose and under left con- 
junctiva, and contusion over left eye. Died in five minutes after 
admission. 
Necropsy.—Epidural haemorrhage, blood still fluid. Frac- 
ture extending downward and forward from behind left parietal 
eminence, across petrous portion, through middle fossa, trans- 
versely across anterior fossa, and terminating at inner extrem- 
ity of lesser wing of right sphenoid. Slight cortical haemorrhage 
on left side, and slight lacerations of under surface of left frontal 
and temporo-sphenoidal lobes. 
Case XU.—Female, aged twenty-three; jumped from fifth- 
story window. Contusions of left hip and shoulder and over 
right parietal eminence; slight haemorrhage from nose and left 
ear; temperature, 99-4°; incontinence of urine and faeces; right 
hemiplegia. Death in two days. 
Necropsy.—Fracture extending from right parietal eminence 
to foramen magnum, of right petrous portion entire length, and 
of left petrous for two inches; laceration of left parietal lobe 
beneath parietal eminence. 
Case XIII.—Male, aged forty-six; fell five stories. Coma, 
stertor, pupils normal; pulse and respiration normal. Death 
in five days. 
Necropsy.—Contusion over right parietal eminence; frac- 
ture extending from this point downward and forward, anterior 
to petrous portion, and through sella turcica; subarachnoid 
haemorrhage over both hemispheres; laceration of under sur- 
face of left temporo-sphenoidal lobe. 
Case XIV.—Male, aged fifty; knocked down by a blow in 
the face and fell upon the back of his head. Patient became 
unconscious, but shortly afterward walked to the hospital ; 
contusion over right parietal eminence; dazed; no other symp- 10 
A CLINICO-PATHOLOGICAL STUDY OF 
toms; walked home; had severe pain in the head for three 
hours after the injury, then became gradually unconscious till 
four hours later, when coma was complete and death occurred 
at the end of another hour. 
Necropsy.—Wound of lip and contusion of forehead; fissure 
of external table, very fine, beginning in right inferior occipital 
fossa and running across right petrous portion ; slight epidural 
haemorrhage about the middle of the fracture; upon left side, large 
subdural extravasation upon lateral border of parietal and frontal 
lobes, extending upward and also downward into middle fossa; 
also some extravasation into pia and several slight contusions 
of brain substance; skull thin, and angles and processes upon 
its inner surface unusually sharp and prominent. 
Case XV.—Male, aged forty; cause of injury unknown. 
Coma; respiration slow and full; right pupil dilated, left con- 
tracted ; reflexes lost; had been seen to move the left side; pulse 
became slower and breathing more labored. Died in nine hours 
and a half. 
Necropsy.—Contusion in left parietal region; fracture from 
this point extending by two fissures into anterior and middle 
fossae; large epidural haemorrhage from rupture of left middle 
meningeal artery ; slight laceration of left parietal lobe at point 
where fracture began, and another upon lateral border of right 
temporo-sphenoidal lobe. 
Case XVL—Male, aged fifty-five; fell upon the street. 
Unconscious; respiration labored; left pupil slightly dilated; 
slight haemorrhage from left ear; slight rigidity of left side. 
He was still stupid upon admission, but could give his name. 
Temperature, 99°. Dilatation of left pupil and rigidity of left 
side increased, and afterward there was complete paralysis of 
left lower extremity, while left arm remained slightly rigid; 
left hemiplegia was finally complete. He died in twenty-one 
hours. Temperature, 101-2°. 
Necropsy.—Contusion of scalp over left occipito-parietal 
suture; skull thin; stellate fracture, originating about the cen- 
ter of left parietal bone; fissures extending upward, across base 
of occipital and along the upper border of petrous portion of 
temporal bone into the middle fossa; subdural haemorrhage INJURIES OF THE HEAD. 
11 
covered right hemisphere; under and lateral surfaces of right 
temporo sphenoidal lobe extensively lacerated; under surface 
of both frontal lobes lacerated along the median fissure ; these 
lacerations were recent; upon the under surface of the left tem- 
poro-sphenoidal lobe there was a deep laceration, irregular in 
outline, but about an inch in its several diameters; there were 
also small and deep lacerations upon its anterior border and 
upon the under surface of the left frontal lobe. All these lacera- 
tions upon the left side extended through the cortex, contained 
no recent clot, but were covered with a grayish-yellow viscid 
substance, and were bounded by a considerable area of yellow 
softening. They evidently antedated the final and fatal injury. 
Section of the brain disclosed marked hyperaemia. 
Case XVII.—Male, aged fifty; cause of injury unknown. 
Unconscious; pulse, 60; respiration full and slow; right pupil 
dilated, the left contracted, neither one responding to light; 
lie had been seen to move the left side of the body; stertor 
supervened and death occurred in eleven hours. 
Necropsy.—Contusion of left parietal region disclosed by in- 
cision; two fissures originated from this point, one extending 
into the anterior and the other into the posterior fossa; large 
epidural clot from rupture of left middle meningeal artery ; gen- 
eral contusion; hyperaemia. 
Case XVIII.—Male, aged thirteen; fell two stories. Haemor- 
rhage from right ear; unconscious; irritable when disturbed; 
consciousness regained in thirty minutes; pulse 78, intermit- 
tent; temperature, 98°; depressed fractures below right tem- 
poral ridge; elevated next day; three fissures, one backward, 
one forward, and one downward; dura incised; only subarach- 
noid haemorrhage; temperature, 101 *8°. Next day patient irri- 
table and somnolent; urine incontinent; temperature slightly 
increased (102°). On second day after operation he was de- 
lirious, and temperature rose steadily till evening, when it was 
105-4°. On the third day the skin was hot and he was very 
restless and sensitive to external impressions; his pupils were 
moderately dilated and reacted slowly. From this time he was 
in deep coma; temperature varied from 104°+ in the morning 12 
A CLINICO-PATHOLOGICAL STUDY OK 
to 105°+ in the evening till death on the evening of the seventh 
day, when it was lOli'S0. 
Necropsy.-— Skull thin. No pus in the wound or in the 
small brain cavity which had been disclosed by the ante-mor- 
tem operation when the depressed bone was elevated. Sub- 
dural haemorrhage in the opposite (left) occipito-parietal region. 
An effusion of thick green pus beneath the arachnoid covered 
the lateral and superior surfaces of the right occipital and 
parietal lobes, but did not extend forward to within an inch of 
the cranial opening left by the ante-mortem operation. A sub- 
dural effusion of similar thick green pus was coextensive with 
the whole right inferior occipital fossa. There was a deep 
laceration, an 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 re- 
moval 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 was intact 
at time of operation, the cavity must be ascribed 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 re- 
pressive force exerted by the skull and dura.) The whole 
brain substance and meningeal vessels were intensely hyper- 
amric, and there were 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 infe- 
rior occipital fossa to the foramen magnum. 
Ca.se XIX.—Male, aged nineteen; fell three stories through 
a hatchway ; unconscious; irritable when disturbed; pulse, 80; 
temperature, 100°; profuse haemorrhage from left ear, which 
continued twenty-four hours, and was then followed by serous 
discharge. At the end of twenty-four hours patient was still 
unconscious, pupils were largely dilated and movable, and he 
had general convulsive movements, most marked in the right 
leg. During the second day coma was more profound and 
general convulsive movements ceased, but he had one prolonged INJURIES OF THE HEAD. 
13 
general convulsion, which was repeated on the third day, the 
movements being most violent on the left side. The left pupi. 
continued from the first day to be more contracted than the 
right. Died in three days and six hours. Temperature con- 
tinued to rise from time of admission, and reached 107'2°. 
Necropsy.—Large hasmatoma in substance of left temporal 
muscle. Fracture extended from left squamous portion of tem- 
poral bone into middle fossa, and by a wide fissure along the 
anterior border of the petrous portion to the sella turcica. 
Large epidural and subdural clots in left middle fossa. Right 
cerebrum covered by a thin subdural coagulum. In the left 
middle fossa diffluent brain substance clung to the dura as it 
was removed. Large and deep laceration of the lateral border 
of the left temporo-sphenoidal lobe and of the lateral border 
and contiguous inferior surface of the right temporo-sphenoidal 
lobe. Small and deep laceration at junction of right parietal 
and occipital lobes. All these lacerations extended into the 
subcortical tissue. 
Case XX.—Male, aged sixty-two; cause of injury unknown ; 
found unconscious in an ice wagon with his head lying on a 
cake of ice. Contusion of left parietal region, and both eyes 
much ecchymosed. Subconjunctival haemorrhage at outer 
part of left eye. Muttered incoherently when disturbed. Slight 
temporary rigidity of right arm. Restless and irritable all day, 
and roused sufficiently in the evening to give a name and ad- 
dress, both of which proved to be incorrect, Condition under- 
went little change till death—at the end of seven days and seven 
hours. Temperature high on admission—101°; in forty-eight 
hours, 104-6° to KM'S0; seventy-eight hours later it receded to 
101-2°; in forty eight hours more it varied from 101° to 102° + , 
and then rose steadily to 107°+ at the time of death. 
Necropsy.—Skull thin; fracture of left anterior and middle 
fossae, apparently beginning with a comminution of orbital plate 
of left frontal bone about its center. At this point two or three 
small fragments were displaced upward with fine fissures run- 
ning off in different directions. One fissure ran outward and 
upward into left squamous portion of temporal bone; another 
ran backward from the crista galli through the bodies of the 14 
A CLINICO-PATHOLOGICAL STUDY OF 
ethmoid and sphenoid, 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. The optic nerves were uninjured. There was a little 
blood extravasated 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 interiorly, near the anterior 
border, where it wras covered in only by the meninges. It was 
separated from the ventricle by a thin saeptum of brain sub- 
stance. This cavity contained commingled blood, clot, and 
brain detritus. There was also a laceration of the anterior two 
thirds of the external lateral border of the right cerebellum, and 
an extravasation the size of a robin-shot existed in the center of 
the right corpus striatum. There was no clot anywhere at the 
base of the brain and no further lesions. 
Case XXL—Male, aged twenty-seven; fell seventeen feet 
into the hold of a vessel, striking his face and stomach. Thirty 
minutes later an officer found him lying upon the dock uncon- 
scious and bleeding from the mouth and nose. In the interval 
which had elapsed he was said to have been excited and abu- 
sive. He was seen upon the dock and twice afterward during 
the night at the station-house by ambulance surgeons, who re- 
fused to take him to a hospital, because, in their opinion, he 
was simply drunk and in no want of surgical treatment. The 
next morning he was taken to court by two policemen. He was 
then conscious, and, in their inexpert opinion, rational. He was 
unable to stand or walk, and was carried between them on 
their arms into a street-car and into court. He was duly sen- 
tenced for intoxication, but by an inspiration of somebody he 
was halted on his way to the Island and placed in the alcoholic 
ward at Bellevue. A little later he was transferred to a surgi- 
cal ward. At that time he was weak, his pulse slow, and res- 
piration labored. There was much ecchymosis of the eyes, and 
the lids could be separated only with great difficulty. There 
was subconjunctival haemorrhage of both eyes, and the arms 
were rigid, more especially the right. Pupils normal. The 
patient soon grew restless, and had muttering delirium, inconti- INJURIES OF THE HEAD. 
15 
nence of urine, and Cheyne-Stokes respiration. Temperature, 
104-8°. Depressed fracture easily felt in right frontal bone. 
The same afternoon he was trephined, and the fracture found to 
be stellate, with a depression an inch by half an inch in diameter. 
The inner table was driven through the dura. Pulse and respi- 
ration temporarily improved, but he grew weaker, and died eight 
hours after admission to the ward. Temperature, 106°. 
Necropsy.—I am indebted to the report of Dr. W. S. Jen- 
kins, late of the coroner’s office. There was a linear fracture in 
the temporal bone three inches long, extending upward and 
backward from the anterior margin. There was a stellate 
fracture in the frontal bone to the right of the median line and 
an inch above the superciliary ridge. On the inner surface of the 
skull the fracture extended across both orbital plates, through 
the ethmoid and body of the sphenoid bone, and on both sides 
through the anterior fossa and through the left middle fossa 
nearly to the petrous portion of the temporal bone. The nasal 
bones were also fractured. These fractures were nearly all 
comminuted. There was no considerable haemorrhage in the 
cranial cavity. The upper surfaces of both hemispheres were 
lacerated, especially at seat of fracture. 
Case XXII.—Male, aged thirty-nine; fell from mizzen-top 
to deck, and struck upon right temporal region; admitted half 
an hour later; unconscious, and bleeding from right ear; ster- 
torous breathing; pulse full and bounding; lacerated wound in 
right parietal region. He had pulmonary oedema, for which he 
had already been bled from the arm by the ship’s surgeon. 
Died in two hours. 
Necropsy.—Haematoma over Avhole right side of the head. 
Multiple fissures of the base (six in number), involving 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 superciliary 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 lacerations of under surface of 
both frontal and right temporo-sphenoidal lobes, which occa- 16 
A CLTNIOO-PATHOLOGICAL SIUDY OF 
sioned slight subdural haemorrhage. Upon the upper and lat- 
eral surfaces of the hemispheres, especially the left, and at the 
base, an epidural haemorrhage of larger size existed in the infe- 
rior occipital fossae, and pressed upon the pons and medulla. 
Case XXIII.—Male, aged forty; found at foot of cellar 
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 diagnosis of ambulance 
surgeon of another hospital, still unconscious. The scalp wound 
was in the parieto-occipital region, to right of 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 un- 
less disturbed, his pupils normal, and respiration slow and regu- 
lar. Temperature, 102'2°; pulse, 96. Temperature 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. 
Necropsy.—Fracture at base, through petrous portion of left 
temporal bone, extending to foramen magnum. Laceration of 
left temporal and frontal lobes, with cortical luemorrhage. 
Case XXIV.—Female, aged thirty-eight; habitual criminal; 
jumped from the third tier of the Tombs Prison to the flagging 
below, thirty feet or more; punctured wound in left occipito- 
parietal region ; unconscious; haemorrhage from left ear; pupils 
moderately dilated, more especially the left; and vomiting per- 
sistent. Temperature, OB^0. The next morning the patient 
was conscious, rational, and the haemorrhage had nearly ceased. 
In the evening she was slightly delirious, and the following day 
required mechanical restraint till quieted by sedatives. Both 
pupils became widely dilated, the left still continuing more di- 
lated 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 re- 
mained clear, but apathetic, till the sixth day, when she fell into 
a stupor. On the same day all the extremities became paretic 
and partially anaesthetic. Up to this time the muscular power 
had been normal. The paresis and anaesthesia were most marked INJURIES OF THE HEAD. 
17 
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 blunted. She answered ques- 
tions slowly and after an interval, and complained of pain in 
the head. On the eighth day she was restle:-s and irritable, and 
had some right facial paralysis, while power in the left foot 
and right hand was still further improved. 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 varied from 100° to 
102°+ ; usually was 101°+ till the twelfth day, when it rose 
to 104°, and was from 103° to 104*5° till she died. 
Necropsy.—Head large and unsymmetrical, and skull thick. 
No lesion of the scalp or of the bone before removing the cal- 
varium. The occiput was disproportionately large, and the 
right occipital fossae were much larger than the left. The left 
middle and anterior lossae 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 anterior surface of the petrous portion, terminated in the 
optic foramen. This fissure was not open, but the fragments 
were quite movable. There was no epidural haemorrhage, but 
pressure was made upon the facial nerve by interosseous haem- 
orrhage as a result of the fracture. There was no meningitis, 
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 larger 
upon its external border, from which a moderate amount of 
blood had spread upward over the occipital lobe, barely reach- 
ing the parietal. Upon section, the cerebral vessels were found 
to be distended with blood, which flowed from the puncta 
vasculosa. The veins could be seen in congeries and filled with 
coagula. The brain substance was softened and oedematous, so 
that the serum followed the knife. The ventricles were dis- 
tended with serum. Subsequent microscopic examination of 
the bruin tissue in the recent state disclosed no inflammatory 18 
A CLIXICO-PATIIOLOGICAL STUDY OF 
changes. There was a considerable extravasation of blood be- 
hind the peritonaeum on the right side, but no injury of the 
viscera. There were no serous effusions in the cavities of the 
body, and no chronic visceral lesions. 
Case XXV.—Male, aged thirty-seven. Cause of injury un- 
known; scalp wound in right posterior temporal region ; haem- 
orrhage from right ear; mental condition stupid, but conscious- 
ness retained; incontinence of urine and faeces. The patient 
had been drinking to excess. On the next day he had active 
delirium, with tremulous muscles and delusions and intervals of 
semi-unconsciousness. On the sixth day there was general mus- 
cular rigidity, stertor, and muttering delirium. The right pupil 
was slightly contracted, with slight serous discharge from right 
ear and slight right facial paralysis. Unconsciousness followed. 
On the eighth day there were two slight convulsions involving 
both arms, the face, and eyes. The face was drawn to the 
right and the eyes turned upward. Paralysis of right arm and 
face succeeded, and a little later the surface temperature of the 
left side was found to be 102°, while that of the right side was 
normal. Rectal temperature, lOS^0, which soon declined to 
104’8°. Death two hours later. Post-mortem temperature, 
106°. The temperature varied from 100° to 102° till fourth 
day, then from 103° to 104° to last day, when it was as noted 
above. 
Necropsy.—Fissure across petrous portion of right temporal 
bone. Large subarachnoid serous effusion. Thin cortical layer 
of blood covering whole of parietal and occipital lobes on both 
sides of the brain. Meningeal vessels congested. Brain struc- 
ture everywhere oedematous. Minute vessels filled with coagula. 
Fluid blood in anterior cornu of left lateral ventricle. Lacera- 
tion of upper and outer surface of right frontal lobe, and upon 
upper and outer surface and posterior border of left occipital 
lobe. A third laceration existed at the base of the brain upon 
either side of the median fissure of the cerebellum. Neither of 
these lacerations was larger than a walnut, and neither involved 
a rupture of the meninges, though they all reached the surface 
of the brain. 
Case XXVI.—Male, aged twenty-three, thrown from a INJURIES OF TIIE HEAD. 
19 
wagon. The ambulance surgeon found him dizzy and feeling 
ill. He had no other symptoms except a scalp wound in right 
temporal region. After admission to hospital he was entirely 
conscious and dictated a letter. There was haemorrhage from 
right ear and nostril. Temperature, 100°. No other symptom*. 
Soon afterward he vomited blood copiously and became un- 
conscious with stertor, and died in four hours from time of 
admission. 
Necropsy.—Depressed fracture of right frontal bone an 
inch from median line and just anterior to coronal suture, tri- 
angular 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 one ran through squamous into petrous portion 
of temporal bone, terminating upon its anterior surface. There 
was an epidural clot extending 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 sub- 
dural haemorrhage 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 an- 
terior columns. The whole brain was hypertemic with a multi- 
tude of punctate extravasations, and the minute vessels were 
filled with c tagula. Upon section, a number of extravasations 
were found in the substance of the pons, mainly in the trans- 
verse fibers, but some in the longitudinal fibers of the crura. 
The smaller ones were of the size of a robin-shot. The largest 
one was half an inch long by a quarter of an inch wide, and was 
just below the surface on the right external border of its in- 
ferior surface. 
Case XXVI1.—Male, aged thirty; cause of injury unknown ; 
unconscious; coma continued till death; hasmatoma of scalp 
at vertex; at base, right side; slight haemorrhage 
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 mark- 
edly so; some rigidity of right side; died same day in eight to 
ten hours after admission into the hospital. 20 
A CLINICO-PATHOLOGICAL STUDY OF 
Necropsy.—Fracture through petrous portion of right tem- 
poral into the occipital bone and into middle fossa. No frac- 
ture of vertex. Epidural clot in right inferior occipital fossa. 
Thin subdural clot over both frontal lobes, especially over left, 
extending nearly to fissure of Rolando. Small laceration of 
left frontal lobe on its under surface near anterior border. 
Case XXVIII.—Female, aged forty-five, fell ten feet upon 
her head; scalp wound in right parietal region; temperature, 
98-8°. Twenty minutes after admission left lower extremity 
became paretic, patellar reflexes lost. Three days later tem- 
perature suddenly rose from 99°+ to 102°. Next day patient 
became delirious. Evening temperature, 105-2°; following 
morning, 106°. Death five days after reception of the injury. 
Necropsy.—Fracture beginning in squamous portion of right 
temporal bone, extended through both anterior fossae, involving 
greater wing of right sphenoid and both orbital plates. Sub- 
dural clot, the size of a pigeon's egg, occupied the left middle 
fossa. Laceration of inferior surface of left temporo-sphenoidal 
lobe. 
Case XXIX.—Female, aged sixty-six; found unconscious 
at foot of cellar stairs; supposed to have been thrown down. 
Scalp wound in left inferior temporal region; left malar hone 
fractured and left side of face much contused; coma, stertor, 
and frothing at the mouth; moist bronchial rales; right pupil 
dilated, left pupil invisible from ecchymosis; right upper ex- 
tremity anaesthetic and soon became paralyzed; temperature, 
101-6°. Three hours later the patient was apparently moribund. 
On the following day she was conscious and rational and the 
paralysis and anaesthesia had disappeared ; the pupils were nor- 
mal; urine incontinent; temperature, 99°-f. For a week’s 
time her condition remained practically unchanged, except that 
her temperature gradually rose to 108° and in the last three days 
gradually fell to 100°, and that the subconjunctival haemorrhage 
increased. Her mental condition was apathetic, and she could 
be rarely induced to make a monosyllabic answer to a question 
asked. On the eighth day she suddenly became unconscious. Her 
temperature rose to 104-8° and within two hours fell to 102-8°. 
She became weaker and died during the ninth day, her tern- INJURIES OF THE HEAD. 
21 
perature having again risen to 106°. Ten minutes post mortem 
it was lOb^0. 
Necropsy.—An open fissure extended through both tables of 
the bone from a little above and to the left of the external oc- 
cipital tubercle to the left foramen lacerum posterius. There 
was moderate subarachnoid serous effusion. There was an ap- 
parent laceration on the median aspect of the left frontal lobe, 
the real character of which only became obvious upon further 
examination. The interior of both frontal lobes was disorgan- 
ized and destroyed, having been broken down by subcortical 
laceration. On the left side the clot was very solid, and the 
external layers of fibrin on its inferior aspect were partially 
decolorized. It had broken through into the anterior part of 
the lateral ventricle and also through the cortex on the median 
surface, involving for a space of half an inch the motor arm 
area and the sensorial center below it in the gyrus fornicatus. 
It was this which at first sight seemed to be an independent 
lesion. The clot in the right frontal lobe, which was of equal 
size, had nowhere broken through the cortex or into the lateral 
ventricle. There was no cortical haemorrhage, although there 
was a deep laceration on the posterior border of the left cere- 
bellum. The interior of the brain generally was softened and 
reddened in patches. 
Case XXX.—Female, aged fifty; no history; admitted as 
case of apoplexy. Small lacerated scalp wound in left posterior 
parietal region; slight haemorrhage from both nostrils; patient 
unconscious; movements sluggish; left pupil dilated, right con- 
tracted; incontinence of urine and faeces; face flushed; visible 
pulsations of carotids ; fine linear fracture running toward tbe 
base discovered by incision ; temperature, 101°; at night, 101 *8° ; 
next day, 101 ’2° to 101°; then rose steadily to lC^’S0 on the 
next day, when death ensued, three days and a half after ad- 
mission, without consciousness having at any time been regained. 
Post-mortem temperature, 109°. On the last day of life sensi- 
tiveness of the corneas was markedly diminished and sensation 
was evidently blunted all over the body. 
Necropsy.—A fissure extended from left of occipital protuber- 
ance through posterior fossa and petrous bone to foramep ovale, 22 
A CLINIC0-PATI10L0GICAL STUDY OF 
There was a large, firm subdural clot, three fluidounces by 
measurement, in the anterior fossae, and a slight subdural 
haemorrhage into right posterior fossa around the foramen 
magnum. A deep laceration extending below the cortex, on 
the under surface of the left cerebellum, made an excavation 
three quarters of an inch broad from the posterior nearly to the 
anterior border. Another extensive laceration deeply excavated 
the inferior portion of the right frontal and extended into the 
external border of the right temporo-sphenoidal lobe. Haemor- 
rhage from the latter laceration reached the vertex anteriorly 
and filled the fissure of Sylvius. Another laceration existed in 
the middle portion of the gyrus fornicatus, filled with brain 
detritus and coagulum, and extended through the cortex. This 
was oval in form and half an inch in diameter. There was some 
general contusion of both hemispheres, most marked in posterior 
portions. 
Case XXXI.—Male, aged forty-five; thrown from a horse 
and struck upon his head. He was temporarily unconscious, 
but on the arrival of the ambulance was able to stand, and said 
he felt very well. He again became unconscious on his way to 
the hospital. His pupils were contracted and his pulse barely 
perceptible. He suddenly became cyanotic and died twenty- 
five minutes later. 
Necropsy.—Haematoma of scalp in left occipital region; 
blood fluid; stellate fracture of calvarium with center in left 
upper occipital region, and with fissures extending downward 
into foramen magnum, forward into middle fossa, and upward 
and laterally; epidural clot in occipital region; subdural haemor- 
rhage in inferior occipital fossa compressing the medulla; ex- 
tensive subarachnoid haemorrhage over temporo-sphenoidal and 
frontal lobes on both sides, with laceration of inferior surface of 
right frontal and temporo-sphenoidal lobes, and in slighter de- 
gree of same region on the left side. 
Case XXXII.—Male, aged thirty-four; struck by a brick 
falling from the fourth story. Compound, comminuted, de- 
pressed fracture of the right parietal bone extending into the 
base; haemorrhage from right ear; patient conscious and with- 
out general symptoms; temperature, 100‘4°, and became normal; INJURIES OF THE HEAD. 
23 
depressed bone elevated; no injury of dura. After twenty- 
three days subcortical abscess of brain developed, with left 
hemiplegia and anaesthesia. Dura incised and abscess evacuated. 
Died sixteen hours later. Temperature, 108°. 
Necropsy.—Fissure through whole length of anterior surface 
of right petrous portion of temporal bone; no superficial cere- 
bral laceration; subcortical abscess cavity of small size, which 
had been evacuated ante mortem through the angular gyrus. 
This case is fully reported in the New York Medical Journal, 
March 29,1890. 
Case XXXII1.—Male, aged thirty-three; cause of injury un- 
known. Consciousness lost and never regained; scalp wound in 
left posterior parietal region; haemorrhage from left ear; both 
pupils dilated, but the right contracted later; pulse, 60; mus- 
cles relaxed and later became rigid. Death in twelve hours. 
Temperature on admission, 99-6° ; later, 98-6° to 100-4°; one 
hour post mortem, 101'2°. 
Necropsy.—Semicircular fracture of squamous portion of left 
temporal bone, with fissure extending into anterior surface of 
petrous portion; deep, well-defined laceration, laterally and 
posteriorly, of left temporo-sphenoidal lobe, from which a thick 
clot extended over the occipital region; brain in all its parts 
excessively hypersemic; on section, the surface was repeatedly 
bathed in blood as it was each time wiped away; no punctate 
extravasation or coagula in minute vessels. 
Case XXXLV.—Male, aged forty; said to have fallen down 
one flight of stairs. Scalp wound in right occipito-parietal re- 
gion ; haemorrhage from the nose and later occurrence of haema- 
temesis; unconsciousness; stertor; pulse, 96 and full; respira- 
tion, 18; temperature, 100°; pupils normal till just before 
death, when they dilated ; restlessness; incontinence of urine; 
temperature rose gradually to 102-6° one hour ante mortem. 
Died in fourteen hours. 
Necropsy.—Linear fracture in right parietal bone and ex- 
tending through middle fossa and greater wing of sphenoid; 
small epidural clot and larger subdural clot beneath the site of 
fracture ; dura ruptured ; cortical laceration an inch and a quar- 
ter by three quarters of an inch in anterior and inferior part of 24 
A CLINICO-PATHOLOGICAL STUDY OF 
right parietal lobe; another laceration involved anterior half of 
middle temporal convolution on the same side. The whole 
brain very hyperaemic, most markedly so on left side posteriorly. 
In almost the exact center of the left cerebellum there was a 
laceration about the size of a pea filled with fluid blood. 
Case XXXV.—Male, aged forty ; fell six stories. Abrasion 
about left eye; unconscious; pulse and respiration too rapid to 
be counted; temperature, 101°; both pupils strongly con- 
tracted ; rigidity of both lower and the right upper extremities; 
temperature in articulo mortis, lOCK0; two hours post mortem, 
99°+ and pupils dilated. 
Necropsy.—No superficial injury upon any part of the body 
except the abrasion noted. An extravasation of blood existed 
below the scalp, covering the whole left parietal region. Sepa- 
ration of coronal suture, left side, from about its middle point, 
extending outward and terminating in a fissure which, in the 
middle fossa, divided into two lines, one lost in the greater 
wing of the sphenoid, the other at the petro-mastoid junction. 
No epidural or subdural hemorrhages. Cortical haemorrhages 
from meningeal contusion—one covering left frontal and parie- 
tal lobes superiorly and laterally, another covering right parietal 
and occipital lobes on either side of their junction. No lacera- 
tion on the surface of the brain, or in any part, except one three 
eighths by one fourth of an inch in the left corpus striatum, 
subcortical, and at junction of middle and posterior thirds. Ex- 
cessive general hyperemia. 
Case XXXVI.—Male, aged sixty-five; fell into the hold of a 
vessel; haemorrhage from the ears and into subconjunctival tis- 
sue; conscious for twenty-four hours; both pupils dilated; 
temperature high; died in forty eight hours. 
Case XXXVII—Male, aged sixty; knocked down by a 
truck; scalp wound in right posterior occipital region. A 
linear fracture running backward and downward was discov- 
ered by incision. Patient unconscious and restless. Pupils con- 
tracted ; pulse, 66; very slight movements of right side of 
body; no facial paralysis; spoke only in monosyllables. In a 
short time right hemiplegia became complete, pulse weaker, 
temperature lower, and there was a slight general convulsion INJURIES OF THE HEAD. 
25 
lasting about ten seconds. Four hours later, coma was pro- 
found, pupils small and irresponsive, pulse and respiration very 
irregular, and restlessness ceased. The patient was trephined 
over left motor area. The fissure was found to extend down- 
ward behind the mastoid. Epidural haemorrhage disclosed, and, 
after incision of dura, subdural haemorrhage. He died three 
hours later, and eleven hours after reception of injury. 
Case XXXVIII.—Male, aged forty; cause of injury un- 
known; contusions behind both ears; free haemorrhage from 
right ear, and during the night from both ears and mouth; 
pupils contracted; pulse full and slow; breathing labored; tem- 
perature, 99‘2°; became 105°. He did not regain conscious- 
ness, and died six hours after admission. 
Case XXXIX.—Male, aged twenty; fell thirteen feet; large 
haematoma in left posterior parietal region; unconscious; ooz- 
ing from left ear and nose; pupils contracted, and eyes turned 
persistently to the right; mouth drawn slightly to the right; 
breathing irregular; vomiting free; extremities cold and muscles 
relaxed; urine incontinent; temperature, 99-5°. Soon after ad- 
mission haemorrhage from nose ceased, but continued from the 
ear. Patient could be roused partially but with difficulty, became 
restless, and moved his right side rather less freely than the left. 
Temperature, 101°. Two hours after admission breathing be- 
came stertorous, and tonic spasms, beginning in the right arm, 
became general. Two attacks of opisthotonos followed, and 
ceased after thirty minutes. Left pupil became the larger, while 
the right eye still turned to the right on exposure. Tempera- 
ture, 105°; pulse, 96; respiration, 32, and of the Cheyne- 
Stokes variety. An hour later, coma was profound, with slow 
and stertorous respiration. Temperature, 106‘6°. Respiration 
became insufficient, four to the minute, and face cyanotic. 
Death occurred in four hours. Pupils post mortem were wide- 
ly dilated. 
Case XL.—Male, aged thirty; fell three stories to the pave- 
ment; four ribs fractured on the right side; contusion over 
right eye, and slight right subconjunctival haemorrhage; un- 
conscious; skin cold and moist; pulse, 120; temperature, 100°. 
Pulse became weaker and respiration more labored, and death 26 
A CLIXICO-PATHOLOG1CAL STUDY OF 
ensued in five hours and a half after reception of injury. No 
pulmonary symptoms. 
Case XLI.—Male, aged forty; cause of injury unknown; 
extensive contusion over right parietal region; haemorrhage 
from right ear and nose; unconscious; stertor; died in four 
hours and a half. 
Case XLII. —Female, aged forty-seven; fell on the street in 
a convulsion during a debauch ; had other convulsions before 
admission; left side of head and eyelid much contused ; mental 
condition stupid; pupils normal; breathing stertorous; pulse, 
108; convulsions continued during the day and night; no in- 
terval of consciousness. During the morning a severe haemor- 
rhage occurred from the mouth without previous warning. In 
the afternoon pulse and respiration became frequent. The 
blood which came from the mouth was bright in color, non- 
aerated, and said to be more than eight ounces in amount. The 
next day the convulsions were diminished in frequency and 
were general, but more severe in the right arm. No initial 
symptom noted. Both arms were rigid and head constantly 
turned to the right. There were in all twenty-three convul- 
sions. Death occurred in thirty-eight hours. Temperature, 
one hour after admission, 102'4° ; morning of next day, 105'6°; 
later, 10T40, lOfi^0, 107'8°—the last, one hour before death. 
Case XLIII.—Male, aged seventeen; fell one story; large 
haematoma on left frontal region ; unconscious till death; haem- 
orrhage from nose, mouth, and left ear, and under conjunctiva 
of both eyes; pupils equally dilated; slight convulsive move- 
ments of right side soon terminating in right hemiplegia, with 
rigidity of left side; death from pulmonary oedema occurred in 
five hours; temperature, one hour before death, was 105-4°. 
Case XLIY.—Male, aged thirty-seven; jumped from a fourth- 
story window to the street while drunk; lacerated scalp wound 
in left posterior parietal region, and fissure running from it into 
posterior fossa; both pupils widely dilated; patient loud and 
abusive in language; slight left facial paralysis; incontinence 
of urine; pulse, 118, soon becoming irregular and almost im- 
perceptible. The patient became quiet, and a little later coma- 
tose. Temperature, 97 6° by rectum. Three hours after ad- INJURIES OF THE HEAD. 
27 
mission he had three clonic spasms of right arm at varying 
points. Died in six hours after admission while under ether, 
given for reduction of a dislocated hip. 
Case XLV.—Male, aged thirty; struck by a falling ladder; 
haemorrhage from mouth and nose, and blood and brain matter 
exuded from the right ear; both eyes protruded, the right eye 
the more so; both pupils contracted and irresponsive to light; 
right facial paralysis; respiration stridulous. Right pupil soon 
began to dilate slowly. Temperature, 100°; pulse, 93. Patient 
remained unconscious till death, two hours after injury. 
Case XLYI.—Female, aged thirty-five ; fell down stairs; 
admitted next day, still unconscious; ecchymosis in left poste- 
rior parietal region ; haemorrhage from left ear; left eye pro- 
truded; left pupil dilated. Temperature, 101°; pulse slow. 
Vomiting profuse. Next day paresis of whole right side; urine 
incontinent; some pulmonary oedema. On the third day rigidi- 
ty ot the muscles of the back of the neck. Haemorrhage from 
the ear continued a week, lessening in amount and becoming 
serous in character. Patient continued unconscious till death, 
at the end of ten days, from asthenia. Temperature ranged 
from 100° to 102° till the morning of the eighth day, when it 
suddenly rose from 101° to 103°. From this time it rose, with 
morning depressions, steadily to 107‘4° on the day of her death. 
Case XLVII.—Male, aged thirty-five; cause of injury un- 
known; found unconscious; small h asm atom a on left temple ; 
hfemorrhage profuse from both ears; evidence of previous 
haemorrhage from both nostrils; pulse scarcely perceptible; 
stertor; pupils both equally dilated ; complete relaxation of 
limbs, and no response to peripheral irritation. Left facial pa- 
ralysis was developed two hours before death, which occurred 
in six hours without restoration of consciousness. Temperature 
on admission was 98-6°, rose to 99°+ ; pulse, 64 to 128 ; respira- 
tion, 24. 
Case XLV1II.—Male, aged twenty-four; fell down stairs; 
wound over right eye ; haemorrhage from right nostril; coma ; 
stertor; pupils contracted; temperature, 98'5°; pulse, 120; 
no paralysis or muscular rigidity ; reflexes normal; fracture of 
left thigh. Clonic spasm of left side five hours after admission. 28 
A CLI.VICO-PATHOLOGICAL STUDY OF 
Death in ten hours after reception of injury. Hourly tempera- 
ture, 100°, 101°, 102-4°, 102-4°, 103°, 104-4°, 105°, 106-4°. Thirty 
minutes post mortem, 108-8°. 
Case XLIX.—Male, aged four; fell two stories, striking 
the back of the head; small scalp wound just above external 
occipital protuberance: large baematoma above each ear; pro- 
fuse haemorrhage from both ears and mouth and haematemesis ; 
depressed fracture could be felt beneath the wound ; uncon- 
scious ; right pupil dilated; neither pupil responsive; slight 
rigidity of muscles of right side. Temperature, 100-8°; pulse 
and respiration very rapid ; respiration became Chevne-Stokes. 
Died in four hours. 
Case L.—Male, aged fifty-nine; fell twro stories through an 
elevator and struck his head; contusion about right ear and 
nose; unconscious for ten days; haemorrhage from right ear 
and nose and under right conjunctiva; stertor; pupils irregu- 
lar. At the end of a week restless, and required to be kept in 
bed by an attendant. Discharge from ear straw-colored. At 
the end of two weeks patient entirely conscious. Ten days 
later he walked a little and began to recognize people, and after 
another ten days he was mentally recovered. 
Case LI.—Male, aged thirty-three ; thrown from a truck 
and received a blow upon the head; scalp wound in left tem- 
poral region ; profuse luemorrhage from left ear; pupils regu- 
lar. He was semi-comatose, but conscious and rational, next 
day, and two days later became delirious. Haemorrhage from 
the ear ceased on the sixth day, delirium continued a week, and 
vertigo for upward of three weeks. No further symptoms were 
developed. 
Case LII.—Male, aged thirty-five; struck on the head by a 
brick falling eight stories; not made unconscious; compound, 
comminuted, depressed fracture at right temporo-parietal junc- 
tion ; squamous portion of temporal much comminuted, and one 
large fragment driven into the brain; haemorrhage from right 
ear and nostril; right pupil contracted ; little or no shock. He 
recovered with some deafness remaining in right ear. 
Case LIII.—Male, aged thirty-five; fell down stairs while 
drunk; coma; stertor; haemorrhage from left ear, which con- INJURIES OF THE HEAD. 
29 
tinued twenty-four hours; pupils contracted. Regained con- 
sciousness in twelve hours. Five days later, left facial paraly- 
sis, both upper and lower face involved, and food accumulated 
between cheek and jaw ; ptosis, etc. No loss of sense of taste. 
He entirely recovered from paralysis, and suffered only from 
occasional vertigo. 
Case LIV.—Male, aged nineteen; thrown from his horse 
while riding, and struck on the back of his head; contused 
wound in right occipital region ; profuse haemorrhage from right 
ear; pupils contracted; unconscious till after his removal to his 
house, a distance of two miles. He then had severe nausea and 
vomiting, and was somnolent for several hours. The next morn- 
ing his pulse and temperature were normal, and he suffered 
from severe pain in the head, which continued for three days. 
Iltemorrhage from the ear ceased at the same time. There was 
no rise at any time in pulse or temperature. At the end of ten 
days there was*still some pain and tenderness on deep pressure 
just abvoe and behind the ear. His recovery was complete. 
Case LV.—Male, aged forty-four; said to have fallen and 
been struck by a plank; admitted to alcoholic ward, and next 
day transferred to surgical service when he had partially recov- 
ered consciousness. The left upper and lower extremities, which 
had been rigid, had become hemiplegic and anaesthetic. There 
was an abrasion of the nose, a contusion of the left eye, and a 
haematoma of the right posterior parietal region. Three days 
later the left hemiplegia had become complete; movements 
from the bowels were conscious but involuntary; bladder con- 
trolled ; temperature, 99°. His mental condition had been un- 
changed since he recovered consciousness. He answTered ques- 
tions rationally, and never varied in his explanation of the man- 
ner in which his injury had been received. He talked con- 
stantly and rambled in his speech. Upon incision, an open fis- 
sure was disclosed, which ran obliquely across the right parietal 
bone, from the anterior superior angle, and into the occipital as 
far as it could be conveniently traced. There was no depression. 
A large opening was made through the bone by trephining and 
use of the rongeur. An epidural clot was found to extend from 
the coronal suture in front to the superior occipital fossa be- 30 
A CLIXICO-PATHOLOGICAL STUDY OF 
hind, and from the median line to the middle fossa, and was an 
inch and a half in thickness in its central portions. This clot, 
when removed, measured four ounces and a half by volume, 
and left a large cavity, the result of cerebral compression. The 
dura was apparently uninjured. As haemorrhage was free from 
some inaccessible point beneath the bone, the cavity was tem- 
porarily packed with gauze. Two hours after the operation he 
could move the left leg. Twelve hours later there was sensa- 
tion in the left arm. The next day sensation was perfect, move- 
ments of the left arm still restricted, and movements of the 
bowels occurred which were controlled. Temperature, 98 5°. 
The second day the brain had regained the volume it had lost 
by compression, and his mental condition was apparently nor- 
mal. In four days he was in all respects entirely well, except 
for his external wound. 
Case LVI.—Male, aged twenty-three; thrown from his 
horse and sustained a depressed fracture of the left frontal bone 
two inches above the orbit. Partial loss of consciousness; 
haemorrhage from nose and mouth; pupils normal; skin pale 
and moist, and extremities cold ; two or three hours later pro- 
jectile vomiting and haematemesis. There was slight ecchymosis 
of the left upper eyelid before the vomiting; after it both eye- 
lids became excessively ecchymotic, and at the same time the 
outer half of the left conjunctiva became filled with blood. 
The temperature was usually about 99°, never above lOO'b0. 
He had temporary amblyopia, and no other results followed. 
Case LVII.—Male, aged forty-five; knocked down and 
beaten about the head; lacerated scalp wounds in left fronto- 
parietal region; coma; haemorrhage from both nostrils; pu- 
pils normal; pulse, 100. He recovered partial consciousness 
in one hour, and became excessively irritable; full conscious- 
ness returned next day, and he was removed from the hos- 
pital. 
Case LYIII.—Male, aged twenty-six months; fell four 
stories; extensive scalp wound in right occipital region; re- 
peated vomiting; haemorrhage from right ear. Three hours 
later he became restless, had clonic spasms upon the right side, 
and gradually lost consciousness. There was apparent complete INJURIES OF THE HEAD. 
31 
right hemiplegia; movements of the left side were easily in- 
duced ; pulse 130 and weak ; breathing stertorous. Conscious- 
ness gradually returned within twelve hours, and no paralysis 
remained. There were no further symptoms. 
Case LIX.—Male, aged thirty; fell from elevated railroad 
to sidewalk, striking upon left side of head and face ; contusion 
over left eye; semi-conscious; haemorrhage from right ear; 
pulse and respiration slow. The next day patient recovered 
consciousness enough to discover that he had become blind in 
the left eye. He responded slowly to questions and slept most 
of the time. Ophthalmoscopic examination of the left retina 
was negative. The left pupil would not respond to direct ex- 
posure to light, but would contract with the other pupil on 
simultaneous exposure. In the opinion of Dr. P. A. Callan, the 
blindness was due to pinching of the optic nerve by a fracture 
involving the optic foramen. Fifteen days later Dr. Callan 
found commencing atrophy of the optic nerve. Eight days 
after the injury there was partial left facial paralysis, and the 
tongue deviated to the right. He complained of pain over the 
left eye and behind the right ear. A slight sero sanguinolent 
discharge began to flow from both ears, continued for some days, 
ceased, and reappeared from the right ear. Temperature on 
admission was 99°, rose to 100°, and afterward varied, usually 
from 99° to normal. 
The patient, a man of unusual intelligence, stated, after bis 
recovery, that for five weeks after his accident he was unable 
to recollect the attendant circumstances or anything that hap- 
pened about that time or afterward ; that bis mental condition 
was one of great confusion. After that period his memory was 
restored and his mental confusion disappeared. His recovery 
was ultimately complete, with the exception of the loss of sight 
of the left eye. 
The diagnosis made was: Fracture of the frontal bone, com- 
mencing on the left side, extending through the anterior fossae 
and through the right middle fossa and petrous portion, involv- 
ing the left optic foramen and lacerating the prefrontal lobe. 
Case LX.—Male, aged forty-seven; was knocked down by a 
blow and his head struck heavily upon the pavement; slight con- 32 
A CLLYICO-PATHOLOGICAL STUDY OF 
tusion upon lip and over right eye; pulse, 72; temperature, 
100‘2°; unconscious; stertor; pupils normal; soon became 
delirious and was unable to articulate. He remained in a con- 
dition of stupor and delirium for ten days; required mechanical 
resraint. He was unable to articulate, and was dysphagic; 
attempted to drink bis urine. His mental condition and power 
of articulation then improved for two weeks, though he de- 
veloped left facial paralysis, involving lower face; dysphagia 
disappeared. There was then an interval of a few days, when 
he was irritable, restless, and disposed to wander about the 
ward at night. His temperature varied from 100° to normal, 
and was usually at the higher point. From this time he became 
quiet and conversed intelligently, though his mind wandered. 
He had no recollection of his injury, of what preceded it, or of 
anything that occurred afterward. He failed to recognize his 
location or to appreciate his surroundings. His memory of 
more distant events was better, but still defective. His laugh 
was vacant, and there was some perceptible loss of power on 
the left side. He continued in a demented condition and inci- 
dentally a dipsomaniac till his removal to an insane asylum 
within the last month, two years after the injury. 
Case LXf.—Male, aged twenty-two; fell two stories and 
struck right side of the head and face and right shoulder; con- 
tusions of those regions and fracture of acromion; uncon- 
scious; haemorrhage from right ear, and four hours later from 
the nose; regained consciousness in five hours; haemorrhage 
from ear ceased in three days; temperature, 101° to 100°; nor- 
mal after four days. 
Case LXII.— aged twenty-two; fell three stories; 
contusions of right side of head, face, and eye; haemorrhage 
from right ear and month; unconscious; pulse slow and full 
(60); breathing labored; temperature, 101°; pupils normal. 
Respiration soon became easier, but the patient was irritable and 
restless lie did not regain consciousness for five days, during 
which time he continued to be irritable when disturbed, and 
was not wholly rational for five days longer. Toward the end 
of the second week his articulation became thick and right 
lower facial paralysis became evident. At the same time a INJURIES OF THE HEAD. 
33 
swelling without discoloration of the left side of the face, which 
had been present since admission, perceptibly increased, but 
soon afterward disappeared. The facial paralysis persisted and 
the difficulty of articulation increased. His mental condition 
varied, but progressively deteriorated. There was slowness of 
perception and hesitation in expression. His laugh was silly 
and his manner vacant. There also seemed to be a sensory 
aphasia at a late period. In reply to questioning about the 
manner of his accident, lie would talk about taking a basket of 
clams from Koster & Bial’s. He might say “ Koster & Bial’s,” 
but was quite likely to say “ Koster and clams.” At the begin- 
ning of the second month there was a sudden change. His 
mind in a day became clear; he knew where he lived and that 
he was in a hospital. He conversed rationally about his acci- 
dent and how it occurred. He lost his delusions and rested 
quietly at night, though his speech was still a little indistinct and 
his facial paralysis had not entirely disappeared. Temperature 
after the third day was rarely above 99° and oftener below it. 
His recovery was ultimately complete. 
Case LXIII.—Male, aged forty ; fell five steps of a stairway . 
walked home; haemorrhage from right ear; had two convul- 
ions next day and was then taken to the hospital; haemorrhages 
from the ear still continued; stupid; muttering; two other con- 
vulsions, most marked on the right side, followed by mild de- 
lirium through the night. No previous history of epilepsy or 
excesses in drink. Temperature, 101 ‘2°. Three days later pa- 
tient was still stupid, said little and that incoherently, and was 
delirious. Temperature had ranged from 101 *2° to 100 6°. He 
was transferred to Bellevue, and there became wildly delirious 
for three days, and then quiet and rational. Temperature, 98'8°. 
No further history noted ; no other symptoms. 
Case LXIV.—Male, aged forty-two; cause of injury un- 
known. Semi-conscious and drunk; haemorrhage from right 
ear which continued eight days; membrana tympani ruptured ; 
violent mania for two days and mild delirium two days longer . 
temperature. 100°. Four days afterward he suffered pain in 
the head; had Occasional delusions; his mental processes were 
slow, and his tongue deviated to the right; urine and faeces A CLINICO-PATHOLOGICAL STUDY OF 
34 
incontinent. In the second week he became rational and only 
occasionally soiled the bed. His tongue still deviated. At the 
end of a month he no longer had symptoms; even the deafness 
had improved. Temperature second day, 103°; gradual de- 
cline to 99° in four days. After seventh day habitually normal 
to 99°. 
Case LXV.— Male, aged forty; fell down a gang plank. 
Unconscious; haemorrhage from both ears, more from the 
right; pulse, 100; temperature, 100°. After some hours con- 
sciousness returned and he was able to speak. Delirious through 
the night. On the next day his tongue deviated to the right; pu- 
pils dilated, left more so than the right; mind still clouded; 
temperature, 99-6°. Four days later he was rational. No fur- 
ther symptoms. 
Case LXVI.—Male, aged twenty-three; walked out of a 
window while sleeping and fell three stories to a stone pave- 
ment below, striking an iron fence on the way down. He re- 
mained unconscious for fifteen or twenty minutes. On admis- 
sion, there was a wound of the external right ear. While this 
wound was being dressed a very profuse serous discharge began 
from this ear and continued for several days. Pupils and respi- 
ration normal; severe vertigo, aggravated on attempting to arise 
or on opening his eyes; he vomited several times; pulse, 90; 
temperature, 99°. On the fourth day he had upper and lower 
incomplete facial paralysis which continued for a week’s time. 
On the eighth day he had three epileptiform convulsions and 
one on the next day. The head and eyes were first turned to 
the right, then the arms and finally the legs were involved. On 
the twentieth day he began to have severe pain in the right ear, 
and as the mastoid region later became swollen and inflamed, it 
was trephined for exploration with negative result. The tem- 
perature but once exceeded 99°. The mastoid inflammation 
disappeared at once after trephination. Recovery was com- 
plete. 
Case LXVTI.—Male, aged fifteen; kicked in the back of the 
head by a horse. No apparent external injury; profuse haemor- 
rhage from right ear; was moaning and restless; became de- 
lirious after a few hours; afterward irrational and incoherent; INJURIES OF THE HEAD. 
35 
irritable; temperature, 100°; delirious or irrational for five 
days; temperature, 100° to 102°; removed from hospital in 
two weeks; temperature, 99°; still had delusions. 
Case LXVIII.—Female, aged six; fell two stories to pave- 
ment ; unconscious; lacerated wound over right eye and haema- 
toina; .contusion of face; severe hemorrhage from mouth and 
nose and haamatemesis; subconjunctival, hemorrhage in both 
eyes; pupils dilated; stertor; respiration frequent; tempera- 
ture, 99° ; reflexes lost; incontinence of urind and feces ; sur- 
face irritation caused violent convulsions; initial'symptom in 
the eyes, continued twenty-four hours; also hemorrhage Iron 
nose and mouth. After that lime all the symptoms disappeared, 
and patient was out of bed on the tenth day ; temperature rose 
in three hours from admission to 103‘2°; fell to 98-6° on the 
second day. 
Case LX1X.—Male, aged four; struck by some falling ob- 
ject; contusions over left frontal and right parietal eminences; 
heemorrhage from mouth, nose, and both ears, and continued 
from left ear for five days; unconscious; left pupil dilated; 
left facial paresis; temperature, 99°; somnolent forty-eight 
hours, but rational when roused; incontinence of urine and 
faeces; temperature, 100° on second day and 100 4° on third 
day; did not get below 100° till tenth day; pulse usually 120; 
symptoms gradually disappeared. 
Case LXX.—Male, aged forty; fell one story to pavement, 
striking back of his head ; scalp wound in right occipital re- 
gion ; haemorrhage from left ear; left pupil dilated; soon be- 
came normal; unconscious; partially restored in ambulance; 
on admission, restless and delirious ; temperature, 99'4° ; pulse, 
60 ; respiration rapid ; moved right side only ; incontinence of 
urine and faeces. Temperature ranged during the first week 
from 100°+ to 101°; then became 99°+ in the morning, and 
at end of second week became normal • pulse varied from 62 to 
54; required continuous mechanical restraint for four days and 
at night for one month. His mind underwent the typical 
changes (see remarks on diagnosis), and became ultimately com- 
pletely restored. 36 
A CLINICO-PATHOLOG1CAL STUDY OF 
Case LXXI.—Male, aged fifty-two; fell backward and struck 
back of bis head, at the same time fracturing his left patella. 
At the hospital to which he was taken his head injury did not 
attract attention. He was delirious on the second day and had 
a convulsion on the fifteenth, and his condition was attributed 
to the alcoholic habit. Six months later the patella was wired 
for non-union. His muscular rigidity under the anesthetic was 
notable. His temperature the day following the operation was 
99° till one o’clock p. m. Half an hour later and without pre- 
monition he had an epileptiform convulsion which began in the 
face and became general, and was followed by wild delirium. 
He had two other similar convulsions, also followed by wild 
delirium, and the last by a temperature of 103°. The kidneys 
acted freely and the urine was normal. The wound of opera- 
tion was the seat of primary union. The temperature was nor- 
mal on the next day and so remained for fifteen days. At that 
time an attempt was made to coapt the fragments of the patella, 
which he had torn assunder in his convulsions and delirium. 
This failed and there was some subsequent suppuration which 
elevated the temperature for the next ten or twelve days to 99° + 
to 102°. The wound was then healed aud the temperature 
again became normal. At each dressing great muscular rigidity 
and tonic spasm had been noted in the affected limb (left). Just 
one month from the previous attack convulsions recurred and 
were frequently repeated for thirty-six hours. They were all 
marked by the same characteristics. Each one was preceded 
by great restlessness. In about fifteen seconds this was followed 
by wide dilatation of both pupils. The muscles of the left side 
of the face began to twitch and the eyes deviated to the left. 
The muscular spasm extended to the other side of the face, then 
to the left arm and leg, and finally became general. The whole 
convulsion lasted about thirty seconds. During the day the de- 
viation of the left eye became permanent. The tendon reflexes 
were markedly increased. After the convulsions ceased he be- 
came delirious and died nine hours later. At the time of the 
seizure his temperature was 100T°, in twelve hours it became 
FRACTtr'KES OF THE VERTEX. INJURIES OF TIIE HEAD. 
37 
102°, in twenty hours 104°, in twenty-four hours 104,8°, and 
afterward fell to 104°. 
Necropsy.—The knee joint of operation was found to be free 
from inflammatory complication, and the wound practically 
healed. A depression was discovered in the skull just above 
the external occipital protuberance in the median line. This 
was confined to the external table and no lesion of the brain ex- 
isted beneath it. At the opposite extremity, however, of the 
antero-posterior diameter there was a circular laceration upon 
the anterior border of the right frontal lobe, and another lacera- 
tion existed upon the under surface of the left frontal lobe, upon 
the middle of the second and third orbital convolutions, an inch 
and a half by an inch in diameter. A still larger laceration of 
the base, at least three inches and a half by an inch and a half 
in diameter, existed upon the right temporo-sphenoidal lobe, in- 
volving a little of the first, and almost the whole of the second 
and third convolutions. All these lacerations were distinctly 
limited, softened, and of a brownish color, showing the consid- 
erable time which had elapsed since they were inflicted. The 
whole right temporo-sphenoidal lobe was greatly atrophied, in- 
durated, and pigmented. The pia was thickened over each 
laceration. 
Case LXXII.—Male, aged forty ; cause of injury unknown; 
found unconscious in bed ; contusion of forehead and left upper 
eyelid ; pupils regular and fixed ; right facial paralysis; both 
arms and right leg rigid; pulse, 96; respiration, 36. Twenty- 
four hours later, right arm paralyzed, but still rigid; could not 
determine whether right leg was paralyzed ; pulseless ; died in 
thirty hours; temperature at admission, 102‘6°; twenty-four 
hours later, 105°. 
Necropsy.—Hematoma over vrhole left parietal region. Lin- 
ear fracture across whole length of parietal bone just above tem- 
poral ridge, recurving upon itself posteriorly for a little distance. 
Large epidural clot beneath the fracture compressing and flatten- 
ing the whole left hemisphere and forming an oblique plane. 
General contusion of the whole brain, which was hypersemic and 
studded with minute extravasations. 
Case LXXI1I.—Male, aged twenty-eight; received a blow 38 
A CLINICO-PATHOLOGICAL STUDY OF 
upon the head from a falling elevator (lift); compound commi- 
nuted fracture of right frontal bone; wound filled with clot and 
brain tissue; opening in the skull an inch and a half by half an 
inch in diameter. After cleansing the wound a cavity was left 
in the frontal lobe as large as a Mandarin orange. The patient 
was semi-conscious, but mental condition soon became normal. 
Pulse, 68; temperature, lOO^0. Vomited frequently. At the 
end of twenty-four hours he was rather heavy and somnolent, 
but could be easily roused, and was rational. Two hours later 
he was found in a comatose condition, with a temperature of 
105’4°, and died soon afterward, twenty-seven hours from the 
time he received the injury. • 
Necropsy.—Two large fissures ran backward on either side 
of the skull, one terminating in the parietal and the other in the 
occipital bone. There was no epidural haemorrhage. An irregu- 
larly shaped piece of the internal table was detached and rested 
upon the brain just above the cavity noted, but nearer the me- 
dian line, and a subdural clot three inches in diameter and half 
an inch thick was situated just posterior to it upon the right 
frontal lobe. There was slight cortical haemorrhage in the left 
occipital region. There was no lesion at the base. The cavity 
made by laceration of the frontal lobe extended nearly to the 
lateral ventricle. The whole brain, including the pons, optic 
thalami, and corpora striata upon both sides, and the cerebel- 
lum, was streaked with minute coagula, some of which, an inch 
in length, could be teased from the vessels. 
Case LXXIV.—Male, aged thirty-two; fell thirty feet into 
the hold of a vessel, striking upon his back. Unconscious; pulse 
and respiration slow ; stertor ; no other symptoms. Condition 
resembled that of alcoholic coma. Next morning the tempera- 
ture was 101'6° ; evening, 10P8o. On the second day, a. m., 
103’8°; m., 104'2°; p. m., 105‘4°. Right hemiplegia and both 
eyes turned to the left. Pupils normal. Pulse feeble and rapid. 
Respiration inadequate from pulmonary oedema. Still uncon- 
scious. On the third day temperature, a. m., 106'4°. Death in 
sixty hours. 
Necropsy.—-Separation of coronary suture from right frontal 
eminence to its left external extremity. Not much epidural INJURIES OF THE HEAD. 
39 
haemorrhage. Laceration of posterior extremity of left tem- 
poro sphenoidal extending into occipital lobe. Consequent 
subdural haemorrhage of moderate amount, involving left mo- 
tor area and occipital lobe to the base. Another laceration 
existed on the posterior border of the left cerebellum. General 
contusion. 
Case LXXV.—Male, aged thirty-two; fell from his truck. 
Contusion of left parietal region ; unconscious ; irritable when 
disturbed ; temperature, 99° ; pulse, 60 and full; coma con- 
tinued for about a week with temperature from 99° to 100°, 
then a period of irritability and mild delirium which lasted two 
weeks longer. Mental condition after the first two weeks apa- 
thetic and weak. He answered questions rationally when 
spoken to, but rambled in his speech. He recognized his friends, 
but spoke only when spoken to and had some delusions. At the 
end of a month he was transferred to Mount Sinai Hospital and 
died there. 
Necropsy.—Fracture found in left occipito-parietal region. 
Laceration. 
Case LXXVI.—Female, aged twenty-three; suicidal gun- 
shot wound through right temporal fossa; median line of ver- 
tex presented a conical elevation ; haemorrhage considerable ; 
patient unconscious with stertor; coma became more profound; 
temperature fell to 95° ; pulse rapid ; death in four hours. 
Necropsy.—Scalp infiltrated with blood. Bullet entered 
frontal bone a little above and external to right eye, penetrated 
the brain, passed inward, upward, and backward, and impinged 
upon the inner surface of the skull, a little to the left of the 
median line in the middle parietal region. It elevated two little 
triangular pieces of bone which remained attached to the peri- 
cranium. The bullet then fell back into the brain. It had en- 
tered at the anterior extremity of the fissure of Sylvius, trav- 
ersed the right frontal lobe, just below the cortex and parallel 
to its curve, and then passed a little backward and across the 
longitudinal fissure below the longitudinal sinus, into the left 
parietal lobe ; after fracturing the left parietal bone and falling 
back into its cerebral track as noted, it rested about half an inch 
below the surface. The skull was very thick and fissured from 40 
A CLINICO-PATIIOLOGICAL STUDY OF 
the point where the bullet entered. There was little intracranial 
haemorrhage. 
Case LXXY1I.—Male, aged twenty-six ; homicidal gunshot 
wound in right temporal fossa; patient unconscious; pupils 
normal; general muscular twitching; coma became profound, 
and death followed in twelve hours. 
Necropsy.—Bullet entered just behind external angular pro- 
cess of right frontal bone, traversed the right hemisphere nearly 
in its antero-posterior diameter, just above corpus callosum, im- 
pinged upon inner surface of the occipital bone, and, rebounding 
through the opening in the dura, fell into the inferior occipital 
fossa. Considerable subdural haemorrhage. 
Case LXXVIII.—Male, aged forty-two; suicidal gunshot 
wound in right temporal fossa; patient nnconsciouss; pulse, 
70; no other symptoms. He soon regained consciousness and 
was rational, but bis mental processes were sluggish. He had 
syphilitic laryngitis and aphonia. Temperature, 99°. An at- 
tempt was made to remove the ball next day, the opening in 
the bone at about the right temporo-frontal junction having 
been enlarged by the trephine. The track of the ball could be 
traced about two inches and a half forward, downward, and in- 
ward, at which distance a piece of bone, carried inward by the 
ball, circular and comprising both tables, was discovered and 
removed. Considerable brain matter oozed out during this ex- 
ploration. The ball was not found. Xo reaction followed the 
operation. The patient lived thirty days. His urine and faeces 
were voided freely, but without attracting his attention. The 
discharge of brain matter from the wound gradually diminished. 
At the time of his deatl) the external wound had almost en- 
tirely healed. The most notable symptom in his condition was 
hebetude. He remained rational but quiet, listless, and taking 
no notice of people or things, and without interest in what 
went on about him, with occasional intervals in which his 
mind seemed brighter. The temperature ranged from 100° + 
to 103'6°, and was usually above 101°. 
Necropsy.—The ball entered the brain about the middle of 
the third right frontal convolution, and passed nearly trans- 
versely through the center of both frontal lobes, and lodged INJURIES OF THE HEAD. 
41 
just behind the ascending arm of the fissure of Sylvius on the 
left side in the upper portion of the island of Reil. Its track 
passed just above the anterior horn of both lateral ventricles, 
and above the corpus callosum, just involving the calloso- margi- 
nal convolutions. On the left side the track was sharply de- 
fined, and formed a cavity five eighths by seven eighths of an 
inch in diameter containing the ball surrounded by clot and 
brain detritus. This was separated by the median fissure from 
the cavity on the right side from which the bone was extracted 
during life. Between the two cavities was a minute piece of 
bone. 
Case LXXIX.—Female, aged eight, fell three stories; con- 
scious; shock; compound comminuted depressed fracture of 
left frontal bone, with laceration of brain and meninges; rest- 
less and delirious; died on the third day; temperature on ad- 
mission, 100*2° ; rose to 104 6°. 
Necropsy.—Cavity in left prefontal lobe filled with clot and 
brain detritus. No considerable intracranial haemorrhage. 
General contusion of brain substance with coagula in minute 
vessels. 
Case LXXX.—Male, aged fifty; cause of injury unknown; 
unconscious; pulse and respiration rapid; temperature, 100°; 
both pupils dilated; died in four hours. 
Necropsy.—Simple fracture of left temporal bone, squamous 
portion. Deep laceration of right temporo-sphenoidal lobe, 
also of anterior border of left temporo-sphenoidal, smaller and 
shallower. Whole superior surfaces of both hemispheres cov- 
ered by cortical haemorrhage. 
Case LXXXI.— Male, aged sixteen; struck on the head by 
an iron wrench; scalp wound; depressed fracture at right 
parieto-occipital junction; trephined and elevated; no general 
symptoms; walking case; no injury of dura; no subsequent 
symptoms. 
Case LXXXIf.—Male, aged thirty; struck on the head; 
compound depressed fracture of left temporal bone at parietal 
junction; temporarily unconscious; afterward dazed; agraphia; 
trephined and bone elevated next day; agraphia continued eight 
days; sensory aphasia on the third day; temperature on ad- 42 
A CLINICO-PATHOLOGICAL STUDY OF 
mission, 99°; next day, 103°; second day, 103-8°; became nor- 
mal on eighth day; afterward varied from 99° to 102° for 
twenty days; did not again become normal till thirtieth day. 
Case LXXXIII.—Male, aged thirty-three; blow from a 
cleaver; fragment of outer table of left frontal cut off and left 
hanging by the periosteum, including the frontal eminence; 
condition irritable; wound healed in four days; no subsequent 
symptoms. 
Case LXXXIY.—Female, aged two years and a half; fell 
down stairs; compound depressed fracture of left parietal bone 
just posterior and external to frontal eminence; wound lacer- 
ated and contused. Three days later, convulsion occurred and 
admitted to hospital. Wound suppurating and sloughy. Xo 
general symptoms. Bone elevated. Highest temperature, 102°. 
Discharged in twenty-eight days; readmitted fourteen days 
later; subdural abscess; hernia cerebri; abscess in brain evacu- 
ated ; hernia subsided and patient discharged. 
Case LXXXV.—Female, aged forty-two; struck with a 
hammer weighing eight pounds; several lacerated and con- 
tused wounds of the scalp, and a depressed fracture of the pos- 
terior inferior part of the right parietal bone one half by three 
fourths of an inch in diameter, with a fissure running forward; 
hsematoma over right malar bone and a contusion of the back 
of the neck; patient conscious, rational, and restless; pulse, 
120 and full; temperature, 99°; third day, 100°; fourth day, 
104°; trephined and elevated; some epidural clot removed; 
dura tense and not pulsa'ing, and was incised; small amount 
of blood and serum escaped; wound healed at once and tem- 
perature fell gradually to 99° in four days ensuing. Six months 
later, I was told by Dr. G. Douglass that he had seen her at 
about that time. She was very nervous, excitable, and com- 
plained that she was confused and “ wrong in her head ” ever 
since her discharge. 
Case LXXXVI.—Male, aged thirty-eight; was struck by a 
bottle in middle of forehead; he was dazed, but able to walk; 
compound depressed fracture of right frontal bone extending 
into orbital plate, and frontal sinus opened; trephined and a 
piece of bone, an inch and a half square, with a sharp edge, INJURIES OF THE HEAD. 
43 
which had penetrated the cerebral substance, was removed. 
The superior longitudinal sinus was torn, and haemorrhage was 
controlled by pressure against the hone with one blade of a 
Langenbeck’s forceps. Sutured in position till the third day. 
The patient for a time was irritable and delirious, requiring me- 
chanical restraint. The temperature was very uniform, vary- 
ing only from 99° to 100°, when it became normal. 
Case LXXXVLI.—Male, aged forty; knocked down by a 
blow upon the head. When he recovered consciousness he 
walked into the hospital. Compound depressed fracture posterior 
to left frontal eminence, and piece of inner table driven in. Dura 
uninjured. No general symptoms. Temperature, 101° to 102° 
for six days, wdien it suddenly dropped from 101° to normal. 
Case LXXXV1II.—Male, aged fourteen; fell two stories; 
temporarily delirious from fright and excitement, and then 
recovered and walked home; depressed fracture in right 
frontal bone near coronal suture; elevated; no subsequent 
symptoms. 
Case LXXXIX.—Male, aged thirty; gunshot fracture of 
right frontal one inch above the zygoma; considerable haemor- 
rhage from wound and beneath the conjunctiva; right eye pro- 
truded so much that the lids could not be closed; no mental 
symptoms; temperature, 99-5° to lOTS0; next day tempera- 
ture 104°. The bullet-opening in the skull was enlarged by the 
trephine, several loose pieces of bone removed, and the bullet 
felt near the optic foramen. The eye was then removed and 
the bullet extracted through the orbit, the dura having been 
first incised. The roof of the orbit was found to be much com- 
minuted. Temperature remained high, and delirium and illu- 
sions continued for three days. The wound suppurated rather 
freely for the first month, and the patient often suffered from 
headache, which was always relieved by changing the dress- 
ings. He remained in the hospital for two months and was 
then discharged entirely well. The temperature for the first 
ten days was 102° to 103° ; for the next twenty days, 100° to 
101°; for the next ten days, 100°; and the next ten days, 99° 
to 99° + . 
Case XC.—Male, aged eighteen ; blow upon the head from 44 
A CLINICO-PATIIOLOGICAL STUDY OF 
a hammer; conscious; compound fissured fracture in left parietal 
region; no depression; no symptoms. 
Case XCI.—Male, aged twelve; ran into an iron post; com- 
pound depressed fracture of right frontal bone, encroaching 
upon coronal suture in temporal region; slight escape of brain- 
substance ; elevated piece of bone three quarters of an inch in 
diameter; no general symptoms of cerebral injury. Had no 
subsequent symptoms, except for a single day following the oper- 
ation, when he responded slowly to questions. 
Case XCII.—Male, aged thirty-five; blow upon the head 
from an earthen mug; compound fissured fracture of external 
table of posterior part of left parietal bone; no general symp- 
toms. 
Case XCIII.—Female, aged thirty-seven; struck by a brick 
falling from a roof; compound depressed fracture of right parie- 
tal bone, three quarters of an inch from median line, double 
comminuted. One fragment removed and the other elevated. 
No general symptoms either before or after the operation. 
Case XCIY.—Male, aged sixteen; thrown from a horse; 
compound depressed fracture of left frontal bone, just above 
superciliary ridge; conscious and irritable; temperature, 99-8°; 
pulse, 60, full. A piece of bone, an inch and a quarter by half 
an inch, completely separated and driven in upon the dura, ele- 
vated and removed under ether. Had no subsequent general 
symptoms except temperature, which for ten days was usually 
from 99° to 100°, and a somewhat irritable mental condition. 
Case XCV.—Female, aged seven; fell one flight of stairs over 
the banisters; struck her head ; unconscious; vomited. Became 
dull and stupid on the second day; next day admitted to hospi- 
tal. Hasmatoma in left parietal region, and linear fracture, dis- 
covered by incision, confined to left parietal bone. Tempera- 
ture, 99°. No subsequent symptoms. 
CAseXCVI.—Male, aged thirty-two; stabbed in the forehead 
with a pocket knife. Three days later no general symptoms. 
Temperature, 99° to 100°; pulse, 76. After incision, the knife 
blade could be seen broken off at the level of the surface of the 
bone, an inch and three quarters above left supra orbital ridge, 
and an inch and a half to left of median line. A button of INJURIES OF THE HEAD. 
45 
bone, which included the knife point in the center, was removed 
by the trephine. The point had penetrated the brain a quarter 
of an inch. Dura incised and closed by suture. No subsequent 
symptoms. 
Case XCV1I.—Male, aped twenty ; knocked down by a blow 
from a heavy stick ; unconscious; linear fracture from just above 
left superciliary ridge, extending into parietal bone, and incised 
wound. No general symptoms. 
Case XCVIII.—Male, aged thirty-one; struck by a shower 
of bricks; compound depressed fracture of right parietal bone. 
Trephined, and loose fragment of inner table, half an inch square, 
removed. No general symptoms. 
Case XOIX —Male, aged twenty-six ; fell thirty-five feet 
from a scaffold; had been temporarily unconscious. A frag- 
ment of the right parietal bone, near its upper posterior angle, 
including both tables,'had been torn out and was missing, two 
inches by one inch and three quarters in diameter. The inner 
table was comminuted, and fragments pressing upon the dura 
were removed. No fissures. Dura uninjured. No disorders 
of sensation or other general symptoms. Temperature, 99° to 
100° + . 
Case C.—Female, aged forty-five; fell down stairway at ele- 
vated railroad station ; unconscious. Admitted after five days. 
Haematoma over left eye, which had been incised; fissure, ex- 
tending into frontal sinus, could be detected through the incis- 
ion. The only general symptom was occipital headache for 
some days after the injury was received. 
Case Cl.—Male, aged eight; kicked by a horse; compound 
depressed fracture of right frontal bone, just above frontal sinus 
and near the median line. Elevated on the fourth day. Dura 
uninjured. Opening in the skull which remained was three 
quarters of an inch in diameter. Had no previous general 
symptoms. Temperature, from 99° to bh'S0; after the opera- 
tion, rose in twenty-four hours to 103°, and in forty-eight hours 
to 104°. In the next five days it fell gradually to 99°, and re- 
mained 99°-f for ten days following. Once during this time— 
on the fifteenth day—some serum escaped from the wound at 
the time of dressing. On the twentieth day some laudable pus 46 
A CLINIOO-PATHOLOGICAL STUDY OF 
escaped, also at the time of dressing, and a probe was carried 
two inches and a half into the frontal lobe parallel to the orbital 
plate. The next day the dura was incised to the extent of the 
cranial opening, and from two to three ounces of laudable pus 
evacuated. The probe could be carried backward two inches 
and a half parallel to the cranial wall on the external aspect of 
the hemisphere, as well as two inches and a half parallel to the 
orbital plate. The temperature at this time was 99’2° and pulse 
96. There were no general symptoms, except a little mental 
dullness or apathy and slight right lower facial paralysis. His 
general condition was also becoming asthenic. The cavity was 
irrigated and drained by tube. Temperature rose next day to 
102°+; became normal in a week. Facial paralysis entirely 
disappeared in ten days. Discharge ceased during the third 
week. Mental condition became normal, and nutrition rapidly 
improved after the first few days. There was a fungus, not 
larger than a hazel-nut, which spontaneously disappeared. The 
external wound was entirely healed in little more than a month, 
and no symptoms of any kind remained. 
INJURIES OF THE ENCEPHALON. 
Case CIT.—Male, aged forty-one; fell upon his face ; contu- 
sions most marked on left side of face and eyes; violent deliri- 
um for two days. Temperature, 103° to 104°. On the sixth 
day again became delirious, and later unconscious and violently 
responsive to irritations. Temperature was at no time below 
100°, and was 103° just previous to death, which occurred at 
the end of six days. 
Necropxy.—Haematoma and small scalp wound in right parie- 
tal region. Thin cortical coagulum over left occipital lube, ex- 
tending into median fissure. Subarachnoid serous effusion. 
Case CIII.—Male, aged sixty ; pushed down three steps of a 
stairway, and sustained minor superficial injuries. No head 
symptoms till the fourth day, when he had four convulsions. 
There was one the next day, and afterward they occurred with 
increasing frequency till his death on the eighth day. Each one 
began by twitching of the muscles of the face, with the head and 
eyes turned to the left, and these extended to the left arm and INJURIES OF TIIE HEAD. 
47 
finally to the left hand. The right side was not involved at all. 
Temperature on admission, 100°; in twelve hours, 103°. From 
this time it varied from 103° to 104° till six hours before his 
death, when it became and continued 105°. 
Necropsy.—No lesion of scalp or skull. Subdural haemor- 
rhage over whole right cerebrum, and extensive laceration of 
right temporo-sphenoidal lobe. 
Case CIV.—Male, aged thirty-two ; fell upon the sidewalk ; 
scalp wound in left occipito-parietal region. Admitted to hos- 
pital ten hours later. Conscious and rational, but dazed, and 
with extreme muscular tremor. Two hours afterward the pa- 
tient had a general convulsion. From this time, during periods 
of about six hours, there would be a succession of convulsions, 
with intervals of unconsciousness or delirium, followed by an 
equal period during which he would remain quiet and rational. 
The convulsions were all general from beginning to end, without 
recognizable initial symptom. Died in two days. 
Necropsy.—Scalp wound, as previously noted. No lesion of 
skull. Cortical haemorrhage on the right side of the vertex, 
from anterior border of frontal lobe to posterior fissure of Ro- 
lando, and covering the temporo sphenoidal lobe laterally and 
at the base. Deep laceration of right frontal lobe, through the 
cortex, upon anterior and lateral borders, and extending well 
into the parietal region. 
Case CV.—An unknown man was found in the street, lean- 
ing against a fence in an upright position, dead. 
Necropsy.—Haetnatoma over right side of the vertex; no 
lesion of the skull; blood fluid and viscera generally much con- 
gested ; area of contusion and laceration over greater part ot 
left frontal and temporo-sphenoidal lobes; subdural haemor- 
rhage over whole left hemisphere. 
Case CVI.—Male, aged thirty ; found unconscious and sup- 
posed to have jumped or fallen from a second-story window. 
Wound over right eye and fracture of the nasal bones; coma 
profound; stertor; pupils contracted. On the two following 
days the temperature rose progressively from 101°+ on admis- 
sion to 104’5°; pulse full, respiration rapid. Patient could be 
roused by pressure on supraorbital nerve. On the third day 48 
A CLINICO-PATHOLOGICAL STUDY OF 
still deeper coma, dysphagia, continued irritability, and rest- 
lessness, and temperature still KM^0. Death at end of four 
days; temperature, 107*4°. 
Necropsy.—No lesion of skull; no meningeal lesions; small 
cortical haemorrhage over posterior part of left parietal lobe, 
and small laceration of brain at parieto occipital junction; both 
cerebra hyperaemic. 
Cask CVII.—Male, aged forty; fell down stairs. Admitted 
to alcoholic ward and transferred to surgical service next day. 
Slight scalp wound above right ear; comatose, but later could 
be roused sufficiently to tell his name; temperature, 103*4°; 
restless; hypera?sthetic; pneumonia discovered; died next 
day. 
Necropsy.—Left lung pneumonic; lower lobe in second 
stage, upper lobe in first stage; no lesion of the skull; dura 
mater adherent to the calvarium ; the left hemisphere on its 
upper surface was completely covered by an organized false 
membrane, which also dipped into the median fissure and cov- 
ered its internal surface. This membrane was divisible poste- 
riorly into two layers; it was thin anteriorly, but fully an eighth 
of an inch in thickness in its posterior part; its upper surface 
was smooth, non-adherent, and comparable in appearance to a 
section.of raw beef; its inferior or cerebral surface was smooth, 
velvety, non adherent, and could be raised without injuring the 
arachnoid; it did not dip into the sulci; it was traversed by 
minute vessels and studded with some fifteen or twenty gray- 
ish, caseous, and partially calcareous nodules, varying in size 
from that of a robin-shot to that of a buckshot. Similar nod- 
ules were found in the basilar vesseb, which were generally 
atheromatous. No recent lesion of the brain was discovered, 
except general contusion indicated by moderate hypersemia and 
some capillary extravasations. 
His wife subsequently stated that he had never lost a day’s 
wrork by reason of sickness, and that he had never had even 
temporary loss of consciousness or paralysis. 
Case CVIII.—Male, aged titty seven; fell from his cab; 
unconscious: large haematoma over left parietal region; respira- 
tion slow and stertorous double facial paralysis and cheeks INJURIES OF THE HEAD. 
49 
flapping; complete right hemiplegia and anaesthesia; tempera- 
ture, 99°. Trephined over left motor area; dura pale, teDse, 
and blQodless; no brain pulsation. After incision of dura, 
serum escaped freely and the quantity increased when the head 
was so turned as to drain from the base. No blood clot found. 
Temperature at time of operation had risep to 103'4° ; six hours 
later it had fallen to 98‘60. The patient had regained con- 
sciousness and could articulate, and gave his name and address. 
Hemiplegia not relieved. After twelve hours, pulsation in the 
brain returned and he could speak rationally and intelligently, 
though with difficulty. Two hours later still he had a slight 
convulsion and death followed in four hours. The temperature 
remained at 98*6° after the operation for fourteen hours, and 
it then rose steadily to 104-6° just previous to death. The lower 
face continued paralyzed and the respiration became frequent 
and insufficient. 
Necropsy.—No lesion of skull; laceration of external bor- 
der of right cerebellum anteriorly, from which clot had formed 
about circle of Willis upon anterior part of pons and in trans- 
verse fissure in front of left cerebellum; the vessels were 
atheromatous; the interior of the left occipital lobe was filled 
with clot which had completely broken down its structure; the 
left lateral ventricle was filled with blood which had broken 
through the saeptum into the right lateral ventricle and also 
communicated with the blood cavity in the occipital lobe. 
Case CIX.—Male, aged sixty-three; struck by some part 
of the machinery of his engine; no general symptoms; tem- 
perature, 100°; wound in posterior parietal region in median 
line and curving to the right; contusion over left parietal emi- 
nence; temperature second day, 103 2°; delirious in the night; 
temperature third day, lOl’S0 to 101°; headache; fourth and 
fifth days, temperature, 103'4° to 103°; no general symptoms; 
sixth day, temperature, lOfi^0, pulse, 140 ; restless and irrita- 
ble, but rational; weaker; died on the eighth day; tempera- 
ture last two days from 105° to 105'2o ; post-mortem tempera- 
ture, 104°. A few hours previous to death there was muscular 
rigidity of all the extremities, most marked on right side and espe- 
cially in right arm. There was perforating ulcer of the cornea. 50 
A CLINICO-PATHOLOGICAL STUDY OF 
Necropsy.—No lesion of skull or meninges ; no haemorrhage; 
no lacerations; cortex of brain and meninges hyperaemic; brain 
substance moderately cedematous and minute vessels filled with 
coagula; this condition involved corpora striata, optic thalami, 
pons, and cerebellum, and was most pronounced on left side 
and at the base; no minute extravasations; both lateral and 
both inferior petrosal sinuses were filled with decolorized 
thx-ombus, extending into jugular vein on the right side; the 
thrombus was colored only near the torcular Herophili. 
Case CX.—Male, aged sixty; fell two stories to the side- 
walk. Contusion of left eye and slight contusion just above it; 
temperature, 101 4; delirium; pupils and respiration normal; 
pulse, 114. Later symptoms: patient very irritable; cried out and 
tried to get away when touched, but replied rationally to ques- 
tions ; incontinence of urine and fceces; delirium continued; 
died on the fifteenth day; temperature rose to 103'2° on the 
fifth day and then fell very gradually to 100°. The day before 
death it was 103'4°, was lOS^0 five hours ante mortem, and 
104’2° one hour post mortem. General symptoms remained 
unchanged. 
Necropsy.—No fracture; subarachnoid haemorrhage over 
both hemispheres, forming a sheet which was thickest about 
occipito-parietal junction on both sides; some subarachnoid 
serous effusion in left frontal region; general contusion, which 
was most marked on left side; hypersemia and punctate haemor- 
rhages. 
Case CXI.—Male, aged forty-five; cause of injury un- 
known ; found unconscious in the street and admitted to hospi- 
tal after forty-eight hours; contused wound in right parietal 
region; muttering stupor; rigidity of left arm ; right hemiple- 
gia, which wras incomplete, but most marked in right arm; 
pulse, 60; temperature, 101°. On the third day the rigidity of 
the left arm was increased, and the paralysis of right arm was 
complete; paralysis of right leg was nearly so; coma absolute ; 
pulse, 128; temperature, 105°. Trephined over motor area 
and incised the dura. Pulsation of brain abstnt at first, but 
soon returned in some degree. His movements became freer, 
and he began to utter articulate sounds. Signs of sensi- INJURIES OF TIIE HEAD. 
51 
bility increased; pulse, 108; temperature still 105°. Died 
next day. 
Necropsy.—Moderate subacute arachnitis over anterior two 
thirds of upper surface of right cerebrum; laceration of left 
temporo-sphenoidal lobe, excavating and tilling with clot its 
whole interior structure. The haemorrhage extended down- 
ward around the circle of Willis and upward upon the cere- 
brum, mainly upon the occipital, but also in patches upon the 
frontal and parietal lobes. 
Case CXII.—Male, aged sixty ; found unconscious in bed ; 
seemed to be in perfect health when lie retired to his room on 
the previous evening. He was heard moaning; no evidence 
of injury could be discovered; stertor; pupils normal; rigid- 
ity of right side; pulse 120 and weak; temperature, 100°. On 
the next day the right side was less rigid; the second day he 
was comatose ; temperature, 103'2°, and he died. 
Necropsy.—No lesion of scalp or skull; large amount of 
serum under the arachnoid. There was a very soft elliptical 
area of disintegrated brain tissue an inch and a half by three 
quarters of an inch in diameter upon the anterior part of the 
left occipital lobe, near the median fissure. There was a simi- 
lar area, smaller in size, on the under surface of the same lobe, 
but with disintegration less advanced, and containing a clot not 
yet decolorized. There was a red, firm clot beneath the latter 
and deep in the substance of the cerebellum of more recent 
formation. The temporal artery was atheromatous, but none 
of the basilar arteries were diseased. 
Case CXIII.—Male, aged thirty; fell down stairs; con- 
sciousness was lost, and only partially .restored. He fell out of 
bed that night, and again the next day, striking each time upon 
his right side. Admitted to hospital that evening. No exter- 
nal evidence of injury except slight contusion over crest of right 
ilium. Rational, but slow to respond to questions ; left pupil 
slightly dilated; temperature, 99°. The following day he again 
fell out of bed, and again the day after, always on the right 
side, and there was a constant tendency to move to the right 
side of the bed, which was quite level. Some left paresis and 
some difficulty in swallowing, which he referred to the left side 52 
A CUNICO-PATHOLOGICAL STUDY OF 
of the throat; transient facial paresis. The amount of paresis 
and the condition of the left pupil varied from day to day. His 
mental condition deteriorated; he was stupid, rambling in talk, 
delirious, apathetic, and had delusions. At first urine, and 
later faeces, were voided unconsciously. His temperature for 
ten days was 99°+ ; it then began to rise and was 100°+ to 
101°; pulse usually from 84 to 96, and respiration nearly nor- 
mal. On the fifteenth day he was trephined over the right 
motor leg area, and a small subcortical cavity discovered, from 
which half a drachm of yellowish fluid was removed. This 
fluid was subsequently found to contain numerous leucocytes. 
There was no marked change in his symptoms after the opera- 
tion. Temperature was a trifle lower—99° to 100°—till the 
eleventh day, when it rose to 104°, fell the next day to 100°, 
and rose again to 104°, when he died from asthenia on the 
twenty-eighth day after his admission. 
Necropsy.—Large subarachnoid serous effusion compressing 
frontal lobes. General cerebral hyperaemia and many minute 
vessels filled with coagula. The brain substance around the 
small cavity discovered during life was so'tened, stained a red- 
dishtgray color, and it contained minute extravasations. 
Case CX1Y.—Male, aged twenty-nine; was found uncon- 
scious in Central Park. He was taken to a hospital, sent to 
court charged with intoxication, and afterward admitted to 
Bellevue, still unconscious. Small contused wound in right 
frontal region; pupils slightly dilated; complete left hemiple- 
gia and hemianaesthesia; slight left facial paralysis; tempera- 
ture, 106°; pulse, 140; respiration accelerated; convulsions 
shortly after admission, which were repeated at frequent inter- 
vals; initial symptom in the mouth and face; arms and legs 
gradually involved; trephined over junction of right arm and 
leg areas by house surgeon ; result negative; temperature two 
hours later, 107’4°, and three hours later still he died in a con- 
vulsion. The ventricle was aspirated in the operation; tem- 
perature forty five minutes post mortem, was 109,4°. 
Necropsy.—Brain and meninges excessively hyperaemic; a 
small tumor as large as a pea was found in right lower face 
area; the surrounding brain tissue was disintegrated, forming INJURIES OF THE HEAD. 
53 
a small cavity; no haemorrhages; the viscera were generally soft 
and congested. 
Case CXV.—Male, aged thirty-seven ; was found at the 
bottom of a stairway with his feet uppermost; unconscious; 
pupils contracted ; muscular rigidity, especially marked in the 
legs; pulse rapid; stertor; died in two days without having 
regained consciousness. 
Case CXVI.—Male, aged twenty-six; thrown out of a 
wagon and struck his head; unconscious, but conscious on ad- 
mission ; contusion in left parietal region; became irritable, 
and later comatose; died suddenly five hours afterward. 
Case CXVII.—Male; struck by a cleat falling from aloft 
aboard ship; large baematoma covering whole right side of the 
head; unconscious; slight rigidity of left side; pulse full and 
slow; died in fifteen minutes after admission. 
Case CXVII I.—Male, aged thirty-two; struck with a shovel; 
contusion of the right posterior parietal region ; pulse full and 
slow; temperature, 100°; pain in back of the head; dilatation 
of left pupil; rigidity of flexor muscles of the arms; somno- 
lence and restlessness. After twenty-four hours patient be- 
came stupid and mildly delirious; left pupil widely dilated; 
urinated unconsciously ; left arm only moved when irritated; 
sensation slightly more acute on right side; dysphagia marked ; 
left pupil irresponsive to light. His condition varied from 
time to time for the first two weeks; left pupil more or less 
dilated and more or less irresponsive to light; mind obscured 
and apathetic; some ptosis of left eye. After that time his 
mind became clear, and he could intelligently describe the 
manner in which he received his injury. Paralysis of the left 
external rectus; optic nerve and retina normal; perforation of 
left tympanum and puriform discharge; some left facial paraly- 
sis. He was discharged at the end of two months. His ptosis 
and external strabismus had disappeared, and there was only a 
perceptible trace of the paralysis of the lower face. His left 
hemiparesis and anaesthesia were no longer noticeable. He was 
dull and stupid, which his family said was his normal condition. 
Case CX1X.—Male, aged twenty five; fell from a truck, 
striking his forehead; unconscious for twenty-four hours; 54 
A CLINICO-PATHOLOGICAL STUDY OF 
slightly delirious for two days; pain in frontal region after that 
time; temperature, 100°, followed by mild dementia, which 
continued till his discharge. 
Case CXX.—Male, aged twenty-one; fell sixty feet down an 
embankment; unconscious; afterward, violent delirium lasting 
a week; then admitted to the hospital, still delirious, but more 
quiet; suppurating scalp wound external to right frontal emi- 
nence ; hone exposed ; also double fracture of right inferior 
maxilla. The following day he had eleven epileptiform con- 
vulsions within two hours. Each one began with twitching in 
right hand and arm, extending to left arm and then to both 
legs, and finally a general convulsion was established. Face not 
much involved, but eyes deviated to the right. After these at- 
tacks he remained unconscious for one hour; the right arm 
was then found to be anaesthetic, and with the right leg paretic. 
The next day he had one similar attack, but he was more 
rational afterward and recognized his paretic condition. On 
the next day he had six convulsions within a little more than 
two hours, each one beginning on right side of the face and ex- 
tending to right side of the body before becoming general, and 
the right arm was paralyzed for five minutes afterward. In the 
next few hours he had six others, one of which was confined to 
right side of the face. 
He was then trephined over left face area and the opening 
freely enlarged. Dura tense and incised, but no lesion discov- 
ered. He was then trephined through the exposed bone on the 
right side without result. No further convulsions occurred. 
The next day he was entirely rational, and it was discovered 
that he was aphasic. Some difficulty in articulation previous 
to the operation was ascribed to the fractures of the jaw. He 
had both motor and sensory aphasia. Called his own name 
McNannold. He was discharged at the end of a month. His 
wounds were entirely healed, right arm still paretic, and mind 
clear. He had some hesitancy in speech, and the selection of 
words required a little time. His temperature ranged from 
99°4- to 101° during his whole convalescence. 
Case CXXI.—Male, aged twenty; cause of injury un- 
known; unconscious for a short time; scalp wound in left INJURIES OF THE HEAD. 
55 
parietal region near the mesian line, and a large haamatoma 
just behind it in posterior parietal region. He had no general 
symptom, except nearly complete paraplegia with flaccid mus- 
cles and somewhat increased reflexes. There was no evidence 
of specific disease, and it was possible to verify the fact that no 
paralysis had existed previous to this recent injury. He was 
discharged at the end of six weeks and could walk fairly 
well. The diagnosis was cortical haamorrhage from direct 
contusion of the brain, extending from left motor leg area 
acr«*s the median line into the corresponding area on the 
right side. 
Case CXXII.—Male, aged twenty-one; cause of injury 
unknown; found unconscious. Committed as drunk and dis- 
orderly, and sent to Bellevue as a case of alcoholism. He again 
became unconscious and was constantly crying out, but always a 
single phrase. He was restless and hyperaesthetic, and the 
muscles of both sides were generally rigid. There was a slight 
scalp wound in right temporal region; incision disclosed no 
fracture. The day following he was more quiet and the muscles 
were less rigid. Partial paralysis of the lower left face was 
developed. He became rational, but apathetic. Then there 
were two days more of active delirium, after which he again 
became quiet, but had delusions. He was coherent in speech, 
though voluble, loquacious, and silly. He had sensory aphasia 
and agraphia, and his memory of recent events returned; he 
thought, however, he was born in September, 1891 —two months 
before. In notation at dictation he interpolated figures, as in 
writing 495 he wrote 490005. He could write two figures cor- 
rectly, but not more. After his discharge he returned to the 
hospital some months later, and was noisy and excitable. Sub- 
sequent inquiry at the station-house made it probable that he 
was not intoxicated at the time of his arrest. He remained un- 
conscious from early evening all night. When he was finally 
roused he made strenuous efforts to speak. He was only able 
to say “Peter,” his first name, which he repeated again and 
again, and evidently strove to give his last name. Tempera- 
ture, 100-2° on admission ; from 100° to 101° for five days, then 
normal. After that time averaged 98,5° to 99'5°. 56 
A CLINICO-PATHOLOGICAL STUDY OF 
Case CXX1II.—Male, aged twenty-one; cause of injury un- 
known ; found unconscious in the street; contusion of left eye 
and wound over superciliary ridge. On admission, he looked 
about with a vacant stare, but could not be induced to speak. 
Next day he had delusions and failed to recognize his family. 
His subsequent symptoms were all mental. Memory of recent 
events lapsed. Never spoke except when disturbed, then an- 
swered questions intelligently but mechanically. For three 
nights he became violently delirious, and attacked his neighbor 
in the next bed; then he became quiet again, and began to 
manifest some interest in what passed about him. Two wreeks 
from the time of his admission his condition suddenly improved, 
and he began to remember some things which immediately pre- 
ceded his injury. For the ensuing two weeks it was mainly 
noticeable that he never suggested or carried on any sustained 
conversation, and that he laughed much and without due cause. 
In the next and final two weeks of his continuance in the hos- 
pital he ceased to laugh inordinately or causelessly, and his 
memory seemed to be restored in reference to matters up to the 
time he was hurt, and since his recovery of consciousness. The 
only abnormal indication in his appearance was a slightly weak 
expression in his face. Temperature on admission, 99*2°; after- 
ward from 99° to 101°. 
Case CXXIV.—Female, aged seventeen, fell three stories 
through a hatchway; contusion of left occcipital region; no 
fissure found on incision. She was unconscious, with muscular 
rigidity of all the extremities, and was irritable when disturbed. 
She moved the right arm and left leg only. Temperature, 
100'2°. Delirious on the fourth day, and noisy and excitable 
for several days afterward. There was left paresis and dilata- 
tion of left pupil on the tenth day, and at the same time incon- 
tinence of urine and faeces which continued eight days. Tem- 
perature was 100°+ for the first five days, 99°+ for next five 
days, and then became normal. It rose on the thirteenth day 
from 99° to 103-5°, and on the next day to 104'5°. For the next 
ten days it was usually from 102° to 103°, at which time she 
was removed from the hospital. She subsequently recovered. 
She was of bad constitution, had inherited syphilis, was deaf, INJURIES OF THE HEAD. 
57 
and had interstitial keratitis in both eyes, with loss of sight in 
one from opacity of cornea. 
The following cases of idiopathic lesion are added to 
illustrate simulated traumatism: 
a. Male, aged fifty five, fell upon the sidewalk, and, after rising 
and walking a short distance, fell again. Upon admission he 
had a small wound in the median line of the frontal region. He 
smelled strongly of spirits and was ascertained to he of intem- 
perate habits. He was unconscious from the time he fell until 
he died, seven hours later. He was restless, and upon irrita- 
tion had muscular spasm of both lower and upper extremi- 
ties. He had incontinence of urine and faeces, dilated pupils, 
and Cheyne-Stokes respiration. No paralysis. Temperature, 
103-4°, 104°, and 105°. It was subsequently learned that the 
scalp wound was received two days previously, and that the 
spirits of which he .smelled so strongly had been spilled upon 
him in an effort to restore him to consciousness before ad- 
mission. 
Necropsy.—Chronic meningitis with great arachnoid opacity 
but no serous effusion. Basilar arteries extremely atheromatous. 
Both lateral ventricles enormously distended with very bloody 
serum. Clot extended through each posterior cornu. The 
right optic thalamus was swollen with clot which also filled the 
third ventricle. 
i. Male, aged seventy-one, said to have accidentally fallen 
from a chair four days previous to admission ; no loss of con- 
sciousness ; subsequent delirium ; required mechanical restraint 
till his death, twenty-four hours later ; pupils contracted ; pos- 
terior cervical muscles rigid; hyperaesthesia; retention of urine; 
temperature, 102°, 102° + , 103° ; pulse, 90 to 114. 
Necropsy.—Abrasion of the nose. Dura mater adherent to 
the calvarium, and arachnoid to the brain. Little serous effu- 
sion. Some opacity of the arachnoid. Meningeal and cerebral 
vessels hyperaemic. Cortex softened. 
The result of an analysis of the preceding cases may be 
expressed in a brief 58 
A CLINICO-PATHOLOGICAL STUDY OF 
SUMMARY. 
I. Fractures of the Base 70 
Recovered 21 
Died 49 
Number of necropsies 35 
II. Fractures of the Vertex 31 
Recovered 21 
Died • 10 
Number of necropsies 10 
III. Fncephalic Injuries without Fracture. ... 23 
Recovered 7 
Died 16 
Number of necropsies 13 
Total number of recoveries 49 
“ “ “ deaths 75 
124 
“ “ “ necropsies 58 
NECROPSIES. 
I. Fracture of the Base. 
Involving posterior fossae 7 
“ middle fossae 6 
“ middle and anterior fossae.... 9 
“ middle and posterior fossae... 11 
“ anterior and posterior fossae.. . 1 
“ all fossae 1 
35 
Total number involving middle fossae. . . 27 
“ “ “ posterior fossae.. 20 
“ “ “ anterior fossae.. . 11 INJURIES OF TIIE HEAD. 
59 
Complications. 
Laceration and resulting haemorrhages 9 
“ “ general contusion 6 
“ “ meningeal contusion 6 
“ “ thrombi, haemorrhages 2 
“ “ epidural haemorrhages 6 
“ “ meningeal contusion, epi- 
dural haemorrhages 1 
“ “ general contusion, epidural 
haemorrhages 1 
Contusion and abscess 1 
General contusion and epidural haemorrhage. 2 
Meningeal contusion 1 
35 
From direct violence 31 
“ contre-coup 4 
i I Fracture of the Vertex. 
Involving frontal bone 4 
“ parietal bone 1 
“ occipital bone 1 
“ parietal and occipital bone 1 
“ parietal and frontal bone....... 1 
“ temporal hone 1 
9 
Complications. 
Laceration and resulting haemorrhage 5 
“ “ general contusion 2 
“ “ atrophy 1 
“ meningeal and general contusion. . 1 
General contusion and epidural haemorrhage 1 
10 60 
A CLINIOO-PATHOLOGICAL STUDY OF 
ITT. Injuries of the Encephalon without Fracture. 
Varieties. 
Laceration and resulting haemorrhage.... 5 
“ “ meningeal contusion 2 
“ “ general contusion 1 
Meningeal contusion 1 
General contusion 2 
“ “ and thrombi 1 
“ and meningeal contusion 1 
13 
In Fifty-eight Necropsies. 
Laceration and resulting haemorrhage. ... 19 
“ “ general contusion 8 
“ “ meningeal contusion 8 
“ “ epidural haemorrhage 6 
“ thrombi, and haemorrhages.... 2 
“ general, and meningeal contu- 
sion 2 
“ and atrophy 1 
“ meningeal contusion, epidural 
haemorrhage 2 
48 
General contusion 2 
Meningeal contusion 2 
General contusion and epidural haemor- 
rhage 3 
General contusion and thrombus . 1 
“ “ “ meningeal contu- 
sion 1 
Subcortical contusion and abscess 1 INJURIES OF THE HEAD. 
61 
Total number of cases in which injury was received by 
Contre-coup alone 31 
Direct violence alone 5 
Contre-coup and direct violence 19 
Unknown 2 
Unrecorded 1 
58 
Pseudo-injuries. 
Apoplexy 1 
Arachnitis 1 
2 
In the majority of instances the subjects were males in 
adult life. Vocation, the blundering helplessness of ine- 
briety, and the homicidal passion sufficiently account for 
the influence of age and sex in the production of these in- 
juries. 
Fractures.—It is a noteworthy fact that so many injuries 
of the head—nearly sixty per cent.—involve fracture at the 
base. 1 have ranked as basic fractures all those which have 
involved that region, even though beginning at the vertex, 
because it is upon the implication of the base that all the 
so-called characteristic symptoms depend. In fact, frac- 
tures of the skull which do not begin at the vertex are ex- 
ceptional. I have found upon necropsic examination but 
four cases in which fracture at the base was not continuous 
with a fissure extending from the point upon the vertex at 
which the violence was inflicted. These four, which began 
and ended in the base, were evidently from contre-coup. 
That they were the result of violence acting directly upon 
the vertex was proved by the history of the injury, as well 
as by existent wound, contusion, or fracture. In neither 
one was there the slightest reason to suspect that the force 62 
A CLINIC0-PATI10L0GICAL STUDY OF 
was transmitted through the spinal column. The greater 
frequency of fractures which extend to the base, when com- 
pared with those which are confined to the vertex, depends 
simply upon the fact that, under ordinary circumstances, the 
physical properties of bone are such that force, even when 
of crushing character, will not expend itself wholly upon the 
point of impact, but will extend to a considerable distance. 
That the fissure extends from vertex to base, and not from 
base to vertex, is proved, even in the absence of a history, 
by the mute evidence of the superficial injury, and by the 
narrowing of the fissure as it passes downward. The ex- 
planation of the fact that fracture through the middle is 
more frequent than through the other fossae is equally sim- 
ple. The experiments of Aran have shown that when any 
part of the vault is subjected to violence it is the corre- 
sponding part of the base which suffers. It follows that 
the central or parietal region is the one most exposed to 
violence, and it is corroborated by post-mortSm examination. 
Four cases, aside from those produced by contre-coup, 
are of special interest simply as fractures. The first is a 
separation of the temporal bone into its constituent parts— 
squamous, petrous, and mastoid—in an adult male, the re- 
sult of an apparently inadequate cause. The specimen was 
shown to this association two years ago. The second was 
a comminuted fracture of nearly the whole occipital, the 
posterior part of, both parietal, and the right temporal bones, 
in which the fragments were completely detached from each 
other. This, like the first, was occasioned by a fall in the 
street, and was accompanied by extensive injuries of the 
brain, sinuses, and membranes. The patient recovered par- 
tial consciousness, and lived for a week’s time. The third 
involved all the fossae on both sides from a fall from the 
mast-head, and the patient survived two hours. This case 
I believe to be the first on record in which all the fossae INJURIES OF THE HEAD. 
63 
were involved in fracture. The fourth case was a wide sepa- 
ration of the coronal suture on both sides, occurring in an 
adult without concomitant fracture. 
The most practical comment to be made upon fractures 
of the skull is that in themselves they are absolutely un- 
important. It is only by their 'Complications, immediate or 
remote, that they involve danger to life. 
COMPLICATIONS OF FRACTURES. 
The complications of fracture are haemorrhages, throm- 
bosis, lacerations, contusions, and paralyses. Their deriva- 
tives are meningitis, abscess, and atrophy. All of these 
may be produced directly from injury to the encephalon 
without fracture, with the exception of one form of haemor- 
rhage. If epidural haemorrhage ever occurs without the 
intervention of fracture, I have never seen it in necropsies, 
or had reason to suspect it in recovering cases. 
Fractures of the skull without complication are not only 
without importance or consequences, but they are devoid of 
symptoms. A simple fissure of the posterior fossa would 
probably be unsuspected, for symptomatic cervical ecchymo- 
sis is of the rarest occurrence. A simple fracture of the 
vault is often overlooked in the absence of pressure symp- 
toms. In fracture at the base, displacement of the frag- 
ment does not occur, or is insufficient to occasion trouble, 
and when the patient survives, union, of course, is without 
provisional callus. The very general existence of compli- 
cations, however, often of the gravest character, has given 
fractuie of the base vicariously both an importance and a 
symptomatology. 
The encephalic lesions which complicate fracture include 
all those which occur independently, and therefore may be 
considered at once, from a double point of view, as compli- 
cations and as primary injuries. 64 
A CLINICO-PATHOLOGICAL STUDY OF 
HEMORRHAGES. 
Epidural haemorrhage is perhaps the most characteristic 
complication of fractures. In moderate quantity from the 
osseous or smaller meningeal vessels, it is the usual source 
of the diagnostic haemorrhages from the ears, nose, or 
mouth, and into the orbital and subconjunctival tissues. 
In larger amount and as a source of danger, it is derived 
from the larger meningeal vessels, notably from the middle 
meningeal artery. In at least two and possibly four cases 
it was the immediate cause of death. In a third, involving 
fracture at the base, life was saved by operation, although 
the clot removed measured four ounces and a half by vol- 
ume. Such a case is in evidence that the brain-tissue is 
really susceptible of compression. 
Subarachnoid or cortical haemorrhage is ordinarily de- 
rived from laceration of the cortical substance, and is often 
the direct cause of death, as well as of certain of the pre- 
cedent symptoms. From a laceration at the base, whether 
of the frontal or temporo-sphenoidal lobe, it may cover the 
whole superior surface of one or both hemispheres, and cause 
various localizing symptoms which accompany or precede 
those of fatal pressure. From a laceration of the occipital 
lobe or cerebellum, it may cause immediate death from 
compression of the medulla; or the hajmorrhage from the 
torn vessels of the brain, even in extensive laceration, may 
be insufficient to seriously modify symptoms or hasten the 
fatal termination. A moderate amount of cortical haemor- 
rhage from rupture of the vessels of the pia is also one of 
the results of meningeal contusion. 
Subdural hccmorrhage I have found most frequently to 
depend upon rupture of the arachnoid and escape of blood 
from the meshes of the pia mater into the arachnoid cavi- 
ty. In a smaller number of instances its source has been in INJURIES OF THE HEAD. 
65 
the meningeal vessels. In a recent case there was rupture 
of the dura mater, and the blood was of epidural origin. 
Cortical haemorrhage, however, is, of all others, the one 
most frequently encountered. The majority of lacerations 
reach the surface of the cortex, and superficial haemorrhage 
results. 
THROMBOSIS OF THE SINUSES. 
The occurrence of thrombi in the sinuses of the dura 
mater and base of the skull in three cases, under varying 
circumstances, is not in all of them susceptible of adequate 
explanation. In the first case, which, like the second, in- 
volved fracture at the base, the posterior part of the skull 
was subjected to crushing violence. There was extensive 
epidural clot, large subdural clot which filled the right in- 
ferior occipital fossa, and a firm cortical clot beneath the 
seat of fracture surrounded by an inflammatory exudation. 
The surface of the posterior part of the right occipital lobe 
was softened and the seat of minute extravasations. There 
were small lacerations of the inferior surface of both frontal 
lobes, and one of considerable size in the right cerebellum, 
beneath the thickest part of the subdural extravasation. 
The wall of the posterior part of the superior longitudinal 
sinus was infiltrated with blood, and the cavity occupied 
by a thrombus. A second large and partially decomposed 
thrombus was situated in the torcular Herophili, and ex- 
tended through the right lateral and petrosal sinuses into 
the jugular vein. In the second case a simple fissure ex- 
tended from the right parietal bone into the posterior fossa, 
terminating in the jugular foramen. There was slight epi- 
dural and considerable subdural haemorrhage at the origin of 
the fracture. There were several lacerations in the anterior 
part of the brain, and on the left side the interior of the tem- 
poro-sphenoidal and that of the frontal lobe were excavated 66 
A CLINICO-PATHOLOGICAL STUDY OF 
and distended by a clot from a haemorrhage, which had also 
broken through into the lateral ventricles and occipital lobes 
and filled them with fluid blood. There was cortical haem- 
orrhage at the base, which had surrounded the optic chiasm 
and extended to the anterior border of the pons. The 
thrombus occupied the torcular Herophili and extended 
through the lateral and petrosal sinuses into the jugular 
vein. In the third and final case there wras no fracture, in- 
tracranial haemorrhage, or laceration. There was, however, 
general contusion, with moderate oedema and distention of 
the minute cerebral vessels with coagula. This condition 
extended to the corpora striata, optic thalami, pons, and 
cerebellum, and was most pronounced at the base and upon 
the left side. The thrombus was decolorized, and occupied 
both lateral and both petrosal sinuses. It extended into 
the right jugular vein, and was colored only near the tor- 
cular Herophili. I have detailed all the accompanying le- 
sions, though I do not believe that they were all related to 
the formation of the thrombi. In the first case the infil- 
tration of the wall of the sinus points to its laceration by 
direct violence as the first step toward the coagulation of 
its contents. The portion of the sinus in which it began 
was, moreover, directly beneath the point at which sufficient 
violence was inflicted to comminute the skull, to rupture its 
membranes, and to cause localized inflammation in connec- 
tion with the hsemorhage. The surrounding inflammation 
might, at first sight, suggest an inflammatory origin, but 
the absence of inflammatory products in the sinus wall cor- 
roborates the view I have taken. It is more difficult to ac- 
count for the thrombus in the second case. There is no 
positive evidence, but a possible clew exists in the termina- 
tion of the fissure in the jugular foramen. It may be that 
some injury done to the vein led to the beginning of throm- 
bosis at this point. It had no evident relation to the other INJURIES OF THE HEAD. 
67 
intracranial lesions which can aid in solving the problem. 
In the third case the thrombus was the only localized le- 
sion, and again a different and conjectural explanation must 
be sought. There was general contusion and general throm- 
bosis of the minute cerebral veins. It is impossible to as- 
sume either that venous canals of such size should have 
primarily participated in the effect of a general contusion, 
or that the obstructing coagula should have extended sec- 
ondarily into the sinuses. It might more naturally he as- 
sumed that the thrombus, which was already decolorized, 
was an antecedent lesion which had led to the venous ob- 
struction and oedema of the brain tissue. There was, how- 
ever, no indication of previous disease, and the man was at 
his work when struck down by the blow which caused his 
death. These pathologically independent of each 
other, and may have no significance in symptomatology or 
treatment. In another case I suspected thrombosis of the 
internal jugular vein, on account of an oedema of one side 
of the face and neck, but his recovery precluded a confir- 
mation of my suspicion. 
I am unacquainted with any similar instances of trau- 
matic thrombosis of these sinuses. They were unconnected 
with pressure or any inflammatory process within or without 
their walls, or with any dyscrasia of the patient. In the 
first and second cases I have been able to suggest an expla- 
nation ; in the third case 1 am still without definite opinion. 
LACERATIONS. 
Lacerations and contusions of the brain are unques- 
tionably first in frequency and importance among all the 
injuries of the head. They play a part in all fatal cases, 
and dominate the symptoms in almost all cases of recov- 
ery. Even when death is the immediate result of haem- 
orrhage or inflammation, or when, though life be saved, 68 
A CLINICO-PATHOLOGICAL STUDY OF 
the mind is lost, they still ride behind. In every fatal case, 
with fracture or without, where necropsy has been per- 
mitted, one at least of these lesions has been found to exist. 
In every one in which necropsy has been denied, as well as 
in every case of recovery, the interpretation of symptoms 
in the light of what has been disclosed by previous post- 
mortem examination has pointed to the same conditions. 
They do not occur, however, with equal frequency. While 
in fifty-eight cases there were forty-eight with lacerations, 
there were but thirty with marked contusions ; or, different- 
ly estimated, there were twenty-eight cases of laceration 
without noticeable contusion, and but ten of contusion 
without laceration. The lacerations may be single or mul- 
tiple ; they may be confined to the cortex, or extend a vari- 
able distance into the subcortical structure ; they may origi- 
nate subcortically and completely disintegrate the interior 
of a lobe without encroaching upon the cortex, or they may 
reach the pia; they may lacerate the pia and rupture the 
arachnoid, with or without diffusion of haemorrhage, or the 
membranes may remain intact. In a large proportion of 
cases the laceration will be with well marked diffusion of 
haemorrhage. Topographically, there is no lobe or convolu- 
tion which may not be wounded. It will be seen from the 
necropsies recorded that the base of the brain, especially 
upon the frontal and temporo-sphenoidal lobes, suffers most 
seriously and most frequently, and that the interior of the 
frontal lobes is oftenest the site of extensive destruction. 
Several cases will be noted in which the haemorrhage from 
a lacerated frontal lobe has broken through the lateral ven- 
tricles into the posterior regions of the brain. I present a 
specimen of small laceration in almost the exact center of 
the cerebellum (Case XXXIV). I have no record of lacer- 
ation of the optic thalami, fornix, velum interpositum, or 
corpus callosum, though such injuries have been described. INJURIES OF THE HEAD. 
69 
I also present a specimen of laceration of the pons (Case 
XXVI). Instances of laceration of the corpora striata and 
gyrus fornicatus are included in the series (Cases XX, 
XXIX, XXX, XXXV). The general appearances of these 
lacerations have been noted by previous writers under the 
name of contusions, and they require but cursory mention. 
As they present themselves in the cortex, they are simply 
lacerated wounds containing more or less coagulum with 
underlying shreds and granular detritus of brain tissue. 
After the removal of the coagulum the bottom of the 
wound is usually pultaceous, and stained with blood or of 
a grayish color. Sometimes the peripheral brain tissue is 
softened and dotted with miliary extravasations, and some- 
times it is of normal consistence and appearance. It is 
rarely the case that there is not some resulting hajmorrhage 
which infiltrates the pia, perhaps trivial in amount, perhaps 
sufficient to thickly cover the base or vertex and the lateral 
aspects of the brain. The wound may be circular, oval, or 
irregular in outline, not larger than a pea, or covering the 
whole extent of the inferior surface of the temporo-sphe- 
noidal lobe. In case of subcortical laceration the lesion 
may be a simple extravasation of blood into the deeper 
brain tissue, as small as in the specimens from the pons 
and central cerebellum which I have just exhibited, and 
either as harmless as it is trivial in extent or of deadly im- 
port. In another instance, as in more than one of the ne- 
crologies which I have just recorded, the whole internal 
structure of both frontal lobes may be disintegrated and 
destroyed; and when the clot and mangled brain have been 
turned out, nothing but the cortical shell remains. 
The subsequent changes which these wounds undergo 
are not numerous. If of considerable size, death ensues in 
the majority of cases before sufficient time has elapsed to 
permit any change of importance. The end to be hoped 70 
A CLINICO-PATHOLOGICAL STUDY OF 
for, as in any wound with loss of tissue, is cicatrization. 
In an experience in the dead-house lasting over many years, 
it has not been my fortune to meet with an instance of such 
reparative process, yet I have seen many cases of recov- 
ery where I am positive laceration had existed. There is 
a remarkable illustrative specimen in the Museum of St. 
George’s Hospital, quoted by Mr. Hewitt, in which two 
large lacerations of the cerebrum, occurring without frac- 
ture, had cicatrized after many years. The cerebral surface 
was excavated and the pia and arachnoid were carried over 
the depression, leaving a cavity tilled with loose areolar tis- 
sue and serum. The man’s intellect had been clear, and he 
had suffered no cerebral symptoms. 
If the patient survives, the process of reparation is evi- 
dently slow. In certain cases in which old lacerations were 
discovered after death from more recent injury, there was 
no contraction of the wounds and no inflammatory changes 
of importance had begun. The edges of the wounds were 
slightly rounded, and the coagula which they contained 
were softened and their color had become rusty or yellow. 
In necropsic cases of recent laceration an interval of 
from a few moments to one day, or several, has probably 
elapsed. The appearances are practically the same what- 
ever the interval may have been. There is no tendency to 
meningeal or visceral inflammation in any cases which I 
have observed, with the exception of the occasional forma- 
tion of abscess from subcortical laceration. As in the case 
of general contusion, with profuse oedema and death after 
fifteen days, no inflammatory changes have been discovered 
even upon careful microscopical examination. In an ex- 
ceptional case (Case VII) the temporo-sphenoidal lobe had 
been seriously lacerated, and after the lapse of six months 
was the seat of interstitial inflammation and atrophy. INJURIES OF THE HEAD. 
71 
CONTUSION. 
Contusion may be regarded as occurring in three forms 
—general and limited, atfecting the brain, and meningeal, 
involving the membranes. The limited form may be either 
cortical or subcortical. Any two or all three of these may 
coexist in the same case. 
Limited contusion of the brain differs from laceration 
as a contusion elsewhere differs from a wound. There is 
no palpable solution of continuity in the brain fibers, and 
consequently the hamiorrliagic extravasation can only be 
minute in quantity and of punctate or miliary form. In 
reparation only absorption, not cicatrization, is required, 
and recovery should occur in the major and not, as in 
laceration, in the minor proportion of cases. It is there- 
fore less frequently met with in post-mortem observations. 
As in cortical or subcortical laceration, either form of lim- 
ited contusion occasionally results in abscess. In the sub- 
cortical forms it may be difficult or impossible to determine 
which one of the two is the responsible lesion. I have very 
carefully described such an abscess in a case reported in 
the New York Medical Journal, March 19, 1890, and in- 
cluded in the present series. This abscess, which compli- 
cated fracture at the base, and two others complicating 
compound fracture of the vertex, comprise the small pro- 
portion of cases which represents the danger of this form 
of inflammation. In the case first mentioned, though frac- 
ture at the base existed and made it technically one of that 
class, there was also compound fracture of the vertex in 
connection with which the abscess was formed. So we may 
properly consider all the abscesses as complicating the latter 
form of fracture. In all three cases the dura was carefully 
examined at the time of accident and found to be unin- 
jured, and after an interval of more than two weeks with- 72 
A CLINICO-PATIIOLOGICAU STUDY OF 
out the occurrence of meningeal inflammation, the abscess 
was developed. In each the external wound had been 
healthy and had nearly closed. These data seem to prove 
that suppurative inflammation of the brain substance is the 
result of primary injury of the brain itself, and not second- 
ary to meningeal inflammation extended from the point of 
fracture. The time for cortical and meningeal suppurations 
passed with the coming of aseptic methods, and at the 
same time hernia cerebri practically disappeared from the 
field of surgery. These cases, however, show that com- 
pound fractures still sustain a relation to deep abscess. It 
is not dependent upon the extent of the attendant lacera- 
tion or contusion, for that is likely to be as great under 
other circumstances. It is more probably due to exposure, 
for, though uninjured, the dura and cortex may not be im- 
pervious to atmospheric influences. The explanation of this 
subcortical suppuration is, at all events, neither more nor 
less difficult than that of subcutaneous suppuration upon 
the surface of the body. The dogmatic assertion that 
traumatic abscess of the brain never occurs except there 
has been wound of the scalp or fracture of the skull is 
erroneous. Though the cases which I record here con- 
form to this proposition, I am cognizant of at least two 
cases which do not. One was a small parietal abscess 
which I saw some years ago; the other an abscess of enor- 
mous size in the frontal lobe from a blow received in the 
ball-field, without the occurrence of superficial injury of any 
sort beyond moderate contusion. The latter specimen is 
still in the Museum of the Carnegie Laboratory. The im- 
portant fact in connection with cerebral abscess at the pres- 
ent day is that it occurs from direct brain lesion independ- 
ent of injuries of the scalp, skull, or meninges. 
General contusion of the brain is more frequent than 
the limited form, but much less frequent than laceration. INJURIES OF TIIE HEAD. 
73 
I am accustomed to recognize it in three post-mortem con- 
ditions : General hyperaemia, with or without oedema, 
punctate or miliary haemorrhages, and thrombosis of the 
minute cerebral vessels. They occur separately or together. 
Examples of each are afforded by the necropsies I have 
described, and the appearances they present are sufficiently 
indicated in the enumeration of post-rriortem conditions 
which I have made. I will only refer to two very recent 
cases (Cases XXXIII and XXXIV) as well-marked instances 
of excessive general hyperaemia from general contusion ac- 
companying laceration, and to one other (Case XXIV) in 
which death was due to general contusion with oedema. The 
very moderate hyperaemia which often exists in connection 
with other lesions I have not specially considered, though 
it may be of serious importance. 
Meningeal contusion, as a distinct complication, occa- 
sions haemorrhage and inflammation. Its relation to gen- 
eral contusion of the brain is not closely defined. The 
two conditions occur together or separately, and severity of 
one when they are coincident is not always proportionate 
to that of the other. I may instance as illustrative of this 
uncertain relation two cases—the one of oedema to which 
I but just now referred, in which the brain tissue was sod- 
den and the ventricles distended with serum, while the 
meningeal vessels were hut slightly congested and the sub- 
arachnoid spaces notably dry; the other, my single case of 
acute arachnitis to which I shall refer later, in which the 
whole subcortical tissue was very markedly hyperaemic and 
the smaller vessels filled with coagula. I do not regard 
simple meningeal hyperaemia as other than a factor in the 
more important lesion of laceration or general contusion, 
with which it may happen to be associated. 
Haemorrhage is of frequent occurrence. The vessels of 
the pia are ruptured and the blood is effused ordinarily in 74 
A CLINICO-PATHOLOGICAL STUDY OF 
a rather thin sheet over one or both hemispheres, but may 
present itself in patches scattered over any part of the 
brain. When the haemorrhage is more profuse and the 
clot thicker, it can probably be traced to its source in a 
cortical laceration. The coexistence of both forms of cor- 
tical haemorrhage is not infrequent. If the fact be fully 
recognized that cortical haemorrhages of traumatic origin, 
unconnected with cortical laceration and without fracture 
as well as with it, are the result of meningeal contusion, the 
subject will not require further comment. 
Traumatic arachnitis, so far as these records show, 
does not result from direct injury transmitted through 
fracture of the skull, nor from an inflammatory process 
propagated from a cortical laceration. This complication 
was once supposed to be the great danger to be feared 
from injuries of the head, and when death ensued it was 
always charged with the fatal result. An examination of 
the fifty-eight post-mortem observations I have made dis- 
closes only seven cases in which it was possibly present, 
and only five in which it was positively determined. Two 
of these occurred in connection with fractures at the base, 
and the remainder in simple injuries of the brain in which 
no fracture existed. One of the former was an acute 
arachnitis; the other six were characterized by a subarach- 
noid serous effusion. They all negative the theory of di- 
rect violence, or of an extension of a prior inflammatory 
process. The acute arachnitis (Case XVIII) was localized 
in the right and left occipital regions, while the attendant 
fracture and subcortical lesion were in the parietal region 
of one side, and separated from it by an interval in which 
there was no purulent effusion. General contusion was 
also present. In the case of subacute arachnitis which 
complicated a fracture at the base (Case IV), the depressed 
portion of the fracture which was in the vertex was con- INJURIES OF THE HEAD. 
75 
fined to the external table, the local lesion was subcortical, 
and there was evidence of general contusion. In the five 
other cases, in which there was more or less evidence of 
subacute arachnitis, there was no fracture at all; in three 
there was no laceration, but general contusion or cortical 
haemorrhage from meningeal contusion; in one of the other 
two the subarachnoid effusion was localized on the opposite 
side of the brain from the site of the laceration ; and in the 
other and last of the series the lacerations were old and 
considerably antedated the immediate cause of death. 
There can be no doubt that all of these were the result of 
meningeal contusion. 
Paralysis.—Another complication which has been sup- 
posed to be a direct result of fracture is paralysis from 
bony compression of the cranial nerves. This condition is 
represented in a single case. In this there was compres- 
sion of the optic nerve. There was fracture extending 
through both anterior fossae, involving the left optic fora- 
men, and pinching the optic nerve at that point (Case LIX). 
Loss of sight was immediate, and ophthalmic examination 
showed the condition of the nerve and eye to be normal. 
Subsequent examinations discovered progressive atrophy. 
The patient recovered, but loss of sight was permanent. 
In other cases in which loss of function occurred in parts 
to which cranial nerves are distributed, as elucidated by 
post-mortem examination, the cause was found to exist in 
lesion of the cortical centers or in compression of the nerve 
by blood effused into its intra-osseous canal of exit. There 
is so little displacement in fracture of the base that such 
instances as the one detailed are probably of great infre- 
quency. 
CONTRE-COUP. 
I have called attention to the fact that fractures are 
usually the result of direct violence, expending its force 76 
A CLINICO-PATHOLOGICAL STUDY OF 
upon the vertex or transmitted in continuity to the base, 
and that fractures by contre-coup are exceptional. Lacera- 
tions and contusions of the brain, on the contrary, are al- 
most invariably produced, either wholly or in part, in this 
way. In the minority of cases in which some encephalic 
lesion exists directly beneath the point at which violence 
has been inflicted, there has usually been further and more 
serious damage done to the brain in some distant part. 
There has been either laceration or general contusion dis- 
covered in each case subjected to post-mortem examination. 
If the cases of gunshot laceration are excluded, and also 
those of general contusion in which a question might arise 
as to the kind of violence to which the lesion should be 
ascribed, there are only five instances in which the violence 
inflicted was exclusively direct. It is almost safe, therefore, 
to assume in any given case that if a lesion of the brain 
exists, it has been produced by contre-coup at a distance 
from the seat of direct injury. A careful examination of 
the cases cited shows this distant point to be almost always 
upon the opposite side of the brain, and confirms all pre- 
vious observations that it is likely to be at the base in the 
middle or anterior lobe. The reasons which have been ad- 
duced to explain the frequent occurrence of brain injury by 
contre-coup and its seat by preference have no relation to 
these necropsies and need not engage our consideration. 
CONCUSSION AND COMPRESSION. 
All traumatisms involving brain symptoms were for many 
years classified as cases of concussion or compression. The 
classification was undoubtedly simple and of easy compre- 
hension. If the intracranial 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 INJURIES OF THE HEAD. 
77 
functional disorder produced by violence. Twenty years ago 
Mr. Prescott Hewitt described several forms of contusion, 
in which he included lacerations, and questioned the occur- 
rence of concussion as a distinctively pathological condition 
without the existence of anatomical change. Previous to 
this time several observers had noted structural changes in 
certain fatal cases, but had not regarded them as either 
necessary or invariable. Some years later von Bergmann, in 
a clinical lecture, admitted the existence of botli concussion 
and compression, with an aetiological difference, and in- 
sisted upon their clinical identity. He attributed concus- 
sion to a direct injury from a single impulse, modified by 
the elasticity of the skull, by which the brain suffered a 
diffuse disturbance of nutrition without appreciable lesion, 
lie considered it a suspension of cortical activity followed 
by a stimulation, and eventually by a depression of the 
medulla. He recognized it as occurring in three degrees: 
1. Involving paralysis of the cortex only. 2. Paralysis of 
the cortex and stimulation of the medulla. 3. Paralysis 
of both cortex and medulla, with brief and unobserved 
medullary stimulation. Cortical paralysis was indicated 
by unconsciousness; medullary 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 being 
identically the same, and as manifested by the same-symp- 
toms, but due to change of cranial capacity and not, as in 
concussion, to change of cranial form. Finally, he con- 
sidered diagnosis as only possible by the duration of the 
symptoms. This clinical lecture was admirably translated 
by Dr. John C. Schapps, late house surgeon at St. Vincent’s 
Hospital, and appeared in the Annals of Surgery in 1882. 
The views of von Bergmann, of which I have presented 
a resume, are of great weight and authority, and probably 78 
A C’LINICO-PATHOLOGICAL STUDY OF 
represent the cumulation of thought and observation up to 
that time. I do not know that very much of importance 
has been added since. I am quite in accord with his opin- 
ion that concussion and compression should be regarded as 
one, but would gb further, and, having consolidated the 
two, would abolish them both together, so far as they are 
terms used to express a pathological condition. The diffi- 
culty with all explanations of concussion is that, of neces- 
sity, they are largely theoretical. To account conclusively 
for unseen pathological changes, or to authoritatively deny 
their existence, requires that the syllogism be very care- 
fully constructed. In this instance, in every fatal case 
where the clinical history has corresponded to that of re- 
covering cases a carefully conducted necropsy has revealed 
organic lesion. In all cases that have been cited to prove 
that no post-mortem lesion exists not one has been ob- 
served with sufficient exactitude to make it of the slightest 
statistical value. There is nothing in analogy to warrant 
at the present time the assumption that any fatal disorder 
terminates 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 is tenable ground, therefore, 
to hold from both negative and positive post-mortem ob- 
servation, as well as from general analogy, that brain injury 
produces structural change with the same certainty that it 
occasions palpable symptoms. If the terms concussion and 
compression be used to indicate a group of symptoms, or a 
variation of pathological condition, it is objectionable, both 
on the score of propriety and as being likely to lead to er- 
roneous diagnosis. If they be discarded, the form of 
injury the patient has suffered in a given case—as lacera- 
tion, general contusion, or fracture with haemorrhage—is 
more likely to be accurately determined than if attention IXJURIES OF THE HEAD. 
79 
be directed solely to a symptomatic condition that may not 
clearly exist. If unconsciousness and variation of pulse be 
accepted as the sole pathognomonic and invariable condi- 
tions of traumatism, there will still remain many cases of 
uncertain status. Examples may be cited from the forego- 
ing necrologies in which, from the earliest moment at which 
the patient could be reached, there was neither unconscious- 
ness nor a typical variation of pulse. There can be no 
doubt, however, that unconsciousness is one of the earliest 
and most constant symptoms of serious brain injury. The 
opinion that consciousness resides in the cortex as a whole, 
and that unconsciousness is paralytic or inhibitory, is con- 
firmed by the negative results of physiological experiment 
and by the artificial production of cerebral anaemia. It 
may properly be regarded, therefore, as symptomatic of 
brain injury with diffuse effect, but not necessarily of dif- 
fuse injury. The primary retardation and subsequent ac- 
celeration of the pulse which have been experimentally 
proved to be attributable to medullary lesion are not as 
constant, and consequently of less symptomatic importance. 
In a majority of cases, at the first moment assistance can 
be rendered, the pulse is accelerated as it would be in 
serious injury of other parts of the body. The ambulance 
serv ice is exceedingly rapid, so that if the retardation of the 
pulse is so evanescent as a symptom, it has no great practi- 
cal diagnostic value. 
The temperature, which has not heretofore received at- 
tention as an important factor in the genesis of symptoms 
or in the diagnosis and prognosis of brain injuries, seems 
to me of primary importance. 
Analysis of the temperatures which have been recorded 
in these histories confirms the impression which I formed 
early in my study of these cases—that an elevation of tem- 
perature was an early, continuous, and very constant symp- 80 
A CLIXICO-PATHOLOGICAL STUDY OF 
tom in all classes of head injury. I have a record of tem- 
peratures in 45 cases in which the diagnosis was confirmed 
by necropsy as well as in 10 other fatal cases and in 28 cases 
of recovery, a total of 83 out of 124 altogether. I think 
there can he no doubt of the propriety of including the 
cases of death without necropsy and the recoveries, since 
the diagnosis was in each well established. I have a defi- 
nite recollection that in a considerable number of other 
cases in which the temperature was carefully observed and 
recorded, but in which the charts were unfortunately lost, 
that the averages were not essentially different. 
Four cases, which proved to be fatal, were admitted 
with subnormal temperatures—from 94° to 98°. In two 
a subsequent rise in temperature was immediate, continu- 
ous, and very considerable ; in the other two death ensued 
in a few hours without reaction—in all the pulse indicated 
medullary paralysis, and the lesions were afterward found 
to be extensive and severe. In six other cases the patient 
was not admitted to a surgical ward till the second day or 
later after the reception of the injury, so that the first tem- 
perature taken chuld not be considered primary, but in 
each case it was then notably elevated—from 101° to 
104‘8°. In one recovering case of fracture of the base with 
epidural hiemorrhage it was normal, and never exceeded 
99°. In the remaining seventy-two cases, without excep- 
tion, the temperature on admission was above normal. In 
the majority it exceeded 100°, and ranged all the way from 
98‘8° to 106°. It would be difficult to trace a relationship 
between the character or location of the lesion and the 
comparative elevation of temperature. The increase was 
usually progressive, without much recession, and the maxi- 
mum was reached just before death and sometimes after- 
ward. The highest temperatures attained were 109° in one 
case, 108° in one, 107°+ in eight, 106o-f- in ten, and 105°-(- INJURIES OF THE HEAD. 
81 
in nine, or in twenty-eight cases it was above 105°. In 
eleven other cases it ranged from 104°-f- to 103°-(-. In 
three cases the post-mortem temperature was 108'8°, 109°, 
lCffi^0. Sufficient data have been given to show that in 
probably no condition, except insolation, is the temperature 
so uniformly high as in cases of encephalic lesion. 
Unconsciousness as an early symptom sometimes fails 
without apparent explanation in cases in which brain injury 
is undoubted. A variation of temperature, therefore, is the 
one invariable symptom, and if the patient has rallied from 
immediate shock, it is always an elevation. Perhaps, like 
the retardation of the pulse, depression of temperature may 
always be the primary change, but, if so, like the primary 
pulse change, it is too evanescent to be practically diag- 
nostic. In many trivial head injuries elevation of tem- 
perature is absolutely the only symptom ever recognized. 
The symptoms should be rated in order of constancy, ele- 
vation of temperature, unconsciousness, and acceleration of 
pulse. 
Since this elevation of temperature is a constant phe- 
nomenon, whatever the nature of the lesion or wherever 
situated, it would seem to be due to an affection of the cor- 
tex as a whole, and not to special lesions of localized heat 
centers. To this extent it might be comparable to experi- 
mental results in the attempt to discover cortical centers 
for organic functions. To what degree and in what man- 
ner the demonstrated heat centers are implicated in the 
general cortical change is not within the scope of this paper 
to discuss, nor within my province or competency to deter- 
mine. 
The primary effect of brain injuries may therefore still 
be attributed to an affection of the cortex in its totality, in 
accordance with von Bergmann’s view, but manifested by 
two symptoms in place of one—an invariable variation in 82 
A CLINICO-PATHOLOGICAL STUDY OF 
temperature and a nearly invariable loss of consciousness. 
There is no reason to doubt that the medulla is next in- 
volved, and the effect of its stimulation and subsequent 
paralysis have been too thoroughly demonstrated to admit 
of question. The diagnostic value of the symptoms it 
affords, however, has not been apparent in these histories. 
I have not quoted the pulse records, because they have not 
been sufficiently characteristic to justify the necessary ex- 
penditure of time and labor. 
The post-mortem observations disclose in every instance 
gross lesions in one or more regions of the brain or its 
membranes, which give a material basis for the symptoms 
which preceded death, whatever may have been the in- 
tervening processes which connected the structural change 
with its outward manifestations. It is for this reason that 
I would exclude the terms concussion and compression 
from systems of classification and descriptive histories of 
cases. 
SYMPTO MATOLOGY. 
The symptoms of injuries of the head, excluding those 
which are casual and without diagnostic significance, are 
fairly numerous. Fracture at the base has two symptoms 
peculiar to itself, and fracture of the vertex has also two ; 
the others are common to both forms of fracture and to 
purely encephalic injuries. Those peculiar to fracture at 
the base are serous discharges from the ears or nose, and 
haemorrhages from the ears, nose, or mouth, and into the 
orbital, subconjunctival, or cervical subcutaneous tissue. 
The characteristic symptom of fracture of the vertex, aside 
from a possible local serous discharge, lies in its perception 
by sight or touch. The symptoms of encephalic injuries, 
as a class, whether they occur independently or as complica- 
tions of fracture, are superficial injuries; peculiarities of 
temperature, pulse, and respiration; unconsciousness; de- INJURIES OF THE HEAD. 
83 
lirium ; irritability ; paralysis ; muscular rigidity ; convul- 
sions ; anaesthesia and hvperaesthesia ; pupillary changes ; 
and, in a late stage, dementia. Other symptoms, as cepha- 
lalgia, vomiting, vertigo, incontinence of urine and faeces, 
are frequent, but of lesser clinical value. 
The haemorrhages, serous discharges, and visual or tac- 
tile detection of fracture are pathognomonic. The haemor- 
rhages occurred in twenty cases and the serous discharge 
in one, and the necropsy in each confirmed the indication 
the symptom had afforded. In the fourteen cases in which 
they were absent, the line of fracture in each was found to 
he such as to preclude the escape of blood during life 
through any of the recognized channels. The direct evi- 
dence of fractured vertex was present in five cases, includ- 
ing three of gunshot wound. 
There were simple contusions, large haematoma, or 
wounds, perceptible in fifty out of the fifty-eight cases. 
These superficial injuries were of great importance, not 
only by affording positive proof that violence had been suf- 
fered in cases where unconsciousness of the patient and 
absence of history rendered such confirmation essential, but 
by indicating the point at which it had been inflicted. 
Sufficient has been said of variations of pulse and tem- 
perature and of unconsciousness, and little need be added 
in regard to peculiarities of respiration. In the majority 
of cases it was simply rapid or normal, and the chart rec- 
ords have not been transcribed for the same reason that 
they were omitted in case of the pulse. It was occasion- 
ally slow, in some instances not more than seven or eight 
in the minute, sometimes irregular or stertorous, sometimes 
of the Cheyne-Stokes variety, and in two or three instances 
dependent in character upon the presence of pulmonary 
oedema. As in case of the pulse symptoms, I have been 
struck by the habitual absence of distinctive respiratory in- 84 
A CLINICO-PATIIOLOGIOAL STUDY OF 
dications of medullary implication in serious cortical dis- 
turbances. 
Delirium, or some form of mental impairment, is of 
rather frequent occurrence. It sometimes replaces uncon- 
sciousness as the earliest noticeable symptom, and some- 
times appears as a much later manifestation. It may be 
violent and simulate alcoholic mania, or it may be mild and 
coexist with stupor. The most characteristic form of men- 
tal disorder which I have encountered in cases of head in- 
jury is that of nocturnal delirium, with more or less mental 
disturbance by day, and in time lapsing into permanent de- 
mentia as a termination, or sequel, of the traumatic lesion. 
It may follow at once upon recovery of consciousness, or it 
may succeed active delirium. At night the patient often 
requires mechanical restraint, while during the day he an- 
swers questions intelligently, is coherent in his speech, and 
may appear entirely rational. His memory, however, is de- 
fective, or wanting altogether, in regard to all the circum- 
stances attending his injury. He has delusions and fails to 
recognize his surroundings. He is prone to drink his urine, 
and is often apathetic. His mind may finally become clear, 
his memory of lost events return, and his mental recovery 
be complete. In other cases his condition becomes one of 
dementia and some degree of mental impairment is perma- 
nent. Such a condition as 1 have described I presume is 
not novel to the alienist, but I note it as a special charac- 
teristic of injuries of the brain substance, not as a sequel, 
but as a symptomatic condition of recent lesion. 
Another allied symptom is the sensitiveness to external 
irritations in cortical lesions. It seems to be not only a 
hyperanajsthesia of the cutaneous surfaces, but also a 
marked mental irritability. There is not only exaggerated 
muscular movement from slight irritations and disturb- 
ances, but the patient manifests great vexation and impa- INJURIES OF THE HEAD. 
85 
tience, though apparently unconscious. It is not usually 
followed by muscular spasm. 
Convulsions, muscular rigidity, and muscular tremor 
may also be classed as irritative symptoms. The first and 
second occur in a considerable number of cases, a majority 
of which prove fatal, and upon necropsic examination dis- 
close haemorrhages and extensive lacerations and possibly 
general contusion. In the case of atrophy of the temporo- 
splienoidal lobe, already described, convulsions were exceed- 
ingly severe; but they followed operation, and a single one 
occurred fifteen days after the original injury, so that it is 
by no means certain that there was any aetiological connec- 
tion between the lesion and the symptom. It is fair to as- 
sume that they are always evidence of serious lesion, even 
when recovery follows. The few instances of muscular 
tremor were in men addicted to drink, but not intoxicated, 
and who died from the effects of extensive structural 
changes. 
Paralysis and anaesthesia, general and local, are recog- 
nized indications of traumatic, not less than of iodiopathic, 
affections of the encephalon. In the present series of cases 
they have occurred perhaps oftener than indicated in the 
histories, since in so many instances consciousness never 
returned. In this condition paralysis of the extremities 
and certain of the local paralyses—facial, ocular, or even 
glosso-pliaryngeal—can be recognized; but many others, as 
well as sensory disturbances, remain hidden. The multi- 
plicity of lesions, which is the rule rather than the excep- 
tion, is confusing. In testing cutaneous sensibility the re- 
sults are sufficiently contradictory and unsatisfactory even 
under more favorable conditions. Yet, despite all these dif- 
ficulties, in two cases of lesion of the gyrus fornicatus the 
observations were productive of some result. In three 
cases of conjugate deviation, the necropsies afforded more 86 
A CLLVICO-PATHOLOGICAL STUDY OF 
or less satisfaction according to the view taken of the loca- 
tion of the cerebral center. In a general way, however, 
while traumatisms may in some instances be of service in 
the solution of various unsettled questions in cerebral local- 
ization, such cases will probably continue to be exceptional. 
The fact that defined lacerations are so largely situated at 
the base of the brain, out of the region in which functional 
areas have been located, still further diminishes the chances 
that traumatism will aid much in perfecting cerebral to- 
pography. It is none the less important, in all cases of 
profound unconsciousness, to examine critically for such 
forms of paralysis as are undoubtedly recognizable as well 
as for those the discovery of which is likely to be more 
problematical. 
Pupillary changes are valuable positive evidence of or- 
ganic injuries, but are less important as negative signs. In 
a minority of fatal, as well as of recovering cases, I have 
found the pupils to be abnormal, either variable, unsym- 
metrical, dilated, or contracted. Unilateral dilatation is 
probably the most frequent deviation from the normal con- 
dition, and is likely to be associated with other and more 
decisive symptoms. 
I shall not stop to consider casual or remote general 
symptoms, though, in connection with others more charac- 
teristic, they sometimes acquire a value which is not in- 
trinsic. Vomiting and incontinence of urine and fajees are 
among the most constant symptoms encountered in head 
injuries; but the one is not less frequent in peritonitis and 
pregnancy, and tjie other is quite as common in a great 
variety of functional and organic disorders of the brain 
which have no relation to traumatism. There can be no 
doubt, however, of the value of such indications when they 
occur under circumstances which render traumatism prob- 
able, either by the history or by the concurrence of more INJURIES OF TIIE HEAD. 
87 
directly suggestive symptoms. In the same connection 
occipital headache might he mentioned as so general in re- 
covering cases of fracture of the base with epidural haemor- 
rhage as to assume almost diagnostic importance. 
I have not specifically noted in the various cases the 
symptoms which were not manifested, but with the excep- 
tion of temperatures, when unmentioned, they may be re- 
garded as absent. 
The results of head injuries have been sufficiently indi- 
cated as recovery, death, and dementia. 
DIAGrNOSIS. 
The diagnosis of injuries of the head as a class is al- 
ways of interest, is usually practicable, and under some 
circumstances is one of the most important in the domain 
of surgery. Grievous error has entailed equal disgrace 
upon the surgeon and suffering upon the patient. These 
lesions are first to be distinguished from all other morbid 
conditions, especially from those involving loss of con- 
sciousness or delirium, and, secondly, they are to be dis- 
criminated from each other. It is unnecessary to enumer- 
ate or consider all those diseases which may simulate their 
symptoms. The one of primary and paramount importance, 
and which demands most earnest and careful attention, is 
the coma produced by alcohol. Its importance can not be 
overestimated, not only because it is the one with which 
the condition of traumatic coma is most likely to be con- 
founded, but because error in diagnosis inflicts so much 
unnecessary suffering, additional danger, and possible dis- 
grace upon the patient, while it places the most serious re- 
sponsibility upon the surgeon. The number of instances 
in which injuries of the brain have been mistaken for alco- 
holic coma and the patient left to die in the cells of a 
police station, or committed to the alcoholic ward at Belle- 88 
A CLINIC0-PATI10LOGICAL STUDY OF 
vue, or even sent from a police court to a term of impris- 
onment, is inexcusably great. A large proportion of such 
cases which came into my service at Bellevue, previous to 
the past year, were transferred from the alcoholic ward. 
It is a pleasure to acknowledge that within the year great 
progress has been made in the acquisition of knowledge 
among those who render first aid to the injured, even to 
the extent of realizing that an unconscious 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 at- 
tention and awaken suspicion of brain lesion. Coma ought 
not to be ascribed to alcohol, except by the strictest pro- 
cess of exclusion. Symptoms which are most likely to 
characterize different forms of head injury should be 
sought seriatim. It should be remembered, finally, that, 
even if the patient be intoxicated, this circumstance should 
strengthen rather than allay suspicion of traumatism. I 
believe the temperature affords the means of absolute diag- 
nosis. I have shown, from the histories I have recorded 
and upon which this paper is founded, that variation of 
temperature in head injuries is invariable, and that in 
exceptional instances in which it is depressed the severity 
of associated symptoms will take them out of the category 
of doubtful cases. In alcoholic coma the temperature is 
subnormal, and I have found this rule to be absolute. The 
one case which seemed to be exceptional was reported to 
me as having a temperature of 100°. Investigation proved 
it to be the result of petit mal from opium smoking in a 
young prostitute of the Chinese quarter who had not yet 
become accustomed to her mode of life. I have made 
some observations to determine the exact temperature in 
alcoholic coma. I have succeeded in obtaining upward of INJURIES OF THE HEAD. 
89 
twenty cases in which coma was more or less profound, 
and the temperature ranged from 96° to 98°, with a usually 
full and slow or normal pulse, and the depression of tem- 
perature was directly proportionate to the depth of coma. 
I had expected at the present time to have collected a larger 
number of cases, but I have found my opportunities unex- 
pectedly limited. Whether it be the quality of whisky or 
the moral tone of the lower stratum of society which has 
improved I know not, but examples are no longer to be 
had for the asking. I believe, however, th§ absolutely 
uniform results in this number of cases makes it more 
than probable that a larger number in the future will cor- 
roborate the conclusion which has been reached. 
In the diagnosis of apoplexy or non-traumatic cranial 
ha;morrhage, I have found that the observations of Bourne- 
ville coincide with those more recently made. They show 
that in the commencement of the attack the temperature is 
subnormal, that it then becomes normal, and remains at 
that point if the patient recovers, but if he dies it rises to 
a marked degree. In twenty-three cases taken from an 
accessible record, of which seven proved fatal, the tempera- 
ture in two of the latter rose to 102° and 104° ; in all the 
others, fatalities included, the highest temperature was 
100° + . This is in marked contrast to traumatic lesions in 
which the temperature continues to rise from the depres- 
sion, if one existed, and remains elevated while the result 
remains in abeyance. A case which suggests the occasional 
difficulty in the diagnosis of idiopathic from traumatic le- 
sion is that (Case CVIII) of the man previously quoted who 
was seized with an apoplectic effusion into his lateral ven- 
tricles and one occipital lobe, and fell from his cab, causing 
a cerebellar laceration. There is still another in this series 
very like it, in which a man after an apoplectic seizure fell 
backward, and, like the first, lacerated his cerebellum. In 90 
A CLINICO-PATHOLOGICAL STUDY OF 
both cases the previous history was known and it was pos- 
sible to diagnosticate both lesions. 
It is unnecessary to refer to uraemic coma, opium nar- 
cosis, hysteria, etc., as the diagnostic problems they present 
are elementary. 
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 fur- 
ther increased by the fact that the subject is of known 
intemperate habits, and very likely intoxicated when first 
brought under observation. In those cases in which de- 
lirium is the first symptom noted, and probably replaces 
unconsciousness (as in Case I), the condition becomes very 
deceptive. Tn this instance we are not aided by the tem- 
perature, which is almost always elevated in alcoholic de- 
lirium, and elevation may be and often is very great. I 
have within a few days seen a case in which, with quite ex- 
tensive superficial injury of the head, there was alcoholism 
to the verge of delirium, a high temperature, a previous 
history of epilepsy, and present epileptiform convulsions 
followed by facial paralysis. The diagnosis, which excluded 
brain injury and which proved to be correct, was made 
from observation of the course of the temperature for the 
first few hours. I am aware of no single diagnostic sign 
upon which dependence can be placed, and yet I have 
never seen a case in which it was not possible to make the 
distinction between the two forms of mental disturbance. 
There are few head injuries in which there are not at least 
one or two characteristic symptoms which can be detected 
if sufficient care be exercised in the examination of the 
case. It seems to me that there are differences even in 
the character of the delirium which may be recognized 
though not easily formulated. INJURIES OF THE HEAD. 
91 
The diagnosis from each other of the several injuries 
which may be inflicted upon the cranium and its contents is 
fraught with difficulties. The lesions are likely to be mul- 
tiple and the symptoms to be equally referable to either one 
of their number; the symptoms of circumscribed lesion are 
often lost in those from one of a diffuse character, and simi- 
lar results constantly ensue from totally different causes. A 
more exhaustive study of the diagnostic value of individual 
symptoms in their relation to each other, and to established 
structural changes, is therefore requisite than I have yet 
been able to undertake. There are, however, well-estab- 
lished facts, as well as strong diagnostic probabilities, which 
are likely to multiply and to make diagnosis possible in an 
increasing number of cases. Thus, it is well known that 
certain haemorrhages positively indicate a definite fracture 
at the base. A trivial injury of the vertex and one or two 
general symptoms may suggest its whole extent and com- 
plications. Again, paralysis of an extremity in a recent 
head injury will positively determine some lesion of a defi- 
nite portion of the parietal cortex on the opposite side. In 
the absence of depressed fracture, and with the knowledge 
that occurrence of laceration or limited contusion at this 
point is unusual, the ascription of the paralysis to haunor- 
rhage becomes justifiable. These conclusions are legitimate 
and founded upon positive knowledge and logical inference 
combined. There can be no doubt, I think, that greater 
diagnostic significance will attach to individual symptoms 
in the light of further pathological observation. As an ex- 
ample, the present series of necrologies seem to show that 
the peculiar mental conditions I have described are usually 
preceded by lesion of the brain tissue, and if it be of the 
membranes, that it is meningeal contusion with inflamma- 
tion. I have insisted upon the importance of temperature 
in the recognition of head injuries as a class. I am not at 92 
A CLINIC0-PATI10L0GICAL STUDY OF 
present prepared to raise the question of its diagnostic re- 
lation to individual lesions. 
PROGNOSIS. 
The prognosis may be first considered from the numer- 
ical results. The total number of cases is one hundred and 
twenty-four, of which forty-nine ended in recovery, or near- 
ly forty per cent. The fractures at the base number seventy, 
of which twenty-one ended in recovery, or exactly thirty 
per cent. 
The popular belief, and possibly the general professional 
impression, is that this fracture is a peculiarly fatal acci- 
dent. I have already expressed the opinion that fracture 
at the base is devoid of danger except for its complications, 
but it is so often attended with grave lesions of the brain 
and meninges that it is not strange that by a species of me- 
tonymy it should come to stand for the traumatism as a 
whole. 
It is difficult to estimate the comparative danger of the 
several lesions, from the fact that they are so generally mul- 
tiple, and all together conspire to bring about the fatal re- 
sult. It is also true that the severity rather than the form 
of lesion is to be made the basis of prognosis. It may be, 
therefore, of no great practical importance to attempt to infer 
from the necropsies the relative responsibility of individual 
lesions in causing death in each instance. So far as I may 
judge from comparisons of symptomatology with post-mor- 
tem appearances, when opportunity has been afforded, I be- 
lieve death has directly resulted in fully fifty per cent, from 
laceration and attendant haemorrhage. In the remainder it 
might be chargeable to epidural haemorrhage, contusion, ab- 
scess, or arachnitis, though doubtless in every case some 
other lesion was contributory. 
The prognosis made from initial symptoms must depend INJURIES OF THE HEAD. 
93 
upon their general severity and upon the extent to which 
the vital powers are implicated. It sometimes happens that 
the patient survives when the obvious extent of the lesion 
has made recovery seem practically hopeless. A fracture 
through both middle and one anterior fossa, and probably 
both, might well put an end to hope, and yet such a case 
(Case LXIX) did recover. I find that none of my patients 
have lived in whom the temperature has risen to 105°, but 
in more than one that degree was approximated. I am not 
at all certain it might not exceed 105° consistently with re- 
covery. A very high temperature, or disturbance of respi- 
ration at an early period, or muscular rigidity, are always 
calculated to excite the gravest apprehension. The late 
prognosis presents no difficulties, but it ceases to be of pro- 
fessional interest. 
I propose to confine whatever I may have to say in 
regard to treatment to questions of operation. I omit all 
reference to medication, as it involves matters of detail 
for which time is wanting. I premise only a brief men- 
tion of what may be properly designated adjuvants in gen- 
eral treatment. The necessity of shaving the head, which 
is conceded in cases with symptoms of marked severity, is 
equally existent in every case in which there seems to be a 
possibility of intracranial injury. It permits the discovery 
of diagnostic contusions which are so often disclosed only 
upon post-mortem examination. It relieves the brain, in 
some cases at least, of a superincumbent and thermogenetic 
weight, which is positively contraindicated and is a factor 
of appreciable influence. It facilitates the use of the ice 
cap, which in cases of high temperature and delirium is an 
appliance of the highest therapeutic value. I have found 
it so effective that I desire to emphasize its importance. I 
have sometimes been compelled to maintain its use for a 
TREATMENT. 94 
A CLINICO-PATHOLOGICAL STUDY OF 
length of time, as whenever it was discontinued the tem- 
perature again increased and delirium returned. The resort 
to a simple form of mechanical restraint is often requisite 
for the mere purpose of retaining the patient in bed. It 
incidentally becomes at the same time a means of quieting 
nervous excitement and of husbanding physical strength. 
Trephining may be regarded with less apprehension by 
the timid since the advent of aseptic methods. Its pro- 
priety may now be decided simply in view of its probable 
advantage, or its more probable futility7-. It may be 
counted quite as safe as the use of the exploring needle in 
suspected abscess, and safer than explorative laparotomy. 
I should not deem it necessary to insist upon this point 
were it not that I am so often surprised hv denials of what 
I had taken to be conceded facts. If, as I am informed, 
the temperature rises to a high degree after craniectomy or 
trephining in children, it is so foreign to my experience in 
traumatism that I am constrained to attribute' it to other 
causes than to simple perforation of the cranium. 1 have 
often found it, on the contrary, to be followed by a depres- 
sion of temperature when no result had been attained be- 
yond the mere removal of the button of bone. The incis- 
ion of the dura, or the further exploration of the brain, 
might be differently regarded, for while trephining, done 
with due regard to time and method, could hardly inure to 
the serious disadvantage of the patient, uncalled-for and in- 
judicious interference with the intracranial contents might 
be of positive disservice. This possibility is not a contrain- 
dication to going further after trephining, if its propriety 
becomes evident. In such case I have always found the 
temperature to rise as it does in injuries of the brain 
generally. In the small abscess which I incised through 
the angular gyrus it rose, in the sixteen hours which pre- 
ceded death, from 102’2° to 108°. In the very large ab- INJURIES OF THE HEAD. 
95 
scess in the frontal lobe, upon which I operated only last 
month, the temperature rose from 99‘2° in twenty-four 
hours to 102'2°, and recovery is even now complete. I 
should expect an elevation of temperature in any case, hut 
I should not expect any serious results from incision of the 
dura or brain per se. So far as subsequent danger or in- 
convenience from hernia cerebri is concerned, I may repeat 
a statement previously made, that in the surgery of to-day 
it has ceased to be an intimidation to the surgeon. 
I am quite of the same mind with those surgeons who 
believe that this operation should be done in every de- 
pressed fracture where elevation and thorough exploration 
can not be otherwise accomplished. I believe with them 
that the absence of general symptoms does not relieve the 
surgeon from the responsibility of operation. This view 
was held by my former preceptors, the late Dr. James R. 
Wood and Dr. J. W. S. Gouley, at a time Avlien to hold 
such opinion was almost an opprobrium. It commended 
itself to my judgment then as it does now. It is doubtful 
if such an operation has been known to do harm when it 
has failed to do good. It is certain that harm has come 
in more than one instance where, because of the absence of 
general symptoms, it has been neglected. It is impossible 
to tell in a depression of the external table of moderate or 
perhaps insignificant extent what more extensive comminu- 
tion of the internal table may not exist. It is this possi- 
bility of even the smallest bony spicula penetrating the 
brain and causing serious nervous disturbance in the indefi- 
nite future that demands thorough examination of every 
cranial fracture. It should be held obligatory on precisely 
the same grounds as the examination and cleansing of a 
wound in the external soft parts. The observance of such 
precaution is free from danger; its neglect may lead to 
either present or future serious complications. 96 
A CLINICO-PATHOLOGICAL STUDY OF 
If the depressed fracture is simple or its existence is in 
doubt, there should be no hesitancy in making sufficiently 
free incision to determine the exact cranial condition. It 
is of very common occurrence that a large liaematoma ex- 
ists in connection with diagnostic symptoms of intracranial 
injury, and that there is no other means than this of acquir- 
ing knowledge which may be of vital importance. If the 
result is nugatory, the incision, made under aseptic condi- 
tions, will be closed by primary union. It is certainly 
better to have made many fruitless incisions than to have 
allowed a single life to be jeopardized by an undiscovered 
fracture. 
In case the fracture proves to be a simple ftssure, a 
different rule of conduct will obtain. The probabilities 
will be against the existence of depression of the inner 
table, and after the fissure has been traced, with or without 
incision, as far as practicable, or till it has become nar- 
rowed to a line, the wound should be closed. If, how- 
ever, the general symptoms should indicate complication, 
further exploration may become proper and necessary. 
The indications for trephination are wanting at the pres- 
ent time in the great majority of cases which involve intra- 
cranial lesion. If the existence of epidural haemorrhage 
is evident and its location is accessible, the propriety of 
operation is unquestioned. If the existence of circum- 
scribed lesion of the brain can be inferred from local 
paralyses, anaesthesia, or muscular rigidity, or from the 
initial symptom of convulsion, I think the propriety of 
operation may be assumed. In the greater number of 
cases, those in which only symptoms of diffuse lesion can 
be recognized, the use of the trephine is entirely empirical 
and without justification, unless undertaken for special 
reason. If in time lacerations at the base come to be diag- 
nosticated with reasonable certainty, it may then be proper INJURIES OF THE HEAD. 
97 
to inquire whether their exposure by the trephine or other- 
wise, disinfection, and drainage would be practicable and 
advantagious. 
The accidental result of trephination, in at least two or 
three cases, suggests its employment on purely medico-legal 
grounds. I will instance the case (Case CVIII), already 
quoted as an example of mixed iodiopathic and traumatic 
lesions, of a man who fell from his cab after an apoplectic 
effusion and secondarily lacerated his cerebellum. He was 
paralyzed, anaesthetic, and absolutely unconscious. He was 
trephined, and a large amount of serous fluid drained away 
from the surface of the brain. His temperature fell in six 
hours from lOS’d0 to 98'6°. He became conscious, could 
articulate, spoke rationally and intelligently, and gave his 
name and address. At the end of fourteen hours his tem- 
perature again rose and he died. The possibilities of such 
a case are not less practical than dramatic. The instances 
I have encountered of such transient returns to conscious- 
ness have been sufficiently prosaic and unimportant. The 
very next, perhaps, might disclose a criminal and avenge 
the crime. In any one of the many homicidal assaults in 
which the victim is found unconscious and the assailant 
has escaped unknown, I believe it to be legitimate to 
trephine for this direct purpose. Even temporary restora- 
tion of the mental faculties might suffice the ends of jus- 
tice. The prospect of success is certainly not altogether 
chimerical, for I have cited a case in which just such a hy- 
pothetical result was absolutely attained. 
The general principles of operative interference in cra- 
nial fractures and encephalic injury may be recapitulated 
and formulated as follows: Incision of the scalp, trephina- 
tion, incision of the dura mater, and perforation of the 
brain, severally or together, should have resort without fear 
or hesitation when indicated. Incision of the scalp and 98 
INJURIES OF THE HEAD. 
trephination are devoid of danger and are always justifiable 
for exploration, which in itself constitutes an indication. 
Incision of the dura mater and incision or perforation of 
the brain are more serious procedures, and should he made 
only when positively indicated by the general symptoma- 
tology. 
I have sketched as rapidly and systematically as possi- 
ble in this paper the conclusions to be derived from the 
series of histories and necrologies by which it is preceded. 
So far as they are confirmatory of previous observations, 
they will have the value which attaches to independent 
study. If in any particular they differ from accepted 
teaching, the inclusion of the historical data will make it 
easy either to verify their truth or to refute their error. 
I beg to acknowledge my indebtedness to the courtesy 
of my colleagues, Dr. J. W. S. Gouley and Dr. F. S. Dennis, 
and also to the successive house surgeons at Bellevue and 
St. Vincent’s Hospitals, for their intelligent co-operation in 
the work of observation. REASONS WHY 
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