' OF MEDICINE NLM005591317 \vfLJ j With the Compliments of • '■■{— "i, Dr. CHARLES PHELPS. The Differential Diagnosis of Traumatic Intracranial Lesions. CHAELES PHELPS, M. D., Surgeon to Bellevne and St. Vincent's Hospitals; Coniulting Surgeon to Gouvemeur Hospital REPRINTED PROM THE Neto STorft JBefelcal Journal for Nov. 10, Dec. 8, 15, 22, 29, 1894, and Jan. 5 and 12, 1895. WL, 1894 Reprinted from the New York Medical Journal. THE DIFFERENTIAL DIAGNOSIS OF TRAUMATIC INTRACRANIAL LESIONS.* By CHARLES PHELPS, M. D., SURGEON TO BELLEVUE AND ST. VINCENT'S HOSPITALS ; CONSULTING SURGEON TO GOUVERNEUR HOSPITAL. In a paper read before this association two years ago, I indicated the comparative facility with which it is possi- ble to diagnosticate cerebral traumatisms from morbid con- ditions of internal origin, and also recognized the difficulty of discriminating various encephalic injuries from each other.f Since that time additional observatipns and analy- ses of their results have served to broaden the diagnostic horizon. I submitted then an abstract of one hundred and twenty four cases. I can now add to these one hundred and seventy six others which I have since noted, a total of three hundred, of which one hundred and thirty terminated in death and were made the subject of necropsv. * Read before the Xew York State Medical Association, October 9, 1894. f A Clinico-pathological Study of Injuries of the Head. New York Med. Jour., January 14, 21, 28, 1892. Copyright, 1824, by D. Appleton and Company. 2 THE DIFFERENTIAL DIAGNOSIS OF These additional cases may be summarized as were those previously recorded: I. Fractures involving the base : Recovered.......................... 36 Died.............................. 59 Number of necropsies................ 5-A II. Fractures confined to the vertex : Recovered.......................... 31 Died.............................. 12 Number of necropsies................ 7 III. Intracranial injuries without fracture : Recovered.......................... 21 Died.............................. 17 Number of necropsies................ 13 The consolidation of the two series affords an aggre- gate of: I. Fractures involving the base : Recovered......................... 57 Died............................. 108 Number of necropsies............... 8 7 II. Fractures confined to the vertex : Recovered.......................... 52 Died.............................. 22 Number of necropsies................ 17 III. Intracranial injuries without fracture : Recovered.......................... 28 Died.............................. 33 Number of necropsies................ -26 Total number of recoveries........... 137 " " deaths............. i63 " " " necropsies.......... 130 In accordance with a more restricted purpose I shall confine myself primarily to the abstraction of essential TRAUMATIC INTRACRANIAL LESIONS. 3 symptoms in the fatal cases, and to their attendant lesions as verified by necropsic inspection. In order to make this synopsis complete in itself, I shall reproduce in connection with these recent histories an epitome of the analogous cases included in the former series. The temperatures quoted are rectal; and haemorrhage is denominated cortical when derived from laceration of the surface of the brain, pial when occasioned by rupture of the pial vessels in meningeal contusion, and epidural when situated between the dura and the skull. FRACTURES INVOLVING THE BASE. Case I. Symptoms. — "Wild delirium; high temperature; coma; haemorrhage from left ear; death in forty-eight hours. Lesions.—Laceration of both parietal lobes upon their lateral and inferior surfaces ; cortical haemorrhage. Case II. Symptoms.—Active delirium only noted; walking case. Suicide by drowning after twenty-four hours. Case III. Symptoms.—Coma, stertor, general muscular rigidity, and dilatation of left pupil; haamorrhage from right ear, and later from right nostril; left hemiplegia after twelve hours, with disappearance of earlier symptoms; urine not con- rolled ; consciousness not restored. Death in six days. Lesions.—Laceration of inferior and external surfaces of left frontal and of right temporo-sphenoidal lobes; corresponding cortical haemorrhages thinning toward base and vertex ; gen- eral hyperaemia. Case IV. Symptoms.—Semicoma, mild delirium, imperfect articulation, with slow and irregular respiration, which con- tinued for three days; paralysis of right upper extremity and of right upper and lower face, differing in degree at different times; mental condition varying from normal to one of noisy delirium ; patient usually restless and during last two days un- conscious. Temperature on admission, 101°; during first week, 100°; in second week, 99°+ ; and rose steadily from 103° to 109° through last two days. Death in forty-five days. Lesions.—Subcortical laceration beneath the site of depressed 4 THE DIFFERENTIAL DIAGNOSIS OF fracture, external to right parietal eminence; subarachnoid serous effusion ; general hyperaemia. Case V. Symptoms. — Stupor; gradual unconsciousness; delirium requiring mechanical restraint. Temperature on ad- mission, 102°; ten hours later, 105°; declined to 101-8°, and then rose steadily to 106-6°. Death in twenty-nine hours. Lesions.—Laceration of inferior surface of left frontal and of both temporo-sphenoidal lobes, and of inner border of right frontal lobe; pial haemorrhage over upper surface of both hemispheres; general hyperaemia. Case VI. Symptoms.—Stupor; incoherence; dilatation of left pupil; slight deviation of eyes to the right; second day— delirium, muscular tremor, irregular pupils, frequent and inter- mittent pulse. Temperature on admission, 103°; five hums later, 102°; and rose to 106-2°. Death in twenty-four hours. Lesions.—Laceration of inferior surface of left frontal and temporo-sphenoidal lobes. Case VII. Symptoms.—Stupor; irregular pupils: general muscular rigidity ; ataxic gait; diminished sensibility, and-loss of urinary control. On the fourth day, temperature normal, mind clear, and muscular rigidity lessened; copious serous dis charge from right ear and right facial paralysis; on the fifth day, increased muscular rigidity and recurrence of stupor ; or the sixth day, unconsciousness and frequent general convul- sions. Temperature on admis-ion, twenty four hours a:ter in- jury, 99°+; on the fourth day, normal; on the fifth day, 100°+; on the seventh day, 105°. Death on the seventh day. Lesions.—Contusion of surface of right occipital lobe pos- teriorly, with minute haemorrhages and softening; laceration of inferior surface of both frontal lobes, and of right cerebel- lum; epidural haemorrhage over both occipital lobes beneath the site of an extensive depressed fracture; cortical haemor- rhage over inferior surface of cerebellum and beneath the situ- ation of the epidural haemorrhage, where it was firmly coagu- lated and surrounded by plastic inflammatory exudation- thrombi in superior longitudinal sinus and torcular Herophili and in right lateral and inferior petrosal sinuses and jugular TRAUMATIC INTRACRANIAL LESIONS. 5 vein; subarachnoid serous effusion over parietal and occipital lobes. Case VIII. Symptoms.—Coma; stertor: muscular rigidity of both sides, most marked on the right; strong contraction of both pupils, but more marked in the left; no change in gen- eral condition till death, fifty-four hours later. Temperature on admission, 100-4°, rising progressively to 103-8°; declined post mortem. Lesions.— Laceration of anterior border of left temporo- sphenoidal lobe and of the anterior and internal borders of both frontal lobes; cortical htemorrhage covering the whole base of the brain ; subcortical laceration with clot occupying the whole interior of the left frontal and temporo-sphenoidal lobes, and filling with blood both lateral ventricles and both occipital lobes; slight epidural haemorrhage at point where fracture began in right inferior and posterior parietal region; slight subarachnoid serous effusion ; thrombus extending from torcu- lar Herophili through right occipital and inferior petrosal sinuses into the jugular vein. Case IX. Symptoms—Partial consciousness for twenty-four hours^ became complete; haemorrhage from both nostrils and from right ear; delirium on the fifth day with post-cervical muscular rigidity, restlessness, and retraction of the abdomen; Cheyne-Stokes respiration and death. Temperature for three days, 99-2°; on the fourth day, 103-2° ; on the fifth day, 104-8°. Lesions.—Laceration of anteroinferior border of left frontal lobe and of inferior surface of right cerebellum ; cortical haemor rhage covering superior and external surface of left cerebrum ; general 'hyperaemia of the left hemisphere with punctate ex- travasations. Case X. Symptoms.—Partial unconsciousness and left hemi- plegia, followed by irritability; haemorrhage from left nostril. Death in twenty-four hours. Lesions.—Epidural haemorrhage orer left temporal region beneath a separation of the coronal suture; laceration of the right frontal, right parietal about the fissure of Rolando, and ot left temporo-sphenoidal lobe. Case XL Symptoms.—Coma; stertor; pulse 70, respiration 6 THE DIFFERENTIAL DIAGNOSIS OF 7; dilatation of left pupil and contraction of right; paraplegia; haemorrhage from left ear and nose and under left conjunctiva. Death in five minutes after admission. Lesions.—Large pial haemorrhage, mainly at the base; blood still fluid; slight lacerations of inferior surface of left frontal and temporo-sphenoidal lobes; slight cortical haemorrhage from frontal laceration. Case XII. Symptoms.—Right hemiplegia; lack of control of urine and faeces; slight haemorrhage from nose and left ear; temperature on admission, 99'8°. Death in two days. Lesions.—Laceration of left parietal lobe beneath parietal eminence. Case XIII. Symptoms.—Coma; stertor; pupils, pulse, and respiration normal. Death in five days. Lesions.—Pial haemorrhage over both cerebra; laceration of inferior surface of left temporo-sphenoidal lobe. Case XIV. Symptoms.—Patient momentarily unconsi ious. then walked to the hospital in a dazed condition, and afterward walked home. Severe cephalalgia"for three hours, followed by gradual supervention of coma, which became complete in four hours. Death in eight hours. Lesions.—Large pial haemorrhage over external aspect of left frontal and parietal lobes : slight epidural haemorrhage be- neath fine linear fracture upon right side; slight contusions of brain substance. Case XV. Symptom^.—Coma; dilatation of right and con- traction of left pupil; right hemiplegia; pulse became slower and respiration more labored. Death in nine hours and a half. Lesions.—Large epidural haemorrhage from rupture of left middle meningeal artery; slight laceration of left parietal, and of lateral border of right temporo-sphenoidal lobe. Case XVI. Symptoms.—Unconsciousness followed by stu- por; slight but increasing dilatation of left pupil; slight haemor- rhage from left ear; rigidity of left side; labored respiration; later, complete left hemiplegia; temperature, 10L2°. Death in twenty-one hours. Lesions.—Laceration of inferior and lateral surfaces of right TRAUMATIC INTRACRANIAL LESIONS. 7 temporo-sphenoidal lobe and slighter lacerations of inferior sur- face of frontal lobes along the median fissure; extensive corti- cal haemorrhage over right cerebrum ; general hyperaemia. Case XVII. Symptoms.—Unconsciousness; right hemiple- gia; dilatation of right and contraction of left pupil; full and slow respiration ; normal pulse; supervention of stertor ; death in eleven hours Lesions.— Extensive epidural haemorrhage from rupture of left middle meningeal artery ; general hyperaemia, with minute coagula and punctate extravasations. Case XVIII. Symptoms.—Unconsciousness for thirty min- utes and subsequent irritability; haemorrhage from right ear; second day, somnolence, continued irritability, and lack of uri- nary control, and temperature 102°; third day, delirium, tem- perature rising to 105'4°; fourth day, moderate dilatation of the pupils, restlessness, hyperaesthesia, increase of surface tem- perature, followed by deep coma; temperature, 104°+ in the morning and 105°+ in the evening till death, at the end of the seventh day, when it rose to 106-5°. Lesions.—Deep laceration of lateral border of left temporo- sphenoidal lobe ; cortical haemorrhage over left occipito parietal region ; cavity in right parietal lobe beneath point of fracture and opening upon the surface; subarachnoid exudation of thick pus over right posterior parietal and occipital lobes and in right inferior occipital fossa; general hyperaemia and punc- tate extravasations. Case XIX. Symptoms.—Permanent unconsciousness; irrita- bility when disturbed; dilatation of both pupils, especially marked in the right; profuse haemorrhage from left ear, which continued for twenty-four hours, and was then followed by se- rous discharge ; general convulsive movements, most pronounced in the right leg; temperature, 100°; pulse, 80; single general convulsion, most violent on the left side, on the second day, and repeated on the third day ; temperature rose steadily to 107-2°. Death in three days six hours. Lesions.—Large epidural clot in left middle fossa; large and deep laceration of the lateral surface of left temporo-sphenoidal and of lateral and inferior surfaces of right temporo-sphenoidal 8 THE DIFFERENTIAL DIAGNOSIS OF lobes; small and deep laceration at right parietooccipital junc- tion ; large cortical clot in left middle fossa ; thin cortical coag- ulum over right cerebrum. Case XX. Symptoms.—Unconsciousness and muttering in- coherence when disturbed; subconjunctival haemorrhage at outer part of left eye; slight temporary rigidity of right arm; restlessness and irritability; little change till death—in seven days ten hours. Temperature on admission, 101° ; in two da? s rose to 104-8°, declined from fourth to sixth days to 101°+ t-j 102° + , and then rose progressively to 107° + . Lesions.—Subcortical laceration of left frontal lobe, com- pletely excavating and fillinrr its interior with clot and disinte- grated brain tissue and inclosed by a thin layer of cortex, except at the base, where it was covered only by the meninges; lacera- tion of anterior two thirds of external border of right cere- bellum ; extravasation of blood of the size of a robin shot in the center of the right corpus striatum ; slight cortical haemor- rhage over posterior part of the right cerebrum. Case XXI. Symptoms. — Unconsciousness and delirium; haemorrhage from mouth and nose ; mental condition in twelve hours became normal; slow pulse; labored respiration; rigid ity of arms, especially of the right; normal pupils, followed by restlessness, muttering delirium, lack of urinary control, and unconsciousness; temperature, 104-8° to 106°. Death in tweny- four hours. Lesions.—Laceration of superior surface of both frontal and both parietal lobes. Case XXII. Symptoms.—Coma; stertor; full pulse; pul- monary oedema beginning before admission; haemorrhage from right ear ; death in two hours. Lesions.—Epidural haemorrhage over both hemispheres and another of larger amount in the inferior occipital fossa? com- pressing the pons and medulla; slight lacerations of inferior surface of both frontal and right temporo-sphenoidal lobes with some cortical haemorrhage. Case XXIII. Symptoms.—Unconsciousness ; restlessness ; coma nearly complete on fourth day ; pupils, pulse, and respira- tion normal; temperature on fourth day, 102-2° ; on fifth dav TRAUMATIC INTRACRANIAL LESIONS. 9 103° to 106°; on sixth day, 107°. Death in five days and a half. Lesions.—Laceration of external surface of left frontal and left temporo-sphenoidal lobes, with consequent cortical haemorrhage. Case XXIV. Symptoms.—Unconsciousness; persistent vom- ining; haemorrhage from left ear; moderate dilatation of pupils, especially of the left; temperature, 98-7° ; second day, restora- tion of consciousness, delirium ; third day, wide dilatation of both pupils, which were only slightly responsive to light, the left continuing to be more markedly affected than the right, and this condition permanent; sixth day, mind clear but apa- thetic, followed by stupor, with paresis and anaesthesia of all the extremities, more marked on the right side; later, left foot and right hand less paretic, mind clear, but senses blunted, some right facial paralysis, cephalalgia, rapid and feeble pulse ; ninth day, delirium and recurring unconsciousness; eleventh day, patient neither .spoke nor moved, nor was conscious of pain or external irritation ; on the fifteenth day, death. Tem- perature below 100° till fourth day, when it rose to 103°, and then varied from 100° to 102° till the twelfth day, when it rose to 104°, and was afterward from 103° to 104-5°. Lesions.—General hyperaemia with minute coagula and ex- cessive oedema; slight lacerations of inferior surface of right temporo-sphenoidal lobe and one somewhat larger upon its ex- ternal surface; very moderate cortical haemorrhage extending over right occipital lobe. Case XXV. Symptoms.—Stupor; haemorrhage from right ear; lack of control of urine and faeces; condition alcoholic; second day, active delirium, muscular tremor, delusions, and in- tervals of unconsciousness ; sixth day, coma, stertor, muttering delirium, general muscular rigidity, slight contraction of right pupil, and slight right facial paralysis; eighth day, two slight convulsions involving arms, face, and eyes, followed by paraly- sis of right arm and face, and elevation of surface temperature of leftside; right side normal, left side 102°. Death on the eighth day. Temperature till fourth day, 100° to 102°; after- ward 103° to 104° till eighth day, when it rose to 105-6° and declined to 104-8°. 10 THE DIFFERENTIAL DIAGNOSIS OF Lesions.—Thin layer of pial haemorrhage, covering both parietal and both occipital lobes, and meningeal hyperaemia; large subarachnoid serous effusion; general oedema of brain substance and minute vessels filled with coagula; fluid blood in anterior cornu of left lateral ventricle ; small lacerations of su- perior and external surface of right frontal and of left occipital lobes and on either side of median fissure of cerebellum. ^ Case XXVI. Symptoms.—Vertigo and feeling of illness; haemorrhage from right ear and nostril; temperature, 100°; soon followed by haematemesis, coma, and stertor. Death in four hours. Lesions.—Epidural haemorrhage, compressing right frontal lobe laterally ; slight pial haemorrhage on either side of the an- terior columns of the medulla; extravasations into the pons in both transverse and longitudinal fibers, the largest a half by a quarter inch in diameter; general hyperaemia with punctate extravasations and coagula in the minute vessels. Case XXVII. Symptoms.—Coma; stertor; frequent weak and irregular pulse; slight haemorrhage from right nostril ; protrusion of both eyes and dilatation of both pupils, especially of the left; rigidity of right side. Death in eight to ten hours. Lesions.— Epidural haemorrhage in right occipital fossa; small laceration of inferior surface of left frontal lobe ante- riorly ; cortical haemorrhage over both froatal lobes. Case XXVIII. Symptoms.—Paresis of left lower extremity ; temperature, 98-8° ; fourth day, temperature suddenly rose to 99°+ to 102°; fifth day, delirium, temperature 105-2° to 106°; death. Lesions.—Laceration of inferior surface of left temporo- sphenoidal lobe; cortical haemorrhage, filling left middle fossa. Case XXIX. Symjitoms.—Coma; stertor; dilatation of right pupil, left invisible from ecchymosis; anaesthesia followed by paralysis of right upper extremity ; pulmonary oedema ; second day, urinary control lost, mind clear, pupils normal, motor and sensory function restored ; fifth day, gradual increase of tem- perature, subconjunctival haemorrhage noted ; sixth and seventh days, mental condition apathetic, subconjunctival haemorrhage increased; eighth day, sudden unconsciousness, and on the TRAUMATIC INTRACRANIAL LESIONS. H ninth day, death. Temperature on admission, 101-6° ; fifth day, 103° ; sixth day gradually declined to 100° ; eighth day, 104-8°, and rapid decline to 102-8° ; ninth day, 106°. Lesions.—Subcortical laceration, disintegrating and filling with clot the interior of both frontal lobts; on left side the median surface ruptured through the arm center and gyrus fornicatus, and the lateral ventricle invaded ; deep laceration of external border of left cerebellum ; internal brain structure softened and reddened in patches of limited contusion. Case XXX. Symptoms.—Unconsciousness which continued till death; slight haemorrhage from both nostrils; left pupil dilated; right contracted; loss of control of urine and fa>ces; face flushed; on the last day of life general sensation markedly diminished. Temperature on admission, 101°; till next day 101° + , then rose progressively to 106-8°. Death in three daT-s and a half. Lesions.—Deep and wide laceration across inferior surface of left cerebellum ; laceration excavating inferior surface of right frontal, extending into temporo-sphenoidal, lobe; laceration of middle portion of gyrus fornicatus, half an inch in diameter ; anterior fossae filled with firm clot, three fluidounces by meas- urement ; cortical haemorrhage in right posterior fossa around foramen magnum, and also over right frontal lobe; general contusion of both hemispheres, most marked posteriorly. Case XXXI. Symptoms.—Brief unconsciousness, which re- curred in the ambulance; in the interval no evidence of serious injury; on admission, pupils contracted, sudden cyanosis, and death in twenty-five minutes. Lesions.—Epidural haemorrhage over left occipital lobe ; pial haemorrhage in inferior occipital fossae, compressing the me- dulla ; cortical haemorrhage over both frontal and both temporo- sphenoidal lobes from laceration of their inferior surfaces. Case XXXII. Symptoms.—Primary: Consciousness re- tained; haemorrhage from right ear; no general symptoms; temperature, 100-4°, and afterward normal. Secondary : On the twentieth day, some lethargy and frontal headache; twenty- third day, severe frontal headache, delirium, somnolence, and left hemiplegia; twenty-fourth day, complete left hemiplegia 12 THE DIFFERENTIAL DIAGNOSIS OF and hemianaesthesia, insensibility of both pupils, continued som- nolence, normal mental condition when roused, temperature 98-5°, pulse 56, cicatrix of wound firm and uninflamed ; twenty- fifth day, patient roused with difficulty, action of bladder and rectum unconscious and involuntary, temperature 100*2°; oper- ation and evacuation of pus, one to two drachms, from subcortical abscess, beneath the angular gyrus. Temperature rose to 108°, and death occurred sixteen hours later. In the interval between the primary and secondary symp- toms there was posterior cervical glandular enlargement, with some constitutional reaction. Lesions.—Subcortical abscess cavity, which had been evacu ated during life. No superficial laceration or haemorrhage. Case XXXIII. Symptoms.—Unconsciousness, which contin- ued till death; haemorrhage from left ear; dilatation of both pupils, and subsequent contraction of the right; muscular relax- ation, followed by later rigidity; temperature on admission, 99-6° ; afterward 99'6° to 100-4° ; an hour post mortem. 101-2°. Death in twelve* hours. Lesions.—Deep laceration of posterior portion and inferior surface of left temporo-sphenoidal lobe, with consequent cort cal haemorrhage over occipital lobe; excessive cerebral hyperaemia. Case XXXIV. Symptoms.—Coma; stertor; loss of urinary control; haemorrhage from nose and later haematemesis ; pul-e, 96 and full; respiration, 18; temperature. 100°, rising gradu- ally to 102-6° some time before death, in fourteen hours after admission. Lesions.—Small epidural haemorrhage at site of fracture; rupture of dura; corresponding laceration in anterior inferior parietal region; laceration of anterior halt of right middle tem- poral convolution; small laceration in center of left cerebellum filled with fluid blood; general hyperaemia, most marked on left side posteriorly. Case XXXV. Symptoms.—Unconsciousness ; contraction of both pupils; rigidity of both lower and of right upper extremi- ties; pulse and respiration too rapid to be counted ; tempera- ture, 101°, and in articulo mortis, 100-4°. Death in two hours Temperature two hours post mortem, 99° + . TRAUMATIC INTRACRANIAL LESIONS. 13 Lesions.—Pial haemorrhage ovei» left frontal and parietal lobes, superiorly and externally, and over region of* right oc- cipito-parietal junction; subcortical laceration of left corpus striatum at junction of middle and posterior thirds; excessive general hyperaemia. Case XXXVI. Symptoms.—Coma; stertor; alcoholic condi- tion; no superficial injury ; muscular relaxation ; face flushed ; pupils slightly contracted; vomiting; temperature, 97°, contin- ued to be subnormal; pulse, 60; respiration, 16; one general convulsion just before death, at the end of eight hours and a half. Lesions.—Fracture through left occipital, parietal, and squa- mous portion of temporal bone to margin of petrous portion; laceration of inferior surface of right frontal lobe and both temporo-sphenoidal lobes; pial haemorrhage over whole right parietal region. Case XXXVII. Symptoms.—Consciousness lost but regained before admission after suicidal pistol-shot wound of the head ; total loss of vision; exophthalmia of both eyes; dilatation of both pupils, which were irresponsive to light; temperature, 100-2° ; pulse, 60; respiration, 20. Ophthalmic examination by Dr. P. A. Callan on the second day disclosed ODly patches of reti- nal haemorrhage ; mental condition unimpaired; sense of smell entirely lost. On the fourth day an unsuccessful attempt was made to extract the ball, and a drainage-tube was afterward car- ried from the foyer of entrance through both frontal lobes to a cranial opening made upon the opposite side ; followed for five days by discharge of brain tissue, and then till death by pus in increasing quantity. Mental condition normal till the fifth day, sluggish till ninth day, and afterward marked by increasing de- lirium, which lapsed into a muttering stupor at the end of life on the thirteenth day. Temperature at time of operation, 99°; rose to 103-6° in ensuing twenty-four hours, and then varied from 102-4" to 1045° on the last day; pulse and respiration nearly normal till just before death. Lesions.—Ball penetrated external wall of the right orbit, just behind the external angular process; passed beneath optic nerve, comminuted inner wall of the orbit, crista galli, cribriform 14 THE DIFFERENTIAL DIAGNOSIS OF plate, and lesser wing of the sphenoid ; entered left orbit through inner wall, and was found beneath left optic nerve. In the cranial cavity its course was beneath both optic nerves. Sub- arachnoid purulent effusion covered both frontal lobes, more copious on the left side and at the base; left frontal lobe was excavated and filled with pus and brain detritus; pus also exist- ed in the tract of the drainage-tube through the right frontal lobe. I am indebted to a colleague for the opportunity of observ- ing this case. Case XXXVIII. Symptoms.—The patient, after having passed through three hospitals, with three discharges and two transfers, and after having wandered about the streets and suf- fered much exposure, was finally received and allowed to re- main in an asylum for the insane on the eighth day after a fall from the stoop of her house. She had then delusions and other symptoms of mental derangement, left facial paralysis, left sub-" conjunctival haemorrhage, and haemorrhage from both ears. She died on the twenty-fourth day from the reception of the injury. Lesions.—Transverse fracture of the base, extending through both petrous portions and left orbital plate; laceration of in- ferior surface of left frontal lobe; small subcortical laceration of left parietal lobe ; cortical haemorrhage at base and over the external surface of both hemispheres; general contusion. Case XXXIX. Symptoms.—Profound coma, which contin- ued till death ; stertor; pulse, 70, full and strong; temperature, 99-4°. Death in seven hours. Lesions.—Linear fracture through right side of the occipital bone to jugular foramen ; pial haemorrhage over both occipital and posterior portion of left parietal lobes; excessive general hyperaemia. Case XL. Symptoms.—Contusion of left parietal region ; primary unconsciousness; epistaxis; delirium, which continued till admission to hospital two days later; unconsciousness at that time; pupils normal; pulse rapid and weak; respiration 21 ; temperature, 101-4°, rose to 102°+ ; consciousness not re- stored. Death in four days. TRAUMATIC INTRACRANIAL LESIONS. 15 Lesions.—Linear fracture of occipital bone from tuber to right jugular foramen; also fissure of left orbital plate; throm- bosis of lateral sinuses; clot firm, but not decolorized; general hyperaemia, with a few minute coagula. Case XLl. Symptoms.—Unconsciousness succeeding an in- jury received on the preceding day; admission to hospital after twenty-four hours; right pupil slightly dilated; temperature, 99-8°; pulse, 96; respiration, 24; temperature rose to 100-2°. Death in about thirty hours from time of injury. Lesions. — Linear fracture running nearly transversely through left parietal bone into right coronal suture; also V- shaped fracture from contre-coup in right middle fossa; epi- dural haemorrhage over right frontal lobe from vertex to base; laceration of middle two fourths of second right temporal con- volution, with cortical haemorrhage extending over parietal lobe; general hyperaemia with minute coagula in all parts of the brain. Case XLII. Symptoms.—Shock; consciousness retained ; temperature, 96°; pulse, 78; respiration, 21; sudden cyanosis, with extreme dyspnoea, and loss of consciousness which lasted for only three or four minutes, followed by numbness of both arms; no further dyspnoea; delirium fourteen hours later, and death four hours later still, preceded by a single convulsive movement and without respiratory disturbance. Lesions.—Occipital contusion and wound behind right ear; bifurcated linear fracture in right inferior occipital fossa; pial haemorrhage beneath tentorium, extending around lateral bor- ders of cerebellum and covering the pons. Moderate general hyperaemia. Case XLIII. Symptoms.—Scalp wounds in left parietal and large haematoma in right parietal region; compound linear left parietal fracture; no known loss of consciousness; shock ; dila- tation of both pupils; pulse feeble; respiration shallow; tem- perature after four hours, 96-4°. Death in nine hours and a half. Lesions.—Parietal fissure extended nearly across greater wing of sphenoid; considerable subarachnoid serous effusion ; general hyperaemia and thrombosis of minute vessels, most marked posteriorly. If) THE DIFFERENTIAL DIAGNOSIS OF Case XLIV. Symptom*.—Unconsciousness till death ; pupils normal; muscular twitchings over whole right side of the body; temperature on admission, 98°; in six hours, 103-6°; in seven hours, 104-4°; in nine hours, 106-6°; pulse, 80 to 145; respiration, 15 to 34. Death in nine hours and a half. Lesions.—Calvarium crushed ; large wound in the skull at the vertex involving the median line, two by three inches in its diameters; on the left side the osseous fragments rested upon the dura, on the right they deeply penetrated the brain ; a fissure extended into the right orbital plate; epidural clot on the left side in which the parietal fragments were imbedded ; on the right side, disintegrated brain tissue, bone, and mem- branes were commingled; anterior part of both lateral ventri- cles contained blood ; cortical haemorrhage, extended beneath the tentorium ; general hyperaemia and vessels even of larger size filled with thrombi. Case XLV. Symptoms.—Scalp wound in left frontal region ; left pupil dilated; consciousness only partially lost; tempera ture on admission, 98°; fell in four hours to 97'6°; pulse, 90; respiration, 24. Death in four hours and a half. Lesions.— Slight depression at left external angular process of frontal bone and fissure, extending thence through both or- bital plates and intervening ethmoid body; deep laceration of frontal lobes on either side of inferior median fissure; smaller laceration of posterior border of cerebellum, near median line, from which a cortical haemorrhage extended over both its su- perior and inferior surfaces ; general hyperaemia and minute coagula. Case XLVI. Symptoms.—Haematoma over whole vertex, and small wound of the scalp ; unconsciousness which con- tinued till death ; dilatation of left pupil; general convulsions beginning in the hands, with marked opisthotonos ; temperature six hours after reception of injury, !'8-6c; pulse, 84; respira- tion, 28; extent of fracture determined by incision. Death in nine hours. Lesions.—Disjunction of coronal s-uture, multiple fissure of frontal bone, and fissure through right parietal and occipital bones, with branch into posterior fossa; laceration of ri^ht TRAUMATIC INTRACRANIAL LESIONS. 17 frontal, parietal, and occipital lobes, and wound of dura per- mitting escape of brain tissue through the osseous parietal opening. Case XLVII. Symptoms.—Contusions of left side of head and face and tactile evidence of simple fractures; unconscious- ness which continued till death; epistaxis and luematemesis; temperature on admission, 99° ; pulse, 96 ; two hours later— temperature, 96-4°; pulse, 140; respiration, 53; five hours later—temperature, 95 6°; pulse and respiration as before; second day, deglutition became possible and sensitiveness to ex- ternal impressions was regained ; pupils slightly dilated; tem- perature, 103° to 103 6° ; pulse, 168 to 196; respiration, 48 to 58. Death in thirty-four hours. (In this, the case of a child, four years and a half of age, the brain weighed forty-eight ounces, and was in all respects symmetrical; the skull was of normal thickness.) Lesions.—Separation of the coronal and of the bifrontal su- ture to nasal bones, which were fractured; fracture continuous into ethmoid body, with complete detachment of the crista galli and cribriform plate; fissure of right parietal bone and de- pressed fracture of left frontal above orbital ridge; slight epi- dural haemorrhage over the vertex; laceration of frontal lobes in the space corresponding to the site of cribriform plate; gen- eral hyperaemia with minute coagula, most marked in cerebel- lum and occipital lobes. Case XLVIII. Symptoms.—None discovered, and admission to hospital refused two days after a fall in the street; found dead two hours later a block away ; wound over left eye. Lesions.—Pneumonia involving lower lobe of right lung, and large, flabby heart; fracture extending through left supra- orbital ridge and orbital plate into greater wing of sphenoid bone; general hyperaemia and thrombosis. Case XLIX. Symptoms.—Large haematoma over right eye; profuse haemorrhage from mouth, nose, and right ear; uncon- sciousness; rapid and feeble pulse and respiration; dilatation of both pupils, especially the left. Death in fifteen minutes. (Caesarean section at six months and a half; child lived forty- five minutes.) 2 18 THE DIFFERENTIAL DIAGNOSIS OF Zmwtm.—Separation of right sutura additamentum lamb- doidalis and fissure continued, through petrous portion and middle fossa, into body of sphenoid bone; large pial haemor- rhage over left parieto-occipital region. Case L. Symptoms.—Wounds over left eye and at the occi- put; shock; unconsciousness; haemorrhage from ears, nose, and mouth; restlessness, and utterance of short, sharp cries; pulse frequent, weak, and symmetrical; respiration slow, irregular, and sighing; right pupil dilated, left invisible from ecchymosis; twitching of right side of face, followed by gen- eral convulsions, preceded death at end of twelve hours. Lesions discovered by incisions: In left temporal region fis- sures ran into temporal fossa, and squamous suture was par- tially disrupted ; in occipital region open fissure ran into right petrous portion and lauibdoid suture was separated ; arachnoid haemorrhage in right occipito-parietal region. Case LI. Symptoms.—Scalp wounds in parietal regions; mo- biliiy and crepitation of calvarium; shock; unconsciousness which continued till death ; slight epistaxis and profuse haematemesis; both pupils dilated, and after three hours and a half the right more so than the left; one radial pulse fuller and stronger than the other; temperature on admission, 101°; in one hour, 102° ; in two hours, 106° ; in four hours, 106-8° ; pulse, 70, 110, 160, 170; respiration in two hours, 48. Death in four hours and a half. Lesions.—Fissure, beginning just above left internal angu- lar process, running across middle of parietal bones, and nearly circumscribing the calvarium; another detached its posterior portion, and others still extended from the primary line of fracture to the base; arachnoid haemorrhage on the left side; further examination refused. Case LII. Symptoms.—Contusion in left frontal region and ecchymosis of left eye; consciousness retained ; haemorrhage from right ear and from nose and mouth ; delirium, becoming violent later in the day and during the night; on the second day, the patient formed a fixed delusion that he had fallen from a mulberry tree. He described with circumstantiality all the details of his imaginary accident. He had no recollection of TRAUMATIC INTRACRANIAL LESIONS. J 9 the manner in which his injury had really occurred, and would give no credence to facts as they were presented to him ; he had other and transitory delusions, but this one remained unal- terable. Both pupils were moderately and symmetrically di- lated. His mind became remarkably alert, and his conversa- tion was logical and coherent. Nine days later haemorrhage from the right ear recurred, subconjunctival haemorrhage, which had been previously noted, increased, and the left eye became prominent. Mechanical restraint was still necessary to keep him in bed. On the twelfth day, haemorrhage from the ear ceased, and subconjunctival haemorrhage diminished; a scarce- ly perceptible facial paralysis existed. His mind seemed clearer; he could recollect the street and neighborhood in which he lived, but not the number of his house; only the one delusion persisted. Later, a frontal headache from which he had constantly suffered became less urgent; but his general condition was not materially changed till two days before his death, when he became progressively asthenic from an intercurrent diarrhoea. His mind remained clear with occa- sional transient delusions, his conversation coherent, and his belief in the mulberry tree unshaken to the last. Temperature on admission was 986°; one hour later, 100°; and five hours later, 104-7° ; for the two days following it was 103° to 103-8° ; and during the fourth and fifth days, 101° to 99°+ ; it varied till the twentieth day from 99-8° to 101-8°, only twice exceeding 100°. The pulse on admission was 85, and the respiration 20, with no considerable subsequent changes till near the close of life. Thirty-six hours ante mortem temperature rose to 102-4°, and twelve hours later to 105°; in another twelve hours it de- clined to 975°, and immediately before death rose again to 100°, with pulse 140, and respiration 42. Death on the twenty-fourth day. Lesions.—Depressed fracture above left supraorbital ridge with fissure extending across both orbital plates and interven- ing cribriform plate, through right middle fossa, external to greater wing of sphenoid, through outer part of petrous por- tion of temporal into posterior fossa, and returning upon it- self across the petrous portion and through the body of the 20 THE DIFFERENTIAL DIAGNOSIS OF sphenoid and ethmoid to finally terminate in itself anteriorly. A second fissure crossed the left orbital plate into the left mid- dle fossa. Small epidural haemorrhage beneath the depressed part of the fracture; laceration of under surface of both frontal lobes, mainly subcortical, crossing median line obliquely from center of left lobe to line of right anterior cerebral artery. This laceration was an inch and a quarter wide by an inch in depth at its commencement on the left side, and on the right side was five eighths of an inch in width by half an inch in depth. In removing the brain the arachnoid was torn and the diffluent contents of the cavity escaped; its margin and the overhanging cortical tissue were dark and sloughy; its deeper portion was yellow and ragged; it was separated anteriorly on the left side from the median fissure by a single convolution. There were general hyperaemia and minute thromboses, most marked posteriorly. Case LIII. Symptoms.—Haematoma in left parietal region ; coma ; stertor; no response to external irritation ; pupils wide- ly dilated; pulse full, slow, and strong; temperature on admis- sion, 99°, and rose steadily to 107-8° ; respiration, 32, 46, 14; pulse, 62, 70, 126. Death in four hours and three quarters. Lesions.—Coronal suture separated and fracture continued into anterior part of middle fossa on both sides ; general hyper- aemia with well-marked but not excessive oedema, and some punctate extravasations. Case LIV. Symptoms.—Consciousness lost but partially re- stored on arrival of ambulance; large haematoma in right pos- terior occipital region; slight epistaxis; pupils moderately con- tracted; respiration shallow ; right radial pulse after two hours more frequent than the left—84 and 74, 114 and 110; tempera- ture on admission, 96° ; in two hours, 95° ; in six hours normal, and rose to 100-4° before death in nine hours. Lesions.—Separation of coronal suture on the left side and fracture continued through middle fossa, sella turcica riht contraction of the left; no motor or sensory disturbances* left brachial pulsation full and strong, the right very small and weak; same conditions existed in the radial arteries but the contrast somewhat obscured by contusion of the left wrist* temperature on admission, 98°; four hours later, 104*6° • imme- TRAUMATIC INTRACRANIAL LESIONS. 29 dlately after death, 105°; half an hour post mortem, 105-4° ; pulse, 40 to 64; respiration, 32 to 36; cyanotic just before death, at the end of five hours. Lesions.—Contusion of scalp, disclosed by incision, extending from coronal suture backward above the temporal ridge; frac- ture in right middle fossa, involving both squamous porticm of temporal and greater wing of the sphenoid bone; firm epidu-al clot from laceration of anterior branch of the arteria meningea media, measuring three fluidounces, which filled the right middle fossa and flattened the temporal lobe laterally and interiorly. When the clot was removed the brain retained its position, widely separated from the base, and leaving the anterior petrous sur- face and the adjacent middle fossa exposed. The smaller superfi- cial veins and arterioles of the brain were congested and the surface between them, at first pale, was soon uniformly red- dened. There was a small laceration of the posterior part of the third left temporal convolution: another somewhat smaller than a buckshot was found in the anterior part of the pons at the apposition of the longitudinal fibers. The brain substance was generally hyperaemic, especially in the left hemisphere, but without minute extravasations or thrombi. The surfaces of section soon became deeply reddened and bathed in watery effusion. Case LXVIII. Symptoms.—Partial unconsciousness ; recur- rent haemorrhage from right ear, succeeded by a flow of serous fluid; vomiting; dilatation of both pupils; retention of urine; greater fullness and strength of left radial pulse than of the right; mental condition normal; intercurrent bronchitis on the third day, which ran its usual course; from the second day a peculiar dusky and swollen appearance of the face, which con- tinued till within two or three days of death; no other indica- tions of cerebral injury till the fourteenth day, when there was occipital pain, which became general headache, and a little later somnolence and occasional irritability. On the eighteenth day, the fifth of this epoch, posterior cervical rigidity; delirium ; temperature at its maximum; tenderness along the course of the larger nerves of the left lower extremity from the twentieth to the twenty-fifth days; delirium more active, lucid intervals 30 THE DIFFERENTIAL DIAGNOSIS OF less frequent, somnolence more continuous, and sense of hear- ing impaired; deafness progressive till complete power of artic- ulation gradually lost, and finally communication only possible by gesture; dysphagia occurred more suddenly and a little later. The mental condition varied from normal to that of stupor or delirium ; emaciation was progressive ; paralysis and hyperaesthesia of the left lower extremity were of late occur- rence; recurrence of posterior cervical rigidity was onoe noted, but was transitory; toward the end control of urine and faeces was lost; during the last twelve hours unconsciousness was complete, and respiration rapid, insufficient, and entirely nasal. Death occurred on the thirty-first day. The temperature on admission was 97°, became normal in four hours, and was after- ward 99° till the invasion of bronchitis, on the third day, when it rose to 103°, and subsided with recovery from the complica tion. On the tenth day it again rose with the recurrence of intracranial symptoms to 103*4°, and afterward varied from 100° to 104°, and was not often less than 101° + . The post-mortem temperature receded in half an hour from 103*4° to 103°. 1 he axillary temperatures, carefully recorded from the sixth day, were symmetrical in nearly half the observations, and in the oth- ers usually varied two tenths of a degree, and were rather more frequently higher on the right side. The pulse was usually from 64 to 90. The respiration, always frequent, was rarely less than 30 in the minute from the time of admission. Lesions.—No external injury; linear fracture extending from squamous, through petrous portion of right temporal bone ; simple thrombosis of lateral sinuses from torcular Herophili into jugular veins; punctate extravasations in pia mater; large occipital veins distended; no serous effusion at the vertex ; but patches of false membrane mainly upon left frontal lobe, and upon either side of'the median fissure. Several ounces of turbid serous effusion at the base, and a large amount in the lateral ventricles; fibrinous exudation covering the pons, medulla, and inferior surface of the cerebellum one to two millimetres in thickness, and in the Sylvian fissures • limited contusion of posterior part of the surface of the right temporo- sphenoidal lobe, covering a space an inch square, which was of TRAUMATIC INTRACRANIAL LESIONS. 31 a yellowish color and studded with hard miliary haemorrhages; fornix much softened, and brain substance generally hyper-. aemic and oedematons. Immediate microscopic examination showed the membra- nous effusion to be crowded with small round cells which ex- tended for some distance in diminishing quantity into the sub- stance of the underlying cerebellum. Other portions of the brain tissue were unchanged. The Strejitoeoccus pyogenes was developed from cultures of the exudation. Case LXIX. Symptoms.—Consciousness lost, but restored at time of admission; haematoma over right frontal region; vomiting; severe frontal headache; face flushed; pupils nor- mal ; temperature, 95° ; pulse, 90 ; respiration, 20. One hour later, wide dilatation of right pupil, and right cornea more sensitive than the left; sudden unconsciousness, followed by rigidity of the left side, and convulsive movements of the right. At the end of an hour and a half, temperature, 97°; pulse, 85, and Cheyne-Stokes respiration. Death in three hours from time of injury. Lesions.—Linear fracture in squamous portion of right tem- poral, continued through anterior part of middle fossa, and ter- minated in the body of sphenoid bone; large epidural haemor- rhage over lateral surface of the right hemisphere nearly to the median fissure; blood partially coagulated and derived from posterior division of the arteria meningea media ; surface of the right temporal and anterior part of the right occipital lobe somewhat flattened; slight contusion of left second tem- poral convolution ; brain moderately hyperaeinic and oedem- atous. Case LXX. Symptoms. — Gunshot wound, immediate uncon- sciousness; rapid and feeble pulse; sighing respiration ; profuse haemorrhage from wound- of entrance and exit. Death within an hour. Lesions.—Gunshot fracture of right frontal bone through temporal fossa; ball grazed the outer and posterior part of the orbital plate and fractured the right lesser wing of the sphenoid, grooved the inferior surface of both frontal lobes just anterior to the fissures of Sylvius, destroying the cortex and subcortex 32 THE DIFFERENTIAL DIAGNOSIS OF for a space three fourths of an inch in width, and emerged through the left temporal fossa at a little higher level than the point of entrance. The vertex and base were fissured from the point of exit, and the coronal and biparietal sutures divulsed and widely separated. The whole surface of the brain was covered by a thin subarachnoid haemorrhage which was partly cortical and partly pial. The brain substance generally was markedly hyperaemic and its minute vessels filled with coagula. The corpora striata and optic thalami, especially the striata, were much contused, their substance studded with punctate extravasations, and their vessels distended with thrombi. The pons, medulla, and cerebellum were but slightly altered. Case LXXI. Symptoms.—Coma; stertor; pulse strong and irregular; respiration slow; slight dilatation of both pupils, which were insensitive; slight twitching of both arms; ex- tremities cold; no external evidence of injury; temperature, 94*2° to 101*2° ; respiration, 24, 20, 14 ; pulse, 42 to 52. Death in eleven hours. Lesions.— Linear fracture extended from just above and be- hind right ear into the posterior inferior fossa ; enormous epi- dural haemorrhage, derived from the posterior division of the middle meningeal artery, which compressed the right hemi- sphere ; slight laceration of the right parietal lobe, posterior to the fissure of Rolando. Case LXXII. Symptoms.—Unconsciousness, which contin- ued till death; contusions and superficial wounds of the left side of the face and temporal region ; dilatation of both pupils. of the right more than of the left; haemorrhage from mouth, nose, and right ear; relaxed muscles, and imperceptible pulse at the wrist. Death occurred five minutes after admission, and in about an hour after reception of injury. Lesions.—Haematoma over left temporal, both parietal, and right occipital regions, from rupture of the intracranial vessels; calvarium crushed on the left side anteriorly, and its fragments deeply depressed and distorted ; zygoma and both orbital plates comminuted; body of the sphenoid bone disintegrated, and the base of the skull extensively fissured; thin pial haemorrhage covered the entire brain, possibly augmented by some cortical TRAUMATIC INTRACRANIAL LESIONS. 33 effusion at the base; limited contusions confined to the cortex about the right parieto-frontal junction and along the right side of the median fissure ; cortical lacerations upon the inferior surface of the left frontal lobe and at the tip of the left tem- poro-sphenoidal lobe; brain substance generally hypersemic and oedematous, with a few punctate extravasations. Case LXXIIf. Symptoms.—Patient was fund in the early morning, sitting in a chair, in which he was said to have passed the night. He would not reply to questions, from seeming lack of comprehension. He could w7alk, though he had little control over his limbs; his face was pale and showed traces of vomiting. On admission, there was partial consciousness, right hemiplegia and hemianaesthesia; dilatation of left pupil and contraction of the right; loss of control of urine and faeces; profuse serous discharge from both ears, and slight oedema of the lungs. Two hours later coma was complete and oedema of the lungs had increased. Death occurred in ten hours. Tem- perature on admission, 99-2°; in two hours, 101*2°; in four hours, 103°; in six hours, 103-4° ; in nine hours, 103*8° ; in ten hours, when in articulo mortis, 104° ; thirty minutes post mor- tem, 106°. The right axillary temperature was 0*2° higher than the left at each observation. Pulse, 90 to 108 ; respiration, 36, 30, 38. Lesions.—Slight haematoma over right parietal region dis- closed by incision; fracture extending from right of occipital tuber, across petrous portion, into greater wing of sphenoid ; opacity of arachnoid in right frontal and anterior parietal re- gions; small cortical haemorrhage over frontal lobes; extensive laceration of the frontal, temporal, and inferior portion of parietal lobes on the left side; these parts were excavated and filled with a dark solid clot which was extruded in large quan- tity through a long tear made in the process of removal of the brain from the cranial cavity ; slight ante-mortem cortical rup- ture through which a little blood had escaped into the middle fossa and ascended upon the frontal region, and another into the posterior cornu of the lateral ventricle, through which the chorioid plexus was infiltrated; small, deep laceration upon the anterior border of the left cerebellum ; moderate general hyper- 2 3i THE DIFFERENTIAL DIAGNOSIS OF aemia and marked oedema, with a few punctate extravasations; thrombi in the superior longitudinal and lateral sinuses. Case LXXIV. Symptoms.—Pistol-shot wound through right temporal fossa; cutaneous opening small and circular; con- sciousness permanently lost; pupils dilated, the right slightly the larger; left corneal reflex absent; urine retained; some pulmonary oedema; temperature on admission, 96*4°, and from 96-8° to 96° for five hours, then declined to 95 6° ; pulse on ad- mission, 85, subsequently from 94 to 80 ; respiration on admis- sion 14, for an hour and a half 12, in two hours and a half 10, in three hours 8, in four hours and a half 6, in five hours 4, and in articulo mortis, a few moments later, 2. Cardiac action con- tinued three minutes after respiration ceased. Lesions.—Ball entered the cranial cavity, severing the trunk of the middle meningeal artery, passed through the third right temporal convolution, and was lodged in the posterior part of the inner border of the right temporo-sphenoidal lobe. A small piece of bone, driven in advance of the ball, was found between the right lateral columns of the medulla. A large arachnoid clot, probably in part epidural and in part cortical, filled the middle fossa, spread over the whole right hemisphere, and thickly cov- ered the pons and medulla. Hyperaemia of the right hemi- sphere and basic ganglia was of considerable intensity. Case LXXV. Symptoms.—Fell down a flight of stairs; still unconscious on admission ; wound in left occipito parietal re- gion ; haemorrhage from left ear; right pupil irresponsive and widely dilated, left pupil moderately dilated ; muscular system relaxed ; temperature on admission 95° and in an hour normal; rose progressively to 104 2°; right axillary temperature uni- formly from 0*2° to 0*4° higher than the left till the last ob- servation, when the difference was 2°; respiration 22 to 24; pulse on admission 72, irregular and intermittent, and afterward 78 to 86 till immediately before death, which occurred in eight hours and a half. Lesions.—Fracture which extended from the left inferior occipital curved line through petrous portion into sella turcica- laceration, two inches long by au inch wide, of t!i6 inferior sur. face of the left temporo-sphenoidal lobe; another, half an inch TRAUMATIC INTRACRANIAL LESIONS. 35 in diameter, at the anterior extremity of the first left temporal convolution; and a third upon the inferior surface of the right frontal lobe, which involved its anterior half; cortical haemor- rhage filled right anterior and both middle fossae, covered the right hemisphere laterally, and extended as a thick clot over the right frontal lobe and along the corpus callosum quite to the cerebellum; some small extravasations in the substance of the pons; general hyperaemia and punctate extravasations in the anterior and posterior portions of the brain. Case LXXVI. Symptoms.—Coma ; stertor ; left pupil di- lated ; small wound and larger haematoma in left parietal re- gion ; sensation diminished in both lower extremities and mus- cular twitching in the right; vomiting; pulse 52. After trephination a soft epidural clot was discovered and a consider- able loss of blood ensued. Using as a guide a fissure which ex- tended through the squamous and petrous portions into the middle fossa, the bone was chiseled and the posterior division of the middle meningeal artery, which was found to be the source of haemorrhage, was clamped. The pulse increased in frequency to 72 to 104, the pupils became normal, but conscious- ness was not restored, and death occurred a few hours later. Lesions as above. Case LXXVII. Symptoms.—Unconsciousness and death im- mediately after admission. Lesions.—Skull crushed and flattened on right side; frag- ments very movable; comminuted on the left side; extensive laceration of the brain posteriorly in the left hemisphere ; only small superficial wounds of the scalp. Case LXXV1II. Symptoms.—Coma ; stertor ; haemorrhage from left ear ; contusion of left parietal region ; pupils dilated ; pulse full and slow ; temperature on admission 98°, and rose progressively to 103-6° at time of death in four hours; no de- crease for one hour post mortem ; respiration 18 to 26 ; pulse on admission 70 and rose to 90. Lesions.—Fissure extended from left parietal eminence, through squamous and petrous portions into middle fossa ; deep laceration of inferior surface of right temporo-sphenoidal lobe and of lateral border of right cerebellum ; cortical haemor- 36 THE DIFFERENTIAL DIAGNOSIS OF rhage filled right middle fossa; hyperaemia of the right side of brain. Case LXXIX. Symptoms.—Consciousness lost and not re- gained ; coma grew more profound; slight oedema of scalp in right temporal region; pupils slightly dilated; great restlessness and irritability; lack of urinary control; temperature on ad- mission 100*4° and rose to 108°, with only two or three brief fractional recessions; pulse, 94, 58, 80; respiration, 28 to 24. Death in forty-three hours. Lesions.—Haematoma over whole right side of the head; linear fracture from right frontal through parietal bone into the inferior occipital fossa ; large epidural clot over the whole base on the right side, extending upward over the lateral surface of the brain; laceration of the inferior surface of both temporo- sphenoidal and both occipital lobes; laceration of the inferior surface of both frontal lobes in their anterior portion, very ex- tensive on .the left side; cortical haemorrhage over posterior border of the cerebellum; extensive general hyperaemia with punctate extravasations. Case LXXX. Symptoms.—None ; patient found dead. Lesions.—Large lacerated pistol-shot wound in right tem- poral region; temporal muscles burned and disintegrated for some distance from the cutaneous opening. The ball passed through both frontal lobes, comminuted both orbital and inter- vening cribriform plates, and emerged through left temporal fossa. The calvarium was separated from the supraorbital ridges and broken into large loose fragments in its anterior portion. Case LXXXI. Symptoms. — Large haematoma over left frontal region ; epistaxis and haematemesis; simple fissure from left frontal eminence into the orbital plate disclosed by incision. On the sixth day, muscular twitching of the whole right side, including the extremities, but not the face, which ceased en- tirely in fourteen hours and was followed by left hemiplegia and hemianaesthesia. On the seventh day a convulsion con- fined for thirty minutes to the right side but afterward becom- ing general, occurred two hours before death. Temperature on admission was 100-2°, rose to 104*4° on the same day, and to TRAUMATIC INTRACRANIAL LESIONS. 37 105*6° on the next, with recessions, and afterward varied from 102° to 105-2°, with no observation for six hours ante mortem. Pulse on admission was 120, and subsequently 130 to 152. Respiration 26 on admission, and later 44 to 58. Lesions.—Fracture extended from the orbit through pos- terior part of the ethmoid and body and right lesser wing of the sphenoid into the floor of the right middle fossa; general subarachnoid purulent effusion most marked in the left frontal region below the site of fracture. Case LXXXII. Symptoms. — Conscious on admission; Cheyne-Stokes respiration; dilatation of left pupil; right radial pulse fuller and stronger than the left; haematoma on the right side of the head anterior to the occipital junction, and small lacerated wounds over both frontal eminences; muscular con- tractions of left side, and later of both sides of the body. On admission, temperature, 99*3° ; pulse, 104, and respiration, 19. Lesions. — Multiple fracture; fissure across frontal bone above the orbits, extending on either side through the parietal bone to the median line of the vertex on both sides, thence to the occiput, and on the right side behind the ear to within an inch of the foramen magnum; another fissure on the left side extended through the orbital plate of the frontal and lesser wing of the sphenoid into the middle fossa. The dura and pia were lacerated from right mastoid region to a point just beyond the median line. The right motor area was extensively lacer- ated, and the right optic thalamus and corpus striatum to a lesser extent. The left hemisphere was uninjured. Case LXXXIII. Symptoms.—Suicidal gunshot wound; ball entered just below right ear and in front of the mastoid pro- cess, and was lodged in the petrous portion of the temporal bone; removed on the following day; delirium and rise of tem- perature on the sixth day, flexion of the right leg on the thigh on the eighth day, and death on the fourteenth day. Lesions.—Fracture of anterior surface of the right petrous portion, epidural and arachnoid haemorrhage at that point, pial haemorrhage over left occipital lobe and left motor area, and laceration of the temporo-sphenoidal lobe at the site of fracture. 38 THE DIFFERENTIAL DIAGNOSIS OF Case LXXXIV. Symptoms.—Suicidal wound through the anterior cervical region ; ball of 0-38 caliber entered in median line over the larynx; no haemorrhage from the wound or mouth; immediate partial aphonia; deglutition of liquids only possible and with difficulty ; haemorrhage from left ear. On the third day, deglutition impossible and mental condition stupid; followed by delirium requiring mechanical restraint on the fourth day, and on the fifth day, by paresis of right arm, hand, and lower extremity, and loss of faecal and urinary con- trol, with some improvement in voice and power of deglutition. On the sixth day there was added right facial paralysis with ptosis; the right pupil was dilated and the left contracted, and the urine was controlled. The temperature on admission was 100°, rose on the second day to 101°, on the third day to 102-4°, and on the fourth day to 1036°; later it attained an elevation of 107-6°. The pulse was from 70 to 86 till the fourth day, when it rose to 132. The respiration was normal for four days and became frequent only at a late period. Death occurred on the seventeenth day. Lesions.—Bullet was lodged in the apex of the left petrous portion ; small fragment of bone driven upward about an eighth of an inch ; no lacerations ; large pial haemorrhage, in greatest amount over left fissure of Rolando ; large subarachnoid serous effusion. Case LXXXV. Symptoms.—Primary and permanent un- consciousness ; wound above right superciliary ridge; ecchy- mosis of both eyes; stertor; haemorrhage from mouth, nose, and both ears; left pupil dilated, the right contracted, and both in- sensitive, and fibrillar twitching of the right chest muscles. No paralysis or muscular rigidity. The temperature on admis- sion was 99-4° ; pulse, 120, full and strong, and the respiration 13 ; the temperature rose to 99-6°, and the respiration was re- duced to 4. Death occurred in twenty minutes; immediate post-mortem decline in temperature. Lesions.—Extensive comminuted fracture of frontal bone and both frontal plates extending through the middle fossae into the petrous portions; the left optic nerve was crushed by a fragment of bone in the optic foramen. The inferior surface TRAUMATIC INTRACRANIAL LESIONS. 39 of both frontal lobes was deeply lacerated over its whole ex- tent, and a cortical haemorrhage, still fluid, occupied all the basic fossae, and covered the pons and medulla. Case LXXXVI. Symptoms.—Primary and permanent com- plete unconsciousness ; haemorrhage from left nostril; dilatation of both pupils; no convulsions or muscular rigidity; respira- tion not more than four to five in the minute at any time after the receipt of injury and finally not more than one; pulse con- tinued full, strong, and of normal frequency for some moments after respiration ceased. Death in forty-five minutes. Lesions.—Fracture extending through left side of the base into middle fossa; moderate pial haemorrhage covering whole surface of the brain, vertex, and base, and also the medulla; marked general hyperaemia and oedema; contusion of under surface of left temporo-sphenoidal and frontal lobes. Case LXXXVII. Symptoms.—Primary and permanent un- consciousness; stertor; dilatation of the pupils; loss of urinary and faecal control, and pulmonary oedema ; left radial pulsation fuller and stronger than the right; no external injury. Tem- perature, 104° to 104-8° ; pulse, 120 to 166 ; respiration, 24 to 52. Death in four hours and a half. Lesions.—Fracture extending into both occipital fossae, and a fissure from contre-coup in the right middle fossa; large epi- dural haemorrhage from contre-coup over right frontal region; complete excavation of right frontal lobe with rupture of infe- rior cortex and consequent cortical haemorrhage over superior surface of whole right hemisphere and left frontal lobe; con- tusion of third left temporo-sphenoidal convolution and small extravasation into center of the pons; general hyperaemia. fractures confined to the vertex. Case LXXXVI1I. Symptoms.—Delirium on the second, and a convulsion on the fifteenth, day after the original injury alone noted and significance not recognized. Late symptoms fol- lowed an operation for fractured patella with use of anae'sthetic six months afterward ; general convulsions on the succeeding day, with wild delirium, and temperature 103°; the tempera- ture and general condition became normal after twenty-four 40 THE DIFFERENTIAL DIAGNOSIS OF hours. One month later general convulsions recurred after an- other operative interference, and continued thirty-six hours, preceded by tonic spasm of affected (left) limb, and succeeded by delirium and death at the end of nine hours. Each convul- sion was preceded by restlessness and wide dilatation of both pupils, and in about fifteen seconds began in the left face, ex- tended to the right face, to the left extremities, and finally be- came general. Temperature rose in twenty-four hours from 101*1° to 104*8°, and afterward declined to 104°. Lesions.—Extensive laceration of the right temporo-sphe- noidal lobe, three inches and a half by an inch and a half in its diameters, involving almost the whole of the second and third, and a little of the first, convolutions; the whole lobe was greatly atrophied, indurated, and pigmented. Circular laceration upon the anterior border of the right frontal, and another, an inch and a half in diameter, upon the inferior surface of the left frontal lobe, in the second and third orbital convolutions. These lacerations were all necrotic. Case LXXXIX. Symptoms. — Haematoma of left parietal region; unconsciousness which was permanent; right facial paralysis, and rigidity of both arms and right leg; and twenty- four hours later, paralysis and rigidity of right arm; paralysis of right leg probable. Temperature on admission, 102*6°; pulse, 96; respiration, 36; later temperature, 105°. Death in thirty hours. Lesions.—Epidural haemorrhage compressing laterally the whole left cerebrum; general hyperaemia and punctate extrava- sations. Case XC. Symptoms.—Consciousness partially lost and soon regained; vomiting frequent; later, somnolence and coma. Temperature on admission, 100 2°; pulse, 48; temperature rose to 105-4°. Death in twenty-seven hours. Lesions.—Compound comminuted fracture of right frontal bone; corresponding laceration of right frontal lobe, through subcortex nearly to lateral ventricle, with cortical haemorrhage extending over parietal region; slight pial haemorrhage over left occipital lobe; minute vessels filled with coagula in all parts of the brain, TRAUMATIC INTRACRANIAL LESIONS. 41 Case XCI. Symptoms. — Coma; stertor; pulse and respira- tion slow; second day—right hemiplegia; eyes deviating to the right; pupils normal; pulse feeble and rapid; respiration inadequate from pulmonary oedema. First temperature, some hours after admission, 10L6°; second day, 103-8° to 105-4°; third day, 106'4°. Death in sixty hours. Lesions.—Laceration of left temporo-sphenoidal lobe extend- ing into occipital region, with cortical haemorrhage over left motor area, and to base of occipital lobe; general hyperaemia and thrombosis. Case XCII. Symptoms.—Unconsciousness and irritability which continued one week. Temperature, 99° to 100°; second and third weeks, delirium and continued irritability; fourth week, apathy, rambling speech, and delusions, after which pa- tient was transferred to another hospital, where he died after operation. Lesions.—Fracture in left occipitoparietal region; lacera- tion of inferior surface of both frontal lobes. Case XCI1I. Symptoms. — Coma; stertor; rapid pulse. Temperature fell to 95°. Death in four hours. Lesions.—Gunshot fracture of right frontal bone; ball en- tered anterior extremity of fissure of Sylvius, traversed right frontal lobe just below the cortex, parallel to its curve and a little backward, crossed median fissure into left parietal lobe, impinged upon the left parietal bone, which it fractured, and fell back into its track half an inch below the surface, where it rested; little intracranial haemorrhage. Case XCIV. Symptoms.—Coma, soon becoming profound; normal pupils; general muscular twitching. Death in twelve hours. Lesions.—Gunshot fracture of right frontal bone; ball trav- ersed right hemisphere nearly in its antero-posterior diameter, just above corpus callosum, impinged upon inner surface of occipital bone, and fell into inferior occipital fossa above the dura; considerable cortical haemorrhage. Case XCV. Symptoms.—Gunshot wound of right temporal region; unconsciousness; no other immediate general symp- toms; pulse, 70; temperature, 99°; consciousness soon re- 4:2 THE DIFFERENTIAL DIAGNOSIS OF stored; mental processes normal but sluggish; some discharge of brain matter followed an unsuccessful attempt to locate and remove the ball on the second day; wound afterward prac- tically healed; mental condition apathetic, rational, but with- out any manifestation of interest in surrounding persons, things, or circumstances; urine and faeces voided without any indica- tion of consciousness. Temperature, 100°+ to 103-6°, usually 101° + . Death in thirty days. Lesions.—Gunshot fracture of right frontal bone; ball en- tered middle of right third frontal convolution, passed through central portion of both frontal lobes to a point just behind ascending arm of fissure of Sylvius in upper portion of island of Reil, and rested in a cavity five eighths by seven eighths of an inch in its diameter, surrounded by clot and brain detritus. Case XCVI. Symptoms.—Shock; consciousness retained; restlessness and delirium ; temperature, 100-2°; rose to 104-6°. Death on the third day. Lesions.—Compound fracture of left frontal bone with cor- responding laceration of brain and meninges ; general hyperae- mia and thrombosis. Case XCV1I. Symptoms.—Unconsciousness; dilatation of pupils ; rapid pulse and respiration ; temperature, 100°. Death in four hours. Lesions.—Deep laceration of inferior surface of right tem- poro-sphenoidal and slight laceration of anterior border of left temporo-sphenoidal lobe ; pial haemorrhage over superior sur- face of both hemispheres. Case XCV1II. Symptoms. Unconsciousness followed by delirium soon after admission ; extensive wounds of the scalp; normal pupils, right becoming dilated a little later ; temperature, 98-2°; in two hours, 99°; pulse, 76; respiration, 22 ; delirium in- creased ; pulse and respiration unchanged. Death in four hours. Lesions.—Compound double camerated fracture, involving right parietal eminence; skull very thick and unsymmetrical ■ posterior fossae large, middle and anterior fossae contracted * extensive pial haemorrhage, confined to meshes of pia, forming a thin sheet which covered superior and outer surface of right hemisphere and inferior surface of both occipital lobes • very TRAUMATIC INTRACRANIAL LESIONS. 43 marked general hyperaemia, especially on right side and in pons and medulla; some minute haemorrhages upon posterior border of right cerebellum and upon the medulla. Case XCIX. Symptoms.—Temporary unconsciousness; no other primary general symptoms ; temperature on admission, 98*4°; second day, 101*6°; afterward, 99° + . On the tenth day, restlessness and slight delirium ; eleventh day, slight chill and increased delirium, which became permanent, but of less active character; fourteenth day, post-cervical rigidity; and on the fifteenth, slight general convulsion ; mental condition slug- gish ; pupils remained normal; respiration, 18 to 22; pulse, 104 to 112. Temperature on the evening of the tenth day rose to 101° and on the eleventh day to 104-6° ; it varied from that point to 103° till the fifteenth day, when it rose progressively and reached 107'4° on the sixteenth day, and death ensued. Lesions.—Compound fracture with slight depression above right supra-orbital ridge, confined to external table; subarach- noid purulent effusion over both frontal lobes, encroaching upon parietal and extending into median fissure. Case C. Symptoms.—Gunshot wound of right side of the head. Left facial paralysis on second day ; hernia cerebri on the third day; mental condition deteriorated and paralysis increased. Patient transferred toBellevueon thethirtieth day ; then suffer- ing from hysteria and melancholia which had preceded the infliction of the injury; restlessness; loss of control of urine and faeces; left hemiplegia; slight dilatation of pupils; articu- lation difficult; sensation normal; pain in right supra-orbital region and at seat of the wound ; mental processes slow. Tem- perature, 100° ; pulse, 120 to 140 ; respiration, 20. At site of injury there was an infected granulating wound through which a probe could be passed into the brain. Four days later, under ether, an attempt was made to locate the ball, and a cavity was found to exist, extending nearly transversely inward two inches and a half, with moderately firm and well-defined wall, and having a small bit of bone at the bottom. The ball was not discovered. Temperature from admission had risen to 102-6° at time of exploration. Death occurred two days later; tem- perature then 107*4°. 44 THE DIFFERENTIAL DIAGNOSIS OF Lesions.—Gunshot fracture of right temporal bone in squa- mous portion; osseous wound had been enlarged by trephina- tion ; slight haemorrhage over right occipital lobe and a few threads of yellow exudate in same region and on the right side of the median fissure; ball passed through lower face area, nearly transversely inward to a point beneath the median sur- face and just above the calloso-marginal fissure ; was then de- flected backward at a right angle by the resistance of the falx cerebri, and was lodged an inch behind the cavity recognized at the time of exploration. General hyperaemia. Case CI. Symptoms.—Gunshot wound of left side of the head. Unconsciousness, which continued till death, five hours later; slight dilatation of left pupil. Temperature one hour after reception of injury 98-2°; two hours afterward, 97*6°; fifteen minutes before death, 99°. Pulse, 118 to 132 ; respira- tion, 28; later, 32 and stertorous; fifteen minutes before death, 7 ; and finally 2. Lesions.— Gunshot fracture of squamous portion of left tem- poral bone in its posterior portion, an inch below temporal ridge; foyer of entrance triangular; each arm half an inch in length; bone comminuted, and the fragments penetrated the cerebral cortex. Ball entered temporal lobe between two large branches of the meningeal artery, passed transversely across the brain immediately below the cortex, and was lodged in the right parietal lobe; cortical haemorrhage from injury of the right parietal lobe by the ball in its course, extended under the tentorium and over the pons and medulla, and was apparently the immediate cause of death ; cerebral hyperaemia confined to the vicinage of the bullet track. Case CII. Symptoms.—Unconsciousness, which continued till death at the end of three hours; general muscular rigidity. Temperature, 101°; pulse, 98; respiration, 20. Lesions.—Penetrating wound and fracture of left temporal bone, above the ear, three eighths of an inch in diameter from a blow inflicted with a revolving screw-driver. The instru- ment passed through both hemispheres, wounding the dura upon the opposite side, and involving the posterior part of the left corpus striatum and both optic thalami; a thin cortical TRAUMATIC INTRACRANIAL LESIONS. 45 haemorrhage covered both hemispheres and the superior surface of the cerebellum. Case CIII. Symptoms.—Patient, nine days previous to ad- mission, came home with head bleeding, vertigo, nausea, and feeling of weakness, from an injury of unknown origin, and was said to have been afterward treated for pneumonia. On ad mission, he was found to have compound depressed fracture of right parietal bone, and the wound was foul and suppurating; mental condition stupid; left hemiplegia and right facial paraly- sis ; deviation of tongue to the left; opposite radial pulsations symmetrical; slight dilatation of left pupil; coma supervened an hour later, and convulsive movements of the right face four hours and a half after admission. After elevation of the de- pressed bone, and escape of a small amount of pus from below the dura, the pupils became normal, and there was a single clonic convulsion of the left side. Death occurred thirteen hours and a half from time of admission. Temperature for twelve hours was 106° + , and afterward 107-2°; one hour post mortem, 107*4°. Pulse, 118, 170,- 158; respiration, 44 to 60. Lesions.—Compound depressed fracture of right parietal bone, just behind coronal suture, and half an inch from median line; purulent subarachnoid effusion over convex surface of right hemisphere, which anteriorly extended to the base; superficial laceration of right parietal lobe beneath the site of fracture, which was prolonged subcortically, both anteriorly and posteriorly, but did not reach the motor area; pus from this laceration had escaped in small quantity into the arachnoid cavity; left hemisphere markedly hyperaemic and moderately oedematons. Case CIV. Symptoms.—Consciousness primarily retained ; thirty minutes later general convulsions followed by complete unconsciousness and an apparently moribund condition. Eleva- tion of a depressed portion of the left parietal bone restored consciousness and some strength to the circulation. Convul- sions recurred next day, and death ensued in twenty-three hours. Temperature, 102-4° to 104-4°; pulse, 108 to 160; res- piration, 32 to 60. 46 THE DIFFERENTIAL DIAGNOSIS OF Lesions.—Fracture confined to the vertex; epidural haemor- rhage of small extent, and laceration of inferior surface of right frontal and temporo-sphenoidal lobes. (Infant, aged twenty- two months.) ENCEPIIALIC INJURIES WITHOUT FRACTURE. Case CV. Symptoms.—Violent delirium for two days; re- curred on the sixth day, followed by unconsciousness and hy- peraesthesia. Temperature, 103° to 104°; afterward, 100° to 103° ; final temperature, 103°. Death in twelve days. Lesions.—Pial haemorrhage over left occipital lobe, extend- ing into median fissure ; subarachnoid serous effusion. Case CVI. Symptoms.—None recognized till fourth day, when there were four unilateral convulsions. A single one oc- curred on the fifth dayT, and they then continued with increasing frequency till death on the eighth day. Each one began by a twitching of the facial muscles, with head and eyes turned to the left, and extended to the left arm, and finally to the left hand. Temperatare on admission, 100°; twelve hours later, 103°; then 103° to 104°, till sixteen hours before death, when it rose to 105°. Lesions.—Extensive laceration of right temporo-sphenoidal lobe, with cortical haemorrhage over whole right hemisphere. Case CVII. Symptoms.—Mental condition clear, but dazed, on admission ten hours after reception of the injury; extreme muscular tremor, followed in two hours by a general convul- sion ; from this time periods of general convulsions, with inter- vals of unconsciousness or delirium, lasting about six hours, alternated with periods of quiescence of equal length; no ini- tial symptom. Death in two days. Lesions.—Deep laceration of right frontal lobe, anteriorly and externally, extending into parietal region; cortical haemor- rhage, covering right frontal lobe, right parietal lobe anterior to the Rolandic fissure, and the temporo-sphenoidal lobe, both lat- erally and interiorly. Case CVIII. Symptoms.—None. Found dead in an upright position, leaning against a fence. Lesions.—Lacerations and contusions covering greater part TRAUMATIC INTRACRANIAL LESIONS. 47 of left frontal and temporo-sphenoidal lobes; cortical haemor- rhage over the whole left hemisphere. Case CIX. Symptoms.—Coma; stertor; contraction of pu- pils; full pulse; rapid respiration. Temperature, 101° + . On the third day coma more profound ; dysphagia; continued irri- tability and restlessness. Temperature, 104-5°. Death in four days; temperature, 107*4°. Lesions.—Small laceration at left parieto-occipital junction ; cortical haemorrhage over posterior part of left parietal lobe; general hyperaemia. Case CX. Symptoms.—Coma, restlessness, and general hy- peraesthesia; temperature, 103-4°; pneumonia discovered on the second day. Death on the third day. Lesions.—General hyperaemia, with some punctate extrava- sations; organized membranous effusion, studded with calca- reous nodules, over left hemisphere. Case CXI. Symptoms.—Sudden coma; stertor; double facial paralysis; complete right hemiplegia and hemianaesthesia; tem- perature, 99° to 103°. Trephination and drainage of serous effusion from the base by position of the head was followed within six hours by return of consciousness, mental clearness, power of articulation, and decline of temperature to 98*6°, and this improvement in condition continued fourteen hours; slight chill then preceded a progressive rise of temperature to 104*6°, and death occurred ten hours later. Lesions.—Interior of left occipital lobe disintegrated by apo- plectic clot, which extended into both lateral ventricles; conse- quent fall from a cab caused a laceration of external border of right cerebellum and cortical haemorrhage, which spread over the pons into the transverse fissure. Case CXII. Symptoms—No primary general symptoms; temperature, 100°. Second day, delirium. Fourth and fifth days, headache. Sixth day, restlessness, irritability, and failing strength; mind clear. Eighth day, general muscular rigidity most marked in right side and arm, and, a few hours previous to death, perforating ulcer of the cornea. Temperature, second day, 103-2°; third day, 101° to 100*8° ; fourth and fifth days, 103-4° to 103°; sixth day, 106*4° ; seventh and eighth days, 105° to 105*2°. 48 THE DIFFERENTIAL DIAGNOSIS OF Lesions.—General hyperaemia; minute thromboses and mod- erate oedema, markedly involving basic ganglia and cerebellum, and most pronounced on the left side; thrombi filled both lateral and both inferior petrosal sinuses, and extended into right jugu- lar vein, and were decolorized only near the torcular Herophili. Case CXIII. Symptoms.—Delirium ; normal pupils and res- piration; temperature, 101-4°; pulse, 114. Later, great hyper- sensitiveness and irritability. The delirium continued, though it did not prevent rational reply to questions; temperature rose to 103*2° on the fifth day, and afterward fell very gradually to 100° ; on the fourteenth day it was 103*4° ; and on the fifteenth, five hours ante mortem, it was 103*8°, and one hour post mor- tem it was 104-2°. Lesions.—Cortical haemorrhage over both hemispheres and in largest quantity over parieto-occipital junctions; some sub- arachnoid serous effusion in left frontal region; general hyper- aemia with punctate haemorrhages, most marked on the left side. Case CXIV. Symptoms.—Primary unconsciousness; on ad- mission, forty-eight hours later, muttering stupor; rigidity of left arm ; incomplete right hemiplegia, more marked in upper extremities; pulse, 60; temperature, 101°; third day, increased rigidity of left arm; complete hemiplegia; profound coma; pulse, 128; temperature, 105°. Trephination was followed by increased freedom of movement and by some power of articula- tion. Death on the fourth day. Lesions.—Moderate subarachnoid serous effusion over ante- rior two thirds of right hemisphere; laceration of left temporo- sphenoidal lobe, excavating and destroying its whole structure; cortical haemorrhage extending around the circle of Willis and upward upon the occipital lobe, and in patches upon the frontal and parietal lobes. Case CXV. Symptoms.—No external evidence of injury; coma; stertor; rigidity of right side; pulse, 120; temperature, 100°. Death on third day; temperature, 103-2°. Lesions.—Large subarachnoid serous effusion • recent clot in substance of left cerebellum. An old laceration existed upon antero superior surface of left occipital lobe and another upon its inferior surface. TRAUMATIC INTRACRANIAL LESIONS. 49 Case CXVI. Symptoms.—Consciousness lost and partially restored before admission, twenty-four hours later; mental condition rational, but comprehension slow ; slight dilatation of left pupil. Temperature, 99°, followed by some left paresis and by some dysphagia referred to the left side of the throat. The patient from the time of injury often fell out of bed, al- ways on the right side. Subsequently transient facial paralysis occurred; amount of paresis and of dilatation of left pupil varied from day to day; mental condition deteriorated. Tem- perature for ten days was 99°+ ; later, 100°+ to 101°; pulse and respiration nearly normal. Trephination on the fifteenth day discovered a small subcortical cavity in the right leg area containing less than a drachm of yellowish fluid, afterward found to contain leucocytes. The temperature was 99°+ till eleventh day after operation, when it rose to 104°; next day, 101° to 104°. Death from asthenia on the twenty-eighth day after admission. Lesions.—Large subarachnoid serous effusion compressing frontal lobes; general hyperaemia with minute coagula. The brain substance around the small subcortical cavity opened during life was softened and contained punctate extravasations. Case CXVII. Symptoms.—Unconsciousness, which still con- tinued upon admission on the second day; slight dilatation of the pupils; complete left hemiplegia and hemianaesthesia; slight left facial paralysis. Temperature, 106°; pulse, 140; respira- tion, 30 ; general convulsions beginning soon after admission, and frequently repeated; initial symptom in mouth and lower face. Trephination same day by house surgeon with negative result. Temperature two hours later, 107-4°. Death in a con- vulsion five hours after operation. Temperature, forty-five minutes post mortem, 109-4°. Lesions.—General hyperaemia of the brain and membranes ; tumor of the size of a pea resting in a small cavity in the left frontal lobe formed by disintegration of surrounding brain tissue. Case CXVIII. Symptoms.—Condition alcoholic and habit epileptic; fell in an epileptic convulsion ; large haematoma over left frontal and parietal region; three convulsions within first six hours, the last followed by partial paralysis of left lower 4 50 THE DIFFERENTIAL DIAGNOSIS OF face. The temperature on the first day was 101*8°, 102*8°, 100°; second to sixth days inclusive, 100*6° to 102° + ; seventh to ninth day, normal; and then for ten days subnormal during the greater part of each twenty-four hours. On the thirteenth day a severe chill was followed by temporary rise of tempera- ture to 101° + ; and on the nineteenth day a slighter chill by an elevation of temperature, which progressively increased till death, on the twenty-first day. Until the occuirence of the second chill there were few general symptoms; some remaining paresis and anaesthesia of the right face, more or less mental aberration, and some delusions. After the second chill strength diminished, the mental condition became sluggish, the respira- tion rapid, and temperature rose to 105*5°. Lesions.—Subcortical laceration and excavation of left pre- frontal lobe, with a prolongation backward to a point opposite to the middle of the corpus striatum ; no haemorrhages; large subarachnoid serous effusion and opacity of the arachnoid over the whole vertex; general hyperaemia and oedema. Case CX1X. Symptoms.—Consciousness retained ; wound in right parietal region ; condition alcoholic; heavy sleep dur- ing the first night after admission ; afterward constant restless- ness ; some pain in the back of the head; vomiting of every- thing taken into the stomach; temperature on admission, 102-6°; second day, 105° ; and at time of death, which occurred some- what suddenly at the end of the third day, 103*8° ; pulse mod- erately accelerated, varying from 120 to 88; pupils and respi- ration normal. Lesions.—Subarachnoid purulent effusion over both frontal lobes, mainly on the left side, with some general oedema of the pia; scanty fibrinous exudation at the base; and fibrinous patches on inner surface of the dura at the convexity. Case CXX. Symptoms.—Absolute unconsciousness till death, an hour and a half after reception of the injury ; small wound behind the right ear ; dilatation and immobility of both pupils; respiration on admission, 42 ; an hour later, 21; ceased at death rather suddenly; no cyanosis; pulse feeble and soon became imperceptible; temperature on admission, 98*6° ; an hour later 98*2°. TRAUMATIC INTRACRANIAL LESIONS. 51 Lesions.—Probably caused by contrecoup, force having been transmitted through the feet and lower extremities; fractures of both tarsi, comminution of both calces and right astragalus, fracture of left leg, and contusion of soles of both feet; pial haemorrhage to extent of several ounces of fluid blood, mainly at the vertex and in larger part on the left side, extending into median fissure, and which had broken through into the arach- noid cavity; also in considerable quantity upon the inferior surface of the cerebellum, about the median line, and covering the pons; no lacerations; excessive general hyperaemia, most strongly marked on the left side and in the pons, optic thalami, and corpora striata, in the order named ; thrombosis of minute vessels generally, but most pronounced in the optic thalami and pons ; oedema of the pons. Case CXXI. Symptoms.—Primary unconsciousness ; and on admission mind confused and speech disconnected; four gen- eral convulsions from twelve to twenty-four hours afterward ; no control of urine or faeces ; second day, semi-consciousness; muscular rigidity in back of the neck and extremities; some irritability; fourth day, mental condition rational, but no re- membrance of the manner in which the injury had been re- ceived ; during the next ten days the urine, but not the faeces, remained uncontrolled ; there was noticeable weakness of the muscles of the trunk, inability to rise or sit up in bed without assistance, dementia and loss of memory, primary union of the wound, and nearly normal pulse and respiration. On the fif- teenth day there was somnolence and increase in temperature and infrequency of the pulse and respiration ; stupor deepened, and on the seventeenth day unconsciousness was complete. Death occurred in eighteen days. Temperature on admission, 99*4° ; fourth day, 99°; till the end of second week, 99° to 100°+ ; on the seventeenth day, 102*7° to 103-8°; on the eight- eenth day, 105-4°. Pulse on admission, 96; normal till fif- teenth day; later, 160. Respiration on admission, 26. Lesions.—Haematoma over right parietal eminence ; throm- bus in superior longitudinal sinus; great fullness of meningeal veins over the vertex; convolutions flattened; frontal lobes relatively small, parietal lobes bulging as though from disten- 52 THE DIFFERENTIAL DIAGNOSIS OF tion; general cerebral hyperaemia and oedema without punctate extravasations and with few minute thrombi; substance of cerebellum nearly normal. By compressing posterior portion of the cerebrum and making vertical sections anteriorly, serous fluid exuded in great quantity; little serum in the ventricles. A clot about the size of a large pea and of elliptical form occu- pied the exact center of the anterior third of the left optic thalamus. There were no lacerations, haemorrhages, or sub- arachnoid effusions, and upon microscopical examination no in- flammatory changes. Case CXX1I. Symptoms.—Walking case; unconsciousness supervened some hours after injury, and continued till death on the third day; wounds in occipital and both parietal regions; slight dilatation of left pupil. Temperature, 103*6° to 106-6°. Lesions.—Large pial haemorrhage compressing left fronto- parietal region; excessive general hyperaemia with numerous minute thromboses; subcortical laceration just external to an- terior part of left corpus striatum, an inch by half an inch in its diameters. Case CXXIII. Symptoms.—None recognized till admission three days after reception of the injury; partial lo>s of con- sciousness ; complete right hemiplegia and hemianaesthesia in- cluding trunk; complete aphonia; slight dilatation of pupils; bilateral convulsive movements of face and neck with the eyes turned to the right, repeated every five minutes; respiration shallow and hurried; pulse rapid, feeble, and irregular. Tem- perature, 101° to 104°; radial pulsation fuller and stronger on the left side than on the right. Trephination disclosed arach- noid clot. Death occurred before operation was completed. Lesions.—Pial haemorrhage with clot covering both frontal and both parietal lobes; right lateral ventricle filled with haem- orrhagic serous effusion; general hyperaemia. Case CXXIV. Symptoms.—Walking case; unconsciousness supervened some hours after apparently trivial injury; no dis- coverable external lesion; dilatation of pupils; second day, partial restoration of consciousness; fourth day, delusions; ninth day, stupor; eleventh day, complete unconsciousness. Death at end of twelfth day. Temperature on the first day, TRAUMATIC INTRACRANIAL LESIONS. 53 102-4°; afterward, 101° to 99°; final observation, 100-8° ; pulse, 76, gradually increasing in frequency; respiration, 24, 20, 28. Lesions.—Thin layer of pial haemorrhage which covered the opposing surfaces of the superior median fissure, and spread over left occipital and parietal lobes to margin of the temporal lobe; some blood, also pial, in the left middle fossa; general hyperaemia and moderate oedema. Case CXXV. Symptoms. — Unconsciousness which soon after admission was replaced by delirium; no external injury; loss of urinary control; delirium constant, of a quiet sort by day and violent by night till the seventh day, when *for some hours before death it was muttering, or typhoid, in character; mental condition stupid from the beginning; patient was at no time able to give any aecount of himself, to respond to a ques- tion, or to show any appreciation of his surroundings. Death from asthenia on the seventh day. Temperature on admission, 96-2°; rose progressively in three days to 103-2°; on the fourth day was 10D8°; on the fifth day, 103°; on the sixth day, 104-6°; and on the seventh day, 101-2° to 107-2°; postmor- tem, 107-8°. The pulse did not exceed 100 till late in the week. Lesions.—Small laceration in the substance of the posterior part of the left frontal lobe; laceration of under part of the corpus callosum in its anterior third, and of left lateral edge of the fornix anteriorly ; small haemorrhage in left lateral ventricle derived from the laceration of the fornix; pial haemorrhage over posterior part of right occipital lobe, upon its border, beneath tentorium, and upon the posterior border of the cerebellum; blood fluid and moderate in amount; moderate general hyper- aemia with minute thromboses. Case CXXV1. Symptoms.—Walking case; unconsciousness after some hours' interval; stertor; loss of urinary control: vomiting. Temperature, 101*8°; rose progressively to 107 8°; pulse, 70 to 162; respiration, 24 to 46. Death in eleven hours. Lesions,—Laceration of superior surface of right parietal lobe; cortical haemorrhage covering whole right hemisphere; general hyperaemia. 54 THE DIFFERENTIAL DIAGNOSIS OF Case CXXVII. Symptoms. — Unconsciousness, which soon became profound; normal pupils; pulse in a few moments rose from 90 to 140; right side of body and right extremities rigid; bilateral convulsive movements; right radial pulse fuller and stronger than the left. Death in eight hours and a half. Tem- perature on admission, 97°; in three hours, 101°; in six hours, 102-2°; pulse, 90 to 140 to 136; respiration, 20, 18, 21; and just before death, 12 and then 7 in the minute, very full and deep, with cyanosis. Lesions.—Small contusion of scalp in left middle parietal region discovered only after post-mortem incision; thin pial haemorrhage, mostly fluid, covered whole superior and external surfaces of both hemispheres as far forward as the middle of the frontal lobes, extended in larger quantity over both surfaces and both borders of the cerebellum, and spread over the pons and medulla; pia mater intensely hyperaemic; small contusion on inner border of right temporo-sphenoidal lobe, and a larger one at left parieto-occipital junction; brain substance generally excessively hyperaemic and oedematous, with many small areas of local contusion filled with small haemorrhages as large as a robin shot. The essential lesion was laceration of the basic ganglia. The right corpus striatum was entirely disintegrated and de- stroyed; its ventricular surface only remained, as a ragged membranous capsule, of which much had altogether disappeared. The laceration extended antero-laterally into the substance of the right frontal and parietal lobes; it was continued posterior- ly through the taenia semicircularis into the anterior part of the optic thalamus. The ventricular surface of the left corpus striatum was contused and marked by small linear lacerations. The fornix and under surface of the corpus callosum were soft- ened and disintegrated. Fluid blood partially filled both lateral ventricles, and in the left had broken through the posterior cor- nu into the occipital lobe in considerable quantity. Case CXXVIII. Symptoms.—Immediate unconsciousness with some response to external irritations, which continued till final coma; continued dilatation of both pupils, which were sen- sitive ; temporary rigidity of left side; right hemiplegia and hemi- TRAUMATIC INTRACRANIAL LESIONS. 55 anaesthesia, and right facial paralysis; restlessness, which was confined to the left side; retention of urine; coma and stertor for five hours before death, which occurred in fifty-three hours. Six hours before death the left hand became icy cold and the left arm and foot cool, while other parts of the body retained a normal surface temperature. At this time the rectal tempera- ture was 102*6° ; the left axillary, 100*4°; and the right axillary, 103*2°. In fifteen minutes the temperature in the left axilla rose to 101-4°, and in thirty minutes to 102-8°, while the rectal and right axillary temperatures remained stationary. The axillary temperatures were at other times symmetrical. Temperature on admission was 98*5°, and in two hours, 102-2°; in eleven hours it receded to 101°, in the next twelve hours rose to 105°, on the second day receded to 100-4°, and a few moments be- fore death was 106°; one hour post mortem, 106-2°. The pulse gradually increased in frequency from 110 to 158. The respiration was never below 30, and was finally 56 in the minute. Lesions.—Contused wound of the scalp over right parietal eminence; slight pial haemorrhage over inferior surface of cere- bellum and posterior left occipital border; copious subarach- noid effusion and arachnoid opacity in posterior parietal regions most marked on the left side; small haemorrhagic serous effu- sion in left lateral ventricle; limited contusion and slight lacer- ation in the substance of the fornix posteriorly; excessive gen- eral hyperaemia and oedema, with a few minute thrombi in all parts of the brain. Case CXXIX. Symptoms.—The patient walked home after a fall of ten feet, had a single convulsion a few hours later, and was stupid or dazed for five days afterward; he then became violently delirious, and was admitted to the hospital. At that time, no visible external injury ; pupils moderately dilated; ra- dial pulsations bilaterally symmetrical; posterior cervical mus- cular rigidity, and loss of urinary control. On the following (seventh) day pupils contracted and muscular rigidity increased ; one convulsion after admission; mental condition marked by alternations of stupor, with wild delirium. No change till the eleventh day, when the patient became quieter, and could an- 56 THE DIFFERENTIAL DIAGNOSIS OF swer a limited number of questions intelligently. On the fif- teenth day the pupils became normal, muscular rigidity dimin- ished, and urinary control was temporarily regained. From the sixteenth day unconsciousness was complete. On the sev- enteenth day the pupils were again contracted, the respiration was stertorous, and the face cyanotic; the lungs became oede- matous, and death occurred on the morning of the nineteenth day. The temperature on admission was 102°, and varied from 99° to 101° + , with occasional elevations to 102°+ till the last thirty-six hours, when it was constant at 105*6°; and half an hour post mortem was 106°. The pulse on admission was 132, and afterward was usually from 96 to 112. The respiration was moderately increased in frequency. Both pulse and respiration were finally greatly accelerated. Lesions.—Cortical haemorrhage, compressing outer and an- terior aspect of right frontal lobe, and filling right anterior fos- sa. This was derived from a laceration of the inferior surface of the right frontal lobe, mainly subcortical, which excavated its inferior and outer portion; cavity as large as a pigeon's egg and lined by a thin, chocolate-colored and pultaceous substance. Small linear laceration upon inner border of left frontal lobe and slight contusion of anterior portion of right temporo-sphe- noidal lobe, both upon inferior surface. Opacity of arachnoid membrane; no subarachnoid serous effusion, and only very moderate hyperaemia of the brain substance. Case CXXX. Symptoms.—Primary and permanent uncon- sciousness; restlessness; general muscular rigidity; stertor; ir- regular pupils. Temperature on admission, 100°, and at death 99*8°; pulse varied from 108 to 160; respiration, 32 to 58. Death in an hour and a half. Lesions.—No fracture or lacerations; large general sub- arachnoid and ventricular serous effusion; general hyperaemia and excessive oedema. general diagnosis. Before attempting to isolate the several forms of en- cephalic injury, I shall recur to two points in their general TRAUMATIC INTRACRANIAL LESIONS. 57 diagnosis which have heen, at least provisionally, estab- lished by the analysis of my first series of cases. I refer to the pathognomonic value of temperature in the symptom- atology of head injuries as a class, and to the recognition of cranial fracture. I shall not enter at length into the re- consideration of either subject, since the relation between symptoms and demonstrated lesions previously determined is found to still subsist, and the more recent observations have hut confirmed the opinions the study of the elder series seemed to warrant. The additional cases have in fact not only substantiated hut strengthened the proposi- tions which I formulated in the original instance; this will be sufficiently evident by a simple reference to their histo- ries as presented. I shall consider more specifically only the two points in general diagnosis which I have designated. PRIMARY SUBNORMAL TEMPERATURE. In all the cases of the first series but two the tempera- ture was elevated at the time of first observation. In the present series, which, like the first, includes recovering as well as fatal cases, the instances of primary subnormal temperature have chanced to be more numerous, but in all which survived primary shock subsequent elevation of temperature was equally noted. In more than seventy-five per cent, of the forty or more cases of the later series in which the* earliest known tem- perature was subnormal, the patient still suffered from evi- dent shock or alcoholic intoxication. It is not inconceiv- able or improbable that in them a characteristic symptom of shock or of alcoholic poison should have taken precedence of others produced by traumatism. In the cases remain- ing, where no other suggestion of shock or of alcoholism is to be derived from the examination of symptoms, the solution of the problem is probably the same. Premising 58 THE DIFFERENTIAL DIAGNOSIS OF that the earliest manifestations of injury—those exhibited before admission—are most difficult to learn, it may well happen that depression of temperature, often the last Anger- ing indication of shock, is all that remains when the first record of the case comes to be made. Three of the resid- ual cases were complicated by severe external injury; in many others there was free intracranial haemorrhage, as de- termined in the majority by necropsic examination, and in the others by the escape of blood during life from ear, nose, or mouth. In one case, in which there was no exter- nal haemorrhage, the general conditions indicated its exist- ence within the cranial cavity. In ail these instances the occurrence of undiscovered or unnoted shock is not only the rational hut more than probable explanation of an otherwise inexplicable early depression of temperature; but whatever may be thought of these exceptional and temporary early conditions, all such cases very soon fall into line and conform to what seems to be an established law—that elevation of temperature is the unfailing mani- festation of traumatic lesions within the cranium. The character of the pulse and respiration in the ex- ceptional instances in which subnormal temperature was observed has not been usually suggestive of general shock; in a few cases the one was notably frequent or the other markedly accelerated; in general there was little if any variation from the normal standard. This requires for ex- planation but another application of the suggested law of precedence in symptomatology ; it may happen that the pulse and respiration reflect for a time the general condi- tion of shock, but it is more frequently the temperature alone which in the presence of intracranial injury is domi- nated by the original impression made upon the sympa thetic nervous system. In all cases, if the patient survives a certain very limited period, temperature, pulse, and respi- TRAUMATIC INTRACRANIAL LESIONS. 59 ration, like all other symptoms, are dependent upon the special injury which has been suffered, and this is ordi- narily the fact at the earliest opportunity afforded for ex- amination. It is sufficient to indicate this law of prefer- ence without attempting to fathom the conditions upon which it rests. I have previously insisted in this relation of tempera ture to general diagnosis upon the importance of distin- guishing alcoholic coma from cerebral trauma. I have no less strenuously asserted the facility, the almost absolute certainty, with which this can be accomplished. I believe the elevation of temperature in the one, and its depression in the other, have been so thoroughly established as to demonstrate the sufficiency of temperature alone, without the existence of external injury or positive general symp- toms, in almost any case in which question may arise. It is fortunate that the occasional early depressions of tem- perature in intracranial injury are likely to be associated with such general conditions as have little room for doubt in diagnosis. I have no reason to revert to a subject so simple in itself, except in the interest of humanity and in protest of the shocking abuses which still persist in this regard in the accident service of the city. Negligence or incompetence still figures in the early history of too many of the serious cranial and intracranial injuries which have at a later period come under my observation. There may be a fair presumption that a man found unconscious in the street, or delirious in a police station, is simply drunk and devoid of surgical interest, but it is not so absolutely over- whelming as to warrant neglect of ordinary physical ex animation; and when a patient with fractured skull and lacerated brain, whether or not in alcoholic condition, has been given admission, it is not creditable to hospital ad- ministration that he should be detained in alcoholic wards, 60 THE DIFFERENTIAL DIAGNOSIS OF transferred to an asylum for the insane, or sent into the street to die almost within the shadow of its walls, even in exceptional instances. It must be in some part due to a defect in professional teaching when hospital assistants dis- play such ignorance or indifference in the discharge of pro- fessional duty. It is well, therefore, for observers who are not public teachers to assume an office, and to direct atten tion to such default if for nobetter purpose than to avert pub- lic scandal. FRACTURES OF THE CRANIUM. The diagnosis of fractured skull is not difficult if the case he subjected to sufficiently careful examination. This is evident in some degree from anatomical considerations, and is illustrated in my first series of cases. Fractures of the vertex can always be discovered by tactile or visual sense, since incision is without danger or subsequent incon- venience to the patient, when doubt exists which it seems important to resolve. Fractures of the base in a large pro- portion of cases traverse some part of the bone which per- mits the escape of blood from the ear, nose, or mouth, or into the subconjunctival or subcutaneous cellular tissue. In fifty per cent, of the eighty-seven necropsies in both series in which fracture of the base existed there had been some form of external haemorrhage during life; in more than seventy five per cent, of the seventy-eight cases which recovered, or in which necropsy was impracticable, there had also been some characteristic haemorrhage, so that in 62*5 per cent, of the total number diagnosis could be made largely from this single symptom. Two of the remaining sixty cases presented an equally characteristic serous dis- charge, and many others had been recognized by tracing fis- sures from the vertex downward into the base in the course of operation. There are left scarcely more than twenty cases in which this fracture was unknown till disclosed TRAUMATIC INTRACRANIAL LESIONS. 61 at necropsy, and of these, several were brought under ob- servation only after the lapse of one or more days—too late to ascertain whether or not haemorrhage, usually a transient symptom, had occurred. In this residuum of cases the fracture very frequently extended into the middle or poste- rior fossa without reaching the petrous portion, and some- times into that bone without involving any part of the auditory passages ; fracture through the anterior or middle fossa in some instances failed to so implicate the ethmoid or sphenoid as to establish communication with the nose or mouth ; in the anterior fossa the thin orbital bones were occasionally fissured without causing either orbital or ocu- lar haemorrhage, visible or concealed. Yet, with all these possibilities of failure of recognition as a symptom, its ab- sence altogether, its lack of means of exit, the neglect of its early observance, external haemorrhage was noted in nearly four out of five of the whole large number of cases which I have recorded. I do not think there is the serious difficulty which has been suggested in determining whether such haemorrhage is the result of fracture. The local examination of ear, nose, or mouth is sufficient to eliminate the most probable source of error. Contusions of the face in the ophthalmic region may sometimes make orbital or ocular haemorrhage of doubtful significance, and habitual epistaxis has once led me to hesitate in the interpretation of 'a nasal haemor- rhage ; but it is usually possible in such instances to give this symptom its proper clinical value. I believe it may be regarded as practically pathognomonic. I have only once found a haemorrhage from the ear to result from a wound of the external meatus. An occasional escape of brain substance through a cranial fracture requires no consideration. The more fre- quent instance of injury of a cranial nerve from a fracture 62 THE DIFFERENTIAL DIAGNOSIS OF passing through its bony canal may be diagnostic if it be practicable to fairly determine that functional disturbance or abeyance does not depend upon lesion within the intra- cranial cavity. I have recorded in the first series an in- stance of facial paralysis which was found upon necropsy to have been occasioned by fracture and haemorrhage into the aquaeductus Fallopii, and I have had reason in more recent recovering cases to refer the same symptom to similar osseous lesion. It is well known that fracture through an anterior fossa often involves the optic foiamen. I have recorded the history of three cases, in which the patient survived, where the optic nerve was thus implicated and suffered subsequent atrophy with immediate and permanent loss of vision. Dr. P. A. Callan has reported nine cases. I have no doubt, therefore, that valuable diagnostic infor- mation may be afforded by nerve disturbance mechanically produced. There remains a symptom which I believe to point to fracture, and to which I have previously adverted, in the existence of acute localized pain at the seat of injury. I have since observed it in a number of cases in which this lesion seemed otherwise probable ; these often resulted in recovery, and, as the indications of intracranial complica- tion were slight, the symptom was unobscured. I quote an illustrative case which occurred in my service at St. Vin- cent's Hospital: A young woman fell from a third-story window to the pavement below and was admitted at once, delirious, with hajmatoma of the left frontal region extending over the eye, and with slight subconjunctival haemorrhage. She had epistaxis, which was repeated the next day, and from which she said she had previously suffered ; no fracture was dis- covered by incision ; severe frontal headache, confined to the site of the haematoma, continued for three days ; the TRAUMATIC INTRACRANIAL LESIONS. 63 mind was clear; the wound of incision healed at once ; the temperature on admission was 101-4°, rose gradually to 103° on the third day, and then declined to 99° on the ninth day ; the pulse on admission was 68, and on the sixth day 120. The degree and course of temperature in this case indi- cated injury of the brain, and while neither the epistaxis nor the ocular haemorrhage could be positively attributed to fracture, the severity of the blow, amount of local injury, and coexistence of brain lesion, gave to my mind a certain diagnostic importance to a severe localized pain which was certainly not ehatacteristic of simple contusion. I shall have occasion to detail in another connection some fatal cases in which the value of this symptom was incidentally verified. The symptoms usually ascribed to fracture—as loss of consciousness, pupillary change, and others—are really those of encephalic complication, and have only a possible indi- rect relation to cranial injury. In assuming that fractures are themselves unimportant, except for their complications, immediate or remote, I have not depreciated the importance of their diagnosis. Frac- tures of the vault induce complications, which are relieved only after recognition and treatment of the fracture itself. Laceration of the brain, wounds of the sinuses, haemor- rhages, and later psychical disorders caused by fragments of bone depressed, can be treated only after detection of the primary lesion. Basic fractures are less likely to require or admit direct interference ; but their appreciation is still of moment. The knowledge that fracture exists may great- ly help to confirm the diagnosis of a deeper seated injury, and greater certainty in regard to the existence and nature of morbid conditions can not fail to increase the possibili- ties of successful treatment. The curative management of intracranial lesions is still so far unsettled that aid from 64 THE DIFFERENTIAL DIAGNOSIS OF any quarter, in giving it firmer basis, is far from unimpor- tant. DIFFERENTIAL DIAGNOSIS. When the transition is made from general to special diagnosis, and beyond the simple recognition of fracture to the differentiation of intracranial injuries, difficulties in- crease, and these, I have found, are to be encountered and surmounted, if at all, with little aid from other than per- sonal observations. The literature of the subject, aside from the contributions of Prescott Hewitt and von Berg- mann, is singularly unsatisfactory, and the most recent sur- gical writers even are hopelessly confused in their descrip- tions of these obscurer forms of injury. There has been no lack of tabulated collections of cases, but they have been disjointed and heterogeneous, incomplete in historical detail, and barren of result for any purpose of useful gen- eralization. They have presented a jumble of symptoms, lesions, and pathic relations, at once perplexing and discour- aging. I limit criticism to methods of culture which have obtained in the field of traumatism, and have no intent to disparage the work which has been done in other depart- ments of neuro- pathology. I have no hesitation in ascribing this want of precision primarily to an erroneous conception of the structural alter- ations which such traumatisms produce, and to a conse- quent failure to either accurately define the resultant mor- bid conditions or to systematize the symptoms which they present. Following an imperfect apprehension of the na- ture and effects of structural lesions, intracranial injuries have been considered largely in the light of theoretical pre- conceptions. Mistaken views of both pathology and symp- tomatology, strengthened by time and tradition, have re- tained acceptance, or have been formally discarded, only to be again practically rehabilitated. Recognition is still given TRAUMATIC INTRACRANIAL LESIONS. 65 to a hypothetical disorder which is without pathological foundation; symptoms are still grouped under a single comprehensive designation, which result from varied patho- genic conditions, and which present as many points of contrast as of similitude; fact has been subordinated to fancy in order to establish antitheses which are inaccurate in every particular; a comprehensive inflammation of the entire cranial contents has been assumed which has no basis of truth. Concussion, compression, and encephalitis are terms which still hold a place in the vocabulary of sur- gical literature. I have heretofore considered the subject of concussion, and shall recur to compression and encepha- litis hereafter. In a previous paper, of which this is a continuation, and to which I am so often compelled to refer, I detailed the traumatic lesions which were revealed in a considerable number of necropsic examinations, and made them the basis of classification of the morbid conditions which they had occasioned. In an even larger number of necropsies ob- served since that time parallel conditions have been found to exist. As each form of lesion is attended by character- istic symptoms, and as no evidence is adduced that symp- toms occur independent of anatomical alteration, it is log- ical and, I think, essential to recognize groups of symptoms under the name of their pathogenic lesion. The attempt to classify traumatic or other diseases by their outward manifestations is arbitrary, misleading, unphilosophical, and contrary to what has come to be accepted as the true principle of nosography. It is beyond my province to insist upon the proper basis of nosology, which has been so learnedly demonstrated and so felicitously formulated by my distinguished colleague, Dr. J. W. S. Gouley.* * Diseases of Man—Nomenclature, Classification, and Genesis. Dr. John W. S. Gouley, Surgeon to Bellevue Hospital, New York, 1888 5 66 THE DIFFERENTIAL DIAGNOSIS OF These lesions, reaffirmed in brief, are : (1) Intracranial haemorrhages from injury of the bone, brain, or membranes; (2) arachnitis, from injury of the arachnoid membrane and pia mater; (3) lacerations and contusions of the brain sub- stance ; to which may be added (4) pyogenic parenchyma- tous inflammation. I omit reference to disorganizing injuries in which the brain and its membranes are alike involved; they are patent and have no relation to classification. There is another lesion—thrombosis of the dural sinuses, which I have been unable to connect with symptoms. The prevalence of errors in pathology and of faulty generalizations in symptomatology, together with the in- herent force which they derive from prescription, may be reckoned extrinsic causes of diagnostic uncertainty. Some of the sources of confusion and failure which I indicated m a previous study of head injuries may be regarded as intrinsic. In the second class the multiplication of lesions in the same case and the apparent identity of symptoms from dissimilar causes may be counted as most efficient. I believe the " Ariadnean thread " should be sought in the study of those cases in which the lesion is either simple or in which one out of many is primary and of paramount importance. The clew once gained, it ought to be possible to follow it through the more complicated cases. I. HAEMORRHAGE. Traumatic intracranial haemorrhages are usually classified as (1) epidural, (2) subdural, and (3) cortical or pial. This is hardly accurate or complete, though not absolutely objec- tionable. No exception can be taken to the term epidural as denominative of an extravasation between the bone and the dura mater, for it is anatomically correct. The use of the word subdural is less felicitous, since the effusion is into the TRAUMATIC INTRACRANIAL LESIONS. 67 arachnoid cavity and not between the dura and the parietal arachnoid. Haemorrhages, again, which occur between the visceral arachnoid and the brain are better subdivided so as to imply cause as well as location. A more accurate classification of haemorrhages, if made purely in accordance with location, would be : (1) Epidural, (2) arachnoid, (3) subarachnoid ; but as the arachnoid variety is merely an accidental extension of any subarachnoid haemorrhage, and as the subarachnoid is of composite origin, a better, and I believe the best possible, subdivision is into (1) epidural, (2) pial, (3) cortical. The matter of nomenclature is of absolute importance, since pathological exactness is essential to correct diagnosis, and a change of established form, always to be deprecated, becomes in this instance a logical necessity. I at one time believed epidural haemorrhage to invaria- bly result from cranial fracture. 1 have more recently seen three cases in which it was occasioned by contusion from contrecoup. Its source may be either in the diploe or in the osseo-dural vascular connection. Pial haemorrhage is caused by contusion of the pia mater and consequent rup- ture of its vessels, while cortical haemorrhage, though occu- pying the same anatomical position in the subarachnoid spaces, is derived from laceration of the brain surface. These three haemorrhages are always primary ; arachnoid haemorrhage, as I have stated, is always secondary. It is in most cases a cortical haemorrhage which breaks through the pia and visceral arachnoid ; a pial haemorrhage from contusion is not often in sufficient amount to rupture the arachnoid membrane, though an occasional instance will be found in the histories which I have presented. That blood from the osseo dural vessels may reach the arachnoid cavity when the injury at the same time involves both bone and dura is evident, but that no epidural haemorrhage in 68 THE DIFFERENTIAL DIAGNOSIS OF itself has power to rend the dura seems equally certain; the fibrous structure resists while the brain substance is compressed and displaced, even though blood is effused in enormous and fatal quantity. Intracerebral haemorrhage is the result of subcortical laceration, or rather a part of it, and therefore not a dis- tinctive lesion. The differential diagnosis of haemorrhage is of special impor:ance, since of all the intracranial lesions it most fre- quently admits of operative interference. Its origin and location are no less important as constituting a second fac- tor in determining the propriety of operation. A casual examination of the cases which I have re- corded will demonstrate the exceeding frequency of haemor- rhage in all forms of intracranial injury. In nearly sixty per cent, it has occurred in sufficient quantity and in such relation as to largely influence the final result, and to be- come a more or less determinate factor in the genesis of symptoms. In one third of this percentage it has been the direct and probably the sole cause of a fatal termination. It is doubtful, however, if it is ever an isolated lesion. In a very large proportion of the whole number it was second- ary to laceration, and while this was in itself often insig- nificant, the haemorrhage was none the less profuse and the source of both symptoms and danger. In the residue of cases, though it was primary, it was not unexpectedly associated with other structural alterations. The same vio- lence which is sufficient to separate the dura from the bone, or to rupture the vessels of the pia mater, can hardly fail to be transmitted to the brain, and its effect either con- centrated in a local laceration by contrecoup or diffused in a general contusion of its substance. A haemorrhage ia often regarded as uncomplicated from want of sufficiently careful necropsic inspection of the brain throughout its TRAUMATIC INTRACRANIAL LESIONS. 69 whole extent. There may be no laceration or other ob- vious local injury, and general contusion is readily over- looked. I have but once observed in necropsy a haemorrhage where the associated cerebral contusion seemed so slight as to be unimportant. There are twenty or more cases, how- ever, in which haemorrhage was the essential lesion, and which, perhaps, afford sufficient ground for inductive ex- amination. There is probably a larger number than I shall analyze, but it is impossible to rate them with even approxi- mate precision. They include nine epidural haemorrhages and eleven of pial or cortical origin, of which five had reached the arachnoid cavity. If to these are added eight cases which were subjected to trephination, and in which the existence and location of haemorrhage was thus verified by operation, and in which no considerable depression of bone or other evident complicating lesion existed, the total number will be increased to twenty-eight. One of the operative cases disclosed both epidural and arachnoid haem- orrhage, and terminated in death; the others were all of epidural character, and resulted in recovery. The symptoms ob>erved were not numerous, and of these temperature, when considered with proper regard to its sur- rounding conditions, was of greatest diagnostic significance. In seven of the necropsic cases it was unrecorded ; in seven of those remaining it was on admission subnormal ; in five it was 99° to 99°+ ; and in one, which also involved slight contusion of the corpus striatum, it was 101°. In those cases, three in number, in which it subsequently exceeded 101°, there were notable coexistent lesions of the brain substance; one presented extensive lacerations of the base, another extensive general hyperaemia and oedema, and in a third, in which the temperature rose from 94° to 102° in the eight to ten hours which preceded death, there was impli- 70 THE DIFFERENTIAL DIAGNOSIS OF cation of a supposed heat center. In the operative cases the highest temperature was 101*6°, and in the only one in which it exceeded that degree it reached 102° after the formation of a fungus cerebri. I have already attributed the early subnormal temperature to shock, and, when the patient has survived this condition, I have seen that the temperature has been restored with the general reaction. In each case in which subsequent elevation exceeded 101° + there has been marked general contusion or other concomi- tant injury of the parenchyma of the brain. In these twenty eight cases, therefore, best fitted for observation, the temperature characteristic of haemorrhage has been found to range from above normal to 101° + . The one constant symptom in fatal cases was some degree of unconsciousness. In the majority it was pro- found, or at least complete, from the moment of injury to the end of life. In four others consciousness was primarily lost, and, after more or less complete restoration, was merged in final coma. In three instances consciousness was retained for some length of time, during which the patient walked for a considerable distance, and then either gradu- ally or suddenly became unconscious. In another case of late unconsciousness delirium followed, and continued till death occurred. In a final instance unconsciousness was primary, but, as in the case just mentioned, delirium fol- lowed hard upon it without a period of conscious intelli- gence. In the operative cases in which recovery ensued, and in which it is fair to assume that the effusion was smaller, loss of consciousness was less constant, occurring in but half their number. In two the mental condition re- mained unaffected, and in one unconsciousness was replaced by delirium; in three cases in which it was a symptom, it was very transitory in two, and in one but moderately pro- longed. TRAUMATIC INTRACRANIAL LESIONS. 71 The varying phases of unconsciousness, the diverse symptomatic conditions with which it is associated, and the uncertain period of its occurrence, render it impossible to accept the traditional explanation of its existence, that it is solely dependent upon a mechanical compression of the subjacent brain substance. It is probable that as a primary symptom—as an instantaneous result of injury— it is due to general contusion, which is itself an instanta- neous lesion. It has been seen in the larger number of the fatal cases collated that it has been absolutely the first symptom, not only at the time of admission, but as learned at the scene of accident and noted in the ambulance history. The effusion of a sufficient amount of blood to act me- chanically requires an appreciable interval. This is evi- dent in two of the cases of rupture of the arteria menin- gea media, in which some hours elapsed before the patient became unconscious, and in which the epidural clot was found to be of enormous size. There may or may not be a restoration of the intellectual faculties between the ear- lier and the later lapses of consciousness. The general cerebral contusion may be so severe that the unconscious- ness which it produces will continue till the effusion has become sufficient to occasion the same condition as a direct result, and one is lost in the other. It is also possible that the central lesion may be insufficient to annul conscious- ness for the time necessary to the effusion of blood in sufficient quantity to act as an immediate stupefying agent. This opinion as to the manner in which loss of conscious- ness occurs in intracranial lesions will be strengthened by the wider comparison of cases to be made, in which haemorrhage was a contributive rather than an essential lesion, and in the direct study of other forms of injury. Much importance has been attached to disturbance of the pupils in traumatic haemorrhage. The cases under 72 THE DIFFERENTIAL DIAGNOSIS OF present consideration in most instances show some change in the pupillary condition. It has been unnoted in two of those which were fatal and in three of those which were subjected to operation ; it has been normal in but three out of the remaining twenty-three. The pupils in the cases of abnormity have afforded almost every possible combina- tion of dilatation with contraction. In six both pupils were dilated, the haemorrhage being in three epidural, in two pio-arachnoid, and in one epidural and pio-arachnoid combined. In four both pupils were contracted, the haem- orrhage being in one epidural, in one pial, in one both epidural and arachnoid, and in one both epidural and cor- tical. In two the pupil was dilated on the side of injury and contracted on the opposite side, the haemorrhage in each being epidural; in two the pupil was contracted on the side of injury and dilated on the opposite side, the haemorrhage in each being epidural and derived from the middle meningeal artery ; in three the pupil was dilated on the side of injury and normal on the opposite side, the haemorrhage in each being epidural; in three the pupil was normal on the side of injury and dilated on the opposite side, the haemorrhage being cortical in two and epi- dural in one. There was no instance of contracted pupil on either side without change in its fellow. In the three cases in which both pupils remained normal the haemor- rhage was epidural in one, pial in another, and cortical in the third. The haemorrhages occurred upon every part of the cerebral and cerebellar surfaces, vertex, and base. There seems to be no change in the pupils, Hutchin- sonian or otherwise, which is positively characteristic. In two thirds of the cases analyzed the haemorrhage was wholly or in part epidural, and in two thirds of these again one pupil or both was dilated; but as in the aggregate all sorts of pupillary changes resulted from all sorts of haemor- TRAUMATIC INTRACRANIAL LESIONS. 73 rhages, their observation can be scarcely more than con- firmatory of an opinion justified by the collation of other symptoms. Their condition as to mobility was scarcely more to the purpose; in the far greater number, whatever the origin, location, or amount of haemorrhage might he, they were freely movable. The pulse was unnoted in three cases; it was normal in four, in two of which the haemorrhage was epidural, cover- ing the convex surface of a hemisphere, and in two was of subarachnoid origin, occupying the inferior occipital fossae. In the larger number of cases it was frequent, and the haemor- rhage, usually large, was of either variety and variously situated. In six cases in whch the pulse was slow, the haemorrhage was in each instance epidural, and the patient profoundly unconscious, and in four the respiration was stertorous In neither the fatal nor the operative cases was there any definite relation discovered between the character of the pulse and the nature of the haemorrhage, or between it and the associated symptoms. There is another pulse condition, a want of symmetry in radial pulsation upon the two sides of the body, which I have found to occur in connection with both haemorrhages and visceral injuries, and shall give consideration hereafter. The respiration afforded more definite indications. It was normal in but a single instance. It was increased in frequency in two cases moderately, and very markedly or excessively in six others, the haemorrhage having occurred with a single exception upon the convex surface of the brain. In nine cases the respiration was stertorous, and in seven of them the haemorrhage, which was epidural in six, not only covered, but compressed the cerebral surface upon the side of injury or occupied the anterior fossae; in the other two it was rapid, accompanied by cyanosis and pul- monary oedema, and the haemorrhage covered the pons and 74 THE DIFFERENTIAL DIAGNOSIS OF to some extent the medulla. None of the operative recov- ering cases presented any noticeable deviations from nor- mal respiration. The disturbance or abrogation of muscular function was an occasional symptom, and was exhibited in accordance with established laws of cerebral localization. Paralysis occurred in three of the fatal cases and in two of those which recovered after operation ; it was hemiplegic in four and paraplegic in one. Muscular rigidity, affecting one side or both, occurred in five cases, and general convulsions in one which was fatal. In each case some part of a motor area was covered by the haemorrhage, which was indiffer- ently epidural, cortical, or pial, and acted as a paralyzing or irritant lesion according to its extent and situation. These motor disturbances, while of great positive diag- nostic importance, are so frequently absent that they have no corresponding negative value. In a single case there was protrusion of both eyes as well as dilatation of both pupils. There was found an epi- dural clot in the right inferior occipital fossa and an arach- noid haemorrhage which covered both frontal, and the parietal lobes as far as the fissure of Rolando. Sensory disturbances were still more infrequent. De- lirium was noted in three cases : in one which recovered it was primary, and the haemorrhage, as disclosed by the trephine, was epidural and in trivial amount; in two fatal cases it was of later occurrence, followed a previous condi- tion of unconsciousness, and was associated, in one with a pial haemorrhage over the right hemisphere and inferior surface of both occipital lobes, and in the other with a cor- tical haemorrhage covering the pons ; in both general con- tusion was well marked. Partial anaesthesia, irritability, and restlessness were observed in isolated cases. In order to further test the diagnostic value of the TRAUMATIC INTRACRANIAL LESIONS. 75 symptoms observed in this limited number of cases, I have analyzed thirty-four others in which, though the associated lesions were more severe, the haemorrhage was sufficiently large, absolutely or relatively, to be a probable source of distinguishable symptoms. They present some points of difference which naturally followed from different attendant conditions. In the larger proportion of both necropsic and operative cases, in which haemorrhage seemed to be the single source of danger, it was of epidural origin. In the present group of cases, in which the brain and its mem- branes are more seriously involved, it is with few excep- tions essentially pial or cortical. When these parts are the seat of excessive general contusion without laceration, the pial vessels are naturally the ones most likely to suffer rup- ture, and in fact in every such instance the haemorrhage, if subdural, was of this character; in two it chanced to be epidural. When the brain substance is superficially wounded, the cortical vessels are obviously most likely to he the source of haemorrhage. It is also inevitable that when life is prolonged the symptoms of haemorrhage should be often modified, superseded, or complicated, by others characteristic of the additional lesions. The temperature loses its diagnostic importance. It is generally higher than in the previous instances where haem- orrhage was less complicated. In ten cases it ranged from 105° to 107*8°, and in twenty-six it was above 103°. In the cases which terminated fatally within twenty-four hours, which was the limit of life ascribed solely to haemor- rhage, the temperature, as in them, did not usually exceed 101°+ ; in four, however, in which death occurred within even less than twelve hours, it rose to 102*2°, 106-8°, 107-8°, and 103°. Subnormal temperatures on admission were in- frequent. Consciousness in these cases, as was noted in those sub- 76 THE DIFFERENTIAL DIAGNOSIS OF jected to operation, was less uniformly lost than when death seemed to result directly from haemorrhage, yet in far the larger number its loss was primary, complete, and perma- nent. In some it was at first partial, but progressive, and eventually complete; in others primary unconsciousness merged in delirium ; in a few instances consciousness was at first retained, only to be lost at a later period. In gen- eral, the results of this examination are confirmatory of those obtained from the study of the less complicated cases. The pupillary condition was less diversified than in the cases previously detailed. It was normal in about the same proportion of those in which record was made. There was much more frequent dilatation of both pupils—more than twofold ; an equal number in which both were contracted, and consequently fewer instances in which the two pre- sented opposite conditions. As before, there was no case in which one pupil was contracted without change in its fellow. When both pupils were abnormal the haemorrhage was usually bilateral; and in unilateral dilatation the haem- orrhage was usually upon the corresponding side; but in neither instance was the rule invariable. In the two cases of normal pupils the haemorrhage, which was large in each, was epidural in one and pial in the other, and in each was associated with important change in the brain substance. The pulse when registered was, perhaps, under the influ- ence of opposing forces, usually normal. It was occasion- ally slow or unduly frequent, but oftener exhibited that want of symmetry in force and fullness upon the two sides which I have mentioned as occurring in different forms of intracranial injury. The respiration was unnoted in a third of the cases, and in many of these, which were among my earlier obser- vations, it was doubtless unaffected, since at that time nor- TRAUMATIC INTRACRANIAL LESIONS. 77 mal conditions were unrecorded. If moderate allowance be made for such omissions, the proportion of mixed cases in which its frequency was from 18 to 24 in the minute, and in which it was without special characteristics, was from one third to one half, while in those in which haemor- rhage was more nearly an isolated lesion it was of nor- mal character in but a single instance. It was stertorous in about the same proportion of cases as in the former class, so that those remaining, in which it was abnormally slow or frequent, are necessarily few. The muscular system again not infrequently afforded symptomatic indications. In each instance in which an irregular excitation of functional activity was manifested by either clonic or tetanic contraction the haemorrhage was complicated by cerebral or cerebellar laceration. In others, in which muscular power was lost or held in abeyance, the complicating lesion was invariably general contusion. Clonic contractions were relatively frequent; general convulsions, while but once observed in the class of comparatively pure haemorrhages, and then as merely localized convulsive move- ments, occurred in six of the mixed cases. General mus- cular rigidity in the two classes occurred with more nearly equal frequency. These facts are suggestive of the influ- ences exerted by different lesions. Since, in the group of cases under consideration, the haemorrhage is in each instance associated with some serious injury of the immediate seat of sensory and intellectual function, symptoms which depend upon disturbance rather than upon simple oppression of the nerve centers are to be regarded here as only indirect. Delirium, irritability, or restlessness, when of immediate occurrence, and the effu- sion of blood is moderate in amount, may be considered symptoms of haemorrhage, but only in the sense that a pleuritic pain is counted a symptom of pneumonia. It is 78 THE DIFFERENTIAL DIAGNOSIS OF unnecessary, therefore, where direct brain injury is a recog- nized factor, to investigate such conditions while engaged in the study of uncomplicated haemorrhages. There are two symptoms which have been often held to be diagnostic of intracranial haemorrhage : these are loss of consciousness following cranial injury after some appre- ciable interval, and dilatation of the pupil. This view is not well sustained by the statistical facts which I have col- lated. Reference to either group of cases will disclose comparatively few instances in which consciousness was lost in the manner indicated. Some change in the pupil- lary condition was found to occur in most of them, but it was varied in character and not to be regarded as typical in any one of its forms. Various other symptomatic manifesta- tions have been suggested as indicative of this particular lesion. Some of them, like the dilated and insensible pupil, occur often enough to afford corroboration of an opinion founded upon other evidence; others which arc possible, but, in fact, infrequent, are given an exaggerated diagnostic importance ; and others still, when they chance to exist, have no relation to haemorrhage. The absolute value to be at- tached to these reputed pathognomonic symptoms can be only determined by a reference to the results of actual ob- servations in such an extended series of cases as I have in this instance collected. II. SUBARACHNOID SEROUS TRANSUDATION. In place of a haemorrhage a subarachnoid serous effu- sion is sometimes encountered which is not of inflamma- tory origin. I first called attention two years ago to a special contusion of the membranes as the immediate eause of traumatic arachnitis. Such a contusion may occa- sion either a simple meningeal hyperaemia, a pial haemor- TRAUMATIC INTRACRANIAL LESIONS. 79 hage, a dropsical subarachnoid serous effusion, or some grade of meningeal inflammation. The dropsical transudation is not of frequent occur- rence, and perhaps not easily distinguished from a low grade of inflammatory exudation. If it occurs over limited areas without subarachnoid clot, and without opacity of the arachnoid membrane, or other evidence of the inflamma- tory process, there would seem to be little doubt of its na- ture. All these conditions rarely concur, but there are at least three such instances in my later series of cases, and in two of them the very early fatal termination, within a few hours only, corroborated the opinion formed from necropsic examination. This oedema, like simple hyperaemia, is found to exist in the presence of more serious organic changes, so that it is impossible to connect it with symptomatic condi- tions. III. ARACHNITIS. The impression conveyed by many surgical writers is that traumatic arachnitis is of rather frequent occurrence, and a constant menace in the convalescence of all cases of intracranial injury. My personal observation has led to a different conclusion. If serous effusions of positive or probable congestive origin, and a limited number of meningeal inflammations which were without apparent in- fluence in the progress of other and directly fatal lesions, are excluded, there remain but thirteen cases in which arachnitis was undoubtedly existent and at the same time influential in compassing the final result. These comprised six in which the effusion was purulent, and seven in which it was serofibrinous, in one of which the presence of the Streptococcus pyogenes was demonstrated by culture. In one of the acute cases the purulent formation was the ex- tension of a more profuse pyogenic process along the course of a drainage-tube which traversed the brain substance, and 80 THE DIFFERENTIAL DIAGNOSIS OF in another it was an equally direct extension from an in- fected compound fracture which lacerated the membranes and cerebral cortex. In both, the symptoms were merged in those of the primary lesion. The number of cases use- ful for purposes of analysis is thus reduced to eleven, in none of which the inflammatory process seemed to be propa- gated from a localized injury of the brain or membranes. They are too few in number to afford a basis for any wide generalization in either symptomatology or diagnosis. The course of traumatic arachnitis, however, is not unlike that of the idiopathic form, and conclusions are thus less dependent upon direct observation than in the study of other intracranial lesions. These cases are at the same time in sufficient number to make their analysis important and to justify an epitome of their already abstracted his- tories. Case I. Acute.—Primary symptoms referable to depressed fracture, subcortical laceration, and general contusion. On the second day, patient irritable and somnolent. Temperature, 102° ; bone elevated. Fourth day, temperature, 105°. Fifth day, patient delirious, restless, and sensitive to external im- pressions ; surface hot, pupils moderately dilated and slow to act, and coma which continued till death on the seventh day. Temperature varied from 104°+ in the morning to 105°+ in the evening; pulse and respiration much increased in frequency. Lesions.—Fracture of base and vertex; lacerations, pial haemorrhage, and contusions of brain and membranes; puru- lent effusion over occipital and posterior parietal lobes on both sides, and in inferior occipital fossa of the side of injury. Case II. Acute.—No primary symptoms. On second day, temperature, 101*6°; and afterward 99°+ till the tenth day, when without the occurrence of intervening symptoms it rose to 101° + , on the next day to 104*6°, and afterward varied from 103° to 104°+ till the fifteenth day, when it began to rise progressively and reached 107*4° on the sixteenth day shortly before death. On the tenth day, coincident with the rise in the TRAUMATIC INTRACRANIAL LESIONS. 81 temperature, the patient became restless and slightly delirious; on the eleventh day he had a slight chill and increased de- lirium ; on the fourteenth day there was posterior cervical rigid- ity, and on the fifteenth a slight general convulsion. The pupils and respiration were normal, pulse was 104 to 112, and mental condition sluggish. Lesions.—Fracture of vertex which was confined to external table; purulent effusion over both frontal lobes, encroaching upon parietal and extending into median fissure. Case III. Acute.—Patient in alcoholic condition ; restless- ness succeeded by stupor, occipital pain, with epigastric pain and vomiting. Temperature on admission, 102-6°; next day, 105°; and third day, 103-8°; pulse moderately accelerated, 120 to 84; respiration not above 24, and pupils normal. Lesions.—Subarachnoid serous effusion; much purulent effu- sion anteriorly upon both sides of the vertex, but mainly upon the left. In each of the previous instances the presence of the strepto- coccus was demonstrated by culture. Case IV. Subacute.—Primary symptoms from subcortical laceration and general contusion, which subsided through sec- ond and third weeks. Temperature fell to below 100°, and pa- tient became asthenic. Three days before death he became unconscious, and the temperature rose to 100° + , and on the next day to 103-8°; then varied from 103° to 104-8°, and later rose progressively to 109°. There were alternating periods of rational intelligence and of wild delirium up to the time of final unconsciousness. Lesions.—Subcortical laceration and excavation of an entire frontal lobe, and excessive general hyperaemia; serous effusion over all parts of the brain with well marked arachnoid opacity. Case V. Subacute.—Primary symptoms of general contusion and of lesion of the motor area. Fourth and last week, mental apathy replaced by mild delirium; three days before death temperature rose from 99° to 104°, declined to 100° on the fol- lowing day, and again rose to 104°. Death occurred on the twenty-eighth day. Lesions.—General contusion and a small superficial cavity 6 82 THE DIFFERENTIAL DIAGNOSIS OF from a local contusion in the leg area of one side; serous effu- sion compressing both frontal lobes. Case VI. Subacute.—Primary symptoms of cerebral injury; temperature did not exceed 99°+ for the first week, then rose suddenly to 102 8° to 103-2°, and afterward varied irregularly from 99° to 104° ; pulse and respiration only became frequent at the last; mental condition alternately stupid and delirious from the beginning. Death occurred in sixteen days. Lesions.—Fracture of the base, laceration of both frontal, and of one temporo-sphenoidal lobe; subarachnoid clot in occip- ital region ; general serous effusion with arachnoid opacity. Case VII. Subacute.—Primary symptoms from cerebral contusion which continued three weeks. Temperature in sec- ond and third weeks, 98-5° to 99° + , with progressive mental improvement. In the fourth week the mental condition de- teriorated. On the twenty-third day, temperature, 101°; in the four days following it varied from 98*5° to 101 6", and the pulse was frequent; on the twenty-seventh day, temperature rose from 100-6° to 106-6° without remission, and in the right axilla was from half a degree to a degree and two tenths higher than in the left; on the twenty-eighth and last day it was 108°, and the pulse, previously frequent, was from 54 to 74. The respiration was accelerated during the last two days, and the patient became irritable and restless. Lesions.—Fracture of the base, several necrotic contusions upon the superior surface of the prefrontal lobes; general con- tusion with oedema; and general serous effusion over superior and lateral surfaces of the brain. Case VIII. Subacute.—Primary symptoms from parenchy- matous injury. Temperature normal from sixth to ninth day, and afterward much of the time subnormal till the thirteenth day, when a severe chill was accompanied by an elevation to 101° + . A second chill on the nineteenth day was followed by a progress- ive rise of temperature to 105*5° at death on the twenty-first day. After the second chill the patient grew mentally sluggish and became weaker; pulse and respiration were frequent. Lesions.—General contusion of the brain with oedema; sub-cortical laceration of a frontal lobe; and serous effu- TRAUMATIC INTRACRANIAL LESIONS. S3 sion with arachnoid opacity over superior and lateral cerebral surfaces Case IX. Subacute.—Primary symptoms, those of general contusion, followed by an intercurrent bronchitis. On the thirteenth day, occipital headache, which became general; somnolence and irritability ; temperature, 101° to 101°, and on the eighteenth day, 105°, with delirium and post-cervical rigidity ; later, increased delirium and somnolence, with symp- toms referable to implication of cranial and spinal nerves ; pn>- gressive emaciation; lack of urinary and faecal control; rapid and insufficient respiration ; unconsciousness and death on the thirty-first day. Temperature from 100° to 104° ; pulse, 64 to 90; axillary temperatures variable, and when unsymmetrical, more frequently half a degree higher on the side opposite origi- nal iniury. Lesions.—Fracture of the base, thrombi in the lateral sinuses, general contusion of the brain with oedema ; turbid serous effusion in the ventricles and at the base; thick membranous effu- sion over the pons, medulla, inferior surface of the cerebellum, and in the fissure of Sylvius; fornix much softened, and trivial lacerations of one temporo-sphenoidal lobe. The Streptococcus pyogenes was discovered in cultures of the membranous effusion. Case X. Subacute.—Primary symptoms of general contu- sion ; unconsciousness which merged in final coma; restless- ness ; pupils widely dilated but responsive to light; urine re- tained ; left side temporarily rigid; right side paretic; pulse and respiration continuously frequent; temperature on admis- sion normal; subsequent variations: 102-2°, 101°, 101° + , 102° 105°, 104° + , 102° + , 100° + , 101° + , 102° + , 105° + , 106°; one hour post mortem, 106*2°. The axillary temperatures were symmetrical for forty-eight hours; then, with a rectal tempera- ture of 102*6°, temperature in the right axilla was 103 2°, while in the left it was 100-4° ; and at fifteen minutes' intervals rose to 101-4° and 102-8° in the left without change in the right. At this time the left upper extremity and foot were in- tensely cold to the touch. Death occurred in fifty-three hours. Lesions.—General contusion with oedema; laceration in substance of the fornix ; small pial haemorrhage upon the in- 84 THE DIFFERENTIAL DIAGNOSIS OF ferior surface of the cerebellum ; small haemorrhagic serous effusion in one lateral ventricle, and large serous effusion with arachnoid opacity over the occipital and posterior portion of the parietal lobes. Case XL Acute.—Primary symptoms of fractured base; temperature high from the first day; from 104°+ to 1056° till fourth and fifth days, when it receded to 102-8° to 101°, and again rose to 104°+ to 105°+ on the sixth and seventh days; muscular twitchings of the right side of the body and left hemi- plegia andjiemianaesthesia on the sixth day; general convul- sion beginning on the right side preceded death, which occurred on the seventh day. Lesions.—General subarachnoid purulent effusion most copious over the left frontal lobe below the origin of the frac- ture. It would seem impossible to determine a priori the cir- cumstances under which an arachnitis is likely to follow meningeal injury. The alcoholic habit existed in but a minority of cases, the previous constitutional condition was often unimpaired, and the age ranged from early youth to past the middle period of life. The coexistent lesions were diverse, and had no obvious relation to the changes which the membranes had suffered. Fractures of the skull, cor- tical or subcortical lacerations, haemorrhages, or notable general contusions were variously discovered upon necrop- sic examination. Some degree of meningeal implication is probably almost invariable in intracranial injuries, but these cases fail to afford a clew to the immediate conditions which occasionally favor the development of arachnoid in- flammation. The time of invasion was equally uncertain; it was in some instances immediate, and in others delayed for weeks after the reception of the injury. The interpreta- tion of symptoms had therefore to he made without mate- rial aid from considerations of time or circumstance. In three cases the arachnitis was primary, in another TRAUMATIC INTRACRANIAL LESIONS. 85 its initial symptoms were so insidious as to fail of recogni- tion, and in the remaining seven its invasion was late and sharply defined. In the larger number, which may be con- sidered typical, the course of symptoms referable to com- plicating lesions was interrupted by a distinct and some- what sudden elevation of temperature accompanied by an evident change in the general condition of the patient. He became irritable, restless, delirious, or somnolent, and in one instance suffered a severe chill, though the effusion did not prove to be of purulent character. The subsequent range of temperature was erratic. It was marked by variations from day to day or from hour to hour, not usual in other intracranial lesions. The arachnitis was so con- stantly associated with other grave structural alterations that it is impossible to demonstrate its exact relation to temperature, but if my observations in these few cases which were capable of verification may be supplemented . with others made in recovering cases which I had reason to believe were arachnoid inflammations, I should infer that this variation was characteristic and ranged from 101°+ to 104° + . In the majority of verified fatal cases the temperature immediately before death was from 105° + to 109° ; but in each some lesion of the brain substance ex- isted in which a very high temperature was to be expected. In one exceptional case without such complication, in which it reached 107-4°, the effusion was purulent. Whether or not these fluctuations of temperature are due to a secondary implication of thermotaxic centers situated in the cerebral cortex, as suggested by Hale White, is im- material in a study of symptoms as related to diagnosis. After the invasion, and aside from peculiarities of tem- perature, the progress of the diseases was especially char- acterized by continued manifestations of cortical irritation. Some grade of delirium persisted in almost every case, and 86 THE DIF1ERENTIAL DIAGNOSIS OF restlessness, irritability, or extreme sensitiveness to exter- nal impressions was often marked long after consciousness was finally lost. General or post-cervical muscular rigid- ity, in one instance a slight general convulsion, and in an- other a chill, were furttier indications of nervous excita- tion. They all, with the exception of the case of basilar inflammation, terminated within the week, and rather from asthenia than from coma the result of pressure. The pupils were oftener normal than otherwise, and the pulse and respiration failed to reflect the existing inflammatory process; moderate acceleration of the pulse and very slight, if any, increase in the frequency of respiration seemed to be the usual conditions. It can not be said that there was any sharp contrast in symptoms which indicated the character of the effusion. In one of the acute cases there were classical symptoms of sthenic inflammation, but there was no chill; in another, which began with a chill, the subsequent symptoms were no more pronounced than is common in the subacute form ; while in the third and last, the invasion and progress of the inflammation were remarkably insidious. The question of infection is uncertain. There was fracture of the vertex in two of the acute cases, and a scalp wound in the third; and in the case of basilar arach- nitis, in which the Streptococcus pyogenes was discovered in a large sero-fibrinous effusion, there was a fracture through the internal auditory canal and rupture of the tympanum. There was no more than a possibility of di- rect infection in three out of the four; the wounds were maintained in an aseptic condition, and in the absence of an evident pyogenic process there was no proved patho- genic relation between the external lesion and the character of the internal inflammation, and no good reason to assume that it existed; if in the fourth case the access of the pyo- TRAUMATIC INTRACRANIAL LESIONS. 87 genie germ is more readily comprehensible, the general history is better interpreted upon the supposition that its development was in the usual course of idiopathic secondary serous inflammations in prolonged disease, with the added predisposition derived from a previous local contusion. I am indebted to the courtesy of Dr. II. M. Biggs for notes of eight unpublished cases of infective purulent arachnitis which were not of traumatic origin. They ex- hibit the same irregular fluctuations of temperature and the same varied manifestations of cortical irritation which were observed in traumatic cases of either form which I have collated. They are of interest here as confirmatory of the proposition that the symptoms of arachnitis are not necessarily modified by its cause or grade. It is clear from this analysis of meningeal haemorrhages and inflammations that the attempt to crystallize their symptoms with those of depressed fractures, and to formu- late in a single word—compression—a resulting condition, is futile and misleading. It is no more defensible than a former practice of grouping organic diseases under the common name, dropsy. These several results of cranial in- jury indicate entirely different pathic conditions, and their external manifestations are more marked in their differences than in their resemblances. Even the cerebral compression which they are supposed to characteristically produce is in the majority of cases absent or replaced by a still more characteristic irritation. When it is further attempted to discriminate these artificially consolidated lesions from in- juries of the brain substance by antithetical tabulations of symptoms, the possibilities of error are arithmetically in- creased. It is practicable from an examination of the cases which I have cited to demonstrate the unreliability, both positively and negatively, of each assumed individual diagnostic symptom in any one of the tables which are 88 THE DIFFERENTIAL DIAGNOSIS OF scattered through surgical text-books. The importance of a statement which I have previously made that a proper classification of morbid conditions must be based upon structural alterations, and their diagnosis established by careful analysis and comparison of resulting symptoms, is warrant for its repetition. The diagnosis of fractures, meningeal haemorrhages, and meningeal inflammations from brain lesions in the manner to which I have excepted fails in both particulars. A defective classification has been supplemented by an inaccurate analysis of symptoms, and faulty generalization has resulted in prevalent confusion. IV. lesions of the brain substance. The injuries which the brain may suffer are general and local: a diffused contusion or a limited lesion, which may be either a contusion or a laceration. The analysis of cases which I have made demonstrates the exceeding fre- quency of visceral lesions. I have intimated the probabil- ity that some degree of general contusion always exists in intracranial injury, even though some other lesion may be paramount. At the time of my earlier observations it was only noted when its evidences were strikingly apparent, and even at a somewhat later date only when they were more than ordinarily well pronounced; yet with these limitations it will be found recorded in more than fifty per cent, of the total number of cases. Local Contusions, on the contrary, have been of comparatively infrequent occur- rence, while lacerations have been discovered even oftener than well-marked structural alterations of a general char- acter. Meningeal contusion, independent of recognized visceral injury, has been encountered in but three instances, in each of which a fatal arachnitis resulted. Epidural haemorrhage, in which the effects of violence inflicted upon the cranium had not been extended to the brain, has not TRAUMATIC INTRACRANIAL LESIONS. 89 been once disclosed. Some implication of the brain, there- fore, may be regarded as practically assured in all cases of cranial injury. In the study of brain lesions it is necessary to deter- mine not only the symptoms they may have in common, but if possible the existence of others characteristic of in- dividual forms. 1. General Contusion.—Notwithstanding the very con- stant occurrence of general contusion, it so rarely terminates fatally when uncomplicated by other structural changes that opportunity for observation of its distinctive symptoms is much more limited than in cases of haemorrhages and arachni- tes. I am enabled, however, to present six cases in which no concomitant lesion existed, or in which, if present, it was so trivial that it may be fairly assumed to have had no influ- ence in the production of symptoms. In one there was ab- solutely nothing beyond the general contusion; in two there were also limited and non-infective dural thromboses ; in another there was a single small extravasation into an optic thalamus, and in the other two there was a slight cor- tical laceration and correspondingly unimportant cortical haemorrhage. In all there was a more or less intense gen- eral hyperaemia, which was sometimes more strongly pro- nounced in some particular region, as anteriorly, poste- riorly, at the base, or in one hemisphere, than elsewhere. In three cases the pia was notably engaged; in three there was well marked or even excessive general oedema; in four, thrombosis of the minute vessels, which generally charac- terizes contusion, was a pronounced feature. I regard the last-mentioned condition as a manifestation of contusion, as it is habitually absent in the hyperaemia of idiopathic dis- ease. Punctate extravasations were less numerous than is usual in the more frequent instances in which hyperaemia is associated with laceration. In those cases in which 90 THE DIFFERENTIAL DIAGNOSIS OF death was long deferred, the absence of inflammatory pro- cesses was verified by microscopic examination made at the time of necropsy. The analysis of symptoms in the six cases is unsatis- factory. The few connecting links which measurably held together the cases of haemorrhage or arachnitis have no corresponding representation. There was no uniformity either in the occurrence of individual symptoms or in their course or termination. In the single one which was abso- lutely uncomplicated there was no loss of consciousness at any time, till its final lapse from asthenia ; in all the others it was primary and in three was permanent. There is no other individual symptom which occurred in more than half the cases cited. The pupils were dilated, contracted, or normal; the pulse and respiration were variable. It is true that delirium, mental irritability, or apathy, combined with muscular rigidity, convulsions, or some degree of paralysis, occurred in each instance save one, and in that one a profound coma from the beginning held in abeyance all mental and motor functions; but the time of their ap- pearance and the method of their combination had no con- formity to rule. Headache, persistent vomiting, and per- forating ulcer of the cornea were isolated phenomena, and in one protracted case dementia preceded death. The temperature again probably affords the earliest indication of the intracranial condition. It was never sub- normal on admission, and was never more than moderately elevated ; in four cases out of five it was from 99° to 100° ; in the fifth it was 101° + , as it was in the sixth, in which it was not recorded till the second day. Its subsequent course was in general progressive, and with one exception attained a high degree before death ensued. Recessions were observed only once or twice in two cases which were considerably prolonged. TRAUMATIC INTRACRANIAL LESIONS. 91 It is not difficult to comprehend the reasons for the diversity of symptoms, or for their irregular development, in view of the comprehensiveness of the lesion and its different degrees of intensity in different regions. The observation of the fact of regional variations is not limited to the comparatively few necropsies in which un- complicated general contusion has been found to exist, but is even redundantly confirmed in the far greater number in which death has resulted from haemorrhage, arachnitis, or extensive laceration. It is not unusual in case of a contusion which involves the entire brain to find that its structural evidences are emphasized in one hemi- sphere or in certain lobes or in certain regions', it may be in the cortex, the basal ganglia, or elsewhere. It is not more unusual to find in a largely diffused contusion that some part, as the cortex, one hemisphere, or the cerebel- lum, has practically escaped. All the characteristic struc- tural alterations are alike subject to localization. The post- mortem inspections of the brain which I have directed have demonstrated also the instability of the parenchymatous serous exudation ; this not only gravitates to dependent parts, but can often be freely expressed by the hand after section has been made. The dropsical effusion moves through the brain substance with the same certainty, if not with the same celerity, that it does through subcutaneous cellular tissue. There is no more reason to question the fluctua- tion during life in the amount or position of serous trans- udation or in the intensity of hyperaemia originally estab- lished by violence, than there is to doubt their often progressive increase or diminution. The punctate haemor- rhages into the brain substance are, of course, not subject to change, but I believe them to be less influential in the modification of symptoms than the conditions previously described. 92 THE DIFFERENTIAL DIAGNOSIS OF These considerations seem sufficient to account for the wide variations noted in symptomatology. It is unneces- sary to review the cases which illustrate the dependence of symptoms of cortical irritation upon cortical contusion of the vertex, or of pressure symptoms upon excessive general subcortical hyperaemia and oedema, or of various other combinations of symptoms with structural changes. It is quite possible that wider observation may further illumine the invasion and march of symptoms, but as these must continue to depend upon unstable conditions they are not likely even then to become fixed elements in diagnosis. (2) Limited Contusion.—The distinctly limited form of contusion as distinguished from laceration demands but brief consideration. In the occasional instances in which it occurs in scattered areas through the centrum ovale it can afford no indications separable from those of a modified general lesion. In its more usual form, in which it is confined to the cortex, it differs from laceration only in the extent of local injury to tissue, and the character of the symptoms will not be further influenced by the fact that the injury is a bruise rather than a wound. It is rarely a fatal lesion, and its ex- istence is likely to be marked by the coexistence of others- of greater magnitude or severity. It has been noted in hut fifteen of the necropsic examinations which I have made, and in none of these had it appreciably contributed to the fatal result, and in but one occasioned recognizable symp- toms. In the exceptional instance there had been no rea- son during life to suspect that there was a limited contu- sion rather than laceration. (3) Laceration.—I have expressed a doubt whether la- ceration of the brain occurs without some degree of contusion. I may add that a resultant cortical haemorrhage, usually pro- portionate to the extent of local injury, and often sufficiently large to have an intrinsic value in the development of syncq> TRAUMATIC INTRACRANIAL LESIONS. 93 toms, is almost certain to exist as a complicating condition. I have failed to recognize one or both of these attendant le- sions in but few instances, and from the time I began to record the full results of necropsic inspection, the accessory lesions as well as those which I regarded as essential, I have found the rule to be practically absolute. It is probable, how- ever, when post-mortem indications of general injury are not pronounced, and laceration is extensive, with no more than moderate cortical haemorrhage, that the significant symptoms have been derived from the local destruction of tissue. I have collated ten cases in which laceration has been considerable, and in which cortical haemorrhage and general contusion have been apparently insufficient to be symp- tomatically important. They include both cortical and sub- cortical injuries, variously situated upon and beneath the several surfaces of the brain, and have involved both local- izing and non-localizing areas. Consciousness was ordinarily lost in the beginning, though in two instances there was simple obscuration of the mental faculties, and in one consciousness was retained and the mental condition was unimpaired. Delirium very generally followed, often characterized by restlessness rather than by violence, or accompanied by fixed delusions. In one rather lengthened case there was a single delusion in which the patient never faltered, even at times when his in- tellectual poise was otherwise undisturbed. The subse- quent progress of the case, when death was not an early termination, was likely to be marked by evidences of men- tal decadence. Irritability, convulsions, loss of faecal and urinary control, were not infrequent symptoms. The pupil- lary condition was variable, as previously noted in haemor- rhages, and, with the characters of the pulse and respira- tion, will be made the subject of later consideration. 91 THE DIFFERENTIAL DIAGNOSIS OF The examination of temperatures is quite as instructive as in any of the conditions previously studied. In two in- stances the temperature was not recorded; in the eight cases remaining the record is worthy of reproduction in brief : Case VI.—103° on admission; 102° in five hours, and progressive rise to 106 2° at death in twenty-four hours. Case XX.—101° on admission; 104*8° in forty-eight hours and for seventy-eight hours afterward; 101°+ to 102°+ for next ensuing forty -eight hours; and 107°+ at death in seven days seven hours. Rise progressive. Case XXI.—104*8° on admission, after eighteen hours, and death in twenty-six hours. Case XLIV.—98° on admission; 103-6°; 104-6°; 106 6° half hour ante mortem; death in nine hours and a half. Case LI I.—98-6° on admission; 1047° in five hours; 103*8° to 103° on second and third days ; 101° to 99° on fourth and fifth days; 99-8° to 101*8° till the end of the twentieth day ; 1024° on the twenty-first day ; 105° on the twenty-second day ; 97-5° before death on the twenty-third day. Case LIX.—99-8° on the first day; 104-6° on the second day ; 1036° on the third day ; 103-2° on the fourth day ; 107° to 108*2° on the fifth day. Death. Case LXXIII.—99*2° on admission after twelve hours ; 103*8° ; 104° in articulo mortis ; 106° half hour post mor- tem. Death in ten hours. Case C.—100° on admission, thirtieth day; 104°+ to 102° from thirty-first to thirty-fourth day ; progressive rise to 107*6° at death after operation on thirty-sixth day. These temperatures call for little comment. Their re- markable primary elevation, following recovery from shock, and in early fatal cases their rapid and progressive increase, sometimes continued even after death, with in general only TRAUMATIC INTRACRANIAL LESIONS. 95 brief and unimportant recessions, are in such contrast to what has been observed in haemorrhages, meningeal in- flammations, or even general contusions, that they are suf- ficiently striking phenomena to at once challenge and arrest attention. In a single instance in which in the last hours of life the temperature became subnormal, the exceptional fact is probably explicable by the asthenic condition finally induced by an advanced necrotic process. A more comprehensive, and at the same time more ac- curate, conception of the symptoms due to laceration may be obtained from a review of the much larger number of cases in which limited destructive lesions are attended by other anatomical changes, perhaps equally important. It is only necessary to exclude those symptoms which have been found to be referable to each of the attendant lesions as they have occurred elsewhere in comparative isolation. I have subjected to analysis forty-two cases of this type, in all of which the laceration has been distinctly marked, and in most of which the history and necropsic record have been fairly complete. An occasional case has been ad- mitted to consideration in which historical detail has been lacking, but in which some characteristic symptom has been strikingly displayed. The region of the brain in- volved or the nature of the complication has not been regarded. The primary loss of consciousness which has been ob- served to precede the development of positive symptoms in the history of each variety of encephalic injury, and of each combination in which they have been heretofore pre- sented, could hardly fail to characterize this series of com- plicated cases in which no new form of structural alteration exists. Variations in its degree or persistence, which have been noted in connection with other lesions, equally occur in the train of lacerations whether simple or complicated. 96 THE DIFFERENTIAL DIAGNOSIS OF The negative phenomena, if such a term is permissible, are indistinguishable if not identical, whatever lesion or lesions may be afterward discovered. This is readily comprehen- sible upon the assumption already made in case of haemor- rhages, that some degree of general contusion attends all other intracranial injuries, and that to it, in conjunction with possible general shock, the immediate effect of trau- matism is to be referred. If life is prolonged, the primary morbid condition will be replaced or supplemented after a variable period by the characteristic symptoms of the co- existent lesions. In cases in which consciousness has been retained from the first, as occasionally happens, the mental condition is often peculiar; it is not that of partial con- sciousness or of stupor, but rather of blunted perception. The patient seems .lethargic, and, if sufficiently roused, ap- parently comprehends simple questions in a dull way and with effort; but the effort is quite likely to fall short of his making answer; he feels and sees, but scarcely thinks. From this condition he may immediately pass through somnolence or complete unconsciousness into coma and death, or he may at once regain his mental equilibrium. In a considerable number of instances, in place of this direct solution of a psychical problem, a new series of mental phenomena are interposed between the primary uncon- sciousness, or the condition of lethargy to which I have referred, and ultimate recovery or death. In the previous paper upon injuries of the head I sketched in outline certain manifestations of mental dis- order which I attributed to the general class. I am con- vinced from further observation and more careful analysis that their significance in symptomatology should have been restricted to injuries of the parenchyma, and mainly to such of them as were of the limited and destructive variety. I spoke of these mental aberrations as of no more than TRAUMATIC INTRACRANIAL LESIONS. 97 " rather frequent" occurrence, but when restricted to their proper place, as indicative of the lesions which they really represent, they become more nearly pathognomonic; they exist in some degree, or in some combination, in a very large majority of the cases which survive the initial stage. I have seen no reason to materially modify the picture I then presented. In a typical case, delirium of some grade or character follows or precedes restoration to conscious- ness ; it may be violent and simulate the alcoholic form of mania, but oftener the patient is simply restless, excitable, incoherent, or perhaps inarticulate in speech, his mind dis- tracted by fleeting fancies, yet amenable to control. A little later he may recognize his friends, converse intelli- gently and coherently, and during the day and upon cur- sory examination appear quite rational, though still delirious and requiring mechanical restraint at night. He has de- lusions, fixed or transitory, and his memory is defective or entirely wanting in regard to circumstances or occurrences which preceded his restoration to consciousness. He has perhaps no knowledge of his place of residence, occupation, or family ; but whatever else he may remember or forget, he is usually absolutely oblivious of all the circumstances attending his injury, and has no apprehension of his pres- ent surroundings. His nocturnal delirium may soon disap- pear, and eventually, after the lapse of weeks or even months, his mind may become clear, his memory be re- stored, and his recovery complete. In a certain proportion of similar cases the termination is less fortunate, and some degree of permanent dementia remains. In many others, unhappily, the mental horizon never brightens after the in- ception of delirium, or, if at all, for a brief time only, and death is not long delayed. In another type of mental dis- order a condition of apathy or hebetude follows active de- lirium, and is likely to be merged in final unconsciousness. 7 98 THE DIFFERENTIAL DIAGNOSIS OF In still other cases delirium is of a muttering character from the beginning, or from an early stage, and is accom- panied by stupor. The occasional instances in which de- lirium, like absolute retention of consciousness, occurs as a primary condition probably concern the complication, gen- eral contusion, rather than the laceration. It may be worth while to call attention to the frequent want of correspondence observed between the severity or mildness of the invasive psychical symptoms and the final outcome of the injury. A violent commencement has not always involved an answerable sequestration, and so too a good beginning has sometimes made a very had ending; but in either instance failure to forecast the future does not necessarily imply inability to recognize pregnant symptoms. Practically the existence of the lesion has been as legibly stamped upon the histories of such cases as upon those which have run a more conventional course. There is a peculiar irritability or sensitiveness to exter- nal impressions which I have noted as of frequent occur- rence, and have ascribed to cortical injury. It is an exag- gerated response to trivial irritations and disturbances which seems due less to cutaneous or muscular hyperaes- thesia than to an abnormal excitability of the emotional centers. Great vexation and impatience are often manifest- ed from slight irritation, even in the last hours of life when the patient has remained motionless and apparently unconscious for a length of time. Aside from symptoms connected with the perceptive and intellectual centers, loss of control over the bladder and rectum is of first importance among general indica- tions. It is impossible to estimate its numerical frequency, for if these receptacles are empty at the time the brain in- jury is inflicted, and if, as often happens in recorded cases, TRAUMATIC INTRACRANIAL LESIONS. 99 life is afterward measured by hours or minutes even, this diagnostic point is necessarily lost. If such explicable cases are excluded, it may be said to have been very gener- ally observed in the clinical studies of laceration which I have made, though it has sometimes failed of record. It has been equally noted in the absence of any form of paralysis, and when consciousness has been retained; and though some form of mental impairment may have always co- existed, the same loss or aberration of mental power when due to other lesions has not been characterized by this par- ticular functional incapacity. The lacerations have been both cortical and subcortical, and have involved all the lobes and all regions of the brain, so that the direct cause of this lack of control would seem to be any wound of the parenchyma, whether or not it may be ultimately traced to some special center. Convulsions have been of comparatively frequent occur- rence in the fatal cases. I recall but one instance of sub- sequent recovery in which laceration was fairly inferential. In the fifty-two cases upon which thus far conclusions have been founded there were general convulsions in ten, con- vulsive movements in three, and general muscular rigidity independent of meningeal inflammation in two. This is largely in excess of the proportion of cases in which this symptom occurs in haemorrhages, of which it has been sup- posed to be characteristic. I have never known it to fol- low simple general contusion even when of marked sever- ity. I believe the pathic condition upon which convul- sions depend to be distinguishable by certain peculiarities in their manifestation. In haemorrhages they result from compression or concomitant injury of the recognized motor area. In the thirteen cases enumerated in which they fol- lowed laceration, the seat of injury was usually in the front- al or temporo-sphenoidal lobes, or in both together ; in 100 THE DIFFERENTIAL DIAGNOSIS OF two exceptional instances, the optic thalamus was lacerated in one, a parietal lobe was wounded by a fragment of bone in an old infected compound fracture in the other. If in some cases there were additional lacerations of other lobes, they were of secondary importance and distant from motor centers. It is obvious that when convulsions re- sult from an intracranial haemorrhage which has relation to motor centers, they are likely to be preceded or accom- panied by paralysis, as in my own cases, or in three recent- ly reported by Dr. A. J. McCosh. If they are induced by laceration, which as it has been shown is in general frontal or temporo sphenoidal, paralysis is an unlikely factor in the case. It really occurred in but two instances : once in the compound parietal lesion mentioned, and once in a frontal necrosis surrounding a small tumor which was only an incident in a general traumatism. The characters of the associated symptoms—of haemor- rhage on the one hand and of laceration on the other—aid much in determining the significance of a convulsion. The temperature which precedes the paroxysm has special value since it is a very early indication of the nature of the lesion and of positive character. In every instance within my observation it has been distinctly higher than that which accompanies haemorrhage. The immediately subse- quent temperature has, of course, no diagnostic importance. I have been able to discover no absolute law which governs the invasive or initial symptoms, though the first spasmodic movements are perhaps rather more frequently developed upon the opposite side. The paralyses and anaesthesias which may follow lacera- tion are of great assistance in fixing its location after the nature of the lesion has been established. Their very gen- eral origin, however, in haemorrhages, inflammatory effu- sions, or depressed fractures does not warrant the assump- TRAUMATIC INTRACRANIAL LESIONS. 101 tion from the mere fact of their existence that there has occurred a destructive lesion of the brain substance ; but the laceration having been determined by other considera- tions, these conditions may be quite sufficient for localiza- tion. Their connection with laceration is exemplified in many of the cases which I have described. The subject of paralysis and anaesthesia in general is sufficiently well un- derstood to obviate the necessity of giving it any special attention in the present review of symptoms. The irregularity of the pupils has not impressed me as of greater symptomatic importance in this than in other en- cephalic lesions. The forms and combinations of pupillary variation have been so numerous, and the instances in which no pupillary changes have occurred have been so frequent, that I have come to doubt the practical value of the indications which they afford. The ten cases of com- paratively uncomplicated laceration, quoted heretofore, will serve to illustrate the inconstant relation which exists be- tween the condition of the pupils and the nature of the brain injury. In four cases there was no pupillary change, though in each one laceration was extensive, and included in one instance an excavation of an entire frontal lobe, in two others cortical destruction of both parietal lobes at the vertex, and in the fourth a considerable laceration of a frontal lobe at the base, besides subsidiary injuries of the temporo-sphenoidal and occipital lobes, the cerebellum, and a corpus striatum, variously distributed. In two cases in which both pupils were very moderately dilated there was gunshot laceration of a parietal lobe in one, and a lacera- tion of the inferior surface of both frontal lobes in the other. In two other cases there was slight dilatation of the corre- sponding pupil with laceration of the frontal, parietal, and occipital lobes in the first, and of the frontal and temporo- sphenoidal lobes in the second. In a case of laceration of 102 THE DIFFERENTIAL DIAGNOSIS OF the lateral aspect of a whole hemisphere there was dilata- tion of the pupil on the opposite side. In the final case there was contraction of both pupils attending similar laceration of the lateral aspect of a hemisphere, with slight injury of the cerebellum and a general cortical haemorrhage. I am incapable of understanding how any general law is to be derived from the comparison of such data as these cases afford. The only generalization which I have been able to make is that the pupils are more frequently normal than in cases of haemorrhage. The high temperatures which characterized simple lacerations were maintained in the presence of complica- tions. In the forty-two complicated cases analyzed the initial observation was made immediately upon admission, but was not recorded as primary if some hours or days had elapsed after the reception of the injury ; the ultimate ob- servation was denominated final only when made nearly or quite in articulo mortis. Rectal temperatures only were noted. The primary temperature was unnoted in two cases, was normal in one, and was subnormal in six ; in the remaining thirty-three it was 99° to 100° in twelve cases, 100°+ in six cases, 101°+ in ten cases, 102°+ in two cases, 103*6° in one case, 106° in one case, and 106*6° in one case. The final temperature was 109° in one case, 108°+ in two cases, 107°+ in eight cases, 106°+ in eleven cases, 105°+ in eight cases, 104*6° in one case, and 103°+ in three cases. In thirty cases in which the intermediate temperatures were recorded, they were in twenty progressive and with- out recession from the beginning to the end. In recover- ing cases the reduction of temperature from 99°+ to normal was very slow and often extended over several months. These very considerable elevations of temperature have TRAUMATIC INTRACRANIAL LESIONS. 103 been often coincident with lesions which have involved what have been described as thermo-genetic centers, and rather noticeably that part situated about the anteroinfe- rior aspect of the corpus striatum. It is also true that laceration of any portion of the brain will be followed by a high temperature, and that the regions in which these sup- posed centers are situated are most subject to injury. It is therefore questionable how far the study of traumatism has confirmed in this regard the results of certain physio- logical investigations. I am still unprepared to estimate the possible impor- tance of bilateral variations in axillary temperatures. So far as my observations have yet extended the results are uncertain and often apparently inconsistent with each other, even in the same case. Temperature is sometimes uniform upon the two sides of the body, but is oftener higher upon one, which is not always the same with refer- ence to the side of the head upon which the lesion is situ- ated. The differences have ranged from two tenths of a degree to, in one instance, nearly three degrees. I am in- clined to believe that this variation exists more uniformly in cases of intracranial injury than under other conditions, and that the temperature is rather more frequently two tenths of a degree higher upon the side opposite, than upon that corresponding to the seat of injury. I have as yet insufficient data to form definite opinions as to its sig- nificance and pathological relations. In eleven cases, including the one to which reference was made in the class of simple lacerations, the progressive rise of temperature was continuous for a certain time even after death ; they constitute a considerable proportion of the cases in which post-mortem observation was made, and are best shown in tabular form : 101 THE DIFFERENTIAL DIAGNOSIS OF Final Post-mortem temperature. temperature. 104-8° 106° 106-8° 109° 100-4° 101 2° 100° 102-6° 107-4° 109-4° 108-6° 110° 107-8° 108° 107-2° 107*8° 106° 106-2° 104° 106° 105-6° 106° The lesions associated with this post-mortem cales- cence, which extended over an hour or more, comprehend- ed all those heretofore described, and involved all parts of the brain ; the only one which was constant was lacera- tion ; but even this was sometimes disproportionate to the severity of a general hyperaemia, or to the amount of a corti- cal haemorrhage, by which it was attended. I am unable to trace any connection between this phenomenon and the region of the brain affected, and it certainly has no depend- ence upon injury of the so-called heat centers. It seems probable that it is a mere continuation of a thermogenetic process, however excited, or the result of deficient thermol- lysis, however occasioned. I shall refer to the pulse and respiration in only gen- eral terms. Their one notable characteristic was a very slight deviation from the normal standard. In the whole number of cases which I have examined, in which lacera- tion was the essential factor and in which there was no tangible interference with the ponto-medullary region, neither the circulatory nor the respiratory function was sensibly affected until late in the progress of the case. None of the positive symptoms have been more constant in such injuries as a class than these negative conditions. If Case Number. 25. 30., 33 . . 34. 117 60 . 61 125 128, 73. 130 TRAUMATIC INTRACRANIAL LESIONS. 105 general shock was intense, as in case of some gunshot wounds or in crushing injuries of the vertex, if haemor- rhage was excessive, or if arachnitis at once supervened upon meningeal contusion, both pulse and respiration were frequent; but these cases were exceptional. The contrast habitually presented by a practically normal and unaccel- erated pulse and respiration, with symptoms of perhaps great severity, seems scarcely less remarkable than the exaggerated temperatures which have been the occasion of surprise in the same series of cases. There have been com- paratively few instances, either fatal or recovering, in which the pulse has exceeded ninety or the respiration twenty-six or twenty eight in frequency ; they have oftener ranged well below than above this rate. The pulse when not entirely normal has inclined to fullness and slowness. The transient stimulation and subsequent paralysis of the medulla, with corresponding retardation and acceleration of the pulse, which von Bergmann attributed to a hypothetical functional disturbance of nutrition, has not yet come within my observation. I have deferred until the present time the consideration of a condition of the pulse which occurs not only in con- nection with laceration, but with other forms of intracra- nial lesion, and which I believe has been only observed in my series of cases. I refer to a lack of symmetry in the radial pulsation upon opposite sides of the body. It was first noticed in May, 1893, and since then has occurred in an aggregate of twenty cases. The bilateral variation in the character of the arterial pulse consists in a differ- ence in its fullness and strength. In some of these in- stances its strength and fullness at one wrist were in start- ling contrast to its weakness and tenuity at the other. It was equally regular and frequent and in all other respects symmetrical upon the two sides. In each case the exist- 106 THE DIFFERENTIAL DIAGNOSIS OF ence of this difference was confirmed by two or more ob- servers, and if not indisputable was rejected as a symptom. Eleven cases terminated fatally, of which nine were sub- jected to necropsy. In the cases of recovery, as well as in those which were fatal but failed of necropsic inspection, the nature of the lesions was sufficiently evident from other indications. The lesions discovered in necropsy differed in each case from those in any of the others. They com- prised all forms of haemorrhage, epidural, cortical, and pial; lacerations more especially of the frontal and temporo- sphenoidal lobes, but also of the parietal lobe and of the pons, corpora striata, and optic thalamus, and almost invari- ably some degree of general contusion existed. There were two cases of haemorrhage without laceration, and one of limited contusion without haemorrhage. The inferential lesions, those occurring without opportunity for necropsic inspection, were somewhat less diversified. They included four cases of depressed fracture of the vertex, with moder- ate general contusion in three, and with epidural haemor- rhage and laceration of the frontal lobe in one; four cases of fractured base, with laceration of frontal and temporo- sphenoidal lobes in three, and with haemorrhage and gen- eral contusion in one ; two cases of laceration of the frontal lobe, with parietal haemorrhage ; and one case with simple general contusion. The pulse was fuller and stronger on the side corre- sponding to the seat of injury in eight cases, upon the opposite side in nine, and in two this relation was unknown, from imperfect clinical record in one instance, and ex ne- cessitate rei, in a case of general contusion, in the other. It would seem impossible, therefore, to infer the charac- ter or location of the lesions from this symptom alone ; it is equally so from any correlation which exists between it and others by which it has been accompanied. The first TRAUMATIC INTRACRANIAL LESIONS. 107 few cases seemed to indicate a suggestive connection with the pupillary condition, which larger experience has shown to be fallacious. The pupils are dilated in a considerable number of cases, normal in an almost equal number, and contracted or asymmetrical in others. The Extent to which Traumatic Lesions Aid in the De- termination of Centers of Functional Control.—The present study of intracranial lesions has been, up to this point, in- dependent of their relation to special areas of functional activity. The question consecutively arises as to the possi- bility of connecting symptoms with the seat of injury in accordance with known laws of cerebral localization. The difficulties in obtaining clinical confirmation of the infer- ences derived from physiological experiment, which have been recognized in the examination of idiopathic disease, are exaggerated in case of the complicated lesions of trau- matic origin. The number of cases in the series which I have collated is sufficiently large to have a certain value, either positive or negative, in determining how far such a relation exists. It is conceded that a motor zone, contigu- ous to the Rolandic fissure in the human brain and analo- gous to a similar area experimentally demonstrated by comparative physiologists, has been heretofore abundantly verified by observation of both idiopathic and traumatic lesions. This is also sufficiently illustrated in the cases which I have described, though in a relatively small pro- portion of their whole number, since violence, even when inflicted upon the vertex, is so generally transmitted to the base, where its limited destructive effect is exerted, that the motor region is likely to escape from injury. The general and local paralyses which follow the functional or structural impairment of the motor centers are so well understood that further reference to them as they have occurred in my own cases may be properly omitted. 108 THE DIFFERENTIAL DIAGNOSIS OF A much larger proportion of the cases which I have in- stanced relate to injuries sustained by regions of the brain in which function has been less successfully studied in the light of clinical observation. These have presented symp- toms which are to a certain extent diagnostic, and at the same time incidentally confirmatory of views of cerebral localization founded upon physiological induction. No part of the brain has been so frequently involved in fatal injury as the frontal lobes. They have been lacerated in more than one third of all the cases which I have sub- jected to necropsic examination. It is evident that un- consciousness or delirium attends any form of lesion situ- ated in any region of the brain; but mental disorder or decadence, apart from these, has been supposed to be de- pendent upon a definite and limited structural alteration, and assumed to be of the prefrontal convolutions. The influence of direct frontal injury in so many cases upon the integrity of thought or its manifestations can hardly fail to be of assistance in determining the accuracy of this localization. The series of one hundred and thirty necropsies in- cludes forty-nine instances of laceration of one or both frontal lobes. In twenty-three cases morbid mental con- ditions had been inappreciable through unconsciousness, which was both primary and permanent. In the remaining twenty six mental changes were observed in nineteen. An examination of the seven cases of frontal laceration which were without mental derangement shows that one, in which early symptoms were not obtainable, involved both lobes ; the other seven were confined to the right side; so that, in practically every instance, every one with a history in which the left lobe was lacerated, there were evidences of mental default or aberration. The special manifestations of disor- dered intellect which they presented have been outlined in TRAUMATIC INTRACRANIAL LESIONS. 109 individual histories and scarcely require repetition in detail. Loss of memory, especially of the fact, manner, or circum- stances of injury, confusion of ideas, inability of compre- hension, incapacity of mental concentration, incoherence, fixed or transitory delusions, apathy, hebetude, or stupor, were of constant occurrence, singly or in combination with each other. A condition of mental confusion and inco- herence with delusions, which occurs at a late period, is often confounded with the early delirium of cortical irrita- tion. The lacerations were not always of the same charac- ter, situation, or extent. Five had led to almost complete subcortical disintegration, eight of the cortical injuries were confined to the base, and the others, wholly or in part, were upon the antero-superior surface. In one instance the in- terior of both lobes was practically destroyed. The symp- toms held some relation to the nature and extent of the lesion; in the subcortical excavations there was in each instance abrogation of mental power, rather than an aber- ration in its manifestations. The patient's condition was noted at the time in the several cases as " sluggish," " apa- thetic," *' without sign of intelligence," or as " apparently devoid of power of comprehension." It was generally char- acterized by torpidity and indifference. In the cortical in- juries, in place of comparative default of intelligence, there was incoherence, perverted memory with delusions, or the stupor which comes from confusion of ideas and mental in- difference ; the mind was alert to external impressions, though they were not always rightly comprehended. It is a noticeable fact that in a large proportion of cases the super- ficial injuries were upon the inferior surface, which has been classed as a latent area. The distinctions which I have made in the mental condition, as it follows cortical or ex- tensive subcortical laceration, are broadly drawn, but I be- HO THE DIFFERENTIAL DIAGNOSIS OF lieve will be found to be justified in an examination of the cases which I have cited. The converse proposition that frontal laceration alone, of all traumatic conditions, occasions a direct loss or de- rangement of intellectual function, independent of delirium or unconsciousness, is only a little less absolutely true. In the same series of one hundred and thirty necropsies death had been preceded by such deficiency or derangement in four instances in which this injury was not disclosed. In one of these, a case of gunshot wound of a parietal lobe, some slowness of comprehension was the only mental symp- tom aside from a hysterical melancholia which had led to a suicidal attempt; this may be properly excluded, as mental disease existed before the reception of injury. In each of the other three mental disorder and subsequent decadence were well pronounced. In one, general hyperaemia and oedema were excessive, with a small haemorrhage into the substance of an optic thalamus; in another, simple general contusion with oedema only existed ; and in the third, a large localized subarachnoid serous effusion compressed the frontal lobes. The exceptional cases, hut three in number, in which these lobes, though not lacerated, were still the part solely affected by a limited lesion in one and included in the general lesion in the other two, can not be said to controvert the presumptive evidence derived from physiological observation and so generally supported by the results of pathological investigation that the control of the intellectual faculties is located in this region of the brain. The difference in the morbid mental conditions which have followed laceration, as it has affected the left frontal lobe or the right, I believe has not been suggested by physiological experiment or noted in previous observations of traumatic lesions. In every case of the present series TRAUMATIC INTRACRANIAL LESIONS. HI in which consciousness was retained or regained, and in which the history was known, laceration of the left frontal lobe has been attended by intellectual aberration apart from simple delirium; in similar cases in which the right lobe has been lacerated without destructive injury of the left, there have been in their larger proportion no symptoms of mental disorder, and in the remainder there has been only stupor or active delirium, as may happen in diffused lesions arad in other parts of the brain. The examination of lacerations which involve the tem- poro-sphenoidal lobes has had scarcely more than a nega- tive importance. They are forty-five in number and were attended by an aphasic condition in but a single instance. In the greater number of cases in which laceration existed, twentv eight, entire unconsciousness, the grave of so many possible symptoms, precluded its recognition. In the sev- enteen cases remaining it was confined to the base, a sup- posed latent area in eight, was unplaced in one, was an ex- tensive subcortical excavation in three, and in four was situate in the lateral region, which includes the centers of speech. The instance of aphasia is detailed in the histori- cal abstracts, and the essential lesion, which was purely lacerative, extended quite through the cortex of the first and second left temporal convolutions. The arachnoid was unruptured, and there was no cortical or other local haemor- rhage ; Broca's convolution was unaffected. In the other cases of lateral laceration there was slight injury of the first or second convolution. None of the forty-five cases, save the one mentioned, presented any symptom, unless it were a convulsion, which could be considered indicative of temporo-sphenoidal injury. In the sixty-two fatal lacerations which comprise all those in which the frontal and temporal lobes were implicated, separately or together, there was but the one instance of aphasia mentioned. In 112 THE DIFFERENTIAL DIAGNOSIS OF the recovering cases it will be found to have been of more frequent occurrence. It has been assumed that haemorrhage compressing the centers of speech is a cause of aphasia. I am compelled to dissent from this proposition, not only as contrary to the results of my own observation, but from general anatomi- cal and pathological considerations. The compression, if exerted by a small amount of blood, must be direct and accurately applied; if it be by a haemorrhage large enough to include these small spaces in the wide expanse of cere- bral surface through which we are brought in touch with the world without, the individual default is lost in the gen- eral obscuration of all the faculties which attends the grosser injury. A pial haemorrhage from meningeal con- tusion in this region is likely to be scant and diffused; a cortical haemorrhage, if small and confined to either area in which the control of speech resides, is derived from laceration of the part itself to which as the primary and more potent lesion the result must be attributed; an epidural haemor- rhage while yet in moderate amount acts indirectly and in- adequately upon the temporal or lower frontal region through the dura which acts as an efficient shield. In wounds of the middle meningeal artery, in which the effu- sion of blood may in time become excessive, the loss of consciousness which then ensues abrogates speech with all the other manifestations of intellectual life, and there no longer remains a question of aphasia. I have never met with a pial or cortical haemorrhage of local origin which suggested an interference with the in- tegrity of speech, nor one where consciousness had been retained or restored in which blood had descended from the vertex in amount sufficient to produce this result by compression of the frontal or temporal lobe. My experi- ence has assured me that such an event, if it happens at all, TRAUMATIC INTRACRANIAL LESIONS. H3 is much too unusual to justify the statement made that it is a contingency to he expected. I have seen cases of large epidural haemorrhage in which consciousness was gradually lost before death or relief by operation, but I have never recognized aphasic symptoms at any time during their progress. There is a case of motor aphasia attributed to haemor- rhage reported by Dr. M. A. Starr in which the patient was trephined with great benefit. The amount of blood was small and limited to the motor region. He immedi- ately regained some power of speech, and a little later indi- cated some mental improvement. I have already expressed a belief that intellectual and emotional impairment is not occasioned by traumatic haemorrhage. There were evi- dences of both in this case which the amount of blood dis- covered and removed was certainly insufficient to explain. It is necessary to assume laceration in order to account for their existence, and it seems more than probable that the same lesion occasioned the aphasia; it might readily have escaped notice in the comparatively small opening of opera- tion, more especially if it were entirely subcortical within the visual area. The patient, I am told, after a lapse of years is still aphasic, a fact difficult to understand if de- pendent upon so small a haemorrhage as described. It by no means follows that haemorrhage was the cause of symptoms because immediate improvement followed operation. The removal of a small portion of bone not in- frequently relieves morbid cerebral conditions though the lesion remains undiscovered and unknown. Examples of successful results from operative failure in cranial surgerv are as varied as the conditions which demand interference ; there is one such in the present series of cases * in which traumatic convulsions of several days' continuance were im- * No. 120, original series. 8 HI THE DIFFERENTIAL DIAGNOSIS OF mediately and permanently controlled by trephining both in the region of direct injury and at the supposed point of contre-coup. though nothing abnormal was discovered and nothing more was done. I am unable to accept this case of aphasia as a result of haemorrhage even as an exceptional phenomenon. There are a number of instances of laceration of the cerebellum, but they can be hardly said to have afforded distinctive symptoms. It was in each complicated by other lesions, and the indications were those of laceration and haemonhage in general, and it might be with added localiz- ing signals of injury to areas of which the function has been more accurately defined. If the cerebellum has any concern in the maintenance of bodily equilibrium, it is not likely to be disclosed in traumatic cases. The pons was occasionally contused ; it was hyperaemic, oedematous, or in some part studded with haemorrhagic ex- travasations, varying from the size of a robin shot to an effusion a half by a quarter of an inch in its diameters; but resultant symptoms, if they existed, were merged in the general traumatism. In some case? of injury of the medulla there were re- spiratory changes of importance, perhaps it might be better said, of interest, since they preceded death by so short an interval that there was no longer question of prognosis or of treatment. The constant lesion was some form of haemorrhage causing direct compression. An extension of a hyperaemia from the pons, or even of a slight oedema, seemed to be void of effect. The symptoms were those of pulmonary oedema, cyanosis, or a marked reduction in the frequency of the respiration. The first and second might be considered characteristic after exclusion of other causes of apncea; the infrequency of respiration when progressive and extreme is almost if not quite pathognomonic. In TRAUMATIC INTRACRANIAL LESIONS. H5 three instances in which the respiratory acts were reduced to no more than two in the minute, radial pulsation was continued for two and three minutes after respiration had entirely ceased, as sometimes happens after mechanical occlusion of the larynx or trachea. The more inaccessible regions of the brain are not ex- empt from destructive alteration. I have described cases in which the corpus striatum, the optic thalamus, the cor- pus callosum, the gyrus fornicatus, or a portion of the fornix was contused or lacerated, and this was sometimes the only localized injury in the midst of general contusion. There is the same insuperable difficulty in connecting symptoms with lesions of the optic thalami or corpora striata as existed in case of the cerebellum. They are not sensitive to minor injuries, and in the severer lacerations, which I have seen extend even to practical disintegration, the patient may lie motionless and unconscious with no apparent symptoms which are not afterward explained by discovered lesions of the adjacent motor or sensory areas. I have unsuccessfully endeavored to verify the exist- ence of heat centers in the human brain by an examination of temperatures following intracranial traumatism, though such centers seem to have been experimentally demon- strated in the lower animals. The multiplicity of lesions, their wide extent and indefinite outline, render the results of accidental injury necessarily uncertain in comparison with the accurately limited cerebral wounds which are in- flicted in vivisection. In some instances very high tem- peratures have attended laceration of regions which corre- spond to the heat centers determined by experimentation. 1 have at times thought that this was especially true of in- juries of the frontal lobe immediately anterior to the corpus striatum, but these were always included in more extended 116 THE DIFFERENTIAL DIAGNOSIS OF cortical ruptures or subcortical excavation, and I have ob- served that large lacerations elsewhere, even in parts unsus- pected of special influence upon the control or production of heat, may be accompanied by temperatures equally ex- aggerated. The only limited injury of the corpus striatum attended by any considerable rise in temperature was small, and was complicated by a frontal laceration quite sufficient in itself to account for the thermic condition. In another case in which there was a large extravasation into the cor- pus striatum, three eighths by a quarter inch in its diame- ters, temperature did not exceed 101°. In still another case the right corpus striatum was completely disintegrated and the left corpus striatum and the right optic thalamus lacerated, yet the temperature rose only to 102*2° in the eight hours and a half which preceded death. In an in- stance of extravasation into an optic thalamus with excess- ive general hyperaemia and oedema, in which the clot was as large as a cherry pit, though the final temperature was 105° + , there was no elevation above 100° till the fifteenth day. Lacerations of the fornix and corpus callosum were followed by much higher temperatures. Laceration of the pons in one case developed an excessively high tempera- ture, but in others there was no unusual elevation. Corti- cal centers, as they have been described, are topographically too indefinite to afford data for accurate comparison of cases. I believe, however, that the highest temperatures which I have recorded have not corresponded to injuries of tissue in what I understand to be their situation. Lacerations of any part of the cortex have been attended by marked elevations of temperature, quite as great whei at the base as when in the uncertain neighborhood of the " cruciate centers." The opinion which I have formed from an analysis of my first series of cases that high elevations of temperature TRAUMATIC INTRACRANIAL LESIONS. H7 from traumatic laceration of the brain were dependent upon general nutritive changes rather than upon lesion of limited thermogenetic or thermotaxic centers has not been disproved or modified by subsequent experience. It is im- possible to predict the result of further clinical observation, but Dr. C. L. Dana's examination of intracranial haemor- rhages of idiopathic origin, in which he reaches the same conclusion, tends to confirm my belief in the correctness of my original impression. I have been equally unable to connect the occurrence of certain circulatory phenomena with lesion of definitely limited vaso-motor centers of control. The lack of sym- metry in the characters of arterial pulsation upon opposite sides of the body, which has been frequent, and the dark flush upon the face which I have noted in two cases of very different import, are to me as yet aetiologically and pathologically inexplicable. The results of a general analysis of all the cases which I have recorded up to the present time, so far as they re- late to functional localization, may be summarized in the following propositions: 1. That the control of the intellectual faculties resides in the frontal lobes, perhaps exclusively in the left, and that manifestations of their aberration or default are due to a destructive alteration which is almost invariably laceration. 2. That the control of the faculty of speech, resident in the frontal and temporal lobes, is impaired by structural alteration alone. 3. That characteristic disturbances of respiration are caused only by compression of the medulla from haemor- rhage. 4. That high elevations of temperature, while depend- ent in occasional instances upon diffused contusion of the 118 THE DIFFERENTIAL DIAGNOSIS OF brain substance, are ordinarily the result of limited lesions which are confined to no special regions or centers of control. (4) Pyogenic Parenchymatous Inflammation.—There remains a parenchymatous inflammation of pyogenic char- acter. It is an infrequent result of traumatism and is of limited form except when produced by the intrusion of a foreign body, as of a bullet or drainage tube. I exclude cases of infection from direct laceration which sometimes follow neglected compound fracture with wound of the dura. They are surgically unpardonable, and at the present time ordinarily due to the stupidity of the laity rather than to the carelessness of the surgeon. They afford no question of diagnosis, since the pyogenic process alike involves the brain, the membranes, and the surface of the wound, and is open to visual inspection. The few cases which have been admitted to my service were recognized without difficulty. The infrequency of central or true abscess as a result of traumatism is confirmed by my experience, in which it has occurred but twice in a series of three hundred cases— once in the frontoparietal and once in the pari eto-occipi- tal region beneath the angular gyrus; in both it succeeded a compound depressed fracture of the vertex without wound of the dura, and was situated at an appreciable dis- tance from the point of cranial injury. In the first case, after elevation of the bone and some primary rise in tem- perature, there were no general symptoms till the twenti- eth day, when a few drops of pus escaped from the wound and a cavity was discovered two inches and more away from the opening in the skull. At this time there was a little mental dullness and slight facial paralysis with a scarcely noticeable elevation of temperature; recovery soon followed. In the second case the wound healed, and there were few indications of trouble beyond those depend- TRAUMATIC INTRACRANIAL LESIONS. H9 ent upon some enlargement of the cervical glands till the twenty-second day, when the patient somewhat suddenly began to suffer from acute frontal headache, became de- lirious, somnolent, hemiplegic, and within twenty-four hours hemianaesthetic, with unconscious and involuntary evacuations, and with infrequent pulse and absolutely nor- mal temperature. The abscess, which was small, was dis- covered and drained, but death ensued sixteen hours after operation. Both cases conform to the dictum of von Bergmann that no traumatic abscess occurs without wound of the integument, and are not inconsistent with the bac- teriological opinion that parenchymatous inflammation of the brain is always septic. Von Bergmann, however, is in error in his general proposition. In a circumstantial re- port of the second of the cases mentioned, I referred to a specimen in the collection of Dr. H. M. Biggs which in connection with its history affords conclusive evidence that an " open wound in the head or soft walls of the cra- nium " is not essential to the formation of a traumatic ab- scess. In this case a youth of seventeen was struck in the forehead by a baseball and suffered temporary unconscious ness ; there was neither cranial fracture nor wound of the scalp, and in two or three days he had apparently recov- ered, though headache persisted. Later there was impair- ment of vision and eventually total blindness. His death occurred suddenly about six months after the reception of the injury. The abscess occupied the whole left frontal lobe, encroaching upon the parietal, displaced the tentorium backward, and compressed the right hemisphere. It is unnecessary to multiply instances, as a single one is suffi- cient to show that a possible general rule is not to be re- garded as absolute. The distinction is important in diag- nosis, for in a large class of cases it prevents the exclusion of a condition which always must be reckoned with as a 120 THE DIFFERENTIAL DIAGNOSIS OF possibility at least. I have no doubt that the external cephalic wound usually exists, and that as the shortest route by which the pyogenic germ can travel it is the one by which entrance to the brain is likely to be expected. In the report to which I have referred I attributed the location of the abscess to a limited subcortical contusion and, as I think, demonstrated the correctness of my conclu- sion. Von Bergmann again errs in making a statement too positive when he denies the existence of this lesion except as a product of extreme violence, which " shatters the entire skull." Bruises and lacerated wounds of the brain are demonstrably very much more frequently super- ficial than subcortical, but instances both of laceration and of areas of limited contusion in its deeper structure, when no extraordinary violence has been inflicted, have been often enough disclosed in this series of cases to make it evident that if infrequent they are hardly to be considered unusual. It is rather the surface abscess, which he be- lieves to exemplify the rule, than the central contusion and abscess which is to be considered exceptional. Pott's puffy tumor, the surface abscess, and even hernia cerebri as a factor of importance, have practically disappeared from the field of American if not of German surgery. In fact, any form of traumatic brain abscess is so exceptional that it seems idle to speak of either rules or exceptions. The immediate cause of the pyogenic process is a ques- tion which so exclusively concerns the bacteriologist that I shall not venture to enter upon its discussion. Dr. Biggs, who commands my confidence, regards all pyogenic pro- cesses in the brain substance as of septic origin, and since the colon bacillus has been found in the product of idio- pathic arachnoid inflammation I am quite prepared to be- lieve that the streptococcus or any other germ can in some Way reach the nidus formed by the bruising of the paren- TRAUMATIC INTRACRANIAL LESIONS. 121 chyma, even though a direct route has not been opened through a cranial wound. It is, of course, impossible to discuss symptomatology or diagnosis upon a basis of observation derived from two cases, and this study of intracranial lesions in their trau- matic aspect has been confined to the results of personal experience. I call attention only to the possible relation of acute posterior cervical glandular enlargement, which oc- curred in the second case, to the beginning of cerebral in- flammation. The term encephalitis has been rather freely used to express a supposed result of intracranial injury. I believe that in the proper sense of the word no such condition ex- ists. In case of any infected cranial wound pyogenic in- flammation may extend through the meninges and include the cortex, or a diffuse purulent inflammation of a portion of the parenchyma may even reach the meninges, and in any acute arachnitis the contiguous brain surface may be infiltrated with cells ; but anything like a concurrent gen- eral inflammation of all the cranial contents is unknown to me either from observation or from definite record. It is often held to he synonymous with cerebritis, which as a general parenchymatous inflammation, independent of the pyogenic process which I have mentioned, I regard as no less apocryphal. I have procured the minute structural examination of many hyperaemic and oedematous brains taken from patients who had survived injury for some days or weeks, but in no instance has any evidence of the inflam- matory state been discovered. This result is in accordance with the opinion of Dr. Biggs which I have already quoted. I have read numerous vague descriptions of traumatic encephalitis or cerebritis, but none in which the disease was fitted to the name, or in which it was connected with precise pathological changes. I am too well aware of the 122 THE DIFFERENTIAL DIAGNOSIS OF danger of unqualified statements to deny absolutely that it ever exists; but, so far as I am enabled to judge, it is no more than a misapplication of words or pure assumption. cases not verified by necropsy. It seems proper at the conclusion of a summary of cases in which the value of symptoms has been established by necropsy to refer to those which by reason of recovery have been heretofore disregarded as incapable of affording positive evidence of the pathogenic condition upon which they depended. I believe no differences in symptomatology will be found to exist except in degree, and in many in- stances the early progress of the case is not at all indicative of the final result. There is probably no symptom which occurs in fatal cases which may not be noted in those des- tined to a more favorable termination, except the infre- quency of respiration which follows compression of the me- dulla ; and no other symptom which is less characteristic- ally present, except elevation of temperature. Even in temperature the distinction is not absolute ; it does not ap- ply in cases of haemorrhage, and only to the later stage of meningeal inflammations and of the morbid conditions occasioned by lesions of the parenchyma. Not only in the beginning but for a considerable time afterward tempera- ture may rise absolutely higher in a recovering case than at any time in the course of one which is to end in death; but in general it is less pronounced. I have never known it to exceed 105°, and rarely to attain so great an elevation. The symptoms altogether exhibit no greater differences, as the issue varies, than obtain in other types of disease. In illustration of the cases in which the significance of symptoms has not been demonstrated by the direct inspec- tion of pathogenic lesions I have abstracted the histories of a certain number, of which some ended in recovery and TRAUMATIC INTRACRANIAL LESIONS. 123 others in death, but without necropsy. This class includes one hundred and four as yet unpublished cases, in addi- tion to the sixty-six which appeared in my first series. Many of these are fractures of the base or vertex, or uncom- plicated general contusions in which symptomatology, diagnosis, and results were so simple that they have scarcely more than a statistical value. I have selected from the re- mainder some which have special interest on account of symptoms which made diagnosis clear, or which occurred in such combination as to make their interpretation diffi- cult. Ca£e I.—Male, aged thirty-five years, fell while dancing and struck the back of his head on the ballroom floor; no loss of consciousness, and no other indication of injury till thirty minutes afterward, when the right upper eyelid began to droop. On examination five hours later, symptoms were confined to right eye and appendages; complete ptosis, external strabis- mus, pare>is cf all the ocular muscles, imperfect accommoda- tion, and diplopia; normal pupil and retina. At the end of eighteen months there was still some weakness of the ocular muscles, but no ptosis. The right pupil was permanently di- lated. Case II.—Male, aged twenty-eight years, received a contu- sion of the right parietal region, and on the second day began to exhibit symptoms which were observed at the time of exami- nation ten days later : wide dilatation of left pupil; incomplete paralysis of all the ocular muscles and of the elevator of the upper lid of the left eye; anaesthesia of the left conjunctiva and of the mucous membrane of the left nostril, with loss of smell on that side; and intense and constant pain in all the parts included in the distribution of the fifth cranial nerve on the left side. No paralysis of the facial muscles. Some numb- ness of the left upper extremity. No other symptoms. Oph- thalmic examination by Dr. Callan disclosed some cloudiness of the fundus and enlargement of its veins in both eyes; accommo- dation very imperfect. Two weeks after the injury the hearing in the left ear was lost. The patient is still under observation, 121 THE DIFFERENTIAL DIAGNOSIS OF Case III.—Male, aged forty years, fell from a truck and struck upon his head; partial loss of consciousness; profuse haemorrhage from right ear ; wide dilatation of left pupil; tem- perature, 99*8°; pulse, 92, and respiration, 23. Second day: slight delirium; mental stupor; no response to questions; tem- perature, 100*8°. Third day: severe general convulsion, begin- ning in left arm and hand; both pupils afterward widely dilated; temperature, 100-2° to 100*6°. Fourth day: similar convulsion, but less severe ; temperature, 99-8° to 100°. Eighth day: mind clear, but torpid; no recollection of an accident hav- ing occurred; speech slow and somewhat aphasic; headache and continued dilatation of pupils. Twelfth day: mental con- dition normal; temperature, 99° + . Discharged without further symptoms on the twenty-ninth day. Case IV.—Male, aged sixty-five years, fell thirty feet; con- sciousness lost, and regained twenty hours after admission to the Presbyterian Hospital; left hemiplegia; temperature, 98°, which fell in four hours to 97°; pulse, 70 to 80; normal pupils; lacerated wound of scalp. Transferred to Bellevue Hospital eighty-two hours after reception of the injury. There was then delirium with delusions; restlessness; no recognition of changed surroundings; normal pupils and respiration ; no paralysis ; tem- perature was 100*5°; pulse, 112. For ten days continued rest- lessness and at times delirium, with lack of urinary control i temperature, 102-6°; pulse and respiration moderately acceler- ated. After that time mental condition became normal, at first only during the day, and all symptoms disappeared. Seventeen months afterward his mental and physical condition wa^entirely restored. Case V.—Male, aged fifty-five years, fell unconscious in the street. On admission, profound shock and entire unconscious- ness ; wound of scalp in right posterior parietal region; free haemorrhage from right ear and uniform contraction of pupils. One hour later, rigidity of left arm and, to a less extent, of left leg. Consciousness restored in twenty-four hours, and a little later the pupils became normal and the mind clear. Tempera- ture on admission, 98°, declined to 97*4°, and rose in twenty- four hours to 99*4°; pulse and respiration normal. On the TRAUMATIC INTRACRANIAL LESIONS. 125 third day, temperature, 99-6°, and only psychic symptoms mental processes a little less slow than on the previous day, but memory defective. No recollection of anything which happened after leaving home in the early morning, some hours previous to the accident; memory of words and facts equally deficient. Upon questioning, the patient said that he lived at " No. 4 in the Ninth Ward "; then remembered that it was opposite a school, which he called " skull," and finally that it was in Grove Street. On the following day he had again forgotten the name of the street, and its mention awakened no remembrance; he mis- placed many words, and could not be brought to recognize his errors. A week later he had much general headache, realized that his mind had been greatly confused, and was still ignorant of all that had happened since leaving his house. He was dis- charged on the eighteenth day, his temperature and mental con- dition having been normal for several days. Case VI.—Male, aged forty-five years, thrown from a truck in collision; admitted in shock and still unconscious; pupils contracted; temperature, 97*5°; pulse, 52 ; respiration, 18 ; twelve hours later, temperature, 97"5° ; pulse, 50 ; respiration, 12 ; in fourteen hours, consciousness restored ; temperature, 98°. Sec- ond day, no recollection of injury, previous occupation, or mar- ried condition. Third day, ecchymosis over right mastoid pro- cess and extending upon the back of the ear, not previously apparent. Fourth day, the patient, after much questioning and trouble, was enabled to remember his residence and occupation ; temperature, 102°. During the rest of the week his tempera- ture declined and mental condition improved, though he was still irrational and at night required mechanical restraint. In the second week he was rational at times; he was capable of expressing the generalization that a man's mind is clearer by day than at night, and described correctly the manner in which he received his hurt, though he again forgot the circumstances and denied that he had said anything about it; he was irritable and forgetful, even of the outrage to which he considered himself subjected in the taking of his temperatures ; he had delusions, saw imaginary persons, and heard unreal voices, made contra- dictory statements about the injury which he had suffered, and 126 THE DIFFERENTIAL DIAGNOSIS OF was much annoyed at the attempts which were made to get from him some coherent and consistent history. Early in the third week his temperature became normal, his memory and other mental faculties were restored, and he was discharged from the hospital. Case VII.—Male, aged forty-five years, mind impaired by alcoholic excess, fell one flight of stairs ; consciousness retained, haematoma in left temporal region, profuse haemorrhage from left ear, and slight epistaxis. Temperature, 98°; pulse, 90; respi- ration, 24. Second day, a little delirium, rigidity of both arms, and left facial paralysis, both upper and lower; temperature, 100-2°; pulse, 100; respiration, 24. Incision made through haematoma revealed linear fracture of left squamous portion ex- tending into the base. In the three days following, the tem- perature and mental condition became normal and facial paraly- sis nearly disappeared. Two days later temperature rose to 100-5°, facial paralysis increased, left side of face and neck be- came swollen, and delirium supervened. From this time there were recurrent maniacal attacks, lasting less than twenty-four hours, in one of which he was transferred to Bellevue Hospital and soon afterward escaped. He was at a subsequent period sent to an asylum for the insane, and is now, after sixteen months, at home, but of recognized unsound mind. Case VIII.—Male, aged thirty-eight years, fell from a sec- ond story window ; unconscious and delirious on immediate admission, and in same condition when transferred from alco- holic ward to surgical service next day. Compound depressed fracture of left temporal bone, extending into the occiput be- tween the curved lines ; irregular dilatation of the pupils; in- ternal strabismus of left eye which was afterward found to be congenital; pulse slow and full; breathing stertorous; no control of urine and faeces. The bone was elevated, and an epidural clot, which extended only toward the base, was removed as far as practicable ; no discoverable dural or subdural lesion. Third day, left radial pulse fuller and stronger than the right; partial left lower facial paralysis and dysphagia. Fourth day, violent delirium. Fifth day, dysphagia and cessation of bilateral varia- tion in radial pulse; delirium continued, with a short interval TRAUMATIC INTRACRANIAL LESIONS. 127 in which it intermitted. The symptoms were variable until the end of the fourth week ; delirium of different grades at differ- ent times alternated with periods of quietude and rational intel- ligence ; various delusions were more or less persistent; dys- phagia, lack of urinary and faecal control, and facial paralysis still continued. After this time mental improvement was pro- gressive, and in the seventh week the mind was entirely clear. At the end of eight weeks recovery was complete, and twenty pounds lost in weight had been regained. The temperature on admission was 97'6°, on the second day 102°, and after opera- tion 104 4° ; it subsequently declined to normal at the end of the second week, and afterward varied from normal to 99° + . The pulse and respiration were varied, but never frequent. At the end of fifteen months he suffers no mental impairment. Case IX.—Male, aged thirty-one years; fell two stories upon an iron beam ; unconscious and delirious on immediate admission ; wound above the left eye and contusion of the left shoulder; loss of urinary and faecal control, which was not re- gained. Subsequently the patient was usually delirious at night and stupid during the day, and without other general symptoms; he was only once or tA-ice able to make coherent reply to a question asked. He died in profound coma at the end of twelve days. Temperature on admission was 99°, rose gradually to 105° on the ninth day, and was 104-8° just before death. The pulse was 82 on admission and the respiration 24, and both afterward varied each day from moderate to extreme frequency. Case X.—Male, aged thirty-one years; was struck by a brick which had fallen five stories; no other immediate gen- eral symptom but unconsciousness. A compound depressed fracture crossed the median line at the vertex. Second day : there was accurate memory of events up to time of injury, no recollection of anything that occurred afterward. Third day : fragments of depressed bone were removed, leaving an opening in the skull two inches by an inch and a half in its diameters ; no lesion of dura or of the sinus. Temperature on admission 104-4°, at time of operation 100°, subsequently 99° + . Pulse and respiration at all times normal. 128 THE DIFFERENTIAL DIAGNOSIS OF Case XI.—Male, aged thirty-two years ; fell from his truck and struck the pavement upon the back of his head; partial loss of consciousness and delirium, which continued for three days. Fourth day: limited power of comprehension, no re- sponse to questions asked, attention fixed only with difficulty, occipital headache which was not increased by pressure or per- cussion, and somnolence. At the end of four weeks the pa- tient sat up, but walked with difficulty on account of imperfect muscular co-ordination in both legs; patellar reflexes normal; mind clear but slow in action, which he himself noted ; vertigo, which was not of previous occurrence; occipital headache re- lieved. Dr. P. A. Callan discovered upon ocular examination a neuritis, more advanced upon the right side than upon the left, and a paralysis of the ocular muscles. Temperature on admission was 99°, rose to 100*4° on the same day, was from 99° to 101° till the sixth day, 98*5° to 99°+ till the twenty- first day, and afterward continuously normal. The pulse was normal. The respiration was 12 for three days, 16 to 18 for six days, 8 to 12 for thirteen days, and afterward 16 to 20. Case XII.—Male, aged thirty-five years; fell one story ; brief unconsciousness followed at once by delirium ; extensive lacerated wound in left parietal region; haemorrhage from left ear caused by wounds of external meatus. Temperature on ad- mission, 101*5°; pulse, 80; respiration, 18. Delirium contin- ued three weeks, gradually diminishing in degree and con- stancy ; no subsequent recollection of the manner of injury. Loss of urinary control lasted one week; no headache at any time, and no later symptoms. Patient recognized his family and surroundings after three or four days. Case XIII.—Female, aged five years; struck by a falling box which seemed to have crushed her head laterally against the floor. Still unconscious at time of admission, but very sen- sitive to external irritations; slight twitching of right side of the face, slight epistaxis, slightly accelerated respiration, slow and irregular pulse; temperature, 95° ; pupils sometimes nor- mal, sometimes widely dilated, with conjugate deviation which was sometimes upward and sometimes to the left; vomiting soon after reception of the injury; haematoma over entire ver- TRAUMATIC INTRACRANIAL LESIONS. 1^9 tex, and contusion of both eyes. Incision disclosed fissures on either side of the calvarium ; one extended from the left tem- poral fossa posteriorly across the vertex to the right occipital region, and anteriorly into the anterior fossa; another, appar- ently beginning in the right anterior fossa, crossed the right parietal bone and terminated in the first. The bone was de- pressed posteriorly and the fissure open ; after elevation and removal of some small fragments considerable epidural haemor- rhage was apparent. Consciousness was fully restored within twenty-four hours, and was marked by restlessness and deliri- um, which continued for two or three days, after which the mental condition was normal. On the fifth day paraplegia oc- curred, which was almost complete from the first, and absolute on the next day, with partial anaesthesia; no paralysis of the bladder or rectum. The paraplegic condition began to improve at the end of a week's time, but very slowly; a few steps could be taken without assistance six weeks later. The tem- perature soon after admission rose from 95° to 98 5°, on the next day to 100-23, and after the third day varied from 98-4° to 99-8° ; usually normal in the morning. The respiration was accelerated for the first ten days, and the pulse frequent for three days. Case XIV.—Female, aged thirty years ; was thrown from a wagon while driving, striking the back other head upon an asphalt pavement ; shock, loss of consciousness for twenty minutes, and severe vomiting, which persisted during the day ; temperature, 100°; not taken afterward; haematoma in right occipital region, and ecchymosis behind the right ear, followed by severe localized pain in the right side of the head posterior- ly. The later symptoms were a muffled feeling in the right ear, with diminished hearing and blunted perceptions of taste and smell which had been noted from the time of the accident. The disorders of hearing did not continue after the fourth week, but the senses of taste and smell have been permanently im- paired. Case XV.—Male, aged thirty-three years, struck on the head with a hammer and was momentarily unconscious, after which he walked to the hospital. Compound depressed fracture of 9 130 THE DIFFERENTIAL DIAGNOSIS OF the mid-vertex ; both pupils dilated ; left radial pulse markedly fuller and stronger than the right till after operation, five days later; no other general symptoms. Depressed fragments of bone were removed, leaving an opening in the skull an inch and a half by one inch in its diameters; haemorrhage from a large wound of the longitudinal sinus controlled by gauze packing. Pulse and respiration became normal on the following day, and radial pulsations symmetrical on the third day. Elevation of temperature was maintained by a slough and inflammatory con- ditions produced by an accidental burn. Temperature on ad- mission was 99*2°, rose in a few hours to 101*4°, and after the operation to 102°+ ; pulse and respiration, normal at first, were subsequently only moderately accelerated. Case XVI.—Male, aged thirty years; fell twenty-five feet from a ship's deck to a raft alongside; consciousness lost for a few moments only; haematoma over right posterior parietal region; moderate contraction of the left pupil; right radial pulse fuller than the left; urine retained; complete paralysis of left lower extremity ; nearly complete paralysis of the left arm ; partial paralysis of the right upper extremity ; anaesthesia of the right side of the body below the third rib; hyperaesthesia of the left lower extremity; great pain and tenderness in cervico-dorsal region, and evident fracture of the first dorsal spine; mental condition apparently normal. During the first week vomiting occurred at least once in each twenty-four hours, and pain in the frontal and in the up- per dorsal region was constant and severe. The bilateral varia- tion of the pulse was distinct till the fifth day. The paresis, hyperaesthesia, and anaesthesia, and the contraction of the left pupil persisted in greater or less degree for several months, and a paresis of the left lower extremity and the anaesthetic and hyperaesthetic conditions and the contracted pupil existed at the time of final discharge from the hospital. An ophthalmic examination was made by Dr. Callan, and repeated at a later period, with negative result. The eye was retracted and a little less sensitive than the other, but there was no retinal change, and no loss of power in the ocular muscles. There was no mental disturbance till the occurrence of noc- TRAUMATIC INTRACRANIAL LESIONS. 131 turnal delirium and restlessness at the beginning of the third week. A few days later the nocturnal delirium ceased, but the restlessness at night increased, and delusions of a painful char- acter began to occur, which occasioned the patient much dis- tress. The first trouble which came to him was the fancied death of his wife, and when, a little later, he became convinced that this bereavement was imaginary, he was equally positive that another delusion, the death of his child, was real, and this new conceit possessed his mind for many weeks. He suffered acute mental anguish in each instance, which could have been scarce exceeded had these pure fancies been actual facts. The facial expression grew a little stupid, and an inclination to weep wTas manifested on ordinary occasions, equally when the amount of cutaneous hyperaesthesia was tested, or when discourse turned npon his family afflictions, but speech was always coherent. At the end of the second month there was some improvement; the facial expression brightened, delusions were less constant and of a more trivial character, and the mental condition was less uniformly clouded. In the third month delusions alto- gether disappeared, and mental processes, though slow, were no longer distorted; he was enabled for the first time to recall the manner of his injury: vertigo, which had been an early symptom, still persisted. The temperature on admission was 98-4°, rose during the day to 101*8°, and on the fifth day reached 105°. It was habitually high till late in the second month at some time in each twenty-four hours, not less than 101°+ to 102° + , the diurnal variations being also considerable. The left axillary tem- perature was markedly higher than the right, usually five tenths of a degree or even more. The pulse was ordinarily from 80 to 90, occasionally 60 to 70, and rarely exceeded 100. The respira- tion during the first month was not often less than 30 and later ranged from 28 to 24. The patient left the hospital seven months after admission. There was then no trace remaining of the cerebral injury beyond a little heaviness of manner and a little slowness of thought. The persistence of the spinal lesion was indicated by a stationary paresis of the left lower extremity and by a continuance of the 132 THE DIFFERENTIAL DIAGNOSIS OF disorders of sensation which immediately followed the trau- matism. The left eye was still retracted and insensitive and its pupil small. Case X VII.—Male, aged thirty-six years; fell ten feet from - vessel to a raft alongside and then into the water ; brief period of unconsciousness, profuse haemorrhage from left ear, slight epistaxis from left nostril, and haematoma in left mastoid re- gion; single general convulsion in the ambulance followed by stertor; consciousness regained at time of admission ; both pupils widely dilated ; haemorrhage from the ear recurred dur- ing the night; urine retained ; temperature, 98 8°. Frontal head- ache continued for several days, and on the third day there was transient photophobia with contracted pupils. The bladder and rectum were controlled. Dilatation of the pupils was per- ceptible till the end of the second week and of the right pupil even longer. The prominent symptoms were mental; noc- turnal restlessness and delirium, and a rather stupid condition during the day, were succeeded in the second week by con- tinned delirium of a mild type with delusions. In the third week active delirium ceased, though restlessness at night per- sisted ; the facial expression was more intelligent and speech was coherent; there was perfect recollection of the manner in which the injury had been received, and also of a similar acci dent which had occurred on the same day and aboard the same ship (Case XVI, immediately preceding), but delusions were numerous and constant. At the beginning of the fourth week the patient was restless, excitable, talkative, and had again for- gotten the manner and even fact of his injury. Ophthalmic ex- amination was made by Dr. Callan with negative result. At the end of the fourth week delusions finally ceased, and when discharged from the hospital in the eighth week there were no symptoms remaining. The sense of smell was entirely lost. The maximum temperature was on the fourteenth day, from 101° to 102 2°; the usual temperature was 99°+ till after the fourth week, and then varied from normal to 99°. The axillary teinperatures were observed from the fourth to the eighth weeks; the left was habitually, but irregularly, higher than the right. The pulse and respiration presented no notable changes. TRAUMATIC INTRACRANIAL LESIONS. 133 Case XVIII.—Female, aged seventeen years; fell from sec- ond floor window ; found in coma with profuse haemorrhage from left ear and some haemorrhage from the mouth; left side of face, eye, and parietal region much contused. Two hours later consciousness was partially restored and sensitiveness to external impressions recovered; haematemesis occurred, and at a later period, after subsidence of ecchymosis of the lids, sub- conjunctival haemorrhage in the left eye was discovered ; the right pupil was dilated. Six hours after admission, tempera- ture, 97-4°; pulse, 70; respiration, 38; lack of urinary con- trol. The haemorrhage from the left ear continued for thirty- six hours, and was followed by a discharge of bloody serum. During the first three or four days the patient was at times noisy and restless and at times quiet. She then became rational and learned for the first time that she had met with an accident and was in a hospital; but she never knew, then or afterward, other own recollection what had happened to her. At about the same time a protrusion of the left eye became marked, and it was discovered that vision was lost on that side. There were no additional symptoms. The temperature on the second day was 100-2° ; pulse, 68; respiration, 18; and temperature afterward varied from 99° to 100° + . At the end of the fourth week ophthalmic examination was made by Dr. Callan. The right eye was in all respects normal. The left eye was on a slightly anterior plane to that of the right; its movements were unimpaired; there was a slight re- maining trace of haemorrhage near the limbus corneae; the pu- pil was mcderately dilated and not responsive to direct rays of light, but acting consensually with the right; there was com- mencing atrophy of the optic nerve and total loss of vision- From the clinical history Dr. Callan was of opinion that a line of fracture had implicated the left optic foramen. Case XIX.—Male, aged forty years; found in the street in an alcoholic condition; could walk with assistance; profuse haemorrhage from left ear; slight oedema of scalp in left occipi- tal region ; no general symptoms. The recollection of having been brought to the hospital and of previous wanderings, but not of the manner of injury, returned with sobriety. Ecchy- 134 THE DIFFERENTIAL DIAGNOSIS OF mosis of both lids of right eye appeared on the following day ; vertigo and occipital headache and some pain behind the left ear existed for ten days. Temperature on admission, 98-4° ; rose to 101° in the course of eighteen hours, and was afterward 99° to 100°+ during the three weeks the patient remained under observation. The axillary temperatures were usually symmet- rical, and when any difference was noted it was higher on the left side. The pulse more frequently exceeded 90 or 100 than is usual in similar cases. The respiration was normal. Case XX.—Male, aged nine years; fell ten feet from a dump into a scow; consciousness lost for fifteen minutes: no exter- nal injury; temperature, 98-2°; pulse, 67; respiration, 28. Third to fifth days, right radial pulse fuller and stronger than the left; somnolence till seventh day, and recurrence on the tenth and eleventh days with a condition of mental indifference; occipital pain continued at intervals during ten days. The temperature five hours after admission was 100*2°, in twelve hours was 101°, and did not exceed that degree; it was 99° + to 100° +for fourteen days, with an occasional decline to nor- mal for a single observation or for a few hours. The axillary temperatures were observed four times daily, and the left was habitually six tenths of a degree or more higher than the right, and sometimes the difference was as great as a degree and eight tenths; they were occasionally symmetrical, but in sixty eight observations the right was never the higher. The pulse was usually 52 to 84, and more frequently approximated the lower figure. The respiration was from 18 to 28. Case XXI.—Male, aged fifty years; fell twelve to fifteen feet from a loft and struck upon the back of his head, six hours previous to admission ; unconscious fifteen minutes; contusion of the vertex in the median line; wound in right occipito-mas- toid region; haemorrhage from right ear; delirium from time consciousness was restored, often requiring mechanical re- straint; dilated pupils, and right radial pulse fuller and stronger than the left; the urine was retained and the right hand and wrist were paretic. There was marked aphasia—e. g., the pa- tient said "talp that" for stop that, " guth Got" for good God, and " 15 Avenue B " when asked his name. The difference in TRAUMATIC INTRACRANIAL LESIONS. 135 the fullness and strength of the radial pulses continued to be strongly marked at all times till death on the eighteenth day. The dilatation of the pupils, which remained sensitive till the seventeenth day, was also permanent. Delirium persisted, and speech was infrequent and unintelligible till the close of the first week; the mental condition then became brighter and speech distinct and coherent, but delusions were constant and the patient was at no time able to recognize his family or friends. There were subsequent alternations of restlessness and excitability with somnolence or lethargy, but no cessation of delirium, delusions, and more or less incoherent and unintelli- gible speech, till final unconsciousness, which occurred three days before death. Sensitiveness to external irritations was marked throughout this later stage. The control of urine and faeces was permanently lost during the first few days. The paresis of the right band was much diminished during the first week. On the sixth day, and on the seventh, there was a short, severe, convulsive attack, followed by a transient high temperature. These were succeeded on the morning of the eleventh day by a general convulsion, which was at first con- fined to the upper extremities, and continued twenty minutes; the right arm was less rigid than the left. Another attack in the afternoon of the same day, of twenty-five minutes' duration, began with a twitching of the facial muscles, and was extended to the trunk; all the extremities remained rigid ; the face was of a natural color, though subsequently much flushed, but the hands were blue. The morning convulsion was followed by prolonged unconsciousness, that of the afternoon by an appar- ently natural sleep after a short interval in which the mind was unusually clear and alert. There was another very brief gen- eral convulsion five days later. Posterior cervical muscular rigidity existed from the ninth to the fourteenth days. The temperature on admission was 1018°, and varied from 100° + to 101°+ till the fourth day, when, without other change in symptoms, it rose to 104°; and in the twelve hours following declined to 101° + , and was continuous at about that degree till the tenth day, except at the time of the first and second con- vulsive attacks, when it rose for a short time to 106° and 136 THE DIFFERENTIAL DIAGNOSIS OF 106 6°; on the morning of the tenth day it rose to 105°, again declined to 101°, and with the occurrence of the third and fourth paroxysms on the eleventh day it rose to 105-4C ; on the twelfth day it declined for a brief interval to normal, and was subsequently uniformly high, from 103° to 106°, and at death was 108°. In fifty-two observations the right axillary tempera- ture was higher than the left in thirty-two, the left higher than the right in seven, and in thirteen the two were uniform; the variation was from two tenths of a degree to a degree and eight tenths. The pulse on admission was 112, and then, for the first ten days, 05 to 100; never afterward below 120. The respiration on admission was 36, and after the first four days rarely below 32. Case XXIL—Male, ayred forty-two years: fell in the street, striking the back of his head ; consciousness lost, but regained on the way to the hospital; mental condition stupid, but ra- tional, becoming normal in a few hours; slight general head- ache; later, frontal pain, followed same day by a single general convulsion of five minutes'duration; head and eyes turned to the right; left side and extremities actively convulsed; right arm and leg motionless. On the third day there was transient posterior cervical rigidity, and on the third and fourth days the left radial pulse was fuller and stronger than the right. During the first ten days the patient's condition was marked by stupor, occasional somnolence, slowness or refusal to answer when que>tioned, nocturnal delirium becoming continuous, frontal pains, and contracted pupils. In the week following there were delusions, lack of faecal and urinary control, in- creased somnolence and stupor, some muttering delirium, and pains in the back of the head and left extremities, succeeded by- left paresis. After this time the patient occasionally indicated more intelligence wdien roused from his habitual stupor, and once conversed intelligently with his wife. The pupils remained contracted and insensitive to light, the urine and faeces uncon- trolled, the limbs drawn upward, and any disturbance of the left side of the body was resented. On the twenty-fifth, the last day of life, articulation was indistinct, deglutition difficult, and death, preceded by restlessness and some brightening of the TRAUMATIC INTRACRANIAL LESIONS. 137 mental condition The temperature on admission was 98°, rose to 103-2° on the third day, and was subsequently 99° to 100° + till the last day, when it was 107-2°. The pulse on admission was SO, on the fifth day 42 to 58, and at other times 68 to 100. The respiration varied from 18 to 24. A few hours before death both pulse and respiration became frequent. Case XXIII.— Male, aged thirty-eight years, admitted in an alcoholic condition without a history; profuse haemorrhage from the left ear. The patient never afterward remembered having been hurt. During the first week hearing was greatly impaired in both ears, and there was much mental confusion, with sensory aphasia and general loss of memory. General headache was severe and vertigo marked. The patient was enabled to recol- lect with great difficulty the place of his employment, and could only suggest his occupation as a waiter by using an imaginary corkscrew in dumb show. The right radial pulse on the second day was fuller and stronger than the left. In the second week hearing was quite restored in the right ear and was nearly re- covered in the left. The mental condition became normal, and there were no further symptoms. The temperature on admis- sion was 99*2°, and did not subsequently exceed 100° + . The left axillary temperature was two tenths of a degree higher than the right when there was a lack of symmetry. The pulse on admission was 80, and was only once above 100. The respira- tion was from 18 to 24. Case XXIV.—Male, aged forty years; fell six feet into an area way; consciousness lost, and not restored at time of ad- mission, but sensitiveness to external impressions retained; profuse haemorrhage from right ear; left radial pulse fuller and stronger than the right; pupils contracted, but responsive to light; right corneal reflex diminished ; right side and right face paretic, and urine retained. The pupils became normal on the second day, and the radial pulses symmetrical on the third, with some signs of returning consciousness. Convulsive move- ments of the extremities occurred on the fourth day. and there was some dysphagia. The patient gave little evidence of intel- ligence till the end of the fourth week; he had no power of speech beyond the utterance of an occasional single word, and 138 THE DIFFERENTIAL DIAGNOSIS OF when his attention could be attracted, which was not often, replied only in inarticulate sounds; he rarely recognized his immediate family, and had no apparent comprehension of what was said to him. The right facial paralysis continued, with added ptosis of the left eye, and both pupils became dilated. His mind then became clearer, but intelligence was very limited ; he articulated several words with moderate distinct- ness, and a little later used several short phrases with pro- priety ; a little later still his attention could be momentarily fixed to comprehend and answer monosyllabically a simple question. An ophthalmic examination made by Dr. Callan dis- closed no retinal changes. At the end of the sixth week he began to notice what went on about him, recognized his mother, and developed destructive tendencies. Early in the seventh week he first gave attention to the natural offices of the body, and his increasing range of words accentuated his aphasia. After the second month there was only a trace of facial paralysis, and no other paretic condition. lie could dress himself, and went about the ward ; he could remember, and could write, his name and address correctly, and seemed to readily understand such questions as were asked him, but re- plied in an endless tirade which was incoherent and largely made up of inarticulate sounds interspersed with recognizable words, and apparently as devoid of meaning to himself as to the listener. He was unable to write from dictation more than a few words before the written characters became incompre- hensible, and he repeated words. He had no knowledge of his occupation, manner of injury, or local surroundings. He was discharged at the end of the third month, and had then upon cursory examination no symptoms of mental disorder remain- ing, except some hesitancy in collating words, and in long sentences a little confusion in expression. If an attempt was made, however, to engage him in a sustained conversation, his thoughts became more and more entangled; he talked rapidly and excitedly, and his words were inextricably jumbled to- gether. On examination, four months later, his mental condi- tion was that of dementia. The temperature on admission was 98-4°, and reached its TRAUMATIC INTRACRANIAL LESIONS. 13^ maximum, 102-6°, on the second and third days. It then gradually but irregularly declined. It was occasionally normal after the first week, but ordinarily 99°+ or 100°, quite up to the time of the patient's discharge from the hospital. The right axillary temperature was the higher twenty-two times, and the left twelve times, and the two were uniform once, in thirty-five observations made during the first nine weeks. The left was afterward usually two tenths to four tenths of a degree the higher. The pulse did not exceed 90 after the fourth day, and the respiration was at no time more than 22. Case XXV.—Male, aged forty years; fell two stories from a fire escape to the pavement below ; was conscious and delirious w7hen seen by the ambulance surgeon. There was a small linear wound in the left anteroinferior parietal region, haemorrhage from mouth and nose, and lack of urinary control. Mild delirium and great restlessness continued for twenty-four hours, and the right side and extremities were noted to be warmer and in more active motion than the left. On the sec- ond day there was post cervical rigidity, and the patient be- came more difficult to rouse. On the third day both pupils were somewhat dilated, the face was flushed, and he lay mo- tionless, with eyes closed, irresponsive to questions or to irrita- tions. <>n the fourth day post-cervical rigidity disappeared. On the sixth day urinary and faecal control was regained. On the seventh day the patient, fully aroused from his condition of stupor, became restless, and was delirious through the night, but not afterward. From this time he suffered only from men- tal disorder. He had confusion of ideas and failed to recollect any of the circumstances which preceded his injury, or in fact that he had received a hurt. He had no appreciation of his surroundings, and gave fanciful explanations of his presence in a hospital when interrogated. His mind was alert and bis speech coherent. During the second month he suffered an attack of facial erysipelas upon the side opposite the original wound, and was actively delirious. His mental processes were afterward slow, and when questioned he remained long buried in thought before making answer, which when made, though hesitating, was fairly intelligent. He had come to realize that HO THE DIFFERENTIAL DIAGNOSIS OF he was in a hospital, but was still ignorant how he happened to be there; "supposed " he had been hurt. The temperature on admission was 97-4°, rose during the day to 102-2°, and was afterward usually from 99°+ to 100° + . The right axillary temperature was two tenths of a degree to a degree higher than the left during the first week, and the left the slightly higher of the two after that time. The pulse and respiration were practi- cally normal at all times. Case XXVI.—Female, aged twenty eight years: gunshot wound through right temporal region inflicted during a parox- ysm of suicidal mania; ball of thirty-two caliber; primary un- consciousness. On admission three hours later no general symptoms: wound of entrance, half an inch posterior to right external angular process, Y-shaped, three quarters of an inch in length in each of its arms ; surface powder-stained, some grains of powder imbedded in the substance of the temporal muscle, but none in the skin; profuse haemorrhage had occurred from the wound and still continued from the mouth and nose; bullet entrance through the bone small and circular and covered by a valve of muscular tissue. On examination the patient was fully conscious, rational, and self-possessed. The right eye was swollen, the lids ecchyinotic, and vision on that side entirely lost. The ball had passed from the temporal fossa beneath the lesser wing of the sphenoid and through the floor of the mid- dle fossa at the margin of the sphenoid body. The track was easily followed through the anterior cerebral lobe, and the bony margin of exit could be defined by slightly opening the blades of the short bullet forceps which had been inserted. A small portion of brain matter, not larger than a pea, escaped from the external wound. On the following day she was rather stupid, and another trivial amount of brain matter was extruded. On the third day the left eyelids became moderately ecchymotic and the right side of the face and neck much swollen and painful. There were convulsive movements of the bands and feet, and a loss of smell in the right nostril was confirmed by careful examination. On the fourth day she was quiet and somnolent and had some headache. The left side of the mouth was drawn a little upward and tenderness existed behind the TRAUMATIC INTRACRANIAL LESIONS. HI left ear. On the fifth day somnolence and headache ceased, pain and swelling of the right side of the face and neck dimin- ished, and the mental condition became brighter. On the tenth day she was restless and began to suffer pain on the right side of the head, which, on the succeeding day, was intense. The eye became more vascular, swollen, and prominent, and on the fourteenth day was extirpated under ether. At the end of a month the bullet wound of entrance had become simply cuta- neous and was in process of cicatrization. The swelling of the right side of the face and neck and the tenderness behind the left ear had ceased to exist. The pain on the right side of the head, which persisted in some degree, was no longer constant or the source of any considerable discomfort. There had been no indication of any form of mental impairment at any time since the slight hebetude on the second and third days after the reception of injury, and no loss of faecal and urinary control. The temperature on admission was 100° ; rose to 102-4° in twelve hours, and declined to 99-8° on the second day, and then varied from 101°+ to 99°+ till the twelfth day ; it did not ex- ceed 100° after the fifteenth day and was subsequently from 99° to 100°. The right axillary temperature was habitually two tenths of a degree higher than the left. The pulse was from 72 to 80 till the third day, from 68 to 52 till the twelfth day, and subsequently from 70 to 78. The respiration was 28 on admission and afterward normal—16 to 22. In the sixth week the wound had healed and there were no symptoms. At the end of three months her mental and physi- cal condition is normal, in her own opinion better than before the injury was received. summary. The differential diagnosis of the intracranial lesions has been incidentally established in the consideration of their individual symptoms. There are few instances in which the nature of the essential lesion and of its complications can not be determined with substantial certainty, and in a considerable proportion of cases its location even can be fixed with some approach to precision. The fact that an 112 THE DIFFERENTIAL DIAGNOSIS OF interval of time may be required for the evolution of symp- toms is paralleled in the case of idiopathic diseases affect- ing the great cavities of the body ; it can scarcely be con- sidered a special diagnostic difficulty, therefore, in the present class of traumatisms. In lesions of the parenchy- ma the delay is unimportant; in haemorrhages of the form in which promptitude in diagnosis is demanded by the necessity for promptitude in action, the development of the case is likely to be correspondingly rapid and decisive. The existence of superficial injuries of the head, the evidences of fracture, and the elevation of temperature, in- dividually or collectively, together with the usual processes of diagnostic exclusion, will be sufficient to determine the fact that some encephalic injury has been suffered. The further determination of the special lesion which dominates the case presents difficulties which, while not insuperable are often considerable. It is perhaps useless to attempt a more condensed summary of points in differential diag- nosis. I have already incidentally stated them as succinct- ly as seemed compatible with their proper presentation ; but it may be of service to recall, or to reiterate, some of the more important diagnostic indications which the study of symptoms has suggested. Haemorrhages.—The morbid conditions which may di- rectly result from traumatic intracranial haemorrhages are : an abnormal temperature, a complete or partial loss of con- sciousness, a change in the character or frequency of the pulse or respiration, a disturbance or abrogation of muscu- ar function, and an irregularity of the pupils. These con- Iditions are subject to complication, modification, or super- sedure by the symptoms of coexistent lesions. A continued subnormal temperature is characteristic of large and comparatively uncomplicated haemorrhages, and as these are more frequently of epidural character, it may TRAUMATIC INTRACRANIAL LESIONS. H3 be regarded as to a certain extent diagnostic of the variety as well as of the class. The absence of symptoms indica- tive of parenchymatous injury will be confirmatory of the opinion that an existent haemorrhage is derived from the epidural vessels. Associated symptoms of diffused contu- sion suggest a pial, and those of laceration a cortical, haemorrhage. In the majority of cases the primary record of temperature is from 99° to 99° + , and in any case in which, then or afterward, it exceeds 101° + , or probably 100°, the elevation is due to an associated lesion. It fol- lows that in pial or cortical haemorrhages the temperature has a higher range than in those of epidural origin, and is proportionate to the extent and importance of the compli- cation. The bilateral variation to which the axillary temperatures are subject is not peculiar to this result of injury. The primary unconsciousness which is of frequent oc- currence in cases of haemorrhage is a symptom of compli- cating general contusion; the secondary unconsciousness, due to the loss as well as pressure of blood effused, follows with or without an interval of restored consciousness, de- pendent upon the severity of the diffused injury of the parenchyma and the rapidity of the haemorrhagic effusion, and is partial or complete in proportion to its amount. Consciousness is always lost in fatal cases; it is retained in fifty per cent, and more in recovering cases, even in those demanding operation. The character and frequency of the pulse have no defi- nite relation to the form, location, or amount of haemor- rhage. The pulse may be normal, slow, or frequent in large extravasations wherever situated; but frequency is of so much more usual occurrence in haemorrhage than in other intracranial lesions that when noted it may be con- sidered fairly diagnostic, with the numerical probabilities 114 THE DIFFERENTIAL DIAGNOSIS OF in favor of its epidural character. The bilateral variation in the force and fullness of the arterial pulsations is com- mon to haemorrhages and to injuries of the brain sub- stance, and of importance, therefore, only in general diag- nosis. An alteration in the character or frequency of respira- tion is almost invariable in fatal cases in which haemor- rhage is an approximately isolated lesion. When the effu- sion is upon the convex surface of the brain, respiration is usually frequent and often stertorous; when at the base posteriorly, it may be frequent with cyanosis, or, if pressure is made upon the medulla, it becomes progressively slower until it ceases altogether, though cardiac and arterial pul- sation may still continue. In recovering cases it is habit- ually unchanged. In complicated or mixed cases it, like the pulse, perhaps as a resultant of opposing forces, very generally remains normal; and if abnormal it is more likely to be stertorous than unduly slow or frequent. General or local paralysis aud disordered muscular ac- tion may be direct symptoms of haemorrhage compressing or irritating recognized centers of muscular control; tetanic spasm is not infrequent, but clonic contractions are of rare occurrence, except as the result of an associated lesion. The pupillary condition usually suffers some change, but none which is characteristic. Every possible combina- tion of contraction, dilatation, and normal condition, with the single exception that contraction of one pupil never oc- curs without some change in its fellow, is associated with every variety and situation of haemorrhage. Dilatation in some combination is more commonly observed than con- traction, but not more frequently upon the side of the effu- sion than upon the opposite ; and not more characteristi- cally with one type of haemorrhage than with another. In complicated haemorrhages dilatation of both pupils is more TRAUMATIC INTRACRANIAL LESIONS. 145 common, and the effusion is more frequently bilateral than in the more nearly simple cases; and in unilateral dilata- tion is more likely to be on the corresponding side. A normal condition of the pupils is compatible with every variety of haemorrhage wherever situated, whether simple or complicated. Sensory disturbances, as delirium or irritability, are not symptoms of haemorrhage, and when they occur are to be regarded as indicative of an accompanying lesion of the parenchyma. Subarachnoid Serous Transudation.—The serous transu- dation from the pial vessels which occasionally results from meningeal contusion can not be connected with symptom- atic conditions. Arachnitis is either acute or subacute in form, and is typically caused by a diffused meningeal contusion, though exceptionally propagated from a point of localized injury. It is sometimes an immediate result of the meningeal le- sion, and it may be insidious in its inception and progress, but its beginning is usually late and is sharply defined. Its invasion is likely to be marked by a distinct and rather sudden elevation of temperature and an evident change in the general condition of the patient. The subsequent course of temperature is erratic, and the characteristic symptoms are those of cortical irritation. The pupils are oftener normal than otherwise, and changes in the charac- ters of the pulse and respiration are slight. The form of the effusion is not necessarily reflected in the course and na- ture of the symptoms. The question of infection is un certain. General contusion is a constant complication of all other forms of intracranial injury, but rarely occurs as an isolated lesion of fatal severity. Its symptoms are irregular in their development, course, and termination, and indefinite 10 146 THE DIFFERENTIAL DIAGNOSIS OF in their mutual relation. This lack of conformity to any classical rule is due to the comprehensiveness of the lesion, its regional variations, and the fluctuations which occur from time to time in the distribution of the movable fluids upon which its manifestations mainly depend. A loss of consciousness, at some time and in some degree, is more nearly constant than any other individual symptom, and the conditions of temperature are more uniform than any of the other phenomena which it occasions. The tempera- ture is not likely to be subnormal at the time of earliest observation, nor to exceed 99°+ ; its subsequent course in cases of intensity is progressive, with few recessions, and ultimately reaches elevations of high degree. Primary or early delirium, like primary unconscious- ness, in both simple and complicated cases, is to he ascribed solely to the influence of this lesion. The diagnosis must largely depend upon the recognition of the fact of intra- cranial injury, and upon the further possibility of exclud- ing its other varieties, or, if they exist, of segregating the effects which they produce from a distinct remainder of symptoms. Limited contusion is comparatively infrequent, and when it occurs in scattered areas through the centrum ovale, is not distinguishable from the general form of the same lesion; when it is cortical, it differs from laceration only in the extent of injury done to tissue; and symptoms, if they result, differ only in degree. It is therefore practi- cally impossible to diagnosticate it from those lesions in their mitigated form. Laceration is almost, if not quite, invariably compli- cated by a concomitant general contusion and by a resultant haemorrhage. The primary loss of consciousness, and the delirium of some grade or character which often precedes or follows its restoration, are attributable to the attendant gen- TRAUMATIC INTRACRANIAL LESIONS. 147 eral contusiou. In trivial cases there may be no secondary symptoms which indicate the fact of laceration. The pri- mary unconsciousness may be replaced by a condition of lethargy or blunted perception, passing through somnolence into coma and death. The primary stage is most frequent- ly succeeded by mental aberration or decadence, which may terminate in recovery, permanent dementia, or death. In exceptional instances consciousness may remain unimpaired, with extensive laceration of even fatal import. There is no necessary relation between the gravity or simplicity of the early psychic symptoms and the outcome of the case. The temperature is higher than in any other form of intracranial injury, and, in cases destined to an early fatal termination, is characterized by a rapid and progressive in- crease, which sometimes continues for a certain time after death has occurred. An irritability or abnormal sensitiveness to external im- pressions, often noticeable even after the supervention of final unconsciousness, and wanting in cases of haemorrhage or contusion, is of frequent occurrence. Convulsions, especially in implications of the frontal or temporo-sphenoidal lobes, are frequent in fatal cases, and so infrequent in the history of other lesions that they may be regarded as characteristic. The presumption that they are occasioned by laceration rather than by haemorrhage is strengthened by a previous high temperature. The loss of faecal and urinary control is common to all extensive lacerations without reference to the abrogation of consciousness or of muscular power. It rarely follows other forms of intracranial injury and is very nearly pathog- nomonic. The urinary and faecal discharges may be either unconscious or involuntary, or they may be the result of the patient's indifference to his surroundings. There are no demonstrated centers of control. 148 THE DIFFERENTIAL DIAGNOSIS OF Paralyses are so much oftener the result of other lesions that they are of service only in determining the location of a laceration the existence of which has been already pre- dicated upon more positive manifestations. The pupillary changes have no greater diagnostic value than in haemorrhages; the pupils are, in fact, normal in a much larger proportion of cases. The characters of the pulse and respiration are habitu- ally unchanged unless modified by the existence of compli- cations. The contrast afforded by their substantially nor- mal condition in an environment of pathic phenomena gives them the highest diagnostic value which they possess in this particular relation. The bilateral variation in axillary temperatures and in the force and fullness of arterial pulsation, already noted as of unknown origin and referred to general diagnosis, is common to all forms of intracranial injury. The manifestations of psychic disturbance are confined to cases in which the frontal lobes are implicated, but this implication is so constant as to make them practically symptoms of laceration in general. The other special symptoms which localize the seat of laceration have been already summarized. The phenomena as indicated which directlv point to laceration may be enumerated as certain peculiarities of temperature, psychic disturbances, loss of faecal and urinary control, and clonic convulsions. Pyogenic parenchymatous inflammation is infrequent, and is of limited form, except when caused by the in- trusion of a foreign body. Direct laceration and in- fection through the medium of compound fracture affords no question of diagnosis and is excluded from considera- tion. The predisposing cause of traumatic central abscess is TRAUMATIC INTRACRANIAL LESIONS. 149 limited contusion; the exciting cause is supposed to be the admission of a pyogenic germ from some source external to the body. Though this supposition as to the source of infection may be correct, the further proposition that a route of entrance is always afforded by a superficial wound of the head is erroneous. Cases have occurred and are recorded in which no such wound existed. The number of instances in which the histories of these limited pyogenic processes have been carefully observed or recorded is insufficient for the formulation of rules for diagnosis. The two cases which I have presented, and a third which I have noted, are in evidence of their uncer tain symptomatology. These conclusions are derived solely from the analysis of the cases which I have detailed, and are stated in as positive terms as the limited number of observations made will warrant. The series of cases presented, if insufficient to afford a basis for statistical inference, is yet so extended that the generalizations which it justifies are entitled to credence until controverted by results obtained from the study of a very much larger number of cases subjected to equally careful examination. It may be questioned whether deductions made, as in this instance, from the comparison of some hundreds of cases are likely to be materially changed by any subsequent multiplication of their number. Symptoms are so diversified, their combinations so varied, and their continuance is sometimes so brief, that constantly careful observation and equally careful record are essential to thorough comprehension of intracranial injuries. If there are few symptoms which are intrinsi- cally pathognomonic there are many which by mutual re- lations of time and circumstance assume a pathognomonic character. 150 TRAUMATIC INTRACRANIAL LESIONS. The possible multiplicity of lesions must be recognized, the relative as well as the absolute value of symptoms esti- mated, and if necessary some interval of time afforded for the development of the pathic condition; diagnosis be- comes then neither more difficult nor more uncertain than in a majority of grave traumatic or idiopathic lesions. 34 Wkst Thirty-seventh Street. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a Are weekly medical journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. 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