Elliott Cor. Yonge and Alexander Sts., Toronto, Ont. Trains Young Men and Women for Business Life HE Business World is full of tempting THE opportunities for the earnest, energetic, The ignorant are crowded to the wall to make Thoroughness" is the Keynote of this Popular College. ENTIRE YEAR. W. J. ELLIOTT Principal Cor. Yonge and Alexander Sts. REPORT OF A CASE OF FRACTURE OF BASE OF SKULL WITH MIDDLE MENINGEAL HEMORRHAGE BETWEEN DURA MATER AND THE SKULL.* BY EDGAR BRANDON, M.D. C.M. Extravasation of blood within the skull necessarily occurs in all cases of injuries of the head accompanied by laceration of the brain, and in many in which the skull is fractured without wound of its contents. This is due to the great vascularity of the parts within the skull, the large sinuses, the numerous arteries that ramify both within the bones and at the base of the brain, and the close vascular network spread over the surface of the organ. The hemorrhage may be due to fracture, in which the fissure tears across one of the meningeal arteries, or a fragment of bone wounding a sinus. In many cases the inner table only has been fractured, and the middle meningeal artery is thus torn as it lies in a groove in the bone. Hemorrhage may occur in four situations: (1) Between the dura mater and the skull, when it proceeds from a wounded middle meningeal artery, or, more rarely, from a sinus; (2) in *Read at the regular monthly meeting of the Post-Graduates' Society of Toronto. the subdural space; (3) in the subarachnoid space and in the meshes of the pia mater on the surface of the brain; (4) in the substance of the brain or in the ventricles. As the time at our disposal will not permit us to take up a discussion of the points in connection with these four situations, and as the case we present to-night comes under the first classification, we shall, therefore, confine ourselves to that form of hemorrhage which takes place between the dura mater and the skull proceeding from a wounded middle meningeal artery. Now, extravasation of blood between the dura mater and the skull is much less common than that, due to injury or laceration of the cortex, which is by far the commonest, but has the distinctive feature that when it does occur the quantity is often quite large. However, even here the quantity is not very large in the great majority of cases, but, as we shall see later on, the case we are about to present quite exceeds anv amount recorded, so far as we have been able to ascertain. Symptoms. The only certain definite symptom of extravasation of blood is gradually increasing paralysis and insensibility, ending in coma within twenty-four hours of the injury. In a typical case there are three distinct stages, viz.: (1) Concussion following the injury; (2) a temporary return to consciousness and a continuance of the same for a time; (3) coma gradually supervening. As accessory signs the following may be mentioned: (a) Paralysis, often preceded by twitching of the muscles, if the clot be over or close to the motor area; (b) certain eye symptoms, such as passive congestion of the eyeball, pareses of some of the ocular muscles and protopsis, with dilated pupil, all due to pressure of the clot on the cavernous sinus, when the extravasation extends to the base of the brain; (c) where a fissure exists in the bone, blood may filter through into the temporal region and produce a marked bulging or fulness there. The amount of concussion or stunning varies, depending upon the severity of the cause, ranging from a slight momentary giddiness and confusion of thought to the most profound insensibility. The period of consciousness is generally of short duration, often only an hour or an hour and a half, sometimes, even, much shorter, the concussion rapidly passing into compression almost without an interval, depending upon the amount of, and the rapidity in which the blood is extravasated. The following case will illustrate. The patient, J. B. H., was brought into the Toronto General Hospital, Tuesday, December 18th, 1903, at 11.30 a.m., by the 3 police ambulance, with an incomplete history of having been injured by the street railway the day before. A complete history of injuries was not ascertained till a few hours before his death. He was examined hurriedly by Dr. McCauley and myself while waiting to be admitted. We found that the left arm was completely paralyzed, but that there was an incomplete paralysis of the left leg, inasmuch as he was able to move the leg and knee Specimen of brain in skull-cap showing depressed brain, separated dura mater, trephine openings and hemorrhage into right temporo-sphenoidal lobe. slightly, and as he resisted Dr. McCauley in his manipulation of the leg. His eyes were closed and the breathing was stertorous. There was inequality of the pupils. He was sent up to the ward and I examined him about twelve o'clock. The patient was a heavy set, well-nourished man about five feet ten inches in height, weighing about 190 pounds, iron grey whiskers and hair. He lay with eyes closed He had no control of and breathing in a stertorous manner. the left arm whatever; lifted from the bed it fell back limp and useless. There appeared to be very slight movement in left foot, but otherwise he had no control. Patient was conscious, as when I asked him to move his right arm he did so without any difficulty. He was also able to move the right leg without any difficulty when asked to do so. Asked to squeeze my hand with his right, he did so, exerting a fair amount of force. He was unable to open his eyes, having no control of his eyelids. The pupil of the right eye was dilated, not fully, but reacted to light. The pupil of the left eye was contracted down to a very fine pin point size, but also reacted to light. There was no hemorrhage from the ears, nose or mouth. He spoke in a mumbling, non-fully articulated way, and at times it was very difficult to understand him, showing that his speech centre was evidently affected. The patient, when asked to put out his tongue, did so. It did not protrude markedly to any one side, but on retracting was drawn over to the right side. Patient seemed quite conscious of all that was going on about him, and answered questions put to him, though his answers were sometimes unintelligible. He also inquired as to why I did certain things, such as the testing of his pupils. I examined him for bruises, and found one in the left anterior tibial surface about three or four inches from the foot. He also had a bruise on the lower lip in the centre, wedge-shaped in character, with apex at the alveolus, which he told me was due to his injury. There were also scratch marks on his cheek and nose. I examined him for signs of a fracture, but made out none. A bruised area was afterwards disclosed upon the right temporal region, extending backwards and downwards to tip of the mastoid. Otherwise patient had no evidence of injury. I drew off, the urine, with the result of only a few ounces, which, on examination, I found to be normal. . His temperature per axilla was normal, pulse 70, respiration 30. He was given croton oil followed by mag. sulph, one-half ounce every hour for seven doses, without effect, when croton oil was repeated, followed by mag. sulph., which was effectual. During day took nourishment and swallowed without any great difficulty. Temperature at 7.30 p.m., 100 deg., pulse 90, respiration 28. What little movement there was in the left foot had disappeared, and at 8 p.m. the nurse had made the observation : "Had very little difficulty in swallowing, knew all that was |