said to him; during night was uneasy, moaning, and throwing the bed clothes off." Next morning, December 10th, his condition had not improved. He was still as conscious as previously, but his respirations were more rapid, heavy and sonorous, about 36 per minute, his pulse 90, temperature 10 deg. During the day his condition did not improve, and the next day he was worse, temperature 102 deg.; pulse 106, weak and intermittent; respiration, 44, heavy, difficult and stertorous. In the afternoon he had involuntary movements of urine and feces, was unconscious, markedly cyanosed, breathing stertorously and with marked rattle in throat, head inclined to right side, pulse very weak and thready. Dr. Baines, who had charge of him, advised me to bleed him, which I did, taking away some eight or ten ounces with difficulty. Stimulants, strychnia, digitalis and ether were used with the result that the cyanosis somewhat lessened. I may say that during the afternoon his wife was present, and she gave us the complete history, which we heard for the first time. She stated that his waggon was struck by the street car and he was pitched out. We have since, however, learned from the inquest, etc., that he was found with his heels in the waggon and his head on the pavement. He was assisted to his feet, and he stood at his horse's head and quieted it while his effects were being gotten together. She also stated that he walked from King Street to Bloor Street, a distance of some miles, went to his home and undressed himself, and retired. During the night the paralysis came on. Dr. Fotheringham, passing through the ward, saw him and thought he should be seen by a surgeon. Dr. Peters being in the building, I asked him to see him, and after examining him and hearing his history, above related, he thought there was evidence of meningeal hemorrhage and advised trephining. I consulted with Dr. Baines, who concurred. Dr. Peters operated upon him at 6.40. He cut a horse-shoe flap over the right temporal region, disclosing considerable sub-aponeurotic hemorrhage, with clotting. The trephine was then introduced over the upper right rolandic area, and the bottom being removed, clotted blood was discovered. Dr. Peters put in his finger, but could not find the dura mater. He began pulling out the clotted material, and again was dissatisfied with the result. A further trephining was done an inch and a half below and behind the right parietal eminence, again disclosing clotted material. After a time the clotted material, weighing eight or ten ounces, was removed, and resulted from the following condition: The dura mater was seen to be separated from the calvarium and the hemorrhage coming from the anterior division of the middle meningeal artery had separated the dura and gradually increasing in quantity, had pressed and crushed the brain substance before it downward, forward and backward. Oozing could be seen from the wounded artery, which was controlled with ease. The compressed brain did not expand, and remained in the condition which we see in the specimen. The wound was packed with iodoform gauze and the patient removed to the ward. During the operation, which was done without anesthetics, the patient showed slight signs of reaction, but his respirations became more and more labored and stertorous, his pulse throughout the operation was very difficult to get, and the result was that he died half an hour after he was removed to the ward. J. B. H. (P. M.)-Nutrition good, rigor mortis well marked, post-mortem staining on dependent parts. Inspection: Slight bluish discoloration about the chin, no ebrasion; scratch marks are visible on nose, cheek and ear of the right side. There is a bluish discoloration in front of the left ear, also some fulness in right side of neck from angle of the jaw to the mastoid portion of the temporal bone, gradually tapering as it descends into the soft tissues of the neck. Bluish discoloration noted over this swelling. Noted a crescent-shaped incised wound in scalp extending from two inches above and one inch in front of the occipital protuberance. Middle of right arm, bluish discoloration one and three-quarter inches by one and one-half inches. Front of right elbow, venesection mark. Outer side of right knee, an abrasion is noted. Another abrasion is noted at upper and inner aspect of left leg two and one-half inches in length. There is also an abrasion, size of a twenty-cent piece, at outer side of head of fibula of left leg.. Head. On removing scalp there was found some dark effused blood, especially well-marked at the sight of swelling previously described. Also noticed two trephine wounds. Noted a fracture extending from parietal eminence downward and forward three inches, this just below the swelling previously described. On removing skull cap, dura is seen to be depressed one and one-half inches from the inner table in the right side, extending from a point midway between the glabella and occiput to the petrous portion of the temporal bone in its vertical axis, and in its transverse axis from a point one and one-half inches above centre of Reid's base line to the occipital pole. Removing brain, hemorrhage is noted below the tem poral sphenoidal lobe in front and right side. Hemorrhage in the pia-arachnoid into the frontal lobes. Slight hemorrhage on under surface of right frontal lobe along the course of the olfactory nerve. Base of Skull.-There is a fracture from the parietal eminence extending downwards, outwards and forwards, crossing the lateral sinus back of the fossa sigmoidea and turns inwards and passes forwards, ending in fossa one-quarter inch to foramen. lacerum posticum. Section.-On section, anterior abdominal wall three inches. in thickness, two inches of which was fat. Omentum.-Shows a large amount of yellow fat, overlies the liver and front of stomach. Peritoneum.-Normal. Pleura. Right: Firm old adhesions behind, in front and below. Left: similar adhesions in front, above, below and behind; diaphragmatic adhesions. Pericardium.-Slight adhesion between the pericardium and pleura on right side; contains bloody colored serum, one-half ounce in amount. Heart weight, 13 ounces. Surface of heart shows small clot plugging a small vessel at the auriculo-ventricular septum. Right side is engorged; pulmonary artery, muscle firm, slightly paler than normal; patchy atheroma of aorta. Coronary arteries-orifices free;, fairly well-marked sclerosis of coronary vessels. Lungs.-Right: weight, 29 ounces; anteriorly fairly wellmarked emphysema; well-marked hypostatic pneumonia with edema, stage of splenization, friable. Left: weight, 21 ounces; hypostatic congestion and edema, very friable. Spleen. Normal, weight 21⁄2 ounces. Kidneys.-Right: 61⁄2 ounces; large amount of perirenal fat, capsule slightly adherent; kidney substance pale, cortex narrowed, ureter normal. Left: 64 ounces, otherwise same as right. Pancreas.-Normal. Intestines. Normal; mesentery diffuse lipomatosis. The mechanism of meningeal extravasation is very interesting to note, and has given rise to much discussion. It is very evident, from experiments performed, that there must be a separation of the dura from the skull, due to fracture or viclence applied, and that the extravasation is consequent on that separa tion. I may here quote from Sir Charles Bell's "Surgical Observations" (London, 1816) : (London, 1816): "It is extraordinary that any one who has ever raised the skull cap in dissection and felt the strength of the universal adhesions of the dura mater to the lower surface of the bone, could for an instant believe that the arteria meningea media has power of throwing out its blood to the effect of tearing up these adhesions from the entire half of the cranium." Here, to substantiate his statements that the dura mater is first of all separated from the skull and that the extravasation is consequent upon that separation, he goes on to describe the following experiments: "Strike the skull of the subject with a heavy mallet; on dissecting you find the dura mater to be shaken from the skull at the part struck. Repeat the experiment on another subject and inject the head minutely with size injection and you will find a clot of the injection lying betwixt the skull and the dura mater at the part struck and having an exact resemblance to the coagulum found after violent blows on the head." This would apparently appear to be conclusive, but to carry it further in cases of fracture, such as occurred in this case, there are also, apart from the blow or injury which must necessarily have been received to produce a fracture, certain alterations in form of the skull accompanying the blows which tend to lessen the attachments of the dura, there always being a certain amount of play bebetween the edges of a fracture sufficient to lessen a certain small amount of the dura from the skull. The dura mater being separated from the skull to a certain extent, how does it come about that such a very large surface of the dura is separated? Simply that the blood is poured out in sufficient force and in ever-increasing amount to strip the membrane from the bone, because it is very difficult to conceive that that membrane can be shaken from the base of the skull by a blow in the parietal region, and yet meningeal hemorrhage often extends as far as the cavernous sinus. Once the blood is forced in it acts on the principle of the hydraulic press. The hydraulic or hydrostatic press depends upon the equal transmission of fluid pressure, viz., "that the pressure exerted anywhere upon a mass of fluid is transmitted undiminished in all directions, and acts with equal intensity upon all equal surfaces and in directions at right angles to these surfaces." Thus by a simple hydraulic press a large weight was supported through the column of water by a much smaller weight and in inverse proportions to the ratio of their areas. This, in turn, gives rise to the hydrostatic paradox in which, by decreasing the 9 smaller area indefinitely and increasing the larger area indefinitely, any force, however small, applied to the smaller area may, by transmission of pressure through the fluid, be made to support upon the greater area any weight, however large. Now, here we had the heart pumping blood through the artery into a closed cavity, and as the cavity enlarged so did the force increase. Now, taking the pressure in an artery to be two pounds to the square inch, when four square inches of dura are separated we have a pressure of eight pounds pressing against it; when it is separated for three square inches in each direction, or nine square inches, the pressure equals eighteen pounds. The area of dura mater stripped off in this case we have just cited was measured and found to be five inches long antero-Dosteriorly, one and five-eighth inches in its greatest transverse diameter, and a greatest vertical diameter of one and one-eighth inches. This is approximately estimated to be about twelve square inches. We should, therefore, estimate that there was a force of twenty-four pounds exerted against the brain. The only resistance against this was the adhesion of the dura mater to the skull and the blood pressure in the capillaries of the brain substance. It is, therefore, not very surprising that we get such very marked effects from the force exerted by the escaping blood, and it is no great wonder, indeed, that the brain, so soft and delicate and so easily injured, becomes compressed into a small space and fails to expand when that pressure is removed. There are a few further points of interest that I should like to draw attention to in regard to this case, points which are very remarkable and very extraordinary, indeed, when one considers the case in all its details: 1. The remarkably slight amount of concussion. After the accident he was found with his feet at the top of the waggon box and his head on the pavement. He was in somewhat dazed condition when assisted to his feet, but was able to go to his horse's head and quiet him while his effects were being gotten together. He subsequently was able to walk from King to Bloor Streets, a distance of about one and one-quarter miles, and after reaching his home to undress and retire. 2. The remarkably slow onset of symptoms and the great As we have length of time elapsing before coma supervened. stated, he was injured during the afternoon and walked home, during the night the paralysis on the left side came on. brought into the hospital at twelve the next day he was still conscious of everything. Coma did not set in for a few days When |