their extent from their external appearance, as at times there will be no contusions which are noticeable upon the scalp and the skull may be found very extensively fractured. Of course we must look very closely at the different symptoms of concussion and compression of brain and determine, if possible, if we have concussion or compression. This is at times a very hard thing to do, as the symptoms are closely allied and one may be deceived in his case, notwithstanding the fact that he may be the most astute observer; so the only thing to do when in doubt is to make an exploratory incision through the scalp, and then determine the exact nature of the injury and govern your treatment accordingly.

We usually find coma with extensive fracture and depression, which is noticeable from the exterior, and the patient in a few hours will regain consciousness. We may find the same condition in a simple case of concussion. We may even have the injury to the extent of laceration of duramater, as in a case I will cite later.

It is always wise to determine without a doubt the exact nature of an injury to the cranium when there is the least symptom of fracture, as we may have a fracture and at the time have what may seem to be a complete recovery, and in six months, or possibly two years, there will develop some nervous trouble, such as Jacksonian epilepsy, as the result of a cicatrix caused by the original injury, which at this time will not be so conveniently and successfully managed.

We cannot always tell just how and what part of the nervous system will suffer. Suppose we have an injury over the sight centres, and before we decide just what the trouble is we have an atrophy of the optic nerve, an irreparable condition, and our patient has darkness before him the balance of his days. Could we ever forgive ourselves, knowing our negligence had been the cause of a patient's total blindness, had drawn a black shade over a patient's eyes, one that never could be raised by human hands? Those are unpardonable errors, as by careful inspection something might be discovered to prevent such a calamity.

With your permission I will cite a case wherein this occurred. Mr. L. P., aged 52, while coming out of the North Woods in September, 1896, riding on a buckboard, an old limb fell from the top of a tree, striking him on the head in line with the top of the ear, two inches posteriorly, the scalp being somewhat lacerated, but not sufficiently to expose the bone. He was dazed for a few moments, but rallied and drove for some ten miles to a railroad station, took train and rode twenty-five miles, where he was attended by a physician, who cleaned the wound thoroughly, on which he applied compresses of arnica, changing them frequently during the night. Next morning patient was considered all right. He went on about his business, thinking he was in as good condition as ever, until along the last of October. Being employed by a woollen manufacturer, one of his duties was to select qualities and colors of cloth which in his judgment would be most salable. He discovered that his sight was not quite as good, that his field of vision was smaller than usual. He did not mind this for several weeks, as it was slight at first, but as time went on his failing eyesight progressed, and he consulted his family physician, who declared that there must be some syphilitic history. This the gentleman protested against, as he said there was no such history in the family, neither was he affected in this way.

From his family physician he went to a noted eye specialist in New York, who declared it must be of syphilitic origin. The gentleman again protested, but it was of no avail, as they put him on the iodine and mercury treatment and continued this for several months. As he grew steadily worse under this treatment, he was examined for locomotor ataxia, but all symptoms, with the exception of unsteady gait, were lacking, and they decided that this was not the trouble. He visited several men after this without benefit. Strange to say, none of these gentlemen inquired into the history of a possible injury to the head; however, they were told of this injury, but did not place enough significance upon this part of the history to even make an examination, deciding it was an atrophy of the optic nerve, due to either

specific origin or diphtheria, which he had had some sixteen years previous.

I examined this patient in March, 1898, and found upon close examination a slight depression of the outer table of the skull, situated over the cuneus. My diagnosis was atrophy of the optic nerve as the result of pressure upon the cuneus, due to an undiscovered fracture at the time of injury in 1896.

Now you will say, why did you not operate? Simply because there was a complete atrophy of both optic nerves, therefore it would have been useless to have operated for that trouble, and then the time was so remote from the time of injury and there had so much change taken place in the brain tissue, that there was a question in my mind if an operation would have been justified. However, if there had been other symptoms developing in the case, I would have advised operation as the last resort, after having informed the patient of possible failure and then he would have taken the responsibility in the matter. There is no doubt in my mind had the gravity of his injuries been recognized at the time of occurrence and a button of the skull been removed, which would have relieved the pressure, a complete recovery would have been the result. Now, what other trouble has he staring him in the face? Jacksonian epilepsy, locomotor ataxia, paresis, etc. Let me say one word right here regarding locomotor ataxia and paresis. You will of course accuse your patient of having had syphilis the first thing when you see one of those cases. Now, if their answer is negative, do not at once believe them to be prevaricating, but see if you cannot elicit the fact that they have suffered an injury to the head.

Master J. A., aged 12, on May 30, 1899, about seven o'clock in the evening, was thrown from his wheel, striking right side of head on the pavement. Getting up quickly, he said he was not injured very much; had some pain in right side of head, which was considered of very little account. He was able to walk and was going to walk home, a distance of three blocks, when a gentleman who happened near the

place of accident drove him to his home. A physician was summoned, who thought there was no injury of any account. Patient visited with family during the evening until about half-past nine, when he said he thought he would retire; said his feet felt numb, but was able to walk and complained of very little pain. At this time another physician was summoned, who also said he would be all right in a short time, as there was no fracture. One hour later they tried to arouse him and found him in a comatose condition. At this time they despatched a messenger for me. I found him in the following condition. Profound coma, incontinence of the urine and feces, right pupil dilated, some twitching of the muscles of the lower portion of the body, stertorous breathing, pulse 48, respiration 14.

Examination of the head revealed a slight contusion. My diagnosis being fracture complicated with hemorrhage, I advised him sent to the hospital for immediate operation. At 1.30 A.M. I had patient on the table. At this time the pulse was intermittent and I feared death would occur before I could get the skull open. I made a horseshoe incision through the scalp, and upon baring the skull a fracture something over three inches in length came in view. Trephining the skull revealed a large clot. I enlarged my opening in skull sufficiently to thoroughly explore and proceeded to remove the clot, which to my surprise weighed over six ounces. This seems rather incredible, and I may say right here that I thought that I would never get through removing clots. When the cavity was thoroughly cleaned out, I found the middle meningeal artery spurting, and I had some trouble in controlling the hemorrhage from this, but succeeded after a little. There was considerable oozing, so I packed the wound with gauze. By this time the patient was quite near eternity, but by the use of salines, strychnine, and whiskey I succeeded in preventing him from passing over the river. He lay in a stupor for about eighteen hours, when he regained consciousness and was quite himself.

Everything went on very nicely until the eighth day,

when about I A.M. I was summoned to the telephone and was told that the patient had had a severe chill. I went to the hospital immediately, and upon being told that he had a temperature of 106.4°, I thought it was all up with him. Looking him over thoroughly, I found his pulse was good and that he was feeling very good indeed, so I told them to prepare him for the table at 9 A.M. At that time I found a slight bulging over where he had received the blow, and inserting my exploring needle to the depth of about an inch, I struck a bloody serum which was purulent. I evacuated this and packed with gauze. With the exception of a few minor troubles which I had with the wound, he made an uninterrupted recovery, and at the end of five weeks the wound was completely healed and he was discharged from the hospital.

If you will bear with me a little longer I have one more case, which to me was exceedingly interesting, which I desire to cite. Mr. C. E., aged 21, was sent to me with the following history. When a lad about seven or eight years old he fell through a bridge, striking on his head, receiving what the physician at that time called nothing but a scalp wound. It was allowed to heal, but within two or three weeks of the time of the injury he began to have a slight twitching of the leg. This would occur once or twice a week, continuing in this way until he was about twelve years old, when the spasms became more frequent. At this point it began to affect his memory. He could learn a lesson easily, but would forget it very soon. From this time on the spasms began to increase, loss of memory increased, and a look of imbecility began to appear until it was quite marked. When I saw him the spasms were coming on every fifteen or twenty minutes and they would last about thirty seconds. The leg would begin to twitch first, then the arm, and last the mouth on the right side. It had gone to the point where he had scarcely any use of his right leg and absolutely no use of his right arm; in fact, he was unable to even close his fingers. I watched the case very closely for about forty-eight hours, and at the end of that