RUPTURE OF MIDDLE MENINGEAL ARTERY 
WITHOUT FRACTURE -, 
LIGATION OF COMMON CAROTID ARTERY. 
BY 
JOSEPH RANSOHOFF, M.D., F.R.C.S., 
OF CINCINNATI, 
PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE OF OHIO. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY, 1890. RUPTURE OF MIDDLE MENINGEAL ARTERY 
WITHOUT FRACTURE; 
LIGATION OF COMMON CAROTID ARTERY. 
BY 
JOSEPH RAN^OHOFF, M.D., F.R.C.S., 
OF CINCINNATI, 
PROFESSOR OF ANATOMY AND CLINICAL SURGERY IN THE MEDICAL COLLEGE OF OHIO. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY, 1890. 
PHILADELPHIA: 
W M. J. DORNAN, PRINTER. 
1890. RUPTURE OF MIDDLE MENINGEAL ARTERY WITH- 
OUT FRACTURE. LIGATURE OF COMMON 
CAROTID ARTERY FOR SECON- 
DARY HEMORRHAGE. 
By JOSEPH RANSOHOFF, M.D., F.R.C.S. Eng., 
OF CINCINNATI, 
PROFESSOR OF ANATOMY AND CLINICAL SURGERY, MEDICAL COLLEGE OF OHIO. 
On March 12th, Joseph B., aged twenty-eight, merchant, fell from 
a ladder into a shaft. Height of fall, about eight feet. When assist- 
ance, which was close at hand, reached him, he was perfectly con- 
scious, complaining only of severe pain in the forearm. Dr. Charles 
Kearns, who was summoned, recognized a Colles fracture, and after 
dressing it sent the patient to his home, a distance of two miles from 
the site of the accident. At no time during a full week from the date 
of the fall did the patient complain of headache, nausea, vomiting, 
or indeed anything indicative of head injury. He walked about the 
house and the streets, transacted some business; ate well, slept well, 
and appeared in his usual mental condition. On the morning of the 
eighth day, after a good night, he descended to the dining-room, com- 
plaining of some headache. A cup of coffee was taken but rejected. 
Seeking relief in sleep, the patient lay down upon a couch, where he 
at once lapsed into a condition of unconsciousness from which he 
could not be roused. 
Three hours later I saw him, in consultation with Drs. Kearns, 
Nickles, and Forchheimer. His breathing was stertorous and 28 per 
minute; pulse 40 and full; temperature normal; coma profound; 
conjunctival and cutaneous reflexes entirely wanting; irregular twitch- 
ing and tossing movements affected the face and extremities on both 
sides of the body. 
There was neither mono- nor hemiplegia. The right pupil was 
small and sluggish; the left dilated almost at maximum and fixed. 4 
RANSOHOFF, 
The urine removed by catheterization had a specific gravity of 1040 
and gave the sugar reaction to both Trommer's and Boettger's tests. 
A careful examination of the head failed to reveal evidences of 
trauma. 
Although the clinical picture was that of cerebral compression from 
sub-cranial hemorrhage, and not that of diabetic coma, the possible 
presence of the latter condition could not be excluded. A drop of 
croton oil was therefore administered for its derivative effects. 
Daring the five hours following the first examination, the pulse had 
risen to 70; the temperature to 101° in the rectum. The coma re- 
mained unchanged. Respiration stertorous as before. In expiration 
a slight paresis of the right cheek seemed discernible to one of the 
consultants. It certainly was not pronounced. 
Recognizing in the increasing pulse-rate and rising temperature fur- 
ther evidences of hemorrhage and speedy dissolution, it was concluded 
to trephine over the left meningeal artery. When the scalp was shaved, 
it showed no trace of recent injury. It was rendered thoroughly 
aseptic and bandaged to prevent hemorrhage. 
A semilunar flap, with base below, was then made, its centre being 
just two inches behind and on a level with the external angular pro- 
cess. On exposing a large portion of the temporal fossa, no trace of 
either fracture or fissure was seen. A bluish tinge of the squamons 
portion of the temporal bone gave certainty of a clot underneath. 
The removal of a small button of bone from this point was followed 
by a very copious flow of dark fluid blood, on the cessation of which a 
clot was exposed which was too firm to be removed through the small 
trephine opening. This was enlarged with rongeur forceps until it 
measured two inches in its antero-posterior and one inch in its vertical 
diameter. The firmness of the clot resisted irrigation. It had to be 
scooped out with the finger, and measured about six fluidounces. The 
anterior and posterior boundaries of the middle cranial fossa could be 
readily felt, the dura being separated by an interval of more than an 
inch from its bony covering. 
With the removal of the clot all hemorrhage ceased. The cavity 
was irrigated with a mercuric solution, a small drainage-tube inserted, 
and the wound closed. 
During the operation, which was made without an anaesthetic, the 
dilatation of the left pupil gradually subsided, so that at its end, it was 
little, if any, larger than the right. The pulse had risen rapidly, and 
when the patient was placed in bed was 140 and very feeble. RUPTURE OF MIDDLE MENINGEAL ARTERY. 
5 
He appeared moribund. Six hours post operationem consciousness 
returned, the patient asking for water. In the morning, while inclined 
to delirium, he was rational most of the time, although quite restless. 
He recognized his attendants perfectly, and was able to converse in a 
rational manner. Pulse 114. Temperature normal. The urine re- 
moved by catheter showed a specific gravity of 1016 and was free from 
sugar. 
The first dressing and the drainage-tube were removed on the third 
day, when there was a slight staining of the bandage. There was 
primary union of the entire wonnd, except where the drainage-tube 
had been. For a week thereafter the temperature did not rise over 
99.50; the pulse rate was reduced to 90; the delirium subsided, and 
the patient appeared on the road to recovery. On March 28th, nine 
days after the operation, while the patient was straining at stool, a 
profuse hemorrhage supervened, saturating the dressings and bed linen. 
When Dr. Nickles, who was summoned, arrived, the hemorrhage had 
ceased. The dressings were changed, the sitting posture ordered to 
be maintained and applications of ice to the head. 
March 29. Was called at 5 a. m. for recurrent hemorrhage. On 
freely opening the wound, which had firmly united, and removing a 
large coagulum, bright arterial blood welled from its depth. Plugging 
with iodoform gauze failed to check it. 
In the hope of reaching its source, the aperture previously made was 
enlarged downward, but without avail. Plugging the cavity was again 
resorted to with negative results. Nothing remained but compression 
or ligation of the common or external carotid artery. The extreme 
restlessness of the patient precluded the former practice. The pro- 
fuseness of the hemorrhage made it appear possible that its source was 
the internal carotid. The common carotid artery was therefore ex- 
posed and included in a catgut ligature at the point of election. 
Unfortunately, as the result shows, proper precautions looking 
toward asepticism could not be taken. The operation had to be 
performed at once on the blood- and food-stained bed. The hemor- 
rhage subsided as soon as the ligature was brought home. Fearing 
wound infection, both wounds were thoroughly irrigated and the 
cervical closed over a catgut strand, while the cranial wound was left 
open. 
The patient rallied well from the loss of blood and the operation, 
but delirium returned and with it extreme restlessness and insomnia. 6 
RANSOHOFF, 
Increasing doses of morphine were needed to procure sleep. Sulfonal 
and the bromides were faithfully tried but found useless. 
The first change of dressings was made forty-eight hours after the 
operation. Suppurative processes had been established in both wounds. 
On raising the scalp flap for irrigation the pulsations of the dura were 
plainly visible. The suppuration over the carotid appeared to be su- 
perficial. The local and general conditions could leave no question 
as to the existence of pyaemia. On the fifth day, with a sudden rise 
of temperature to 103.50 and increase of delirium, there developed an 
embolic pneumonia with profuse expectoration of blood, which con- 
tinued for twenty-four hours and then gave way to purulent sputum. 
After continuing for four days this also subsided. On the tenth day 
the patient again seemed on the road to recovery. The temperature 
continued at about ioo°; the pulse at about 108, and of fair volume. 
The delirium was subsiding and sleep was easily, though artificially, 
procured. Both wounds were covered with granulations and pre- 
sented a healthy appearance. 
On the fifteenth day hemorrhage supervened from the carotid at 
point of ligation, but subsided spontaneously for several hours. While 
discussing the advisability of treating it expectantly, a sudden gush of 
blood decided the course. With the assistance of Dr. Dandridge, the 
wound was rapidly opened and the bleeding vessel sought for. The 
ends were separated more than an inch. The bleeding came for the 
most part from the distal portion of the vessel and only with great 
difficulty could this be caught and retained in haemostatic forceps. 
The hemorrhage was checked, but the patient, who had lost conscious- 
ness soon after the artery gave way, failed to rally. He died ten 
hours after all bleeding had ceased. A post-mortem could not be 
obtained. 
If an apology be needed for offering the record of a case in 
many respects similar to the more than 400 cases recorded and 
tabulated by Vogt, Wiessman, Jacobson and others, I beg that 
you will find in it some of the unusual features presented. Of 
all the evidences of middle meningeal extravasation, the interval 
of lucidity between the accident and the appearance of com- 
pression symptoms comes first in importance. This interval 
may be only a few minutes, it often is one or two hours, but 
rarely as many days. Not once in twenty cases does the in- RUPTURE OF MIDDLE MENINGEAL ARTERY. 
7 
terval of freedom from brain symptoms last longer than forty- 
eight hours. Koenig alludes briefly to a case in which marked' 
cerebral symptoms developed on the eighth day, and in one of 
Wiessman's tables (No. 171 )1 coma supervened as late as the 
eleventh. But this was a case of extensive compound basal 
fracture in which the coma developed as a result of secondary 
hemorrhage. 
In rather an extensive search of the literature of allied cases 
I have found none in which, as in the case reported, a full week 
passed before any symptoms of intra-cranial trauma developed. 
The pressure of a firm clot, and of a large fluid extravasa- 
tion, above the dura may explain the long delay of symptoms. 
Experiment and clinical observation abundantly demonstrate 
the ready adaptability of the brain to moderate general com- 
pression gradually applied. It is only when the limit is passed 
that this makes itself manifest. The firm clot was probably 
the result of a hemorrhage during the first day after the acci- 
dent, whereas the fluid portion of the haematoma was recently 
extravasated, the bleeding becoming foudroyante when the 
recumbent posture was taken by the patient for the relief of 
headache. It is in many cases of meningeal hemorrhage as in 
idiopathic apoplexies : the severe symptoms of compression do 
not supervene until the patient has been placed in bed. 
Another feature of the case reported, is*the absence of par- 
alytic or paretic symptoms on the opposite side of the body. 
In 257 cases collected by Wiessman this absence was specially 
noted only 16 times. 
In Jacobson's 70 cases2 the absence of paralysis was noted in 
only 2. 
In each case middle meningeal extravasation had taken 
place. In both there was much blood beneath the scalp, and 
therein lies the explanation of the absence of paralysis. The 
course of the artery over the face, arm- and leg-centres readily 
explains the frequency of contra-lateral paralysis in these cases. 
Though the effects of a localized compression are felt by the 
1 Wiessman: Zeitsch. f. Chir., Bd. xxi. S. 300. 
2 Jacobson: Guy's Hosp. Rep., 1886. 8 
RANSOHOFF, 
cerebrum as a whole, the parts in proximity are most affected. 
Therefore in hemorrhages which are partly basal the probability 
of paralysis of the opposite side diminishes ; while that of direct 
pressure on the oculo-motor nerve and consequent dilatation of 
the pupil increases. Hutchinson1 was the first to call attention 
to this condition of the pupil in two cases. Its diagnostic im- 
portance in the absence of other paretic symptoms can hardly 
be overrated. In the tabulated cases of Wiessman where dila- 
tation of the pupil existed at all, it was present twenty times on 
the side of extravasation and only four times on the opposite. 
There need not be any concomitant paralysis of the extrinsic 
ocular muscles. Only four cases have been recorded in which 
there was either ptosis or paralysis of the external rectus. 
In the case presented the dilatation of the pupil was the only 
evidence pointing to the side of the lesion, and in the absence 
of paralysis of the face or arm led me to believe that hemor- 
rhage extended more to the base than is usually the case. 
The trephine was accordingly applied half an inch below the 
point generally selected in cases of supra-dural hemorrhage. 
Without " Hutchinson's pupil," operative interference in this case 
would have been impossible, and its immediate disappearance 
on removal of the clot amounted to a physiological experiment. 
Another feature of this case, to my knowledge not mentioned 
in any case hitherto reported, is the glycosuria, the relations of 
which to disturbed circulation of the intra-cranial viscera is 
more readily recognized than satisfactorily explained. 
Quite recently Nagel2 reports two cases in which the diabetes 
followed directly an apoplectic attack and in which it improved 
with the mitigation of the cerebral symptoms. 
In spinal compression similar results are occasionally en- 
countered. Baum3 and Scheuplein4 report cases of injury and 
disease in which the relief of compression of the cord was 
speedily followed by disappearance of the glycosuria. 
1 Hutchinson : Lond. Hosp. Rep., iv. p. 20. 
2 Nagel: Schmidt's Jahrb., 219, p. 475. 
3 Baum: Berl. klin. Wochensch., 1880, p. 608. 
4 Scheuplein : Arch. f. klin. Chir., Bd. xxix. S. 365. RUPTURE OF MIDDLE MENINGEAL ARTERY. 
9 
In the case reported the urine was normal within twelve 
hours of the operation. Its subsidence with the disappearance 
of the coma, slowness of pulse, prove it to be but an evidence 
of compression. 
Although deficient in post-mortem evidence, this I believe 
adds another to the small number of cases of supra-dural men- 
ingeal hemorrhage without fracture. Fully aware that the pos- 
sibility of such an occurrence has often been denied, and that 
Marchant,1 voicing the opinion of the latest French surgeons, 
rejects such lesions as " not proven," the evidence in this case 
appears to me sufficient to warrant the view expressed. 
The greater portion of the temporal and part of the zygo- 
matic fossa were exposed; there was no trace of fracture or 
fissure. Digital exploration of the middle fossa from its anterior 
to its posterior limits and almost to the foramen spinosum was 
also negative in its results. The subject was young, and the 
skull thin-walled Its elasticity surpassed the arterial resistance. 
As in other cases of this nature, the injuring force seemed so 
slight as to leave no evidence of damage even to the soft parts. 
There may, of course, have been a fissure of the base to the 
inner side of the point explored ; but nothing in the clinical 
history warrants such an assumption. 
There was no bleeding from the ear, no paralysis : and con- 
cussion symptoms, if at all present, were so slight as to form no 
factor in the record of the case. 
Banner2 reports a case in which the artery was torn across 
just within the cranium. This, I believe, occurred in my patient, 
the extravasation continuing until the more adherent parts of 
the dura along the borders of the fossa were reached. Fol- 
lowing the classification of Kroenlein,3 the case is one of cir- 
cumscribed temporo-parietal haematoma. 
Secondary hemorrhage is not often mentioned as a cause of 
death from rupture of the middle meningeal and its appearance 
so late as the eighth day, as in the case reported, is certainly 
1 Marchant: These de Paris, 8i,p. 27. 
2 Banner : Trans. Provincial Med. and Surg. Association, 1841. 
3 Kroenlein: Zeitsch. f. Chir., Bd. xxiii. S. 209. 10 
RANSOHOFF, 
uncommon. In cases of penetrating gunshot and stab wounds 
it has developed as late as the twelfth, the eighteenth, and 
twenty-first day. In the case reported by Gamgee1 the hemor- 
rhage sprang from a false aneurism ; in the case of Lang,2 the 
bleeding penetrated into the cerebrum through a punctured 
wound of the dura, and in the case of Alexander,3 so far as I 
know the latest case of secondary hemorrhage from the men 
ingeal recorded, the injury followed an extensive shell-fracture 
of the left temporal region. While these cases have only the 
secondary hemorrhage in common with the one reported, 
together they demonstrate that the danger from this source 
continues longer than the calibre of the vessel would lead one 
to suppose. 
A more important problem than that of haemostasis rarely 
presents itself for technical solution and this applies particularly 
to secondary hemorrhages where impassable anatomical bounds 
limit the field of operation. When the secondary bleeding pre- 
sented itself as a thing to be speedily met there passed before 
me the many methods of securing the bleeding vessel. 
Direct ligation of the vessel, inclusion with the transfixed 
dura and plugging its osseous canal were not attempted, on the 
principle that a man cannot be hanged until caught. When 
tamponing the cavity failed nothing remained but the ligation 
of the common carotid artery, a plan originally suggested by 
Forneaux Jordan4 as in the first place preferable to trephining. 
Compression of the artery was successfully applied by Mr. 
Howse5 for three hours for meningeal hemorrhage, but the 
comatose condition of the patient admitted such practice. In a 
very recent article Mr. Horsley6 recommends it in the manage- 
ment of intra-cranial hemorrhages. In a restless patient, except 
in a hospital ward, the plan appears to me unfeasible. 
1 S. Gamgee: Lond. Lancet, 1875, i. p. 535. 
2 Lang: Weismann: loc. cit., p. 331. 
s Alexander: Surg. Hist. War, i. p. 314 
4 Jordan: Med. Times and Gazette, 1863,!. p. 314; also Surgical Enquiries, 2d Lond. 
Ed., 1880, p. 182. 
5 Howse: Jacobson's cases, No. 9. 
6 Horsley: Brit. Med. Journ., 1889, i. p. 457. RUPTURE OF MIDDLE MENINGEAL ARTERY. 
11 
From a rather careful search of the literature of the subject, I 
find that there are only three cases on record in which the com- 
mon carotid was tied for hemorrhage from the middle meningeal, 
the operators being Bentley,1 Alexander, and Gamgee. 
The case of Alexander, already referred to, was the only one 
followed by recovery. In Bentley's case a fatal hemorrhage 
recurred on the third day. Roser's suggestion of ligating the 
external carotid found only one follower in Mr. Howse. This 
case also proved fatal. 
In conclusion, I would remark that although the immediate 
cause of death was hemorrhage, this was but a sequel of septic 
infection. I am consoled in the belief that it was unavoidable. 
It is not often that surgical emergencies arise in which we can- 
not obtain asepsis; but one disastrous result like this brings 
into strong relief how helpless we are without this greatest 
factor of surgical success. 
1 Bentley: Surg. Hist. War, i. p. 255. 12 
DISCUSSION. 
DISCUSSION. 
Dr. W. W. Keen, of Philadelphia. 
I think that it is very fitting that this case should be recorded 
because of the peculiarities to which Dr. Ransohoff has called attention. 
It certainly is excessively rare to have intra-cranial hemorrhage going 
on to such an extent as in this case for eight days without any signs of 
its existence. I congratulate Dr. Ransohoff upon the acumen with 
which he made the diagnosis, with almost complete absence of symp- 
toms. I should like to suggest that the better plan, as shown by the 
history of several cases of hemorrhage from the middle meningeal 
artery referred to, would have been to tie the main trunk low down, 
enlarging the opening in the skull, and passing a ligature by means of 
a curved needle under the vessel. In the absence of any knowledge 
of where the artery was ruptured, it might be difficult to do this. 
While the problem can be solved easier now than at the time of the 
operation, it seems to me that the rule should be to ligate the middle 
meningeal, rather than the carotid artery. My remarks apply, of 
course, to the primary and not to the secondary hemorrhage. If the 
artery could have been found and tied, it would have prevented the 
secondary hemorrhage. Statistics have shown that the main trunk is 
rarely ruptured as compared with its branches. It is possible that the 
artery could not have been seen, yet if it could have been found at the 
first trephining, it would have been better. 
Dr. F. S. Dennis, of New York. 
I have had a number of cases of meningeal hemorrhage, and my ex- 
perience is that ligation of the common carotid is uncalled for because 
the hemorrhage can be arrested by other means. After removing the 
bone, I have found it impossible to catch the vessel with forceps. I 
have then taken a tenaculum and passed it under the dura and thus 
drew up the dura, and seized the vessel and tied it. In that way the 
necessity for tying the common carotid is obviated. With the vessel 
raised in this way it is possible to tie it in the curve of the tenaculum. 
During this spring I trephined in one case without meeting with 
hemorrhage. There was paralysis on one side. I then incised the 
dura, but found no clot. I next incised the cerebral substance and 
went into the lateral ventricle and removed a clot the size of a walnut. RUPTURE OF MENINGEAL ARTERY. 
13 
This is, I believe, the first case in which a clot was removed from the 
lateral ventricle. This was a case of apoplexy due to traumatism. 
In regard to sugar in the urine, I have seen it quite often. It will 
probably be found in those cases where there is any irritation of the 
pons. 
Dr. James McCann, of Pittsburg. 
I infer from the history which has been given of the case by Dr. 
Ransohoff that the hemorrhage was complicated by a fracture of the 
base of the skull, and that the vessel from which the bleeding came 
had been lacerated at some deep and inaccessible point, either in the 
membranes, or within the brain itself; and if this inference is correct, 
the methods which have been suggested for securing the vessel would 
have been of little use. 
It should never be a matter of great difficulty to control hemor- 
rhage from the meningeal artery or its branches, if the bleeding point 
is visible. The late Professor Mutter, of Philadelphia, many years 
ago successfully accomplished this by plugging the torn end of the 
vessel with a piece of pine wood. There ought not to be much trouble 
encountered in twisting or ligating the vessel, or in applying forci- 
pressure to it. But when the blood wells up from a point far down 
toward the base of the skull, and the bleeding vessel cannot be seen 
or reached, the difficulties are greatly increased. Such cases are fre- 
quently associated with serious injury to the brain and its membranes. 
A case presenting many points of resemblance to Dr. Ransohoff's is 
reported by Dr. J. Collins Warren, in The American Journal of Med- 
ical Sciences for May, 1890. A youth, aged seventeen years, was 
thrown from a horse and at once became comatose. There was pro- 
fuse bleeding from the nose and left ear, with some escape of brain 
matter from the left ear; but there was no wound and no external 
evidence of depression; the pupils were normal, and there was no 
paralysis. An exploratory incision revealed a fracture extending down- 
ward from the squamous portion of the temporal bone toward the base 
of the skull. A portion of the bone was removed by trephine, and 
some clots and a quantity of fluid blood evacuated, when it was seen 
that not only was the middle meningeal artery torn and the membranes 
of the brain ruptured, but that a portion of the anterior and middle 
lobes of the brain was extensively lacerated. The bleeding was easily 
controlled by pressure. Under a rigidly antiseptic treatment, with 
free drainage, this man ultimately recovered. In the management of 14 
DISCUSSION. 
Dr. Ransohoff's case it would probably have been better practice to 
remove with trephine, or rongeur forceps, an area of the skull suffi- 
ciently large to expose the bleeding vessel, and to secure it at the 
bleeding point, rather than resort to ligation of the carotid artery. 
Dr. J. R. Weist, of Richmond, Indiana. 
I wish to mention a case which is apropos. A man, forty-five years 
of age, in a quarrel was struck by the fist of a companion. He did 
not fall, but went about his work for a time and then walked two miles 
and commenced an action against the man who had struck him. He 
attended to some other business, and was about for four hours without 
special complaint. He then had severe pains in the head, and went to 
the office of a homoeopathic practitioner. The doctor proceeded to 
bleed him, and about the time he had finished the operation the 
patient was seized with a violent convulsion. The convulsion was fol- 
lowed by coma. When I saw him he was profoundly comatose, with 
the hands contracted-equally so, as far as I could determine. The 
right pupil was slightly dilated. The left side of the head had been 
struck just above the middle of the parietal bone. At that point there 
was slight swelling and other evidences of contusion. It was clear that 
there was cerebral hemorrhage. I was unable to get any history of the 
convulsions beginning on one side before appearing on the other. Not 
much weight was attached to the difference in the size of the pupils for 
the reason that it seemed most probable the bleeding was on the side of 
the injury. I proceeded to trephine at the point of contusion. There 
were no signs of injury to the skull or membranes at that point. I at 
once trephined on the opposite side and found an extensive intra-dural 
hemorrhage. The clots were removed with the finger. I was unable 
to determine the point from which the blood came. Compression was 
made on the common carotid and continued some three hours. The 
patient never rallied from the coma, and died in six hours. The diffi- 
culty in this case before operation was to determine on which side the 
hemorrhage had occurred. If it is true that dilatation of the pupil 
indicates the side on which the hemorrhage is present, it is a valuable 
sign. If a prosecution for murder had followed in the case narrated, 
it is certain the question would have been raised if it were possible for 
the surgeon to determine the location of the hemorrhage before using 
the trephine. RUPTURE OF MENINGEAL ARTERY. 
15 
Dr. Ransohoff.-I stated distinctly that when the secondary hem- 
orrhage supervened, my first effort was to find the middle meningeal 
artery. I enlarged the trephine orifice as far as I possibly could, but 
the blood still seemed to come from the depth of the wound; I could 
see nothing of the artery. There was only one of two things to do : 
either to compress the carotid for a considerable length of time, or to 
tie the artery. Compression in this case was out of the question. The 
most interesting feature of the case is that the patient was perfectly 
well for eight days. Another fact of almost equal interest was the 
absence of fracture or other injury.