at its termination.
Removal of the calvarium
disclosed
a
congested dura mater. At the posterior inferior angle of the left parietal bone, and corresponding to the course of the middle meningeal artery, a large clot of blood wa3 found, measuring antero-posteriorly two, and from above downwards three inches, and weighing about 4 ounces. The brain substance corresponding to this clot was slightly injured. There
NOTES OF By Ulice
A
CASE OF FRACTURE SKULL.
J. Bottrkb,
OF
THE
Surgeon, A.M.D., Madras.
Private J. K., aged 26, was brought into hospital in a dhoolie, at 11 o'clock on the night of the 5th February last. He was then seen by the apothecary on duty, -who described his state A fracture of on admission as one of partial insensibility. the right olecranon process was then noticed. The previous history of the case seemed somewhat obscure, no distinct account being obtainable as to how he received his present injuries, one version stating that he fell from one of the verandahs of the barracks?a fall of some thirty feet. He was seen next morning by the medical officer in charge. The partial insensibility still continued. Ice was ordered to be applied to head. Calomel and jalap were given, and subsequently small dose3 of
calomel.
February 8th, 7-30 a.m.?The case was handed over to my charge this morning. He still continues in the state of partial insensibility, answering questions hurriedly when spoken to and again returning to his drowsy condition. Heat of skin natural; pulse 80 ; pupils equal, regular and sensitive to light; temperature 100*4J There are marked abrasions over the right parietal eminence
to the extent of an inch and a half. Both knees are somewhat scratched. There is a slight darkening of scrotum. This morning a few drops of blood were passed per urethram. Bowels have been freely moved. To continue treatment as before. 3 p.m.?At 11-30 this morning convulsions set in ; they were rapidly followed by complete insensiblity, and at about 12-30 he At 1 o'clock p.m., his condition was, was in a moribund state. complete insensibility; stertorous breathing; pulse 70, labored and slightly intermittent; skin warm; temp. 104? ; great heat of head accompanied by universal puffiness of scalp ; pupils irregular and not sensitive to light; right one considerably contracted. A consultation was then held, when it wa3 deemed advisable to trephine. The operation was performed over the seat of injury?the right parietal eminence. A crucial incision was made, and the operation readily gone through. No fracture, linear or otherwise, was discovered, neither was there any clot of blood to be seen. A fair amount of blood escaped during and subsequent to the operation. His condition remained unchanged after the operation and up to the time of penning these notes. 9th.?This man just died as I entered the ward last evening about 6 o'clock, fto change took place up to half an hour of death when his breathing became more stertorous. No convulsious set in. Death occurred by coma. Autopsy.?14 hours after death. well nourished ; abrasions on External both knees ; discoloration of scrotum ; right elbow joint much swollen, and olecranon process fractured; abrasions over right parietal eminence together witli great oedema of the whole scalp which pits on pressure. Head.?On removal of scalp, extravasated blood found uni-
appearances.?Body
versally extending
over
skull, "which,
on
being cleaned, revealed
linear fracture commencing about half an inch above the seat of operation, extending over the vertex of the skull parallel to the course of the coronal suture, and fading into the latter a
effusion into the ventricles.
was
no
body
were
healthy.
The other organs of tho
Such are the notes of a case which will be interesting to your readers in a few points. In the first place, I might ask, are to consider the fracture in this case a direct one or one we known as by " ContrejCoup The fact of an abrasion over the parietal eminence would show that this part came in contact with the ground, and this strong eminence would, a3 Erichsen points out, be very likely to transmit the fracture, not a3 in this case, towards the opposite eminence, but to the base, or again may wo look on this as a direct fracture, though not quite commencing at the seat of injury. No doubt, the same fall which caused the injury to the head likewise gave rise to the fracture of the olecranon, as also to the abrasions on the knees, so that it might be inferred that the head did not receive the entire shock of the fall, but only its share in common with the other injured parts. It would seem probable that the injury to the brain substance arose from the impulse of the fall. It is also a striking feature in this case that, considering the brain injury, the fracture, and, especially, the presence of such a large clot of blood, that there should have been present no symptoms indicating such conditions. It is just one of those cases which adds to the many others which have clearly shown, that no matter what injuries of the head one may have to deal with, there is no knowing what the result may be even in "what we would consider as slight cases. The autopsy clearly showed that trephining was the best treatment which could have been adopted, although perhaps, with a more favorable termination if performed on the other side ; but looking at the above symptoms, I decidedly think that the seat of injury was the proper place for the operation.
Removal of the calvarium
disclosed
a
congested dura mater. At the posterior inferior angle of the left parietal bone, and corresponding to the course of the middle meningeal artery, a large clot of blood wa3 found, measuring antero-posteriorly two, and from above downwards three inches, and weighing about 4 ounces. The brain substance corresponding to this clot was slightly injured. There
NOTES OF By Ulice
A
CASE OF FRACTURE SKULL.
J. Bottrkb,
OF
THE
Surgeon, A.M.D., Madras.
Private J. K., aged 26, was brought into hospital in a dhoolie, at 11 o'clock on the night of the 5th February last. He was then seen by the apothecary on duty, -who described his state A fracture of on admission as one of partial insensibility. the right olecranon process was then noticed. The previous history of the case seemed somewhat obscure, no distinct account being obtainable as to how he received his present injuries, one version stating that he fell from one of the verandahs of the barracks?a fall of some thirty feet. He was seen next morning by the medical officer in charge. The partial insensibility still continued. Ice was ordered to be applied to head. Calomel and jalap were given, and subsequently small dose3 of
calomel.
February 8th, 7-30 a.m.?The case was handed over to my charge this morning. He still continues in the state of partial insensibility, answering questions hurriedly when spoken to and again returning to his drowsy condition. Heat of skin natural; pulse 80 ; pupils equal, regular and sensitive to light; temperature 100*4J There are marked abrasions over the right parietal eminence
to the extent of an inch and a half. Both knees are somewhat scratched. There is a slight darkening of scrotum. This morning a few drops of blood were passed per urethram. Bowels have been freely moved. To continue treatment as before. 3 p.m.?At 11-30 this morning convulsions set in ; they were rapidly followed by complete insensiblity, and at about 12-30 he At 1 o'clock p.m., his condition was, was in a moribund state. complete insensibility; stertorous breathing; pulse 70, labored and slightly intermittent; skin warm; temp. 104? ; great heat of head accompanied by universal puffiness of scalp ; pupils irregular and not sensitive to light; right one considerably contracted. A consultation was then held, when it wa3 deemed advisable to trephine. The operation was performed over the seat of injury?the right parietal eminence. A crucial incision was made, and the operation readily gone through. No fracture, linear or otherwise, was discovered, neither was there any clot of blood to be seen. A fair amount of blood escaped during and subsequent to the operation. His condition remained unchanged after the operation and up to the time of penning these notes. 9th.?This man just died as I entered the ward last evening about 6 o'clock, fto change took place up to half an hour of death when his breathing became more stertorous. No convulsious set in. Death occurred by coma. Autopsy.?14 hours after death. well nourished ; abrasions on External both knees ; discoloration of scrotum ; right elbow joint much swollen, and olecranon process fractured; abrasions over right parietal eminence together witli great oedema of the whole scalp which pits on pressure. Head.?On removal of scalp, extravasated blood found uni-
appearances.?Body
versally extending
over
skull, "which,
on
being cleaned, revealed
linear fracture commencing about half an inch above the seat of operation, extending over the vertex of the skull parallel to the course of the coronal suture, and fading into the latter a
effusion into the ventricles.
was
no
body
were
healthy.
The other organs of tho
Such are the notes of a case which will be interesting to your readers in a few points. In the first place, I might ask, are to consider the fracture in this case a direct one or one we known as by " ContrejCoup The fact of an abrasion over the parietal eminence would show that this part came in contact with the ground, and this strong eminence would, a3 Erichsen points out, be very likely to transmit the fracture, not a3 in this case, towards the opposite eminence, but to the base, or again may wo look on this as a direct fracture, though not quite commencing at the seat of injury. No doubt, the same fall which caused the injury to the head likewise gave rise to the fracture of the olecranon, as also to the abrasions on the knees, so that it might be inferred that the head did not receive the entire shock of the fall, but only its share in common with the other injured parts. It would seem probable that the injury to the brain substance arose from the impulse of the fall. It is also a striking feature in this case that, considering the brain injury, the fracture, and, especially, the presence of such a large clot of blood, that there should have been present no symptoms indicating such conditions. It is just one of those cases which adds to the many others which have clearly shown, that no matter what injuries of the head one may have to deal with, there is no knowing what the result may be even in "what we would consider as slight cases. The autopsy clearly showed that trephining was the best treatment which could have been adopted, although perhaps, with a more favorable termination if performed on the other side ; but looking at the above symptoms, I decidedly think that the seat of injury was the proper place for the operation.
