CASE OP COMPOUND FRACTURE OP THE CRA- NIUM WITH IMPACTION OP BONE : SUCCESS- FULLY TREATED.

By Surgeon P. J. Fbetee, A.B., M.D., Bengal Army, Offg. Civil Surgeon, Mainpuri.

Aa there is always a peculiarly grave interest attached to the treatment of fractures of the skull, complicated with depres- sion of bone, I consider the following case worth recording.

Kassy, a Hindoo, aged 55 years, was admitted into tlie wards of the Mainpuri Dispensary on the 21st of August, in on insensible condition, suffering from injuries of the head and other parts of the body.

Tlie night before his admission he had been sleeping in the open air, keeping watch over his corn-field, when he was

vigorously attacked and beaten by thieves armed with bamboo sticks, and left in an insensible condition, in which state he was brought into hospital.

At my morning visit to the dispensary, about 8 A.M., I saw him one hour after his admission. On examination I found that he had sustained a severe scalp wound, which partook of the nature partly of both the contused and punctured varieties.

November 1, 1877.] A MIRROR OF HOSPITAL PRACTICE. 293

This was situated over the posterior part of the frontal bone nnd slightly to the left of the median line. Antero-posterior in direction, it was nearly 2 inches long, half inch broad in

front, and three-fourths inch behind, and extending down to the bone. On passing a probe and subsequently the finger into the

wound, I found that the skull was fractured, and a large wedge-shaped piece of bone impacted between the edges of the adjacent bone, the base of the wedge being directed backward and depressed half an inch beyond the general surface of the ?vault of the cranium; the narrow end of the wedge was slightly elevated. The eyelids were dark and much swollen from effusion of blood into the areolar tissue of the orbits, and Bub-conjunctival haemorrhage was present on both sides, most marked in the right eye. A few minutes after admission he had vomited a quantity of blood. There was no bleeding from the nostrils. There were several contusions on various

parts of the body, but these were not of a severe character. Complete loss of consciousness existed, but there was no

paralysis present. He lay on his side with his body in a bent position, the legs being flexed on the thighs, and the thighs drawn up towards the abdomen. The skin was warm and

moist; the pulse slow and full; the temperature and respi- ration normal; the pupils were both contracted.

Such being the state of matters, I considered it expedient to have recourse to operation for the removal of the depressed portion of bone. The wound was enlarged longitudinally by means of a scalpel, and the soft tissues separated by means of the finger, thus bringing the fractured bone into view. The

wedge of bone seemed to be so firmly impacted that; I feared it would be necessary to use the trephine for its removal. But I determined to try first the effect of the elevator and a seques- trum forceps. Grasping the wedge of bone with the latter, and using the former as a lever, after a considerable amount of force being used, I happily succeeded in removing the

depressed bone. I then examined the wound with my finger, and found that there was no spiculum of bone left. There was an irregular depression in the brain and membranes, half an inch deep. A simple fracture passed forward through the frontal bone from the anterior part of this fracture, but this did not appear to be continued more than an inch or two.

The wound was dressed with carbolised oil, and its margins brought together as far as practicable by means of strips of adhesive plaster, an opening being left for the discharge of pus ; a calomel and jalap purgative was given, and the patient put to bed. The removal of the depressed bone seemed to have an

almost immediate effect in removing the state of unconscious- ness, for at 1 P. M. that same day the man asked for a drink, and endeavoured to sit up in the bed. At my morning visit next day, though still stupid, he spoke in a rational manner.

It will be unnecessary to go further into details than to

state thathc rapidly improved ; the temperature and pulse scarce-

ly at any period exceeded the normal. There was very little

suppuration from the wound, which took on a healthy granu- lating appearance, the soft tissues growing in over the bone. The effusion of blood into the eyelids and beneath the conjunc- tivae was gradually absorbed, that into the conjunctiva of the right eye lasting longest and being completely absorbed only three weeks after the receipt of the injury. This man was

discharged from hospital on the 23rd Septembor in excellent health, the scalp wound having completely filled in. Remarks.?There are several points of interest attached to

this case, which may be summed up as follows :?

(1.) The relief of all the symptoms of compression and irritation following on the elevation of the depressed bone, and the rapidity with which these symptoms passed off.

(2.) The non-Bupervention of meningitis, notwithstanding the injuries to the brain and its membranes from the depressed and sharp-edged portion of bone : the temperature and pulse throughout, being normal.

(3.) The symptoms of effusion of blood into the eyelids and beneath the conjunctiva?, and the vomiting of blood (which no doubt passed from the pharynx into the stomach), taken in connection with the injury to the vault, indicate a fracture of

the base of the cranium through the supra-orbital and ethmoid plates of the frontal bone.

(4.) Not the least interesting point is the rapid and com- plete recovery of the patient from sucli severe injuries to the cranium and its contents.

Mainpuei, 2ith September 1877.