the INDIAN MEDICAL GAZETTE.
74i A CASE OF DEATH FROM
FRACTURE OF
THE SKULL.
By Surgeon-Major
Wm.
CtjheaN',
A.M.D.
I submit herewith a short abstract of the following case, which lately occurred under my care, as such accidents are, according to my experience, comparatively rare in this country among soldiers, as also because it shows in a very striking man" the enormous extent to which the skull may be fractured ner, without an immediately fatal issue." It happened, in September last, at a place called Kala-Bagh, on the Murree and Abbot-, tabad road, where I was then stationed, and I regret I am unable to supply fuller details respecting the conditions of the puise, respirations, and temperature, as the book containing
Casualty Report of Age last DAY.
1875.
these is not now in xnv possession : these are, however, scarcely necessary, as the facts so briefly stated below, speak emphatically for themselves, and the mode of recording post-mortem results now enforced in our department is such an improvement on the former hap-hazard method, that I am willing to believe its introduction here may interest others than those for whom it ha3 been specially prepared. As such, and in this spirit it is offered for inspection, and I cannot think I am violating my confidences in thus reproducing a general outline of a case which greatly interested me during life, and absolutely astonished me after death, by the evidence it afforded of the extraordinary tolerance which the system sometimes exhibits under the pressure of an otherwise necessarily, if not
instantaneously, fatal injury
Private J. R
,
2-60th
:?
Royal Rifles.
Service India.
Total Service.
BIRTH-
[Mabch 1,
in
Disease.
Kane and Names.
Place of Death.
Died.
Admitted.
Years.
Pvte.
the
B
J. E.
10
Wounds of face.
16th Sep. 1874 19th
Sep.
1871
Kala-Bagh.
Should the post-mortem evidence have rendered a change of nomenclature necessary, enter the disease to -which original admission has had to be changed, below this line.
| Pvte.
J. It.
10
Fracture of the vault ofthe skull. (/).) Simple with
19th Sep. 1874
19th
Sep.
1874
Kala-Bajrh.
depression.
1 st.?Ifote
the
general
of health, previous to the last illness, and enumerstate
the diseases suffered ate from in the course of the six months preceding the date of the last admission. 2nd.?State the cause of the disease, or the circumstances under which it made its appearance.
3rd.?Give the on
symptoms
admission, during the
progress of the disease, and towards its close, stating also the mode of death.
Was in fair general health, and only suffered from a few very slight attacks of ague during his residence here. He lias not been in hospital for upwards of a year. A
fall
over
"
the
where the ground,
Khuaa,"
first gravelly and ODly slightly sloping, soon became sheer, and finally precipitated him on the rocks of a water course, at a distance of about one hundred yards below the road. Quite insensible and pulseless from shock and loss of blood; the face was frightfully lacerated and contused, and the breath freely exhaled an odour of liquor. at
He subsequently became delirious and violent, passed feces involuntarily, and though able to answer questions in a confused and hasty manner, he never regained consciousness, or betrayed any evidence of suffering; (lie eyelids were from the beginning puffy, (Edematous and livid, and the pulse was throughout feeble and irregular, disposed to jerk at one time and to bound at another, and always very compressible ; the breathing always hurried and sometimes puffy, only became stertorous towards the end, and this was preceded by deep 4 th.?Kecord the diagnosis formed during life, :ind add any further explanatory remarks -which uiuy be thought necessary.
It
wii3
interred
irom
me
appearance of the eyelids and the condition of the pulse, as
well as from the other circumstances attending the injury, that the vault or base of the skull must have been fractured, but this could not be verified, and the gravity of the symp-
life bore no prothe extent of the lesions disclosed by death.
during position to
toms
Post-mortem appearances twelve hours after death. On section the body was found to be well nourished and and the face very rigid, both eyelids were livid and swollen, On raising was bruised and disfigured with numerous wounds. the coverings of the skull, blood was found lying loosely on the slieath and the substance of scalp, as well as extravasated into the oceipito-frontalis muscle, and further dissection disclosed an
extensive
depressed
fracture of the frontal
bone, which,
pass-
ing through the superciliary ridge of the right side, entered the
orbit and extended through its floor as far as tho ethmoidal fissure. The roof of the left orbit was loosened from its attachment, yet the eyes remained intact, and the nasal bones were involved, doubtless by the contre-coup in the same injury ; so extensive indeed was this, that evidence of its effects was found in tho middle fossa of the base, in the shape of a fracture that ran through the sella turcica and dorsum ephippii, and involved both clinoid processes, and the membranes were everywhere unduly' adherent ; the surface of the brain, was deeply suffused with 'blood, especially so on the right side, and the superficial vessels of the hemispheres and sulci were enormously distended ; congestion was in fact everywhere observable, and the puncta vasculosa were throughout abnormally numerous and prominent. The cerebellum and pons were also the seat of this congestion, and such being the case, it was uot considered necessary to extend the examination further. Remahks.?This case is a very good illustration of the " glorious uncertainty" that attends the origin and progress of severe injuries of the cranium, unaccompanied by wounds of the scalp or other palpable lesion: on admission ho looked exactly like a man who had just been subjected, during a debauch, to a bad beating about the head, the only disfigurement apparent was that of the face, and this did not exceed what one might any day witness, after a street-brawl, in a London hospital, or from a heavy fall on tho pavement during frosty weather: yet was the skull broken, smashed, I smight almost say, to an extent which I have rarely and that, too, under
witnessed)
llxncn 1,
1875.]
A MIRROR OF HOSPITAL PRACTICE.
circumstances which, as regards the rugged shelving stony precipice over which he fell, ought to have produced much greater mutilation, as will be seen from the table prefixed to this report. wounds I at first simply returned him under the heading of of the face," but of course this designation could only be and temporary provisional, and I had, at any moment, the power of changing it according as symptoms may suggest or require : it changed certainly was in time, but with what a difference! and it is but fair to myself to add, that, though, as already "
a fracture of some kind or other from the beginning, neither I nor my friend and colleague Dr. Sankey, who kindly saw the case with me, ever dreamt The of such an amount of smash as that disclosed within. difficulty of arriving at any definite diagnosis was in great measure due to the puffy swollen state of his eyelids, which prevented a free inspection of the pupils, to his own iritability and opposition, and to our natural desire of keeping him as quiet He partook of fluid nutriment freely, answered as possible. questions, at times, rationally, breathed quietly and without any appearance of severe suffering, and looked, as far as expression may be gauged by the face alone, as if lie only wanted rest to After the first involuntary evacuation or two the recover. bowels refused to act spontaneously, and what remained of urine in the bladder after some dribbling was removed by aid of the catheter : yet was the brain all this while enclosed in a case which pressed on it partially in front and sadly lacked continuity throughout, and delirium having supervened and this being followed by stertor, he passed away quietly late on the fourth night from that on which he received the injury.
intimated, I assumed the presence of
Muuree, January 11th, 1875.
75
74i A CASE OF DEATH FROM
FRACTURE OF
THE SKULL.
By Surgeon-Major
Wm.
CtjheaN',
A.M.D.
I submit herewith a short abstract of the following case, which lately occurred under my care, as such accidents are, according to my experience, comparatively rare in this country among soldiers, as also because it shows in a very striking man" the enormous extent to which the skull may be fractured ner, without an immediately fatal issue." It happened, in September last, at a place called Kala-Bagh, on the Murree and Abbot-, tabad road, where I was then stationed, and I regret I am unable to supply fuller details respecting the conditions of the puise, respirations, and temperature, as the book containing
Casualty Report of Age last DAY.
1875.
these is not now in xnv possession : these are, however, scarcely necessary, as the facts so briefly stated below, speak emphatically for themselves, and the mode of recording post-mortem results now enforced in our department is such an improvement on the former hap-hazard method, that I am willing to believe its introduction here may interest others than those for whom it ha3 been specially prepared. As such, and in this spirit it is offered for inspection, and I cannot think I am violating my confidences in thus reproducing a general outline of a case which greatly interested me during life, and absolutely astonished me after death, by the evidence it afforded of the extraordinary tolerance which the system sometimes exhibits under the pressure of an otherwise necessarily, if not
instantaneously, fatal injury
Private J. R
,
2-60th
:?
Royal Rifles.
Service India.
Total Service.
BIRTH-
[Mabch 1,
in
Disease.
Kane and Names.
Place of Death.
Died.
Admitted.
Years.
Pvte.
the
B
J. E.
10
Wounds of face.
16th Sep. 1874 19th
Sep.
1871
Kala-Bagh.
Should the post-mortem evidence have rendered a change of nomenclature necessary, enter the disease to -which original admission has had to be changed, below this line.
| Pvte.
J. It.
10
Fracture of the vault ofthe skull. (/).) Simple with
19th Sep. 1874
19th
Sep.
1874
Kala-Bajrh.
depression.
1 st.?Ifote
the
general
of health, previous to the last illness, and enumerstate
the diseases suffered ate from in the course of the six months preceding the date of the last admission. 2nd.?State the cause of the disease, or the circumstances under which it made its appearance.
3rd.?Give the on
symptoms
admission, during the
progress of the disease, and towards its close, stating also the mode of death.
Was in fair general health, and only suffered from a few very slight attacks of ague during his residence here. He lias not been in hospital for upwards of a year. A
fall
over
"
the
where the ground,
Khuaa,"
first gravelly and ODly slightly sloping, soon became sheer, and finally precipitated him on the rocks of a water course, at a distance of about one hundred yards below the road. Quite insensible and pulseless from shock and loss of blood; the face was frightfully lacerated and contused, and the breath freely exhaled an odour of liquor. at
He subsequently became delirious and violent, passed feces involuntarily, and though able to answer questions in a confused and hasty manner, he never regained consciousness, or betrayed any evidence of suffering; (lie eyelids were from the beginning puffy, (Edematous and livid, and the pulse was throughout feeble and irregular, disposed to jerk at one time and to bound at another, and always very compressible ; the breathing always hurried and sometimes puffy, only became stertorous towards the end, and this was preceded by deep 4 th.?Kecord the diagnosis formed during life, :ind add any further explanatory remarks -which uiuy be thought necessary.
It
wii3
interred
irom
me
appearance of the eyelids and the condition of the pulse, as
well as from the other circumstances attending the injury, that the vault or base of the skull must have been fractured, but this could not be verified, and the gravity of the symp-
life bore no prothe extent of the lesions disclosed by death.
during position to
toms
Post-mortem appearances twelve hours after death. On section the body was found to be well nourished and and the face very rigid, both eyelids were livid and swollen, On raising was bruised and disfigured with numerous wounds. the coverings of the skull, blood was found lying loosely on the slieath and the substance of scalp, as well as extravasated into the oceipito-frontalis muscle, and further dissection disclosed an
extensive
depressed
fracture of the frontal
bone, which,
pass-
ing through the superciliary ridge of the right side, entered the
orbit and extended through its floor as far as tho ethmoidal fissure. The roof of the left orbit was loosened from its attachment, yet the eyes remained intact, and the nasal bones were involved, doubtless by the contre-coup in the same injury ; so extensive indeed was this, that evidence of its effects was found in tho middle fossa of the base, in the shape of a fracture that ran through the sella turcica and dorsum ephippii, and involved both clinoid processes, and the membranes were everywhere unduly' adherent ; the surface of the brain, was deeply suffused with 'blood, especially so on the right side, and the superficial vessels of the hemispheres and sulci were enormously distended ; congestion was in fact everywhere observable, and the puncta vasculosa were throughout abnormally numerous and prominent. The cerebellum and pons were also the seat of this congestion, and such being the case, it was uot considered necessary to extend the examination further. Remahks.?This case is a very good illustration of the " glorious uncertainty" that attends the origin and progress of severe injuries of the cranium, unaccompanied by wounds of the scalp or other palpable lesion: on admission ho looked exactly like a man who had just been subjected, during a debauch, to a bad beating about the head, the only disfigurement apparent was that of the face, and this did not exceed what one might any day witness, after a street-brawl, in a London hospital, or from a heavy fall on tho pavement during frosty weather: yet was the skull broken, smashed, I smight almost say, to an extent which I have rarely and that, too, under
witnessed)
llxncn 1,
1875.]
A MIRROR OF HOSPITAL PRACTICE.
circumstances which, as regards the rugged shelving stony precipice over which he fell, ought to have produced much greater mutilation, as will be seen from the table prefixed to this report. wounds I at first simply returned him under the heading of of the face," but of course this designation could only be and temporary provisional, and I had, at any moment, the power of changing it according as symptoms may suggest or require : it changed certainly was in time, but with what a difference! and it is but fair to myself to add, that, though, as already "
a fracture of some kind or other from the beginning, neither I nor my friend and colleague Dr. Sankey, who kindly saw the case with me, ever dreamt The of such an amount of smash as that disclosed within. difficulty of arriving at any definite diagnosis was in great measure due to the puffy swollen state of his eyelids, which prevented a free inspection of the pupils, to his own iritability and opposition, and to our natural desire of keeping him as quiet He partook of fluid nutriment freely, answered as possible. questions, at times, rationally, breathed quietly and without any appearance of severe suffering, and looked, as far as expression may be gauged by the face alone, as if lie only wanted rest to After the first involuntary evacuation or two the recover. bowels refused to act spontaneously, and what remained of urine in the bladder after some dribbling was removed by aid of the catheter : yet was the brain all this while enclosed in a case which pressed on it partially in front and sadly lacked continuity throughout, and delirium having supervened and this being followed by stertor, he passed away quietly late on the fourth night from that on which he received the injury.
intimated, I assumed the presence of
Muuree, January 11th, 1875.
75
