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F (Reprinted from the Montreal Medical Journal, October, 1899.) 1 1 COMI'LICATIONS AND TRKATM KNT OF l-KACTLRK 01-' TllK HASK OK TllK SKULL.*' J. .M. Ei.i)i;u, H.A., M.l)., CM., Sm-Kfon to the. Montreal (Jeiiural Hospital ; Lecturer on Medical and Surgiiial Apolied Aniitoiiiy, M((iill University. 1 intend only to speak of the " Complications and Treatment of Frac- tures of the Base of the Skull"; and even to do that briefly will, 1 fear, tiix your patience quite enough, leaving aside the much wider, and vastly more interesting, subject of Fractures of the Skull in general. My reason for taking up this subject was, primarily, that 1 had under my care this summer, in my wards in the IMontreal General Hospital, a rather remarkable series of Fractures of the Base — remarkable in the fact that no fewer than five were there at the same time, affording opportunity of comparative study — and also remarkable for the further fact, that they all recovered. I do not say this boastfully, for several of them should have died to preserve my prognosis. This series of cases, naturally, made me study up the subject of I'^racture of the Ba,se as I had never done before ; and the good results of the routine treatment followed made me wonder whether we — as general practitioners — have not been too prone in the past to assume that this was a form of injury for which any treat- ment was useless, and that all we should do was to make a correct diagno- sis, give a grave prognosis, and then fold our hands and await the result. Such an attitude, I maintain, in these aseptic days is quite as unjustifi- able in the case of a fracture of the base of the skull as it would be in a compound fracture of the tibia, for instance. I crave your permission to now refer shortly to the following seven cases of the injury under discussion, as I have excluded the cases of fracture of the vertex, which did not show any symptom^ of having extended to the base. Case I. Mabel S., aged 8, was brought to the Hospital on May 30th, unconscious, the result of a fall of 15 feet, striking head first. There was a large ha^matoma over left parietal bone, and also a depressed fracture above left ear. Blood was oozing from mouth, no,se and left ear: pupils widely dilated : convulsive movements of left side of body, but no movements of right side. Pulse weak and compressible, face pallid, and respirations shallow. She shortly began to vomit small quan- tities of bright red blood and rapidly grew weaker. Examination with * Read before the Canadian Medical Association, Toronto, August 31, 18!)9. n laryngeal mirror showed hlood dropijing down from the vault of the pharynx, which would collect in the .stomach, and he rejcc'ed from time to time. So that, in addition to the fracture of tlie parietal bone (or as a continuation of it), there was fracture through the middle fossa of the skull, involving both the car and the naso-pharynx. As the child was bleeding to deatii, jtossibly from rupture of tiie middle meningeal artery at, or near, llie foninien spiiiosum, I I'elt that something had to be done at once. 1 remembered some years previously helping my senior col- league. Dr. Shepherd, oi)erate upon a case of fracture of the skull, in which he could not reach the point- of bleeding from the meningeal artery, wliich was evidently ruptured at the foramen spinosum, and he very cleverly saved his patient by ligating the common carotid artery of that .side. You will find the case reported at length in the Brit. Med. Journal, Vol. 1., p. 905, 1890. It occurred to me that I should follow the same rule here, especially as my little patient was in no condition to stand any prolonged operation (m the skull or brain. 1 hurriedly ligated the left eommon ( arotid artery and put the patient to bed. She was absent I rom the ward, in the operating room, oidy half-an hour. She regained consciousness on the third day. She developed thrombosis on the twelfth day ; first of the superior longitudinal sinus, followed, on the sixteenth day, by thrombosi.s of the left cavernous sinus, and, a little later, of the right cavernous sinus. The study of the various forms of squint thus produced was most interesting. These were the only unto- ward incidents in her recovery, as the depressed fracture of the parietal bone righted itself, as such fractures so often do in children. She left the hospital, perfectly well, in 2() days, and continues well. J show you a photograph taken four days ago. Case II. George W., aged 36, was brought to the hospital on May 31st, having fallen down a hoist .shaft. He was bleeding from right ear, nose and mouth, conscious, but complaining of great pain in the head. He had also a compound fracture of the right lower jaw, and two punc- tured wounds of the neck, one going into the mouth. The wounds in the neck were dressed and sutured, and a splint applied to the broken jaw. In addition to dressing the wounds of the neck and of the mouth caused by the broken jaw, I gave precise instructions regarding cleansing and keeping as aseptic as possible all the cavities affected by the fracture of the base, and I shall detail these instructions later on, a^ they pertain to all these oases. The patient convalesced rapidly, never had any fever worth mention- ing, and left the hospital in eighteen days with all his rounds healed but a splint still on the broken jaw, which had quite united a little later. Case III. Mrs. W., aged 31, on June 15th jumped from a moving eleo- ault of the . from tinio jiie (or as a ossa of the i cliild was igcal artery to hii done senior col- le skull, in meninyoal losuni, and 'otid artery Brit. Med. 3uld follow ondition to )dly ligated was absent le regained ;is on the ■ed, on the nd, a little IS forms of only unto- ;he parietal . She left I show you al on May 1 right ear, 1 the head, two punc- wounds in the broken mth caused ansing and fracture of ley pertain h mention- healed but 3 later, oving eleo- tric street car, and struck her head on the pavement. On admission, hloi.d was oozing Jroely Irom iier rigiit ear. i'our inches al)ove llie occipital protuberance and one inch to the left of tiie sagittal suture, was a lacerated and contused wound of the scalp leading down to a depressed fracture of the skull (i)osterior part of leil parietal bone). Two weeks previously she had been confined, and was in active lactation. She was dull and stui)id, ditlicult to arouse, with both pupils dilated and sluggish to light. She vomited frequently, a slight trace of blood being found in vomited matter. The wound in the scalp was sutured and dressed but no elfort was made to raise the saucer-like depression of bone underneath. 'I he ear and nose were treated in the usual way, and tiie usual routine of diet, vest and cold applications to the iiead followed. The vomiting was most troublesome, and the patient was very weak before it ceased, having ejected a good deal of blood, the source of which 1 could not make out but suspected it entered the pliarynx through the right Eustachian tube. Her temperature never went above 101 '^ l\, and she made a good recovery, being conveyed home on ilie eleventh day. J have since seen her, and she complains of nothing as a result of her accident. Case I V. P. M. K., aged 43, was brought to the hospital by the police patrol, which had found him unconscious in the street. He was semi- conscious, inclined to sleep at limes, and wildly delirious at others. He was in the ward for a week before we could iind out his name or get any information whatever about him. JUood was trickling from both ears, and from nose and mouth. He vomited blood at different times in small quantises. He had paralysis of all muscles supplied by the left facial nerve, which was evidently involved in tiie Fallopian aqueduct. Closer examination showed a slightly depressed fracture of the left parietal bone, about one inch above the left ear. The ears, mouth and nose were treated as usual and ice was applied to the head. He was very delirious for a week, and suffered from retention of urine for several (lays. His mental condition then (juite siuldenly improved, but he still had deafness and facial jmlsy when.he left the hopsital in three weeks. Dr. Stirling, assistant occulist and aurist of the hospital, reported rupture of both drum heads, and did not hold ouL much hope of regaining hearing in the left ear, as he feared the portio mollis of the seventh pair of nerves had suft'ered with the portio dura and was involved in some scar connected with the fracture through tlie petrous portion of the temporal bono. His temperature while in hospital never rose about 100° F. Case V. L. C, aged 37, was brought to hospital unconscious, smelling strongly of alcoholj with both' pupils dilated, right more than left, and blood oozing from the right ear, nose and mouth. There was a scalp wound over the occiput, but no fracture of the skull underneath ; the left nostril torn open to the cheek ; flesh wounds of the right hand and right shoulder. The wounds wen; sutured, after oleansinj;;, and then the cranial orMiees treated as usual. For three days he was delirious, and the temperature rose to lUl'' K. on the fourth day, b'ut then rapitlly got better, ami he left the hospital very well in eleven days. dusc VI. A. U., aged 2d, was brougiit to hospital on July Ji3rd, having fallen from a moving train and struck on the head. Blood was llowing from the nostrils and left ear, and a very large luematoma was present over the right temporal and malar regions involving tlie right orbit, lie was unconscious and vomiting blood occasionally. JJell's palsy of the left side of face, but no other evidences of paralysis. Breath- ing stertorous. The usual orders as to treatment were as well carried out as a public hospital ward would allow, and the patient made a rapid recovery, unconscious delirium being followcti by intelligence and (piiet, and the facial palsy disappearing. In lifteen days he was discharged, apparently perfectly well, but with the usual caution not to work hard or excite himself for another month. 'J'he temperature in this case never ro.sc above W)'^ F., though he was wihily delirious for two nights, and had to have several hypodermics of liattley's solution. Oase VII. 0. S., aged 81, was brought to hospital on the night of August 1st, isemi-conscious, the result of a fall on his head into a culvert, and bleeding freely from the nose and left ear. The usual treatment was followed. He complained of great pain in the head, worse at night, and in spite of sedatives was very noisy, lie began to improve on tlie fourth day, and on the sixth day his brothers insisted on his, removal from hospital, and I have since heard that he made a good recovery. In all these cases the following general plan of treatment was followed out as systematically as circumstances would allow : — 1. Rest in bed. 2. Quiet was enjoined, and preferably the patient should be kept in a dark room. In the private cases, only, could this be done. 3. An ice bag was kept to the head. ^ 4. The affected ears were thoroughly syringed out with carbolic acid solution 1-60, and packed with iodoform gauze, over which was bandaged a pad of sterilized cotton wool. This was repeated as often as the cotton wool showed any moisture. The nose was sprayed every four hours with the following, taken from the Montreal General Hospital Pharraacopceia : 1^ Sod. biborat., sod. bicarb, aa. grs. iii, acid carbolic gr. i, glycerine 5i, aq. ad §1. Sig. Use in the atomizer. In addition, the mstrils were plugged with sterilized absorbent cotton cJianged frequently. Where a mouth wash and gargle could be used and was indicated by involvement of the vault of the pharynx in the fracture, the following was used every two hours : — I^ Pot chlor. gr. xlv., acid hydrochlr. m. xx, glycerine 5iv, aq destillat ad f,x. Sig. As a gargle and mouth-wash. then the ioiis, iiiiil iipiilly got ily 23rd, Blood was tmim was the right ik'lTs ih'oalh- carric'd Ic a rapid iiid (luicl, ischargt'd, k liard or ;ase iiuvcr gilts, and L' niglit of a culvert, treatment ! at night, ve on the ^, removal avery. s followed kept in a bolie acid bandaged ;he cotton ours with lacopcoia : cerine 51, ;rils were icated by following Ir. m. XX, i^ash. T). The diet was strictly fluid, and in many ca.-