NICKLES, Dr. SAM'L..... ... Cincinnati, Ohio. PARVIN, Prof. THEOPHILUS. .Indianapolis. PECK, Dr. S. W....... Washington, Ind. ...Jacksonville, Ill. PIERCE, Dr. WINSLOW S.... Indianapolis. TURNER, Dr. WM. MASON.... Philadelphia, Penn. TURNEY, Dr. S. D... . . . . . . . . Circleville, Ohio. WALTER, Dr. A. G..........Pittsburgh, Penn. WATERMAN, Dr. L. D.......Indianapolis. WHITTAKER, Dr. Jas. T..... Cincinnati, Ohio. WELLS, Dr. N. B. WOOD, Dr. THOS..... WOODRUFF, Dr. L.... . Cincinnati, Ohio. .Alton, Ohio. WRIGHT, Prof. M. B........ Cincinnati, Ohio. THE CINCINNATI JOURNAL OF MEDICINE JANUARY, 1867. ART. I.-Fracture at Base of Skull-Recovery. By THOS. L. NEAL, M. D. Being a Paper read before the Montgomery County Medical Society. John Ingersoll, express driver, aged 48, has been a constant drinker for a number of years. October 3, he fell headlong from the top of the seat of his wagon, upon the paved gutter, a distance of eleven feet. He was taken up insensible, and carried home, where, in company with Dr. Adams Jewett, I saw him shortly after the accident. He was bleeding from the nose, mouth and left ear. There was a cut three fourths of an inch long in the left temple, down to the bone; but, beside a bruise of the left ear, the skin was nowhere else broken. A careful examination of the head did not discover a fracture within reach. The surface was pale and cold; the respiration was so feeble as to appear scarcely performed at all; pulse rapid and without force; pupils widely dilated, and there was not the slightest evidence of sensibility. The symptoms of compression soon became more manifest; the respiration became slower, sterterous and labored; pulse fell to fifty strokes to the minute, was soft and irregular, and toward evening there was developed a partial paralysis of the left side. The bleeding from the ear continued copiously for several hours after the injury; but was followed by a pretty free discharge of VOL. II-No. 1. serum, which, by the way, continued more or less for several days; in quantity sufficient to saturate, not only the pillow, but cloths put about him to keep his head dry. There was blood ejected from the stomach during the first twenty-four hours. The violence of the symptoms abated somewhat within twelve hours; still, the bad breathing remained for ten days, and the pulse did not rise above sixty for about twenty-four days. After the puffiness of the face subsided sufficiently, it was discovered that the left eye squinted inwardly, and great ecchymosis obtained within the orbit, "not," as Mr. Druitt says, "a mere speck of blood beneath the connjuctiva, but a complete ecchymosis coming from behind." There was complete deafness of the left ear, which up to the present promises but little improvement. Consciousness. returned very slowly, although we were soon directed by him as to the kind of local applications to apply to his head. He had been ordered evaporating lotions, but he tore them off, and said he wanted "hot ashes." He got hot spirits and water, and was soothed and satisfied. Another point in this connection-as the symptoms were of the adynamic type, and remembering the habits of the man, he was allowed egg-nog, and whisky stews, both of which he scornfully refused to take. On the night of the twenty-fourth day, the patient had a paroxysm of pain, which he referred to the left side of the head and ear, and which was truly agonizing, abating somewhat, and again returning until toward morning. At ny visit, made early, I was surprised to find my patient had almost entirely recovered his reason, said he was suffering greatly, yet seemed sorely perplexed to know for the first time that he had received a fall, and had lost so much time. Now, whatever may be the explanation, the fact must be admitted as remarkable, that the return of reason was coincident with the appearance, or rather the lull of this violent pain. He passed the day badly enough, but the night brought all the horrors of its predecessor. The next morning he was better again, and dozed for a short time, but was aroused with his pain, which, although not so violent as the night attacks, came on with considerable severity. To give details of the next two weeks, would be to repeat what has been said of those two days and nights, and my design in going into detail at all, is to place beyond doubt the efficacy of a remedy in this, if it may not prove so in other cases of like character. To follow, then, the history, these pains subsided rather abruptly about the 10th of November, and he has been steadily, yet slowly, recovering up to the time when this report was undertaken. In mentioning the treatment, in order to be brief, I shall assume that пр to the time of the occurrence of these violent head pains, he got about what is generally recommended in such cases, leaning strongly toward expectancy. With their appearance, I am free to confess, I was somewhat puzzled as to what course to pursue. I began, however, by giving small doses of morphine, to be carefully increased, until he was getting half grain doses every three hours. This seeming to have no effect, he next got belladonna with no better results. I then asked Dr. Reeve to see iny patient, and at his suggestion I gave him tincture of the root of aconite, and iodide of potash, which was continued until the physiological effects of the aconite were manifested; but as no amelioration of the pain followed, it was discontinued. I next gave him R. Potassii bromidi 3iss; tinc. valerianæ ammonia. fl. 3viij; aqua camphoræ fl. 3viij. Mix. Tablespoonful every three hours. This formula, after twenty-four hours, had developed such marked good results, and so beyond my expectation, that I was then in doubt as to whether its exhibition, and the subsidence of pain might not be merely coincident. I did not risk it, and kept up the medicine for six days longer. Now, as the patient was quite comfortable, and in order to fully satisfy myself to what it was due, the medicine was withdrawn; but before morning I was sent for, and found him suffering as much as before the medicine was first given. I then gave him twentyfive grains of the bromide, to be repeated every four or six hours-looking confidently for the relief of my patient, and in which I was happily not disappointed. Again, there had now elapsed another week since the man had complained of pain; the appetite was good; he slept well, and every thing promised so favorably with him, I did not think there could be any necessity for continuing the remedy, and so in good faith this time, I suspended it. He had pain again, not violent however, yet enough to prevent sleep. The bromide acted as happily as before, and, consenting to the urgent solicitations of the patient, he was allowed to continue its use up to the middle of December. The commentary upon this case, undoubtedly is, that it was a remarkable instance of recovery from an extensive fracture of the base of the skull. All injuries of the head, however slight, may prove mischievous, while on the other hand grave accidents, implicating the brain itself, are not necessarily mortal. The symptoms of fracture of the base of the cranium, may, as Prof. Gross says, in a "perfectly simple case be mild; mild remedies sufficing for its relief;" "but," says the same author, "it is far otherwise when the fissure is extensive, owing to the lesion sustained by the brain and its envelopes." There is, then, profound collapse, and not the slightest sensibility of any kind. This may last a longer or shorter time, and leave it possible for an entire recovery at some remote period; or what frequently takes place, the unfortunate patient never reacts. There is almost always blood poured from the mouth, nose, and ears; and frequently also, sooner or later, a serosity issues from these same cavities. I have merely referred to what is usually observed of the cerebral symptoms in the kind of injury under consideration, from the fact that within themselves they can never be depended upon as pathognomonic of fracture: and a hint at what occurs in the simple form, and to notice what has been designated profound collapse in the grave, must serve our purpose, since they can only be held as concomitant indications, and of no value in the light of differential diagnosis. There are symptoms, however, which certainly tell us of injuries of structures in immediate contact with bones, and further indicate at what points, and to what extent these structures may be involved. Mr. John Hilton has grouped these symptoms into three divisions, and I can do no better than borrow his classification. "1. Those symptoms resulting from an escape of blood to tho exterior of the cranium by the orbits, nose, mouth, pharynx, or ear. 2. Those resulting from injury to the nerves traversing the foramina of the base, and must vary according to the normal functions of the nerve or nerves involved, and, 3rd, The escape of the cerebro-spinal fluid from the ear or other parts |