ART. IV.-Cases of Injury of the Head. By A. B. SHIPMAN, M.D., President of the Cortland County, New York, Medical Society.

CASE I. Fracture-Lesion of Brain-Death.-Fox, ætat. 17, while riding a horse at a race in Homer, in this county, on the 20th of August, 1833, was thrown, and the left side of his head struck upon the hard road. He was taken up insensible, a surgeon sent for, Dr. Lewis Riggs of Homer, who bled him on the spot. There was a small wound in the scalp at the left side of the head, and an abrasion of the cuticle on the forehead, with extensive ecchymosis of the eyelids and around the eyes. He remained insensible for some hours; but in the evening he was rather restless with delirium.

I saw him on Friday evening, the 22d, the third day from the receipt of the injury, in consultation with Dr. John Lynds of Homer, who had bled him and given him a cathartic the day before. He had been restless most of the time with stupor; at this time he was rather comatose, but could be roused to take drinks and medicines; restlessness; occasionally stertorous breathing; involuntary stools and urine; pulse regular in strength and frequency; no paralysis or fever; skin cool and natural. The pupil of the left eye (the side injured) greatly dilated, yet slightly contracting on holding a lighted candle near; right eye pupil natural; eyelids closed and greatly distended by ecchymosis.

23d. I again visited him, found him apparently better. Cold applications had been kept to his head, and blisters to his legs and between his shoulders. His senses had returned so as to enable him to converse with his friends, who had been sent for from a distance, calmly and rationally; he recollects how his injury was received; complains of no pain; in the afternoon relapsed into a drowsy state, with incoherent talking.

24th. Symptoms more favourable; pretty rational; stood upon his feet; no fever or pain; slight delirium in the evening.

25th. Remains in nearly the same condition as yesterday.

26th. Was bled, when he became worse almost immediately; he sank into a comatose state; the surface became cold and the face sunken; the ecchymosis in great part disappeared from the eyelids; the breathing laborious. He continued gradually to sink, and expired at 5 P. M., on the 28th, just one week from the injury.

Autopsy 12 hours after death, in the presence of Drs. Boies, Lynds and Bradford. Very little blood was found in the scalp; the left temporal muscle was filled with a coagula of effused blood, and under the pericranium, near the seat of the wound, there was also suffused blood. On removing the skull cap, a fissure was discovered extending from the upper part of the frontal bone, on the left side, through the superciliary ridge and through the orbitar process, across the suture connecting the lesser wings of the sphenoid

bone, into the foramen lacerum of the orbit; another fissure extended across the orbitar process to the christi galli of the ethmoid bone, then downwards, terminating near the anterior clinoid process, in the foramen lacerum near the termination of the other fissure, leaving a triangular portion of bone entirely insulated and depressed about one-eighth of an inch. Corresponding to the perpendicular fissure, there was a laceration of the dura mater, two inches in length, and a wound of the brain of the same length and threefourths of an inch in depth, in the anterior lobe of the left hemisphere, about an inch and a quarter from the falx, and parallel with it. On each side of the fracture the dura mater was separated from the bone with extravasation between it and the bone, to the amount, perhaps, of two ounces. There was also some extravasation in the middle fossa of the skull on the opposite side. The sockets of the eyes also were filled with extravasated blood. The wound in the brain was filled with coagula and disorganized brain broken down into a pulp. The laceration of the dura mater and lesion of the brain were produced by the fractured edge of the bone being driven inwards by the force of the fall, but springing back, by its elasticity, to near its natural state. There were no marks of inflammation to be discovered in any portion of the brain; the vessels of the pia mater slightly injected; no suppuration or coagulable lymph; the parts, on inspection, appeared like a wound of very recent occurrence.

The diagnosis in this case was not so perfectly clear as might have been supposed from the degree of injury discovered in the post mortem examination. The symptoms might have been the result of violent concussion, and when, on the fourth day, returning sense and consciousness took place and continued a portion of the time for three days, some hopes might have been reasonably indulged in that no fatal lesion had taken place. The extravasation most likely took place immediately after the injury, and it is rather surprising that so few symptoms of compression should have been present. The wound of the brain was enough, we should think, to have caused paralysis or some more disturbance of the functions of the optic nerve; but when he was rational, no such effect was discovered. The injury was of so grave a character as to prevent that degree of reaction necessary to the development of the inflammatory process. The last bleeding was unnecessary, and probably hastened the fatal termination of the case. No operation would have been of any service if the precise nature of the injury had been known.

CASE II. Fracture, with Depression-Recovery without an Operation.October 15th, 1833.-M. W., a young gentleman of the medical profession, was thrown from his horse during a violent shower of rain. He was but little stunned with the fall, remounted his horse and rode to this village, a distance of more than a mile. I saw him within a short time after the accident; found a wound on the left side of the forehead; the scalp was torn up in a triangular flap, extending to the cranium; the pericranium was also lacerated,

exposing the bone; a fracture was discovered, with depression to a small extent, as though made by coming in contact with a sharp stone; this was in the upper and left side of the frontal bone. He was able to sit up; while the wound was dressed, the hair shaved off, and the wound cleansed from the dirt and gravel, the flap laid down and retained with adhesive straps. There were no symptoms of concussion or compression, or any disturbance of the mental faculties; he rested well during the night, and in the morning, as his pulse was somewhat strong and full, he was bled, took a cathartic, and in three days rode four miles to his home, and recovered without any bad symptoms. The force which fractured the skull in this case was confined to a small point of the bone, and whatever injury there was, it was circumscribed; the depression was not sufficient to cause compression, and it is probable that there was not any effusion beneath the bone.

CASE III. Fracture, without Depression-Recovery without Operation. -September 15th, 1836. George Martin, hostler, ætat. 21, was kicked by a horse upon the upper portion of the right side of the frontal bone; the scalp and pericranium was torn up from the bone the size of a crown piece, and also a piece of the external table of the bone the size of a shilling; a fracture of the bone also traversed the skull in a perpendicular direction and both above and below in the sound skin. He was at first insensible from the blow, but partially recovered his senses; was carried into the hotel and placed in bed. I saw him within an hour. He was drowsy and torpid, but could be roused to answer questions, quickly however relapsing into stupor; his extremities were cold; pulse slow; pupils dilated. Ordered bottles of hot water to his extremities, and a glass of warm brandy and water. In the evening, six hours from the time of the injury he was nearly in the same situation, except that he was rather warmer and the pulse somewhat more frequent. In the course of the night reaction took place with stertor and heat of the skin.

16th, 8 o'clock A. M. Bled him twenty ounces, which seemed to rouse him in some measure. Twelve o'clock, noon, as there was some stupor, with much reaction, he was bled again sixteen ounces; took a cathartic of jalap and calomel, which operated well by nine in the evening. He then became perfectly sensible, and the heat of skin and activity of the pulse subsided. The scalp which was torn had been placed back in its natural position, and the loose piece of bone removed, and the wound was now dressed with adhesive straps, with light dressings to the head; cold applications were also made use of, with sinapisms of mustard to the feet and arms.

17th. Got out of bed, dressed himself and walked down stairs. From this time he went on doing well, and resumed his labor without any unpleasant symptoms; the wound healed in a few days, and he never had any farther inconvenience while he remained under my observation for six months afterwards.

This was a strongly marked case of concussion, and from the length of time which it remained after reaction came on, must have led to the conclusion that extravasation had also taken place, demanding the operation of trephining. The promptly salutary effect of venesection was striking; had the trephine been resorted to the next morning after the hurt, and there were some symptoms indicating its employment, no cause of compression would have been discovered, and the danger would have been increased. The injury was probably done with the cork, and struck the bone in a glancing manner; which chipped off a piece of the outer table of the bone and caused the fracture. The force of the blow was confined to a small surface, or the result would probably have been more serious.

CASE IV. Fracture, without Depression-Recovery without Operation. —November 28th, 1836. Mrs. Stafford, of Virgil, ætat. 50, was thrown from a wagon upon the frozen ground. She was taken up insensible, and carried home, the distance of a mile. I saw her in the evening four hours after the accident. She had partially regained her senses, and complained of violent pain in her head and jaws. Her friends stated that she was very cold when they first got home, and they had but partially succeeded in getting her warm when I arrived. The eyes were both closed by the ecchymosis, and on examining the head a small wound was found in the scalp on the left side of the frontal bone, which would admit the point of the finger; at the bottom of this wound a fracture was distinctly felt, which separated so as readily to admit the finger-nail; the scalp was much bruised, and infiltrated with blood over the left side of the head; pupils much dilated; pulse slow and feeble; complains of difficulty of swallowing; she can be easily roused, and answers questions rationally. Ordered her warm sling, with bottles of hot water to the extremities. In about two hours she became warm, with a stronger pulse. Venesection to eight ounces, when she fainted; gave a cathartic of calomel and jalap; cold applications to the head. During the night she was restless with slight delirium.

29th. Cathartic operated well; is stupid most of the time, but answers questions rationally when roused; no fever; complains of severe headache, and is very restless a portion of the time; starts frequently in her sleep; moans and grinds her teeth; face and scalp much swollen, and dark colored; pulse slow and full; skin and extremities warm; venesection, twelve ounces, after which she became faint.

30th. Considerable febrile action; had chills in the morning; pulse quick; skin hot; restlessness, and delirium; complains of no pain, but starts at noises, and moans; pupils of the eyes much contracted. Venesection twelve ounces; calomel to be followed by senna and salts; blister to each arm; ordered the head to be kept elevated, with cold iced water to be applied.

December 2d. Febrile action less than on the 30th, but still considerable; pulse more full and less frequent; bowels have kept acting for the last

thirty hours; is rational, but her friends say she was delirious most of the night; complains of pain in the head, neck, and jaws; pupils still contracted. Blister to the back of the neck and calves of the legs; cold applications to the head continued.

4th. Found she had been feverish and delirious through the night with starting and picking at the bed-clothes; but is more calm in the day time; blisters drew well; less fever; pulse more natural; swelling of the face and eyes subsiding; pupils more dilated; but not more so than would be natural; has had strangury in a slight degree. Ordered the blisters to be dressed with epispastic ointment and lard. Continue the cold applications, and the general antiphlogistic regimen.

6th. Symptoms improved; less fever; no delirium since the 4th; some pain in the head; begins to call for more substantial food; has had strangury most of the time since the 4th, which she complains of more than any thing else; blisters discharge freely. From this time she gradually improved without any alarming symptoms, and without any other treatment than a mild antiphlogistic course; the blisters were kept running for ten days longer; a low diet with an occasional laxative to obviate costiveness was all she required.

She has enjoyed her usual health since that time, with the exception of occasional attacks of headache-for which it has been necessary to resort to venesection and active cathartics. The dilated pupils at first, and the stupor and general torpor of the system, might have led to the fear that extravasation had taken place; and the early development of fever and inflammation which followed was of an alarming character; but the happy termination of the case renders it probable that no effusion of blood, at least of any consequence took place; but cerebral inflammation was unquestionably present to a certain degree. The strangury I hailed as a favorable omen, as I always do in cases of cerebral disease, having frequently seen most striking benefits immediately follow its appearance.

CASE V. Fracture-Trephining.-Death.-David Robinson, of Virgil, in this county, ætat. 73, while in the woods felling timber, February 25th, 1835, received a blow from the fall of a tree upon the left side of the head. When picked up he was totally insensible; nor did he exhibit any signs of returning sense until he had been conveyed to his house, which occupied perhaps half an hour. Dr. Bronson was called, and on his arrival opened a vein, but obtained little blood. Soon after the patient regained his senses, was able to converse three quarters of an hour, when he relapsed into insensibility. I saw him 11 A. M. four hours after the accident; he was then comatose; could not be roused; breathing stertorous; pupils dilated and insensible to light; writhing of the body from side to side; slow feeble pulse; cold extremities; oozing of blood from mouth, ears, and nostrils. He had swallowed some warm sling before I arrived; on examining the head the scalp