THREE CASES 
OF 
Fracture of the Skull. 
By OSCAR J. COSKERY, 1ST. D. 
Professor of Surgery, 
College Physicians and Surgeons, 
Baltimore. 
Reprint 
FROM TRANSACTIONS OF 
.flftfbical anb <£ftirur0ical 
of the State of Maryland. 
1886. STEAM PRESS OF 
GUGQENHEIMER, WEIL & CO. 
BALTIMORE. [Reprint from “Transactions of the Medical and Chirwrgical Faculty of 
Maryland” for 1880.] 
THREE CASES OE FRACTURE OF THE SKULL. 
By Oscar J. Coskery, M. D. 
Professor of Surgery, College Physicians and Surgeons, Baltimore. 
Herman G., aged 40, German farmer, while crossing a railroad 
m a two-horse wagon had the vehicle struck by a rapidly moving 
engine. Both horses were killed, as was his son, who was also in 
the wagon. About two hours after the accident the patient was 
admitted into the City Hospital, October G, 1885. Besides a bad 
compound-comminuted fracture of the left leg, the following 
injuries to the head were found: a lacerated wound, inches in 
length, extending from right parietal eminence upwards and for- 
wards. The larger part of this parietal hone was depressed and 
in many fragments (saucer-fracture). A piece of the skull, one 
and three-quarters by three-eighths of an inch in size, which was 
loose, was removed and the depressed bone elevated. There was 
also an extensive triangular lacerated wound of the scalp over the 
left parietal bone. Shock was very great; he was conscious but 
stupid, pupils were widely dilated, and his general sensibility 
obtunded. Respiration slow and shallow. He had bled consid- 
erably from both scalp and leg and was thirsty.* After the 
depressed bone had been raised drainage tubes were inserted 
under the scalp, the surfaces dusted with iodoform and the edges 
approximated by heavy silk thread. On the next day he had 
rallied somewhat, but was still thirsty and stupid. At the even- 
ing visit he was decidedly better in every way and had urinated 
naturally. 
October 7 and 8.—Patient quiet and shows a constant tendency 
to sleep, but is easily aroused. On the latter day scalp wounds 
were dressed. 
* I will dismiss the injury to the leg' here by saying that an unsuccessful attempt 
was made to convert the fracture into a simple one ; resection was performed, but 
the patient left the hospital with an ununited tibia. 2 
OSCAlt ,1. COSKEKY, M. I). 
October 9.—Brighter, but still sleepy. Complains of some 
pain in head, but no fever, lie steadily improved and the drain- 
age tubes were removed on the 14th. The discharge is very free. 
On October 17, the pupils were found irregular but responsive 
to light; patient was apathetic and there was some intellectual 
disturbance, but no hallucinations. No note of anything of moment 
connected with the head symptoms was taken. The mind slowly 
became clear, the inequality of the pupils disappeared, and when 
he left the hospital on March 29, 1880, not a single sign, mental 
or physical, was present, to show what serious trouble had been 
done to the skull and its contents. 
The temperature was 1014° on the fourth and fifth days, and 
101° on the sixth and tenth, but never went beyond 100° after- 
ward, and then only on one afternoon. 
Emmanuel 1’., carpenter, aged 52, was thrown from his buggy 
while his horse was running away, and his vertex struck the curb- 
stone. Was admitted into the City Hospital about two hours 
afterward—on November 24, 1885. There was found a lacerated 
wound in front of the left parietal boss, triangular in shape, and 
through which a depressed, comminuted fracture of the bone could 
be felt. There was great swelling of the left upper lid and sub- 
conjunctival ecchymosis ; there was also a small lacerated wound 
over posterior portion of right parietal bone. The patient was 
comatose, snoring loudly. The wound was enlarged upon the left 
side and a pair of bone nippers used to remove a small triangular 
portion of the solid bone. Through the opening thus made the 
elevator was introduced and a piece of the lower portion of the 
parietal bone, in shape a parallelogram, one inch by three-quarters 
of an inch in dimensions, being found very loose, was removed. 
The balance of the depressed bones, which seemed to consist of 
the major part of the parietal and squamous portion of the tem- 
poral was then moulded into what seemed good shape, and very 
little effort made to approximate the edges of the wound. The 
hemorrhage, which was pretty profuse during the operation, was 
controlled by packing the wound and a bandage. 
November 25.—No change in cerebral condition. Passes urine 
involuntarily ; no albumen found in urine on introducing catheter. 
The bandage and packing were removed and the hemorrhage did 
not recur, but the wound gaped widely; the latter was dressed 
lightly. REPORT OF THE SECTION ON SURGERY. 
3 
November 26.—Much the same, hut shows some irritability 
when interfered with, and the comatose condition is disappearing. 
November 27.—Cerebral irritability increased ; patient lying 
upon one or other side with limbs flexed, and he is constantly 
pulling at his penis; urine still flows into the bed, pupils normal 
and responsive, and swelling of eye-lid is decreasing. Since 
admission the pulse has averaged GO beats to the minute, full; for 
first time opens eyes voluntarily; bed-sores have appeared over 
sacrum ; seems to recognize friends ; no stool since admission ; a 
calomel purge acted freely. ~ 
December 3.—From day after admission the wound had been 
allowed to gape and had suppurated freely ; at; bottom of wound 
pulsation of dura-mater was plainly to be seen ; patient, on this 
date, steadily improving, his appetite for food was good, the cere- 
bral irritability had passed away, but he still passed water in bed ; 
is conscious, but slow to answer when addressed, then answers 
rationally. 
December G.—Now asks regularly for urinal and is fully aware 
of his surroundings; wound over left parietal still gaping and 
suppurating freely; wound over right parietal has long since 
healed. Nothing to note of consequence until— 
December 14.—On this day, at his request, he was discharged. 
Ilis condition then was as follows: He sjflll speaks slowly (this 
may be a peculiarity of the patient); his gat/ is somewhat totter- 
ing, but shows no tendeiicy to ataxia or paralysis of either side ; is 
perfectly sensible, and has lately gained in weight. 
April 14, 1886.—Patient presented himself to-day; mental 
condition good. He still speaks slowly, but distinctly. There 
is no strabismus, vision and pupil contraction are good, and hand- 
grip is seemingly as strong upon one side as upon the other. 
There was a depression upon left side of skull, in parieto tem- 
poral region, of fully one-half inch in depth; at bottom of 
depression a granulating wound one-half by one-eighth of an inch 
in size. This wound did not pulsate. The patient has won- 
derfully increased in weight and strength. 
April 30, 188G.—Wound has now entirely healed, no pulsation, 
and patient is going on a trip of pleasure to last some weeks. 
Case 111.—Henry L., German painter, aged 54, 5 feet 0 inches 
in height, weighs 1G0 pounds. At 3:30 P. M., April 1G, 1886, 
fell 22 feet, striking fairly upon his head. Was admitted into 4 
OSCAR J. COSlvERY, M. I). 
City Hospital half an hour afterward. Ilad been unconscious 
since fall. 
Condition on admission, 4 P. M. : Greatly shocked, but could 
ho aroused. In answer to questions, nothing but his name could 
be recognized; a very large hematoma under the scalp on both 
sides, rapidly increasing; a very small lacerated wound of scalp 
over left parietal bone, near boss; a considerable depression of 
the skull to be recognized in the neighborhood; pupils normal; 
no bleeding from the nose, ear or mouth ; left arm motionless ; 
left leg drawn up and extended constantly ; apparently some vol- 
untary movement of limbs of right side ; two lower true ribs, 
left side, fractured near axillary line; pulse 84, weak; respirations 
stertorous and slow. 5 P. M., patient cannot be roused : right 
pupil dilated, left normal; movements of left leg continue; 
right arm is now in continuous motion ; pulse 88; diagnosis was 
made of depressed fracture of left parietal bone, extending by a 
linear separation of bone into the base of the skull, with lacera- 
tion of brain ; too much shocked to admit of operation. At 0:20, 
pulse 120, slightly stronger. An incision, an inch and a half in 
length, was made through the scalp down to the bone, commencing 
at the small wound. Another of same length at an obtuse angle, 
to first enable me to raise a fhvp and get upon the bone, which I 
denuded of periosteum over a space one inch in every diameter. 
Skull was here smooth, and no fracture was anywhere discovered 
by the finger-nail or probe. Hemorrhage considerable, and pulse 
again became imperceptible. Whiskey, hypodermically, rallied 
pulse somewhat. At 11 P. M., pulse still stronger, the only sign of 
improvement. 
April 17, 7 A. M.—Pulse stronger ; breathing stertorous at 
intervals ; right pupil still dilated, but left contracted. 3 1*. M., 
temperature 99°; general condition otherwise the same; hema- 
toma increased, though wound in scalp gaped widely; emphysema 
over fractured ribs ; takes small quantities of milk. G P. M., 
temperature 100 ; priapism ; tickling sole of foot produces strong 
contraction of lower extremity on either side; arms have been 
kept still all day, but any attempt to straighten them reveals 
presence of the state of “irritative paralysis.” 
April 18.—No change for better. Gradual rise of temperature 
to 102.5°, and death at 3.45 P. M. Patient never having regained 
consciousness. HE PORT OF THE SECTION ON SURGERY. 
5 
* Post-mortem Appearances. 
Extensive bruise of right upper extremity; a large collection of 
blood over the skull, one-quarter of an inch in thickness ; a 
depressed fracture of skull, saucer-shaped, three by four inches 
in diameter, involving parietal bone of left side and crushing 
bone into many pieces. From one part of this crush a linear frac- 
ture ran downward through external angle of frontal bone, lesser 
wing of sphenoid, greater wing of same bone, and ended at 
foramen rotundum. 
On right side of skull the parietal was separated from the tem- 
poral, except at lower part, where a line of fracture ran downward 
through a small part of parietal, then temporal and towards 
median line to end at foramen spinomm. There was found an 
extra meningeal hemorrhage, to extent of about four ounces, cover- 
ing an area two by three inches, and half an inch thick, and 
situated over fissure of Rolando on right side. Under this clot 
a rent in the dura-mater two inches in length and corresponding 
to the separation of the bones in coronal suture. 
There was also an intra-meningeal clot to the extent of about 
three ounces, covering two-thirds of right hemisphere and directly 
connected with the extra-meningeal clot. The sources of 
hemorrhage were found to be the superior longitudinal sinus 
(which was torn up), as well as the brain substance itself at sight 
of laceration (in superior frontal convolutions of right side). 
The extent of the brain laceration was one inch in length by half 
an inch in depth. 
♦Made by Dr. Friedenwald, Assistant House Surgeon.