[Reprinted from The Medical News, November 18, 1893.] 
A CASE OF DEPRESSED FRACTURE OF THE 
SKULL IN A CHILD, WITH AN ENORMOUS 
CLOT; OPERATION; RECOVERY. 
By WM. N. JOHNSON, M.D., 
OP GERMAWTIMWai) TA. 
Sallie R., eleven years of age, was admitted to the 
Germantown Hospital on Saturday, July 29, 1893. Two 
days previously she had fallen from an apple-tree a 
distance of fifteen feet, and struck directly on her head, 
and immediately became unconscious. How long this 
primary unconsciousness continued is not definitely 
known, for after a time she recovered sufficiently to walk 
to her house, about five hundred yards distant. While 
there, she again became unconscious, and a physician 
was summoned, who did not recognize her true condi- 
tion until Saturday morning, when he advised removal 
to the hospital. Upon admission, the following condition 
was present: The temperature was 970, the pulse 135, the 
respiration 26. There was total unconsciousness, even 
to absence of the conjunctival reflex. Ptosis of the right 
eyelid was present, and the right pupil was widely di- 
lated and insensible to light. The left pupil was normal. 
Urine and feces were passed involuntarily. I am unable 
to state whether there was hemiplegia or not, as owing 
to the precarious condition of the patient, examination 
in this direction was not pushed. 
When the child’s head was shaved, a large depression 
over the right side, between the frontal and parietal emi- 
nences, could be made out, although no external wound 
was visible. 2 
No anesthetic being required, and with antiseptic pre- 
cautions, an incision about three inches in length was 
made over the central portion of the depression, and a 
large stellate fracture, involving the lower border of the 
parietal bone, and the adjacent portion of the temporal 
bone,was revealed. With a thumb gouge,an opening large 
enough to admit one blade of the rongeur forceps was 
made, and with this latter instrument three square inches 
of bone were removed, disclosing a large clot between 
the dura and the bone. This clot was so extensive, 
being fully the size of a seven months’ placenta, that it 
was necessary to remove it piecemeal, and in order to do 
this, a considerably larger quantity of bone had to be 
chiselled away. When the clot had been entirely ex- 
tracted, the space left was large enough to allow the hand 
to sweep downward as far as the orbital plate of the frontal 
bone, and upward to the longitudinal sinus. The brain- 
substance did not expand after the pressure was removed, 
and there was considerable capillary oozing from all that 
portion of the dura underneath the clot. To control 
this the cavity was thoroughly washed out with a hot 
solution of boric acid (gr. x : £j) and afterward filled with 
a 25 per cent, solution of boroglycerid, which was 
allowed to remain. 
At this time the patient’s condition seemed hopeless, 
the pulse being 178 and the heart sounds barely per- 
ceptible. Two large drainage-tubes were introduced into 
the wound ; the scalp was rapidly approximated by means 
of four or five silk sutures, a large antiseptic dressing 
applied, and the girl was put to bed, surrounded with 
hot-water bottles, and a hypodermatic injection of 
strychnin, gr. fa, administered. 
At 3.30 p.m., half an hour after the completion of the 
operation, the pulse was 130, the respiration 34, and the 
temperature 101.40. One hour later the girl opened her 
eyes, recognized her father, and complained of pain. At 
midnight she was perfectly conscious, and passed her 3 
discharges voluntarily. She was given calomel in one- 
tenth-grain doses every half-hour, and strychnin sulfate 
hypodermatically, gr. every third hour, with milk- 
diet, and whiskey in moderate quantities. 
The following day she complained of “ seeing every- 
thing double.” The right pupil was still widely dilated, 
but responded slightly to light. Ptosis of the right lid 
continued. At the end of the second week diplopia had 
disappeared, and the ptosis was markedly improved, 
although the dilatation of the pupil still continued. 
The greater portion of the wound healed by granu- 
lation. The temperature never exceeded 101.4°, and this 
was immediately after operation, and the pulse dropped 
from its highest point—178, during the operation—to 81, 
on the third day, and remained there. 
Then followed an excellent and uninterrupted recovery, 
and the child was discharged cured on September 9th, 
six weeks after operation. On September 15th there was 
still a slight dilatation of the right pupil. The wound 
was entirely healed, with the exception of one small sinus, 
and considerable regeneration of bone had taken place. 
On October 30th the wound had entirely healed, pulsa- 
tion of the brain being distinctly visible over the scalp. 
There are no symptoms at present, except possibly a 
little slowness of mental activity. 
5346 Main Street.