[Reprinted from The Medical News, November io, 1894.] 
ONE CASE OF COMPOUND pEPRESSED FRAC- 
TURE OF THE SKULL AND ONE OF A 
BULLET-WOUND IN THE BRAIN. 
By J. S. TFm/lETT, M.D., 
OF HARRtSdWltLR, '!«>. 
Almost every personal experience should be of in- 
terest to us all, inasmuch as it may clear up some doubt- 
ful point and produce a clear mental picture of what is 
the best treatment in subsequent similar cases; more- 
over, familiarity with similar cases better prepares one to 
undertake measures in their management which one 
would shrink from doing were they few or seldom re- 
ported. Timidity and conservatism in surgery are ac- 
countable for many deaths; especially is this true in 
places remote from the large cities and hospitals. It 
is, however, gratifying to reflect that now these condi- 
tions obtain less than formerly, since antisepticism and 
improved technique are on a scientific basis. It is mainly 
for the purpose of emphasizing the facts alluded to that 
this case is reported. 
On June 13th of the present year, at about 1 o'clock 
p.m., Fred D., eleven years of age, well developed and 
of healthy parentage, on going into the barn was kicked 
on the left side of the head by a mule. His father hear- 
ing the noise, hastened to the barn, lifted up the boy and 
carried him to the house, where I saw him about an hour 
after the inception of the injury. He was then in a semi- 
conscious condition, but would answer questions on 
being aroused; the pupils were of equal size and reacted 
to light. There was no noticeable paralysis, but espe- 2 
cial examination was not made to determine accurately 
as to the e/istence of paralysis or paresis. Inspection 
showed a two-and-one-half inch elliptical scalp-wound, 
one-and-one-half inches to the left of the median line 
and one inch behind the Rolandic region, with its con- 
vexity outward and forward, and a depressed fracture 
of the left parietal bone. The condition of the parts was 
explained to the parents, and operation to relieve the 
pressure advised, which was assented to. It was noticed 
that the symptoms of cerebral compression were increas- 
ing, and on two or three occasions convulsions seemed 
imminent. 
The field was prepared for operation by washing with 
soap and water, then shaving around the wound for two 
or three inches (his hair was very short, having been cut 
on the previous day, and for this reason a larger area was 
not shaved) after which it was washed thoroughly with 
an antiseptic solution. 
Under chloroform-anesthesia the scalp-wound was en- 
larged by carrying the incision toward the median line, 
thus making a flap which could be reflected and the frac- 
ture exposed. The bone was depressed about three- 
eighths of an inch below the external surface of the outer 
table; it was about three-fourths of an inch wide and 
one inch long, and beveled at the expense of the inner 
table. The depressed portion was comminuted and was 
wedged so tightly that it could not be elevated without 
trephining or otherwise enlarging the opening. Bone- 
gnawing-forceps was used in preference to the trephine, 
as less bone would thus be sacrificed. The depressed 
fragments were now loosened and removed; consid- 
erable force was required to separate the bone from 
the dura. The dura was of a bluish-white tint and un- 
injured. Pulsations were perceptible. The sharpened 
edges of the bone were rounded off, the parts thoroughly 
irrigated, a small drain of iodoform-gauze placed in 
the wound, and the scalp-wound closed with interrupted 3 
silk sutures, the ordinary antiseptic dressing applied and 
he boy put to bed in good condition. 
At 7.30 p.m. the temperature was 99.5° and the boy 
was resting well, excepting for a little pain in the head 
and soreness from bruises on other parts of the body, re- 
ceived at the same time as the head-injury. At no time 
during the period of convalescence did the temperature 
rise above 99.5°; it was normal after the first three or 
four days. 
The scalp-wound healed by first intention, and there 
was no suppuration except from a stitch-abscess; the 
drainage-gauze was removed on the second day, but as 
a small quantity of limpid fluid collected each day, a 
small wick of gauze was put in at each daily visitation, 
until June 28th, when the wound was allowed to close. 
Recovery was rapid and uneventful. 
I believe that all depressed skull-bones should be ele- 
vated, and especially if the outer surface of the external 
table is on a level with or below the visceral surface of 
the inner table, even if no symptoms of compression or 
irritation are present; for subsequent trouble, such as 
severe headache, mental hebetude, or even epilepsy 
and insanity, often ensue from the irritation of the 
depressed bone. 
The adage that "misfortunes never come singly'' 
seems to be verified in regard to fractures of the skull 
for this locality-the case just reported being the fourth 
that has come under my observation within the last few 
months. 
The first of these cases, seen in consultation, was 
remarkable, inasmuch as the majority of cases of 
like severity generally prove fatal in a few minutes. 
The patient, a healthy and well-developed man of 
about thirty-five years, was shot about two inches behind 
the left ear with a thirty-eight caliber revolver, on Sep- 
tember 9, 1893, the ball passing a little upward and for- 
ward through the brain, and glancing when it reached 4 
the opposite side of the skull. The man was uncon- 
scious for several hours and semi-conscious for two or 
three days. 
Immediately after the injury the wound in both the 
scalp and the skull was enlarged and fragments of bone 
and foreign objects removed. Search was made for the 
ball, but without avail. The nozzle of a syringe was in- 
troduced along the tract of the ball for the distance of 
six inches, and the parts well irrigated, after which the 
wound was lightly plugged with antiseptic gauze and the 
man put to bed with an ice-cap to his head. 
The shooting occurred early in the morning, and in 
the evening at 9 o'clock another unsuccessful search 
was made for the ball, after which the tract was again 
irrigated and plugged with antiseptic gauze and the ice- 
cap applied. At the time of and before both these 
operations considerable brain-substance escaped; two 
ounces, I think, constitute a low estimate of what was 
lost. 
The parts healed by granulation, and recovery was 
slow but uneventful. No sequelae remained to locate the 
ball, and the only evidence that the brain had been in- 
jured was some impairment of hearing and of visual 
acuteness, both of which gradually improved up to the 
normal or nearly so. 
The man is at present doing manual labor and is in 
perfect health, notwithstanding the fact that he carries a 
bullet somewhere in his skull-cavity, from which he 
suffers no inconvenience.