after a short deliberation, to perform a Csesarian section in preference to any operation for break- ing up the child.
Preparations were at once made, and the operation carried out in the usual way. The uterus was opened by a longitudinal incision along its interior a^pect. The placenta was met with first and was torn through. A dead foetus was then extracted.
The uterus was douched with 1 in 2,000 per- chloride of mercury lotion and sutured. No blood-vessels were ligatured. On taking off the elastic ligature from the cervix some oozing took place, but this soon stopped on the application of pressure. I should have said that a hypodermic injection of adrenalin chloride, as well as one of ergotin, were given before the operation, and the former repeated during it. Extremely little blood was lost, and not a single ligature was applied to a blood-vessel throughout the opera- tion. This effect, I imagine, was in some degree due to the above-mentioned doses. The woman progressed favorably from the day of operation, and beyond a little suppuration at the site of one of the sutures, there was nothing to retard recovery. She was discharged well on the 22nd September 1903.
CASE OF DEPRESSED FRACTURE OF THE SKULL: OPERATION, RECOVERY.
By H. MARTIN NEWTON,
CHURCH OF SCOTLAND,
Earm Dai, three years of age, was admitted to hospital, on Mawh 18th, with the history of having five days previously fallen a distance of 15 feet. The patient was in a semi-comatose condition, and had been so since the accident. She was fretful on being handled. Examination showed a depressed fracture of the right parietal bone just above and a little to the back of the ear; from tbere a line of fracture could be made out running forwards almost to the root of the nose. At this latter point was a small soft pulsating swelling. The pupils were somewhat dilated and there was extensive extravasation of blood in the right orbit. Breathing was regular. Pulse quick. Right arm was kept still, though no sign of bruising. No paralysis of the left side. Bladder and rectum unaffected.
l%th — Operation. —Two large flaps were made, with the purpose of avoiding the anterior or posterior temporal arteries. Thus very nearly the whole length of the fracture was exposed, a fracture five inches in length.
Over the parietal bone was a cone-shaped depression ; of only a small part, however, was the continuity of the bone broken. Passing forwards was a gaping fracture, being at its widest, very nearly quarter of an inch. At this
point the dura was torn to the extent of two inches^ and brain substance was protruding. The depression was dealt with by means of ^ mastoid trephine. Three holes had to be bored, the last being at the apex of the cone, before the bone could be kept in position ; since every time it was raised, it would spring back again.
The hernia was then dealt with. On pressing this gently back, a large quantity of blood escaped from the temporal region. The pressure thus being relieved, the brain substance slipped back into its normal position. Owing to the extensive laceration it was found impossible to stitch the dura.
The bones had to be left as they were, since with gentle pressure it was found that they would not meet. An undue force was not deemed advisable. The flaps were brought together, and firm pressure applied, and thus a reappearance of the hernia prevented.
\9ih, — No marked change in condition. Pupils dilated. Pulse 180. Breathing 29. Restless, and dies on being touched. The eyelids ^re closed. Moves the left arm, but not the right. Urine and motions normal.
2l8^. — Condition much better. Pulse 114. Respiration 24. Breathing easy and regular.
227id. — Improving. Is beginning to take notice of her surroundings. Pupils are normal. Pulse 112. Respiration 20. No attempt at speaking.
24//i. — Return of consciousness is more marked. 2bth. — Much brighter to-day. Has laughed, but still no attempt at speech.
Qih Api'il. — Has b^ea improving steadily during the last few days. The wound has healed. Over the frontal bones, the line of fracture can still be made out, but there is no swelling, nor any sign of pulsation. She now understands when spoken to, but cannot reply, although she can make a few sounds. She is able to use her ri(^ht arm slightly. Points to her head and arm if asked where hurt. Was taken home to-day.
Wth. — Was brought t^ hospital. Can now say a few words. She also tries to sit up. Under- stands everything quite readily. A small portion of the fracture can still be made out.
12^A May, — Today she walked routd the hospital with me. Speech quite restored ; so too use of aim. Line of fracture perceptible.
Remarks. — Operation five days after accident. Consciousness began to return on the eleventh day after accident. Aphasia was the chief and most persistent symptom. Note that the escape of blood was from temporal region, and extra- vasation to the right eye. In this case the nH>tor areas of arm and leg were only slightly affected. The paralysis of the right arm was no doubt due to injury of the arm itself.
One has come across fatal cases in which no > operation has been attempted.^ This^ cas^is^
