Suspected Fracture of the Base of the Skull, attended with peculiar pathological phenomena

R P Thomas
1861 American Journal of the Medical Sciences  
College of Physicians of Philadelphia. 121 the jejunum, there was a patch of redness with several erosions. Peyer's patches seemed somewhat thickened, and stained deep grayish-brown. Here and there in the small intestines were patches of a yellow deposit. All along the large intestine the nmcons membrane was studded with small dark round spots, very much like the deposit in the patches already men¬ tioned ; they corresponded to the solitary glands, and made the membrane resemble a leopard's
more » ... ble a leopard's skin. No other change in the large intestine. Suspected Fracture of the Base of the Skull, attended with peculiar pathological phenomena.-Dr. R. P. Thomas read the following report:-Michael-, aged 27, was admitted into the surgical ward of the Epis¬ copal Hospital, July 27th, I860. While in a state of partial intoxication, he pitched head-long down one of the chutes on the Richmond coal wharves, a distance of eight or ten feet, and fell upon the-right malar and temporal bones. He was taken immediately to the hospital. Upon examination the ramus of the right lower jaw was found broken about midway between the angle and the condyle. There was severe contusion of the right antero¬ lateral part of the head, but no fracture of the bone in that region, and but little laceration of the soft parts. Blood flowed freely from the nostrils and both ears. There had been vomiting prior to admission. The patient was almost unconscious; the face covered with a clammy sweat; the pulse 1)0, feeble; and the skin cold. Both pupils dilated, though unequally; the right eye was open, the left closed. Diagnosis.-Concussion of the brain, with a probable fracture of the base of the skull towards the left side from the contrecoup. To sustain the sinking powers, small portions of milk punch were cautiously administered from time to time for the first few hours. Reaction took place; the pulse became fuller and stronger, and the skin warm, but the intellect remained obtuse. When the reaction was established, a mixture containing one-fourth of a grain of sulphate of morphia, and three grains of extract of conium was administered every four hours with a view of controlling the brain, and preventing the development of excitement, or delirium. This plan, with beef tea as nourishment, was continued for three days, all alcoholic stimulus being avoided. At the expiration of the period named, the patient had the control of his sphincters, and could answer questions rationally, but could neither open nor close his eyes. The oozing of blood from the ears had nearly ceased, and the dilatation of the pupils was not so great. Their inequality, however, was still manifest. Improvement in all the symptoms occurred ; the fracture of the lower jaw united, and at the end of six weeks he was permitted to walk about the ward. At the present time his appetite is excellent; he sleeps all night; is entirely free from pain ; and his general condition is good. Unring the progress of convalescence, some singular phenomena have been manifested, which afford a pathological confirmation of the correctness of the usual anatomical descriptions of the distribution of the nerves of the face and the eyeball. The blow that fractured the ramus on the right side, paralyzed the portio dura nerve where it passed over the jaw, as evidenced by the drawing of the mouth to the left when he laughs, by the flat and expressionless aspect of the right cheek, and his inability to close the right eyelid, which is supplied by this nerve. The right eyelid never has been closed since the time of the accident. The injury to the portio dura must have been external, because the parts supplied by its branches, arising posterior to the ramus of the jaw, are not paralyzed. It is not probable that any internal injury involv-
doi:10.1097/00000441-186101000-00018 fatcat:n6babrvrpbeclkhggbg5cj5eni