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cavity. In one case we have seen the ball escape in the roof of the mouth, and in another case be buried in the labyrinth of the ear, without producing a fatal result ; but in neither case did it enter the cranial cavity. To complete the technique, if the vessels cannot be readily caught, the cavity can be well packed with gauze and the edges of the wound sutured after twenty- four or forty- eight hours, or partly sutured at the time, and the gauze removed after twenty- four hours, and then the sutures completed or not according to the amount of discharge. Over all put a full dressing and good firm bandage. A drainage tube will seldom be necessary, and if used should not come in contact with the brain it- self. The sinuses sometimes give trouble from hemor- rhage, but gauze packing and good compression generally suffice to control it. In ordinary cases when a light gauze drain is used — and we are not prepared to commend its omission — the case is redressed in four days, the drain left out and then not redressed for six days unless the dressings become loose. After this a very simple dressing suffices and the patient gets about, going home in two or three days more. In private practice this period Cheap Crestor of confinement to bed would hardly be less than a fortnight and to the house another week. A direct examination of the cases reported shows that six were fatal, and of these all but one had a fracture of the base, and this exception had an extensive fracture What Is Rosuvastatin with considerable loss of bone substance (a loss increased by the use of the trephine) followed by a large hernia cere- bri. My own fatal case was in extremis when admitted. In none of the cases did the operation for relief of the depression have any relation to the fatal termination, and in a fair number of the favorable cases serious danger or death was inevitable without an operation. The trephine was only used in Cases X., an impacted foreign body, XV., for no reason apparently, XXIII., a linear fracture with suspected blood- clot and compression, and XL., where probably a conoidal piece had been driven in by an ice-pick ; but in Cases VIII. and XVIII. the chisel was sufficient; indeed, it is but right to protest here again against the use of the trephine for depression, unless it is impossible to elevate with the chisel and Crestor Price ele- vator. In fifteen cases the symptoms were noted as being absent, and it is not unlikely that such was true of several others. In Case XXXIII. the symptoms of compression were present, but no Atorvastatin Rosuvastatin compression was found. The ages varied from two and one half to fifty- seven years. Anaesthesia was not used in six cases ; cocaine was used in one case and ether was used in the remainder. Resume. Fatal Cases. — Operator, Harris. Case VII., aged twenty one. Fracture base. Fell four stories. Probable laceration brain. Large piece of bone removed. Operator, Stimson. Case XIV., aged twenty. Fract- ure base. Operator, Wilkin. Case XV., aged twenty. Exten- sive fracture and loss of bone substance ; hernia cerebri. Operator, Cole. Case XIX., aged fifty-seven. Fract- ure base ; laceration brain ; intra-cranial hemorrhage ; rapidly fatal. Operator, Crofton. Case XXIX., aged twenty-eight. Fracture base. Operator, Manning. Case XXXIX., aged forty-eight. Probably fractured into base and compressed by blood- clot. Trephine. — Operator, Stimson. Case X., aged fifty. Impacted foreign body. Operator, Wilkin. Case XV., aged twenty. Extensive depression ; but could have been relieved by chisel elevator with less loss of bone. Operator, Hancock. Case XXXIII. Linear fracture ; supposed clot ; none found. Operator, Manning. Case XL., aged twenty- four. Probably conoidal piece depressed ; but compare VIII. and XVIII., where the chisel was efficient. Symptoms. — Noted as entirely absent in fifteen cases. December i6, 1893] MEDICAL RECORD. 779 thirty-seven and one-half per cent. Present but no com- pression found in one case (XXXIII.). Operators, Kimball, I.; Harris, II., III., IV., V., VI., VII., VIII.; Southworth, IX.; Stimson, X., XL, XIV.; Harvey, XII., XIII., XXI.; Wilkin, XV.; Cole, XVI., XVII., XVIIL, XIX., XX., XXL, XXIL, XXXIL; Hancock. XXIII. , XXIV., XXXIII.; Wells, XXV., XXVI. , XXVII., XXVIII.; Crofton, XXIX., XXXIV., XXXV.; Proctor, XXX.; Van Rensselaer, XXXVI.. XXXVIL, XXXVIIL; Manning, XXXIX., XV. The fact that the same general result obtained for thir- teen operators would indicate the general applicability of the practice. Of the whole number, if we exclude of the fatal cases those inevitably so under any form of treatment, we have a single fatal case (XV.), and it is hardly fair to say that this was the result of the operation, though it would certainly have been much more rapidly so without operation. On the other hand, of the thirty-four remain- ing cases, at least one-fourth would in all probability have proved fatal without operative measures, and one half, if not a much larger proportion, would have been followed by disastrous secondary troubles. Of the cases reported, all but one were depressed, and in this case the symptoms of compression were present. I have purposely omitted the linear fractures without depression, in which our rule was to explore and then treat as a simple scalp Purchase Crestor Online wound ; of these, not a single one gave any after trouble. Likewise, I have not reported the suicidal penetrating pistol-shot wounds of the vault, every one of which has proved rapidly fatal, with or without operative measures. If I have demonstrated the value of an immediate and accurate determination, by an incision, if necessary, Crestor Tablets of the variety and extent of the lesion in injuries to the vault of the cranium ; of the necessity for their immediate relief by the use of the chisel and elevator ; of the facility of the steps and of the easy technique of such procedures, I shall, at least, hope that my Crestor Mg efforts have not been mis- spent. Depressed Fractures of the Skull From August 23, 1888 to January 1, 1892.— Case I.-— Operator, Kimball. Josephine D , aged eight. Admitted August 23, 1888. Lacerated wound three fourths inch long, just be- low right parietal eminence. Triangular piece depressed ; size finger-nail. No symptoms. Operation, August 24th. — Ether. Depressed bone, one-fourth inch, re- moved. Chisel. Several small pieces removed. Inter- rupted sutures Catgut drain. September 2d. — Re- dressed ; drain removed. September 13th.— Cured. Case II. — Operator, Harris. Richard O'M , aged thirty ; married ; Ireland ; longshoreman. Admitted October 5 , 1888. Struck Order Crestor with iron in right parietal frontal region. Semi conscious, slight but increasing pa- ralysis left arm, and convulsive movements left side of face ; speech thick and indistinct. Respiration, pupils, pulse, normal. Ether. Depression nearly one inch ; four pieces bone, pyramidal. Depressed area bounded anteriorly by coronal suture ; inferiorly, one- fourth inch above parietal suture. Lower border, two and one half inches ; superior border convex and parallel to temporal ridge and at highest point one half inch above. Curves backward Crestor Cost and downward and joins lower line at a point about two and one-half inches above, and one and one- half inch posteriorly to, external auditory meatus. Dis- tance between inside points of superior and inferior bor- ders is about two and three-fourths inches. Rongeur ; inner table more extensively fractured than outer ; small pieces of bones removed : rubber drain. Iodoform and bichloride dressing. Pulse quick and strong. Respira- tion bad. October 9th. — Redressed ; drain removed. October 1 6th. — Redressed. October 20th. — Put in small drain. October 28th. — Drain removed. November 5th. — Cured. Case III. — Operator, Harris. Patrick McA , aged twenty-five ; single ; 'longshoreman. Admitted Octo- ber 27, 1888. Walked in. Struck with water pitcher night before. Lacerated wound about one inch front of fronto parietal suture, two inches to left median line. Depression one-fourth inch. Operation, ether (after twelve hours) ; washed, shaved, etc. ; chisel ; elevator. Dura uninjured ; small pieces removed ; rest elevated ; rubber drain. October 29th. — Tube removed Rosuvastatin Calcium ; horse- hair inserted. November 4th. — Redressed ; drain short- ened. November 8th. — Drain shortened. November 9th. — Drain removed. November loth. — Cured. Case IV. — Operator, Harris. John S , aged thirty- four; single; Ireland; 'longshoreman. Walked in to Dispensary November 21, 1888. Struck by block one and a half hour before. Lacerated wound in anterior Buy Crestor Online superior parietal region. Circular depressed fracture, cone-shaped. Operation: No ansesthesia; chisel, ron- geur, elevator. Loose and depressed fragments removed ; dura uninjured ; catgut drain. November 23d. — Re- dressed. November 30th. — Drain removed. December 3d. — Cured. Case V. — Operator, Harris. Cornelius G , aged forty- two; single; Buy Crestor Germany; clerk. Admitted Novem- ber 27, 1888. Brought in ; fell down stone steps ; small Rosuvastatin 10 Mg lacerated wound on post- inferior part of right Generic Crestor pjarietal bone. November 28th, ether. Elliptical depression one and one-half inches ; Crestor Online anterior part one inch deep; chisel, elevator ; and large piece of bone of outer table removed. Diploe bled extensively ; internal table removed over corresponding area ; dura uninjured ; rubber tube ; peri- osteum and scalp separately sutured. November 30th. — Redressed; removed tube. December 3d. — Redressed. December Sth. — Cured. C.^iSE VI. — Operator, Harris. Nicholas P , aged twenty six ; single; Italy. Admitted January 2, 1889. Shot with 38 calibre pistol, one inch above orbital, one and three quarter inch from median line; second wound one and a half inch further up. Operation : Cocaine. Piece one inch long, three-quarters inch at base, removed ; dura lacerated ; silk sutures : considerable hemorrhage ; compression. January 5th. — Redressed ; rubber drain down to dura. January loth. — Redressed ; drain re- Buy Cheap Crestor moved. January iSth. — Discharged, cured. Case VII. — Operator, Harris. Harry T , aged twenty-one ; single ; United States ; painter. Brought in January 18, 1889, 6.25 p.m. Fell four stories through elevator shaft. Hematoma over posterior portion of right parietal region. Superficial scalp wound. No fracture can be made out ; perfectly conscious. Head shaved and dressed bichloride. May 9th, 10 a.m. — Purchase Crestor Patient slightly delirious, but pupils are regular, of normal size. 3 p.m., .exploratory incision because of the delirium recurring at intervals ; cocaine. Large area depressed bone involving post-superior part of right parietal bone, extending one- half inch beyond suture on left ; below bounded by lambdoidal suture two and one-half inches long vertically. Two pieces, the upper one inch square, loose, and re- moved, lower one elevated and left. Thick clot be- tween skull and dura. Deep parts affixed with catgut, and another Order Crestor Online line used for scalp; rubber drain. January i9th.^ — Plaster Paris bandages Rosuvastatin 10 to keep on dressings at night because of delirium. January 20th. — Noisy and

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