Part 33
A counter-fracture or fissure of one parietal or temporal bone, caused by a blow on the opposite one, is of such rare occurrence that it is in general unnoticed by later writers on injuries of the head. It is not so, however, with respect to a fracture at the base of the cranium from a blow on the vertex, or on the back part of the head--a kind of accident which occurs more frequently perhaps than any other in civil life--because persons who suffer from fractures of the skull do so more generally by falling from a height, or from being pitched on their heads, than by direct blows or other injuries. This accident principally depends on the superincumbent weight of the body pressing on the unsupported flat and thin base of the skull, and is but little connected with the unyielding nature of the spine; for it occurs to as great an extent in consequence of falls from a short distance without any impetus, as from falls from a great height. Some of the worst cases take place by the sufferer having been thrown from the back of a horse by the sudden starting of the animal, without any running away. Although in these cases a fissure may often be traced to the foramen magnum, the great fracture is essentially distinct, extending from the petrous portion of the temporal bone on each side, across, and between the sphenoid bone and the os frontis, and even separating the edges of the coronal suture nearly to the opposite side.
A noted gambler was thrown from his horse, and pitched on the top of his head at the door of the Westminster Hospital, late at night; he was taken up insensible, and died shortly afterward. The skull was fractured quite round from the vertex to the base, and from side to side, so that the fore and back parts might have been easily separated into halves, if the soft parts had been removed. Fractures of the base of the cranium are generally fatal, but not always so; for some persons live a considerable time afterward, and appear to die from other causes; so that partial, if not perfect recovery is possible.
H. Cochrane, forty-five years of age, fell a distance of twenty feet upon his head, and was taken up apparently lifeless, bleeding largely from the ears, nose, and mouth, but more particularly from the ears. He was seen within half an hour of the accident. He was then quite insensible; the surface of the body cold; pulse about 68, and very feeble; in three hours after the accident he was bled to sixteen ounces, when his pulse rose to 76, and the breathing, which before was rather oppressed, became more free. He was ordered six grains of calomel, followed by moderate doses of senna, till the bowels should be relieved.
He continued progressively mending, but in a state of stupidity, accompanied by extreme listlessness; answered questions sullenly, and frequently rested upon one arm without appearing conscious of pain; the mouth was drawn to the left side, to which there had been a slight tendency for some days; the tongue not at all affected.
He continued under treatment for three weeks longer, soon after which he was permitted to resume his employment, the mouth being still drawn in some degree to the left side. His habits became silent and solitary, but he performed his task with the greatest exactness. He was occasionally subject to vertigo, particularly in hot weather, after any violent exertion or taking a small quantity of beer; a pint of ale would render him stupid or insensible. Six months afterward he was found dead, lying in a ditch.
_Sectio cadaveris._--The nasal bones were fractured by a blow which had made a transverse incision in the upper part of the face. The femur was found fractured upon the right side, and the scalp puffy and ecchymosed on the left. On removing the skull-cap, the dura mater appeared perfectly healthy, without any sign of extravasated blood upon the surface. Beneath the pia mater on the left side the sulci of the brain were filled with black blood, apparently very recently effused. The brain was removed without the least violence, when a lesion was found upon its inferior surface, corresponding to the petrous portion of the right temporal bone. The dura mater in this situation was externally of its natural structure, and adhered with its usual degree of firmness to the bone beneath. The arachnoid and pia mater were here deficient; the lesion consisted of a cavity about fifteen lines in length, nine in breadth, and three in depth, coated with a light-yellow lining, which also adhered to the corresponding portion of the inner surface of the dura mater, which completed the walls of the cavity inferiorly; it contained a turbid serum, in which were seen floating numerous but exceedingly minute white globules. The portion of the brain in this situation did not appear to have been disturbed by the recent violence, except that from the upper part of the cavity a probe was admitted without any resistance into the descending horn of the right lateral ventricle, which, with the one on the opposite side, was filled with a large quantity of bloody serum, none of which, however, had escaped into the cavity beneath. The brain generally appeared perfectly healthy, and not more vascular than usual. Even within a line of the yellow deposit above mentioned there appeared not the slightest change of structure. On removing the dura mater from the base of the skull, indications of a former fracture were discovered, leading vertically down through the squamous portion of the temporal bone, whence it appeared to have been continued along the anterior part of the petrous portion into the Vidian canal; the edges of this fracture, both internally and externally, had been rounded by absorption; it was met at right angles by another which ran across the base of the petrous portion of the temporal bone. The direction of the last fracture was marked by numerous small, rough particles of bone, which adhered so slightly to the rest that they separated on maceration. The transverse ligament of the second vertebra was ruptured, and the atlas forced forward. The connection between the articular processes of the second and third cervical vertebræ on the right side had also been separated by the fall which had caused death.
William Clayton, forty-four years of age, was admitted on the 31st of July, 1841, into the Westminster Hospital, having received a blow on the RIGHT side of his head from the handle of a windlass, by which his skull was fractured. The fracture extended downward from the parietal bone across the temporal, and in all probability through its petrous portion, as blood flowed freely from the ear for the first six hours; he was stunned for a few minutes at first, but became sensible by the time he was brought to the hospital. The bleeding from the ear was followed by the discharge of a fluid resembling water--which is a very dangerous symptom, as it usually flows from the sac of the arachnoid membrane--and afterward at intervals by a discharge of blood and matter, particularly, he said, on coughing; he was also quite deaf, with a little pain on the right side of the head. The bowels were well opened, and he lost sixteen ounces of blood. On the evening of the third of August, the fourth day after the accident, paralysis of the muscles of the RIGHT side of the face supplied by the portio dura came on, or was first observed. Pulse 80. He was well purged, but lost no blood, as he was apparently weak and the pulse soft; it fell next day to 72. Mercury was now administered twice a day until the mouth became sore. On the eighteenth of September he was discharged, cured of the paralysis, the wound on the head being open, and a piece of bone bare and likely to exfoliate. October 8. Readmitted in consequence of great headache after drunkenness, with numbness of the toes and fingers; he was well purged, and felt relieved. He remained in the hospital for a month, his mouth being again slightly affected, occasionally drinking in spite of all remonstrance; he then returned to his work on the piers of Westminster bridge. On the eighth of June several small pieces of bone came away; and the wound nearly healed. The course of the fracture can be traced, in consequence of the scalp having adhered to the bone, causing a slight depression and hardness, which can be felt by the finger, extending down to the ear.
An hostler was thrown on his head from a horse, and was carried to the Westminster Hospital late at night in a state of stupefaction; no other injury could be discovered. The next morning he could answer questions, although not always correctly; complained of pain in his head, had bled from the ears all night, and had vomited some blood two or three times. Pupils dilated, but they contracted on bringing a lighted candle near them; the left eyelid more open than the right; pulse 52; very restless, and constantly turning in bed. V. S. ad ℥xxiv. Calomel and colocynth: salts and senna. Cold to the head. The pulse rose to 60 after the loss of blood. 2d day. Is delirious; bleeding from the ears but trifling; complains of pain in the head; bowels open; passes urine freely; pulse 54, a little irregular. Y. S. ad ℥xvj gave relief. Continue calomel, and salts and senna. 3d day. Restless all night; headache and thirst; bowels open. V. S. ad ℥xiv relieved the pain in the head. Pulse 56. 4th day. Restless and delirious at night; pulse 60, regular; bowels open; headache. V. S. ad ℥xiv. No discharge from the ears. 6th day. Slightly paralytic on the left side of the face, tongue drawn to that side; headache, restless, delirious; feces and urine passed unconsciously; pulse 80. V. S. ad ℥xx. Pulse rose to 100, and was weaker. Calomel, gr. iii every six hours. 7th day. Pulse 88, compressible; restless at all times, delirious at night; bowels open, but he is more conscious of everything. 8th day. Pulse 80, small, intermitting; occasionally slept a little, and is generally better; bowels well purged; paralysis of the face continues. Has taken a little farinaceous food. Continue calomel and inf. sennæ. 10th day. Improved; slept tolerably well. 12th day. Continues to improve. Omit the calomel, but continue the infus. sennæ. 16th day. Is better. Paralysis lessened. Recollects he was thrown from a horse, but nothing else. Is free from pain, but very weak. Mouth a little sore.
After this time he gradually recovered, but was for a long time unable to work, or to undergo any exposure. A very little more mischief, and he would have gradually sunk, and died after the seventh day, instead of slowly recovering.
LECTURE XVIII.
INJURIES OF THE HEAD.
262. A fracture of the inner or vitreous table of the skull, as it has been termed from its peculiar brittleness, as opposed to the greater toughness of the outer, is a rare occurrence without some signs of depression or fracture of the outer table, or detachment of the pericranium.
Mr. S. Cooper says: “One case of this kind, attended with urgent symptoms of compression, I trephined at Brussels. A large splinter of the inner table was driven more than an inch into the brain, and on its extraction the patient’s senses and power of voluntary motion instantly returned. The part of the skull to which the trephine was applied did not indicate externally any depression, although the external table came away in the hollow of the trephine, leaving the inner table behind.”
The records of eighteen centuries have produced but little information on this most interesting subject: and if the cases were collected which have been overlooked by authors, as well as those which have been altogether omitted, little would be gained; it may be concluded, therefore, that although such things have happened, they are of rare occurrence. I have never, in the great number of broken heads I have had under my care on many different and grand occasions, actually known the inner table to be separated from the outer, without positive marks of an injury having been inflicted on the bone or pericranium. Although it is not possible to doubt the fact of fracture of the inner table having occurred, without apparent injury to the outer, it is very desirable in a practical point of view not to bear it too strongly in mind; for if a surgeon should be prepossessed with the idea that the inner table may be so readily fractured and separated from the diploe placed between it and the outer table, and thus cause irritation or pressure on the brain, few persons who had received a knock on the head, followed by any serious symptoms, without fracture or depression, would escape the trephine, and the worst practice would be again established. An operation should never be performed under the expectation that such an accident may have happened, unless it be apparently required by the urgency of the symptoms indicating compression or irritation of the brain, which cannot be relieved by other means, and are about to prove fatal.
It is by no means intended to imply by these remarks that a blow on the head will not frequently detach the dura mater from the inner table by rupturing its vessels, and thus give rise to compression or irritation of the brain from the effusion of blood or the formation of matter; or that the inner table may not from the same cause become diseased, and thus lead to ulterior mischief; but these are altogether different states of injury, and require a different consideration.
Mr. Deane, of Chatteris, in Cambridgeshire, had occasion to examine the head of a young man after death from a blow on the left side, just below the parietal protuberance, there being only a _slight detachment_ of the pericranium, but no fracture. On removing the skull-cap, a very distinct fracture of the inner table, about three-quarters of an inch long, was seen corresponding to the external part injured, extending outwardly as far as the diploe, but no farther. The dura mater adhered firmly everywhere, except at this part, and for some distance around, a quantity of fluid blood being interposed between it and the bone. If this man had outlived the first symptoms, he would not, in all probability, have recovered without an operation for the removal of the extravasated blood.
263. Severe effects do not always take place in such cases in the course of the first treatment, but occur afterward; or the unfavorable symptoms, never having been entirely removed, increase so much at a later period as to render the aid of operative surgery necessary for the removal of the bone, in order to save life.
M. A. Farnham, aged twenty-three, a stout, healthy-looking girl, received a blow, two years before, from a stone falling from a door-way under which she was passing; it struck her upon the left side of the head at a spot an inch anterior to the parietal prominence, the weight of the stone and the space through which it fell making the estimated force with which it struck the head equal to sixteen pounds. The immediate effect of the blow was insensibility, followed by acute fixed pain in the head, which has ever since continued to mark the seat of injury. A week after the receipt of the blow she began to lose the power of moving the right arm, there being, however, no loss of sensation or any disturbance of the cerebral functions.
During the following twelve mouths the symptoms remained unchanged; this period was spent in several London hospitals; not having derived any relief while in any of these institutions, she became an out-patient of the Westminster Hospital.
The arm and leg of the right side were quite paralytic, the former, which had previously been flaccid, having now become remarkably rigid, its temperature being below that of the opposite side; vision, particularly of the left eye, imperfect, the pupils, however, acting naturally; hearing on that side also affected; memory bad; respiration frequently slow and almost stertorous; the countenance had assumed a dull, heavy expression, and she manifested an unusual tendency to sleep.
April 1st, 1841.--Mr. Guthrie this day removed a disk of bone from the exact point in the parietal region to which she referred the pain. The portion of bone presented no evidence of disease; its thickness varied from two and a half to four lines, the latter measurement corresponding to the part most distant from the sagittal suture; the vessels of the diploe bled freely, the dura mater was quite healthy, and without any very evident motion.
On visiting her _an hour_ after the operation, she raised the previously paralytic arm several inches from the bed, and was able to bend and extend the fingers. The pain in the head was considerably less, and her countenance, before dull and heavy, was now remarkably animated. Sensation had returned in the arm, and partially in the leg. Her pulse was calm, and the skin cool.
Ten hours after the operation she was attacked with rigors, followed by pyrexia and all the symptoms of commencing inflammation of the brain. By the immediate abstraction of blood, which was three times repeated during the succeeding twelve hours, whenever the pain in the head or the force of the circulation increased, every bad symptom was removed. In the course of three days the paralysis had completely disappeared, sight and hearing again became perfect, and after passing through a speedy convalescence, she quitted the hospital completely recovered.
She has since had some relapses of pain and uneasiness in the head, but is altogether a different person, although of a very hysterical temperament. The cicatrix on the head is firm, and she considers herself to have been cured by the operation.
264. The inner table is sometimes broken in a peculiar manner, and to this attention was first drawn in my lectures, since trepanning has ceased to be the rule of practice in all cases of fractures. It occurs from the blow of a sword, hatchet, or other clean-cutting instrument, which strikes the head perpendicularly, and makes one clean cut through the scalp and skull into the brain. This kind of cut is usually considered as a mere solution of continuity, and not as a fracture, the bone being apparently only divided, with scarcely any crack or fissure extending beyond the part actually penetrated by the instrument. When the outer table alone has been divided, the wound in the scalp should be treated as a simple incised one, and united as quickly as possible, a practice of which I have seen several successful instances. When the instrument even penetrates to the diploe, the same course should be pursued; for although the external wound may not unite by the adhesive process, and some small exfoliations may occur, it is not common for serious consequences to ensue under that strictly antiphlogistic plan of treatment to which all persons with such injuries should be subjected.
265. When the sword or ax has penetrated the inner table, the case is of a much more serious nature; for this part will be broken almost always to a greater extent than the outer table. It may be separated from it, and driven into the membranes, if not into the substance of the brain itself, the surface of the bone showing merely a separation of the edges of the cut made into it. These cases should all be examined carefully. The length of the wound on the top, or side, or any part of the head which is curved and not flat, will readily show to what depth the sword or ax has penetrated. A blunt or flat-ended probe should in such cases be carefully passed into the wound, and being gently pressed against one of the cut edges of the bone, its thickness may be measured, and the presence or absence of the inner table may thus be ascertained. If it should be separated from the diploe, the continued but careful insertion of the probe will detect it deeper in the wound. A further careful investigation will show the extent in length of this separation, although not in width; and will in all probability satisfy the surgeon that those portions of bone which have thus been broken and driven in are sticking in or irritating the brain. In many such cases there has not been more than a momentary stunning felt by the patient; he says he is free from symptoms, that he is not much hurt, and is satisfied he shall be well in a few days.
An officer was struck on the head, in Halifax, Nova Scotia, by a drunken workman with a tomahawk, or small Indian hatchet, which made a perpendicular cut into his left parietal bone, and knocked him down. As he soon recovered from the blow, and suffered nothing but the ordinary symptoms of a common wound of the head with fracture, it was considered to be a favorable case, and was treated simply, although with sufficient precaution. He sat up, and shaved himself until the fourteenth day, when he observed that the corner of his mouth on the opposite side to that on which he had been wounded was fixed, and the other drawn aside; and that he had not the free use of the right arm so as to enable him to shave. He was bled largely, but the symptoms increased until he lost the use of the right side, became comatose, and died. On examination, the inner table was found broken, separated from the diploe, and driven through the membranes into the brain, which was at that part soft, yellow, and in a state of suppuration.
Mr. B., of the 29th Regiment, when in Halifax, Nova Scotia, was struck, in a drunken frolic, on the anterior part of the left parietal bone, with his own sword, which was a straight, heavy one, and a wound about two inches long was made in the side of his head through the bone. His little finger was cut at the same time, and it was not until the finger had been dressed that I was asked to look at the head, which he declared had nothing the matter with it. He was vomited, and purged, and the next morning bled, and as symptoms of inflammation of the membranes of the brain came on or increased, the bleedings were repeated, the quantity taken at each time being gradually diminished. He lost 250 ounces of blood in five days, after which he gradually although slowly recovered, some small spiculæ of bone coming away during the cure. Returning to England, the vessel was taken off the Scilly Islands, and he was sent to Verdun, where he remained several years, until liberated by the peace of 1814, when he rejoined his regiment, which had served in the Peninsula, and had returned to North America. It was soon found that he became outrageous on drinking a very little wine, and was odd in his manner, and had a great propensity to set out walking for hours without apparently knowing what he was about, or where he was going. When his regiment came immediately in front of the enemy, he was found going over to their lines, without being aware of what he was doing; and he was at last obliged to be sent to England, having evidently become deranged. This gentleman has ever since been confined in a private mad-house. His brother offered to allow the bone to be removed; but after thirty years of derangement a recovery could not be expected, and it was declined. If the examination I have since learned to be proper in such cases, had been made at the time, the inner table of the bone would have been found broken and depressed; and he might now have been in health both of mind and body.
I removed, in Lisbon, in the hospital appropriated to the wounded French prisoners in 1812, a portion of bone by the trephine, which had been fractured by a sword some months before: the wound had not healed, and some pieces of bone were depressed. One piece, in particular, of the inner table, was sticking in and irritating the dura mater, and was in all probability the immediate cause of the fits from which the patient had been suffering. He recovered.