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.
A British soldier received a wound at the affair of El Boden, in front
of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied
me to Alfaiates, on the retreat of the army. The bone was apparently
only cut through, yet the inner table was depressed, and felt rugged
when examined with the probe. The symptoms of inflammation increasing
on the fourth day, and not being relieved by copious bleeding, I
removed a central portion of the cut bone by one large crown of the
trephine, and took away several small pieces which were sticking into
the dura mater, after which all the symptoms gradually subsided.
266. The whole of the French wounded, who remained on the ground or
were taken prisoners after the battle of Salamanca, were under my
care, and among them there were several severely wounded by sword-cuts
received in the charges of heavy cavalry made by Generals Le Merchant
and Bock. The cerebellum was laid bare in two cases without any
immediate bad effect. In one particular case, which recovered, (after
the battle of Waterloo,) the brain was seen pulsating for several
weeks; and the statements made to me by the different officers at
Brussels and Antwerp, and afterward at Yarmouth and Colchester,
entirely confirmed the observations I had made, and the recommendations
I have inculcated on this particular point as resulting from the
practice of the Peninsular war.
267. It would appear that too much stress is laid upon a difference
which is supposed to exist in the danger of trephining a man on the
first or on the seventh day after an accident; and that an error may be
committed in believing that the trephine is a more dangerous instrument
on the first day than on the seventh. The question is not whether the
man is to be trephined or not, but which will be the best and safest
day or time to do the operation. I do not hesitate to say the first,
believing the violence to be greater when done on parts already in
a state of inflammation, than when they are sound. When the inner
table has pierced the membranes and gone into the brain itself, the
individual will in most cases ultimately die miserably of the accident
if not relieved by art. It is less safe to let him designedly run the
certain risk of cerebral irritation, which when once excited is often
indomitable, than to remove the cause, and endeavor to prevent the
evil. If the cerebral irritation only manifested its effects on the
surface of the dura mater by causing suppuration there, delay might
be admitted; but as it usually gives rise under these circumstances
to the formation of matter on the surface, and even in the substance
of the brain, where it is deadly, “la chirurgie expectante” cannot
be allowed. Lastly, there is not more danger of a hernia cerebri, as
has been supposed, when the operation is done early, than when it is
done at a later period; on the contrary, the patient has a much better
chance of escape from hernia cerebri, and from all other evil, when the
local and the general treatment are decided and efficient.
If, on attempting to remove a fragment buried in the brain, serious
convulsive movements should be excited, it would be proper to desist
from all further attempts to extract the splinters until the brain has
become more quiescent.
It is necessary to recollect that the brain appears to be insensible,
or nearly so, when first exposed; and it has rarely occurred that a
serious convulsion or anything beyond vomiting has taken place on the
removal of a piece of bone from the brain; nor will any difficulty be
found in removing such small fragments as can be seen with a pair of
forceps duly adapted for the purpose. It is impossible to say at what
period of time the brain may become irritable, and no longer admit of
its being touched without convulsive movements ensuing; but when this
state of irritation has commenced, and its existence is proclaimed by
the excitement which takes place on touching the fragment of bone, the
surgeon should at once desist from all attempts to remove the foreign
body. The brain under ordinary circumstances is much more likely to
recover from an injury, all foreign or irritating matters having been
removed, than when suffering from their presence.
268. The establishment of the principles which ought to regulate the
practice of surgery in cases of fracture with depression of the inner
table of the skull, is of the greatest importance. The principle being
laid down that it is right and proper to examine all such wounds with a
blunt, flat probe, in order to ascertain if possible whether the inner
table be depressed and broken, the question necessarily arises, what is
to be done when such depression and breaking down of the inner table
have been ascertained to have taken place? There can be no hesitation
in answering, that in all such cases the trephine should be applied,
although no symptoms should exist, with the view of anticipating them.
The old doctrine, it may be said, in regard to fractures generally, is
revived in these cases, but on a principle with which our predecessors
were not sufficiently acquainted. A patient very often survives a
mere depression of the skull; he may, and occasionally does survive, a
greater depression of the inner than of the outer table; but it has not
been shown that he ever does survive and remain in tolerable health,
after a depression with fracture of the inner table, when portions of
it have been driven into the dura mater. If cases could be advanced of
complete recovery after such injuries, they would not supersede the
practice recommended, unless they were so numerous as to establish
the fact that injuries of the dura mater and brain by pieces of bone
sticking in them are curable without an operation, and without leaving
any serious defects. There are great objections to the trephine being
applied in ordinary cases of fracture, not attended by symptoms of
further mischief; but the nature of the cases particularly referred to
having been ascertained, the practice should be prompt and decisive
in every instance in which the surgeon is satisfied that there is
not merely a slight depression or separation of the inner table, but
that several points of it have been driven into the dura mater. If
one trephine will suffice, the central point being applied close to
the edge of the middle of the wound in the bone, it should be applied
there; but if the cut be longer, and the spiculæ of bone extend upward
and downward in its length, a small trephine should be applied as near
each end as may be judged advisable, and one edge of the cut bone
should be removed by the straight saw, of which Paré and Scultetus made
such use in ancient times, and which Mr. Hey of Leeds revived in modern
surgery; or the small straight saw may be used alone, if the object
of removing a portion of bone can be attained without the trephine.
By these means sufficient room will be obtained to remove the broken
pieces of bone which are irritating the dura mater and brain. The
danger resulting from the application of the trephine, in such cases,
bears no proportion to the risk incurred by leaving the broken portions
of bone as a constant cause of irritation.
269. There is an essential difference between a depression of the
skull in a CHILD and in an ADULT. In the child the inner table is not
brittle--it bends equally and does not break; it very often does little
mischief when depressed, and gradually recovers its level. The brain
in young persons is softer and less consistent, and can accommodate
itself more readily to pressure for a limited time, without ultimate
mischief, than the brain of an adult; so that a continuance of the most
urgent symptoms can alone authorize the application of the trephine in
children, and in young persons under fifteen or sixteen years of age. A
similar bending of the long bones in young children is often observed
at an early period in life.
270. The propriety of dividing the scalp in an adult, in order to
examine the state of the bone beneath, when evidently depressed, thus
rendering a simple although comminuted fracture a compound one, is
a matter of very great importance, the decision of which rests upon
the still more essential point--viz., whether a depressed portion of
bone ought or ought not to be removed? This again must depend upon the
nature and extent of the depression, for many persons who have suffered
from such a misfortune have recovered without the depressed portion
being raised. It is a question of degree or extent, upon which every
surgeon must form a judgment from his own observation and experience.
The difference between a simple and a compound fracture of the leg is
often considerable; it is more often dependent on degree. When the
fracture is nearly transverse, and the skin is cleanly divided, the
difference between it and a simple fracture of the same part is little
more than one of time. This may be the case with an injury of the head;
the difference between the two states in fractures of the skull has,
however, been much exaggerated; so much so, that no reliance can be
placed on the supposition that there is more real danger in a case of
fracture with depression in which the scalp has been divided, than when
it has been only bruised, and not divided. I admit that theoretically
it ought to be otherwise, but theory and practice do not always
correspond. In all cases in which a fracture with _marked_ depression
is known to have occurred in an ADULT, it is good practice to ascertain
the nature and extent of the depression. It is imperatively necessary
if accompanied by symptoms of compression.
If the result of a great number of comparative trials should be in
favor of never, under any circumstances, raising a depressed portion
of bone in an adult, but of leaving it to the efforts of nature, an
incision in order to ascertain the state of parts below ought not to be
made; but as such a result is not likely to be obtained, the practice
recommended appears to be the best.
The scalp should be divided, in such cases as may require the
operation, by a straight, crucial, or such other shaped incision as may
be found most convenient to the surgeon; but no part should be removed
which can be preserved with the hope of maintaining its life.
271. The cranium, together with the fracture and depression, being
exposed, the question whether the trephine should be applied or not is
next to be determined. If the operation by the trephine, or that of
sawing a piece of bone out of the head, were not in itself dangerous,
there could be no hesitation about its use; but it is a dangerous
operation, especially in crowded hospitals, and ought not to be
resorted to when it can be avoided. If any ten healthy persons were
trephined in a hospital, one would in all probability die from the
effects of the operation, and three or four more might have a narrow
escape from the inflammation of the brain and its membranes, or the
other consequences which would probably ensue. It is not the admission
of air, which has been even lately supposed to do mischief, that is
to be dreaded in these cases, but the same kind of irritation which
often follows the abstraction of a piece of bone under other and more
ordinary circumstances at a later period of time.