jured the parts beneath ; consequently, insjiection of the sujierflcial
wound gives no real idea as to the harm that may have been done un-
derneath. A second form of injury to the brain is by splinters or frag-
ments from the fractured area, whose sharp borders or corners may cut
into or otherwise injure the membranes or the cortex. Inasmuch as
we have seen that the internal table is often splintered without
external evidence, we see how frequently this kind of injury may hap-
pen. Finallv, a third form of injury may be produced by the absolute
separation of bone-fragments and tlicir ])cnctratioii into tlie Iirain be-
neath. Experience has shown that almost without exception those frac-
tures which occur with injury to the lirain jiroduce more or less bleeding
between the bone and the dura. Pick' found that of 13 patients dying
of depressed fracture of the skull, 9 showed injuries to the brain, and 3
extravasations inside the membranes, while 1 showed an extradural clot.
These extravasations of course cause diminution of the cranial cavity,
and consequent pressure upon the brain, to which most of the serious
consequences arc to be directly ascribed.
Surgeons have for a long time discussed which was the more serious
— pressure from dcjn-essed bone or from effused blood. The experience
of to-day seems to siiow that of the two the latter is much more serious.
As bearing on this may be mentioned here the remarkable case reported
by Cline,^ as follows : In a naval battle a sailor was thrown upon the
<leck, where he lay unconscious. Later there was found a very marked
depression of the skull. For fourteen months the man lay practically
unconscious upon his back, with regular pulse and respiration ; when he
called for nourishment, it was only by moving the lips or tongue, where-
upon it was lu'ought to him. At the expiration of fourteen months
Cline removed tlie depressed piece of bone : the operation was done at
one o'clock in the afternoon, and three hours later the patient became
' Bril. Med. Jaurn., 1863, No. xxi. ^ Med.-Chir. Review, vol. i. p. 471.
GENERAL REMARKS CONCERNING FRACTURES OF THE SKULL. 583
conscious and sat up in bed; in four days he left his bed, began to speak,
and within a sliort time was practically well again. Here was a total
suspension of all voluntary function for a period of fourteen months as
the result of depression of bone : this could not have occurred had the
pressure been ihie to a l)lood-clot. Other .-.imilar eases haVe been re-
ported — e.g. briefly as follows: Samuel S. Cooper reports a gunshot
injury to the right parietal bone ; scarcely was the depressed bone re-
moved wiien the almost lifeless soldier sat up in bed and soon began to
speak. Dietfenl)ach o])crated on a nine-year-old bov whose head iiad
been run over by a wagon, a portion of wliosc left parietal bone liad
been depressed. It was removed after applying the trepan three times,
and immediately the previously unconscious boy opened his eves and
recovered speech and ci>nseiousness.'
Such cases as these have in time past brought about livclv discussion
of the advis;diility of early operation ; as an illustration of whii'h take
the following statement from Dietfeuliach, whose writings are not now
very widely read : "A boy fell out of a window one stt)rv high upon the
pavement and broke his right parietal bone, which was deepiv depressed
over an extent of three inches. He lay unconscious ; I trephined him.
He recovered, and I believed that I had saved him by the operation. A
year later he fell again in the same way, and broke his left parietal bone
in an almost similar fashion. This time I did not triphiue him, and he
recovered ; and now I believed 1 had saved him again, and was of the
opinion that the boy had undergone an extraordinary amount of inter-
ference because he survived the first trephining." Take again, Hutch-
inson's statement in his lectures on compression,- that he had never been
able to convince himself of the existence of brain-symptoms as the sole
result of depression of bone. Again, Textor in liis writings uj)on the
inutility of trephining in cranial depressions alludes to 12 cases — in 7
of which section Mas made — of positive <leprcssion of the outer and inner
tables without any sign of brain-disturlianee. These experiences can be
jiaralleled by those of many other surgeons, and it is not strange that in
time past they have caused a great deal of diseussi<in as to the propriety
of early o])enition. When we consider the fatality attending much of
tliis work in the ])re-antise]itic era, we may feel sure that the question
was discussed U|H(n its merits ; at present, however, in view of clearer
knowledge concerning remote results of these injuries, and in view of
the ordinary harmlessness of aseptic operations, we may feel that we are
depriving patients of their best chances when we neglect to operate, no
matter what past records may show.
This natin-aily brings uj) the question of remote results of injuries to
the head. It was, perhaps, Broca '^ who first called attention to the dis-
turbances following depressions where healing was su])posed to have
been perfect, he being cpiickly followed by Bnscli,^ who elaborated upon
the same theme. Since that time a mass of literature has aeeunnilatcd,
all ])ointing toward the frequently un])leasant, and therefore seriously
untoward or even fatal, results of neglectc<l head-injuries, these being
partly of a neuro-j)syehic character, and jiartly of an infectious type,
' For further illustrations see Berjrniami, j) 126.
- London Ilompilnl Repoiis, vol. iv. ^ Gaz. des. Hop., 18(57, p. 123.
* Arch./, klin. Cliir., vol. xv. p. 46.
58-4
Xi/.yA'.Ji'i'.V .L\D LXJl'llJKs OF THE IIKAD.
Fio. -J^l.
siieli as al)scossc>.*, etc. Of tlicso (listiirhances more will 1k' said under
aiiotiier licadin>^ : it is enouiili to say liere tliat it would lie niueli wiser
in the IdUi;' run to sulijeet every traumatic dejiression of tile cranial bones
to operation than to tidl hack njion certain fortunate cases recorded in
literature as an cxcum' for uoii-interference.
Aside from the infectious consc(|Uenccs of these injiu'ics — alluding
fiir the most ])art to o.-titis and osteomyelitis, already spoken of, or to
intracranial abscesses, to be <lcscribcd hiter — the results of fractures of
the vertex are for tiic most part confined t<i the fate of the fraii'inents of
bone which may have been partially or completely separated at the time
of the injury, yet not removed. Tiicse frcijuently necrose, and cither
separate spontaneously as sequestra or have to be removed by subsequent
operation. The extent to which loss of bone-substance may occur in
some of these cases is remarkabh'. Schneider has described a man who
lost fully one-fifth of th(> bone of his skull by necrosis ti)llowint;- injury.
Numi ' reports a two-and-a-half-year-old child who, as the result of a
blow upon the head, had very ex-
tensive necrosis of the parietal
region, one sequestrum measuring
four inches in length and two
others each two inches, and all
this witliout the slightest brain-
disturljanee. The separation of
sequestra may occur in all sorts
of ways, and they may be re-
moved from considerable depths,
as toward the base of the sktdl.
Sometimes these arc perforated,
as, apparently, for previous escape
of pus from Ix'ucath them. Pott
has descrilied quite a classical
form of skull-necrosis with for-
mation of pus between the bone
and the dura, by whicii the mem-
brane is completely separated
from the bone. This is the later
result of a form of contusion of
till' lioiie described bv him and already referred to.
\'an Swieten relates the case of a begi>ar-wonian who lost half her
skull by accident, and who was in the habit of carrying the bone about
from house to house. If the finger were pressed on tlic dura, she
screamed aloud and said she saw " a thousand lights."
In the re])air of these injiirii's we have ])ractically no provisional
callus produced, as is tiie case in long bones, while the definitive callus
is but slight in amount and met with only between the bone-edges, as is
the case in the other fiat liones, like the scajiula and the pelvis. Thus it
appears that the bones of the skull and their periosteal coverings are not
in a general way disposed toward new formation of bone. There is
every reason to think that were moi'c of provisional callus thrown out in
' Tmn.t. Path. Soc. London, 1864, p. 205.
"^Med. Prrxx Weglem ^^ew York, Aug., 1888, p. 317.
CasL- from the author's clinie : resiiltof ttlii injury,
with loss of one parietal bonu and sloughing of
brain."-*
GEXERAL REMARKS COyCERXING FRACTURES OF THE SKULL. 585
tlu'sc injuries we would liavo f'ower cases of necrosis and similar unto-
ward results to deal with. â– It seems almost abst)lutely necessary to have
the honv margins in fair contact in order to get enough new bone to make
an ideal union. Moreover, the callus-formation does not seem to go at
all l)cV(iii(l the limits of the periosteum, and one never sees anything like
the exuberant callus w Inch is so often met witii in the limbs. The dura
seems to participate uku'c in this formation than the pericranium ; it has
been found that loosened fragments are more apt to be bound together
bv callus on the inside of the skull than on the outside.
(Bergmann has tigured a skull from the Leipsic collection, which
shows a vcrv perfect formation of flat osteophytes in connection with the
dura. This coiulition, however, is very rare.)
The Surc/icdl HlMtn-ii of the Vlnil War refers only to one case of
hvjK'rostosis after gunshot fracture of the skull : the patient was injured
in 1864, two years later became epileptic, and in 1871 was trepjiined
with good result ; the jiortiou of bone removed was nearly an inch thick.
Emiuert ' removed a hyperostitic portion from the frontal bone of a
man who six vears previously had been injured by a shovel, sustaining
a fracture of that lionc.
Asa further consequence of the relative mn)roduetivity of the peri-
osteum of the skull, one finds that about all callus that is met with comes
from the diploetic structure. It is so also in the scapula. The pro-
ductivity of this layer of bone has been studied experimentally by
numerous observers — among the most prominent by Oilier," from which
it would apjx'ar that the ])ericranium does but little in these cases by
granulation, the grantdations )>erhaps later ossifying, whereas the true
bone-forming material comes almost entirely from the marrow-tissue of
the dii>loe. The first result of callus-formation is the complete bony
closure of fissures and of small openings, although it takes place rela-
tively more slowly than in other parts of the body. Bi'uus has quoted
ol)scrvations by Conradi and lioiuet,' from which it a])pears that four
months after injury fissures may be scarcely closed, aTid that even a year
and a half later a long fissure extending from the ]xirietal to the occipital
bone was not completely ossified. However, it is satisfactory in this
rcs))ect that healing almost always does ensue, and that every collection
of any size gives abundant evidence of the fact that fractures of the
>kull are ea])able of al)solute and comjilctc reunion.
.So far as the greater productivity of the internal tabic is concerned,
there is particular evidence of the .same in the reunion of completely-
separated bone-fragments. It has been established by numen)us ob-
servers that fragments of the vitrea which have been absolutely separated
or i)artially so do not die, but in some way secure nourishment, and later
reunite with the main b()nes. Among numerous rc|)orts of this kind
there is one by Beck, who found in two cases a. penetrating wound in
which pfeces of the inner table were broken loo.se, and that these were
com])letely united with the dura by a plastic exudate. Again, Demme
has di'scribed the following case : In 1849 a wounded Hungarian soldier
died in Italy of typiioid. Under a depressed area of his skull were
' Lehi-buck der Chir., 1860, vol. ii. p. 69.
'' Ti-aite de la Reqenefalion des Os, 1867, p. 28.5.
' Arch, gen., 1837, vol. ii. p. 337.
586 DISEASES AND INJURIES OF THE HEAD.
t'oiiiid two ('()inplt'ti'ly-sc|);irnt(Ml fVnunieiits of hone ('nc;(]isiilat('(l in the
(liira, OIK' bcinj;' tif'teeii liiu'^; hjiig and the other twulve.
It is evident tliat observations such as these have a signiticancc of
their own, beeauso wlien so many instances of neerosis and decj) infec-
tion, usually fatal, are known to follow the injuries above described, it
is well to reniend)er that it is possible for splinters to become reunited
or encaj)sulate(l — in other words, to be made harmless without further
disturbance. It is, moreover, extremely likely that there are many more
of tliese cases than is generally a|)preeiated in which recovery has fol-
lowed, and whose right character has never been discovered. Huguenin '
foun<l in the body of a man dead of typhus a splinter of the vitrea
without ])erceptible lesion of the external surface of the bone: this man
had fallen five months previously from a wagon, and had sutt'ered for
some little time with the customary disturbances of brain-commotion ;
even at that time it could not be told upon what part of the skull lie
liad struck. The autopsy showed that a piece of the inner surface of
the frontal bone, h by 1 centimetre, had been completely separated and
had ])erforated the dura ; there was some yellow softening of the cortex,
but absolutely no indication of meningitis or encei)halitis.
Fractures with loss of substance heal only exce])tionally by anything
like comj)lete repair. As a rule, there are deficiencies which are coveretl
or filled only with membrane, ossification being imperfect and irregular.
Most of these injuries heal about as do trei)hine openings. We are
justified in holding, then, that a complete bony repair of defects of this
kind is a rarity, and that defects covering an area of more than six by
eight centimetres can scarcely be expected to heal in this way. Gud-
don's experiments on the skulls of animals are quite instructive in this
direction. He found that when the edges of a freshly-made fracture lay
in close contact there were synostoses, but that when there was some
little defect between the borders the reunion was only jiartial or some-
times very defective." He found also that in some cases of loss of bony
substance there were granulations produced from the dura wliieh par-
ticipated in the membrane which closed the defect, and which were
adherent by a sort of connective tissue with the arachnoid beneath or
even with the cortex of the brain.
Diagnosis of Fractures of the Vertex. ^ — In simple fractures there
is ])ractieally but one method ojieu to us : the local examination must be
made with the finger outside of the soft parts, while a study of the
general condition of the patient may lend corroborating or distinctive
signs. With the finger we seek to detect difl'erences in level — /. e. de-
pressions or jjossible fissures whose margins are separated or whose levels
ai'c altered. Obviously, there must lie physical differences of consider-
able extent before the palpating finger upon the skin without can detect
them. In this connection we nuist emphasize the possibility of mistake
of some older or possibly congenital lesion for the effects of recent
injury. Plattner'^ long ago related the case of a man who had fallen,
M'as picked up unconscious, and in whose skull there was an evident
depression ; he was prepared for operation, but, recovering consciousness
before it was performed, related how this was a peculiarity dating back
' Ziemssen's Handbuch. ' Untersuchun. tt. d. Schiidetwachsthum, 1874.
^ Institut. C hirurgice, 1758.
GENERAL nE^fARKS COXCERXTXG FRACTURES OF THE sKFLL. 587
to liis vouth. Mistakes oocur also sometiines in rojranling the eflects
(if atropliy or of other nutritive disturbances as due to injury. Cooper'
iias related liow a man of forty-one had suffered seven years previously
from an injury to the head, followed by hemiplcijia. He was operated
upon and died of secondary heniorrliage, after wliich it was found that
the (h'])ressi()n upon which so nnich stress liad lieen laid was due to
atrophy of tlie bone. jNlistakes may also occur in tlie skulls of sypliilitic
patients, in whom, as is well known, the disap])earaucc of a oununy
tumor is often accompanied by absorption of the compromised bone.
Finally, must be remembered the effects of congenital or ac(iuired asym-
nietrv, as tlic result of whicli wc jjet skulls occasionally of peculiar form
or juTsenting peculiar irregularities, which in tlie excitement of the mo-
ment mav easily 1)6 mistaken for tiie results of traumatism, or when |)re-
senting superficial lesions which call particular attention to them. The
history of these cases, when it can be secured, the existence of old scars,
or the possible symmetrical arrangement of the skull by which a similar
defect or prominence may be found on the other side, or the evidence
afforded bv distinct sy})liilitic lesions, will usually enable one to guard
against errors of this kind.
Very much more fre(pKntly mistakes arise in the difficulty of appre-
ciating the deeper condition through tiie injured and swollen superficial
soft parts. Every surgeon has often been in doubt as to wlietlier a
depression in tiie soft parts really overlaid a distinct dejiression in tiie
bone or not, and incision or other investigation lias often been made to
clear up this uncertainty alone. Incisions are jierfectly justifialile wlien
made for this purpose, providing aseptic jirecautions lie oliserved. Still,
it may often hajjpen that one may get suttieient information by the use
of a needle, with which the level of the bone can be easily ascertained.
Certain it is, however, tiiat an area of infiltration of blood witii its
somewhat abrupt margin may lead even the elect into error. Wlieu the
patient is conscious he may lie able to give important information, and
especially his sensation of ])ain wlien pressure is made is of value, since
lie will be much more likely to complain when pressure is made over
really depressed bone than when otherwise. The pain is usually as well
located in these cases as in a limb when one of the long bones is broken.
In spite, however, of all aids to diagnosis, it is certain that not a small
jiroportion of actual fractures of the skull go undetected. Many of
tliese patients recover, while some of them come to the dissecting table,
usually brought there by brain-complications or otiier intercurrent atl'ec-
tions. Bergniann is, for his own part, convinced that many children
recover from fractured skull in whom it is sometimes not even suspected
at all. iSo long as the fracture is purely a siiii])le one, its exact deter-
mination is a matter of scientific interest rather than of clinical necessity,
the treatment being mainly that for whatever injury may have been
received" to the soft parts.
A peculiar result of subcutaneous fractures of the vertex, which is
especially observed in young children, is the development of a more or
less circumscribed tumor, tilled with fluid, located under the soft parts
of the skull. This is in large measure of the kind already alluded to as
described by Pott. This fluid, however, is in the cases alluded to not
' Am. Med. Times, 1862.
588 DfSKASES AXn TXJrnTES OF THE HEAD.
pus, l)iit usually (•{'r('l)r(i-s|)in;il Huid. Tliis accidcut in-csupiidscs iujurv
to the dura as well as to thu arachnoid, through whii'h ojicuiui;- this fluid
may oscape. Another possible ex])lanation is afforded by the presence
of those eysts in and about the skull which are well known to exist
cither couocnitally or as the result of alteration in blood-clot. Koki-
taiisky has ])aid considerable attention to these collections of Huid, and
regards them, for the most jjart, as of the latter variety—'. ''. results of
i)lood-clot, which he says may be more easily explained when wa re-
member the ri(!h vascularity of the bones in children and the ease with
\vhich arterial branches may be torn, especially when they cross the
sutures.'
W hen the soft parts are so i'ar disturbed that access may be had to
the bone, then diatiiiosis is about as simj)le as it can be made: simply
with the finger, or often with the eye, a solution of continuity may
be appreciated. However, it does not always happen that the fracture
lies visible at the depths of the external wound. Moreover, there may
be roundabout connection between the cranial cavity and the outer
wound as the result of lacerations or separations of continuity, so that
cercliro-spinal fluid may escajH'. ^\'hen this is noted it points practically
invariably to fracture, even though this itself may not be pcrcej)til)le.
Sometimes also brain-matter may appear. It does not always follow that
that which may at first seem brain-matter is really such, since Quesnay 'â–
(|Uotes jMarechal as mistaking, in one case of fracture of the frontal bone,
for brain-substance that which ])roved later to be the contents of the
frontal sinus. In certain cases it may be noted that the fluid used for
irrigating and cleansing, with which a wound has l)een filled, begins to
pulsate. This means, ))ractically always, connection with the cranial cav-
ity, and consecpiently fracture. Sir Prescott Hewett relates the follow-
ing incident, which is worthy of reproduction here : A physician with-
drew from a wound of the skull a piece of bone of considerable size,
and beneath where it lay could feel with the finger an opening in the
skull ; his diagnosis was instantly made, as would ordinarily be natural.
But it apjK'ared a little later that the extracted bone was not human
bone, and that the opening in the skull was merely a perforation of the
tem))oral fascia. It seemed that the patient while walking upon the
street had fallen upon a piece of bone, which had penetrated the bone
and fascia and was withdrawn as above.
Aids to diagnosis are more at hand when by the injury the seat of
fracture is more or less widely exposed. Difficulties or errors may arise
in discovering minute fissures, which may perhaps have been diastases
of sutures, since these may be mistaken for the sutures themselves, for
grooves for vessels, or for im|)risoncd hairs. So far as the sutures are
concerned, a knowledge of their location will guard against this error.
Hi])pocrates himself mistook for a fracture the suture between the two
halves of the frontal bone ; and there is on record the well-known anec-
dote of Saucerotte, who protected a patient from an ojieration for tre-
phining because he discovered that the alleged line of fissure was only
the line of suture between the occipital lione and an enlarged Wormian
bone. The grateful patient left him his skull as a legacy.
Information may sometimes be obtained as to the degree of splinter-
' Viile infra, on Intracranial Tumors. 'Memoiresde I' Acad, de t'/aV., vol. i. p. -47.
GEXEEAL EEMABKS COXCERXTXG FRACTURES OF THE SKULL. 589
iiisi of tlif internal table by the use of a tine probe tliroui;li the openino\s,
by whieh the deptii to whieh it is dcjjressed or its motility — /. c. its
se])aration — may be made out. But cases in which this method can be
resorted to are quite exce])tional. We may always be guided by an accu-
rate account of the injury, since it is a safe rule to follow that the more
localized the effect of violence and the narrower the liiuits of the frac-
ture, tiie more probalile that the inner table is broki'u into fnianients
somewhat corresponding to those of the outer tal)le.
Diagnosis of isolated fracture of the inner table is practically out of
the question. Macchisi has suggested that for this purpose we resort to
percussion of the skull with some metallic instrument, claiming that at
a point overlving the injured inner table the percussion-sounds will vary
from those obtained over other parts of the skull. A much more fanci-
ful suggestion (>f Sedillot was to listen for sounds that might l)c produced
by friction between the dura and the fragments. It has been suggested
also that a surface thermometer would show an elevated temperatiu'c
over the area of injury ; this, however, is very questionable. In one
case, however, Stromeyer made a brilliant diagnosis of this injury,
noticing that so soon as his patient assumed a horizontal position he
began to vomit. On autopsy it was found that there was a depressed
splinter of the inner table which had pertbrated the dura ; in the upright