INJURIES OF THE SKULL 
THEIR RELATION TO MEDICAL EVIDENCE, WITH REPORTS OF 
CASES, AND REMARKS UPON THE EMPLOYMENT OF 
THE TREPHINE. 
C, C, F. GAY, M, D,, 
SURGEON OF THE BUFFALO GENERAL HOSPITAL. 
Injuries of the head are so often associated with crime or erimi- 
nal intent, or at least, their infliction so often becomes a subject of 
legal investigation, that Surgeons as experts, are called into court 
to testify how an injury is produced, by what kind of missile or 
instrument, the amount of danger caused and the probable results 
to be expected. 
The amount of damages to be paid by individuals or corpora- 
tions or the degree of punishment—whether by imprisonment or 
death, largely depends upon the testimony of the Surgeon. 
But a few days since, the enquiry was made by the able District 
Attorney, Mr. Williams, whether or not a blow upon the head 
which did not fracture the skull might be considered as dangerous, 
or even more dangerous than another blow that fractured the 
skull. To which I replied affirmatively. He said a case had oc- 
curred in court during his term of office, wherein endeavor was 
made to elicit this fact from medical witnesses, but that there was 
conflict of opinion. 
One of the purposes of the writer in preparing this article, is to 2 
INJURIES OF THE SKULL.—GAY. 
examine this question, in order to ascertain if there be any valid 
reason why medical opinions should not be uniform, and testimony 
devoid of discrepancy. 
The fact, elicited by the question propounded by the District 
Attorney, is probably well established, still there may be vacillation 
and uncertainty in the minds of some; if so, I hope to give addi- 
tional evidence of the fact, by report of cases of injury to the skulb 
selected from among several recorded in my note-book. The 
report of the cases themselves it is believed will not be wholly barren 
of interest. 
Case ].— Compound fracture of'parietal lone.—Thomas Man- 
ning, aged 30 years, admitted to Hospital on April Ist, 1873, was 
at work excavating earth, when the stone foundation of a building 
caved in upon him, causing compound fracture of the cranium. I 
saw the patient soon after the injury was inflicted. He has scalp 
wound extending from forehead over the vertex to occipital bone 
down behind the ear, almost entirely denuding the right cranial 
hemisphere. The parietal bone is fractured through its entire ver- 
tical diameter, the fracture riming obliquely downwards in the di- 
rection of the posterior inferior angle and depressed quite one 
quarter of an inch, and three inches or more in extent. Symp- 
toms of compression present. There is no consciousness nor sen- 
sibility. Pupils contracted, pulse 30 per minute and intermitting. 
Assisted by Drs. Van Peyma apd Slacer, and Mr. Bartow I re- 
moved a section of bone with the trephine. By the opening thus 
made I was able, with the use of the handle of strong forceps to 
elevate the bone. To accomplish this, much strength in the instru- 
ment was required and force of muscle necessary to be employed 
on account of over-riding of the bones. 
By a canting motion of the elevator the bone was made to fly 
back to its normal position with a snapping sound which was audi- 
ble in the most remote part of the ward. 
The elevation of bone wTas perfect throughout the entire extent 
of the fracture. Anaesthetics wrere unnecessary, and were not used. 
Almost simultaneous with the elevation of depressed bone, the 
patient became sensible and conscious. His pulse wumt up to 60 INJURIES OF THE SKULL.—GAY. 
3 
beats per minute, all symptoms of compression disappeared at once. 
The scalp wound was dressed, and an anodyne ordered; on April 
2d, the patient promised well, on the 3d was worse, his pulse ran 
up to 140 per minute, and on the afternoon of the 4th he died. I 
have recorded in my note-book that he died from shock or cerebral 
contusion or concussion. 
Case 2.—Compound Comminuted Fracture of Temporal Bone 
and Tibia.—Francis McKevett, aged 18 years, fell April 24th, 1873, 
from the mast of a vessel, distance one hundred feet. The fall 
was twice broken, the first landing place was upon the cross-tree, 
a distance of forty feet. He was brought to Hospital in the 
evening. I first saw him at 10 A. M., next morning. 
He has compound comminuted fracture of right tibia near the 
knee, and there is also compound comminuted fracture of the right 
temporal bone, with depression, but there are no symptoms of com- 
pression. Pulse 120 per minute, pupils normal and consciousness 
unimpaired. Assisted by Drs. Barnes, Yan Peyma and Rolph, I ap- 
plied the trephine and elevated all depressed bone, and removed 
several spiculse of bone which were driven into the brain. It be- 
came necessary in removing all the loose fragments of bone, to re- 
move a good share of the temporal bone itself. 
Ether was administered, and anassthesia maintained until the 
tibia was dressed. Water dressings were order to the head, and an 
anodyne given. Pulse after operation 120 per minute. April 28th, 
right leg, and extending a considerable distance upon the thigh, 
is becoming gangrenous, pulse 140. He is conscious and per- 
spires very much. 
30th. Died at 2 o’clock this morning. 
Post-mortem at 11 A. M. 
Found the leg gangrenous, fracture of the leg oblique, extending 
well up toward the knee joint. The wound of the head presented 
no unhealthy appearance. 
Case 3.—Injuries caused by falling 40 or 50 feet.—Cardiac dis- 
placement without a Fracture or Contusion.—Lying in close prox- 
imity in the Surgical Ward to case 2, was John Krohn, aged 22 
years, of full habit, who had fallen on April 10th, 1873, a distance 
of 40 or 50 feet from the arch of a Propeller, without either frao- INJURIES OF THE SKULL.—GAY. 
Turing any bones or causing the least contusion anywhere upon his 
person, yet causing a most unusual and remarkable “shaking up” 
of a vital organ, namely, displacement of the heart, which was not 
discovered until a day or two after his entrance to the Hospital. At 
this time his pulse was 42 per minute with no cerebral symptoms. 
The apex beat was found near the eusiforni cartilage, three inches 
on a horizontal line below and four inches on a vertical line to the 
right of the left nipple. 
Best in the recumbent posture was ordered and maintained. On 
June 12th, he left the Hospital, feeling pretty well. His heart 
gradually from week to week had moved toward—until it had 
nearly or quite assumed—its normal position. 
Epistaxis occurred twice during his residence in Hospital. 
Case 4.—Compound Comminuted Fracture of Parietal Bone.— 
A lad 11 years of age was struck upon the head by a falling brick 
from a building in process of construction. 
The brick fell probably a distance of 24 feet, causing compound 
comminuted fracture with depression of left parietal bone. The 
bone wras depressed one-eighth of an inch. I was requested by Dr 
Wetmore, to see this case with him in consultation. There were 
no signs present of compression except unusual dilitation of pu- 
pils, and depressed pulse, still the extent of the depression seemed 
to warrant surgical interference. After the doctor had used the 
trephine, it was found that the bone could not be elevated by all 
the force we could use, therefore with the use of gnawing-forceps 
all of the depressed bone was removed, exposing the meninges of 
the brain to the extent of one and a half inch in length, by one 
half inch in breadth. The recovery was uninterrupted. In ten 
days the boy was up and walking about well. Chloroform was used. 
Case s.—Necrosis of the Skull, Operation for Trephining.—Mr. 
B. German, aged 40 years, has necrosis of the skull, cannot ascer- 
tain that he ever had syphilis, but he admits that he had gonor- 
rhoea twenty years since. His scalp has been inflamed, and sup- 
puration has continued for several months. May 22d, 1871, 
administered chloroform, cut down upon the bone and find it .rough- 
ened and necrosed at the posterior superior angle of the parietal 
bone. The trephine and the gnawing-forceps were employed, by INJURIES OF THE SKULL.—GAY. 
5 
which all the necrosed bone was removed, leaving an opening two 
inches in diameter. 
Water dressings were employed, on the 27th erysipelas super- 
vened upon the face. 
June sth, erysipilas disappeared and the wound was closed. 
On July 31st, was discharged well. 
Case 6.—Compound Comminuted Fracture of Arm, and a sup- 
posed fracture and depression of Shull.—Emma Golhe, German, 
aged 13 years, was brought to General Hospital on the evening of 
May 11th, 1874. She was exhumed from the ruins of the McAr- 
thur building, and taken to Crowley’s morgue. From the time the 
building fell until the body was recovered, nearly an hour and a 
half intervened. She was supposed to be dead, but soon exhibit- 
ing signs of life, was removed to Hospital. It was ascertained that 
she had compound comminuted fracture of left humerus near the 
shoulder. There was found depression upon the frontal bone one 
and a half inches in length by three-fourths of an inch in width, 
with sharp abrupt margins. There were found other injuries upon 
the person, but these were slight, such as contusions and one lac- 
eration of gastrocnemius muscle. 
During her ride to Hospital, she became semi-conscious, pupils 
were dilated and reaction was established. 
Ether wvas administered, when, assisted by Drs. Boardman, Bar- 
tow and Boysen, I amputated the arm, and decided to wTait until 
morning for symptoms of compression before exploring the head 
injuries. Several physicians saw this patient while she was lying 
apparently lifeless at the morgue, all of them concurred in opinion 
that there was fracture of the cranium. The depression was deep 
with sharp edges, but upon lifting a flap, which as a rule I could 
not be justified on authority in doing, for the purpose of making 
diagnosis, I discovered there was neither fracture nor depressed 
bone. The deformity was such as to lead almost any one into 
error of diagnosis, and in case of this character where several com- 
petent physicians were deceived, it ought to furnish an exception 
to the rule, never to cut for the mere purpose of establishing a 
diagnosis. On the next day the patient’s pulse ran to 170 and 180, 
convulsions supervened, she gradually became unconscious, and 6 
INJURIES OF THE SKULL.—GAY 
died on the morning of the 14th, having lived three days after re- 
ceiving the injury. 
These cases, separately, are interesting and instructive, but when 
grouped together furnish a text for remarks, having a broader 
scope than would be afforded, had not the cases been brought to- 
gether in this connection. Cases first and second necessitated em- 
ployment of the trephine. The first case was one of severe con- 
cussion and was fatal. The other case would not have been fatal 
if there had been no complex injury. Cases fourth and fifth 
required employment of the trephine, but the cause which necessi- 
tated its use, was not of a nature to produce more than slight 
shock in one case, while the other was unattended by shock, and 
both patients recovered. 
Case fourth which I have reported, a lad eleven years of age, re- 
covered without an untoward symptom. Ilis age was in his favor, 
but the case could not be included in the class of those reported 
by Dr. Hamilton, in the Buffalo Medical Journal, Hov., 1846. He 
had passed the period of infancy and childhood, when non-inter- 
ference is advised. With the presure of bone upon the brain re- 
moved, he is exempt from future risk of epileptoid convulsions 
and death from this cause. 
Many years since 1 witnessed an operation for trephining, by Dr. 
Pan cost, of Philadelphia, upon an epileptic boy. The injury had 
been inflicted nine years before, by a fall upon a curbstone. The 
lad had enjoyed good health for several years after the accident, 
when convulsions supervened, said to be epileptic in character 
recurring at intervals more and more frequent. Dr. P., decided to 
perforate the frontal bone, removing therefrom a spicula of bone 
which projected from the inner plate. Only for this delay to oper- 
ate, for which the doctor was not responsible, the lad would have 
been spared the convulsions and his life saved. 
Case third is reported along with the other cases, as showing the 
effect upon the system—when the force of a blow is not broken by 
giving way of bones in any part of the body—of general concus- 
sion. It could not be ascertained how or where this patient struck, 
whether upon his head or side or feet. But the presumption is, 
that he did not strike upon the head, for it would hardly be possi IKJURIEES OF THE SKULL.—GAY. 
7 
ble for 02ie to fall the distance of 40 feet, striking upon the head 
without producing, if not fracture, at least a wound or contusion 
upon the scalp or cerebral concussion. 1 regret that 1 am unable 
to state the termination of the case. Adopting the views of Brich- 
sen, enunciated in his able work on concussion of the spine in 
Bail Eoad injuries, I can readily prognose a fatal termination with- 
in from two to three years. 
In the two fatal cases, the fracture was in one case simple, in the 
other comminuted. In the former the compression was profound. 
In the latter the symptoms of compression were scarcely apprecia- 
ble. A section of the parietal bone in one case was flattened down 
upon the meninges of the brain to considerable extent. A smaller 
section of bone in the other case was comminuted, the fragments 
of bone depressed, and spiculaa driven down upon the brain sub- 
stance. Why were there profound symptoms of compression in the 
one and not in the other? The solution of the question may be 
found in the fact that the cerebral shock is lessened in proportion 
to the degree and amount of comminution. In this case the fract- 
ured leg diminished the cerebro-spunal shock. Erichsen happily 
illustrates this point by stating, that if a “ watch falls to the floor 
without breaking its crystal, the work of the watch stops and per- 
chance will be permanently injured, but if the crystal breaks in 
the fall the shock is lessened, so that the watch keeps on running 
and is not injured.” “ When a magnet is struck a heavy blow with 
a hammer, the magnetic force is jarred, shaken, or concussed out 
of the horse shoe, and the iron has lost its magnetic power,” and 
this is about as good a definition of the term “shock” as can be 
given at present. 
A person, says this author, “ who by any of the accidents of civil 
life meets with an injury by which one of the limbs is fractured 
or is dislocated, necessarily sustains a very severe shock, but it is 
the rarest thing possible to find that the spinal cord or the brain 
has been injuriously influenced by this shock that has been im- 
pressed on the body. 
It would appear as if the violence of the shock expended itself 
in the production of the fracture or the dislocation, and that a jar 
of the more delicate nervous structures is thus avoided.” 8 
INJURIES OF THE SKULL.—GAY. 
This question of “shook” or concussion from Railway and other 
injuries of the nervous system has often come up in the courts, 
and the testimony of physicians has not always been of a charac- 
ter to boast or be proud of. Discordant testimony has exerted 
its influence in bringing into bad repute the standing ot the pro- 
fession. 
Erichsen has done much by way of establishing principles and 
harmonizing conflicting views in relation to injuries inflicted by 
railway accidents, so much so that there need not hereafter as 
heretofore be such conflict in medical opinion on questions of diag- 
nosis, pathology and prognosis, in injuries such as cause “shock” 
to the nervous system. I think lam prepared to assert on authority, 
that comminuted fracture of the cranium is less fatal than simple 
fractures, and that comminuted or simple fractures are less danger- 
ous than no fracture at all provided the shock, in all cases, is equal. 
I am quite positive therefore, should I be called upon to testify 
as an expert, that I should be obliged under the sanctity of an 
oath to state my belief, that a blow which did not fracture the 
skull, being equal in momentum to another blow upon the head 
causing fracture, either simple, compound or comminuted, would 
be the more dangerous and fatal even, of the two. 
Personal experience and observation, together with the light 
thrown upon the subject matter by Erichsen’s theory of injuries 
causing cerebral or cerebro-spinal concession, would be the basis 
of this belief. 
In one case, the shock or shaking up, would be so much more 
intense than in another, that an expert could be able with certainty 
to prognose a fatal termination within a given period of time' 
from acute or chronic meningitis or subacute myelitis, or perma- 
nent breaking down of the nervous system. 
“ In the spine, just as in the head,” says Erichsen, “it will some- 
times be found after death from what appears to be, and in reality 
is, simple injury of the nervous centres, that the vertebral column 
in the one case, and the skull in the other, have suffered an amount 
of injury that was unsuspected during life; and which, though it 
may not in any way have determined to the fatality of the result, 
yet affords conclusive evidence of the violence to which the parts INJURIES OF THE SKULL.—GAY. 
have been subjected, and the intensity of the disorganizing shock 
that they have suffered. 
There is, however, this very essential difference between the spine 
and the head in these respects—that a simple fracture of the crani- 
um may be of no moment except so far as the violence that has 
occasioned it may have influenced the brain, whilst in the spine 
the case is not parallel; for as the vertebral column is the centre of 
support to the body, its influence in this respect will be lost when 
broken; even though the spinal cord may not have been injured 
by the edges of the fractured vertebrae, but simply violently and 
fatally concussed by the same force that broke the spine itself. ” 
Holmes cites Drummond’s case as an example of extensive de- 
struction of the vault of the skull, originating in a blow upon the 
head -without fracture or scalp wound. The destruction of the 
vault being caused by inflammation starting in he dipice. 
It is conceded by the best authority that comminuted fractures 
are limited in their consequences to the seat of injury, and that 
compound fractures are much more frequent!; limited to the seat 
of injury than in cases of simple fracture. Says Holmes; “Out 
of 56 cases of simple fracture this strict limitation existed only in 
one single instance.” 
These views, held by the highest surgical authority, have a di- 
rect bearing upon the question propounded by the district attorney 
and furnishes an affirmative answer. 
Of these two most recent and very able writers and authors— 
namely, Erichsen and Holmes, it may be affirmed that the former 
errs by placing too much emphasis upon the,term “ concussion,” as 
limited to the brain and spinal cord, while the latter, being more 
conservative, strikes the happy medium when he says: “ Thus all 
the great constituents of the nervous system—brain, spinal cord, 
and sympathetic system—are included in the common risk of the 
catastrophe. And the account would be incomplete, if the influ- 
ence of mental shock—that of fright and of witnessing appalling 
spectacles—were neglected.” 
In this connection it is not irrelevant to observe that much ob- 
loquy has been thrown upon the operation of trephning which 
it does .not deserve, since so many fatal cases occur after this ope- 10 
INJURIES OF THE SKULL.—GAY. 
rative procedure. But much of the discredit belongs not to the 
operation, but rather to the causes which make the operation im- 
perative and necessary. The causes may have been so severe in' 
character, producing such instant and severe injury—not by way 
of lesion to the soft or hard parts—but to the nervous centres that 
death, which is inevitable, is neither deferred nor hastened by the 
operation of trephining. Yet there are risks in the future from 
omission to elevate depressed bone, the certainty of the occurrence 
of which no man may be able to determine, which Justify the em- 
ployment of the trephine. 
It must of necessity be an injury—severe in character—that sug- 
gests the employment of the trephine. Its use can add but little 
if any to the shock already inflicted. Trephining is one of the 
simplest operations in surgery. But little pain is caused—an an- 
aesthetic is scarcely called for, but little time is consumed or blood 
lost, and in these severe injuries of the head, ablation of a section 
of bone may be readily effected, whether the fracture be comminu- 
ted or not by the use of the gnawing-forceps without use of tre- 
phine!, therefore I cannot but think that more immediate and re- 
mote danger to patient results from non-use than from use of this 
instrument or its congener, the gnawing-forceps. Well established 
rules are laid down by authors regulating the employment of the 
trephine. These rules and their exceptions are nowhere better 
defined and more succinctly stated than they are in Hamilton’s 
Principles and Practice of Surgery. 
I am quite well convinced, however, that no rule can be so in- 
flexibly established that there shall be no departure therefrom. 
Exceptions will arise and may be made to all rules that are now or 
may hereafter be laid down and apparently established. Yet while 
a surgeon, without reputation, may be obliged to follow these rules 
for his own professional safety, a surgeon with reputation, will oc- 
casionally find it expedient and necessary for the safety of his pa- 
tient to depart from them. lam unable to bring myself to the be- 
lief that in case of fracture with depression and without compres- 
sion in the adult, that good surgery, as a rule, requires me to wait 
for the development of symptoms. Promptness in decision and 
action, at least in exceptional cases, and the elevation of depressed INJURIES OF THE SKULL.—GAY. 
11 
bone should be aimed at, when the fall duty of the surgeon has 
been done and the consequences may be left to take care of them- 
selves. 
The Divine Architect has so wonderfully constructed the human 
cranium as to enable it to resist great violence. Any one who will, 
may demonstrate upon the cadaver the immense power necessaary 
to be brought into requisition, adequate to a fracture of the cranial 
bones. Whosoever, I think, makes the trial, will be convinced 
that the impact of a force that fractures the bones of the skull 
must almost of necessity so contuse the brain substance or inflict 
injury upon the investing membranes, or cause extravisation and 
blood clot with or without fracture as to produce, with the atten- 
dant shock, inevitable death, whether the trephine be employed or 
not, but should doubt arise in the mind of the surgeon as to the 
propriety of its use, in legal parlance, give the patient the benefit 
of the doubt for, perchance, benefit may accrue to him by prompt 
decision and action and future risks avoided. 
At all events, but little if any more is added to the so called 
shock of the injury by the employment of the trephine. The sur- 
geon indeed cannot quite feel at rest and certain that his whole 
obligation to his patient is discharged if he leaves any portion of 
the cranial vault depressed. Still authority seems to have set at 
rest the question of operative, interference or non-interference, to 
swerve from which would be dangerous to the young surgeon if it 
should not prove to be so to his patient. 
A little more warrant for an occasional deviation from the rule 
is all I should be willing to insist upon, and this warrant I suspect 
will, in due time, be granted.