TWO CASES OF FRACTURED SKULL. 
Recovery in One: Death from Chloroform in the Other. 
BY 
THOMAS MANLEY, M.D., 
VISITING SURGEON TO THE HARLEM HOSPITAL, NEW YORK. 
FROM 
T HE MEDICAL NEWS 
October 4, 1890. Reprinted from The Medical News, October 4, 1890. 
TWO CASES OF FRACTURED SKULL. 
Recovery in One; Death from Chloroform in the Other. 
By THOMAS MANLEY, M.D., 
VISITING SURGEON TO THE HARLEM HOSPITAL, NEW YORK. 
Although traumatic lesions of the cranial shell, 
in large cities, are of frequent occurrence, those of 
the kind here described are rarely seen. Both cases 
are singularly interesting in causation, age of the 
patients, location and similarity of the lesions, clini- 
cal history, pathological conditions, and in the state 
of the nerve-centres when the patients came under 
observation. 
Now, that cerebral localization is being investi- 
gated with great care and minuteness, it is inter- 
esting to note how far experiments on the lower 
animals can be utilized for clinical purposes in man. 
And further, since the two Hyderabad Commissions 
have given their, rather conflicting, but, neverthe- 
less, very full and exhaustive, reports on the lethal 
action of chloroform, it is timely to note precisely 
the phenomena which attend the mortal action of 
this drug on man. 
The two boys who are the subject of this history 
were injured on the afternoon of June n, 1890. 
They, with eight or ten companions, found a truck, 
used for moving stone, standing by the roadside. 
They got hold of it, some pulling and others push- 2 
MANLEY, 
ing, and dragged it up a steep hill. Reaching the 
summit, they turned it around, got aboard, and 
let it go down. What the ultimate fate of all the 
adventurers was after they started on their journey 
down the hill we are unable to record, but a police 
officer, hearing the noise of the truck and the 
screams of the children, hurried into the field, to 
find the truck capsized near the foot of the hill, and 
two boys lying about midway down the declivity, 
both being unconscious, and one apparently dead. 
The Harlem Hospital ambulance was sent for, and, 
on its arrival, Dr. F. P. Hammond, the ambulance- 
surgeon, found W. P., the older boy, apparently 
moribund. He breathed only in gasps, at long 
intervals; the pulse was absent in one wrist, and in 
the other only a feeble flicker could be detected. 
Respiration was stertorous; blood mingled with saliva 
was oozing from the mouth and nose, and there was 
a bloody fluid flowing from the left ear. Dr. Ham- 
mond vigorously stimulated the patient by hypo- 
dermic injections, sponged out the mouth, and 
douched the face with cold water. The little fellow 
gradually reacted, and in half an hour was in the 
ambulance. 
The other boy, B. J., lay on his back, bleeding 
freely from a wound of the head, and was also 
insensible. His general condition was not bad, and 
before he reached the hospital he regained conscious- 
ness. 
In each case antiseptic dressings were immedi- 
ately applied with as much care as possible. 
I saw the cases three hours after they were ad- 
mitted to the hospital. They were then perfectly 
conscious, but could not give a clear account of the 
accident. The older boy was still suffering from 
shock. His pulse was slow, 60 beats to the minute, 
and the pupils were markedly contracted. The out- TWO CASFS OF FRACTURED SKULL. 
3 
line of the features was regular, and the nose, ears, 
and lips of an ashy pallor. The extremities were 
cool, with marked, though not total, abolition of 
the reflexes. There were areas on the inner side of 
the thighs in which sensation was wholly lost, and 
others on the palmar surface of the hands where, 
though sensation was intact, mobility was lost. 
When asked to move a limb he did so slightly, but 
with great effort, and on one side only. He was 
somewhat deaf. Immediately behind the right ear 
there was a scalp wound exposing the bone. There 
was free haemorrhage from the nose, mouth, and left 
ear, and from the latter the blood was somewhat 
serous and straw-colored in character. 
His condition indicated fracture of the base of the 
skull, probably with free haemorrhage into one of 
the great cavities of the body. 
He was brought into the operating-room, and, as 
a preliminary to the examination of the wound, we 
adopted the recommendation of Dr. F. S. Dennis, 
and shaved the entire scalp, in order that antisepsis 
might be more rigorously carried out. At the seat of 
injury we found a fracture which was almost circular, 
with its greatest diameter from before backward. 
The large disk of bone was driven into the brain, 
being wholly detached at its circumference. The 
position of the fracture was on a line with, and im- 
mediately behind, the concha of the ear. The skull 
surrounding the fracture was fissured in a radiating 
manner, the fissures extending backward and toward 
the base being the deepest and most widely separated. 
Considering the cranio-cerebral topography of the 
lesion, it was evident that the left lateral sinus was 
nearly in the centre of this depressed plate of bone, 
which was evidently a part of both the parietal and 
occipital bones. 
The safest course to pursue was now a question 4 
MANLEY, 
which did not permit much deliberation. Whether, 
bearing in mind the close proximity of the large 
venous channel, it might not be safer to cleanse the 
parts thoroughly, and let the fracture alone-as, in- 
dependent of the eyes, we had no distinctive indi- 
cation of cerebral pressure-or whether it would not 
be better to trephine at once, were the questions 
which had to be decided. We all know that haem- 
orrhage from vessels within the skull is sometimes 
difficult or absolutely impossible to check. We know, 
too, that an aseptic blood-clot-if not large or within 
the brain-often undergoes disintegration, organiza- 
tion, or absorption, without causing serious harm. 
We know further-though, unfortunately, operators 
are loath to report such cases-that an operation 
to remove depressed bone, or large blood-clots, 
may in itself be fatal. I have had, in about one 
hundred and fifty fractured skulls which I have 
treated, two such cases. 
In one we were removing a large fragment of 
bone driven into the brain, almost at the confluence 
of the cranial sinuses. The spicula of bone came 
out quite readily, but it was followed by a deluge 
of blood which could not be controlled. In the 
other case, I trephined above the ear, over the tem- 
poro-parietal articulation, for symptoms of com- 
pression following an injury. We came at once, 
upon a very large intradural coagulum. After I had 
gnawed away, with the rongeur, sufficient bone to 
remove the clot, I commenced to crush it gently 
with the fingers, working cautiously until I be- 
lieved it was nearly displaced, when a jet of dark, 
tarry blood welled up from the bottom of the space 
left by the clot. It came in torrents, and our 
compresses and haemostatic forceps were useless. 
We had re-opened a large trunk which the clot had 
plugged, and it was fatal. I may add, that I have TWO CASES OF FRACTURED SKULL. 
5 
heard of similar disasters, in the hands of others, 
but they have not been published. 
To return to the present case. I decided to try to 
elevate, as the fragment was driven in so far that I 
was able, by chipping off enough bone from the 
overlapping margin, to get my elevator between 
the dura and the skull, using the edge as a fulcrum. 
Happily, I was able to raise quite easily the frag- 
ment to its normal position. Very little blood was 
lost, and the wound, with the entire cranium, the 
neck, and the eyes, were enveloped in soft antisep- 
tic gauze. 
During the night, following the operation, the 
patient moaned, groaned, cried, and vomited. He 
had two or three sinking spells and became cold; 
but Dr. Guest, the house-surgeon, used heat and 
stimulants energetically, and the boy reacted. 
I saw him at io a.m., June 17th. At this time 
it seemed that he could not recover. His pulse was 
186, and his temperature subnormal, and he had 
the heaving respiration which Bell1 has so well de- 
scribed, as a sure precursor of death. But by noon 
he commenced to rally and he has made a good 
recovery; although both pupils are dilated, and he 
has double convergent squint. Hearing has been 
perfectly regained and there is no trace of paralysis. 
It is interesting to note that in this case we had 
almost unequivocal evidence of fracture through 
the base of the skull, and yet the patient made a 
good recovery, the only organic disturbance at this 
date being confined to the organs of vision. 
Dr. Ferrier in his recent Croonian lectures on 
" Cerebral Localization," tells us that " theoccipto- 
anterior region is the visual area of the cortex." 
1 Sir Charles Bell: Nervous System, second edition, p. 203. 6 
MANLEY, 
It seems that this conclusion has been reached, 
mainly by experiments on monkeys and clinical 
observations on man. Considering the location of 
the lesion, in the case just described, and the 
marked disturbance of the visual organs, at the time 
of the injury and since, I think that the patient's 
condition is strong evidence in favor of the cor- 
rectness and accuracy of the statement made by Dr. 
Ferrier. 
There can be no doubt that considerable blood 
escaped into, and through the cerebral substance, 
and that, following the line of fracture, it ulti- 
mately lodged in close contact with the base of the 
pons Varolii and the corpus pyramidale, where, by 
pressure, it interfered with the nutrition and func- 
tions of the ocular nerves, notably and persistently 
with the abducens. 
With the ultimate reduction and absorption of 
the effused blood, I expect perfect restoration of 
accommodation. 
The younger of the two boys, B. J., when I saw 
him, had a large haematoma directly behind the 
right ear, in precisely the same situation as the 
wound in the preceding case, except that the tumor 
extended slightly downward into the cellular tissue 
of the neck. The house-surgeon had made a diag- 
nosis of fracture of the skull. The patient had 
almost no constitutional disturbance, but there had 
been nasal haemorrhage. He did not complain 
of pain, and moved about in bed without difficulty. 
He was slightly pale, however, and vomited twice 
after entering the hospital. 
The contour of the haematoma, with its firm, 
bevelled border and depressed centre-characters TWO CASES of fractured skull. 
7 
common to all cranial haematomata-and the total 
absence of any cerebral symptoms, led me to be- 
lieve that there was no fracture. 
The scalp over the swelling was shaved and 
cleansed, after which I made an incision into the 
tumor and evacuated it, when I found well-marked 
linear fractures; one running antero-posteriorly, 
intersected by another passing toward the base. 
The greatest extent of fracture was in the occipital 
bone, extending but two or three lines into the 
parietal. There was very slight depression of the 
upper boundary, of the divided plate. Under 
strict antisepsis, I closed the incision with a con- 
tinuous suture, and applied the usual dressing. 
The following morning the patient was in excel- 
lent condition, and speedy recovery seemed probable. 
At noon of this day he vomited. At 2 p.m. the 
temperature was 1020. Internal squint of the left 
eye, varying in degree, was noticed, and the pupil 
was slightly dilated. He was able to urinate and 
had no paralysis of the extremities. 
On June 17th it was noted that he had passed a 
restless night. At 8 a.m., temperature was 103^°, 
and at 10.40 a.m. was the same; at 12.30 p.m. 
temperature was 103^°. At 1.20 a.m., June 19th, 
temperature was io3f°; at 2 p.m. temperature was 
104I0. 
I saw him at 3 p.m. on this date. He now had 
well-marked symptoms of compression with menin- 
gitis. His pulse was very rapid, the temperature 
high, and he was incessantly moving about in the 
bed. Marked congestion of the conjunctival vessels 
clearly indicated cerebral hyperaemia. 
His mental condition at this stage presented many 
features of interest. He would have intervals of 
repose, in which he would lie on his back, with his 
eyeballs immovably set and the lids widely opened, 8 
MANLEY, 
muttering incoherently to himself. Every few min- 
utes he would arouse from this condition for a short 
time. When asked how he felt, he would look up, 
answer intelligently and complain of great pain 
throughout his head. Then he wou'd immediately 
lapse into a semi-conscious condition with his eyes 
open. 
It was only too apparent that serious mischief 
had resulted from the injury, but whether from local 
conditions, as the pressure of a shattered internal 
table, or of a clot, was difficult to determine. It 
was too early for pus to have formed. 
I had recently seen two cases of traumatic menin- 
gitis in boys: one from fracture of the skull, the 
other from an infected scalp wound. In both there 
were well-defined cortical lesions, with all the typical 
symptoms. On trephining these cases however, 
nothing was found but a general meningitis, a diag- 
nosis confirmed by autopsy. 
In the present case, it seemed to me that there 
were no symptoms which could be relied upon as an 
indication to operate. Besides, in refraining from 
operating I followed the opinion of the veteran 
French surgeon Verneuil, who says : "Qu'on fasse 
dans le laboratoire toutes les experiences, qu'on 
vondra ; mais qu'on se garde les transportes au lit 
du malade."1 This entirely harmonizes with my 
own experience. 
I was anxious to ascertain the condition of the 
wound, and, if I found indications of incipient 
ostitis, to trephine, as recommended by Bryant.2 
My intention was to remove one or two sutures, in- 
spect the line of incision, and reclose the wound 
without using an anaesthetic. But I found the 
1 Mercr€di Medical, May 27, 1890. 
2 Surgery, third edition. TWO CASES OF FRACTURED SKULL. 
9 
tissues behind the ear puffed, oedematous, and dis- 
colored. On freeing two or three of the sutures I 
saw that the whole wound was in a bad condition. 
The edges were covered with a dirty grayish 
exudate, and were slightly everted, and the whole 
had an appearance indicative of disease beneath the 
bone. 
As I saw that our operative procedures would be 
somewhat tedious, and as the patient was keenly 
sensitive to pain, and, excepting his temperature, in 
a good general condition, I decided to give him a 
few whiffs of chloroform, presuming that this would 
be taken with less resistance and more rapidly than 
ether, and that it would not congest the vessels of 
the brain. 
Dr. F. P. Hammond, third assistant-surgeon of 
the hospital, an extremely cautious and painstaking 
man, administered the chloroform by sprinkling a 
few drops on lint placed in a tumbler. I had de- 
nuded the skull, and removed a piece of bone with 
a small trephine and rongeur, when I noticed, in 
an instant, several terrible changes. The patient 
ceased to breathe; his features were black and 
bloated; he foamed at the mouth; the eyes 
bulged, and plainly he was asphyxiated. Feeling 
for the radial pulse, I was amazed to find it full, 
slow, and regular-about 60 to the minute. We 
had before us a genuine case of chloroform-poison- 
ing, with all the symptoms which have been de- 
scribed by other authors and investigators. 
The respiratory centres yieldedfirst. This was clear 
and unmistakable. All our resources were immedi- 
ately applied, namely, artificial respiration, inversion, 
inhalation of nitrite of amyl, hypodermic injection 
of atropine, drawing the tongue forward, douching 
of the face, and friction of the body. After an in- 
terval of what seemed five, though in reality not 10 
MAN LEY, 
more than two, minutes, the patient gasped several 
times. A little later he breathed again, but very 
irregularly, and would cease unless artificial respira- 
tion were continued. Respiration seemed quite 
fairly reestablished at one time. It was interesting 
to note the condition of the brain in the meantime. 
With dyspnoea and apnoea the brain-tissue crowded 
into the gap made by the rongeur. The vessels 
were enormously distended, and of a deep black 
color. With partial return of respiration the brain 
gradually receded, and the vessels collapsed to their 
usual calibre and assumed their normal tint. I had 
noticed, however, before the symptoms of asphyxia 
developed, that the cerebral vessels were greatly dis- 
tended. 
No more chloroform was given after the first lethal 
symptoms were manifest. 
Although respiration was partially restored, the 
deep cyanosis remained, the breathing continued 
stertorous, and frothy mucus, tinged with blood, 
oozed from the mouth. In about five minutes, or 
possibly a little longer, there was another break in 
the rhythm of the breathing. This time all our efforts 
were futile. As in the first instance, the pulse con- 
tinued to beat fully two minutes after the patient 
was apparently dead, or rather had ceased to breathe. 
Although I have witnessed the administration of 
ether and chloroform a great many times, this is the 
first case in which I have seen death immediately 
and directly attributable to the antesthetic. 
This case so clearly and absolutely provesthat the 
lethal action of chloroform begins by benumbing 
the respiratory centres, that no one can question it. 
The condition is a veritable asphyxia. The phe- 
nomena, to the eye, are precisely the same as those 
seen in cases of spasm or stenosis of the larynx; in TWO CASES OF FRACTURED SKULL. 
11 
persons who have been submerged in water, and in 
those struggling through an epileptic fit, when the 
laryngeal muscles are temporarily convulsed. 
It was in the initial stages of anaesthesia that the 
respirations ceased, and after very little chloroform 
had been given. The vaso-motor nerves and the 
cardiac centres were affected consecutively. The 
blood, surcharged with carbonic acid, soon de- 
stroyed the vitality and irritability of the pneumo- 
gastric and sympathetic nerves. 
Clearly perceiving, then, how the action of the 
drug manifests itself, we are in a position to deal 
with it intelligently. We should act with two 
objects in view: first, to unload the vascular system, 
and the brain; and, second, to keep up respiration. 
It may be said that when breathing ceases the 
respiratory centres are paralyzed, and all efforts at 
resuscitation are useless. 
But we see many cases which prove that this is not 
always true. A case of tracheotomy, for instance, re- 
ported by me in the New England Medical Monthly, 
January, 1890, is an illustration. In this case, after 
the trachea was opened, the patient inspired blood. 
He ceased to breathe, but the pulse continued to 
beat for some time. With the body limp' and 
apparently lifeless, we worked fully five minutes with 
artificial respiration, when the patient gasped, and 
shortly revived, ultimately making a good recovery. 
A surgeon related to me, how in a case of croup, 
he called in a consultant, who advised tracheotomy. 
Some blood was drawn into the windpipe, the in- 
fant had a terrible convulsion, and turned over 
apparently dead. The consultant, quite shocked at 12 
MANLEY, 
the result, and fearing the maledictions of the 
parents, immediately left. But the attending physi- 
cian remained at his post, wiped out the bleeding 
opening, and with his own lips blew into the child's 
trachea. In a few moments-fully ten, he thinks- 
the child commenced to breathe, and finally made 
a good recovery. 
In the case reported above, had we worked more 
diligently at renewing the air in the lungs, and 
given less attention to the incision, the result might 
have been different. But we were too confident; 
besides, I had to search for and ligate a small 
meningeal vessel which commenced to spurt freely. 
When respiratory paralysis occurred for the second 
time, had we done a tracheotomy and used the in- 
valuable apparatus of Dr. Joseph Fell, of Buffalo, 
for forced respiration, I am confident our patient 
might have been saved. 
The unfortunate termination of this case has 
more strongly than ever convinced me of the im- 
perative need of an experienced and trained anaes- 
thetizer-one who will give his whole attention to 
administering anaesthetics; a man of good judgment 
and who is solely concerned with the patient's gen- 
eral condition. He should be specially licensed, 
and the administration of an anaesthetic, other than 
in an emergency, by anyone not professionally and 
legally qualified should be regarded as a misde- 
meanor. The present custom is dangerous, and little 
short of being positively criminal. Usually the an-, 
aesthetic is committed to the junior assistant, who 
is almost wholly ignorant of practical work. He is 
often more interested in the operation than in giving TWO CASES OF FRACTURED SKULL. 
13 
the anaesthetic, so that when he finally looks into 
his patient's face, and feels the pulse, perchance the 
patient is dead. Let us hope that a reform in this 
matter will soon be accomplished. 
The physical characteristics of the two fractures 
demand only brief mention. From a medico-legal 
point of view, they are full of interest, and also to 
those who may be called on, in a court of justice, 
to testify as to the quality and direction of force 
brought to bear in traumatic lesions of the skull. 
It will be noted that the children were found 
alone and unconscious, in an open field. No one 
has been found who saw the accident, or at least 
who will admit that he saw it. 
In each case, so similar were the osseous lesions in 
extent and direction, that it would certainly seem 
that they were inflicted with precision and deliber- 
ation. The violence must have been great and 
concentrated. Its point of impact was very lim- 
ited, and chiefly in the direction of the base. There 
were no rocks in the place where the boys were in- 
jured. It is hard to conceive how these boys, of 
light weight, precipitated from a stone-truck, about 
two feet from the ground, to soft, elastic turf, could 
receive such injuries. Did the wheels pass over 
their necks or heads? There were no abrasions 
or contusions except those immediately over the 
wounds, and if the wheel had passed over their 
heads the wounds would have been larger. 
Had not the boys regained consciousness, or had 
they been found dead, so that no history could have 
been obtained from themselves, the state of the in- 14 
TWO CASES OF FRACTURED SKULL. 
tegument, the shape, direction, and extent of the 
fractures would have thrown no light on the injury. 
These cases would seem to prove that there are 
serious bone-lesions in which we are absolutely un- 
able, from the condition of the parts, to say what 
was the nature of the force, or in what direction it 
was applied; hence the importance of the surgeon 
proceeding with great caution when giving testi- 
mony, on which great consequences or even a 
human life may depend, when such testimony is 
merely presumption or hypothetical premises. THE MEDICAL NEWS. 
A National Weekly Medical Periodical, containing 24-28 Double- 
Columned Quarto Pages of Reading Matter in Each 
Issue. $4.00 per annum, post-paid. 
The year 1890 witnesses important changes in THE MEDICAL NEWS 
resulting from a careful study of the needs of the profession. Its price 
has been reduced, and its bulk also, though in less proportion. The mass 
of information, on the other hand, has been increased by condensing to 
the limit of clearness everything admitted to its columns. Three new 
departments have been added to its contents-viz.: Clinical Memoranda, 
being very short signed original articles, Therapeutical Notes, presenting 
suggestive practical information, and regular Correspondence from medical 
centres. Hospital Notes will detail the latest methods and results of leading 
hospital physicians and surgeons. Special articles will be obtained from 
those best qualified to write on subjects of timely importance. Every 
avenue of information appropriate to a weekly medical newspaper will 
be made to contribute its due information to the readers of The News. 
The American Journal of the Medical Sciences. 
Published monthly. Each number contains 112 octavo pages, 
illustrated. $4.00 per annum, post-paid. 
IN his contribution to A Century of American Medicine, published in 
1876, Dr. John S. Billings, U. S. A., Librarian of the National Medical 
Library, Washington, thus graphically outlines the character and services 
of The American Journal : " The ninety-seven volumes of this Journal 
need no eulogy. They contain many original papers of the highest value; 
nearly all the real criticisms and reviews which we possess; and such care- 
fully prepared summaries of the progress of medical science, and abstracts 
and notices of foreign works, that from this file alone, were all other pro- 
ductions of the press for the last fifty years destroyed, it would be possible 
to reproduce the great majority of the real contributions of the world to 
medical science during that period." 
COMMVTATION RATE Postage paid. 
The Medical News, published every Saturday, 1 
The American Journal of the Medica'l > in advance, $7.50. 
Sciences, monthly, J 
LEA BROTHERS & CO., 706 and 708 Sansom St, Ph Ha.