A soldier of the 29th Regiment was struck on the right parietal bone in a similar manner, shortly after daylight, at the battle of Talavera, during the first attack on the hill, the key of the British position. He walked to me soon afterward to the place where the wounded of the evening before had been collected in the rear. Being otherwise employed, I heard his story but could not attend to him at the moment, and found him some time afterward insensible, with a slow, intermitting pulse, breathing loudly, and supposed to be dying. The fractured parts were sufficiently broken to admit of the introduction of two elevators, by means of which they were gradually removed, together with a large coagulum of blood which had depressed the brain. When this had been done the brain regained its level, the man opened his eyes, looked around, knew and thanked me. The pulse and breathing became regular; he said he suffered only a little pain in the part, and should soon get well. He died, however, on the third day.
During the battle of Salamanca a soldier of the 27th Regiment was brought to me, who had walked to the rear, and had fallen down insensible within a few yards of the hospital station. I found a considerable fracture, with depression at the inferior part of the parietal bone before and above the ear. The end of the elevator having been introduced, a small piece of bone was first raised, then another, and a third, when a thick coagulum was exposed and removed. The dura mater was not separated from the bone around to any extent, and the coagulum, although thick, was not large. The brain, which had been depressed, regained its level immediately; the man recovered his senses, and was cured of his wound, but remained unfit for service. The artery did not bleed after it had been exposed.
The rule in surgery, to remove the bone in such cases, is absolute.
261. Fractures of the skull are stated, from almost the earliest records of surgery, to occur on one side of the head in consequence of blows received on the other. The facts which ancient authors have collected and related on this point are so numerous and so well attested that it appears almost more than skeptical to doubt their accuracy, however seldom they may be now observed.
A counter-fracture or fissure of one parietal or temporal bone, caused by a blow on the opposite one, is of such rare occurrence that it is in general unnoticed by later writers on injuries of the head. It is not so, however, with respect to a fracture at the base of the cranium from a blow on the vertex, or on the back part of the head—a kind of accident which occurs more frequently perhaps than any other in civil life—because persons who suffer from fractures of the skull do so more generally by falling from a height, or from being pitched on their heads, than by direct blows or other injuries. This accident principally depends on the superincumbent weight of the body pressing on the unsupported flat and thin base of the skull, and is but little connected with the unyielding nature of the spine; for it occurs to as great an extent in consequence of falls from a short distance without any impetus, as from falls from a great height. Some of the worst cases take place by the sufferer having been thrown from the back of a horse by the sudden starting of the animal, without any running away. Although in these cases a fissure may often be traced to the foramen magnum, the great fracture is essentially distinct, extending from the petrous portion of the temporal bone on each side, across, and between the sphenoid bone and the os frontis, and even separating the edges of the coronal suture nearly to the opposite side.
A noted gambler was thrown from his horse, and pitched on the top of his head at the door of the Westminster Hospital, late at night; he was taken up insensible, and died shortly afterward. The skull was fractured quite round from the vertex to the base, and from side to side, so that the fore and back parts might have been easily separated into halves, if the soft parts had been removed. Fractures of the base of the cranium are generally fatal, but not always so; for some persons live a considerable time afterward, and appear to die from other causes; so that partial, if not perfect recovery is possible.
H. Cochrane, forty-five years of age, fell a distance of twenty feet upon his head, and was taken up apparently lifeless, bleeding largely from the ears, nose, and mouth, but more particularly from the ears. He was seen within half an hour of the accident. He was then quite insensible; the surface of the body cold; pulse about 68, and very feeble; in three hours after the accident he was bled to sixteen ounces, when his pulse rose to 76, and the breathing, which before was rather oppressed, became more free. He was ordered six grains of calomel, followed by moderate doses of senna, till the bowels should be relieved.
He continued progressively mending, but in a state of stupidity, accompanied by extreme listlessness; answered questions sullenly, and frequently rested upon one arm without appearing conscious of pain; the mouth was drawn to the left side, to which there had been a slight tendency for some days; the tongue not at all affected.
He continued under treatment for three weeks longer, soon after which he was permitted to resume his employment, the mouth being still drawn in some degree to the left side. His habits became silent and solitary, but he performed his task with the greatest exactness. He was occasionally subject to vertigo, particularly in hot weather, after any violent exertion or taking a small quantity of beer; a pint of ale would render him stupid or insensible. Six months afterward he was found dead, lying in a ditch.
Sectio cadaveris.—The nasal bones were fractured by a blow which had made a transverse incision in the upper part of the face. The femur was found fractured upon the right side, and the scalp puffy and ecchymosed on the left. On removing the skull-cap, the dura mater appeared perfectly healthy, without any sign of extravasated blood upon the surface. Beneath the pia mater on the left side the sulci of the brain were filled with black blood, apparently very recently effused. The brain was removed without the least violence, when a lesion was found upon its inferior surface, corresponding to the petrous portion of the right temporal bone. The dura mater in this situation was externally of its natural structure, and adhered with its usual degree of firmness to the bone beneath. The arachnoid and pia mater were here deficient; the lesion consisted of a cavity about fifteen lines in length, nine in breadth, and three in depth, coated with a light-yellow lining, which also adhered to the corresponding portion of the inner surface of the dura mater, which completed the walls of the cavity inferiorly; it contained a turbid serum, in which were seen floating numerous but exceedingly minute white globules. The portion of the brain in this situation did not appear to have been disturbed by the recent violence, except that from the upper part of the cavity a probe was admitted without any resistance into the descending horn of the right lateral ventricle, which, with the one on the opposite side, was filled with a large quantity of bloody serum, none of which, however, had escaped into the cavity beneath. The brain generally appeared perfectly healthy, and not more vascular than usual. Even within a line of the yellow deposit above mentioned there appeared not the slightest change of structure. On removing the dura mater from the base of the skull, indications of a former fracture were discovered, leading vertically down through the squamous portion of the temporal bone, whence it appeared to have been continued along the anterior part of the petrous portion into the Vidian canal; the edges of this fracture, both internally and externally, had been rounded by absorption; it was met at right angles by another which ran across the base of the petrous portion of the temporal bone. The direction of the last fracture was marked by numerous small, rough particles of bone, which adhered so slightly to the rest that they separated on maceration. The transverse ligament of the second vertebra was ruptured, and the atlas forced forward. The connection between the articular processes of the second and third cervical vertebræ on the right side had also been separated by the fall which had caused death.