William Clayton, forty-four years of age, was admitted on the 31st of July, 1841, into the Westminster Hospital, having received a blow on the RIGHT side of his head from the handle of a windlass, by which his skull was fractured. The fracture extended downward from the parietal bone across the temporal, and in all probability through its petrous portion, as blood flowed freely from the ear for the first six hours; he was stunned for a few minutes at first, but became sensible by the time he was brought to the hospital. The bleeding from the ear was followed by the discharge of a fluid resembling water—which is a very dangerous symptom, as it usually flows from the sac of the arachnoid membrane—and afterward at intervals by a discharge of blood and matter, particularly, he said, on coughing; he was also quite deaf, with a little pain on the right side of the head. The bowels were well opened, and he lost sixteen ounces of blood. On the evening of the third of August, the fourth day after the accident, paralysis of the muscles of the RIGHT side of the face supplied by the portio dura came on, or was first observed. Pulse 80. He was well purged, but lost no blood, as he was apparently weak and the pulse soft; it fell next day to 72. Mercury was now administered twice a day until the mouth became sore. On the eighteenth of September he was discharged, cured of the paralysis, the wound on the head being open, and a piece of bone bare and likely to exfoliate. October 8. Readmitted in consequence of great headache after drunkenness, with numbness of the toes and fingers; he was well purged, and felt relieved. He remained in the hospital for a month, his mouth being again slightly affected, occasionally drinking in spite of all remonstrance; he then returned to his work on the piers of Westminster bridge. On the eighth of June several small pieces of bone came away; and the wound nearly healed. The course of the fracture can be traced, in consequence of the scalp having adhered to the bone, causing a slight depression and hardness, which can be felt by the finger, extending down to the ear.
An hostler was thrown on his head from a horse, and was carried to the Westminster Hospital late at night in a state of stupefaction; no other injury could be discovered. The next morning he could answer questions, although not always correctly; complained of pain in his head, had bled from the ears all night, and had vomited some blood two or three times. Pupils dilated, but they contracted on bringing a lighted candle near them; the left eyelid more open than the right; pulse 52; very restless, and constantly turning in bed. V. S. ad ℥xxiv. Calomel and colocynth: salts and senna. Cold to the head. The pulse rose to 60 after the loss of blood. 2d day. Is delirious; bleeding from the ears but trifling; complains of pain in the head; bowels open; passes urine freely; pulse 54, a little irregular. Y. S. ad ℥xvj gave relief. Continue calomel, and salts and senna. 3d day. Restless all night; headache and thirst; bowels open. V. S. ad ℥xiv relieved the pain in the head. Pulse 56. 4th day. Restless and delirious at night; pulse 60, regular; bowels open; headache. V. S. ad ℥xiv. No discharge from the ears. 6th day. Slightly paralytic on the left side of the face, tongue drawn to that side; headache, restless, delirious; feces and urine passed unconsciously; pulse 80. V. S. ad ℥xx. Pulse rose to 100, and was weaker. Calomel, gr. iii every six hours. 7th day. Pulse 88, compressible; restless at all times, delirious at night; bowels open, but he is more conscious of everything. 8th day. Pulse 80, small, intermitting; occasionally slept a little, and is generally better; bowels well purged; paralysis of the face continues. Has taken a little farinaceous food. Continue calomel and inf. sennæ. 10th day. Improved; slept tolerably well. 12th day. Continues to improve. Omit the calomel, but continue the infus. sennæ. 16th day. Is better. Paralysis lessened. Recollects he was thrown from a horse, but nothing else. Is free from pain, but very weak. Mouth a little sore.
After this time he gradually recovered, but was for a long time unable to work, or to undergo any exposure. A very little more mischief, and he would have gradually sunk, and died after the seventh day, instead of slowly recovering.
LECTURE XVIII.
INJURIES OF THE HEAD.
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.