of Trephining. 
FRACTURE OF THE INNER TABLE OF THE 
CRANIUM-DEPRESSED BONE—COMPRES- 
SION OF THE BRAIN—A CASE—STRA- 
BISMUS—RECOVER Y. 
William D. Roster 0). D. 
KANSASCITY, MO. 
Reprint from the Transactions of the American Institute of 
Homceopathy, at the Session held at Niagara Falls, 
Neio York, June 19-22, 1883. 
KANSAS CITY: 
PRINTED AT THE PANTAGRAPH JOB OFFICE, SHEIDLEY BUILDING, NINTH & MAIN. 
1884. HISTORY OF TREPHINING. 
Fracture of the Inner Table of the Cranium,— 
Depressed Bone,—Compression of the Brain- 
History of Trephining,—A Case.—Strabismus.— 
Recovery, 
Wm. D. Foster, M. D., Kansas City, Mo. 
“No Injury to the head is too slight to be despised, or too grave to be despaired 
of.’’—Hippocrates , 
The treatment of fractures of the skull hag been 
justly held to involve many difficulties. From its 
exposed position, the head is liable to frequent and 
varied accidents; from the importance of its con- 
tents—the brain, injuries to this part present an 
interesting study to the surgeon, possessing, usually, 
marked elements of danger to the individual. The 
surgeon, brought face to face with the grave and 
often complicated problems thus unfolded must de- 
termine and act with celerity. He has little time 
to reflect, and none to consult authorities. He 
must be prepared for the emergency. With the 
purpose, therefore, of elucidating some of the latest 
views and soundest principles which prevail rela- 
tive to the treatment of these injuries, we will in- 
terrogate somewhat in detail, the surgical records 
of the past as well as those of the most distinguish- 
ed authors of the present, and inquire into the re- 
sults of the operation of trephining. 
The student is bewildered at the outset by the 
diversity of notions encountered. Were the begin- 
ner, the tyro, to govern his operative steps by the 
voice of authority, to whose dictum would he give 
ear? In surgery it is not always wise to be gov- 
erned by the prepond erence. of testimony. This 
inquiry is not only interesting from a surgical stand- 2 
HISTORY OF TREPHINING. 
point, but will develop, incidentally, the multifa- 
rious and conflicting doctrines which have gained 
prominence in different countries, and at widely 
remote periods. The practical fact in regard to the 
operation of trephining is: When is it clearly war- 
rantable ? 
Operation of Trephining. 
The 'tircnm stances which require this operation 
are: 
1. Compound fracture with depression of bone, 
with Or without symptoms of compression. 
2. Simple fracture with depression and symptoms 
of compression, after a fair trial of ordinary means. 
8. Punctured fractures, no matter what may be 
the condition of the brain. 
4. Extravasation of blood between the skull and 
dura mater, or in the arachnoid sac on the cerebral 
hemispheres. 
5. The existence of pus in the same situations. 
6. Foreign bodies. 
7. Epilepsy and other secondary effects.* 
Trephining the cranium should be regarded as an 
operation always fraught with danger,! and only to 
be performed from absolute necessity.X 
The following general rules should guide us in 
deciding the question:§ 
1. In diffused injuries to the cranium and its con- 
tents all operative interference is unjustifiable. 
2. In simple fractures, with or without depres- 
sion, operative interference is only called for when 
marked and persistent symptoms of local compres- 
sion of the brain exist. 
8. In compound comminuted fractures, with or 
without brain symptoms, the depressed bones should 
be elevated and the fragments removed, with the 
object of taking away known sources of irritation 
to the membranes—a common cause of encephalitis. 
4. In all local cases of traumatism of the cra- 
nium, of fractures or other injury, followed by clear 
* Gross, System of Surgery, Vol. 2, p. 174. Edition 1877. 
+ Erichsen, Science of Art of Surgery, 1860. 
i Ranney, Practical Medical Anatomy, 1882. 
§ Bryant, Practice of Surgery, 1872. HISTORY OF TREPHINING. 
3 
clinical evidence of local inflammation of the bone, 
and persistent symptoms of brain irritation or sub- 
osteal suppuration, the operation should be under- 
taken. 
There are certain suggestions* which are safe to 
follow in cases where the propriety of surgical re- 
lief is called in question: 
1. If the injury be situated on the motor area of 
the cortex, the presence of anaesthesia in combination 
with motor hemiplegia, is a contraindication to at- 
tempts at relief. 
2. If the sensory region of the cortex be involved 
and paralysis or convulsive movements occur, an 
operation is contraindicated. 
8. The occurrence of paralysis on the same 
side as that upon which the injury was received, is 
always a contraindication to any surgical proceed- 
ure at the seat of injury, since it indicates some 
lesion of the opposite side, probably dependent upon 
transmitted force {centre coup). 
4. The completeness of the paralysis may be 
often taken as a guide to the amount of injury done 
to the cerebrum; if the paralysis be very profound, 
the chance of success from the trephining is ex- 
tremely small. 
5. The appearance of paralysis of any of the spe- 
cial nerves of the cranium and vomiting may be re- 
garded as contraindications to surgical interference. 
6. If the region over the fissure of Rolando be 
subjected to apparent injury, and the symptoms of 
some of the special types of monoplsegia appear, 
successful trephining may be reasonably expected. 
The presence of anaesthesia would, however, still 
be a strong contraindication to such a step. It must 
be also remembered that the motor paralysis of 
whatever kind must be confined to the side of the 
body opposite to the seat of injury, if benefit is to be 
expected. 
The foregoing rules and suggestions are deserv- 
ing of the most pointed condemnation. They are 
neither theoretically plausible, nor clinically correct, 
*Eanney, loc. sit. 4 
HISTORY OF TREPHINING. 
and clearly calculated to mislead. A rigid adher- 
ence thereto would have deterred any surgeon from 
undertaking the operation reported further on; nay, 
gauged thereby, it would have been plainly unjus- 
tifiable. Further, were these propositions sound, the 
availability of the trephine would be at an end; for 
after a careful examination of the details of every 
well authenticated case of trephining to be found 
recorded in the annals of surgery—both civil and 
military—no single case falls entirely within their 
scope. Confronted with such advice, and acting 
thereon, the surgeon would let his patient with a 
broken head perish without attempting any opera- 
tive step for his relief. Such refinements are, and 
have been always, the cause of great mischief, and 
are undoubtedly responsible for much of the bad 
surgery in all ages. 
The trephine should not be applied to any of the 
following points: the frontal sinus, the anterior in- 
ferior angle of the parietal bone; the course of the 
longitudinal sinus, the occipital protuberance and 
the different sutures.* 
The accomplished Sir Wm. Fergussonf assures us 
that “the trepan may be applied to any part of the 
side or upper portion of the cranium,” that he im- 
agines the meningeal artery and sinuses may be 
avoided, giving directions how to proceed in case 
the former is wounded. 
It is a nice point to determine whether in a given 
case the patient is laboring under concussion or 
compression, and to which condition the symptoms 
are due. In practice it is not uncommon to find 
these states co-exist. The appended differential ep- 
itome:); will aid in reaching a just conclusion; 
* Gross, Ibid, p. 175. 
t Practical Surgery, p 471. Phiiadeiplua, 1845. 
j Gross, Ibid. p. 181-2. HISTORY OF TREPHINING 
5 
Conclusion. 
Compression. 
1. The symptoms are Immediate, com- 
ing on instantly after the infliction of the 
injury. 
1. An Interval of a few minutes, or 
even of a quarter of an hour, some- 
times elapses, especially if the com- 
pression is caused by extravesatlon 
of blood. 
2. The patient is able to answer ques- 
tions with difficulty, and usually only in 
monosyllables, as yes or no. 
2. The power of speech is totally 
abolished; we may hollow In the pa- 
tient’s ear as loudly as possible, and 
yet there will be no response. 
3. Special sensation is still going on, 
the patient being able to hear, see, smell, 
taste and feel. 
B. Special sensation is destroyed. 
4. The respiration is slow; labored, 
stertorous, and performed with a pecu- 
liar sound. 
4. The respiration is feeble, inperfect 
and noiseless. 
5. The pulse is labored, soft, irregu- 
lar, and unnaturally slow, often beat- 
ing not more than fifty, fifty-five or 
sixty in a minute. 
5, The pulse is weak, tremulous, inter- 
mittent and unnaturally frequent. 
6. There is nausea and sometimes 
vomiting. 
6. The stomach is quiet and Insen 
sible to ordinary impressions, even 
emetics. 
7. The bowels are relaxed, and there 
are sometimes Involuntary evacuations. 
7. The bowels are torpid, and are 
with difficulty excited by the action of 
purgatives. 
8. The power of deglutition is im- 
paired, but not abolished. 
8. Deglutition is impossible, and 
sometimes does not return for several 
days. 
9. The bladder retains the power of 
expelling its contents; but sometimes, 
owing to the weakness of its sphincter, 
the water flows off involuntarily. 
9. The bladder is paralyzed, and 
therefore Incapable of relieving Itself, 
tfie surgeon being obliged to use the 
catheter. 
10. The voluntary muscles, although 
much weakened are still able to contract, 
there being no paralysis. 
10. There is always paralysis on one 
side of the body, generally opposite to 
that of the compressing cause. 
11. The pupils are usually contracted, 
and somewhat sensitive to light: the lids 
are open and movable. 
11. The pupils are widely dilated, 
and unaffected by light, the lids being 
closed and Immovable. 
12. In concussion the mind is in a state 
ot abeyance; it is weak and contused, 
not abolished. 
12. In compression the patient is 
comatose, and the mind is temporarily 
abolished. HISTORY OF TREPHINING. 
That the intricacy of diagnosis may be still more 
distinctly emphasized, it has been pertinently ob- 
served that “ail these symptoms, conditions and 
causes have been made by many authors to appear 
very distinct in so far as language and printing are 
concerned, but in practice the difficulties in diag- 
nosis are often so great that even the most exper- 
ienced surgeon will occasionally be at fault; the co- 
existence of concussion and compression has been 
especially noticed by practical men, as also the im- 
possibility of distinguishing which of these condi- 
tions is most urgent, and there are few indeed who 
can congratulate themselves on their invariable accu- 
racy in the investigation of such cases.* The same 
eminent surgeon has further declared that in con- 
cussion, unless the injury be immediately fatal, na- 
ture seems in a manner to struggle against such an 
event, the patient recovers to a certain extent, and 
then perhaps inflammation may run its course, or 
possibly, the rally may be complete. Not so, how- 
ever, in compression : this condition may not evince 
itself for several hours, days or weeks after the inju- 
ry. Sometimes, in injury of the head, a-person seems 
at first to suffer from concussion ; in the course of a 
few minutes, half an hour dr more, he, as it were, 
recovers from the shock, but for a brief time only. 
Hegradually becomes insensible again, and all the 
symptoms of compression become more or less dis- 
tinct. Such has been the history of some instances 
when the middle meningeal artery has been torn. 
The treatment of depression must depend on cir- 
cumstances. If the symptoms are evidently due to 
a depressed fracture of the cranium, recourse should 
at once be had to the operation of trephining. 
Where the compression results from effusion of 
blood within the membranes, the rule is laid down 
that if the symptoms are such as to show that the 
immediate dangers from compression are so great as 
to overbalance those arising from the meningitis 
which the puncture may induce, the membranes 
should be incised and the blood evacuated.f If a 
* Fergusson, loc. sit. 
t Smith, H. H., Practice ol Surgery, p. 299, Ed. 1856. HISTORY OF TREPHINING. 
7 
person had received a blow on the temple, and if 
from the symptoms I suspected effusion of blood 
from the meningeal artery, I should not hesitate to 
perforate the cranium with a trephine, over the sup- 
posed collection ; and in the event of compression 
coming on in the course of a number of days, and 
when suppuration might be suspected, the same 
method might be adopted.* 
The treatment of depressed fractures, when com- 
bined with symptoms of compression, will consist 
in antiphlogistic resources and in the performance 
of the operation of trephining, with the view of 
elevating the depressed fragments and thus reliev- 
ing the compression, f 
In order to determine those parts of the brain 
which underlie definite points marked upon the ex- 
terior of the skull, the following engraving is sug- 
gestive. The line described by the base of the fig- 
ure is known as the Alveolo—Condyloid Plane of 
Broca : J 
pig. 1. 
Outline of skull resting upon the Alveola-Condyloid Plane of Broca (modified) 
* Ferguson, Ibid, p. 469. 
t Smith, Ibid, p. 336. 
$ Ranney, Ibid. 8 
HISTORY OF TREPHINING. 
Vertical line A, or anriculo-bregmatic line 9-10, 
drawn parallel to the plane of Broca. Upon this 
line, at a distance of 45 m.m., posterior to the breg- 
ma or vertical line 1-2, will pass through the upper 
(inner) end of the fissure of Rolando, b, b, and through 
the posterior extremity of the thalamus opticus (c). 
A third vertical line 8-4, drawn at 30 m.m., forward 
of the bregma, will pass through the fold of the 
third frontal gyrus (a), and through the head of the 
nucleus caudatus (d). The horizontal line 7-8, at 
45 m.m. below the bregma (scalp) indicates the up- 
per limit of the central ganglia. The third horizon- 
tal line 5-6, passing through the external angular 
process of the frontal bone and the occipito-parietal 
junction, approximately indicates the course of the 
fissure of Sylvius, and serves for measurements. , At 
18 or 20 m.m. behind the external angular process 
on this line, is the speech center of Broca; sto 8 
m.m. behind the intersection of 8-4 and 5-6, is the 
beginning of the fissure of Sylvius ; and at 28 or 80 
m.m. behind this intersection, is the lower end of 
the fissure of Rolando, b, b, placed a little too far 
back in the cut. At x (near 6), near the medium 
line, is the location of the occipito-parietal fissure. 
Some of the preplexities of diagnosis and treat- 
ment are further illustrated in the following 
Case. 
On the 24th of August, 1882, at four o’clock p. m., 
Oeorge F., set. 15, was thrown from his horse. The 
animal became frightened and ran; the lad’s foot 
hung in the stirrup, whereby he was dragged a con- 
siderable distance. In this predicament he was pre- 
sumably struck on the head by the horse’s shoe ; the 
saddle girth finally broke and thus released the boy 
from his peril. He was carried home in a partially 
unconscious condition. Shortly afterwards vomit- 
ing set in and continued at intervals throughout the 
night. 
Some hours subsequently he apparently fully re- 
covered consciousness and complained bitterly of HISTORY OF TREPHINING. 
9 
pain in his head. The following day, Friday, he ap- 
peared conscious when aroused ; took some nourish- 
ment ; he was stupid and slept a good deal, Friday 
night he spent badly; his head was hot; he was rest- 
less and could only sleep a few minutes at a time ; 
frequently got up and changed from one bed to an- 
other ; he grew steadily and gradually worse, when, 
at five o’clock Saturday morning, August 26th— 
thirty-seven hours after the receipt of the injury— 
he had a convulsion, and became again profoundly 
unconscious. The convulsions recurred at inter- 
vals of thirty or forty minutes during the day. He 
took Belladonna, and had inhalations of Chloroform 
during the paroxysms. He became speedily quiet 
under the anaesthetic. 
At four p. m., Saturday—forty-eight hours after the 
accident occurred—I was requested to see'this pa- 
tient in consultatian with Dr. Peter Baker, who had 
the case in charge. At that time I learned the fore- 
going history and found the boy in the condition 
stated. 
Examination revealed contusion and swelling over 
the left parietal region ; contusion and laceration 
of the skin on left side of ’the spinal column from 
the shoulder to the hip ; unconsciousness profound ; 
pulse slow and very full; respiration retarded and 
partly stertorous. Fracture and depression of the 
left parietal bone, with compression of the brain 
diagnosed. Prognosis unfavorable. It is apparent 
that the vital powers are • becoming rapidly ex- 
hausted ; that no medicinal measures are adequate to 
lift him out of his lethargy; that the nerve centers 
cannot rally, unaided, from these accumulated bur- 
dens, thus excluding a trial of expectant treatment; 
that unless the cerebral pressure be speedily relieved 
the patient will perish. In this emergency the ques- 
tion arises, What shall be done ? “ The indication is 
the evident necessity for a fixed course of action.”— 
(Galen.) What is that “fixed course of action?” 
Undoubtedly to relieve the brain pressure by formal 
trephining. This alternative was suggested to the 
parents as offering the only hope of relief; that the 10 
HISTORY OF TREPHINING. 
result was doubtful and that the patient might suc- 
cumb under the operation. Consent was unhes- 
itatingly given, with the added injunction, to do the 
work thoroughly, omitting nothing which might 
conduce to their son’s relief and to his ultimate re- 
covery. Dr. Baker and myself were ably assisted 
and seconded in the various steps of the operation 
by Dr. Nofsinger (retired). 
Operation. 
A crucial incison thus -|-, one and one-half inches 
long was made through the scalp over the center of 
the parietal bone. A considerable quantity of ex- 
travasated blood was turned out from under the scalp 
which was found to. be extensively detached. The 
flaps were held aside with tenaculse. The margins 
of the parietal at the sutures could be plainly felt 
by the probe under the scalp. The external surface 
of the bone was smooth, presenting no evidence of 
fracture in the outer table. Being guided by and 
acting upon general surgical principles, and keeping 
in mind that wise maxim, “Think you are operating 
on the thinnest skull ever seen, and thinner in one- 
half the circle than the other; ”* the trephine was 
applied over the most depressed point on the bone, 
and a segment cautiously removed. Considerable 
haemorrhage occurred immediately the cranial cav- 
ity was penetrated. The blood was dark, being un- 
doubtedly extravasated between the membranes and 
the bone. Examination of the button elucidated the 
whole situation; the fracture was found to be limited 
to the vitreous plate, the fissure being fortunately cut 
across by the trephine. 
Appearance of Inner surface of the button, showing line of fissure. 
Fig. 2. 
♦Holden. Landmarks : Anatomical and Surgical. London, 1876. HISTORY OF TREPHINING. 
11 
The dura mater presented a dark red color, reveal- 
ing inflammatory action ; no laceration of the mem- 
branes could be detected. The elevator was intro- 
duced and the depressed tables restored to their 
normal position. The boy stood the operation well 
and rallied promptly. He had no more spasms after 
the operation, and rested well during the night. 
At three o’clock the following morning he roused 
up with returning consciousness, asked for something 
to eat, remarking that a “fellow couldn’t get well 
if he did not eat,” etc.—the first coherent utterance 
he had made in twenty-four hours. He speedily re- 
gained full consciousness, and made an uninterrupted 
and complete recovery. The scalp wound healed on 
October 81st. 
During convalescence he had strabismus; very 
marked in the left eye, a mere trace in the right 
one; double vision ; objects appeared one on top of 
the other, or sidways, thus : 
h h 
hor thus, h 
This muscular asthenopia and the attendant errors 
of vision were speedily relieved by appropriate lenses 
-thirty-six inch convex for both eyes—and the ad- 
ministration of Grelsem.O every three hours. The 
lenses and the remedy were prescribed by my friend, 
Dr. F. F. Casseday, oculist, of this city. 
The return of conciousness a short time after the 
accident and the long interval between that event 
and the supervention of unmistakable symptoms of 
compression, will recall the observation of Fergus- 
son, already cited. Entire absence of paralysis of 
sphincters or other muscles will be noted. 
From this history and the symptoms named it will 
be readily inferred that the diagnosis in this case was 
no easy affair; that the proper course to pursue was 
at first in some doubt; and indeed it may appear to 
the minds of some that the operation was underta- 
ken upon insufficient ground. The result, however, 
demonstrated the wisdom of the proceeding. 
Remarks. 12 
HISTORY OF TREPHINING. 
The operation in civil practice has been followed 
by varying results in the hands of different surgeons.* 
In the hospitals of Paris and Vienna the operation 
is nearly always fatal; in London, Dublin, Edin- 
burgh, Glasgow, and other large cities of Great Brit- 
ain, the mortality, although also very high, is much 
less ; and in the United States the number of recov- 
eries in proportion to the number of deaths, is as near- 
ly as can be arrived at, as Ito 4. Dr. Lente reports 
that of forty-five cases of fracture of the skull subjec- 
ted to trephining, eleven were cured. The operation 
finds undoubtedly its greatest success in private 
practice. Of six cases coming under the writer’s 
observation—five in his own practice—all made ad- 
mirable and perfect recoveries. The sources of 
danger after operation are haemorrhage, erysipelas, 
encephalo-meningitis, pyaemia, fungus of the brain, 
profuse suppuration, hectic irritation, periostitis and 
caries. 
Remarkable operations upon the bony vault are 
recorded by several different authors. Saviard tre- 
phined one person twenty times successfully ; Martel 
and Le Gendre, in 1686, took away nearly the whole 
of both parietal bones, and yet the patient made an 
excellent recovery. Marechal applied the trephine 
successfully twelve times; Gooch thirteen times; 
Desportes twelve times; Schumaker relates a case 
where the operation was performed eleven times in 
less than a month, and with so little inconvenience 
to the patient that he seldom went to bed after it. 
Phillip, Count of Nassau, fractured his skull in sev- 
eral places by a fall from his horse; he was trephined 
twenty-seven times by Henry Chadborn, a surgeon 
of Neomagen, to whom, after his recovery, he gave 
a certificate as a proof of skill. 
The most extensive use of the trephine in modern 
times is that recorded by Mr. Guthrie, to whom the 
details were furnished by Dr. Evans. The case was 
one involving both tables; twelve perforations were 
required to render the elevation of the depressed bone 
Results of Trephining. 
*Gross. Ibid. HISTORY OF TREPHINING. 
possible. The pressure was not then fully relieved 
until the dura mater was incised to evacuate the ex- 
tra vasated blood. The.patient fully recovered. The 
membranes should not be incised if possible to avoid 
it, owing to the great danger of haemorrhage and of 
encephalitis. Other cases of very extensive destruc- 
tion of the cranial bones are recorded where the 
trephine was applied and the patients fully restored. 
In military practice the results of trephining for 
fracture of the skull with depression are extremely 
disastrous. In the Schleswig-Holstein war, Stro- 
meyer reports that of forty-one cases of gunshot 
fracture of the skull with depression, seven 
died and thirty-four recovered. Of the latter one 
was trephined—the only operation throughout 
that war, which issued favorably. This opera- 
tion was most pointedly condemned by Stromey- 
er and the surgeons generally in that war. In the 
Crimean war the English surgeons operated, suc- 
cessfully, only four times, and then not on account 
of rifle ball wounds. In the French army Dr. Scrive 
asserted that the operation was mostly unsuccess- 
ful. Of twenty cases operated upon by Pirogoff and 
others only six recovered. In explanation of this 
melancholy result, it may be presumed that the 
operation was only a little more in fashion than 
with Stromeyer, and resorted to in cases of the grav- 
est character alone ; and that then, in fact, the pa- 
tients did not perish from the trephining, but from 
the primary wounds for the relief of which the oper- 
ation was undertaken.* 
In our late war the trephine was applied, it would 
appear, with much greater frequency, and with 
vastly more gratifying results. Of sixteen cases of 
operative interference after gun-shot contusions of 
the cranial bones, four only had a favorable termi- 
nation, and these were examples of the secondary 
removal of exfoliated fragments, wherein nature 
was supplemented by art.f Dr. records twenty 
cases of fracture of the inner table—nineteen of 
*Gross. Ibid. 
f Medical and Surgical History of the War. Ft. 1, Vol. 1, p. 126. 
t Ibid, p. 150. 14 
HISTORY OF TREPHINING. 
whom died. Trephining in four cases was unavail- 
ing. The operations were performed on general sur- 
gical principles. That they were unsuccessful only 
corroborates the opinion that has been so strongly 
impressed on the minds of surgeons of the present 
day that authentic examples of successful trephin- 
ing for matter between the bone and dura mater 
are now very rarely cited. 
The result of trephining for all causes in 220 cases, 
was : 95 recoveries, 124 deaths, 1 undetermined— 
being a mortality ratio of 56.6. To this list is added 
from records subsequently examined, nine cases— 
the histories of which are detailed : seven made 
more or less complete recoveries, aud two died. 
The distinguished Gross* states that fracture of 
the inner table of the cranium is “ chiefly, if not ex- 
clusively, caused by gun-shot injury.” “ The lesion 
is seldom discovered until after death, as it does not 
give rise to any marked, much less characteristic 
symptoms.” These assertions may be regarded as 
too comprehensive, as a considerable number of 
cases of this form of fracture are recorded by credi- 
ble observers, which were not caused by gun-shot 
wounds, were correctly diagnosed, subjected to tre- 
phining and cured. That this fracture is most com- 
monly caused as stated, and that the recognized cases 
are comparatively infrequent, would more nearly 
convey the exact truth. The writer of this paper 
has successfully trephined three cases of fracture 
of the inner table alone, under well-defined indica- 
tions for the operation—none of which were caused 
by gun-shot injury. 
History of Trephining for Fracture of the 
Inner Table. 
It has been asserted that this form of fracture 
was known to Hippocrates, Celsus, Paul of Aegina, 
Yidus Yidius, and other ancient writers, but the ev- 
idence is insufficient. Mr. Teevanf declares that 
Jacobus Berengarius was one of the earliest writers 
* System of Surgery, Vol. 2, p. 152. 
t The British and Foreign Med. Chlr. Rev., Vol. 36, p. 189. HISTORY OF TREPHINING. 
15 
who was aware of this lesion. Ambroise Pare;}; cer- 
tainly records the first case of this fracture wherein 
he found, after death, that the inner table was de- 
pressed, the outer being uninjured. Subsequently 
cases are recorded, one by Garengeot § successfully 
trephined. Saucerotte, || among others, quotes one 
case from Tulpius, 1716, which terminated fatally 
after trephining. Le Dran* records an example of 
this lesion caused by a fall, unsuccessfully trephined. 
Pott f furnishes two cases, both of whom died, one 
being trephined. In one instance the fracture was 
produced by a fall, in the other it resulted from a 
blow on the head. Pott adds that these are the 
only instances he had met of fracture of the inner 
tables alone, but that he made no doubt that some 
of those “ thought to have been destroyed by con- 
cussion, have sunk under this kind of mischief.” 
Bilgeurff records the case of a colonel of grena- 
diers, wherein the inner plate of the frontal bone 
was fractured by a small bullet; the trephine was 
applied three times, and the patient fully recovered. 
Ravaton§§ adduces one case, the injury being caused 
by a ball, the patient perishing without operation. 
Samuel Cooper |||] trephined a man after the battle 
of Waterloo for compression resulting from a shot 
wound on right parietal bone ; the external table 
came away in the hollow of the trephine, leaving 
the internal table behind, which was fractured and 
driven into the brain. No sooner were the frag- 
ments taken out than the man instantly sat up in 
bed, looked around, and began talking with the ut- 
most rationality. He got up and dressed himself 
the same day and never had a bad symptom after- 
pards. records one case not subjected to 
operation, the patient dying on the fourth day from 
encephalitis. Bernhard Beck ** relates three cases 
$ Oeuvres, Edition 1653, T. X., p. 225. 
§ Garengoet, Tralte des Operations de Chlrurgle, Paris, 1738. 
H Saucerotte, T. 4, p. 322. 
* Le Dran, Obs de Chirurg. T. 1, Obs. 17. 
t Pott, Wounds and Contusslons of the Head and Chlr. Works. 
aßiigeur, J. U., Chlrurglsche Wahrnehmungen, Berlin, 1863, p. 30. 
Pratique Moderne de la Chlrurgle, Paris, 1776, T. 1, p. 210 
III! Surgical Dictionary, Hennen, and Brodle Med. Chlr. Trans. 
II Clinique des Plales d’Armes a Feu, Paris, 1836, p. 80. 
** Beck. Die Schusswunden, 1850. Langenbeck’s Arch., 1862. Krel- 
gschirurlsche Erlahrangen, 1867. 16 
HISTORY OF TREPHINING. 
—all fatal—in two of which the injury was caused 
by gunshot wounds, the other by a blow on the 
head from a beer glass ; none of these were tre- 
phined. 
Ochwadt * records the case of a soldier who was 
struck on the left parietal bone by a bullet; death 
from encephalitis resulted on the seventh day. No 
operation was attempted. 
Guttenburg f relates the case of a Baden soldier, 
who at Rastadt—1861—received a blow from a mus- 
ket lock over thfe right parietal protuberance. He 
was not trephined and died on the twenty-fourth 
day. 
Guthrie $ adds two instances of this lesion, one 
died and one recovered. 
La Motte supposes that fracture of the inner table 
alone might be ascertained by the peculiarity of the 
resonance of the skull on percussion, resembling 
the “cracked pot” sound, described in late years by 
auscultators of the chest, and cites an illustrative 
case.§ Atthalen, of Besancon held the same .view, 
adducing an interesting and illustrative case which 
happened in 1746 ; but in this instance there was a 
fissure in the external table also. Stromeyer|| also 
attaches value to this mode of diagnosis. He cites 
two cases, resulting fatally, neither of whom were 
subjected to the trephine. His interesting remarks 
on this subject are quoted at length ; “ This kind of 
injury, of which only one case has come to my no- 
tice, might be observed oftener if we still used the 
trepan as Pott did, or if one could obtain a reliable 
diagnosis without opening the cranium. By means 
of percussing with a silver probe, I was enabled in 
one case, when there was only a barely perceptible 
fissure in the outer table, to diagnosticate the extent 
of the inner separation accurately, and after the de- 
cease from pyaemia, in this same case, many of the 
young surgeons had the opportunity of convincing 
themselves of the correctness of my diagnosis. Any 
* Krlegschlrurglsche Erfahrungen, Berlin, 1865. 
+ Guttenburg In Langenbeck’s Archives, B. 4. 
i Guthrie, Commentaries, 1855. 
§ La Motte, Observation de Chlrurgie, T. 2, p. 303. 
II Stromeyer, Maxlmera. HISTORY OF TREPHINING. 
17 
one of them, who possessed a practiced ear, could 
discriminate the sounds when percussing the outer 
table at the point of the internal fracture, or at other 
points of the cranium. At the point of the internal 
fracture the pitch is somewhat higher. Lanfrancus 
and Ambrose Pare, I find, already knew of this di- 
agnostic expedient. It is wonderful that the inner 
table can be fractured and driven inwards consider- 
ably, while it is impossible to detect the least injury 
on the outer table by means of a lens even, as is 
the case in my specimens. At the same time, these 
cases are not isolated. Partial fractures of bones 
by bending are analogous to them. The outer table 
evidently possesses a greater elasticity, and is more 
pliable than the inner. One can form a good idea 
of the elasticity of the skull, as Hyrtl says, by throw- 
ing a fresh cranium on the floor, when it will re- 
bound. These inner separations remain generally 
undiscovered, which is in my opinion lucky for the 
patient, because thereby he escapes the danger of 
being trepanned. It is not assuming too much to 
suppose that these cases would generally result fa- 
vorably if the patient was subjected sufficiently long 
to an antiphlogistic diefi because the danger in- 
curred by these cases is evidently less than in others, 
where the access of air to the splintered part of the 
inner table takes place. For the older surgeons, 
who did not know the difference between subcuta- 
neous wounds and those exposed to the atmosphere, 
the lesions in cases of head injuries formed a con- 
stant source of anxiety. They could not explain to 
themselves what would become of the secretion of 
the wound. We now know that when the atmos- 
phere is excluded and proper care is taken the in- 
flammatory exudation will become reduced to a 
minimum, sufficient only to permit the healing pro- 
cess ; while it will never become so much as to re- 
quire an external exit channel. 
One need not revert fifteen years in surgical liter- 
ature to be convinced that an unfounded dread of 
the impossibility of an exit for the secretions of the 
wound were then considered proper indications for HISTORY OF TREPHINING. 
trepanning. The ample information which one of 
the most zealous advocates of trepanning, one who 
was an excellent surgeon as well as a truthful man, 
I mean Percival Pott, has given us in regard to the 
effects of trepanning, leaves no doubt as to the 
theory that the access of air increases suppuration. 
In most cases of simple contusions, in which he tre- 
phined on account of the formation of pus internally, 
very little pus was found at the first operation; yet 
the symptons were generally aggravated, and tre- 
panning was resorted to a sesond or third time, and 
not until the secondary operations were great quan- 
tities of pus disclosed. Thus, as usual, one mistake 
brought about another, and one ill-advised use of 
the trephine rendered its repetition necessary. The 
main symptoms which seemed to demand trephining, 
for the majority of surgeons addicted to the trephine, 
consisted in the stupor or insensibility of the patient. 
It really requires no small degree of firmness of con- 
viction of the danger of the trejihine to see a patient, 
not only for days but weeks, in a state of greater or 
less stupor or insensibility without resorting to the 
operation, when sometimes complete consciousness 
is restored immediately by a successful elevation of 
the depressed bone, or the removal of extravasated 
blood. It is not enough to remind one that patients 
with typhus often remain for weeks in a still deeper 
stupor, and yet gradually resume the use of their 
mental faculties; nor is it sufficient to recall the 
innumerable cases where trepanning, notwithstand- 
ing the apparent success of its purpose of elevating 
depressed bone, or removing extravasations, did not 
influence the restoration of consciousness, but where 
this was only gradually regained by means of an 
antiphlogistic treatment, one must have observed 
as often the successful cure of head injuries without 
trephining to be enabled to acquire such accuracy 
of observation, as nearly every physician possesses 
in regard to fever patients. Would not every one 
be called a miserable quack nowadays who would 
give a typhus patient musk, camphor or serpen- 
taria on account of stupor ? It will not be long be- HISTORY OF TREPHINING. 
19 
fore no favorable estimate will be had of any sur- 
geon who will use the trepan on account of coma- 
tose conditions alone. The campaigns of 1849 and 
1850 have, hajDpily, given many young surgeons the 
opportunity to convince themselves with their own 
eyes, that one may look on a condition of semi-stu- 
por for weeks without resorting to the trepan.” 
Pathological specimens of several other examp3les 
of fractures of the inner table only from external 
violence are referred to : one in the Dupuytren 
Museum, 29 A.* It is the calvarium of a young 
man trephined by Denonvilliers, in 1848, during the 
revolution in Paris ; he died on the sixth day from 
encephalitis. Legonest f refers to a specimen of 
this fracture which he brought from the Crimea. 
Cowan X presented a specimen to the Museum at 
Fort Pitt. The subject was a soldier who died on 
the thirteenth day from a fracture of the inner ta- 
ble. No operation was made. Hewitt § states that 
he observed three specimens of this form of fract- 
ure at St. Heorge’s Hospital. 
Mr. Edwards (I presented a specimen to the Medi- 
co-Chirurgical Society of Edinburgh. The injury 
was produced by a blow from a cricket ball. 
refers to one case, resulting from a 
musket ball, the preparation of which he has pre- 
served ; Friedburg * * reports one case in Virchow’s 
Archives, the injury being caused by a fall; Bone- 
tus ff mentions that Cortesius had a skull in which 
this fracture was illustrated. 
References to further examples are to be found 
by Scultetus, 1662; by Soulier, of Montpelier, 1819; 
by Salmuthius, 1648; by Plainer, 1758; by Baiting; 
by Smethius ;by Boring; by Kuhk. Still other 
examples are ascribed to Arcaeus, 1658 ; to Yalleri- 
ola ; and to Borel, 1676, but they do not appear to 
have been fair illustrations. 
* Compendium de Chlrurgle Practique. 
f Legonest, Op. Cit. , , „ 
I Williamson’s Military Surgery; Holme’s System of Surgery. 
§ Medico-Chirurgical Transactions. 1853. 
II Edinburgh Medical Journal, 1862. 
Tf Demme, Speclelle Chlrurgle, etc. Wurzburg, 1857. 
** Virchow Archiv. 1861. 
ft Bonetus. Geneva, 1700. 20 
HISTORY OF TREPHINING. 
Guthrie remarks that “the records of eig’hteen 
centuries have produced but little information on 
this most interesting subject. 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 he separated from the 
outer, without positive marks of an injury having 
been inflicted on the bone or pericranium, however 
slight that injury may have been. An operation 
should never, then, be performed under the expec- 
tation that such an accident may have happened 
unless it is apparently required by the urgency of 
the symptoms indicating compression or irritation of 
the brain, which cannot be relieved by other means.” 
The mechanism of this form of fracture has been 
misunderstood until a recent date. Gross, appears 
to be among the earliest American surgeons who 
had a correct opinion on this point. “ For centuries 
it had been taught that this form of fracture took 
place because of the great brittleness of the inner 
table.” * Brodie f expresses the English view: “ The 
greater elasticity of the outer table of the skull and 
the greater btittleness of the inner table, seems to 
afford the only reasonable solution of these phenom- 
ena.” The French and German surgeons entertained 
a similar view. This was universally held and 
taught until 1865, when TeevanJ demonstrated that 
the cause of this fracture was not the brittleness of 
the vitreous plate, neither was it to be sought for 
in any of the reasons heretofore assigned ; but that 
it occurred in obedience to a well-known physical 
law, viz.: that fracture always commences in the 
line of extension, not that of compression. 
Fig. 1. 
Fig. 2. 
Fig. 8. Diagrams showing the mechanism of 
fracture of the inner table alone, of the skull. 
tt Guthrie, On Injuries of the Head, etc., p. 79. 
* Medical and Surgical History of the War, op. clt. 
f Brodie, Med. Chlrurg. Trans., Yol. 14, p. 331. 
j Teevan, Brit, and For. Med. Chlr. Rev., October, 1865. HISTORY OF TREPHINING. 
21 
Explanation of the Diagrams. 
Let AB, Fig. 1, be a section of the skull. Draw 
two vertical lines, C E and D F, parallel to one an- 
other. Now, if pressure de applied at Gr, temporary 
depression takes place, and the bone assumes the 
shape of H E, Fig. 2, and the lines C, E, D, F are no 
longer parallel to each other, but converge towards 
each other, at the upper surface I, L, J, M, so that 
the distance from I to J is less than that from C to 
D, but the distance from L to M is greater than that 
from E to F, signifying that the atoms of bone in 
the upper surface from I to J have been brought 
nearer to each other or compressed, whilst the atoms 
of bone in the lower surface from L to M have been 
extended or separated from _ each other ; therefore 
if any fracture takes place, it is clear it must do so 
in the line of extension L M, and at that point in 
the line where the greatest extension is going on, 
which is at N, exactly opposite the spot 0, where 
the pressure was applied. 
Proof. 
Take a cane slightly bent, say A B, Fig. 1, and in- 
sert two pins or wires, C, E, D, F vertically and par- 
allel to each other, the more the pins project at each 
surface the more manifest will be the result. Ex- 
ert pressure at G till the cane is made flatter, H K. 
It will now be found that the wires are no longer 
parallel to each other, but converge along the upper 
surface so that the distance between them, from I 
to J, is less than that from C to D, but the distance 
from L to M is greater than that from E to F, showing 
clearly that the atoms along the line I J have been 
compressed and brought nearer to each other, whilst 
those along the line L M have been extended ; con- 
sequently, if any fracture takes place it must be at 
N. If the pressure on the cane be continued till it 
breaks, it will be found it commences to break at N. 
It is the force and not the direction of the violence 
that produces the fracture. “It is justly remarked 
that many cases of this form of injury terminate fa- 22 
HISTORY OF TREPHINING. 
vorably and are never recognized, and, therefore that 
the diagnosis must generally be obscure until clear- 
ed up by the trephine or by autopsy.” “It is evi- 
dent that the treatment of this form of injury must 
be determined by those principles which guide us in 
treating scalp wounds, contusions of the cranial 
bones, concussion and compression of the brain. 
When symptoms of compression are urgent and per- 
sistent, the application of the trephine is undeniably 
justifiable.”* 
*Otis, Medical and Surgical History ot the War.