Reprinted from the Colorado Medical Journal, January, 1897. 
TWO CASES OF FRACTURE OF THE SKULL. 
CLAYTON PARKHILL, M.D., 
Denver, Colo. 
Professor of the Principles and Practice of Surgery and Clinical Surgery, and 
Dean of the Medical Department of the University of Colorado; Visiting 
Surgeon to the Arapahoe County and St. Luke's Hospitals: Sur- 
geon General, Colorado National Guard, Etc. Reprinted from the Colorado Medical Journal, January, 1897. 
TWO CASES OF FRACTURE OF THE SKULL* 
CLAYTON PARKHILL, M.D., 
Denver, Colo. 
Professor of the Principles and Practice of Surgery and Clinical Surgery, and 
Dean of the Medical Department of the University of Colorado; Visiting 
Surgeon to the Arapahoe County and St. Luke's Hospitals; Sur- 
geon General, Colorado National Guard, Etc. 
We have two cases of unusual interest to show you to-day. 
Both were admitted yesterday, and I will ask you to examine them 
with me. Both give a history of head injury. 
The first you see before you. He is perfectly conscious and 
tells me that two days ago, on alighting from a street car, he was 
struck from behind by a bicycle and thrown forward, striking his 
head against the side of the car. Yesterday he presented himself 
as a patient at the University of Colorado Dispensary, and walked 
from there to this Hospital, a distance of about a mile. 
On examination several significant facts are apparent. First, 
the blow was received on the right side of the head, in the temporal 
region. You will recall that this is one of the weakest and thinnest 
portions of the skull. You will observe that he has on the cor- 
responding side a “black eye,” with no evidence of injury in that 
immediate region. In head injuries this may be a symptom of the 
greatest importance. In this case it probably indicates a fracture 
of the orbital roof, permitting an outflow of blood into the loose 
orbital tissues. On separating the lids we have another indication 
of fracture at the base of the skull in a sub-conjunctival ecchymosis. 
This is indicative of haemorrhage into the sheath of the optic nerve. 
It is one of the most reliable indicatiions of fracture at the base of 
♦ A Clinical Lecture Delivered at the Arapahoe County Hospital, November 24, iBqb. the skull involving the anterior fossa. On inquiry I find that he 
suffered a severe haemorrhage from the nose and from the mouth 
immediately following the injury. This is significant, in as much 
as he says he never had nose-bleed before in his life. 
The haemorrhage from the nose might come from two sources. 
It might either be poured out from one or both of the Eustachian 
tubes, indicating involvement of the petrous portion of the temporal 
bone, or it might come from a fracture of the cribiform plate of the 
ethmoid, extending into the foramen caecum and opening the supe- 
rir longitudinal sinus. In that event the haemorrhage would probably 
be of dark blood, and difficult to control. This, the man says, was 
the case. The haemorrhage into the mouth might either have been 
due to the trickling of the blood from the posterior nares or it 
might indicate a fracture throught he basilar process of the occipital 
bone with rupture of the pharyngeal vault. An examination of the 
throat shows no ecchymosis behind the posterior pharyngeal wall, 
which probably eliminates basilar fracture, but it shows the pharynx 
smeared with blood. 
He further gives a history of bleeding from the left ear. An 
examination shows no injury of the external ear. Some dried blood 
is found in the meatus. This bleeding may either be due to injury 
of the tympanum alone, or to a fracture through the petrous portion 
of the temporal bone. In as much as you will observe that he can- 
not hear my watch held close to the ear, it is probable that the lat- 
ter condition obtains and that the auditory nerve has been de- 
stroyed, I find also that he complains of a loss of sensation in the 
region supplied by the first and second divisions of the right fifth 
nerve. The first is significant of a fracture involving the foramen 
lacerum anterius, and the second of a fracturein volving the foramen 
retundum, those being the bony openings which give exit to those 
divisions. He finds it impossible to protrude his tongue. This is 
probably not indicative of paralysis of the muscles as he complains 
of inability to separate the jaws to the full extent, owing, no doubt, 
to a contusion of the right masseter muscle, evidence of which you 
see in an abrasion over that region. An examination of the reflexes 
show them to be somewhat exaggerated on the left side. This is 
probably indicative of pressure from the haemorrhage at the base of 
the brain. That it is not great in amount is shown by the fact that he is perfectly conscious and has a practically normal pulse and 
temperature. From this examination I think you will agree with 
me in a diagnosis of extensive fracture at the base of the skull, in- 
volving the anterior and middle fossae. 
You might now ask me what treatment should be instituted for 
this man. Very little. The most important will be absolute rest in 
bed. We will keep the excretory organs active, because that will 
assist in nature’s effort to absorb the effused blood at the base of 
the brain. We will give him light, easily digested food. Most sur- 
geons recommend an ice bag to the head in these cases, but I have 
always been very skeptical as to the good resulting from such treat- 
ment. In case he should become delirious and show excessive ir- 
ritability of the nervous system, we will give him some of the seda- 
tives, preferably bromides. The nasal cavities and external ear 
should be cleansed with some antiseptic solution several times a 
day, in order to prevent infection of the wounds in this region. 
Such an infection may be very disastrous, and would probably re- 
sult in septic basilar meningitis. 
Case 2—This patient gives a history of having been struck on 
the head with an ax about twenty-four hours ago. After the injury 
he was able to walk from Globeville to the city hall, a distance of 
about four or five miles. Since his entrance into this hospital he has 
been dressed, and has been anaesthetized, preparatory to our exam- 
ination and operation, if necessary. On the dressing being removed 
you will observe that the entire scalp has been shaved. This is a 
point in the treatment of scalp wounds, whether associated with 
fractures of the skull or not, which is of great importance. It is im- 
possible to thoroughly cleanse a wound of the scalp unless the en- 
tire head has been shaved. You will observe an irregular lacerated 
wound directly on top of the head, or at a point described by an- 
atomists as the obelion. On examining this wound I find at its bot- 
tom a well marked depressed fracture of the skull. The depression 
is not great, but evidently corresponds to the size and shape of the 
pole of the ax. Before anaesthetization he did not present a single 
symptom referable to brain injury either in the way of mental de- 
rangement, compression or concussion. 
In the abscence of symptoms you might ask me what is the 
proper treatment for this fracture. Should we simply stitch up this scalp wound and wait for symptoms and treat him on the “expect- 
ant plan” or should we trepine the skull and elevate the depressed 
bone? If you will read the books of most the older surgeons you 
will find that they will advise you to pursue the former method. In 
the light of modern surgery 1 insist that such is absolutely bad 
practice, and that every case of depressed fracture of the skull, 
simple or compound, with or without symptoms,should be operated 
upon. This depressed bone, whether giving rise to immediate 
symptoms or not, cannot fail to act as an irritant to the membranes 
of the brain or to the brain itself. This irritation is likely sooner 
or later to result in a pachy-meningitis or cerebritis, as a conse- 
quence of which the patient may suffer from epilepsy, from cyst of 
the membranes or the brain structure itself, and possibly insanity. 
Before proceeding to operate on this case, however, it is neces- 
sary to remember an important anatomical fact, which is that the 
superior longitudinal sinus lies directly under this depressed bone. 
In applying the trephine we will not place it over the line of the 
sinus, but to one side of it. It is possible that the bone itself may 
have wounded the sinus as its superior wall is extremely thin, but 
we will take no chances in using this instrument. I find it neces- 
sary to enlarge the wound in the soft parts very considerably in 
order to give room for our operation upon the bone. This does 
not increase the risk to the patient, but no operation should be 
undertaken until a clear view is had of the field of injury. Permit 
me to call your attention to a fact which a close inspection of the 
line of fracture reveals. I find hair caught and retained in the fis- 
sure, around almost the entire circumference of the fracture. This 
may seem a trifling matter, but it still further emphasizes what I 
said before regarding the necessity for operation in all of these 
cases. The hair of the scalp is always loaded with micro-organisms 
and its retention here would certainly lead to infection of the 
wound with the probability of the dangers of septic meningitis. I 
will now apply the trephine as far away from the longitudinal sinus 
as possible. You will observe that the stylet is placed on the sound 
bone with only about one-third of the circumference of the instru- 
ment extending over the line of fracture. It is necessary to cut a 
button out of the sound bone in order to secure a solid fulcrum on 
which to rest the elevator with which to bring into place the de- pressed portion. There is one rule for the use of this instrument 
which should never be forgotten, and that is to proceed as though 
this were the thinnest skull ever seen. I have trephined skulls as 
thin as an egg-shell, I have removed the button without wound- 
ing the dura. On using the elevator you will observe that it is 
impossible to bring the depressed portion of bone into its normal 
relationship. In this case I cut away with forceps, using the Keen 
rongeur for that purpose. lam careful to remove all the hair en- 
tangled in the fissure together with the irregular projecting margins. 
The removal of the bone has resulted in a considerable haemorrhage. 
It is dark and comes from two or three points in the longitudinal 
sinus. This probably marks the location of the entrance of the 
parietal veins into the sinus. 
1 will now cleanse the wound with an antiseptic solution. The 
dura has not been opened, so we will be perfectly safe in using it. 
Had there been an opening in the dura we would have used simply 
the normal salt solution. We must now decide how to check this 
haemorrhage. It may be done in two ways, cither packing gauze 
over the sinus when we close the wound, or by enlarging the open- 
ing into the sinus and packing that great vessel with gauze. We 
will employ the former method in this case. 
You might ask me if I will take any precautions to prevent ad- 
hesion between the tissues of the scalp and the membrane of the 
brain, because it is a well-known fact that such conditions frequent- 
ly give rise at subsequent periods to unpleasant nervous manifesta- 
tions. A heavy gold foil is the material most frequently used. It 
would be inadmissible in this case, however, on account of the ne- 
cessity for packing over the sinus to check haemorrhage, but if there 
was no bleeding and no probability of infection I would use it. 
This should be done at a subsequent operation. We will now suture 
the wound, pack a strip of iodoform gauze over the sinus, apply a 
dressing and return the patient to bed.