Reprinted from Columbus Medical Journal for March, 1886. 
AN INTERESTING CASE OF BUZZ-SAW INJURY 
TO THE HEAD. 
BY R. HARVEY REED, M. D. ,* MANSFIELD, OHIO. 
A paper read before the Muskingum Valley District Medical Society, held at 
Newark, 0., February 15, 1886. 
Mr. F., aged thirty, a robust farmer, received a severe wound of the 
head about nine years ago, by falling against a large circular saw, while 
it was in motion. The wound extended from about the upper third of 
the forehead along the line of the longitudinal sinus to almost the crown; 
the skull being completely sawn through for a space of about four inches 
in length and half an inch in width; breaking the attachment of the falx 
cerebri for over three inches, and entirely destroying the longitudinal 
sinus for nearly the same distance. 
A council of physicians was held to consider the advisability of 
removing any spicules of bone that might be pressing on the brain; but, 
as too often is the case, this council came to nought from a disagreement; 
some favoring an operation, but the majority objecting to surgical 
interference. 
He being a man of exemplary habits, and the Lord being on his side, 
notwithstanding his severe injury he lived through it all, and made a 
rapid recovery, but only to eke out a miserable existence the remainder 
of his life. He was only confined to his bed for a few days, the wound 
healed rapidly, and he was soon out and attending to his daily avocations 
on the farm. 
For the next four or five years he enjoyed comparatively good 
health; about this time, however, it was observed that a perceptible 
change was taking place in the skin and vascular system, with an appre- 
*Surgeon for the Baltimore & Ohio and Pennsylvania Companies. Communications. 
2 
ciable enlargement of the head. These symptoms gradually increased 
until the time of his death, some four or five years later (Dec 31, 1885). 
The skin commenced to gradually change from its natural color to 
that of a red hue, which increased in intensity until at the time of his 
death it was an intense florid, especially over the face, while on the breast, 
abdomen, and down the legs, corresponding to the normal locations of 
the larger veins, were intense red bands varying from half an inch to an 
inch wide, while the skin between remained more nearly of a normal 
color, and his hands became covered with warty excrescences. The 
coats of the veins all over the body had by this time lost their elasticity 
and assumed a varicose condition, the heart sounds had become dimin- 
ished, and the arteries had lost, to a great extent, their tone and elasticity. 
For the last three years of his life, there was a tendency to the 
formation of multiple abscesses, especially about the face and hands, 
which only healed with the greatest difficulty, and when relieved in one 
place repeated themselves in another. 
His last illness commenced about five days prior to his death. He 
had at that time a number of large abscesses on the left hand and a 
fistulous opening in the right cheek, and was taken down with pyemia, 
from which he died Dec. 31st, 1885. 
The post-mortem was made thirty-six hours after death, by Dr. J. 
Harvey Craig, in the presence of Dr. J. W. Craig and the writer. It 
revealed that nature had made a desperate effort to restore all the parts 
to a normal condition, and had almost closed the wound in the skull, 
leaving only an opening sufficiently large to admit a darning needle, 
about the centei of the wound. The entire skull was abnormally soft; 
even the vitreous table being so degenerated as to be easily cut with a 
cartilage knife, the entire skull having about the hardness of the cancel- 
lated structure of the long bones. 
On removal of the calvarium, a large spicule of bone was found 
projecting from the right side of the opening in the wound, and in front; 
being fully the third of an inch long and the fourth of an inch wide, 
while the whole inner surface of the calvarium was rough and uneven. 
The dura-mater was decidedly thickened throughout, and adherent to the 
pia mater at various places, with destruction of the intervening arachnoid, 
but especially in the immediate region of the wound the adhesions and 
thickening were more marked, and it was with great difficulty the mem- 
branes could be removed without tearing the brain substance. The Reed—An Interesting Case of Buzz-Sazv Injury. 
3 
membranes being removed there was observed an unusual number of 
abnormally large veins, which no doubt were due to nature’s effort to 
establish the collateral circulation, owing to the entire destruction of 
over three inches of the longitudinal sinus in the immediate vicinitj' 
of the wound, the remainder of the sinus being about normal. 
A recent blood clot about the size of a Japan bean was found on the 
right hemisphere, opposite the middle of the wound and half an inch to 
the side. All the veins of the brain were engorged, while patches of 
lymph coated almost the entire upper surface of the brain, accompanied 
with effusion. 
The brain was unusually dense all through, excepting in the imme- 
diate region of the wound, where incipient softening was apparent. The 
partial destruction of the falx cerebri allowed the brain to settle down, as 
it were, which gave it a squatty appearance, which, with the softened 
condition of the skull, will probably account for the abnormal enlarge- 
ment of the head, which was greatest latterally, and antro-posteriorly. 
On further examination of the brain, nothing of importance was 
revealed, other than effusions into the ventricles which were both well 
nigh filled with serum. 
In summing up this interesting case, we are led to the following con- 
clusions, which are fully indorsed by Dr. Craig and son : 
First—That the injury to the head received some nine years since, 
causing a spicule of bone to project against the brain substance, and thus 
keep up a constant irritation, produced a depressed action of the whole 
nervous system, but especially of the vaso-motor. 
Second—This partial paralysis of the vaso-motor nerves accounts for 
the discoloration of the skin, and also for the material interference with 
the nutrition. 
Third—Mal-nutrition was followed by a multiplicity of warty ex- 
crescences on the extremities, and the continual formation of numerous 
abscesses. 
Fourth—These abscesses were finally followed by pyemia and death. 
Would it not have been good surgery to have removed this spicule 
of bone at the proper time ? 
The above case is interesting, primarily, in that it recovered at all; 
secondarily, from the peculiar train of symptoms that followed, undoubt- 
edly from the irritation produced by the spicule of bone that projected 4 
Communications. 
Into the brain, and, in the third place, in that it was a proper case for 
operative interference. 
It is true, if there is any one class of cases that are baffling and per- 
plexing to surgeons, it is injuries of the head, with all their multiplicity 
of forms and endless variety of symptoms. One patient will recover 
from wounds that are apparently of a fatal character; while the next 
patient dies from what appears to be the most trivial injury. Until com- 
paratively recently, operative interference for injuries of the skull was 
looked upon with a great deal of discredit, and only those cases were 
operated on which had received compound, or compound comminuted 
fractures with marked compression of the brain ; and then only the 
bolder surgeons would pretend to interfere and give the poor unfortunate 
what little chance there was left for his life. More recently, however, 
great advances have been made in this line of surgery by modern sur- 
geons, to which aseptic dressings have given a decided impulse, by re- 
moving many of the dangers formerly attending such operations; and 
now wounds of the head, that formerly were treated on the expectant 
plan of “waiting for something to turn up,” are being fearlessly dealt 
with, the same as injuries of a similar character occurring in other parts 
of the economy. Abscesses of the brain are exposed by trephining and 
their contents given free exit by the use of the bistory and drainage tube, 
or of the vacuum syringe and probe-pointed needle; and patients that 
heretofore were unconditionally consigned to the tomb, are given a new 
lease on life, at.the rate of 50 per cent, as reported by Blun, and over 50 
per cent, according to Virchow, in cases that without operative inter- 
ference show a mortality ranging from 90 to 100 per cent. 
It requires time to obliterate the impressions and prejudices formed 
in the minds of the profession by such men as Sir Astley Cooper, who 
opposed all surgical interference with the brain, not even to the removal 
of an offending spicule of bone that was penetrating the brain substance 
itself. But thanks to the progressive spirit of the present age, such ob- 
jections are becoming as “ sounding brass and a tinkling cymbal ” in the 
ears of the majority of modern surgeons, and instead, we find such men 
as Fenger, Nancrede, Ashhurst, Bontecou, Peck and others of America, 
and Dupuytren, Guthrie and many more of equal merit and ability in 
Europe, not only recommending such operations, but proving them a 
success by repeated practical demonstrations. Nay more, the operation 
that after one trial by La Motte, in 1705, lay dormant for ninety-nine Reed—An Interesting Case of Buzz-Saw Injury. 
5 
years, to be resuscitated by Dudley, of Kentucky, in 1828, is now being 
revived with remarkable success, and operative interference, for the re- 
lief of epilepsy and insanity, not only recommended but practiced by 
such men as Briggs, Gross, Pancoast, Sayre, Byrd, Bigelow, Gilmore, 
Warren, Brainard, Dawson, Hayward, Van Buren and other American 
surgeons of acknowledged ability and national reputation, who, by the 
free use of the trephine in these dreaded diseases, especially epilepsy, 
have met with a degree of success that we, as Americans, may well be 
proud of; especially when 92 American operations for epilepsy show 63 
recoveries, 13 relieved, 2 not relieved, with only 14 deaths. On the 
other side of the Atlantic are reported 82 operations to which are to be 
added 48 American operations, making in all 130 cases, of which 75 
were completely cured, 18 improved, 7 unimproved, and only 30 died, 
while to this we must add 30 cases operated on by Briggs, of Tennessee, 
alone, of which 25 were cured, 3 relieved, 1 not changed, and only 1 
died. If such results can be obtained by operative interference in epi- 
lepsy, saying nothing of the use of the trephine in abscesses of the brain 
and for insanity, why should surgeons stand with folded arms and allow 
their patients to either die, or live a life of misery worse than death,when 
surgical skill, properly applied, could have given relief? 
It is remarkable what an amount of injury the brain will endure, and 
the patient still survive. I remember attending a young man whose brain 
was literally riddled with pieces of lead from a gun-shot wound, who, 
after three or four pieces of lead had been removed from the brain sub- 
stance, in which they had been buried to the depth of two inches or 
more, yet lived for over 90 hours, notwithstanding more than a score of 
pieces of lead and skull had pierced the brain in every direction, as was 
shown by the subsequent autopsy. In another case that came under my 
care, the right side of the frontal bone was literally crushed and driven 
down on the brain. This I removed, and the patient lived for eight 
days, although a post-mortem showed that the counter-violence sustained 
by the back portion of the brain and skull had driven a spicule of bone 
into the base of the brain and formed a blood clot which caused death. 
In another case, a kick trom a horse crushed in the skull over the back 
part of the head which was forced down on the torcular herophili with 
great violence. In this case I assisted Dr. J. W, Craig in removing 
(some three days after the accident,) a number of large fragments of 
bone; after which the boy fully recovered without a single bad symptom, 
the opening in the skull having been supplied, by nature, with sufficient 6 
Communications. 
bony tissue to close it. A remarkable case is reported by Prof. Briggs, 
in which a patient of his carried an ounce minnie ball imbedded in his 
brain for over a year. It was removed by trephining, and the patient 
recovered. 
On the other hand, patients often die from what appear to be the 
most trivial injuries. Last week I was called to make a post mortem on 
a Polander who was alleged to have been assaulted by two ruffians who 
demanded his money, and in the attempt to rob him struck him over the 
hand, and also over the left malar bone, with a club. The old man went 
home and reported what had been done, took sick, called a German 
quack, who told the family “ his tongue was broken and his gall bladder 
bursted,” and “he could’nt live.” Sure enough he did’nt live, but d'ed 
in just two weeks after the injury with decided cerebral symptoms. Ex- 
ternally there was but a light abrasion of the skin over the malar bone, 
with ecchymosis extending over the side of the face, no fracture of any 
bones; but about the middle of the latter third of the median fissure was 
a large blood clot, and also about two inches to the left of that one, and 
between the larger and smaller brains was another, which had produced 
compression, inflammation and death; and yet the violence had not been 
great. A sacculated hydatid tumor located in each lateral ventricle, to- 
gether with calcarious degeneration of the arteries may account for the 
results, notwithstanding the violence was apparently insignificant. 
Thus these cases of brain injuries might be multiplied indefinitely, 
by surgeons in active practice. The question, however, that naturally 
arises, in the minds of all practical surgeons, is whether trephining is 
good surgery at all; and, if so, when, and under what circumstances? 
This is a question that should be well settled in the mind of every mod 
ern surgeon; all that he should have to do when he arrives at the side of 
the wounded is to ascertain the degree of injury, which should be his 
guide as to the mode of treatment. He has no time then to look up au- 
thorities, nor can he take the chances of making a mistake, either by 
omission or commission. 
Prof. Gunn, in an able paper on the “ Treatment of Fractures of 
the Skull ” read before the American Surgical Association in 1882 and 
reported in Vol. lof their transactions, says: “As in compound frac- 
tures the removal of loose fragments or the elevation of the depressed 
portion of the bone, even though requiring the use of Hey’s saw or the 
trephine in order to effect such elevation, does not materially add to Reed—An Interesting Case of Buzz-Saw Injury. 
7 
the dangers of the case; so now in a case of simple fracture, which 
through improved methods, we venture to make compound, we may con- 
fidently proceed to a full correction of the displacement. Such operative 
procedures are, however, contraindicated when symptoms of violent con- 
cussion with the attendant tendency to collapse are present; but in the 
absence of symptoms, or when the symptoms point to compression in- 
stead of concussion, operative measures should be promptly instituted.” 
Prof. Gross, in the same volume, says in his remarks on Prof. Gunn’s 
paper: “In all recent fractures with depression, if the latter be moder- 
ate, whether simple or compound, the patient should be left alone. If, 
however, fixed and severe pain at the point of injury, febrile excitement, 
increase of local temperature, and a commencing puffing of the scalp 
supervene, within a few days after the accident—signs which are indica- 
tive of depression of the internal table and the development of pachy- 
meningitis—elevation of the depression should be promptly effected. In 
all recent fractures, whether simple or compound, attended with symp- 
toms of compression, the trephine should be resorted to; and the same 
rule should apply, whether symptoms be present or not, if the depression 
be considerable Jand funnel-shaped. Punctured fractures should inva- 
riably be subjected to operation.” 
I neard Dr. Roberts, of Philadelphia, read an able paper before the 
American Surgical Association last year in which he advocated the free 
use of the trephine, and even recommended it for diagnostic purposes 
under certain cicumstances, in which he said “ perforation of the cra- 
nium is to be adopted as an exploratory measure almost as often as it is 
demanded for therapeutic reasons.” As to the dangers of such operative 
procedures he said: “The removal of portions of the cranium by the 
trephine or other cutting instruments is, if properly done, attended with 
but little more risk to the life than amputation of a finger through the 
metacarpal bone.” 
With such authorities at our back, besides scores of other equally 
prominent surgeons, who advocate the free use of the trephine in proper 
cases, I feel that we are justified in resorting to this operation more fre- 
quently than has generally been advised by our older surgeons; for as 
demonstrated by the unerring hand of practical experience the use of the 
trephine, especially when guarded by the precautions of antiseptic sur- 
gery, is not more dangerous than other operations of equal magnitude in 
other parts of the human economy.