[Reprinted from The Medical News, July 16, 1892.] 
INJURIES TO THE HEAD. 
By WILLIAM M. LEWIS, M.D., 
OF LOS ANGELES, CAL. 
When I was a boy, ten years of age, I fell from a 
horse, fracturing my frontal bone in two places. The 
four-inch cut in the forehead was sutured-that was all 
of the treatment. Recovery was prompt. 
Shortly after that I saw a soldier strike a comrade with 
his fist a blow immediately above the left ear, and death 
resulted in an hour. The treatment was venesection. 
These two incidents, more especially the first, made an 
indelible impression on my youthful mind, and through- 
out my student and professional life I have tried to learn 
upon what the element of danger depends in cases of 
head-injuries. Bryant states that ''all injuries to the 
head should be treated with extreme care, and always 
regarded as serious." (Italics mine.) 
I have read somewhere that no injury to the head is 
so slight but that there is danger, and none so grave but 
that there is hope. No rule or law can be laid down to 
govern these cases. Every case must be a law unto itself. 
Case I.-In 1885, J. D. was struck on the frontal bone, 
at the edge of the hair, by a companion, with a foot-adze 
(a cooper's tool). The result was a depressed fracture, 
nearly four inches long, and hemorrhage sufficient to 
occasion syncope. Two hours afterward, the depressed 
bone was lifted to its place, when arterial hemorrhage 
again threatened the life of the patient. Other means 
proving useless, the bone was allowed to press upon the 
brain and the bleeding ceased. The patient had not lost 2 
LEWIS, 
consciousness, except when he fainted. He was advised 
of his danger and put upon ergot and cold compresses. 
This treatment may be criticized as bad surgery, but the 
patient made an uninterrupted recovery, and is alive and 
well to-day, a deep depression being the only result. 
Case II.-In an altercation with his brother, T. M. 
was struck on the head with a small scaly rock, receiv- 
ing a wound that bled only a few drops. No impression 
was made on the general system, and the patient paid 
no attention to his hurt. Twenty days afterward, inflam- 
mation of the diploe set in, and was rapidly followed by 
meningeal inflammation and death. 
Case III.-While engaged in compressing a radial 
artery of a small boy, severed in opening a fruit-can, 
my attention was called to a street fight in front of my 
office; as I looked, a strong, muscular teamster plunged 
a pocket-knife into his adversary's brain, at a point near 
the junction of the sagittal and coronal sutures (bregma). 
The blade sank to the hilt, and in extracting it the assail- 
ant used all his power and wrenched it from side to 
side three times. When the three-and-a-quarter inch 
blade was finally withdrawn, arterial blood, in a solid 
column, flew high in air, and the victim sank to the 
ground unconscious. When I reached his side he was 
exsanguine and pulseless, ahd bleeding had ceased-in 
less than five minutes. A wound of the arm was sutured 
and the patient was taken to a hotel, stripped of his 
bloo*d-soaked clothing, his head enveloped in iced cloths, 
and ergotine, gr. ij, administered hypodermatically. In 
six hours paralysis of the opposite half of the body was 
complete ; the pulse reappeared at the wrist and signs of 
reaction set in. In eighteen hours the patient opened 
his eyes and asked for a drink of whiskey. During the 
three weeks of illness that followed, the paralysis gradu- 
ally subsided and recovery became complete. Now, two 
years and a half after the reception of the injury, the 
patient is in perfect health, and smokes a strong pipe INJURIES TO THE HEAD. 
3 
almost constantly. The amount of brain-tissue that was 
disorganized must have been considerable, and the loss 
of blood was measured by the capacity of the heart to 
pump it out. The man belonged to that innumerable 
throng around which no surgeon can place antiseptic 
precautions, while the opportunity for infection was con- 
stant ; still he escaped. 
Case IV.-In play, a schoolboy, ten years old, was 
struck upon the head by a small falling rock which his 
companion had tossed into the air. There was no abra- 
sion and very slight contusion. On the third day after- 
ward, severe headache set in and continued. On the 
seventh day the usual symptoms of meningeal inflam- 
mation developed, and death closed the scene in less 
than three weeks from the day of injury. A reviewer 
might say that the traumatism and the fatal illness were 
merely coincident, but the impartial judgment of the 
physicians concerned in the case attributed death to the 
head-injury. Unfortunately no post-mortem examination 
was permitted. 
Case V.-J. M., sixty years old, while asleep in bed, 
was struck by an insane person two blows with an axe. 
The ball or blunt end of the axe was used, and the first 
blow landed on the side of the head, half an inch above 
the left ear. The sleeping victim turned partly over and 
received the second blow transversely across the fore- 
head, an inch above the eyebrow. The entire arch of 
one eye was fractured loose and hung down nearly an 
inch lower than that of the other side. At least a table- 
spoonful of brain-matter had oozed from the gaping 
wounds and ran down on the man's face, and blood was 
flowing freely from both ears. Loose fragments of bone 
were removed, and the battered head was shaped up, and 
with a few stitches and strips of adhesive plaster the man 
was made moderately presentable. During the toilet, 
brain-matter was washed and wiped away freely. Deep 
stupor, with very shallow and slow respiration and slow 4 
LEWIS, 
pulse, continued for four days. The patient then showed 
slight signs of rallying, and after two months of illness 
made a good recovery-only a slight degree of mental 
impairment remaining four years afterward. 
Case VI.-A. C., thirty-five years old, was thrown 
from a buggy by a runaway horse. In addition to a cut 
on one foot and dislocation of two fingers, he received a 
wound about one inch long, some two inches above the 
inion, in the middle line. Upon washing the wound a 
stellate fracture was observed. No symptoms of internal 
injury were present; the patient was conscious and con- 
versed freely. Convalescence seemed well established, 
and for three or four weeks not a symptom occurred 
indicative of any deep-seated injury to the head. At 
the end of that time mental aberration and motor and 
amnesic aphasia supervened. The usual symptoms of 
general diffuse inflammation of the meninges rapidly 
followed in succession. In consultation, it was decided 
not to trephine at the seat of injury, as the symptoms 
pointed to injury by contre-coup in the frontal lobes. 
The post-mortem examination disclosed a large abscess 
at the seat of injury and another on the upper surface of 
the right frontal lobe. Trephining and draining the 
posterior abscess would not have saved the patient. 
Case VII.-While riding along the road, M. W. was 
fired upon and received a bullet in the left side of his 
head, at the anterior inferior angle of the parietal bone. 
The post-mortem examination, made thirty-six hours 
afterward, showed that the bullet had been deflected 
downward, had passed through the brain, and had 
lodged against the temporal bone on the opposite side of 
the head. Notwithstanding this injury, the man dis- 
mounted, climbed over a fence, and pursued his assassin 
twenty or thirty yards, in fact until he received another 
bullet, this time in the abdomen. He then went back to 
his horse and rode two miles. To the physicians who 
attended him he repeatedly said that the wound in his INJURIES TO THE HEAD. 
5 
head was insignificant. He remained rational as long 
as he lived, and never manifested the slightest symptom 
of brain-injury. The cause of the death was hemor- 
rhage into the abdominal cavity from a severed small 
artery. 
In this series of cases one feature is most noticeable, 
that is, that when hemorrhage was free the patients re- 
covered, even though there was loss of brain-substance. 
Should all injuries to the head be regarded as serious ? 
Should a physician treat every case of head-traumatism 
as serious ? 
A few weeks ago I was called to see a man who had 
received a severe blow on top of the head with a blunt 
instrument. When I reached his side he was vomiting, 
and plainly in a state of shock. I regarded the case as 
serious, and advised him to remain in bed five or six 
days. On the following day he went about his business. 
Of course, such a case proves nothing, but it indicates 
that the physician ought not to be precipitate in action. 
I knew a surgeon who had made extensive prepara- 
tions to do the operation of trephining for depressed 
fracture. With grips and boxes and bottles and assist- 
ants, he approached the house of the patient only to find 
that the latter had gone out of doors.