FRACTURE OF THE SKULL: TREPHINING; 
RETRO-ANTEROGRADE AMNESIA; RE- 
COVERY; DEATH ONE MONTH SUB- 
SEQUENTLY FROM OTHER 
CAUSES; AUTOPSY: 
BY 
EDMUND J. A. ROGERS, M.D., 
OF DENVER, COL. J 
PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF 
DENVER: SURGEON TO THE ARAPAHOE COUNTY AND ST. LUKE'S HOSPITALS: 
AND 
J. T. ESKRIDGE, M.D., 
OF DENVER, COL. J 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT 
OF THE UNIVERSITY OF COLORADO J NEUROLOGIST TO THE ARAPAHOE 
COUNTY AND ST. LUKE'S HOSPITALS. 
FROM 
THE MEDICAL NEWS. 
May 12, 1894. [Reprinted from The Medical News, May 12, 1894.] 
FRACTURE OF THE SKULL; TREPHINING; 
RETRO-ANTEROGRADE AMNESIA; RE- 
COVERY; DEATH ONE MONTH SUB- 
SEQUENTLY FROM OTHER 
CAUSES; AUTOPSY. 
By EDMUND J. A. ROGERS, M.D., 
OF DENVER, COL. J 
PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE 
UNIVERSITY OF DENVER ; SURGEON TO THE ARAPAHOE 
COUNTY AND ST. LUKE'S HOSPITALS J 
AND 
J. T. ESKRIDGE, M.D., 
OF DENVER, COL. J 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL 
DEPARTMENT OF THE UNIVERSITY OF COLORADO ; NEUROL- 
OGIST TO THE ARAPAHOE COUNTY AND ST. LUKE'S 
SURGICAL REPORT, BY DR. ROGERS. 
William D., a passenger on a Rio Grande train 
coming into Denver on the night of June 7, 1893, while 
intoxicated, walked off the train, which was running at 
full speed, and was soon after missed. Upon search 
being made, he was found lying beside the track uncon- 
scious, with a very severe wound in the head. He was 
picked up and placed in the bunk of a freight caboose, 
where the torn scalp and exposed skull were in contact 
with the fittings, brought seventy-five miles into Denver, 
and, after he had examined the wound on the head, 
transferred by the police surgeon to St. Luke's Hospital. 
I saw him there immediately. He appeared to be per- 
fectly conscious and stated that he had been hurt in a 2 
coal mine by an accident which had happened the day 
before; that his head had been slightly injured, but 
that he knew the injury was not severe. On being 
questioned more closely he stated that he had come to 
Denver for treatment of his own free will; that he had 
knowingly, passed Pueblo, where the company's hospital 
is situated, because he did not care to be treated there. 
He answered every question about the journey and 
about the accident rationally and was quite positive that 
the statements he made were correct; still he was not 
dogmatic. His story seemed so rational and so well 
connected that I telephoned again to the railroad com- 
pany for assurances as to how the accident had hap- 
pened. 
On examining the head I found that the scalp on the 
left side had been caught toward the front side by a 
backward blow, and an extended flap, triangular in 
shape, had torn backward. Just inside the apex of the 
flap was a very extensive compound fracture, also 
angular in shape, corresponding to the line of tear 
of the scalp. The depression was quite marked at the 
apex of this triangle, which was situated one inch in 
front of the sagittal suture and about three inches below 
the median line. Externally the two sides of the frac- 
ture diverged at an angle of about thirty-five degrees 
backward, and were each about two inches long. As 
there were no urgent symptoms I cleansed the wound 
thoroughly, put on a temporary dressing, and left the 
patient till the following afternoon. I then trephined 
just beyond the apex of the fracture, so as to reach the 
point of greatest depression. I first removed a three- 
fourths inch button and then enlarged the opening so as 
to easily get under the inner plate, which we found de- 
pressed over a much larger area than was the external 
plate, the lines of fracture not corresponding in the two 
plates. The dura was found extensively torn, and on 
raising the depressed area, which was easily done, the 3 
blood flowed very freely from under the membranes 
through this wound. Bleeding was so free that it was 
not deemed wise to close the wound entirely. The 
scalp was replaced and closed everywhere, except imme- 
diately over the opening into the skull. 
The patient's general condition was excellent. He 
was examined carefully before and after the operation 
by Dr. Eskridge, who from this time on saw him fre- 
quently with me. Dr. Eskridge's notes, given herewith, 
fully describe the mental phenomena which were now 
one of the marked features of the case. 
The wound was dressed on the third day and was 
found doing well. On that day his temperature fell to 
normal and never rose above it again. The wound, 
which had been left open, began to close quite rapidly, 
but the pulsating brain could be seen at the bottom of 
it at all times. The patient went on without a bad 
symptom of any kind, and at the meeting of the State 
Medical Society, on June 20th, he was taken before the 
members and the wound exhibited. The brain could 
be seen pulsating over a very small area. 
The patient continued to improve and apparently felt 
quite well in every particular until the morning of July 
4th, when he was taken suddenly with a severe choleraic 
diarrhea. This, after a few hours, completely prostrated 
him. It was a form of diarrhea of which there were 
then many cases about the city. The patient never 
rallied from this prostration, but died on the 8th of July 
seemingly from an entire loss of recuperative force. 
On the following day a post-mortem examination was 
made and the conditions thoroughly examined. The 
wound in the skull was found completely closed, except 
a small orifice about a sixteenth of an inch in diam- 
eter. New bone seemed completely formed, making a 
translucent diaphragm across the opening. The line 
of fracture, both in the internal plate and in the external 
plate, was distinctly visible, the area of fracture in the 4 
internal plate being very much larger than that in the 
external. The membranes were found completely 
healed and showed no signs of ever having been 
injured, and the brain beneath was perfectly normal and 
healthy. The entire brain was very anemic, but no 
gross lesion was found. 
MENTAL PHENOMENA, BY DR. ESKRIDGE. 
I am indebted to the courtesy of Dr. Rogers for the 
privilege of studying the interesting mental phenomena 
of the case he has reported in this paper. 
That the patient's confused mental state may be the 
better understood, I will first state facts in the history 
of the patient, especially those surrounding the accident 
and extending over his amnesic period, as they really 
occurred, and refer to his story as he gave it to Dr. 
Rogers on his admission into the hospital, reporting 
circumstances as they seemed to occur to him in his 
blurred conscious state; and finally, I shall try to show 
the relation between the real and the supposed occur- 
rences, or the structure on which his delusions were 
founded. 
William D., forty-six years of age, of England, single, 
a miner, came to Colorado fifteen years ago. His 
family history, so far as I was able to learn, is negative. 
His health during childhood was excellent, and he de- 
nied any venereal disease. He was not a " steady 
drinker,'' but indulged in alcohol to great excess period- 
ically for a number of years. He stated that when he 
indulged in alcoholic liquors he did so on account of an 
overpowering desire for alcohol. 
About June 4th or 5th an explosion occurred in the 
mine in which he had been accustomed to work, and 
several men were injured, but D. was not in the mine 
on the day of the explosion. On June 6, 1893, he fell 
in the mine and slightly injured his nose, but the next 
day he felt but little inconvenience from the fall. On 5 
June 7, 1893, at 10 a.m., he left Calumet, Col., on a 
freight train and reached Salida at 11 a.m. Between 
this hour and 2.45 p.m. he drank six glasses of beer. 
Before leaving Salida at 2.45 p.m., with two or three 
companions, he purchased a bottle of whiskey, and 
from this bottle he took three drinks before reaching 
Pueblo, during two or three hours' ride. After leaving 
Pueblo he felt a desire to urinate and went to the water- 
closet ; but finding it closed, he went out upon the rear 
platform, from which he fell. 
The remainder of the patient's experience on the 
nights of June 7th and 8th ; his story, as told by 
himself on reaching the hospital, together with the 
treatment and subsequent surgical progress of the case, 
are related by Dr. Rogers, under whose care he re- 
mained until he died, nearly a month after his admission 
into the hospital. 
He rode on a passenger train from Salida to Denver. 
To prevent a break in the history of the case, and to 
save the reader the trouble of referring to the first part 
of this report, I shall have to repeat some things already 
given by Dr. Rogers. 
D.'s Account of Himself a few hours after the Injury 
to his Head. 
(For this I am entirely indebted to Dr. Rogers, who 
has kindly allowed me to use his notes.) 
On reaching the hospital the man seemed to be per- 
fectly conscious, and stated that there had been an acci- 
dent the day before in the Calumet coal-mine, and his 
head had been slightly injured by a fall, but that he 
knew the injury was not severe and he would be all 
right in a few days. When asked by Dr. Rogers why 
he had not left the train at Pueblo and gone into the 
company's hospital there, he replied that " The men 
wanted me to do this, but I would not do it, as I pre- 
ferred coming to Denver." In Dr. Rogers's own words : 6 
" He answered every question about the journey and 
about the accident rationally, and was quite positive 
that the statements he made were correct; still he was 
not dogmatic. His story seemed so rational and so 
well connected that I telephoned again to the railroad 
company for assurances as to how the accident had hap- 
pened." He said that his head had been examined. 
(It is probable that the examination here referred to was 
that made by the police-surgeon on his reaching 
Denver.) He was quite positive that he had not been 
on a passenger train, but had ridden all the way from 
Salida on a freight train. He seemed conscious of the 
day and the month. He stated that he had no friends 
in Denver, and nothing more than acquaintances in 
Colorado, miners with whom he had been working, and 
that most of his near relatives in England were dead. 
He appeared rational all the next day. 
I saw him for the first time on June the 8th, a few 
minutes before the operation at 5 p.m., but I had no 
opportunity to inquire into his mental condition. The 
physical condition was as given by Dr. Rogers. Some 
time during the day subsequent to the operation, June 
9th, he awoke, seemed confused, looked around the 
ward, and said, " Where am I ? " On inquiry, I found 
that his mind was almost a complete blank. He could 
give no account of himself, seemed utterly bewildered, 
and would relapse into a semi-stupor immediately on 
being left alone. On June 10th, 1 ith and 12th, his mental 
condition seemed to be improving, but his answers to 
questions were so contradictory as to be wholly unreli- 
able. On June 13th and 14th he was much brighter and 
gave a consecutive account of his early history, his 
occupation, and his habits; but while he appeared to 
respond to impressions made upon him at the time, he 
retained no memory of them a few minutes afterward. 
He was not aware that he had been injured on a train, 
that he had been operated upon, or that he had been 7 
in the operating-room at all, although he had been 
taken into the operating-room several times since his 
entrance into the hospital. 
On June 15th he was quite bright and answered 
questions coherently, but he remembered absolutely 
nothing from the time he reached Salida until he found 
himself in the hospital yesterday. He did not remem- 
ber yesterday afternoon that he had been in the hospital 
all day, but on the 15th he was conscious of having been 
in the hospital one entire day before the 15th. He 
thought he had been in the hospital longer than this, 
but he said he only inferred this, as he remembered 
absolutely nothing that occurred two days before. When 
he was taken to the operating-room on the 15th, he 
remembered that he had been in that room once before, 
but he could not tell when he had been there. I was 
informed that he had been in the operating-room on 
the 14th. 
He gave an account of his journey in a freight car 
from Calumet to Salida; thought he drank something 
while in Salida, but of this he was not sure. He spoke 
of his fall in the Calmumet mine, and of the accident to 
his nose, of the explosion that had occurred in the mine 
a few days before his fall, and of the injury of several of 
the miners; but of his boarding a passenger train at 
Salida for Denver he had no remembrance. 
On June 16th he was still improving, and remembered 
quite distinctly of drinking in Salida, but was still under 
the impression that he came all the way to Denver in a 
freight car. 
On June 18th, at 8 a.m., he remembered that he had 
talked with a large man in the ward about mining several 
days ago. On inquiry of Mr. Le Strange, the man with 
whom he had talked, this was found to be on Tuesday, 
June 13th. A few hours later he remembered having 
had his head dressed in the operating-room the day 
before he had the conversation with Le Strange. At 7 
p.m. of the same day (June 18th), he remembered hav- 8 
ing been in the hospital one week ago, June 1 ith. This 
fact he recollected during the afternoon, and at my even- 
ing visit he stated that he was in a certain bed on that 
day on the opposite side of the ward. This, on inquiry, 
I found to betrue. 
On June 20th he could give the number of drinks of 
beer that he drank while in Salida, and tell what he and 
his companions did while there from 11 a.m. till 2.45 
p.m. ; he mentioned purchasing a bottle of whiskey in 
Salida, and taking three drinks out of it before reaching 
Pueblo, and said the last thing which he remembered on 
that day, June 7th, was going to the water-closet at the 
rear end of the car to empty his bladder, and finding 
the closet occupied he went out upon the rear platform 
of the car. After this all was a blank. He was not posi- 
tive whether he rode on a passenger or freight car from 
Salida to Denver, but supposed it must have been a 
passenger car. 
His memory was carefully inquired into daily, and 
sometimes several times daily, from June 20th till the 
beginning of his fatal illness, July 4th, but nothing 
further was remembered by him. 
Occurrences on which D.'s 
delusions were founded. 
D.'s delusions. 
i. An explosion in the Calumet 
1, 2. Believed that his head had 
mine in which several miners 
been slightly injured in a 
were injured on June the 4th 
mine explosion, and that he 
or 5th. 
2. D.'s falling in the same mine 
on June 6th, and injuring his 
nose. 
had not been severely injured 
by a fall from a train. 
3. Travelled from Calumet to 
3. Believed he had ridden all 
Salida on a freight train, and 
the way from Calumet to 
drank heavily at Salida. 
Denver' on a freight train, 
and that he had not been on 
a passenger train at all; and 
all his answers to questions in 
relation to the journey based 
on the belief of his having 
come all the way in a freight 
train. 9 
Occurrences on which D.'s 
delusions were founded. 
D.'s delusions. 
4. Prejudice of 
the miners 
4. He said the men wanted him 
against the company's hospi- 
to get off at Pueblo and go 
tai m Pueblo. 
to the company's hospital 
there, but he refused, as he 
preferred coming to Denver 
to be treated. 
The separate and distinct accidents-the one, the ex- 
plosion in the mine in which several miners had been 
injured, although D. was not in the mine at the time ; and 
the other, D.'s falling in the same mine a day or two 
subsequently to the explosion, by which he had injured 
his nose-in his confused mental condition were not 
separate in his own mind, and as the explosion had 
probably made a greater impression upon his mind in 
its normal condition than the trivial accident by which 
he had been slightly injured, he attributed his head- 
injury to that accident which had made the greater 
impression upon him at the time of its occurrence. He 
did not realize that he was severely injured, although the 
wound was in a different portion of his person than the 
one really received at the time of his fall, but contended 
that he was only slightly disabled and would be all right 
in a few days. 
His firm belief that he had ridden all the way from the 
Calumet mine to Denver on a freight train, and had not 
travelled the greater portion of the distance, from Salida 
to Denver, in a passenger coach, can be accounted for 
either on the theory of temporary retrograde amnesia, 
extending back from the time of the injury to the time 
of his arrival in Salida on a freight train from Calumet, 
or from the effect of his free indulgence in beer soon 
after he reached Salida, thus clogging his mental powers 
so that he was scarcely able to distinguish the difference 
between a coach and a box car. That alcohol played 
some part in his temporary retrograde amnesia becomes 
the more probable when we recall to mind the fact that 10 
his actions during this period of his temporary amnesic 
state were the last to be recollected. 
Things that were correctly remembered during his 
most profoundly amnesic state were events long past, as, 
or example, that he was born in England and that 
most of his near relatives were dead. 
As to certain circumstances relating to his own personal 
condition and environments, he realized that he was a 
miner and that he had no intimate friends in Colorado, 
his only aquaintances being miners with whom he had 
been accustomed to labor. 
The total amnesic period extended from June 7th, at 
11 A.M., until June 14th, at 5 p.m. Of this period, 
eleven hours, from 11 a.m. until 10 p.m., are of the retro- 
grade type, and six days and nineteen hours are of the 
anterograde. It is possible, and even probable, that he 
might have remembered something on June 14th, before 
5 p.m., but at my morning visit, at 8 o'clock, he did not, 
and Dr. Fish, one of the hospital residents, had been 
unable, between my visits, to find out that he remem- 
bered anything of the occurrences of the day before. 
Besides this complete amnesic period shading off, both 
before and after the accident, there was at first a greater 
or less length of time during which he only remembered 
imperfectly. During these incomplete ante-amnesic and 
post-amnesic periods memory was the worse the nearer 
the complete amnesic state was approached in point of 
time, and best the longer the interval of time that had 
intervened between the state of complete amnesia and the 
time at which his memory was investigated; so that 
soon after the amnesia ceased to be complete, memory 
was only reliable for things relating to himself, such as 
being in the operating-room and having his head 
dressed, his conversation about mining, his being in the 
hospital ward, etc. 
The permanent amnesic period began just immediately 
preceding his fall from the train, when he went upon the 11 
rear platform of the passenger coach, and continued 
until June nth, a period of four days, all of which was 
of the anterograde type. During the twenty-three days 
that intervened between the nth of June and the 
beginning of his fatal illness, July 4th, this period of 
complete amnesia was not encroached upon by his 
being able to recall a single incident that had occurred 
at any time of this period. 
As to the manner in which D. 's memory returned for 
events occurring during his temporary amnesic state, it 
may be noted that at 8 a.m. of June 18th he remembered 
that some days before he had talked with a man in the 
ward about the Calumet mine. On inquiry of the 
patients in the ward I found that the conversation was 
held with a miner by the name of Le Strange, on June 
13th, just five days before. About 12 M. of June 18th 
he remembered that he had been dressed in the 
operating-room. On looking up the records of his case 
I found that this occurred on Monday, June 12th, six 
days before. At 7 p.m. of the same day he remembered 
that he was in bed on the other side of the ward several 
days ago, and this fact came to his consciousness some- 
time during the afternoon. I ascertained that he had 
occupied a bed on the other side of the ward on June 
nth. 
It will be seen that for events occurring after the accident 
memory manifested itself first for periods furthest from the 
time of the occurrence of the injury to his head, and that 
each registration of memory was for events that had taken 
place, in point of time, at periods nearer and nearer the 
time at which he had sustained the injury. Further, the 
things that his memory was first able to recollect were 
those relating to himself, either directly or indirectly. 
On examining into the manner in which the retrograde 
period of amnesia was obliterated it was found that he 
was first able to give the number of drinks of beer that 
he had taken in Salida, what he and his companions did 12 
while there, from ir a.m. until 2.45 p.m., including the 
purchasing of a bottle of whiskey to take on the train 
with them. He next remembered getting into a car for 
Denver, but never had any distinct idea whether it was 
a coach or a freight car. The next day he remembered 
taking three drinks on his way from Salida to Pueblo. 
The last thing that he was able to remember occurred 
just a few minutes before the accident. He said that he 
remembered feeling a desire to urinate, going to the 
water-closet, finding it occupied, and then going to the 
rear platform. 
Here again the things first remembered were most 
remote from the accident and those last recalled to his 
mind occurred just prior to it. Everything that he 
remembered during this period was something relating 
to himself. It is important to bear in mind that the 
thing remembered as occurring nearest to the time of 
the accident was something relating to his personal dis- 
comfort and means taken to relieve this. 
As to the diagnosis of amnesia. If a person after 
coming out of an amnesic condition should be able to 
recall anything that took place during the time of the 
existence of the amnesia the memory for such occurrences 
seems to be, in the majority of instances, accurate and 
reliable ; but if any portion of the events thus recollected 
should prove to be false, the cause for the inaccuracy, if 
thorough investigation is made, will be found in the 
environments of the subject or in the history of his acts 
previous to the occurrence of the accident, or other 
causes which produced the amnesia. 
In the case just given, D. was never able to remember 
clearly that he came to Denver in a passenger coach and 
not in a freight car. The explanation of this discrepancy 
is found in the fact that he rode from Calumet to Salida 
in a freight car, and then became partially intoxicated 
before leaving Salida in a passenger coach for Denver. 
Other things being equal, the history of this case 13 
shows that events occurring furthest from the time when 
the amnesia begins are remembered before things occur- 
ring in point of time more nearly related to the begin- 
ning of the amnesia. This rule seems to hold good in 
all forms of amnesia, and when it is modified the cause 
may be found in the difference in intensity and duration 
of the impressions upon the individual made by the 
different events at the time of their occurrence. 
Another point in the diagnosis of amnesia is that 
personal feelings, such as hunger, pain, uncomfortable 
sensations, and means resorted to relieve them, will 
be recalled more readily than mental impressions, 
especially those of an intellectual character. The fifth 
conclusion in my paper entitled " Retro-anterograde 
Amnesia " ( The Alienist and Neurologist, July, 1892) is : 
" Personal feelings and emotional states are more stable 
in memory than the results of the intellectual facul- 
ties." 
Ribot tersely states that "feelings form the self; am- 
nesia of the feelings is the destruction of the self." 
The diagnosis of periods of complete amnesia, which 
remain complete and are unassociated with periods of 
partial amnesia, is most difficult. As a rule, such a 
condition is suggestive of feigning. Most persons who 
feign amnesia pretend to remember nothing. That 
states of complete amnesia, unassociated with partial 
amnesia, do occur I have verified in certain cases of 
epilepsy. Each of such cases requires a careful study. 
Dr. W. P. Munn, in an editorial article entitled " Unre- 
liability of Ante-mortem Statements," in the Denver Med- 
ical Tinies, on learning the facts in the case reported in 
this paper, took issue with the rule of the courts in 
allowing the admission of ante mortem declarations as 
evidence in homicidal or murder cases. 
An imaginary case might be instanced. Suppose that 
D. had had an altercation with someone and had in 
consequence received a slight wound about the face or 14 
head, and he should shortly afterward accidentally 
have seriously injured himself by a fall, striking his 
head against some unyielding substance, which pro- 
duced the same amnesic condition in which D. was found 
on entering the hospital. Under such circumstances the 
altercation would have been more impressed upon his 
mind than the fall from which death might result, and he 
would naturally have attributed his wound to the blow 
inflicted by the man with whom he had had trouble. 
At first thought this supposititious case seems to mili- 
tate against the value of ante mortem declarations. But 
we most remember that the law provides that an ante- 
mortem statement, to be of any value, must be made by 
the person making it, when he believes himself fatally 
injured, without any chance (even though that should be 
small) of recovery, and usually while he is in imminent 
danger of speedy death. 
So far as my experience goes with head-injuries, all 
persons who have been rendered amnesic by them have 
regarded their wounds as slight and have expressed the 
belief that they would soon be all right again. I have 
records of some eight or ten cases of amnesia produced 
by injuries to the head, and in all of them the firm 
belief of the trivial nature of their injuries has been ex- 
pressed. The Medical News. 
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