Injuries of such a delicate organ as the eye, in which the slightest accident can produce such disastrous consequences, naturally elicit the interest of all. Examples of exophthalmos, or protrusion of the eye from the orbit from bizarre causes, are of particular interest. Among the older writers we find Ficker and the Ephemerides giving instances of exophthalmos from vomiting. Fabricius Hildanus mentions a similar instance. Salmuth, Verduc, and others mention extrusion of the eyeball from the socket, due to excessive coughing. Ab Heers and Sennert mention instances in which after replacement the sight was uninjured. Tyler relates the case of a man who, after arising in the morning, blew his nose violently, and to his horror his left eye extruded from the orbit. With the assistance of his wife it was immediately replaced and a bandage placed over it. When Tyler saw him the upper lid was slightly swollen and discolored, but there was no hemorrhage.
Hutchinson describes extrusion of the eyeball from the orbit caused by a thrust with a stick. There was paraphymotic strangulation of the globe, entirely preventing replacement and necessitating excision. Reyssie speaks of a patient who, during a fire, was struck in the right eye by a stream of water from a hose, violently thrusting the eye backward. Contracting under the double influence of shock and cold, the surrounding tissues forced the eyeball from the orbit, and an hour later Reyssie saw the patient with the eye hanging by the optic nerve and muscles. Its reduction was easy, and after some minor treatment vision was perfectly restored in the injured organ. Thirty months after the accident the patient had perfect vision, and the eye had never in the slightest way discommoded him.
Bodkin mentions the case of a woman of sixty who fell on the key in a door and completely avulsed her eye. In von Graefe's Archiv there is a record of a man of seventy-five who suffered complete avulsion of the eye by a cart-wheel passing over his head. Verhaeghe records complete avulsion of the eye caused by a man falling against the ring of a sharp-worn key. Hamill describes the case of a young girl whose conjunctiva was pierced by one of the rests of an ordinary gas-bracket. Being hooked at one of its extremities the iron became entangled in either the inferior oblique or external rectus muscles, and completely avulsed the eyeball upon the cheek. The real damage could not be estimated, as the patient never returned after the muscle was clipped off close to its conjunctival insertion. Calhoun mentions an instance of a little Esquimaux dog whose head was seized between the jaws of a large Newfoundland with such force as to press the left eyeball from the socket. The ball rested on the cheek, held by the taut optic nerve; the cornea was opaque. The ball was carefully and gently replaced, and sight soon returned to the eye.
In former days there was an old-fashioned manner of fighting called "gouging." In this brutal contest the combatant was successful who could, with his thumb, press his opponent's eyeball out. Strange to say, little serious or permanently bad results followed such inhuman treatment of the eye. Von Langenbeck of Berlin mentions an instance of fracture of the superior maxilla, in which the eyeball was so much displaced as to lodge in the antrum of Highmore. Von Becker of Heidelberg reports the history of a case in which a blow from the horn of a cow dislocated the eye so far back in the orbit as to present the appearance of enucleation. The conjunctiva hid the organ from view, but when it was pulled aside the eyeball was exposed, and in its remote position still possessed the power of vision. In some cases in which exophthalmos has been seemingly spontaneous, extreme laxity of the lids may serve as an explanation. There is an instance on record in which a Polish dew appeared in a Continental hospital, saying that while turning in bed, without any apparent cause, his eyeball was completely extruded. There have been people who prided themselves on their ability to produce partial exophthalmos.
Rupture of the Eyeball.—Jessop mentions the case of a child of eight who suffered a blow on the eye from a fall against a bedpost, followed by compound rupture of the organ. The wound in the sclerotic was three or four lines in length, and the rent in the conjunctiva was so large that it required three sutures. The chief interest in this case was the rapid and complete recovery of vision.
Adler reports a case of fracture of the superior maxillary in which the dislocated bone-fragment of the lower orbital border, through pressure on the inferior maxillary and counter pressure on the skull, caused rupture of the conjunctiva of the left eye.
Serious Sequelae of Orbital Injuries.—In some instances injuries primarily to the orbit either by extension or implication of the cerebral contents provoke the most serious issues. Pointed instruments thrust into the orbital cavity may by this route reach the brain. There is a record of death caused by a wound of a cavernous sinus through the orbit by the stem of a tobacco-pipe. Bower saw a woman at the Gloucester Infirmary who had been stabbed in the eye by the end of an umbrella. There was profuse hemorrhage from the nostrils and left eye, but no signs indicative of its origin. Death shortly ensued, and at the necropsy a fracture through the roof of the orbit was revealed, the umbrella point having completely severed the optic nerve and divided the ophthalmic artery. The internal carotid artery was wounded in one-half of its circumference at its bend, just before it passes up between the anterior clinoid process and the optic nerve. The cavernous sinus was also opened. In this rare injury, although there was a considerable quantity of clotted blood at the base of the brain, there was no wound to the eyeball nor to the brain itself.
Pepper records a case in which a knife was thrust through the spheroidal fissure, wounding a large meningeal vein, causing death from intracranial hemorrhage. Nelaton describes an instance in which the point of an umbrella wounded the cavernous sinus and internal carotid artery of the opposite side, causing the formation of an arteriovenous aneurysm which ultimately burst, and death ensued. Polaillon saw a boy of eighteen who was found in a state of coma. It was stated that an umbrella stick had been thrust up through the roof of the orbit and had been withdrawn with much difficulty. The anterior lobe of the brain was evidently much wounded; an incision was made in the forehead and a portion of the frontal bone chiseled away entrance being thus effected, the aura was incised, and some blood and cerebrospinal fluid escaped. Five splinters were removed and a portion of the damaged brain-substance, and a small artery was tied with catgut. The debris of the eyeball was enucleated and a drain was placed in the frontal wound, coming out through the orbit. The patient soon regained consciousness and experienced no bad symptoms afterward. The drains were gradually withdrawn, the process of healing advanced rapidly, and recovery soon ensued.
Annandale mentions an instance in which a knitting-needle penetrated the brain through the orbit. Hewett speaks of perforation of the roof of the orbit and injury to the brain by a lead-pencil.
Gunshot Injuries of the Orbit.—Barkan recites the case in which a leaden ball 32/100 inch in diameter was thrown from a sling into the left orbital cavity, penetrating between the eyeball and osseous wall of the orbit without rupturing the tunics of the eye or breaking the bony wall of the cavity. It remained lodged two weeks without causing any pain or symptoms, and subsequently worked itself forward, contained in a perfect conjunctival sac, in which it was freely movable.
Buchanan recites the case of a private in the army who was shot at a distance of three feet away, the ball entering the inner canthus of the right eye and lodging under the skin of the opposite side. The eye was not lost, and opacity of the lower part of the cornea alone resulted. Cold water and purging constituted the treatment.
It is said a that an old soldier of one of Napoleon's armies had a musket-ball removed from his left orbit after twenty-four years' lodgment. He was struck in the orbit by a musket-ball, but as at the same time a companion fell dead at his side he inferred that the bullet rebounded from his orbit and killed his comrade. For twenty-four years he had suffered from cephalalgia and pains and partial exophthalmos of the left eye. After removal of the ball the eye partially atrophied.
Warren reports a case of a man of thirty-five whose eyeball was destroyed by the explosion of a gun, the breech-pin flying off and penetrating the head. The orbit was crushed; fourteen months afterward the man complained of soreness on the hard palate, and the whole breech-pin, with screw attached, was extracted. The removal of the pin was followed by fissure of the hard palate, which, however, was relieved by operation. The following is an extract of a report by Wenyon of Fatshan, South China:—
"Tang Shan, Chinese farmer, thirty-one years of age, was injured in the face by the bursting of a shot-gun. After being for upward of two months under the treatment of native practitioners, he came to me on December 4, 1891. I observed a cicatrix on the right side of his nose, and above this a sinus, still unhealed, the orifice of which involved the inner canthus of the right eye, and extended downward and inward for about a centimeter. The sight of the right eye was entirely lost, and the anterior surface of the globe was so uniformly red that the cornea could hardly be distinguished from the surrounding conjunctiva. There was no perceptible enlargement or protrusion of the eyeball, and it did not appear to have sustained any mechanical injury or loss of tissue. The ophthalmia and keratitis were possibly caused by the irritating substances applied to the wound by the Chinese doctors. The sinus on the side of the nose gave exit to a continuous discharge of slightly putrid pus, and the patient complained of continuous headache and occasional dizziness, which interfered with his work. The pain was referred to the right frontal and temporal regions, and the skin on this part of the head had a slight blush, but there was no superficial tenderness. The patient had been told by his native doctors, and he believed it himself, that there was no foreign body in the wound; but on probing it I easily recognized the lower edge of a hard metallic substance at a depth of about one inch posteriorly from the orifice of the sinus. Being unable to obtain any reliable information as to the probable size or shape of the object, I cautiously made several attempts to remove it through a slightly enlarged opening, but without success. I therefore continued the incision along the side of the nose to the nostril, thus laying open the right nasal cavity; then, seizing the foreign body with a pair of strong forceps, I with difficulty removed the complete breech-pin of a Chinese gun. Its size and shape are accurately represented by the accompanying drawing. The breech-pin measures a little over three inches in length, and weighs 21 ounces, or 75.6 grams. It had evidently lain at the back of the orbit, inclined upward and slightly backward from its point of entrance, at an angle of about 45 degrees. On its removal the headache was at once relieved and did not return. In ten days the wound was perfectly healed and the patient went back to his work. A somewhat similar case, but which terminated fatally, is recorded in the American Journal of the Medical Sciences of July, 1882."
The extent of permanent injury done by foreign bodies in the orbit is variable. In some instances the most extensive wound is followed by the happiest result, while in others vision is entirely destroyed by a minor injury.
Carter reports a case in which a hat-peg 3 3/10 inches long and about 1/4 inch in diameter (upon one end of which was a knob nearly 1/2 inch in diameter) was impacted in the orbit for from ten to twenty days, and during this time the patient was not aware of the fact. Recovery followed its extraction, the vision and movements of the eye being unimpaired.
According to the Philosophical Transactions a laborer thrust a long lath with great violence into the inner canthus of the left eye of his fellow workman, Edward Roberts. The lath broke off short, leaving a piece two inches long, 1/2 inch wide, and 1/4 inch thick, in situ. Roberts rode about a mile to the surgery of Mr. Justinian Morse, who extracted it with much difficulty; recovery followed, together with restoration of the sight and muscular action. The lath was supposed to have passed behind the eyeball. Collette speaks of an instance in which 186 pieces of glass were extracted from the left orbit, the whole mass weighing 186 Belgian grains. They were blown in by a gust of wind that broke a pane of glass; after extraction no affection of the brain or eye occurred. Watson speaks of a case in which a chip of steel 3/8 inch long was imbedded in cellular tissue of the orbit for four days, and was removed without injury to the eye. Wordsworth reports a case in which a foreign body was deeply imbedded in the orbit for six weeks, and was removed with subsequent recovery. Chisholm has seen a case in which for five weeks a fly was imbedded in the culdesac between the lower lid and the eyeball.
Foreign bodies are sometimes contained in the eyeball for many years. There is an instance on record in which a wooden splinter, five mm. long and two mm. br remained in the eye forty-seven years. It was extracted, with the lens in which it was lodged, to relieve pain and other distressing symptoms. Snell reports a case in which a piece of steel was imbedded and encapsulated in the ciliary process twenty-nine years without producing sympathetic irritation of its fellow, but causing such pain as to warrant enucleation of this eye. Gunning speaks of a piece of thorn 5/8 inch long, imbedded in the left eyeball of an old man for six years, causing total loss of vision; he adds that, after its removal, some improvement was noticed.
Williams mentions a stone-cutter whose left eye was put out by a piece of stone. Shortly after this his right eye was wounded by a knife, causing traumatic cataract, which was extracted by Sir William Wilde, giving the man good sight for twelve years, after which iritis attacked the right eye and produced a false membrane over the pupil so that the man could not work. It was in this condition that he consulted Williams, fourteen years after the loss of the left eye. The eye was atrophied, and on examination a piece of stone was seen projecting from it directly between the lids. The visible portion was 1/4 inch long, and the end in the shrunken eye was evidently longer than the end protruding. The sclera was incised, and, after fourteen years' duration in the eye, the stone was removed.
Taylor reports the removal of a piece of bone which had remained quiescent in the eye for fourteen years; after the removal of the eye the bone was found adherent to the inner tunics. It resembled the lens in size and shape. Williams mentions continual tolerance of foreign bodies in the eyeball for fifteen and twenty-two years; and Chisholm reports the lodgment of a fragment of metal in the iris for twenty-three years. Liebreich extracted a piece of steel from the interior of the eye where it had been lodged twenty-two years. Barkar speaks of a piece of steel which penetrated through the cornea and lens, and which, five months later, was successfully removed by the extraction of the cataractous lens. Critchett gives an instance of a foreign body being loose in the anterior chamber for sixteen years. Rider speaks of the lodgment of a fragment of a copper percussion cap in the left eye, back of the inner ciliary margin of the iris, for thirty-five years; and Bartholinus mentions a thorn in the canthus for thirty years. Jacob reports a case in which a chip of iron remained in the eyeball twenty-eight years without giving indications for removal. It was clearly visible, protruding into the anterior surface of the iris, and although it was rusted by its long lodgment, sight in the eye was fairly good, and there was no sign of irritation.
Snell gives an instance in which a piece of steel was imbedded close to the optic disc with retention of sight. It was plainly visible by the opthalmoscope eighteen months after the accident, when as yet no diminution of sight was apparent. Smyly speaks of a portion of a tobacco pipe which was successfully removed from the anterior chamber by an incision through the cornea. Clark mentions a case in which molten lead in the eye caused no permanent injury; and there are several cases mentioned in confirmation of the statement that the eye seems to be remarkably free from disastrous effects after this injury.
Williamson mentions eyelashes in the anterior chamber of the eye, the result of a stab wound of this organ.
Contusion of the eyeball may cause dislocation of the lens into the anterior chamber, and several instances have been recorded. We regret our inability to give the reference or authority for a report that we have seen, stating that by one kick of a horse the lenses of both eyes of a man were synchronously knocked through the eyeballs by the calkins of the horseshoe. Oliver mentions extraction of a lens by a thrust of a cow's horn.
Lowe speaks of rupture of the anterior capsule of the lens from violent sneezing, with subsequent absorption of the lenticular substance and restoration of vision. Trioen mentions a curious case of expulsion of the crystalline lens from the eye in ophthalmia, through the formation of a corneal fissure. The authors have personal knowledge of a case of spontaneous extrusion of the lens through a corneal ulcer, in a case of ophthalmia of the new-born.
Injury of the Eyeball by Birds.—There are several instances in which birds have pierced the eyeball with their bills, completely destroying vision. Not long since a prominent taxidermist winged a crane, picked it up, and started to examine it, when it made one thrust with its bill and totally destroyed his eyeball. In another instance a man was going from the railrstation to his hotel in a gale of wind, when, as he turned the corner of the street, an English sparrow was blown into his face. Its bill penetrated his eyeball and completely ruined his sight. There are several instances on record in which game fowls have destroyed the eyes of their owners. In one case a game cock almost completed the enucleation of the eye of his handler by striking him with his gaff while preparing in a cock-pit.
Moorehead explains a rare accident to an eye as follows:—
"Mr. S. B. A., while attending to his bees, was stung by one upon the right upper eyelid near its center. An employee, who was assisting in the work, immediately discovered the sting driven in the lid and cautiously extracted it, stating that he made sufficient traction to lift the lid well away from the globe. In a few hours the lid became much swollen, but the pain experienced at first had disappeared. Before retiring for the night he began gentle massage of the lid, stroking it horizontally with his finger. The edematous condition was by this means much reduced in a short time. While thus engaged in stroking the lid he suddenly experienced intense pain in the eye as if it had been pierced by a sharp instrument. The suffering was very severe, and he passed a wretched night, constantly feeling 'something in his eye.'
"The next morning, the trouble continuing, he came to me for relief. Upon examination of the lid, no opening could be made out where the sting had penetrated, and a minute inspection of the conjunctival surface with a good glass failed to reveal any foreign substance. Cleansing the lid thoroughly, and carefully inspecting with a lens under strong light, a minute dark point was made out about the center of the lid. Feeling that this might be the point of the sting, I had recourse to several expedients for its removal, but without success. Finally, with a fine knife, I succeeded in cutting down by the side of the body and tilting it out. Examination with a 1/5 inch objective confirmed my opinion that it was the point of the bee-sting.
"The barbed formation of the point explains how, under the stroking with the finger, it was forced through the dense tarsal cartilage and against the cornea of the eye."
There is a story told in La Medecine Moderne of a seamstress of Berlin who was in the habit of allowing her dog to lick her face. She was attacked with a severe inflammation of the right eye, which had to be enucleated, and was found full of tenia echinococcus, evidently derived from the dog's tongue.
Gabb mentions a case of epistaxis in which the blood welled up through the lacrimal ducts and suffused into the eye so that it was constantly necessary to wipe the lower eyelid, and the discharge ceased only when the nose stopped bleeding. A brief editorial note on epistaxis through the eyes, referring to a case in the Medical News of November 30, 1895, provoked further reports from numerous correspondents. Among others, the following:—
"Dr. T. L. Wilson of Bellwood, Pa., relates the case of an old lady of seventy-eight whom he found with the blood gushing from the nostrils. After plugging the nares thoroughly with absorbent cotton dusted with tannic acid he was surprised to see the blood ooze out around the eyelids and trickle down the cheeks. This oozing continued for the greater part of an hour, being controlled by applications of ice to both sides of the nose."
"Dr. F. L. Donlon of New York City reports the case of a married woman, about fifty years old, in whom epistaxis set in suddenly at 11 P.M., and had continued for several hours, when the anterior nares were plugged. In a short time the woman complained that she could scarcely see, owing to the welling up of blood in the eyes and trickling down her face. The bleeding only ceased when the posterior nares also were plugged."
"Dr. T. G. Wright of Plainville, Conn., narrates the case of a young man whom he found in the night, bleeding profusely, and having already lost a large amount of blood. Shortly after plugging both anterior and posterior nares the blood found its way through the lacrimal ducts to the eyes and trickled down the cheeks."
"Dr. Charles W. Crumb cites the case of a man, sixty-five years old, with chronic nephritis, in whom a slight bruise of the nose was followed by epistaxis lasting twenty-four hours. When the nares were plugged blood escaped freely from the eyes. A cone-shaped bit of sponge, saturated with ferrous sulphate, was passed into each anterior naris, and another piece of sponge, similarly medicated, into either posterior naris. The patient had been taking various preparations of potassium, and it was thought that his blood contained a deficiency of fibrin. Upon removal of the nasal plugs a catarrhal inflammation developed which lasted a long time and was attended with considerable purulent discharge."
Late Restoration of Sight.—There are some marvelous cases on record in which, after many years of blindness, the surgeon has been able, by operation, to restore the sight. McKeown gives the history of a blind fiddler of sixty-three, who, when one and a half years old, had lost the sight of both eyes after an attack of small-pox. Iridectomy was performed, and after over sixty years of total blindness his sight was restored; color-perception was good. Berncastle mentions a case of extraction of double cataract and double iridectomy for occluded pupils, which, after thirty years of blindness, resulted in the recovery of good sight. The patient was a blind beggar of Sydney.
To those interested in this subject, Jauffret has a most interesting description of a man by the name of Garin, who was born blind, who talked at eight or nine months, showed great intelligence, and who was educated at a blind asylum. At the age of twenty-four he entered the hospital of Forlenze, to be operated upon by that famous oculist. Garin had never seen, but could distinguish night or darkness by one eye only, and recognized orange and red when placed close to that eye. He could tell at once the sex and age of a person approximately by the voice and tread, and formed his conclusions more rapidly in regard to females than males. Forlenze diagnosed cataract, and, in the presence of a distinguished gathering, operated with the happiest result. The description that follows, which is quoted by Fournier and is readily accessible to any one, is well worth reading, as it contains an account of the first sensations of light, objects, distance, etc., and minor analogous thoughts, of an educated and matured mind experiencing its first sensations of sight.
Hansell and Clark say that the perplexities of learning to see after twenty-six years of blindness from congenital disease, as described by a patient of Franke, remind one of the experience of Shelley's Frankenstein. Franke's patient was successfully operated on for congenital double cataract, at twenty-six years of age. The author describes the difficulties the patient had of recognizing by means of vision the objects he had hitherto known through his other senses, and his slowness in learning to estimate distances and the comparative size of objects.
Sight is popularly supposed to be occasionally restored without the aid of art, after long years of blindness. Benjamin Rush saw a man of forty-five who, twelve years before, became blind without ascertainable cause, and recovered his sight equally without reason. St. Clair mentions Marshal Vivian, who at the age of one hundred regained sight that for nearly forty years had gradually been failing almost to blindness, and preserved this new sight to the time of his death.
There are many superstitions prevalent among uneducated people as to "second sight," recovery of vision, etc., which render their reports of such things untrustworthy. The real explanations of such cases are too varied for discussion here.
Nyctalopia etymologically means night blindness, but the general usage, making the term mean night-vision, is so strongly intrenched that it is useless and confusing to attempt any reinstatement of the old significance. The condition in which one sees better by night, relatively speaking, than by day is due to some lesion of the macular region, rendering it blind. At night the pupil dilates more than in the day-time, and hence vision with the extramacular or peripheral portions of the retina is correspondingly better. It is, therefore, a symptom of serious retinal disease. All night-prowling animals have widely dilatable pupils, and in addition to this they have in the retina a special organ called the tapetum lucidum, the function of which is to reflect to a focus in front of them the relatively few rays of light that enter the widely-dilated pupil and thus enable them the better to see their way. Hence the luminous appearance of the eyes of such animals in the dark.
Hemeralopia (etymologically day-blindness, but by common usage meaning day-vision or night-blindness) is a symptom of a peculiar degenerative disease of the retina, called retinitis pigmentosa. It also occurs in some cases of extreme denutrition, numerous cases having been reported among those who make the prolonged fasts customary in the Russian church. In retinitis pigmentosa the peripheral or extramacular portions of the retina are subject to a pigmentary degeneration that renders them insensitive to light, and patients so afflicted are consequently incapable of seeing at night as well as others. They stumble and run against objects easily seen by the normal eye.
Snow-blindness occurs from prolonged exposure of the eyes to snow upon which the sun is shining. Some years ago, some seventy laborers, who were clearing away snow-drifts in the Caucasus, were seized, and thirty of them could not find their way home, so great was the photophobia, conjunctivitis, and lacrimation. Graddy reports six cases, and many others are constantly occurring.
Other forms of retinal injury from too great or too prolonged exposure to light are "moon-blindness," due to sleeping with the eyes exposed to bright moonlight, and that due to lightning—a case, e.g., being reported by Knies. Silex also reports such a case and reviews the reported cases, 25 in number, in ten of which cataract ensued. In the Annual of the Universal Medical Sciences, 1888, there is a report of seven cases of retinal injury with central scotoma, amblyopia, etc., in Japanese medical students, caused by observation of the sun in eclipse.
In discussing the question of electric-light injuries of the eyes Gould reviews the literature of the subject and epitomizes the cases reported up to that time. They numbered 23. No patient was seriously or permanently injured, and none was in a person who used the electric light in a proper manner as an illuminant. All were in scientific investigators or workmen about the light, who approached it too closely or gazed at it too long and without the colored protecting spectacles now found necessary by such workers.
Injuries to the Ear.—The folly of the practice of boxing children's ears, and the possible disastrous results subsequent to this punishment, are well exemplified throughout medical literature. Stewart quotes four cases of rupture of the tympanum from boxing the ears, and there is an instance of a boy of eight, who was boxed on the ear at school, in whom subsequent brain-disease developed early, and death followed. Roosa of New York mentions the loss of hearing following a kiss on the ear.
Dalby, in a paper citing many different causes of rupture of the tympanic membrane, mentions the following: A blow in sparring; violent sneezing; blowing the nose; forcible dilatation of the Eustachian canal; a thorn or twig of a tree accidentally thrust into the head; picking the ear with a toothpick. In time of battle soldiers sometimes have their tympanums ruptured by the concussion caused by the firing of cannon. Dalby mentions an instance of an officer who was discharged for deafness acquired in this manner during the Crimean War. He was standing beside a mortar which, unexpectedly to him, was fired, causing rupture of the tympanic membrane, followed by hemorrhage from the ear. Similar cases were reported in the recent naval engagements between the Chinese and Japanese. Wilson reports two cases of rupture of the membrane tympani caused by diving. Roosa divides the causes into traumatic, hemorrhagic, and inflammatory, and primary lesions of the labyrinth, exemplifying each by numerous instances. Under traumatic causes he mentions severe falls, blows about the head or face, constant listening to a telegraphic instrument, cannonading, and finally eight cases of boiler-makers' deafness. Roosa cites a curious case of sudden and profound deafness in a young man in perfect health, while calling upon the parents of his lady-love to ask her hand in marriage. Strange to say that after he had had a favorable reply he gradually recovered his hearing! In the same paper there is an instance of a case of deafness due to the sudden cessation of perspiration, and an instance of tinnitus due to the excessive use of tobacco; Roosa also mentions a case of deafness due to excessive mental employment.
Perforation of the Tympanum.—Kealy relates an instance in which a pin was introduced into the left ear to relieve an intolerable itching. It perforated the tympanum, and before the expiration of twenty-four hours was coughed up from the throat with a small quantity of blood. The pin was bent at an angle of about 120 degrees. Another similar case was that of a girl of twenty-two who, while pricking her ear with a hair-pin, was jerked or struck on the arm by a child, and the pin forced into the ear; great pain and deafness followed, together with the loss of taste on the same side of the tongue; after treatment both of the disturbed senses were restored. A man of twenty was pricked in the ear by a needle entering the meatus. He uttered a cry, fell senseless, and so continued until the fourth day when he died. The whole auditory meatus was destroyed by suppuration. Gamgee tells of a constable who was stabbed in the left ear, severing the middle meningeal artery, death ensuing. In this instance, after digital compression, ligature of the common carotid was practiced as a last resort. There is an account of a provision-dealer's agent who fell asleep at a public house at Tottenham. In sport an attendant tickled his ear with a wooden article used as a pipe light. A quick, unconscious movement forced the wooden point through the tympanum, causing cerebral inflammation and subsequent death. There is a record of death, in a child of nine, caused by the passage of a knitting-needle into the auditory meatus.
Kauffmann reports a case of what he calls objective tinnitus aurium, in which the noise originating in the patient's ears was distinctly audible by others. The patient was a boy of fourteen, who had fallen on the back of his head and had remained unconscious for nearly two weeks. The noises were bilateral, but more distinct on the left than on the right side. The sounds were described as crackling, and seemed to depend on movements of the arch of the palate. Kauffmann expresses the opinion that the noises were due to clonic spasm of the tensor velum palati, and states that under appropriate treatment the tinnitus gradually subsided.
The introduction of foreign bodies in the ear is usually accidental, although in children we often find it as a result of sport or curiosity. There is an instance on record of a man who was accustomed to catch flies and put them in his ear, deriving from them a pleasurable sensation from the tickling which ensued. There have been cases in which children, and even adults, have held grasshoppers, crickets, or lady-birds to their ears in order to more attentively listen to the noise, and while in this position the insects have escaped and penetrated the auditory canal. Insects often enter the ears of persons reposing in the fields with the ear to the ground. Fabricius Hildanus speaks of a cricket penetrating the ear during sleep. Calhoun mentions an instance of disease of the ear which he found was due to the presence of several living maggots in the interior of the ear. The patient had been sleeping in a horse stall in which were found maggots similar to those extracted from his ear. An analogous instance was seen in a negro in the Emergency Hospital, Washington, D.C., in the summer of 1894; and many others are recorded. The insects are frequently removed only after a prolonged lodgment.
D'Aguanno gives an account of two instances of living larvae of the musca sarcophaga in the ears of children. In one of the cases the larvae entered the drum-cavity through a rupture in the tympanic membrane. In both cases the maggots were removed by forceps. Haug has observed a tic (ixodes ricinus) in the ear of a lad of seventeen. The creature was killed by a mercuric-chlorid solution, and removed with a probe.
There is a common superstition that centipedes have the faculty of entering the ear and penetrating the brain, causing death. The authors have knowledge of an instance in which three small centipedes were taken from the ear of a policeman after remaining there three days; during this time they caused excruciating pain, but there was no permanent injury. The Ephemerides contains instances in which, while yet living, worms, crickets, ants, and beetles have all been taken from the ear. In one case the entrance of a cricket in the auditory canal was the cause of death. Martin gives an instance in which larvae were deposited in the ear. Stalpart van der Wiel relates an instance of the lodgment of a living spider in the ear.
Far more common than insects are inanimate objects as foreign bodies in the ear, and numerous examples are to be found in literature. Fabricius Hildanus tells of a glass ball introduced into the auditory canal of a girl of ten, followed by headache, numbness on the left side, and after four or five years epileptic seizures, and atrophy of the arm. He extracted it and the symptoms immediately ceased. Sabatier speaks of an abscess of the brain caused by a ball of paper in the ear; and it is quite common for persons in the habit of using a tampon of cotton in the meatus to mistake the deep entrance of this substance for functional derangement, and many cases of temporary deafness are simply due to forgetfulness of the cause. A strange case is reported in a girl of fourteen, who lost her tympanum from a profuse otorrhea, and who substituted an artificial tympanum which was, in its turn, lost by deep penetration, causing augmentation of the symptoms, of the cause of which the patient herself seemed unaware. Sometimes artificial otoliths are produced by the insufflation of various powders which become agglutinated, and are veritable foreign bodies. Holman tells of a negro, aged thirty-five, whose wife poured molten pewter in his ear while asleep. It was removed, but total deafness was the result.
Alley mentions a New Orleans wharf laborer, in whose ear was poured some molten lead; seventeen months afterward the lead was still occupying the external auditory meatus. It is quite remarkable that the lead should have remained such a length of time without causing meningeal inflammation. There was deafness and palsy of that side of the face. A fungous growth occupied the external portion of the ear; the man suffered pain and discharge from the ear, and had also great difficulty in closing his right eyelid. Morrison mentions an alcoholic patient of forty who, on June 6, 1833, had nitric acid poured in her right ear. There were no headache, febrile symptoms, stupor, or vertigo. Debility alone was present. Two weeks after the injury paralysis began on the right side, and six weeks from the injury the patient died. This case is interesting from the mode of death, the perfect paralysis of the arm, paralysis agitans of the body (occurring as hemorrhage from the ear came on, and subsiding with it), and extensive caries of the petrous bone, without sensation of pain or any indicative symptoms.
There is an instance in a young girl in which a piece of pencil remained in the right ear for seven years. Haug speaks of two beads lying in the auditory canal for twenty-eight years without causing any harm.
A boy of six introduced a carob-nut kernel into each ear. On the next day incompetent persons attempted to extract the kernel from the left side, but only caused pain and hemorrhage. The nut issued spontaneously from the right side. In the afternoon the auditory canal was found excoriated and red, and deep in the meatus the kernel was found, covered with blood. The patient had been so excited and pained by the bungling attempts at extraction that the employment of instruments was impossible; prolonged employment of injections was substituted. Discharge from the ear commenced, intense fever and delirium ensued, and the patient had to be chloroformed to facilitate the operation of extraction. The nut, when taken out, was found to have a consistency much larger than originally, caused by the agglutination of wax and blood. Unfortunately the symptoms of meningitis increased; three days after the operation coma followed, and on the next day death ensued. In 75 cases collected by Mayer, and cited by Poulet (whose work on "Foreign Bodies" is the most extensive in existence), death as a consequence of meningitis was found in three.
Fleury de Clermont mentions a woman of twenty-five who consulted him for removal of a pin which was in her right ear. Vain attempts by some of her lay-friends to extract the pin had only made matters worse. The pin was directed transversely, and its middle part touched the membrane tympanum. The mere touching of the pin caused the woman intense pain; even after etherization it was necessary to construct a special instrument to extract it. She suffered intense cephalalgia and other signs of meningitis; despite vigorous treatment she lost consciousness and died shortly after the operation.
Winterbotham reports an instance in which a cherry-stone was removed from the meatus auditorius after lodgment of upward of sixty years. Marchal de Calvi mentions intermittent deafness for forty years, caused by the lodgment of a small foreign body in the auditory canal. There is an instance in which a carious molar tooth has been tolerated in the same location for forty years.
Albucasius, Fabricius Hildanus, Pare, and others, have mentioned the fact that seeds and beans have been frequently seen to increase in volume while lodged in the auditory canal. Tulpius speaks of an infant, playing with his comrades, who put a cherry-seed in his ear which he was not able to extract. The seed increased in volume to such an extent that it was only by surgical interference that it could be extracted, and then such serious consequences followed that death resulted. Albers reports an instance in which a pin introduced into the ear issued from the pharynx.
Confusion of diagnosis is occasionally noticed in terrified or hysteric persons. Lowenberg was called to see a child of five who had introduced a button into his left ear. When he saw the child it complained of all the pain in the right ear, and he naturally examined this ear first but found nothing to indicate the presence of a foreign body. He examined the ear supposed to be healthy and there found the button lying against the tympanum. This was explained by the fact that the child was so pained and terrified by the previous explorations of the affected ear that rather than undergo them again he presented the well ear for examination. In the British Medical Journal for 1877 is an account of an unjustified exploration of an ear for a foreign body by an incompetent physician, who spent a half hour in exploration and manipulation, and whose efforts resulted in the extraction of several pieces of bone. The child died in one and a half hours afterward from extreme hemorrhage, and the medical bungler was compelled to appear before a coroner's jury in explanation of his ignorance.
In the external ear of a child Tansley observed a diamond which he removed under chloroform. The mother of the child had pushed the body further inward in her endeavors to remove it and had wounded the canal. Schmiegelow reports a foreign body forced into the drum-cavity, followed by rough extraction, great irritation, tetanus, and death; and there are on record several cases of fatal meningitis, induced by rough endeavors to extract a body from the external ear.
In the Therapeutic Gazette, August 15, 1896, there is a translation of the report of a case by Voss, in which a child of five pushed a dry pea in his ear. Four doctors spent several days endeavoring to extract it, but only succeeded in pushing it in further. It was removed by operation on the fifth day, but suppuration of the tympanic cavity caused death on the ninth day.
Barclay reports a rare case of ensnared aural foreign body in a lady, aged about forty years, who, while "picking" her left ear with a so-called "invisible hair-pin" several hours before the consultation, had heard a sudden "twang" in the ear, as if the hair-pin had broken. And so, indeed, it had; for on the instant she had attempted to jerk it quickly from the ear the sharp extremity of the inner portion of its lower prong sprang away from its fellow, penetrated the soft tissues of the floor of the external auditory canal, and remained imbedded there, the separated end of this prong only coming away in her grasp. Every attempt on her part to remove the hair-pin by traction on its projecting prong—she durst not force it INWARD for fear of wounding the drumhead—had served but to bury the point of the broken prong more deeply into the flesh of the canal, thereby increasing her suffering. Advised by her family physician not to delay, she forthwith sought advice and aid. On examination, it was found that the lower prong of the "invisible hair-pin" had broken at the outer end of its wavy portion, and seemed firmly imbedded in the floor of the auditory canal, now quite inflamed, at a point about one-third of its depth from the outlet of the canal. The loop or turn of the hair-pin was about 1/2 inch from the flaccid portion of the drumhead, and, together with the unbroken prong, it lay closely against the roof of the canal. Projecting from the meatus there was enough of this prong to be easily grasped between one's thumb and finger. Removal of the hair-pin was effected by first inserting within the meatus a Gruber speculum, encircling the unbroken projecting prong, and then raising the end of the broken one with a long-shanked aural hook, when the hair-pin was readily withdrawn. The wound of the canal-floor promptly healed.
In the severest forms of scalp-injuries, such as avulsion of the scalp from the entangling of the hair in machinery, skin-grafting or replantation is of particular value. Ashhurst reports a case which he considers the severest case of scalp-wound that he had ever seen, followed by recovery. The patient was a girl of fifteen, an operative in a cotton-mill, who was caught by her hair between two rollers which were revolving in opposite directions; her scalp being thus, as it were, squeezed off from her head, forming a large horseshoe flap. The linear extent of the wound was 14 inches, the distance between the two extremities being but four inches. This large flap was thrown backward, like the lid of a box, the skull being denuded of its pericranium for the space of 2 1/2 by one inch in extent. The anterior temporal artery was divided and bled profusely, and when admitted to the hospital the patient was extremely depressed by shock and hemorrhage. A ligature was applied to the bleeding vessel, and after it had been gently but carefully cleansed the flap was replaced and held in place with gauze and collodion dressing. A large compress soaked in warm olive oil was then placed over the scalp, covered with oiled silk and with a recurrent bandage. A considerable portion of the wound healed by adhesions, and the patient was discharged, cured, in fifty-four days. No exfoliation of bone occurred. Reverdin, a relative of the discoverer of transplantation of skin, reported the case of a girl of twenty-one whose entire scalp was detached by her hair being caught in machinery, leaving a wound measuring 35 cm. from the root of the nose to the nape of the neck, 28 cm. from one ear to the other, and 57 cm. in circumference. Grafts from the rabbit and dog failed, and the skin from the amputated stump of a boy was employed, and the patient was able to leave the hospital in seven months. Cowley speaks of a girl of fourteen whose hair was caught in the revolving shaft of a steam-engine, which resulted in the tearing off of her whole scalp. A triangular portion of the skin was hanging over her face, the apex of the triangle containing short hair, from which the long hair had been detached. Both ears were hanging down the neck, having been detached above. The right pinna was entire, and the upper half of the left pinna had disappeared. The whole of the head and back of the neck was denuded of skin. One of the temporal arteries was ligated, and the scalp cleansed and reapplied. The hanging ears and the skin of the forehead were successfully restored to their proper position. The patient had no bad symptoms and little pain, and the shock was slight. Where the periosteum had sloughed the bone was granulating, and at the time of the report skin-grafting was shortly to be tried.
Schaeffer has presented quite an extensive article on scalp-injuries in which grafting and transplantation has been used, and besides reporting his own he mentions several other cases. One was that of a young lady of twenty-four. While at work under a revolving shaft in a laundry the wind blew her hair and it was caught in the shaft. The entire skull was laid bare from the margin of the eyelids to the neck. The nasal bones were uncovered and broken, exposing the superior nasal meatus. The skin of the eyelids was removed from within three mm. of their edges. The lower margin of the wound was traceable from the lower portion of the left external process of the frontal bone, downward and backward below the left ear (which was entirely removed), thence across the neck, five cm. below the superior curved line of the occipital bone, and forward through the lower one-third of the right auricle to the right external angular process of the frontal bone and margin of the right upper eyelid, across the lid, nose, and left eyelid, to the point of commencement. Every vessel and nerve supplying the scalp was destroyed, and the pericranium was torn off in three places, one of the denuded spots measuring five by seven cm. and another five by six cm. The neck flap of the wound fell away from the muscular structures beneath it, exposing the trapezius muscle almost one-half the distance to the shoulder blade. The right ear was torn across in its lower third, and hung by the side of the neck by a piece of skin less than five mm. wide. The exposed surface of the wound measured 40 cm. from before back, and 34 cm. in width near the temporal portion. The cranial sutures were distinctly seen in several places, and only a few muscular fibers of the temporal were left on each side. Hemorrhage was profuse from the temporal, occipital, and posterior auricular arteries, which were tied. The patient was seen three-quarters of an hour after the injury, and the mangled scalp was thoroughly washed in warm carbolized water, and stitched back in position, after the hair was cut from the outer surface. Six weeks after the injury suppuration was still free, and skin-grafting was commenced. In all, 4800 grafts were used, the patient supplying at different times 1800 small grafts. Her own skin invariably did better than foreign grafts. In ten months she had almost completely recovered, and sight and hearing had returned. Figure 191 shows the extent of the injury, and the ultimate results of the treatment.
Schaeffer also reports the case of a woman working in a button factory at Union City, Conn., in 1871, who placed her head under a swiftly turning shaft to pick up a button, when her hair caught in the shaft, taking off her scalp from the nape of the neck to the eyebrows. The scalp was cleansed by her physician, Dr. Bartlett, and placed on her head about two hours after the accident, but it did not stay in position. Then the head was covered twice by skin-grafts, but each time the grafts were lost; but the third time a successful grafting was performed and she was enabled to work after a period of two years. The same authority also quotes Wilson and Way of Bristol, Conn., in an account of a complete avulsion of the scalp, together with tearing of the eyelid and ear. The result of the skin-grafting was not given. Powell of Chicago gives an account of a girl of nineteen who lost her scalp while working in the Elgin Watch Factory at Elgin, Illinois. The wound extended across the forehead above the eyebrows, but the ears were untouched. Skin-grafting was tried in this case but with no result, and the woman afterward lost an eye by exposure, from retraction of the eyelid.
In some cases extensive wounds of the scalp heal without artificial aid by simply cicatrizing over. Gross mentions such a case in a young lady, who, in 1869, lost her scalp in a factory. There is reported an account of a conductor on the Union Pacific Railr who, near Cheyenne, in 1869, was scalped by Sioux Indians. He suffered an elliptic wound, ten by eight cm., a portion of the outer table of the cranium being removed, yet the wound healed over.
Cerebral Injuries.—The recent advances in brain-surgery have, in a measure, diminished the interest and wonder of some of the older instances of major injuries of the cerebral contents with unimportant after-results, and in reviewing the older cases we must remember that the recoveries were made under the most unfavorable conditions, and without the slightest knowledge of all important asepsis and antisepsis.
Penetration or even complete transfixion of the brain is not always attended with serious symptoms. Dubrisay is accredited with the description of a man of forty-four, who, with suicidal intent, drove a dagger ten cm. long and one cm. wide into his brain. He had deliberately held the dagger in his left hand, and with a mallet in his right hand struck the steel several blows. When seen two hours later he claimed that he experienced no pain, and the dagger was sticking out of his head. For half an hour efforts at extraction were made, but with no avail. He was placed on the ground and held by two persons while traction was made with carpenter's pliers. This failing, he was taken to a coppersmith's, where he was fastened by rings to the ground, and strong pinchers were placed over the dagger and attached to a chain which was fastened to a cylinder revolved by steam force. At the second turn of the cylinder the dagger came out. During all the efforts at extraction the patient remained perfectly cool and complained of no pain. A few drops of blood escaped from the wound after the removal of the dagger, and in a few minutes the man walked to a hospital where he remained a few days without fever or pain. The wound healed, and he soon returned to work. By experiments on the cadaver Dubrisay found that the difficulty in extraction was due to rust on the steel, and by the serrated edges of the wound in the bone.
Warren describes a case of epilepsy of seven months' standing, from depression of the skull caused by a red hot poker thrown at the subject's head. Striking the frontal bone just above the orbit, it entered three inches into the cerebral substance. Kesteven reports the history of a boy of thirteen who, while holding a fork in his hand, fell from the top of a lof straw. One of the prongs entered the head one inch behind and on a line with the lobe of the left ear and passed upward and slightly backward to almost its entire length. With some difficulty it was withdrawn by a fellow workman; the point was bent on itself to the extent of two inches. The patient lived nine days. Abel and Colman have reported a case of puncture of the brain with loss of memory, of which the following extract is an epitome: "A railway-fireman, thirty-six years old, while carrying an oil-feeder in his hand, slipped and fell forward, the spout of the can being driven forcibly into his face. There was transitory loss of consciousness, followed by twitching and jerking movements of the limbs, most marked on the left side, the legs being drawn up and the body bent forward. There was no hemorrhage from mouth, nose, or ears. The metallic spout of the oil-can was firmly fixed in the base of the skull, and was only removed from the grasp of the bone by firm traction with forceps. It had passed upward and toward the middle line, with its concavity directed from the middle line. Its end was firmly plugged by bone from the base of the skull. No hemorrhage followed its removal. The wound was cleansed and a simple iodoform-dressing applied. The violent jerking movements were replaced by a few occasional twitchings. It was now found that the left side of the face and the left arm were paralyzed, with inability to close the left eye completely. The man became drowsy and confused, and was unable to give replies to any but the simplest questions. The temperature rose to 102 degrees; the pupils became contracted, the right in a greater degree than the left; both reacted to light. The left leg began to lose power. There was complete anesthesia of the right eyebrow and of both eyelids and of the right cheek for an uncertain distance below the lower eyelid. The conjunctiva of the right eye became congested, and a small ulcer formed on the right cornea, which healed without much trouble. In the course of a few days power began to return, first in the left leg and afterward, though to a much less extent, in the left arm. For two weeks there was drowsiness, and the man slept considerably. He was apathetic, and for many days passed urine in bed. He could not recognize his wife or old comrades, and had also difficulty in recognizing common objects and their uses. The most remarkable feature was the loss of all memory of his life for twenty years before the accident. As time went on, the period included in this loss of memory was reduced to five years preceding the accident. The hemiplegia persisted, although the man was able to get about. Sensibility was lost to all forms of stimuli in the right upper eyelid, forehead, and anterior part of the scalp, corresponding with the distribution of the supraorbital and nasal nerves. The cornea was completely anesthetic, and the right cheek, an inch and a half external to the angle of the nose, presented a small patch of anesthesia. There was undue emotional mobility, the patient laughing or crying on slight provocation. The condition of mind-blindness remained. It is believed that the spout of the oil-can must have passed under the zygoma to the base of the skull, perforating the great wing of the spheroid bone and penetrating the centrum ovale, injuring the anterior fibers of the motor tract in the internal capsule near the genu."
Figures 192 and 193 show the outline and probable course of the spout.
Beaumont reports the history of an injury in a man of forty-five, who, standing but 12 yards away, was struck in the orbit by a rocket, which penetrated through the spheroidal fissure into the middle and posterior lobes of the left hemisphere. He did not fall at the time he was struck, and fifteen minutes after the stick was removed he arose without help and walked away. Apparently no extensive cerebral lesion had been caused, and the man suffered no subsequent cerebral symptoms except, three years afterward, impairment of memory.
There is an account given by Chelius of an extraordinary wound caused by a ramrod. The rod was accidentally discharged while being employed in lng, and struck a person a few paces away. It entered the head near the root of the zygomatic arch, about a finger's breadth from the outer corner of the right eye, passed through the head, emerging at the posterior superior angle of the parietal bone, a finger's breadth from the sagittal suture, and about the same distance above the superior angle of the occipital bone. The wounded man attempted to pull the ramrod out, but all his efforts were ineffectual. After the tolerance of this foreign body for some time, one of his companions managed to extract it, and when it was brought out it was as straight as the day it left the maker's shop. Little blood was lost, and the wound healed rapidly and completely; in spite of this major injury the patient recovered.
Carpenter reports the curious case of an insane man who deliberately bored holes through his skull, and at different times, at a point above the ear, he inserted into his brain five pieces of No. 20 broom wire from 2 1/16 to 6 3/4 inches in length, a fourpenny nail 2 1/4 inches long, and a needle 1 5/8 inches long. Despite these desperate attempts at suicide he lived several months, finally accomplishing his purpose by taking an overdose of morphin. MacQueen has given the history of a man of thirty-five, who drove one three-inch nail into his forehead, another close to his occiput, and a third into his vertex an inch in front and 1/4 inch to the left of the middle line. He had used a hammer to effect complete penetration, hoping that death would result from his injuries. He failed in this, as about five weeks later he was discharged from the Princess Alice Hospital at Eastbourne, perfectly recovered. There is a record of a man by the name of Bulkley who was found, by a police officer in Philadelphia, staggering along the streets, and was taken to the inebriate ward of the Blockley Hospital, where he subsequently sank and died, after having been transferred from ward to ward, his symptoms appearing inexplicable. A postmortem examination revealed the fact that an ordinary knife-blade had been driven into his brain on the right side, just above the ear, and was completely hidden by the skin. It had evidently become loosened from the handle when the patient was stabbed, and had remained in the brain several days. No clue to the assailant was found.
Thudicum mentions the case of a man who walked from Strafford to Newcastle, and from Newcastle to London, where he died, and in his brain was found the breech-pin of a gun. Neiman describes a severe gunshot wound of the frontal region, in which the iron breech-block of an old-fashioned muzzle-lng gun was driven into the substance of the brain, requiring great force for its extraction. The patient, a young man of twenty-eight, was unconscious but a short time, and happily made a good recovery. A few pieces of bone came away, and the wound healed with only a slight depression of the forehead. Wilson speaks of a child who fell on an upright copper paper-file, which penetrated the right side of the occipital bone, below the external orifice of the ear, and entered the brain for more than three inches; and yet the child made a speedy recovery.
Baron Larrey knew of a man whose head was completely transfixed by a ramrod, which extended from the middle of the forehead to the left side of the nape of the neck; despite this serious injury the man lived two days.
Jewett records the case of an Irish drayman who, without treatment, worked for forty-seven days after receiving a penetrating wound of the skull 1/4 inch in diameter and four inches deep. Recovery ensued in spite of the delay in treatment.
Gunshot Injuries.—Swain mentions a patient who stood before a looking glass, and, turning his head far around to the left, fired a pistol shot into his brain behind the right ear. The bullet passed into his mouth, and he spat it out. Some bleeding occurred from both the internal and external wounds; the man soon began to suffer with a troublesome cough, with bloody expectoration; his tongue was coated and drawn to the right; he became slightly deaf in his right ear and dragged his left leg in walking. These symptoms, together with those of congestion of the lung, continued for about a week, when he died, apparently from his pulmonary trouble.
Ford quotes the case of a lad of fifteen who was shot in the head, 3/4 inch anterior to the summit of the right ear, the ball escaping through the left os frontis, 1 1/4 inch above the center of the brow. Recovery ensued, with a cicatrix on the forehead, through which the pulsations of the brain could be distinctly seen. The senses were not at all deteriorated.
Richardson tells of a soldier who was struck by a Minie ball on the left temporal bone; the missile passed out through the left frontal bone 1/2 inch to the left of the middle of the forehead. He was only stunned, and twenty-four hours later his intellect was undisturbed. There was no operation; free suppuration with discharges of fragments of skull and broken-down substance ensued for four weeks, when the wounds closed kindly, and recovery followed.
Angle records the case of a cowboy who was shot by a comrade in mistake. The ball entered the skull beneath the left mastoid process and passed out of the right eye. The man recovered.
Rice describes the case of a boy of fourteen who was shot in the head, the ball directly traversing the brain substance, some of which protruded from the wound. The boy recovered. The ball entered one inch above and in front of the right ear and made its exit through the lambdoidal suture posteriorly.
Hall of Denver, Col., in an interesting study of gunshot wounds of the brain, writes as follows:—
"It is in regard to injuries involving the brain that the question of the production of immediate unconsciousness assumes the greatest interest. We may state bry that if the medulla or the great centers at the base of the brain are wounded by a bullet, instant unconsciousness must result; with any other wounds involving the brain-substance it will, with very great probability, result. But there is a very brarea of uncertainty. Many instances have been recorded in which the entrance of a small bullet into the anterior part of the brain has not prevented the firing of a second shot on the part of the suicide. Personally, I have not observed such a case, however. But, aside from the injuries by the smallest missiles in the anterior parts of the brain, we may speak with almost absolute certainty with regard to the production of unconsciousness, for the jar to the brain from the blow of the bullet upon the skull would produce such a result even if the damage to the brain were not sufficient to do so.
"Many injuries to the brain from bullets of moderate size and low velocity do not cause more than a temporary loss of consciousness, and the subjects are seen by the surgeon, after the lapse of half an hour or more, apparently sound of mind. These are the cases in which the ball has lost its momentum in passing through the skull, and has consequently done little damage to the brain-substance, excepting to make a passage for itself for a short distance into the brain. It is apparently well established that, in the case of the rifle-bullet of high velocity, and especially if fired from the modern military weapons using nitro-powders, and giving an enormous initial velocity to the bullet, the transmission of the force from the displaced particles of brain (and this rule applies to any other of the soft organs as well) to the adjacent parts is such as to disorganize much of the tissue surrounding the original track of the missile. Under these circumstances a much slighter wound would be necessary to produce unconsciousness or death than in the case of a bullet of low velocity, especially if it were light in weight. Thus I have recorded elsewhere an instance of instant death in a grizzly bear, an animal certainly as tenacious of life as any we have, from a mere furrow, less than a quarter of an inch in depth, through the cortex of the brain, without injury of the skull excepting the removal of the bone necessary for the production of this furrow. The jar to the brain from a bullet of great velocity, as in this case, was alone sufficient to injure the organ irreparably. In a similar manner I have known a deer to be killed by the impact of a heavy rifle-ball against one horn, although there was no evidence of fracture of the skull. On the other hand, game animals often escape after such injuries not directly involving the brain, although temporarily rendered unconscious, as I have observed in several instances, the diagnosis undoubtedly being concussion of the brain.
"Slight injury to the brain, and especially if it be unilateral, then, may not produce unconsciousness. It is not very uncommon for a missile from a heavy weapon to strike the skull, and be deflected without the production of such a state. Near the town in which I formerly practiced, the town-marshal shot at a negro, who resisted arrest, at a distance of only a few feet, with a 44-caliber revolver, striking the culprit on the side of the head. The wound showed that the ball struck the skull and plowed along under the scalp for several inches before emerging, but it did not even knock the negro down, and no unconsciousness followed later. I once examined an express-messenger who had been shot in the occipital region by a weapon of similar size, while seated at his desk in the car. The blow was a very glancing one and did not produce unconsciousness, and probably, as in the case of the negro, because it did not strike with sufficient directness."
Head Injuries with Loss of Cerebral Substance.—The brain and its membranes may be severely wounded, portions of the cranium or cerebral substance destroyed or lost, and yet recovery ensue. Possibly the most noted injury of this class was that reported by Harlow and commonly known as "Bigelow's Case" or the "American Crow-bar Case." Phineas P. Gage, aged twenty-five, a foreman on the Rutland and Burlington Railr was employed September 13, 1847, in charging a hole with powder preparatory to blasting. A premature explosion drove a tamping-iron, three feet seven inches long, 1 1/4 inches in diameter, weighing 13 1/4 pounds, completely through the man's head. The iron was round and comparatively smooth; the pointed end entered first. The iron struck against the left side of the face, immediately anterior to the inferior maxillary and passed under the zygomatic arch, fracturing portions of the spheroid bone and the floor of the left orbit; it then passed through the left anterior lobe of the cerebrum, and, in the median line, made its exit at the junction of the coronal and sagittal sutures, lacerating the longitudinal sinus, fracturing the parietal and frontal bones, and breaking up considerable of the brain; the globe of the left eye protruded nearly one-half of its diameter. The patient was thrown backward and gave a few convulsive movements of the extremities. He was taken to a hotel 3/4 mile distant, and during the transportation seemed slightly dazed, but not at all unconscious. Upon arriving at the hotel he dismounted from the conveyance, and without assistance walked up a long flight of stairs to the hall where his wound was to be dressed. Harlow saw him at about six o'clock in the evening, and from his condition could hardly credit the story of his injury, although his person and his bed were drenched with blood. His scalp was shaved, the coagula and debris removed, and among other portions of bone was a piece of the anterior superior angle of each parietal bone and a semicircular piece of the frontal bone, leaving an opening 3 1/2 inches in diameter. At 10 P.M. on the day of the injury Gage was perfectly rational and asked about his work and after his friends. After a while delirium set in for a few days, and on the eleventh day he lost the vision in the left eye. His convalescence was rapid and uneventful. It was said that he discharged pieces of bone and cerebral substance from his mouth for a few days. The iron when found was smeared with blood and cerebral substance.
As was most natural such a wonderful case of cerebral injury attracted much notice. Not only was the case remarkable in the apparent innocuous loss of cerebral substance, but in the singular chance which exempted the brain from either concussion or compression, and subsequent inflammation. Professor Bigelow examined the patient in January, 1850, and made a most excellent report of the case, and it is due to his efforts that the case attained world-wide notoriety. Bigelow found the patient quite recovered in his faculties of body and mind, except that he had lost the sight of the injured eye. He exhibited a linear cicatrix one inch long near the angle of the ramus of the left lower jaw. His left eyelid was involuntarily closed and he had no power to overcome his ptosis. Upon the head, well covered by the hair, was a large unequal depression and elevation. In order to ascertain how far it might be possible for a bar of the size causing the injury to traverse the skull in the track assigned to it, Bigelow procured a common skull in which the zygomatic arches were barely visible from above, and having entered a drill near the left angle of the inferior maxilla, he passed it obliquely upward to the median line of the cranium just in front of the junction of the sagittal and coronal sutures. This aperture was then enlarged until it allowed the passage of the bar in question, and the loss of substance strikingly corresponded with the lesion said to have been received by the patient. From the coronoid process of the inferior maxilla there was removed a fragment measuring about 3/4 inch in length. This fragment, in the patient's case, might have been fractured and subsequently reunited. The iron bar, together with a cast of the patient's head, was placed in the Museum of the Massachusetts Medical College.
Bigelow appends an engraving to his paper. In the illustration the parts are as follows:—
(1) Lateral view of a prepared cranium representing the iron bar traversing its cavity.
(2) Front view of same.
(3) Plan of the base seen from within. In these three figures the optic foramina are seen to be intact and are occupied by small white rods.
(4) Cast taken from the shaved head of the patient representing the appearance of the fracture in 1850, the anterior fragment being considerably elevated in the profile view.
(5) The iron bar with length and diameter in proportion to the size of the other figures.
Heaton reports a case in which, by an explosion, a tamping-iron was driven through the chin of a man into the cerebrum. Although there was loss of brain-substance, the man recovered with his mental faculties unimpaired. A second case was that of a man who, during an explosion, was wounded in the skull. There was visible a triangular depression, from which, possibly, an ounce of brain-substance issued. This man also recovered.
Jewett mentions a case in which an injury somewhat similar to that in Bigelow's case was produced by a gas-pipe.
Among older writers, speaking of loss of brain-substance with subsequent recovery, Brasavolus saw as much brain evacuated as would fill an egg shell; the patient afterward had an impediment of speech and grew stupid. Franciscus Arcaeus gives the narrative of a workman who was struck on the head by a stone weighing 24 pounds falling from a height. The skull was fractured; fragments of bone were driven into the brain. For three days the patient was unconscious and almost lifeless. After the eighth day a cranial abscess spontaneously opened, from the sinciput to the occiput, and a large quantity of "corruption" was evacuated. Speech returned soon after, the eyes opened, and in twenty days the man could distinguish objects. In four months recovery was entire. Bontius relates a singular accident to a sailor, whose head was crushed between a ship and a small boat; the greater part of the occipital bone was taken away in fragments, the injury extending almost to the foremen magnum. Bontius asserts that the patient was perfectly cured by another surgeon and himself. Galen mentions an injury to a youth in Smyrna, in whom the brain was so seriously wounded that the anterior ventricles were opened; and vet the patient recovered. Glandorp mentions a case of fracture of the skull out of which his father took large portions of brain and some fragments of bone. He adds that the man was afterward paralyzed an the opposite side and became singularly irritable. In his "Chirurgical Observations," Job van Meek'ren tells the story of a Russian nobleman who lost part of his skull, and a dog's skull was supplied in its place. The bigoted divines of the country excommunicated the man, and would not annul his sentence until he submitted to have the bit of foreign bone removed.
Mendenhall reports the history of an injury to a laborer nineteen years old. While sitting on a log a few feet from a comrade who was chopping wood, the axe glanced and, slipping from the woodman's grasp, struck him just above the ear, burying the "bit" of the axe in his skull. Two hours afterward he was seen almost pulseless, and his clothing drenched with blood which was still oozing from the wound with mixed brain-substance and fragments of bone. The cut was horizontal on a level with the orbit, 5 1/2 inches long externally, and, owing to the convex shape of the axe, a little less internally. Small spicules of bone were removed, and a cloth was placed on the battered skull to receive the discharges for the inspection of the surgeon, who on his arrival saw at least two tablespoonfuls of cerebral substance on this cloth. Contrary to all expectation this man recovered, but, strangely, he had a marked and peculiar change of voice, and this was permanent. From the time of the reception of the injury his whole mental and moral nature had undergone a pronounced change. Before the injury, the patient was considered a quiet, unassuming, and stupid boy, but universally regarded as honest. Afterward he became noisy, self-asserting, sharp, and seemingly devoid of moral sense or honesty. These new traits developed immediately, and more strikingly so soon as convalescence was established.
Bergtold quotes a case reported in 1857 of extreme injury to the cranium and its contents. While sleeping on the deck of a canal boat, a man at Highspire was seriously injured by striking his head against a bridge. When seen by the surgeon his hair was matted and his clothes saturated with blood. There was a terrible gap in the scalp from the superciliary ridge to the occipital bone, and, though full of clots, the wound was still oozing. In a cloth on a bench opposite were rolled up a portion of the malar bone, some fragments of the os frontis, one entire right parietal bone, detached from its fellow along the sagittel suture, and from the occipital along the lambdoidal suture, perhaps taking with it some of the occipital bone together with some of the squamous portion of the temporal bone. This bone was as clean of soft parts as if it had been removed from a dead subject with a scalpel and saw. No sight of the membranes or of the substance of the brain was obtained. The piece of cranium removed was 6 3/4 inches in the longitudinal diameter, and 5 3/4 inches in the short oval diameter. The dressing occupied an hour, at the end of which the patient arose to his feet and changed his clothes as though nothing had happened. Twenty-six years after the accident there was slight unsteadiness of gait, and gradual paralysis of the left leg and arm and the opposite side of the face, but otherwise the man was in good condition. In place of the parietal bone the head presented a marked deficiency as though a slice of the skull were cut out. The depressed area measured five by six inches. In 1887 the man left the hospital in Buffalo with the paralysis improved, but his mental equilibrium could be easily disturbed. He became hysteric and sobbed when scolded.
Buchanan mentions the history of a case in a woman of twenty-one, who, while working in a mill, was struck by a bolt. Her skull was fractured and driven into the brain comminuted. Hanging from the wound was a bit of brain-substance, the size of a finger, composed of convolution as well as white matter. The wound healed, there was no hernia, and at the time of report the girl was conscious of no disturbance, not even a headache. There was nothing indicative of the reception of the injury except a scar near the edge of the hair on the upper part of the right side of the forehead. Steele, in a school-boy of eight, mentions a case of very severe injury to the bones of the face and head, with escape of cerebral substance, and recovery. The injury was caused by falling into machinery.
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