Anomalies And Curiosities Of Medicine Part 44

Projecting from the meatus there was enough of this p.r.o.ng 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 p.r.o.ng, and then raising the end of the broken one with a long-shanked aural hook, when the hair-pin was readily withdrawn.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 ca.n.a.l-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 s.p.a.ce 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 circ.u.mference. 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 st.i.tched 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 b.u.t.ton factory at Union City, Conn., in 1871, who placed her head under a swiftly turning shaft to pick up a b.u.t.ton, 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 Railroad, 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 load of straw. One of the p.r.o.ngs entered the head one inch behind and on a line with the lobe of the left ear and pa.s.sed 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 pa.s.sed 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 pa.s.sed 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 pa.s.sed 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 loading, 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, pa.s.sed 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 a.s.sailant was found.

Thudic.u.m 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-loading 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 gla.s.s, and, turning his head far around to the left, fired a pistol shot into his brain behind the right ear. The bullet pa.s.sed 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 b.l.o.o.d.y 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 pa.s.sed 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 pa.s.sed 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 a.s.sumes the greatest interest. We may state broadly 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 broad area 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 pa.s.sing through the skull, and has consequently done little damage to the brain-substance, excepting to make a pa.s.sage 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 circ.u.mstances 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 cla.s.s 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 Railroad, 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 pa.s.sed under the zygomatic arch, fracturing portions of the spheroid bone and the floor of the left orbit; it then pa.s.sed 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 a.s.sistance 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 a.s.signed 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 pa.s.sed 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 pa.s.sage 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 Ma.s.sachusetts Medical College.

Bigelow appends an engraving to his paper. In the ill.u.s.tration 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 sh.e.l.l; 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 quant.i.ty 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 a.s.serts 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 n.o.bleman 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 p.r.o.nounced change. Before the injury, the patient was considered a quiet, una.s.suming, and stupid boy, but universally regarded as honest. Afterward he became noisy, self-a.s.serting, 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 ca.n.a.l 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.

There was a seaman aboard of the U.S.S. "Constellation," who fell through a hatchway from the masthead, landing on the vertex of the head. There was copious bleeding from the ears, 50 to 60 fluid-ounces of blood oozing in a few hours, mingled with small fragments of brain-tissue. The next day the discharge became watery, and in it were found small pieces of true brain-substance. In five weeks the man returned to duty complaining only of giddiness and of a "stuffed-up"

head. In 1846 there is a record of a man of forty who fell from a scaffold, erected at a height of 20 feet, striking on his head. He was at first stunned, but on admission to the hospital recovered consciousness. A small wound was found over the right eyebrow, protruding from which was a portion of brain-substance. There was slight hemorrhage from the right nostril, and some pain in the head, but the pulse and respiration were undisturbed. On the following day a fragment of the cerebral substance, about the size of a hazel-nut, together with some brood-clots, escaped from the right nostril. In this case the inner wall of the frontal sinus was broken, affording exit for the lacerated brain.

Cooke and Layc.o.c.k mention a case of intracranial injury with extensive destruction of brain-substance around the Rolandic area; there was recovery but with loss of the so called muscular sense. The patient, a workman of twenty-nine, while cutting down a gum-tree, was struck by a branch as thick as a man's arm, which fell from 100 feet overhead, inflicting a compound comminuted fracture of the cranium. The right eye was contused but the pupils equal; the vertex-wound was full of brain-substance and pieces of bone, ten of which were removed, leaving an oval opening four by three inches. The base of the skull was fractured behind the orbits; a fissure 1/4 inch wide was discernible, and the right frontal bone could be easily moved. The lacerated and contused brain-substance was removed. Consciousness returned six days after the operation. The accompanying ill.u.s.trations (Figs. 196 and 197) show the extent of the injury. The lower half of the ascending frontal convolution, the greater half of the sigmoid gyrus, the posterior third of the lower and middle frontal convolutions, the base and posterior end of the upper convolution, and the base of the corresponding portion of the falciform lobe were involved. The sensory and motor functions of the arm were retained in a relative degree.

There was power of simple movements, but complex movements were awkward. The tactile localization was almost lost.

Morton mentions a patient of forty-seven, who was injured in a railroad accident near Phoenixville, Pa.; there was a compound comminuted fracture of the skull involving the left temporal, spheroid, and superior maxillary bones. The side of the head and the ear were considerably lacerated; several teeth were broken, and besides this there was injury to the aura and cerebral substance. There was profound coma for ten days and paralysis of the 1st, 2d, 3d, 4th, 6th, and 7th cranial nerves, particularly affecting the left side of the face. There was scarcely enough blood-supply left to the orbit to maintain life in the globe. The man primarily recovered, but ninety-one days from the injury he died of cerebral abscess.

There is the record of a curious brain-injury in a man of twenty-two, who was struck on the skull by a circular saw. The saw cut directly down into the brain, severing the superior longitudinal sinus, besides tearing a branch of the meningeal artery. The wound was filled with sawdust left by the saw while it was tearing through the parts. After ordinary treatment the man recovered.