PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 20 page

sharp point striking the forehead in the frontal suture, crushing the

os frontis, destroying 1 3/4 inches of the longitudinal sinus, and

causing severe hemorrhage from both the longitudinal and frontal

sinuses. The pin was pulled out by the boy, who washed his own face,

and lay down; he soon became semi-comatose, in which condition he

remained for some days; but, after operation, he made complete recovery.

Loss of Brain-substance from Cerebral Tumor.--Koser is accredited with

reporting results of a postmortem held on a young man of twenty who

suffered from a cerebral tumor of considerable duration. It was stated

that, although there was a cavity in the brain at least five inches in

length, the patient, almost up to the time of death, was possessed of

the senses of touch, taste, hearing, and smell, showed considerable

control over his locomotor muscles, and could talk. In fact, he was

practically discommoded in no other way than by loss of vision, caused

by pressure on the optic centers. It was also stated that the retention

of memory was remarkable, and, up to within two weeks of his death, the

patient was able to memorize poems. The amount of involvement

discovered postmortem in cases similar to the preceding is astonishing.

At a recent pathologic display in London several remarkable specimens

were shown.

Extensive Fractures of the Skull. Jennings mentions an instance of

extensive fracture of the skull, 14 pieces of the cranium being found.

The patient lived five weeks and two days after the injury, the

immediate cause of death being edema of the lungs. His language was

incoherent and full of oaths. Belloste, in his "Hospital Surgeon,"

states that he had under has care a most dreadful case of a girl of

eleven or twelve years, who received 18 or 19 cutlass wounds of the

head, each so violent as to chip out pieces of bone; but,

notwithstanding her severe injuries, she made recovery. At the

Emergency Hospital in Washington, D.C., there was received a negress

with at least six gaping wounds of the head, in some cases denuding the

periosteum and cutting the cranium. During a debauch the night before

she had been engaged in a quarrel with a negro with whom she lived, and

was struck by him several times on the head with an axe. She lay all

night unconscious, and was discovered the next morning with her hair

and clothes and the floor on which she lay drenched with blood. The

ambulance was summoned to take her to the morgue, but on the arrival of

the police it was seen that feeble signs of life still existed. On

admission to the hospital she was semi-comatose, almost pulseless,

cold, and exhibiting all the signs of extreme hemorrhage and shock. Her

head was cleaned up, but her condition would not permit of any other

treatment than a corrosive-sublimate compress and a bandage of

Scultetus. She was taken to the hospital ward, where warmth and

stimulants were applied, after which she completely reacted. She

progressed so well that it was not deemed advisable to remove the

head-bandage until the fourth day, when it was seen that the wounds had

almost entirely healed and suppuration was virtually absent. The

patient rapidly and completely recovered, and her neighbors, on her

return home, could hardly believe that she was the same woman whom, a

few days before, they were preparing to take to the morgue.

A serious injury, which is not at all infrequent, is that caused by

diving into shallow water, or into a bath from which water has been

withdrawn. Curran mentions a British officer in India who, being

overheated, stopped at a station bath in which the previous night he

had had a plunge, and without examining, took a violent "header" into

the tank, confidently expecting to strike from eight to ten feet of

water. He dashed his head against the concrete bottom 12 feet below

(the water two hours previously having been withdrawn) and crushed his

brain and skull into an indistinguishable mass.

There are many cases on record in which an injury, particularly a

gunshot wound of the skull, though showing no external wound, has

caused death by producing a fracture of the internal table of the

cranium. Pare gives details of the case of a nobleman whose head was

guarded by a helmet and who was struck by a ball, leaving no external

sign of injury, but it was subsequently found that there was an

internal fracture of the cranium. Tulpius and Scultetus are among the

older writers reporting somewhat similar instances, and there are

several analogous cases reported as having occurred during the War of

the Rebellion. Boling reports a case in which the internal table was

splintered to a much greater extent than the external.

Fracture of the base of the skull is ordinarily spoken of as a fatal

injury, reported instances of recovery being extremely rare, but

Battle, in a paper on this subject, has collected numerous statistics

of nonfatal fracture of the base of the brain, viz.:--

Male. Female.

Anterior fossa, . . . . . . . . . . . 16 5

Middle fossa, . . . . . . . . . . . . 50 6

Posterior fossa,. . . . . . . . . . . 10 1

Middle and anterior fossae, . . . . . 15 5

Middle and posterior fossae,. . . . . 4 1

Anterior, middle, and posterior fossae, 1 0

------ ------

96 18 Total, 114.

In a paper on nonmortal fractures of the base of the skull, Lidell

gives an account of 135 cases. MacCormac reports a case of a boy of

nine who was run over by a carriage drawn by a pair of horses. He

suffered fracture of the base of the skull, of the bones of the face,

and of the left ulna, and although suppuration at the points of

fracture ensued, followed by an optic neuritis, an ultimate recovery

was effected. Ball, an Irish surgeon, has collected several instances

in which the base of the skull has been driven in and the condyle of

the jaw impacted in the opening by force transmitted through the lower

maxilla.

The tolerance of foreign bodies in the brain is most marvelous. In the

ancient chronicles of Koenigsberg there is recorded the history of a

man who for fourteen years carried in his head a piece of iron as large

as his finger. After its long lodgment, during which the subject was

little discommoded, it finally came out by the palatine arch. There is

also an old record of a ball lodging near the sella turcica for over a

year, the patient dying suddenly of an entirely different accident.

Fabricius Hildanus relates the history of an injury, in which, without

causing any uncomfortable symptoms, a ball rested between the skull and

dura for six months.

Amatus Lusitanus speaks of a drunken courtesan who was wounded in a

fray with a long, sharp-pointed knife which was driven into the head.

No apparent injury resulted, and death from fever took place eight

years after the reception of the injury. On opening the head a large

piece of knife was found between the skull and dura. It is said that

Benedictus mentions a Greek who was wounded, at the siege of Colchis,

in the right temple by a dart and taken captive by the Turks; he lived

for twenty years in slavery, the wound having completely healed.

Obtaining his liberty, he came to Sidon, and five years after, as he

was washing his face, he was seized by a violent fit of sneezing, and

discharged from one of his nostrils a piece of the dart having an iron

point of considerable length.

In about 1884 there died in the Vienna Hospital a bookbinder of

forty-five, who had always passed as an intelligent man, but who had at

irregular intervals suffered from epileptic convulsions. An iron nail

covered with rust was discovered in his brain; from the history of his

life and from the appearances of the nail it had evidently been lodged

in the cerebrum since childhood.

Slee mentions a case in which, after the death of a man from septic

peritonitis following a bullet-wound of the intestines, he found

postmortem a knife-blade 5/16 inch in width projecting into the brain

to the depth of one inch. The blade was ensheathed in a strong fibrous

capsule 1/2 inch thick, and the adjacent brain-structure was apparently

normal. The blade was black and corroded, and had evidently passed

between the sutures during boyhood as there was no depression or

displacement of the cranial bones. The weapon had broken off just on a

level with the skull, and had remained in situ until the time of death

without causing any indicative symptoms. Slee does not state the man's

age, but remarks that he was a married man and a father at the time of

his death, and had enjoyed the best of health up to the time he was

shot in the abdomen. Callaghan, quoted in Erichsen's "Surgery," remarks

that he knew of an officer who lived seven years with a portion of a

gun-breech weighing three ounces lodged in his brain.

Lawson mentions the impaction of a portion of a breech of a gun in the

forehead of a man for twelve years, with subsequent removal and

recovery. Waldon speaks of a similar case in which a fragment of the

breech weighing three ounces penetrated the cranium, and was lodged in

the brain for two months previous to the death of the patient.

Huppert tells of the lodgment of a slate-pencil three inches long in

the brain during lifetime, death ultimately being caused by a slight

head-injury. Larry mentions a person who for some time carried a six

ounce ball in the brain and ultimately recovered. Peter removed a

musket-ball from the frontal sinus after six years' lodgment, with

successful issue. Mastin has given an instance in which the blade of a

pen-knife remained in the brain six months, recovery following its

removal. Camden reports a case in which a ball received in a gunshot

wound of the brain remained in situ for thirteen years; Cronyn mentions

a similar case in which a bullet rested in the brain for eight years.

Doyle successfully removed an ounce Minie ball from the brain after a

fifteen years' lodgment.

Pipe-stems, wires, shot, and other foreign bodies, are from time to

time recorded as remaining in the brain for some time. Wharton has

compiled elaborate statistics on this subject, commenting on 316 cases

in which foreign bodies were lodged in the brain, and furnishing all

the necessary information to persons interested in this subject.

Injuries of the nose, with marked deformity, are in a measure combated

by devices invented for restoring the missing portions of the injured

member. Taliacotius, the distinguished Italian surgeon of the sixteenth

century, devised an operation which now bears his name, and consists in

fashioning a nose from the fleshy tissues of the arm. The arm is

approximated to the head and held in this position by an apparatus or

system of bandages for about ten days, at which time it is supposed

that it can be severed, and further trimming and paring of the nose is

then practiced. A column is subsequently made from the upper lip. In

the olden days there was a timorous legend representing Taliacotius

making noses for his patients from the gluteal regions of other

persons, which statement, needless to say, is not founded on fact.

Various modifications and improvements on the a Talicotian method have

been made; but in recent years the Indian method, introduced by Carpue

into England in 1816, is generally preferred. Syme of Edinburgh, Wood,

and Ollier have devised methods of restoring the nose, which bear their

names.

Ohmann-Dumesnil reports a case of rhinophyma in a man of seventy-two,

an alcoholic, who was originally affected with acne rosacea, on whom he

performed a most successful operation for restoration. The accompanying

illustration shows the original deformity--a growth weighing two

pounds--and also pictures the appearance shortly after the operation.

This case is illustrative of the possibilities of plastic surgery in

the hands of a skilful and ingenious operator.

About 1892 Dr. J. P. Parker then of Kansas City, Mo., restored the

missing bridge of a patient's nose by laying the sunken part open in

two long flaps, denuding the distal extremity of the little finger of

the patient's right hand of nail, flesh, tendons, etc., and binding it

into the wound of the nose until firm union had taken place. The finger

was then amputated at the second joint and the plastic operation

completed, with a result pleasing both to patient and operator.

There is a case quoted of a young man who, when first seen by his

medical attendant, had all the soft parts of the nose gone, except

one-third of the left ala and a thin flap of the septum which was lying

on the upper lip. The missing member was ferreted out and cleansed, and

after an hour's separation sutured on. The nostrils were daily syringed

with a corrosive sublimate solution, and on the tenth day the dressing

was removed; the nose was found active and well, with the single

exception of a triangular notch on the right side, which was too

greatly bruised by the violence of the blow to recover. When we

consider the varicosity of this organ we can readily believe the

possibility of the foregoing facts, and there is little doubt that more

precaution in suturing severed portions of the nose would render the

operation of nose making a very rare one.

Maxwell mentions a curious case of attempted suicide in which the ball,

passing through the palatine process of the superior maxillary bone,

crushing the vomer to the extent of its own diameter, fell back through

the right nostril into the pharynx, was swallowed, and discharged from

the anus.

Deformities of the nose causing enormous development, or the condition

called "double-nose" by Bartholinus, Borellus, Bidault, and others, are

ordinarily results of a pathologic development of the sebaceous glands.

In some cases tumors develop from the root of the nose, forming what

appears to be a second nose. In other cases monstrous vegetations

divide the nose into many tumors. In the early portion of this century

much was heard about a man who was a daily habitue of the Palais-Royal

Gardens. His nose was divided into unequally sized tumors, covering

nearly his entire face. Similar instances have been observed in recent

years. Hey mentions a case in which the tumor extended to the lower

part of the under lip, which compressed the patient's mouth and

nostrils to such an extent that while sleeping, in order to insure

sufficient respiration, he had to insert a tin-tube into one of his

nostrils. Imbert de Lannes is quoted as operating on a former Mayor of

Angouleme. This gentleman's nose was divided into five lobes by

sarcomatous tumors weighing two pounds, occupying the external surface

of the face, adherent to the buccinator muscles to which they extended,

and covering the chin. In the upright position the tumors sealed the

nostrils and mouth, and the man had to bend his head before and after

respiration. In eating, this unfortunate: person had to lift his tumors

away from his mouth, and during sleep the monstrous growths were

supported in a sling attached to his night cap. He presented such a

hideous aspect that he was virtually ostracized from society The growth

had been in progress for twelve years, but during twenty-two months'

confinement in Revolutionary prisons the enlargement had been very

rapid. Fournier says that the most beautiful result followed the

operation which was considered quite hazardous.

Foreign bodies in the nose present phenomena as interesting as wounds

of this organ. Among the living objects which have been found in the

nose may be mentioned flies, maggots, worms, leeches, centipedes, and

even lizards. Zacutus Lusitanus tells of a person who died in two days

from the effects of a leech which was inadvertently introduced into the

nasal fossa, and there is a somewhat similar case of a military

pharmacist, a member of the French army in Spain, who drank some water

from a pitcher and exhibited, about a half hour afterward, a persistent

hemorrhage from the nose. Emaciation progressively continued, although

his appetite was normal. Three doctors, called in consultation,

prescribed bleeding, which, however, proved of no avail. Three weeks

afterward he carried in his nostril a tampon of lint, wet with an

astringent solution, and, on the next day, on blowing his nose, there

fell from the right nostril a body which he recognized as a leech.

Healey gives the history of four cases in which medicinal leeches were

removed from the mouth and posterior nares of persons who had, for some

days previously, been drinking turbid water. Sinclair mentions the

removal of a leech from the posterior nares.

In some regions, more particularly tropical ones, there are certain

flies that crawl into the nostrils of the inhabitants and deposit eggs,

in the cavities. The larvae develop and multiply with great rapidity,

and sometimes gain admission into the frontal sinus, causing intense

cephalalgia, and even death.

Dempster reports an instance of the lodgment of numerous live maggots

within the cavity of the nose, causing sloughing of the palate and

other complications. Nicholson mentions a case of ulceration and

abscess of the nostrils and face from which maggots were discharged.

Jarvis gives the history of a strange and repeated hemorrhage from the

nose and adjacent parts that was found to be due to maggots from the

ova of a fly, which had been deposited in the nose while the patient

was asleep. Tomlinson gives a case in which maggots traversed the

Eustachian tube, some being picked out of the nostrils, while others

were coughed up. Packard records the accidental entrance of a

centipede into the nostril. There is an account of a native who was

admitted to the Madras General Hospital, saying that a small lizard had

crawled up his nose. The urine of these animals is very irritating,

blistering any surface it touches. Despite vigorous treatment the

patient died in consequence of the entrance of this little creature.

There have been instances among the older writers in which a pea has

remained in the nose for such a length of time as to present evidences

of sprouting. The Ephemerides renders an instance of this kind, and

Breschet cites the history of a young boy, who, in 1718, introduced a

pea into his nostril; in three days it had swollen to such an extent as

to fill the whole passage. It could not be extracted by an instrument,

so tobacco snuff was used, which excited sneezing, and the pea was

ejected.

Vidal and the Ephemerides report several instances of tolerance of

foreign bodies in the nasal cavities for from twenty to twenty-five

years. Wiesman, in 1893, reported a rhinolith, which was composed of a

cherry-stone enveloped in chalk, that had been removed after a sojourn

of sixty years, with intense ozena as a consequence of its lodgment.

Waring mentions the case of a housemaid who carried a rhinolith, with a

cherry-stone for a nucleus, which had been introduced twenty-seven

years before, and which for twenty-five years had caused no symptoms.

Grove describes a necrosed inferior turbinated bone, to which was

attached a coffee-grain which had been retained in the nostril for

twenty years., Hickman gives an instance of a steel ring which for

thirteen and a half years had been impacted in the nasopharyngeal fossa

of a child. It was detected by the rhinoscope and was removed. Parker

speaks of a gunbreech bolt which was removed from the nose after five

years' lodgment. Major mentions the removal of a foreign body from the

nose seven years after its introduction.

Howard removed a large thimble from the posterior nares, although it

had remained in its position for some time undetected. Eve reports a

case in which a thimble was impacted in the right posterior nares.

Gazdar speaks, of a case of persistent neuralgia of one-half of the

face, caused by a foreign body in the nose. The obstruction was

removed after seven years' lodgment and the neuralgia disappeared.

Molinier has an observation on the extraction of a fragment of a

knife-blade which had rested four years in the nasal fossae, where the

blade had broken off during a quarrel.

A peculiar habit, sometimes seen in nervous individuals, is that of

"swallowing the tongue." Cohen claims that in some cases of supposed

laryngeal spasm the tongue is swallowed, occluding the larynx, and

sometimes with fatal consequences. There are possibly a half score of

cases recorded, but this anomaly is very rare, and Major is possibly

the only one who has to a certainty demonstrated the fact by a

laryngoscopic examination. By the laryngoscope he was enabled to

observe a paroxysm in a woman, in which the tongue retracted and

impinged on the epiglottis, but quickly recovered its position. Pettit

mentions suffocation from "tongue swallowing," both with and without

section of the frenum. Schobinger cites a similar instance, due to

loosening of the frenum.

Analogous to the foregoing phenomenon is the habit of "tongue sucking."

Morris mentions a young lady of fifteen who spontaneously dislocated

her jaw, owing indirectly to this habit. Morris says that from infancy

the patient was addicted to this habit, which was so audible as to be

heard in all parts of the room. The continued action of the pterygoid

muscles had so preternaturally loosened the ligaments and muscular

structures supporting the joint as to render them unable to resist the

violent action of "tongue sucking" even during sleep.

Injuries to the Tongue.--Hobbs describes a man of twenty-three who,

while working, had a habit of protruding his tongue. One day he was hit

under the chin by the chain of a crane on a pier, his upper teeth

inflicting a wound two inches deep, three inches from the tip, and

dividing the entire structure of the tongue except the arteries. The

edges of the wound were brought into apposition by sutures, and after

the removal of the latter perfect union and complete restoration of the

sensation of taste ensued. Franck mentions regeneration of a severed

tongue; and Van Wy has seen union of almost entirely severed parts of

the tongue. De Fuisseaux reports reunion of the tongue by suture after

almost complete transverse division.

There is an account of a German soldier who, May 2, 1813, was wounded

at the battle of Gross-Gorschen by a musket ball which penetrated the

left cheek, carrying away the last four molars of the upper jaw and

passing through the tongue, making exit on the left side, and forcing

out several teeth of the left lower jaw. To his surprise, thirty years

afterward, one of the teeth was removed from an abscess of the tongue.

Baker speaks of a boy of thirteen who was shot at three yards distance.

The bullet knocked out two teeth and passed through the tongue,

although it produced no wound of the pharynx, and was passed from the

anus on the sixth day. Stevenson mentions a case of an organist who

fell forward when stooping with a pipe in his mouth, driving its stem

into the roof of the pharynx. He complained of a sore throat for

several days, and, after explanation, Stevenson removed from the soft

palate a piece of clay pipe nearly 1 1/4 inches long. Herbert tells of

a case resembling carcinoma of the tongue, which was really due to the

lodgment of a piece of tooth in that organ.

Articulation Without the Tongue.--Total or partial destruction of the

tongue does not necessarily make articulation impossible. Banon

mentions a man who had nothing in his mouth representing a tongue. When

he was young, he was attacked by an ulceration destroying every vestige

of this member. The epiglottis, larynx, and pharynx, in fact the

surrounding structures were normal, and articulation, which was at

first lost, became fairly distinct, and deglutition was never

interfered with. Pare gives a description of a man whose tongue was

completely severed, in consequence of which he lost speech for three

years, but was afterward able to make himself understood by an

ingenious bit of mechanism. He inserted under the stump of the tongue a

small piece of wood, in a most marvelous way replacing the missing

member. Articulation with the absence of some constituent of the vocal

apparatus has been spoken of on page 254.

Hypertrophy of the Tongue.--It sometimes happens that the tongue is so

large that it is rendered not only useless but a decided hindrance to

the performance of the ordinary functions into which it always enters.

Ehrlich, Ficker, Klein, Rodforffer, and the Ephemerides, all record

instances in which a large tongue was removed either by ligation or

amputation. Von Siebold records an instance in which death was caused

by the ligature of an abnormally sized tongue. There is a modern record

of three cases of enormous tongues, the result of simple hypertrophy.

In one case the tongue measured 6 1/4 inches from the angle of the

mouth about the sides and tip to the opposite angle, necessitating

amputation of the protruding portion.

Carnochan reports a case in which hypertrophy of the tongue was reduced

to nearly the normal size by first tying the external carotid, and six

weeks later the common carotid artery. Chalk mentions partial

dislocation of the lower jaw from an enlarged tongue. Lyford speaks of

enlargement of the tongue causing death.

The above conditions are known as macroglossia, which is a congenital

hypertrophy of the tongue analogous to elephantiasis. It is of slow

growth, and as the organ enlarges it interferes with deglutition and

speech. It may protrude over the chin and reach even as far down as the

sternum.

The great enlargement may cause deformities of the teeth and lower jaw,

and even present itself as an enormous tumor in the neck. The

protruding tongue itself may ulcerate, possibly bleed, and there is

constant dribbling of saliva. The disease is probably due to congenital

defect aggravated by frequent attacks of glossitis, and the treatment

consists in the removal of the protruding portions by the knife,

ligation, the cautery, or ecraseur.

Living Fish in the Pharynx.--Probably the most interesting cases of

foreign bodies are those in which living fish enter the pharynx and

esophagus. Chevers has collected five cases in which death was caused

by living fish entering the mouth and occluding the air-passages. He

has mentioned a case in which a large catfish jumped into the mouth of

a Madras bheestie. An operation on the esophagus was immediately

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