PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 18 page

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 novel 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 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 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

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