PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 19 page

must have passed under the zygoma to the base of the skull, perforating

the great wing of the spheroid bone and penetrating the centrum ovale,

injuring the anterior fibers of the motor tract in the internal capsule

near the genu."

Figures 192 and 193 show the outline and probable course of the spout.

Beaumont reports the history of an injury in a man of forty-five, who,

standing but 12 yards away, was struck in the orbit by a rocket, which

penetrated through the spheroidal fissure into the middle and posterior

lobes of the left hemisphere. He did not fall at the time he was

struck, and fifteen minutes after the stick was removed he arose

without help and walked away. Apparently no extensive cerebral lesion

had been caused, and the man suffered no subsequent cerebral symptoms

except, three years afterward, impairment of memory.

There is an account given by Chelius of an extraordinary wound caused

by a ramrod. The rod was accidentally discharged while being employed

in 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, passed through the head, emerging at the

posterior superior angle of the parietal bone, a finger's breadth from

the sagittal suture, and about the same distance above the superior

angle of the occipital bone. The wounded man attempted to pull the

ramrod out, but all his efforts were ineffectual. After the tolerance

of this foreign body for some time, one of his companions managed to

extract it, and when it was brought out it was as straight as the day

it left the maker's shop. Little blood was lost, and the wound healed

rapidly and completely; in spite of this major injury the patient

recovered.

Carpenter reports the curious case of an insane man who deliberately

bored holes through his skull, and at different times, at a point above

the ear, he inserted into his brain five pieces of No. 20 broom wire

from 2 1/16 to 6 3/4 inches in length, a fourpenny nail 2 1/4 inches

long, and a needle 1 5/8 inches long. Despite these desperate attempts

at suicide he lived several months, finally accomplishing his purpose

by taking an overdose of morphin. MacQueen has given the history of a

man of thirty-five, who drove one three-inch nail into his forehead,

another close to his occiput, and a third into his vertex an inch in

front and 1/4 inch to the left of the middle line. He had used a hammer

to effect complete penetration, hoping that death would result from his

injuries. He failed in this, as about five weeks later he was

discharged from the Princess Alice Hospital at Eastbourne, perfectly

recovered. There is a record of a man by the name of Bulkley who was

found, by a police officer in Philadelphia, staggering along the

streets, and was taken to the inebriate ward of the Blockley Hospital,

where he subsequently sank and died, after having been transferred from

ward to ward, his symptoms appearing inexplicable. A postmortem

examination revealed the fact that an ordinary knife-blade had been

driven into his brain on the right side, just above the ear, and was

completely hidden by the skin. It had evidently become loosened from

the handle when the patient was stabbed, and had remained in the brain

several days. No clue to the assailant was found.

Thudicum mentions the case of a man who walked from Strafford to

Newcastle, and from Newcastle to London, where he died, and in his

brain was found the breech-pin of a gun. Neiman describes a severe

gunshot wound of the frontal region, in which the iron breech-block of

an old-fashioned muzzle-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

glass, and, turning his head far around to the left, fired a pistol

shot into his brain behind the right ear. The bullet passed into his

mouth, and he spat it out. Some bleeding occurred from both the

internal and external wounds; the man soon began to suffer with a

troublesome cough, with bloody expectoration; his tongue was coated and

drawn to the right; he became slightly deaf in his right ear and

dragged his left leg in walking. These symptoms, together with those of

congestion of the lung, continued for about a week, when he died,

apparently from his pulmonary trouble.

Ford quotes the case of a lad of fifteen who was shot in the head, 3/4

inch anterior to the summit of the right ear, the ball escaping through

the left os frontis, 1 1/4 inch above the center of the brow. Recovery

ensued, with a cicatrix on the forehead, through which the pulsations

of the brain could be distinctly seen. The senses were not at all

deteriorated.

Richardson tells of a soldier who was struck by a Minie ball on the

left temporal bone; the missile passed out through the left frontal

bone 1/2 inch to the left of the middle of the forehead. He was only

stunned, and twenty-four hours later his intellect was undisturbed.

There was no operation; free suppuration with discharges of fragments

of skull and broken-down substance ensued for four weeks, when the

wounds closed kindly, and recovery followed.

Angle records the case of a cowboy who was shot by a comrade in

mistake. The ball entered the skull beneath the left mastoid process

and passed out of the right eye. The man recovered.

Rice describes the case of a boy of fourteen who was shot in the head,

the ball directly traversing the brain substance, some of which

protruded from the wound. The boy recovered. The ball entered one inch

above and in front of the right ear and made its exit through the

lambdoidal suture posteriorly.

Hall of Denver, Col., in an interesting study of gunshot wounds of the

brain, writes as follows:--

"It is in regard to injuries involving the brain that the question of

the production of immediate unconsciousness assumes the greatest

interest. We may state 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 passing through the skull, and has

consequently done little damage to the brain-substance, excepting to

make a passage for itself for a short distance into the brain. It is

apparently well established that, in the case of the rifle-bullet of

high velocity, and especially if fired from the modern military weapons

using nitro-powders, and giving an enormous initial velocity to the

bullet, the transmission of the force from the displaced particles of

brain (and this rule applies to any other of the soft organs as well)

to the adjacent parts is such as to disorganize much of the tissue

surrounding the original track of the missile. Under these

circumstances a much slighter wound would be necessary to produce

unconsciousness or death than in the case of a bullet of low velocity,

especially if it were light in weight. Thus I have recorded elsewhere

an instance of instant death in a grizzly bear, an animal certainly as

tenacious of life as any we have, from a mere furrow, less than a

quarter of an inch in depth, through the cortex of the brain, without

injury of the skull excepting the removal of the bone necessary for the

production of this furrow. The jar to the brain from a bullet of great

velocity, as in this case, was alone sufficient to injure the organ

irreparably. In a similar manner I have known a deer to be killed by

the impact of a heavy rifle-ball against one horn, although there was

no evidence of fracture of the skull. On the other hand, game animals

often escape after such injuries not directly involving the brain,

although temporarily rendered unconscious, as I have observed in

several instances, the diagnosis undoubtedly being concussion of the

brain.

"Slight injury to the brain, and especially if it be unilateral, then,

may not produce unconsciousness. It is not very uncommon for a missile

from a heavy weapon to strike the skull, and be deflected without the

production of such a state. Near the town in which I formerly

practiced, the town-marshal shot at a negro, who resisted arrest, at a

distance of only a few feet, with a 44-caliber revolver, striking the

culprit on the side of the head. The wound showed that the ball struck

the skull and plowed along under the scalp for several inches before

emerging, but it did not even knock the negro down, and no

unconsciousness followed later. I once examined an express-messenger

who had been shot in the occipital region by a weapon of similar size,

while seated at his desk in the car. The blow was a very glancing one

and did not produce unconsciousness, and probably, as in the case of

the negro, because it did not strike with sufficient directness."

Head Injuries with Loss of Cerebral Substance.--The brain and its

membranes may be severely wounded, portions of the cranium or cerebral

substance destroyed or lost, and yet recovery ensue. Possibly the most

noted injury of this class was that reported by Harlow and commonly

known as "Bigelow's Case" or the "American Crow-bar Case." Phineas P.

Gage, aged twenty-five, a foreman on the Rutland and Burlington

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 passed under the zygomatic arch, fracturing

portions of the spheroid bone and the floor of the left orbit; it then

passed through the left anterior lobe of the cerebrum, and, in the

median line, made its exit at the junction of the coronal and sagittal

sutures, lacerating the longitudinal sinus, fracturing the parietal and

frontal bones, and breaking up considerable of the brain; the globe of

the left eye protruded nearly one-half of its diameter. The patient was

thrown backward and gave a few convulsive movements of the extremities.

He was taken to a hotel 3/4 mile distant, and during the transportation

seemed slightly dazed, but not at all unconscious. Upon arriving at the

hotel he dismounted from the conveyance, and without assistance walked

up a long flight of stairs to the hall where his wound was to be

dressed. Harlow saw him at about six o'clock in the evening, and from

his condition could hardly credit the story of his injury, although his

person and his bed were drenched with blood. His scalp was shaved, the

coagula and debris removed, and among other portions of bone was a

piece of the anterior superior angle of each parietal bone and a

semicircular piece of the frontal bone, leaving an opening 3 1/2 inches

in diameter. At 10 P.M. on the day of the injury Gage was perfectly

rational and asked about his work and after his friends. After a while

delirium set in for a few days, and on the eleventh day he lost the

vision in the left eye. His convalescence was rapid and uneventful. It

was said that he discharged pieces of bone and cerebral substance from

his mouth for a few days. The iron when found was smeared with blood

and cerebral substance.

As was most natural such a wonderful case of cerebral injury attracted

much notice. Not only was the case remarkable in the apparent innocuous

loss of cerebral substance, but in the singular chance which exempted

the brain from either concussion or compression, and subsequent

inflammation. Professor Bigelow examined the patient in January, 1850,

and made a most excellent report of the case, and it is due to his

efforts that the case attained world-wide notoriety. Bigelow found the

patient quite recovered in his faculties of body and mind, except that

he had lost the sight of the injured eye. He exhibited a linear

cicatrix one inch long near the angle of the ramus of the left lower

jaw. His left eyelid was involuntarily closed and he had no power to

overcome his ptosis. Upon the head, well covered by the hair, was a

large unequal depression and elevation. In order to ascertain how far

it might be possible for a bar of the size causing the injury to

traverse the skull in the track assigned to it, Bigelow procured a

common skull in which the zygomatic arches were barely visible from

above, and having entered a drill near the left angle of the inferior

maxilla, he passed it obliquely upward to the median line of the

cranium just in front of the junction of the sagittal and coronal

sutures. This aperture was then enlarged until it allowed the passage

of the bar in question, and the loss of substance strikingly

corresponded with the lesion said to have been received by the patient.

From the coronoid process of the inferior maxilla there was removed a

fragment measuring about 3/4 inch in length. This fragment, in the

patient's case, might have been fractured and subsequently reunited.

The iron bar, together with a cast of the patient's head, was placed in

the Museum of the Massachusetts Medical College.

Bigelow appends an engraving to his paper. In the illustration the

parts are as follows:--

(1) Lateral view of a prepared cranium representing the iron bar

traversing its cavity.

(2) Front view of same.

(3) Plan of the base seen from within. In these three figures the optic

foramina are seen to be intact and are occupied by small white rods.

(4) Cast taken from the shaved head of the patient representing the

appearance of the fracture in 1850, the anterior fragment being

considerably elevated in the profile view.

(5) The iron bar with length and diameter in proportion to the size of

the other figures.

Heaton reports a case in which, by an explosion, a tamping-iron was

driven through the chin of a man into the cerebrum. Although there was

loss of brain-substance, the man recovered with his mental faculties

unimpaired. A second case was that of a man who, during an explosion,

was wounded in the skull. There was visible a triangular depression,

from which, possibly, an ounce of brain-substance issued. This man also

recovered.

Jewett mentions a case in which an injury somewhat similar to that in

Bigelow's case was produced by a gas-pipe.

Among older writers, speaking of loss of brain-substance with

subsequent recovery, Brasavolus saw as much brain evacuated as would

fill an egg shell; the patient afterward had an impediment of speech

and grew stupid. Franciscus Arcaeus gives the narrative of a workman

who was struck on the head by a stone weighing 24 pounds falling from a

height. The skull was fractured; fragments of bone were driven into the

brain. For three days the patient was unconscious and almost lifeless.

After the eighth day a cranial abscess spontaneously opened, from the

sinciput to the occiput, and a large quantity of "corruption" was

evacuated. Speech returned soon after, the eyes opened, and in twenty

days the man could distinguish objects. In four months recovery was

entire. Bontius relates a singular accident to a sailor, whose head was

crushed between a ship and a small boat; the greater part of the

occipital bone was taken away in fragments, the injury extending almost

to the foremen magnum. Bontius asserts that the patient was perfectly

cured by another surgeon and himself. Galen mentions an injury to a

youth in Smyrna, in whom the brain was so seriously wounded that the

anterior ventricles were opened; and vet the patient recovered.

Glandorp mentions a case of fracture of the skull out of which his

father took large portions of brain and some fragments of bone. He adds

that the man was afterward paralyzed an the opposite side and became

singularly irritable. In his "Chirurgical Observations," Job van

Meek'ren tells the story of a Russian nobleman who lost part of his

skull, and a dog's skull was supplied in its place. The bigoted divines

of the country excommunicated the man, and would not annul his sentence

until he submitted to have the bit of foreign bone removed.

Mendenhall reports the history of an injury to a laborer nineteen years

old. While sitting on a log a few feet from a comrade who was chopping

wood, the axe glanced and, slipping from the woodman's grasp, struck

him just above the ear, burying the "bit" of the axe in his skull. Two

hours afterward he was seen almost pulseless, and his clothing drenched

with blood which was still oozing from the wound with mixed

brain-substance and fragments of bone. The cut was horizontal on a

level with the orbit, 5 1/2 inches long externally, and, owing to the

convex shape of the axe, a little less internally. Small spicules of

bone were removed, and a cloth was placed on the battered skull to

receive the discharges for the inspection of the surgeon, who on his

arrival saw at least two tablespoonfuls of cerebral substance on this

cloth. Contrary to all expectation this man recovered, but, strangely,

he had a marked and peculiar change of voice, and this was permanent.

From the time of the reception of the injury his whole mental and moral

nature had undergone a pronounced change. Before the injury, the

patient was considered a quiet, unassuming, and stupid boy, but

universally regarded as honest. Afterward he became noisy,

self-asserting, sharp, and seemingly devoid of moral sense or honesty.

These new traits developed immediately, and more strikingly so soon as

convalescence was established.

Bergtold quotes a case reported in 1857 of extreme injury to the

cranium and its contents. While sleeping on the deck of a canal boat, a

man at Highspire was seriously injured by striking his head against a

bridge. When seen by the surgeon his hair was matted and his clothes

saturated with blood. There was a terrible gap in the scalp from the

superciliary ridge to the occipital bone, and, though full of clots,

the wound was still oozing. In a cloth on a bench opposite were rolled

up a portion of the malar bone, some fragments of the os frontis, one

entire right parietal bone, detached from its fellow along the sagittel

suture, and from the occipital along the lambdoidal suture, perhaps

taking with it some of the occipital bone together with some of the

squamous portion of the temporal bone. This bone was as clean of soft

parts as if it had been removed from a dead subject with a scalpel and

saw. No sight of the membranes or of the substance of the brain was

obtained. The piece of cranium removed was 6 3/4 inches in the

longitudinal diameter, and 5 3/4 inches in the short oval diameter. The

dressing occupied an hour, at the end of which the patient arose to his

feet and changed his clothes as though nothing had happened. Twenty-six

years after the accident there was slight unsteadiness of gait, and

gradual paralysis of the left leg and arm and the opposite side of the

face, but otherwise the man was in good condition. In place of the

parietal bone the head presented a marked deficiency as though a slice

of the skull were cut out. The depressed area measured five by six

inches. In 1887 the man left the hospital in Buffalo with the paralysis

improved, but his mental equilibrium could be easily disturbed. He

became hysteric and sobbed when scolded.

Buchanan mentions the history of a case in a woman of twenty-one, who,

while working in a mill, was struck by a bolt. Her skull was fractured

and driven into the brain comminuted. Hanging from the wound was a bit

of brain-substance, the size of a finger, composed of convolution as

well as white matter. The wound healed, there was no hernia, and at the

time of report the girl was conscious of no disturbance, not even a

headache. There was nothing indicative of the reception of the injury

except a scar near the edge of the hair on the upper part of the right

side of the forehead. Steele, in a school-boy of eight, mentions a case

of very severe injury to the bones of the face and head, with escape of

cerebral substance, and recovery. The injury was caused by falling into

machinery.

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 Laycock 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 illustrations (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.

Bird reports a compound comminuted fracture of the left temporal

region, with loss of bone, together with six drams of brain-substance,

which, however, was followed by recovery. Tagert gives an instance of

compound depressed fracture of the skull, with loss of brain-substance,

in which recovery was effected without operative interference. Ballou,

Bartlett, Buckner, Capon, Carmichael, Corban, Maunder and many others,

cite instances of cranial fracture and loss of brain-substance, with

subsequent recovery. Halsted reports the history of a boy of seventeen,

who, while out fowling, had the breech-pin of a shot-gun blown out, the

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