Chapter X: Surgical Anomalies of the Head and Neck (2)

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 With some difficulty it was withdrawn by a fellow workman; the point was bent on itself to the extent of two inches.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 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 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.