Cerebral Injuries

Anomalies and Curiosities of Medicine
by George M. Gould, M.D., Walter L. Pyle, M.D.

(Page 19 of 41)

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 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.