anomalies and curiosities of medicine-第131部分

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It　is　not　uncommon　that　death　ensues　from　the　shock　alone　following　blows　that　cause　no　visible　injury；　but　administered　to　vital　parts。　This　is　particularly　true　of　blows　about　the　external　genital　region；　or　epigastrium；　where　the　solar　plexus　is　an　active　factor　in　inhibition。　Ivanhoff　of　Bulgaria　in　1886　speaks　of　a　man　of　forty…five　who　was　dealt　a　blow　on　the　testicle　in　a　violent　street　fight；　and　staggering；　he　fell　insensible。　Despite　vigorous　medical　efforts　he　never　regained　consciousness　and　died　in　forty…five　minutes。　Postmortem　examination　revealed　everything　normal；　and　death　must　have　been　caused　by　syncope　following　violent　pain。　Watkins　cites　an　instance　occurring　in　South　Africa。　A　native　shearing　sheep　for　a　farmer　provoked　his　master's　ire　by　calling　him　by　some　nickname。　While　the　man　was　in　a　squatting　posture　the　farmer　struck　him　in　the　epigastrium。　He　followed　this　up　by　a　kick　in　the　side　and　a　blow　on　the　head；　neither　of　which；　however；　was　as　severe　as　the　first　blow。　The　man　fell　unconscious　and　died。　At　the　autopsy　there　were　no　signs　indicative　of　death；　which　must　have　been　due　to　the　shock　following　the　blow　on　the　epigastrium。

As　illustrative　of　the　sensitiveness　of　the　epigastric　region；　Vincent　relates　the　following　case：　〃A　man　received　a　blow　by　a　stick　upon　the　epigastrium。　He　had　an　anxious　expression　and　suffered　from　oppression。　Irregular　heart…action　and　shivering　were　symptoms　that　gradually　disappeared　during　the　day。　In　the　evening　his　appetite　returned　and　he　felt　well；　during　the　night　he　died　without　a　struggle；　and　at　the　autopsy　there　was　absolutely　nothing　abnormal　to　be　found。〃　Blows　upon　the　neck　often　produce　sudden　collapse。　Prize…fighters　are　well　aware　of　the　effects　of　a　blow　on　the　jugular　vein。　Maschka；　quoted　by　Warren；　reports　the　case　of　a　boy　of　twelve；　who　was　struck　on　the　anterior　portion　of　the　larynx　by　a　stone。　He　fell　lifeless　to　the　ground；　and　at　autopsy　no　local　lesion　was　found　nor　any　lesion　elsewhere。　The　sudden　death　may　be　attributed　in　this　case　partly　to　shock　and　partly　to　cerebral　anemia。

Soldiers　have　been　seen　to　drop　lifeless　on　the　battle…field　without　apparent　injury　or　organic　derangement；　in　the　olden　times　this　death　was　attributed　to　fear　and　fright；　and　later　was　supposed　to　be　caused　by　what　is　called　〃the　wind　of　a　cannon…ball。〃　Tolifree　has　written　an　article　on　this　cause　of　sudden　death　and　others　have　discussed　it。　By　some　it　is　maintained　that　the　momentum　acquired　by　a　cannon…ball　generates　enough　force　in　the　neighboring　air　to　prostrate　a　person　in　the　immediate　vicinity　of　its　path　of　flight。



CHAPTER　X。

SURGICAL　ANOMALIES　OF　THE　HEAD　AND　NECK。

Injuries　of　such　a　delicate　organ　as　the　eye；　in　which　the　slightest　accident　can　produce　such　disastrous　consequences；　naturally　elicit　the　interest　of　all。　Examples　of　exophthalmos；　or　protrusion　of　the　eye　from　the　orbit　from　bizarre　causes；　are　of　particular　interest。　Among　the　older　writers　we　find　Ficker　and　the　Ephemerides　giving　instances　of　exophthalmos　from　vomiting。　Fabricius　Hildanus　mentions　a　similar　instance。　Salmuth；　Verduc；　and　others　mention　extrusion　of　the　eyeball　from　the　socket；　due　to　excessive　coughing。　Ab　Heers　and　Sennert　mention　instances　in　which　after　replacement　the　sight　was　uninjured。　Tyler　relates　the　case　of　a　man　who；　after　arising　in　the　morning；　blew　his　nose　violently；　and　to　his　horror　his　left　eye　extruded　from　the　orbit。　With　the　assistance　of　his　wife　it　was　immediately　replaced　and　a　bandage　placed　over　it。　When　Tyler　saw　him　the　upper　lid　was　slightly　swollen　and　discolored；　but　there　was　no　hemorrhage。

Hutchinson　describes　extrusion　of　the　eyeball　from　the　orbit　caused　by　a　thrust　with　a　stick。　There　was　paraphymotic　strangulation　of　the　globe；　entirely　preventing　replacement　and　necessitating　excision。　Reyssie　speaks　of　a　patient　who；　during　a　fire；　was　struck　in　the　right　eye　by　a　stream　of　water　from　a　hose；　violently　thrusting　the　eye　backward。　Contracting　under　the　double　influence　of　shock　and　cold；　the　surrounding　tissues　forced　the　eyeball　from　the　orbit；　and　an　hour　later　Reyssie　saw　the　patient　with　the　eye　hanging　by　the　optic　nerve　and　muscles。　Its　reduction　was　easy；　and　after　some　minor　treatment　vision　was　perfectly　restored　in　the　injured　organ。　Thirty　months　after　the　accident　the　patient　had　perfect　vision；　and　the　eye　had　never　in　the　slightest　way　discommoded　him。

Bodkin　mentions　the　case　of　a　woman　of　sixty　who　fell　on　the　key　in　a　door　and　completely　avulsed　her　eye。　In　von　Graefe's　Archiv　there　is　a　record　of　a　man　of　seventy…five　who　suffered　complete　avulsion　of　the　eye　by　a　cart…wheel　passing　over　his　head。　Verhaeghe　records　complete　avulsion　of　the　eye　caused　by　a　man　falling　against　the　ring　of　a　sharp…worn　key。　Hamill　describes　the　case　of　a　young　girl　whose　conjunctiva　was　pierced　by　one　of　the　rests　of　an　ordinary　gas…bracket。　Being　hooked　at　one　of　its　extremities　the　iron　became　entangled　in　either　the　inferior　oblique　or　external　rectus　muscles；　and　completely　avulsed　the　eyeball　upon　the　cheek。　The　real　damage　could　not　be　estimated；　as　the　patient　never　returned　after　the　muscle　was　clipped　off　close　to　its　conjunctival　insertion。　Calhoun　mentions　an　instance　of　a　little　Esquimaux　dog　whose　head　was　seized　between　the　jaws　of　a　large　Newfoundland　with　such　force　as　to　press　the　left　eyeball　from　the　socket。　The　ball　rested　on　the　cheek；　held　by　the　taut　optic　nerve；　the　cornea　was　opaque。　The　ball　was　carefully　and　gently　replaced；　and　sight　soon　returned　to　the　eye。

In　former　days　there　was　an　old…fashioned　manner　of　fighting　called　〃gouging。〃　In　this　brutal　contest　the　combatant　was　successful　who　could；　with　his　thumb；　press　his　opponent's　eyeball　out。　Strange　to　say；　little　serious　or　permanently　bad　results　followed　such　inhuman　treatment　of　the　eye。　Von　Langenbeck　of　Berlin　mentions　an　instance　of　fracture　of　the　superior　maxilla；　in　which　the　eyeball　was　so　much　displaced　as　to　lodge　in　the　antrum　of　Highmore。　Von　Becker　of　Heidelberg　reports　the　history　of　a　case　in　which　a　blow　from　the　horn　of　a　cow　dislocated　the　eye　so　far　back　in　the　orbit　as　to　present　the　appearance　of　enucleation。　The　conjunctiva　hid　the　organ　from　view；　but　when　it　was　pulled　aside　the　eyeball　was　exposed；　and　in　its　remote　position　still　possessed　the　power　of　vision。　In　some　cases　in　which　exophthalmos　has　been　seemingly　spontaneous；　extreme　laxity　of　the　lids　may　serve　as　an　explanation。　There　is　an　instance　on　record　in　which　a　Polish　dew　appeared　in　a　Continental　hospital；　saying　that　while　turning　in　bed；　without　any　apparent　cause；　his　eyeball　was　completely　extruded。　There　have　been　people　who　prided　themselves　on　their　ability　to　produce　partial　exophthalmos。

Rupture　of　the　Eyeball。Jessop　mentions　the　case　of　a　child　of　eight　who　suffered　a　blow　on　the　eye　from　a　fall　against　a　bedpost；　followed　by　compound　rupture　of　the　organ。　The　wound　in　the　sclerotic　was　three　or　four　lines　in　length；　and　the　rent　in　the　conjunctiva　was　so　large　that　it　required　three　sutures。　The　chief　interest　in　this　case　was　the　rapid　and　complete　recovery　of　vision。

Adler　reports　a　case　of　fracture　of　the　superior　maxillary　in　which　the　dislocated　bone…fragment　of　the　lower　orbital　border；　through　pressure　on　the　inferior　maxillary　and　counter　pressure　on　the　skull；　caused　rupture　of　the　conjunctiva　of　the　left　eye。

Serious　Sequelae　of　Orbital　Injuries。In　some　instances　injuries　primarily　to　the　orbit　either　by　extension　or　implication　of　the　cerebral　contents　provoke　the　most　serious　issues。　Pointed　instruments　thrust　into　the　orbital　cavity　may　by　this　route　reach　the　brain。　There　is　a　record　of　death　caused　by　a　wound　of　a　cavernous　sinus　through　the　orbit　by　the　stem　of　a　tobacco…pipe。　Bower　saw　a　woman　at　the　Gloucester　Infirmary　who　had　been　stabbed　in　the　eye　by　the　end　of　an　umbrella。　There　was　profuse　hemorrhage　from　the　nostrils　and　left　eye；　but　no　signs　indicative　of　its　origin。　Death　shortly　ensued；　and　at　the　necropsy　a　fracture　through　the　roof　of　the　orbit　was　revealed；　the　umbrella　point　having　completely　severed　the　optic　nerve　and　divided　the　ophthalmic　artery。　The　internal　carotid　artery　was　wounded　in　one…half　of　its　circumference　at　its　bend；　just　before　it　passes　up　between　the　anterior　clinoid　process　and　the　optic　nerve。　The　cavernous　sinus　was　also　opened。　In　this　rare　injury；　although　there　was　a　considerable　quantity　of　clotted　blood　at　the　base　of　the　brain；　there　was　no　wound　to　the　eyeball　nor　to　the　brain　itself。

Pepper　records　a　case　in　which　a　knife　was　thrust　through　the　spheroidal　fissure；　wounding　a　large　meningeal　vein；　causing　death　from　intracranial　hemorrhage。　Nelaton　describes　an　instance　in　which　the　point　of　an　umbrella　wounded　the　cavernous　sinus　and　internal　carotid　artery　of　the　opposite　side；　causing　the　formation　of　an　arteriovenous　aneurysm　which　ultimately　burst；　and　death　ensued。　Polaillon　saw　a　boy　of　eighteen　who　was　found　in　a　state　of　coma。　It　was　stated　that　an　umbrella　stick　had　been　thrust　up　through　the　roof　of　the　orbit　and　had　been　withdrawn　with　much　difficulty。　The　anterior　lobe　of　the　brain　was　evidently　much　wounded；　an　incision　was　made　in　the　forehead　and　a　portion　of　the　frontal　bone　chiseled　away　entrance　being　thus　effected；　the　aura　was　incised；　and　some　blood　and　cerebrospinal　fluid　escaped。　Five　splinters　were　removed　and　a　portion　of　the　damaged　brain…substance；　and　a　small　artery　was　tied　with　catgut。　The　debris　of　the　eyeball　was　enucleated　and　a　drain　was　placed　in　the　frontal　wound；　coming　out　through　the　orbit。　The　patient　soon　regained　consciousness　and　experienced　no　bad　symptoms　afterward。　The　drains　were　gradually　withdrawn；　the　process　of　healing　advanced　rapidly；　and　recovery　soon　ensued。

Annandale　mentions　an　instance　in　which　a　knitting…needle　penetrated　the　brain　through　the　orbit。　Hewett　speaks　of　perforation　of　the　roof　of　the　orbit　and　injury　to　the　brain　by　a　lead…pencil。

Gunshot　Injuries　of　the　Orbit。Barkan　recites　the　case　in　which　a　leaden　ball　32/100　inch　in　diameter　was　thrown　from　a　sling　into　the　left　orbital　cavity；　penetrating　between　the　eyeball　and　osseous　wall　of　the　orbit　without　rupturing　the　tunic