*SOME CASES OF HEAD INJURY AND CONSERVATIVE TREATMENT.

B. M. BARNETT, M. D.
Rosedale, Kas.

Of all the injuries to which the human body is heir, there are, perhaps, none of such vast importance and of such farreaching consequences as those of the cranium. These injuries tax the ingenuity, diagnostic skill and acumen of the surgeon, perhaps more than those in any other part of the body. Man's cranium is an ever-ready target for the assault of all forms of missiles, from the automobile escapade and the railroad collision to the bullet of the suicide and the homicide. These injuries very frequently first fall into the hands of the general practitioner, and it becomes a matter in his judgment to determine if the services of a surgeon will be necessary to carry his case to a favorable termination. Injuries about the head sometimes appear very trivial on the surface, but in the end mav prove most serious and disastrous; while others appearing very severe and grave may, upon the most careful and conservative lines of treatment, make a splendid and unexpected recovery.

In support of these facts, I wish to present a few clinical cases:

On December 5, 1893, G. W., a machinist working for the Kansas City Wire and Iron Works, located at Rosedale, and which at that time was being moved across the Memphis tracks to its present location, was struck on the left side of the head by the bumper of a passenger engine. At the point of crossing and recrossing the tracks, there was a gap left between the cars standing along the side. tracks. These, naturally, obstructed the view to the main line, and, as this man stepped out, his head inclining forward, the bumper of the engine struck him squarely on the side of the head. was carried to the City hall in an unconscious condition, and I so found him about half an hour later. Examination revealed a fracture and depression of the outer tables, at least covering the entire parietal surface and the occipita

He

*Paper read before the Frisco System Medical Association, at Kansas City, Mo., May 26, 1908.

sinus. Fluid and blood was oozing freely from both ears, indicating a probable fracture at the base of the brain also.

A surgeon was summoned in consultation, from this city, who arrived an hour later, and the propriety of trephining and raising the depressed portions of bone was thoroughly discussed; but we decided that from the apparent extent of the fracture and depressions, and the probability of having to open the occipital sinus, in so doing, the risk from hemorrhage would be far greater than to wait for later developments. He was removed to his boarding house. Reaction set in slowly and his condition improved without, however, any return of consciousness. He was now removed to a quiet and comfortable room in the Rosedale hotel, where he continued to improve his general physical condition up to the fifth day when he had a violent convulsion. The bowels were then again thoroughly evacuated with a saline catharthic, after which consciousness returned and recovery was rapid. At the end of three weeks, he returned to his home in Joplin, and shortly after returned to work at his former trade. Here is a case where the early prognosis was very grave, which made a splendid recovery on a carefully guarded expectant plan of treatment.

Some years ago I was called to treat a young man who had become involved in a "Kansas joint" quarrel, and who, during the melee was struck on the left side of the head with a beer glass directly over the island of rile. He lost his speech, which indicated that there was compression. Careful examination révealed no fracture or depression. It, therefore, appeared clear that it must be due to clot. I recommended perfect rest in bed; evacuated the bowels thoroughly with saline cathartics and gave moderate doses of potassium iodide as an absorbent. Assuring the young man that he would be all right after a reasonable period but as his speech did not return within two or three days, a ssiter, who became very solicitous for his welfare, took him to Kansas City, Mo., and consulted one of the ablest surgeons who recommended an immediate operation as imperative to establish his speech. The

only bar to this operation was the usual. surgeon's fee for performing same. I was again consulted and advised giving nature a still further chance to do her work, and later operation, if absolutely imperative. At the end of a week or ten days the young man had fully recovered and talked as fluently as ever.

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On the 6th of April, 1903, several lads about 15 years of age left the Rosedale school for a little fun. One of them carried a pistol of No. 22 caliber. They proceeded up Turkey Creek, no doubt to see what they could kill, but they did not know it was loaded, and, in carelessly pointing it at one of his campanions, it was discharged and sent a bullet into his brain. It entered the cranium about 11⁄2 inches obliquely upward from the outer angle of the right eye, just at the roots of the hair. It caused but little constitutional disturbance and very slight shock, the boy having walked home from the place of the accident, about one-half mile distant. I cleaned the wound as carefully and thoroughly as possible and dressed it with moist antiseptic dressings. I kept him in bed, absolutely quiet in a darkened room, allowing no one but the immediate family to see him for a period of two weeks or more. When the external opening had thoroughly closed, I allowed him to get up and go about the house. He has so far suffered no inconvenience from the retention of this small missile in his brain. During the treatment of this case I was constantly besieged by the laity who wanted to know why I did not locate the bullet by means of the X-rays. My reply invariably was that such a proçedure could be resorted to at any time, and that so long as the bullet did not trouble the boy I did not consider it good judgment to bother the bullet.

In this case, also, the prognosis looked rather grave, yet, on the most conservative lines of treatment, carefully regulating the secretions and with absolute rest and quiet in bed, the patient made a splendid and uneventful. recovery.

On May 5, 1904, Mrs. M., a slender German woman, a patient whom I was treating, and who was hovering on the borderline of melancholia, in a fit of despondency over the disappearance of her

son from the public school, discharged the contents of a 32 caliber revolver in her right ear. My colleague, Dr. Longenecker, had preceded me to the scene of the accident but a few minutes. We found her lying on the floor in a large pool of blood in an apparently lifeless condition. We litfed her on the bed, and as immediate shock subsided, it became apparent from the oblique position in which the weapon was held that the bullet had passed obliquely downward through the mastoid and petrous portions of the temporal bone and had lodged just short of the meninges.

Dr. Ernest F. Robinson of Kansas City, Mo., removed the bullet, and the case proceeded favorably and the wound healed. In about five weeks, however, she began to complain of excruciating headache. The pulse became feeble and slow, 52 per minute, with persistent vomiting and obstinate constipation; inequality of the pupils and all the symptoms of brain pressure, which we decided was due to probable abscess of the brain, caused either from absorption or from the concussion. About June 23, 1904, I removed her to St. Joseph's hospital, and Dr. Robinson again operated by trephining and removed about 2 drachms of pus from a temperosphenoidal abscess. After this our patient made a gradual but substantial improvement physically, the mind remaining impaired with slight facial paralysis, the result of injury to the facial nerve, and so remained until 1907, when she was accidentally burned to death while alone in her home.

Some years ago I was requested by the coroner of Wyandotte county to make an autopsy in a case where a very large and powerful negro called on another negro's wife. The husband was also a powerful stalwart of his race, and when he dropped in upon the love scene, in the desperate struggle that ensued, he was struck a violent blow with a heavy club on the outer angle of the right eye, which proved fatal. There was nothing to show any point of violence, except at contused, lacerated wound at the angle of the eye.

A most careful and painstaking external examination revealed no fracture nor any serious injury to the bony structure. However, as a precau

tionary measure, and, also, out of some curiosity, I removed the vault of the cranium, when I discovered a piece of bone as large as the nail on my little finger, jarred out of the greater wing of the sphenoid bone. A crack also extended upward through the parietal bone above the parietal eminence. There was an immense clot of blood covering the entire right hemisphere, which, no doubt, caused death from pressure.

I cite this case simply to show the peculiar forms of fracture we may meet in head injuries, and how impossible it is in some cases to come to any definite conclusions without an exploratory operation. Had death not ensued in this case from hemorrhage, this man might have made a good recovery on the expectant plan of treatment and the attendant would not have khown that a fracture existed.

I hope these clinical pictures are sufficiently varied and have been drawn sufficiently strong and clear to impress upon all the gravity and the importance that cranial injuries merit. However slight, or however severe, the injury may appear on first impression, we should be ever on our guard and use our most acute judgment in not operating hast ily, and yet not foolhardy in desisting from operation when the symptoms of the case and the condition of the patient warrant such procedure.

*FOREIGN BODIES IN THE
RECTUM.

H. C. DUNAVANT, M. D.
Osceola, Ark.

On Aug. 10, 1907, I was called by Dr. Turner over the telephone to come some eight miles down the railroad to help him recover a pepper sauce bottle out of a man's rectum. Preparing my emergency bag I drove down and found a man whom I knew very well, and he informed me that he had been suffering severely with piles, and that sometime in the latter part of the night he had gotten up and tried to ease him

*Paper read before the Frisco System Medical Association, at Kansas City, Mo.,

May 26, 1908.

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self by placing some pile ointment on the top of the pepper sauce bottle and forcing it up the gut. He said it was very painful and he supposed he must. have fainted and fallen, as he was lying on the floor an dthought from his feeling the bottle was inside his bowel. He was in a room alone up over his. store. When daylight came he had Dr., Turner, who lived near by, called., We; had him placed on a table and Dr. Turner administered an anesthetic. I, could just feel the bottom of the bottle with my index finger and could by palpatation locate the top of the neck, of the bottle in left upper quadrant. Having secured a companion bottle from the shelves "I found Lound my three, blade anal speculum would take it in; I introduced it up to and against the bottom of the bottle and with my hand on the upper end, I succeeded in push, ing the bottle down in the speculum when by reversing the handle I was able to secure, sufficient hold to draw. it with ease without any break or serious injury. There was no trouble following and the man has since informed me that his piles were in a much better condition.

I,

The bottle was eight and a quarter. inches long and two inches in diameter. It was one of those little corrugated bottles with the folds running

around it.

Some years a ago I called up one night by a Mr. Bragg, who told me, that Tom Craig, was at my office and wanted, to see, me. I dressed and ac companied him to my office, where I found Craig awaiting me. This was on Sunday night. Craig said: "Doctor, I am in a bad fix; I came to town on the Saturday before and bought a lot of fish hooks and proceeded to get drunk"; and in some way one of the fish hooks had gotten out of his pocket and had gotten up his rectum. "All right," I said. "It is going to spoil one or the other in getting it out." I intended forcing the point with the beard through the skin and cut it off and extract the remainder. of the hook. Putting him in position with a good light I could see what resembled the flat end of a large fish hook, and this he'

had felt and taken to be a fish hook. Taking hold of it with a pair of forceps, I began to move it and as he did not complain of any pain I succeeded in extracting a full size pulling bone of a chicken. His explanation was that when he got home Saturday, drunk, that they gave him stewed chicken and he swallowed bones and all. He was a very large, powerful man with an awful big mouth and his alimentary canal must have been large all the way through. He was very much chagrinned, and said if it got out on him he would never hear the last of it, and swore if I told it on him he would whip me.

He being such a powerful man, with the courage of a tiger, I have remained silent, but he is now dead and I feel safe in reporting the case. I can remember a number of serious cases in children where the bowels had been locked for days, when on removing chunks of the common chewing gum from the rectum their troubles would

cease.

A few months ago I had a case where a 10-year-old boy had swallowed a lead marble. His parents wanted to give him oil or some purgative. This I prohibited and ordered him fed on sweet potatoes and flour bread and on the third day had the satisfaction of recovering the marble, which was near one inch in diameter.

There are different ways foreign bodies may enter the rectum. Bodies may be swallowed and pass through the whole intestinal canal and lodge at the rectal spincter. There may be a development in some portion of the tract and pass through to the sigmoid or rectum or may be intentionally or accidentally introduced in the anus.

Medical literature abounds with instances of foreign bodies of varied and most wonderful size and character found in the rectum, such as ale jugs, champagne bottles, needles, pins, spools of thread, pipes, chains, screws, nails, coins, bones, doorknobs, cow's horns, pocketbooks, medicine glasses, etc., toa numerous to mention.

Where the intestinal secretions are constantly dry and hard, or there may

be deficient secretion of the liver or too much limestone, water may assist in the formation of calcareous masses in the gut.

A marked rheumatic or gouty diathesis are said to assist in their formation, while old age and constipation are predisposing causes.

There are also pathological conditions. A vitiated appetite, such as eating dirt, slate pencils, chalks, etc., have a tendency to irritate and narrow the rectum and sigmoid and furnish a neuclous for the formtaion of an enterolith. Paulet says that peresis plays an important part in the production of constipation and foramtion and arrest of foreign bodies in the rectum.

There are also anatomical predisposing causes, such as unusual developments of the folds of Houston or the crypts of Morgagri and the diverticuti occasionally found in the large intestines, may act as wayside stopping places for foreign bodies in the gut.

For the purpose of concealment, thieves and criminals have long been known to use the rectum for hiding stolen articles, false keys, small saws,

etc.

In the well known report of a society of surgery, 1861 (French), a case is on record of a criminal from whose transverse color a box covered with the omentum of a lamb was removed containing small saws and other instruments for effecting his escape from prison. These articles had been introduced into the rectum for the purpose of concealment and had gradually worked its way upwards to where it was found.

Foreign bodies in the rectum by accident are considered very rare. It is possible that a person may fall upon objects and have them forced up the rectum, such as pointed sticks, pailings of fence, etc. An interesting case is reported by Hawkins, 1898, in which an Italian, while dancing an obscene. dance around a tumbler set on the floor, slipped and fell upon the tumbler, when it broke and about twothirds of its bowl penetrated the anus and lodged in the rectum. There was a hemorrhage. The points of the broken tumbler had entered deeply the