Surgical Experiences in South Africa, 1899-1900 Part 25

Cases 66 and 67 are instances of damage to both occipital lobes. In 66, although the wound was a glancing one, and did not perforate, it was so near the median line, and accompanied by such severe damage to the bone, that a symmetrical lesion of the cuneate and precuneate lobules of both right and left sides is to be inferred. In 67 the great longitudinal fissure was traversed by the bullet obliquely. It is of great interest to observe that in each of these cases the lesion of the visual field was a horizontal one and affected the lower half in place of a.s.suming a lateral distribution.

In all four cases the primary effect of the occipital injury was the same--viz. absolute blindness--while the return of vision in each was of the nature of the dawning of light. I regret that I am unable to furnish any detail as to increase of the field of vision in the progress of the cases, but circ.u.mstances rendered continuous observation of the patients impossible.

In each case deafness was apparently the direct result of concussion of the ear on the side corresponding to the wound. Deafness of the opposite ear was never noted.

In case 67 some general blunting of sensation was noted in the paralysed upper extremity, and in this patient, no doubt, injury to the inferior parietal lobule accompanied the occipital lesion.

(65) _Injury to left occipital lobe._--Wounded at Belmont. A single transverse wound, 2 inches in length, extended across the occipital bone, 2 inches above the level of the external protuberance. When seen on the third day the wound was gaping and pulped cerebral matter was found in it. The patient was very drowsy, lying with closed eyes, and complaining of great coronal and frontal headache. He could distinguish light and darkness, but not persons. Total blindness immediately followed the injury, persisting some three days, and the patient spoke of return of sight as of the appearance of dawn. The pupils were equal, moderately dilated and acted to light, which was unpleasant to him. He was somewhat irritable and silent, but apparently rational. Temperature 99. Pulse 56 full. Tongue clean. No sickness, no difficulty in micturition.

Fifty-six hours after the injury the wound was opened up and cleaned, and an oval fractured opening about 3/4 by 1/2 inch was exposed 3/4 inch to the left, and 2 inches above the occipital protuberance. The margins of the opening showed several small fragments of lead attached to the bone. A 3/4-inch trephine was applied at the left extremity of the opening, and it was found that about a square inch of the internal table was comminuted and driven into the brain, together with several small fragments of lead. On introducing the finger, about 1-1/2 square inches of the occipital lobe were found to be pulped, and the finger could be swept across the tentorium. There was no sinus haemorrhage (nor did the history suggest that haemorrhage had ever been severe). The cavity was carefully sponged out, and the wound closed with a drainage aperture. Little change followed in the patient's condition, and on the sixth day he was sent to the Base hospital.

Three weeks later the wound was firmly healed. The patient still complained of frontal headache, and wore a shade, as the light hurt his eyes and made them water freely. The pupils acted, but were wide; objects could be distinguished, and also persons. Otherwise, the man's condition was good: he began to get up, and at the end of six weeks returned to England.

A year later the man was earning his living as a Commissionaire porter. He complains of giddiness when he stoops, or when he looks upwards, and at times he suffers much with headache both in the region of the injury and across the temples.

There is a bony defect and slight pulsation at the site of the injury, but no prominence. When attempts are made to read the lines run together, and a dark shadow comes before his eyes. He speaks of the latter as still terribly weak. Speech is slow and somewhat simple, but he makes no mistakes as to words. Memory is bad for recent events.

Mr. Fisher makes the following report as to the eyes: Pupils and movement of eyes normal in every respect. No changes in fundi.

Vision, R. 5/12 with--0.5 5/6 L. 5/9 with--0.5 5/5

[Ill.u.s.tration: FIG. 73.--Right Visual Field, in case 65. Injury to left occipital lobe. Field for white. Test spot 10 mm. Good daylight. Right h.o.m.onymous hemianopsia]

[Ill.u.s.tration: FIG. 74.--Left Visual Field, case 65]

There is therefore practically full direct vision. Though the man chooses a concave gla.s.s he is not really myopic. There is typical right h.o.m.onymous hemianopsia; the answers, when tested with the perimeter, are quite certain, and the fields absolutely reliable.

The man's statements confirm the condition; he is aware of his inability to see objects to his right-hand side, and is apt to collide with persons or objects on that side.

The lesion is one of the left occipital cortex in the cuneate lobe and the neighbourhood of the calcarine fissure. The speech suggests a slight degree of aphasia.

(66) _Injury to occipital lobes._--Wounded at Magersfontein while in p.r.o.ne position. Distance, 500 yards. He says he was never unconscious, but for two days was absolutely blind. His eyesight gradually improved, but headache was very severe, and sleeplessness nearly absolute. On the eighth day the wound, which was situated over the right posterior superior angle of the parietal bone, was opened up, and a number of fragments of bone and a quant.i.ty of pulped brain removed from a depressed punctured fracture, surrounded by an annular fissure, completely encircling it, 1-1/2 inch from the opening. The portion of brain destroyed was probably a considerable portion of the cuneate and precuneate lobules of both sides, as well as a portion of the first occipital convolution, and the superior parietal lobule of the right side. There was no evidence of injury to the superior longitudinal sinus in the way of haemorrhage.

After the operation the patient slept better, but still complained of headache, and when he arrived at the Base, the flap became oedematous, and the st.i.tch holes and also the central part of the wound suppurated. The temperature rose to 101. The wound was therefore re-opened, and a number of additional fragments of bone, some as deeply situated as 2 inches from the surface, were removed. Steady improvement followed, and at the end of a further three weeks the wound was healed, the headache had ceased, and there were no abnormal symptoms, except that light was unpleasant to the right eye, and the field of vision was manifestly contracted (Mr. Pooley).

A year later the man was employed as a letter-carrier. He complains of headache at times, and on six occasions has had 'fainting fits.' He says that the latter commence with tremor, that his legs then give way and he falls. In a quarter of an hour he gets up, and feels no further inconvenience. Speech is perfect, there is no deafness. The bone defect is very nearly completely closed.

Mr. Fisher reports as follows as to the vision. There is a high degree of hypermetropia in each eye, the R. has nearly 6.0 D and the L. about 5.0 D. With correction he gets practically full direct vision with each.

[Ill.u.s.tration: FIG. 75.--Right Visual Field, in case 66. Injury to both occipital lobes. Field for white. Test spot 10 mm. Good artificial light. Defect in field complicated by functional symptoms]

[Ill.u.s.tration: FIG. 76.--Left Visual Field, in case 66. Defect in lower half of field]

The patient has been examined before, and has been informed that his vision quite incapacitates him from further service.

He began by stating that he could not see on either side of him, but only straight in front; that he is apt to collide with people in walking, was nearly knocked down by a horse, and that his acquaintances accuse him of pa.s.sing them unnoticed. The fields of vision are very small, but the loss is not typically in the temporal half of either. That of the right eye which we know as the spiral field, becoming more and more contracted as the perimeter test is continued, is what is found in functional cases; that of the left, however, shows a characteristic loss of the lower part of the field of vision, and agrees with the statement of the man that he can see the upper part of my face but not the lower when he looks at me. Such a loss agrees with a lesion involving the upper part of the cuneate lobe above the calcarine fissure.

I feel satisfied that there is considerable loss in the right field also, but the functional element obscures its exact nature.

The fundi, pupils, and ocular movements are all normal.

(67) _Injury to occipital lobes and left motor and sensory areas._--Wounded outside Lindley (Spitzkop). Range within 1,000 yards. _Entry_, one inch within the right lateral angle of the occipital bone, external wound more than 1/2 an inch in diameter; _exit_, 2 inches from the median line, over the upper half of the left fissure of Rolando. Behind the wound of exit comminution of the parietal bone, extending back to the lambdoid suture, existed. I attributed this to oblique lateral impact by the bullet on the inner surface of the skull.

The patient could afterwards remember being struck, but became rapidly unconscious. When brought into the Field hospital some five hours later the condition was as follows: Semi-conscious, can speak, apparently blind, pupils equal, of moderate size, do not react to light. Right hemiplegia. No sickness. Moans with pain in head. Pa.s.ses water normally.

Considerable haemorrhage had occurred from each wound, the scalp was puffy, and the bones yielded on pressure over the left parietal bone, indicating considerable comminution.

The night was so cold that no operation could be considered, so the head was partly shaved, the wounds cleansed, and a dressing applied. The next morning the Division marched at 5 A.M., and it was considered wise to leave the man at Lindley in the local hospital.

[Ill.u.s.tration: FIG. 77.--Right Visual Field, in case 67. Injury to both occipital lobes. Field for white. Test spot 10 mm. Good artificial light. Defect in lower half of field]

[Ill.u.s.tration: FIG. 78.--Left Visual Field, in case 67]

No operation was performed there, but I heard later that the man recovered full consciousness at the end of five days, and at the end of a fortnight he commenced to see again.

Six weeks later he travelled to Kroonstadt, thence to Bloemfontein, and thence to Cape Town and home to Netley. The paralytic symptoms meanwhile steadily improved.

Seven months later his condition is as follows: Scarcely a trace of facial paralysis. Slight power of movement of arm, forearm, and fingers, but grip is very weak. Little power of abduction of the shoulder or of straightening the elbow. The latter movement is made with effort and in jerks. Sensation over the back of the arm is somewhat lowered, and is 'furry' at the finger tips. There is very little wasting of the muscles noticeable.

Walks well, but with some foot-drop. Slight increase of patellar reflex. He says that he does not walk in the street with confidence, as he often feels as if omnibuses &c. were coming too near him.

He is absolutely deaf in the right ear.

The openings in the skull are closed, the occipital lies about halfway between the external auditory meatus and the external occipital protuberance, while the parietal still affords evidence of the earlier comminution, one fissure pa.s.sing backwards as far as the lambda, and the whole surface is lumpy and uneven.

The track through the brain no doubt involved a considerable extent of the outer aspect of the right occipital lobe and the cuneate lobule. It must also have crossed the great longitudinal fissure, and penetrated the left Rolandic region, just above its centre, probably involving the precuneate lobule, and a portion of the internal capsular fibres as well as the cortex on the left side. The deafness was probably due to concussion of the internal ear.

Mr. Fisher has kindly furnished the following note regarding the vision. The pupils, movements, and fundi are quite healthy.

There is good direct vision R. or L. 5/5 fairly, and together 5/5. The man complains he has lost his side sight, also the lower; he demonstrates the latter quite obviously with his hand, and says he has to repeatedly look down when walking. He thinks no improvement has taken place during the last month.

The accompanying fields of vision show the loss quite characteristically.

(68) _Injury to left occipital lobe._--Wounded at Paardeberg.

_Entry_ (Mauser), through the lambdoid suture on the right side of the mid line. Bullet retained, but a palpable prominence behind the left ear suggested its localisation.

The patient became at once unconscious and remained so for several days. He was completely blind; vision returned later, but only to a limited degree. There was complete loss of memory as to the events of the day.

When admitted at Rondebosch into No. 3 General Hospital the condition was as follows: The field of vision is limited, and examination shows right h.o.m.onymous hemianopsia. When any one comes into the tent the patient sees a shadow only until his bed is reached.

When spoken to the patient 'thinks and thinks,' and then apologises for not answering, saying he will remember at some future time. He is absolutely unable to remember times, names, or localities, but places his hand to his head and appears to think deeply in the effort to recall them. Occasionally when you go into his tent he suddenly remembers something he has been trying to think of for some days, and will tell you.

A fortnight later after an attack of influenza the patient was not so well, and vision was apparently becoming more impaired.

An incision was made (Mr. J. E. Ker) so as to raise a flap the centre of the convexity of which was 2-1/2 inches behind the left external auditory meatus. A slight prominence and a fissure was discovered in the temporal bone, and over this a trephine was applied. On removal of the crown of bone the bullet was discovered with the point turned backwards (having evidently undergone a partial ricochet turn) on the upper surface of the petrous bone, just above the lateral sinus. The dura-mater was healed but thickened, and some clot upon its surface was removed.

The wound healed per primam, and a rapid recovery was made. Ten days later a running water-tap was able to be detected 120 yards from the tent door. The hemianopsia however persisted.

The following letter, dictated by the patient to his wife, and sent to me, gives a clear account of his condition ten months later:--

I am pleased to say my memory is better than it was some time ago, though at times I am entirely lost and really forget all that I was speaking about. I also find that I often call things and places by their wrong names. I sometimes try to read a paper or book which I have to read letter by letter, sometimes calling out the wrong letter, such as B for D &c., and by the time I have read almost halfway through, I have forgotten the commencement.