The broken sword, nominal aphasia and monocular quadrantanopsia: The eve of correlative neuroanatomy
Ronen BLECHER and Moshe FEINSOD
In 1820, a young soldier was injured in a fencing accident as the button of the sword broke and the blade penetrated through the mesh and the roof of the right orbit into the brain. Careful and detailed examination by Baron Larrey disclosed nominal aphasia, right hemiplegia and superior quadrantanopia in the right eye only.
Superb anatomical knowledge enabled Larrey to delineate the course of the blade from the medial chiasmal root of the right optic nerve into the vicinity of the left Sylvian fissure. The clinical diagnosis was verified posthumously.
The association between right hemiplegia, involving mainly the hand, and loss of speech was observe already in Biblical times, but Larrey was the first to describe traumatic aphasia due to left temporal injury already in 1809. He referred ten more patients that he observed to Gall for further studies. It seems that the close association with Gall, of himself and leading academicians like Bouillaud, prevented the identification of the left frontotemporal region as the seat of articulated speech, even though all his patients were injured at that area.
Monocular field defect is a very rare symptom of damage to the intracranial anterior visual pathways. In a study of this entity in twenty-four patients and review of the literature superior quadrantanopia dominated the clinical picture. Most of the patients had various parachiasmal tumors, some had optic disc diversion and nearly a tenth were functional, as was the patient reported as early as 1878. Larrey’s patient is thus singular being most probably the first to be described and unique by being caused by a transorbital penetrating head injury.
The detailed clinical examination and the ensuing conclusions were much ahead of their time. The systematic use of circumscribed cerebral lesions caused by penetrating head injuries for constructing human correlative neuroanatomy lingered till World War I.
Pavia, Italy, 2006