Remarkable case of a boy, who lost a considerable portion of brain: and is recovered, without detriment to any faculty, mental or corporeal. By R. Leny.
ALTHOUGH the brain be not only the ſeat of thoſe powers which diſtinguiſh animate from inanimate matter, but alſo of all thoſe mental operations which dignify man above the inferior orders of animals, yet there is no part of the human body concerning which we poſſeſs ſo limited a knowledge. Its intricacy is great, and to that our ignorance ſeems to bear proportion. We neither know the manner in which it performs its functions, nor the ſhare each of its parts have in their performance. The former is perhaps for wiſe purpoſes placed above human [Page 4] underſtanding, and the latter, though it appears more within our reach, has hitherto eluded the reſearch of enquirers. Perhaps with regard to it alſo we ſhall always remain in the dark. Its different parts are ſo intimately connected, that when one is affected, ſo, in general, are the whole; and it is poſſeſſed of ſuch delicacy of ſtructure, and is ſo immediately connected with the vital principle, that it cannot eaſily be made the ſubject of experiment. Accidental injuries ſeem to bid faireſt towards its elucidation; but even theſe, as a ſource of information, muſt be regarded as exceedingly uncertain. Some times, when to appearance ſmall, their effects have been almoſt inſtantly fatal, while at other times, when ſeemingly of much greater importance, they have been productive of little ſubſequent harm. Of the latter kind, the following caſe of William Stewart, in the pariſh of Kippen, and ſhire of Perth, affords a moſt remarkable inſtance, the detail of which, if it [Page 5] can in the leaſt conduce to illuſtrate a ſubject ſo curious and intereſting, will afford much pleaſure to the perſon within whoſe obſervation it fell. This at leaſt he thinks it points out, that every part of the brain is not equally concerned in the execution of its functions; but being little acquainted with this ſubject, he neither pretends to trace cauſes, nor to draw concluſions. Whatever inferences it may ſuggeſt, he leaves to be deduced by thoſe more verſed in phyſiology. He only aims at an accurate ſtatement of facts, which, from a regular journal he kept during the progreſs of the cure, he hopes he ſhall be able to give, and, if in this he ſhall ſucceed, the ſingularity of the caſe will, he hopes, of itſelf, entitle it to attention.
The patient is a ſervant boy, about 14 years of age, and met with the accident on the 1ſt of July laſt, in conſequence of a blow from the foot of a horſe, which knocked him to the ground, and left him in a ſtate of inſenſibility. [Page 6] He remained alone nearly two hours, and was then accidentally diſcovered by a perſon of the ſame family, who, being ſtrictly interrogated concerning the condition in which he found him, and what happened before the circumſtances of the caſe were examined into, related, ‘"That his face, and the ground underneath, were covered with blood, which ſtill continued to iſſue in conſiderable quantity, from a wound on the right ſide of his forehead: That, from the ſame wound, a whitiſh, or rather greyiſh ſubſtance, of a ſoft and pulpy conſiſtence, and of nearly the ſize of a hen's egg, was diſcharged, but that no pieces of bone were obſerved along with it: That he was ſenſible, (which, from the boy's own account, he became ſoon after the accident), but was ſo weak, that he could not riſe: That, upon raiſing him from the ground, he fell into a ſwoon, (perhaps from the erect poſture), and continued in it till brought home, and laid in bed: That his recovery [Page 7] from this was attended with ſeveral efforts to vomit, which occaſioned the diſcharge of about half the quantity of the ſame greyiſh coloured ſubſtance, as formerly, from the wound; but that, from this time, till he fell within the writer's own obſervation, in about an hour thereafter, nothing remarkable took place."’ The laſt portion of the greyiſh ſubſtance diſcharged from the wound, being preſerved for the purpoſe of examination, was now found to conſiſt of brain, principally cortical, but that alſo intermixed with ſtriae of medullary ſubſtance. The former was left on the field where the injury was ſuſtained, but from the exact ſimilarity obſerved by the perſon who diſcovered the patient, muſt have been of the ſame nature.
When the wound, which was ragged and unequal, was laid open, the ſubſtance of the brain projected a little way from its ſurface, [Page 8] which being wiped off, expoſed to view an orifice in the bone, extending from a conſiderable way above the external corner of the right eye-brow upwards, and backwards toward the coronal future. That this might be examined with accuracy, the integuments were more freely divided through its whole extent, and its dimenſions thereby aſcertained to be in breadth at the middle part about an inch, and in length rather more than two inches, with its ſides gradually converging together, ſo as to form an acute angle at each extremity. From its edges fiſſures ran in almoſt all directions, and one piece of bone, about the ſize of a ſixpence, on its upper ſide, was ſo nearly detached, that it could have been removed by the finger; but being no ways depreſſed, was left remaining. That portion, the ſeparation of which occaſioned the hole, was in all probability either beat out by the horſe's foot, or left ſo looſe as to be carried away by the firſt portion of brain diſcharged, [Page 9] as no pieces of it could be detected, though ſought after with all poſſible attention. The dura mater appeared on all ſides torn and ragged, and the heaving and falling of the brain underneath, were ſo great during examination, from the full inſpirations and expirations occaſioned by his cries, that at one time ſome of it was puſhed out through the wound, while at another it receded ſo far from the bone, that a void ſpace was left, into which the finger could for a good way eaſily have been inſinuated. The protruded parts were ſo torn by the ſharp and ragged edges of the bone, that at different times more than the ſize of a hazle nut required to be wiped off; and this appeared to conſiſt principally of medullary ſubſtance, or, at leaſt, contained now a much ſmaller intermixture of cortical than that formerly diſcharged.
It being by a careful ſearch made pretty evident, that no pieces of bone were ſo ſituated, as to be productive of any future injury [Page 10] to the parts below, either by compreſſion or irritation, the integuments were brought together, and ſecured near the upper extremity of the wound with a ſuture. This was done, to prevent as much as poſſible the acceſs of air, while more was thought improper, for fear of obſtructing the egreſs of matter, which apparently would be great, and which, if in any way confined, might occaſion very pernicious effects. The wound was covered with lint, and all ſecured with a bandage; and in order that the lower extremity of the wound might be made as depending as poſſible, he was laid to reſt, with his head pretty much elevated in bed.
The patient's pulſe, which before the examination of the wound, was 120, in about half an hour after it, had riſen in frequency to 160, and was ſo weak as hardly to be counted. His reſpiration was very anxious, and he felt very feeble and languid. On being raiſed erect, he had a tendency to deliquium. [Page 11] A clammy moiſture was preſent on his ſkin, and he had frequent ſtarting of the muſcles of his extremities.
Every circumſtance here was unfavourable, and ſeemed to forebode approaching diſſolution; but a deſire to know the iſſue of ſo remarkable an accident made it appear improper to deſert the patient till the fatal event had actually taken place. This, with another conſideration of equal importance, namely, that of the boy's low ſituation in life, excluding him from proper medical aſſiſtance, and not the ſanguine expectation of performing a cure, were the motives which induced the writer to undertake its management; and this he did, though he had been hitherto more engaged in the ſtudy than in the practice of his profeſſion. He regulated the medical treatment, entirely by the ſymptoms which preſented themſelves, thinking it more expedient carefully to watch the efforts of nature, and implicitly to follow her indications, than by too active an interference [Page 12] upon the rules of method and ſyſtem, probably to counteract her operations. This plan was adopted the more readily, as it coincided exactly with the ſentiments of Mr Campbell, a very intelligent ſurgeon at Balfron, who was preſent at the examination and dreſſing of the wound; and it afterwards gave much ſatisfaction to hear it approved of by Dr Leckie of Broich, a gentleman who has had an extenſive and ſucceſsful practice, both here and in the Weſt Indies, for many years, who ſaw the patient during the progreſs of the cure.
As the ſymptom which required moſt to be counteracted, ſeemed debility, the patient was ordered a drink moderately cordial*, and this appeared to take effect ſo far, that next day his pulſe had deſcended to 120, and had now a much fuller and firmer beat than the preceding evening. The ſtarting of the muſcles was quite gone; the ſenſation of langour was much diminiſhed, and he breathed [Page 13] with conſiderable freedom; but the ſymptoms of debility were again aggravated by a ſlight hoemorrhagy from the wound, which, during the firſt two days, took place repeatedly. On this account, the ſame cordial was continued, and had ſeemingly the ſame good effects. Afterwards, however, the pulſe gradually roſe in ſtrength, and the other ſymptoms of fever ſupervened which required the diſcontinuation of this and the purſuit of another very different plan. The antiphlogiſtic regimen, in all its branches, was ſtrictly enjoined. All impreſſions from ſound, from light, and from heat were carefully avoided, ſo likewiſe whatever could call the attention, or in any way excite to action any of the internal faculties. Indeed all this ſeemed ſtrongly pointed out by nature herſelf, an over ſenſibility to every impreſſion appearing a very urgent ſymptom. Sleep was awanting; but ſupervening inflammation, ſeemed to forbid opiates. The thirſt too was great, but was as much as poſſible [Page 14] guarded againſt by acidulated drink. The only medicines adminiſtered were refrigerants and cooling laxatives; by the former, if poſſible, to moderate the violence of circulation; and by the latter, not only to produce the ſame effect, but alſo to obviate any irritation from an improper ſtate of the alimentary canal. On the fourth and fifth days, he was at times delirious, with his pulſe above 100; great heat of ſkin, thirſt and reſtleſſneſs. From theſe circumſtances, blood-letting was on the point of being uſed; but a general ſweat upon the morning of the ſixth day, moderated all the ſymptoms, and made it afterwards unneceſſary.
In the mean time, the wound was very painful. The diſcharge of blood mentioned took place from its edges, on the two firſt days, but from that till the fourth, its edges were rather dry; when by the help of emollient applications, it began to diſcharge copiouſly; at firſt a matter thin, and intolerably [Page 15] foetid, but about the ninth day became changed into a laudable pus. About that time alſo, ſmall maſſes, ſeemingly brain, in a dead and corrupted ſtate, conſtituted a part of the diſcharge, the egreſs of which was much aſſiſted by the depending poſition in which the wound was always kept.
After the ſixth day, the ſymptoms of fever began to diſappear. His tongue, which was before white, and furred, gradually became clean. The heat of his ſkin, and thirſt, totally went off, and his pulſe from 100, deſcended firſt to the natural ſtandard, and afterwards ſunk ſo low, as for a number of days, not much to exceed 60. It ſunk however in frequency, not in ſtrength. With this his ſenſibility alſo diminiſhed, but could never be perceived to be below its natural ſtate. His ſleep was now ſound, abundant, and refreſhing, and his appetite began to recover. His urine, which was red, and in ſmall quantity, was now more copious, and depoſited a large [Page 16] browniſh ſediment. He had ſtill tranſitory headach, but except of this, and general weakneſs, from the 11th day onwards, he made little or no complaint.
The diſcharge was at this time great, but conſiſted of matter that was well formed. The edges of the wound looked clean, and granulations began to ſprout out all around. No adheſion was the conſequence of the future; but as the orifice in the integuments was rather ſuperior to that in the bone, that in the latter was thereby kept pretty well covered. The motion of the brain ſeemed now to be ſynchronous with the action of the heart and arteries, and not with reſpiration. This indeed was the caſe from the beginning, except when the latter was increaſed by preternatural cauſes. The edges of the wound were daily covered with ſlips of linen, ſpread with common cerate, and lint was laid over its middle part, to abſorb any matter diſcharged. About the 18th day the diſcharge ſeemed to diminiſh, [Page 17] and the integuments had fallen conſiderably inwards, thereby forming a hollow. The former of theſe circumſtances aroſe apparently from the matter not getting free exit, in conſequence of partial adheſions having formed underneath. This gave conſiderable irritation, which for a ſhort time cauſed headach, quickneſs of pulſe, and a ſlight return of fever. But theſe ſymptoms were prevented from running high, by the introduction of a probe below the integuments, by which they were gradually raiſed, and free exit given to matter which had accumulated in conſiderable quantity.
From this time he felt himſelf ſo well, as to have an inclination to get out of bed, and being permitted, he roſe at firſt for a ſhort ſpace only, but increaſed it by degrees. He was now alſo allowed to take more nutritive diet than for ſome time he had been permitted to do, which was thought the more neceſſary as the diſcharge was great, and as night ſweats, [Page 18] and the other ſymptoms of hectic fever appeared in a ſlight degree to ſupervene; but theſe were in this manner obviated.
The diſcharge now diminiſhed apace, and the wound gradually filled up, ſo that at the end of the month, it was almoſt well. Only a ſmall portion of it remained open, which in little more than a week afterwards, was completely cicatrized. The part was ſtill conſiderably hollow, and to all appearance will remain permanently ſo, it being hitherto little filled. At that time its bottom felt ſoft and yielding; wherefore to prevent the chance of its ſuſtaining any injury from accidental cauſes, a piece of paſte-board lined with flannel, was thought proper to cover all that ſide of the forehead.—He was now ſent home to his friends, who lived farther north in the country, with ſtrict injunctions to avoid exerciſe. Indeed that he might the more conveniently do ſo, was the principal reaſon for ſending him thither; and its propriety was evident from [Page 19] this, that its uſe always gave him pain on the ſide of the head affected.
On the 10th of September, an opportunity having offered of examining him, it was found, that the paſte-board was laid aſide, and the orifice which had been in the bone, ſeemed completely oſſified in its whole extent. The bottom of the hollow part, felt hard, and made a reſiſtance when preſſed upon that could only be done by bone. His general health was now complete, and had been ſo ſince he was ſent to his friends. In ſhort, he ſaid, that he never enjoyed more perfect health. Every function, both mental and corporeal, was unimpaired, and indeed had always been ſo ſince the accident, except the ſhort time he was delirious. His external ſenſes were all entire, and his internal faculties, ſo far as could be diſtinguiſhed either by his relations, or by others who have ſeen him, have not ſuffered the ſmalleſt diminution of acuteneſs. He ſeems naturally to poſſeſs great [Page 20] vivacity, and quickneſs of apprehenſion, which to all appearance will continue. At leaſt ſo far as yet appears, no alteration in theſe, or any other endowment, will be the conſequence of the preſent accident.
N. B.—Since the above was written, the patient has been examined frequently, and is found to enjoy health, ſtrength, and the exerciſe of all his functions, entirely as before the accident. A circumſtance of ſome curioſity which he has repeatedly mentioned, is, that ſince his recovery he has been quite free from an occaſional headach, with which he was formerly much troubled.
GARDEN, Stirlingſhire, Nov. 9. 1792.