Oshkosh, by gosh

Severe fracture of the skullHere’s a spectacular head injury (and recovery) reported in the Transactions of the Wisconsin State Medical Society in 1869.  This lucky, lucky man survived an accident which left him with a large portion of his brain hanging out of his skull. The unusual case was reported by Dr Linde of Oshkosh, Wisconsin – a city perhaps best known today as the headquarters of the snappily-named clothing company OshKosh B’Gosh. 

Mr. S., aged thirty-four, German, while at work in Kellog & Rouirey’s lumber camp, as sawyer, received a severe fracture of the skull. While engaged in sawing a log with another workman, a limb, 12 feet long and 8 inches in diameter at the butt, that had lodged in a pine-tree near by, fell a distance of 70 or 80 feet and struck him on the head; a knot on the limb, 2 inches in length, penetrated the skull and broke off. Severe as the blow was, it did not knock him down. After the injury he remarked to a workman standing near him, that he was hurt; he then walked to the camp, about one quarter of a mile from the place of accident, without difficulty.

The nearest doctor was seven miles away; a messenger was sent for him. When Dr La Count arrived some four hours later, his patient was (miraculously) still alive.  Dr La Count removed the knot which had pierced his skull, along with a few loose pieces of bone. The patient’s hair had been driven in with the knot, and a considerable amount came out with it. Eight days after the accident, Dr Linde was asked to see Mr S.:

I went immediately to Mr. S.’s house, while my father went after his trephining instruments, as the messenger stated that the patient’s skull was fractured.

Trephining was an operation to relieve pressure inside the skull. It involved drilling or cutting a small hole through the bone.

I found him perfectly rational and walking about; found on examination a cicatrix [scar], four inches in length, from the junction of the sagittal, with the coronal sutures extending downward. The wound was healed except about half an inch of the upper portion, wherefrom I removed a number of pieces of bark and hair. Not having the previous history of the case, we concluded by the symptoms of the patient, not to operate at present, but to watch the ease closely. His pulse was fifty; his mind rational, but rather sluggish, bowels constipated. We applied light dressings to the wound; ordering rest and a cathartic. I watched the case for a week, seeing him daily and dressing the wound. At each dressing I removed several pieces of bark and hair. Patient’s appetite was good, but the sluggishness of his mind (I could not call it stupor) increased; the pulse diminished during this time in number of beats, though not in volume, to 43 per minute. Worst of all, his bowels would not move without large and repeated doses of Croton oil.

These days I’m pretty sure that most doctors would be more concerned by the catastrophic head injury than by the state of the patient’s bowels. Dr Linde decided to operate – luckily he had chloroform to hand.

skullThe old cicatrix was opened its entire length. From the upper portion of the wound another incision was made towards the left side, making it a V shaped flap. A fracture was found with depression extending towards the left ear; this was raised with the elevator to its normal position. A portion of brain was found protruding about the size of a pigeon’s egg, rather congested and covered with the dura mater. In trying to smoothen the roughened edges with the bone forceps, a large detached portion of bone was felt, lying almost vertically in the brain substance. After the elevation of the depressed portion of skull, and removal of the loose fragments, I examined the pulse, finding it risen to 75 per minute. After the removal of the large pieces of bone, four smaller pieces were removed with some fragments of bark. After the operation the brain protruded considerably.

A worrying symptom, but to be expected: after head injuries the brain tends to swell. If there had not been a wound for it to escape through, it is likely that the resulting pressure inside the skull would have killed the patient.

He recovered perfectly from the anaesthesia, and we left him comparatively comfortable. The next day I found S. with hiu pulse 75. His bowels had moved during the night. I dressed the wound, removing several pieces of bark and hair; Asking him how he felt, he replied “very well” except a severe pain in the left ear. He had slept well during the night. There was no marked change in the ease for the next week, except that the hernia cerebri [escaped brain matter] was gradually increasing in size, it being then the size of a hen’s egg. 

This must have been quite a sight. 

I tried to keep it down with adhesive plaster but could not succeed. I then put a compress over the hernia and by gradual and protracted compression, succeeded in reducing it to the inside of the skull.

Some patients do exactly what their doctors tell them. This one seems to have been an awkward customer, since he refused to stay in bed.

On the 14th day after the operation, I removed a piece of knot. Hairs and bark showed themselves more or less every day during the treatment, which lasted three months. The wound looked healthy and closed up from the sides. The third week I removed a fragment of bone; another the seventh week. On about the 10th of May, the wound closed entirely.

Genuinely a triumph for his doctors: a depressed skull fracture with protrusion of brain matter is not exactly a simple case.

Mr. S worked in a saw mill during the last summer; this last winter in the pinery. He has been quite well since the wound closed, with the exception of the 8th day of March, ’72, when he had two convulsions. Ever since he has enjoyed good health.

 It seems that getting out of bed against his doctor’s wishes was not Mr S.’s only shortcoming as a patient:

He has a weakness for strong drink; I have seen him repeatedly intoxicated since his recovery. It was after one of his sprees that he had the convulsions, as above stated. Even during the treatment he drank whiskey without my knowledge, but he concluded that it did not agree with him. He can now drink half a keg of beer with several drinks of whiskey during the day, without the least inconvenience.

Thank goodness for that!

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