Brained by a bull

A remarkable recovery from a goring by a bull was recorded in 1774 in the pages of the Medical and Philosophical Commentaries.

Published in Edinburgh, this was the first regular medical journal to be published in the British Isles and had been founded the previous year by the physician Andrew Duncan (the elder).

Dr Robert Maclagan from Coaltulach (a place of which I can find no trace; either the village was depopulated or the name has changed) wrote to the journal to report this extraordinary case:

Last summer, in the middle of June, I was called to see a boy about ten years of age, who had been gored in the head by a bull. One of the bull’s horns had entered about half an inch below the upper part of the right temporal bone, and raised a piece of the skull, about two inches in length, and an inch in breadth, which consisted of part of the Parietal and temporal bones, of the right side. The dura and pia mater were both torn. This I easily discovered, although the integuments were swelled, by introducing a Probe, the end of which brought out part of the substance of the brain.

It’s fair to say that this method of investigating a head injury is not ideal.  Thankfully, less invasive methods are available to the modern physician.

Several splinters of the skull were sticking in the brain.  These I extracted by a pair of forceps. Another part of the skull was raised upon one side, but united at the other. This I attempted to raise to its natural position, but could not wholly effect it.

In the 1770s there was little else that could be done, so the boy was put to bed.  Dr Maclagan next saw him four days later.

There was then some protrusion of the brain at the wound. This protrusion increased from the fourth till the fourteenth day. At that time it had risen to the height of an inch, or rather more, above the skull, and was so extended and spread out in all directions, as to be about the size of a goose egg.

Let me clarify the mental image you may just have formed: this poor boy had several cubic inches of brain projecting outside his skull. Grotesque as this sounds, it probably saved his life.  Brain swelling (cerebral oedema) is a lethal consequence of serious head injuries.  When the skull is intact, this swelling can result in compression of vital parts of the brain, such as those controlling respiration, causing neurological damage or death.  One of the oldest surgical operations is trepanning, in which a hole is deliberately bored into the skull to relieve intracranial pressure.  In this case the injury to the boy’s skull had much the same effect, giving the brain space to swell.

In the treatment of this case, my chief aims were to moderate the fever, and to keep the different excretions from the body in their natural state. This I attempted by bleeding, purgatives, and cooling regimen.

Bleeding a patient with a head injury: not recommended.  Hypothermia, however, has been much used by neurosurgeons.

I at the same time applied externally spirit of mindereri to abate the inflammation and swelling, which were become pretty general upon the right side of the head, before my arrival.

‘Spirit of mindereri’ was a solution of ammonium acetate, popularised by Raymond Minderer, an early seventeenth-century physician from Augsburg.  It was also believed to induce sweating and to act as a diuretic.  It is rarely (if ever) used today, although until recently it was listed in pharmacological reference works as a diuretic.  There is, however, some evidence that it interferes with cell mechanisms in the brain.

The substance of the brain I dressed with dry lint. From prosecuting this course, it soon began to skin over at the edges; and, in proportion as the skin approached that part of the brain which had protruded, suppurated, and dropt off in pretty large pieces. In two months it was completely skinned over, and the boy perfectly well. He still continues so; only there is a small protuberance on the cranium, at that part where I could not reduce the bone to its natural situation.

The very definition of a lucky escape.