CASE 
OF 
FRACTURE OF THE SKULL, 
WITH 
LOSS OF A PORTION OF THE SUBSTANCE OF THE 
BRAIN—RECOVERY. 
JAMES C. FITCH, M.D. 
[Extracted from the New Jersey Medical Reporter for Feb. 1852.] 
On the 19th of July, 1849, George D. Fitch, aged eleven 
years, son of the writer, was thrown from a horse, and after re- 
gaining the erect position, was kicked by the animal on the head. 
This occurred about seven o’clock, P. M. 
He was borne to his residence perfectly insensible, and in a 
state of complete prostration. On examination, there was found 
a compound comminuted fracture of the skull, at the superior 
part of the junction between the right parietal and temporal 
bones; a portion of the bone, about two and a half inches in 
length by about an inch in breadth (or the width of the horse’s 
shoe), having been driven in upon the brain. 
The hemorrhage was profuse, and in dressing the wound a por- 
tion of the brain came out. Reaction did not take place until 
four o’clock the next morning, patient still remaining in a coma- 
tose state. 
July 20th. Dressed the wound with Dr. W. P. Clark,* of 
Belvidere, when another portion of brain came out. 
* To Dr. W. P. Clark, my friend and more than brother, I would here tender my 
grateful acknowledgments for the promptness with which he responded to ray call, 2 
21st. In dressing the wound to-day, a portion of the brain one 
inch in length protruded, but was confined by the membranes. 
Patient manifested sensitiveness when this was touched; but 
in other respects continuing in the same insensible condition as 
heretofore. Not able to swallow anything. The strength of 
two or three persons is required to keep him on the bed, and he 
lies still at no time more than three minutes. 
25th. Continues much in the same condition. Put a little 
water in his mouth, part of which ran out. A little seemed to 
go down the throat, and gave rise to strangling and spasms, re- 
sembling somewhat spasms of hydrophobia. 
27th. Opened his eyes for the first time since the accident, 
and took notice of a glass of water in my hand, and seemed 
desirous of drinking, but was unable to swallow. An hour after- 
wards, he again opened his eyes, and the water was offered him, 
of which he seemed to swallow a little. In another hour, he by 
looks expressed a desire to drink, and on presenting him the 
glass, he bit a piece from it, which he held so firmly in his mouth 
that it was with great difficulty extracted. Up to this time he 
had received no nourishment whatever, except from enemas of 
arrow-root and milk. 
28th. Looked up and spoke a word indistinctly—being the 
first word he had spoken since the accident. For the first time 
he seemed to recognize his friends. He also to-day received 
nourishment into his stomach for the first time, taking every two 
hours a teaspoonful of milk, thickened with arrow-root; this was 
continued until Wednesday, August Ist, when one cracker in 
twenty-four hours was added to the above. This plan of giving 
nourishment was continued till Friday, August 3d, when he re- 
jected all that had previously been given by the mouth, showing 
that the stomach had been incapable of performing its function. 
The act of vomiting exhausted him to such a degree that we 
feared the vital force was expended. A few drops of strong 
brandy were given every few hours, and in the course of two 
days he had regained his former position, and from that time the 
and for his punctual and daily attendance for more than three weeks (though living 
at a distance of ten miles), as well as for the consolation he afforded me in my afflic- 
tion.—J. C. F. nourishment given him by the month seemed to he digested with- 
out difficulty. 
Aug. 9th. Patient having had no discharge from the bowels 
since the accident, at the recommendation of my friend Dr. 
Clark, a suppository was given, wdiich had the desired effect. 
The wound looks well. Two pieces of bone were removed. Pa- 
tient seems to be perfectly sensible, and, though he has great dif- 
ficulty in articulating, converses on ordinary topics. He has no 
recollection of what has passed during the last few weeks, ex- 
pressing by his looks much astonishment, when informed of -the 
length of time that has elapsed. Has the appearance of just 
having awakened from a sound sleep. 
13th. Wound looks well. With assistance, he got up and 
walked across the room. 
15th. Appetite and digestion very good. Bowels moved daily 
by injections. 
18th. The wound still improves, and with it his general health. 
Experiences much difficulty in articulating some words. Becog- 
nizes persons and things, but cannot call their names, though 
when the name is once repeated, he retains it. For instance, a 
friend called to see him; and though he seemed by his looks to 
recognize him, he could not call his name until it was repeated to 
him, after which he had no difficulty as far as that particular 
individual was concerned. All eatables he calls bread, until he 
hears their names called. When he wishes an article of which 
he cannot call the name, he can describe it and compare it to 
things of which he does know the name, so that he can be under- 
stood. 
His loss of memory seems also to involve the memory of things 
as associated with taste. For instance, being very fond of rasp- 
berry brandy, he desired some, but not being able to call it by 
name, he succeeded in giving his mother to understand that it 
was kept on an upper shelf in a cupboard in the room, and with 
considerable difficulty made her understand that it wTas in a bottle. 
Fearing the stimulant effect of the brandy, it was easy to satisfy 
him with a little sweetened water, which he supposed was the 
raspberry brandy. 
Sept. 14th. Wound continues to improve. Patient has been 4 
out riding. Kecollects the circumstances connected with the 
accident, and relates them very correctly. Continues to experi- 
ence difficulty in articulating some words. Still recognizes per- 
sons and things without being able to call their names. 
Oct. 19th. Wound slowly healing, discharging a large quantity 
of pus daily. Complains when he coughs. Memory, and the 
difficulty in articulating words improving. 
Nov. 19th. Wound still discharges. Complains of weakness 
in his right arm. Yery active; health good; articulation im- 
proving. Goes to school. Has difficulty in remembering some 
of the letters of the alphabet, and some words. Has difficulty 
in forming some of the letters in writing. His memory fails in 
mathematics, but when one example is performed for him where 
he left off in algebra, his knowledge is revived, and he can per- 
form other examples without assistance. 
25th. In dressing the wound, a portion of bone came out. 
Dec. 3d. Wound still discharging. A small piece of bone 
came out. 
IQth. Five months since the accident. Wound still discharg- 
ing. Two small pieces of bone came out. 
Jan. 19th, 1850. Wound still discharging. 
March 19th. Wound discharges a great deal. Health very 
good. 
May 9th. Extracted a piece of bone from the wound which 
caused a profuse hemorrhage. This is the largest piece of bone 
that has come away. 
June 13th. Extracted a piece of bone. 
July 19th. One year since the accident. Wound still dis- 
charging. A piece of bone looks as if it would come away soon. 
Enjoys good health, learns well, is active, and in all respects 
mentally sound. 
Sept. Ist. Wound seems closed. 15th. Wound discharging 
much matter. 16th. Extracted a portion of bone. 
Dee. 20th. Extracted a large piece of bone, after which the 
wound closed up and is perfectly sound to this day, Nov. 16, 
1851. 
Hope, Warren Co., N. J., Nov. 1851. 5 
Remarks on the above Case. By S. W. Butler, M. D. 
The rare occurrence of severe injuries to the brain, and the 
very great danger that necessarily accompanies such lesions, 
when they do occur, combine to throw around them an interest 
which attaches itself to no other species of injury. Until 
the celebrated Perceval Pott, by his judicious teachings and 
writings, completely revolutionized the whole plan of treatment 
in injuries to the brain, they were much more frequently fatal 
than at present. Perhaps in no one department has modern 
surgery achieved a greater triumph than in this. It is a popular 
notion, and even some of the profession are involved in it, that 
injuries to the brain, more especially where any portion of its 
substance has been lost, necessarily involve loss of life. 
Such, indeed, was generally the case before the observations 
and untiring energy of Pott, and others of his time, introduced 
more rational methods of treating such injuries than had been 
pursued before. Yet we doubt whether the credulity of even a 
Pott would not have been somewhat taxed, had he read reports 
of the success in treating some cases of injury to the brain which 
have occurred in modern times. Doubtless some of our readers 
may remember a case published two or three years since, by Dr. 
Harlow of Cavendish, Vermont, in which a man recovered after 
having had an iron bar or “ tamping-iron,” three feet seven 
inches in length, one and a quarter inches in diameter, weighing 
thirteen and a quarter pounds, driven “ with a crash” through 
his brain high into the air, and thrown several rods beyond him, 
where it was picked up “ covered with blood and brains !’’ This 
is no fancy picture, drawn to task credulity, but a well authenti- 
cated fact. The patient, Phineas P. Gage, is probably still alive, 
and retains in a perfect degree his mental powers. Indeed, at 
no time during his recovery, was his mind seriously affected. In 
this case, the iron bar entered near the angle of the lower jaw of 
the left side, and passing upwards, involved the left eye, so as 
ultimately to destroy vision in it, and finally passed out near 
the centre of the frontal bone just in advance of the coronal suture. It therefore, in its course, involved only the anterior 
lobes of the brain, consequently, not necessarily involving those 
parts, whose peculiar function it is to govern the movements on 
which life is absolutely dependent. Probably there is not on record 
a case of recovery from such an extensive lesion of the brain as 
the one just mentioned. 
Indeed, though the writer has examined a number of surgical 
works, he has not succeeded in finding the report of but one other 
case of injury to the brain, with loss of a portion of its substance, 
followed by recovery. This was published by a Dr. J. Snyder 
of Ya., during the last year, in the Stethoscope, or Virginia Me- 
dical Gazette. Two cases published by the late Prof. Sewall, of 
Washington city, are referred to by the American editor of 
Cooper s Surgical Dictionary, but w'e have not succeeded in pro- 
curing the Journal containing them. 
So far as the writer has examined, Pott neither reports nor 
speaks of a case where any portion of the substance of the brain 
was lost. In the case spoken of above, reported by Dr. Snyder, 
the patient, a lad about eight years of age, was run over by a 
horse, and thrown against a stone, which caused an extensive 
fracture and loss of a considerable quantity of the cerebral mass. 
These, with the rapid recovery, were the principal points of in- 
terest mentioned in this case. The patient recovered from the 
effect of the injury in less than four months. 
In the case reported above by Dr. Pitch, there are several 
points of very great interest in a physiological as well as a pa- 
thological point of view'. We have neither time nor space to do 
more than refer to them now, leaving our readers to comment on 
them at leisure. 
As the injury received was by a blow on the side of the head, 
it is evident, that aside from the fracture and depression caused 
by the blow, there was a possibility of another effect, viz. : extra- 
vasation on the opposite side, the result of what the French term 
contre coup; and that this did occur, seems probable from the 
fact that there was, as long as four months after the receipt of 
the injury, a weakness in the patient’s right arm. Another thing 
worthy of attention is the fact, that the jactitation and the spas- 
modic action in the fauces, when the patient attempted to swal- low fluids, bore some resemblance to the morbid nervous action 
of a patient laboring under an attack of hydrophobia. It is 
evident, that the nervous influence supplied to the stomach, was 
insufficient to enable it to perform its function for the period of 
two weeks, during which time the patient was nourished wholly 
by enemata of milk and arroAY-root; and that the loAver boAvels 
readily assumed the duties thus thrown upon them, is proved by 
the fact that, although these injections Avere used daily from the 
time of the accident, yet it Avas full three weeks before there Avas 
any discharge from the bowels, Avhen a purgative suppository 
was used with success. 
Another interesting feature in the caseys, the great length of 
time that elapsed before all the fragments and spiculse of bone 
were discharged, viz., one year and five months. During all 
this time, although an exhausting drain was kept up, and that 
so near the brain, the patient improved constantly both mentally 
and physically. 
But there still remains the most interesting feature in the 
case, viz. : the effect of the injury on the patient’s mind, and on 
at least one of the organs of special sense—the taste. Why was 
it that the patient retained the memory of the countenance of an 
individual Avhile he had forgotten his name ? On Avhat physio- 
logical principle was he able to describe the shape, size, appear- 
ance, and position of an article he desired, Avhile he could not 
call it by name ? Why did he find it so difficult to remember 
the names of some letters of the alphabet, Avhile he had no diffi- 
culty Avhatever Avith others? To say, simply, that he had lost 
the memory of names, is by no means a sufficient answer to these 
inquiries. It Avould seem too, that the effect on the taste involved 
not the loss of that sense, but the inability to remember the taste 
belonging to a particular article. 
The Avriter, not feeling competent to undertake the solution of 
the interesting questions started in this connection, Avill here 
bring these already too extended remarks to a close, Avith the 
hope that others may be led to think and observe on the subject, 
should they have the opportunity to do so, and record minutely 
such facts as may present themselves. 
Burlington, N. J., Jan., 1852.