REPARATION 
UP 
BRAIN-TISSUE AFTER INJURY. 
BY 
JOHN P. GRAY, M. D., LL.D., 
MEDICAL SUPERINTENDENT OE THE NEW YORK STATE LUNATIC ASYLUM 
UTICA. N. Y. 
[REPRINTED FROM THE TRANSACTIONS OF THE NEW YORK ACADEMY 
OF MEDICINE] 
UNA FIDE9. ALTARE COMMUNE. 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1875. REPARATION 
OF 
BRAIN-TISSUE AFTER INJURY. 
BY 
JOHN P. GRAY, M. I)., LL.D., 
MEDICAL SUPERINTENDENT OF THE NEW YORK STATE LUNATIC ASYLUM, 
UTICA, N. Y. 
rREPRINTED FROM THE TRANSACTIONS OF THE NEW YORK ACADEMY 
OF MEDICINE1] 
UNA F1DES, ALTARK COMMUNE. 
NEW YORK: 
I). APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1875. REPARATION OF BRAIN-TISSUE AFTER INJURY. 
By JOHN P. GRAY, M. D„ LL. D„ 
MEDICAL SUPERINTENDENT OP THE NEW YORK STATE LUNATIC ASYLUM, UTICA, N. Y. 
Read February 18, 1875. 
In February, 1868, I saw, witli Dr. Edwin Hutchinson, 
of Utica, a case of fracture of the cranium, in H. Galli, a 
boy three years old. He had fallen against a stove, striking 
the right side of his head. No unconsciousness followed; 
when we saw him he was sitting on his mother’s lap, not 
complaining, and the side of his face was smeared over with 
brain-substance. Examination revealed fracture of the an- 
terior portion of the right parietal bone, a piece of which, 
more than an inch in diameter, had been driven into the 
brain, standing at right angles with the surface, with one 
edge still adherent. It had torn through the membranes, and 
lacerated the brain-substance, a portion of which had been 
forced through the opening. After laying back the scalp by 
a V-incision, the tearing up of the brain-convolutions was very 
apparent. Elevating the bone forced out a quantity of brain- 
substance. When the edges of the wound were brought to- 
gether, a small opening remained in the cranium, where an 
irregular piece had been broken off. For seven days the child 
continued quite comfortable; a little fever, but pulse not ris- 
ing above 132; appetite good, and did not complain of pain. 
On the seventh day lie became restless, head hot, some 
discharge of thin pus; pulse rose to 110. This condition 
continued for three days, when the flow of pus ceased and 
the ragged membranes projected through the opening. The 
child was dull and somnolent. The wound was carefully ex- 
plored with a probe, and the projecting membranes clipped 4 
off. This was followed by a small discharge of pus, and on 
the following morning the pulse fell to 116 ; heat of head 
lessened; the boy brighter. 
On the eleventh day there were twitchings about the 
right eye, and the eyeballs were in constant oscillation hori- 
zontally. 
On the twelfth day there were loss of movement and low- 
ering of temperature in left arm ; pulse 112 when awake and 
100 when asleep; skin was cool, tongue moist, and urine 
free ; child restless, crying, and at times screaming. A probe 
was again passed into the wound, and a free discharge of 
dark-colored pus followed, with some broken-down brain-tis- 
sue. Immediately after, Dr. Hutchinson removed a spicula 
of bone which had been embedded some two inches in the 
brain, and the child brightened up. 
On the fourteenth day, pulse 98, movement of the eye- 
balls ceased, and slight motion and increase of temperature 
appeared in the left arm. Quite a free discharge of pus. 
On the sixteenth day, movement in arm returned and 
child bright; flow of pus continued. 
On the twentieth day, a small growth protruded through 
the opening, and, increasing, pressed the piece of bone back- 
ward and downward. This mass was again cut away. It 
was rapidly renewed, however, and was again cut away on the 
twenty-flrst, twenty-third, and twenty-fifth days. 
On the thirty-first day a protrusion, the size of a pigeon’s 
egg, was cut away. 
On the thirty-second day a still larger mass was removed. 
On the thirty-third day some haemorrhage occurred. 
On the thirty-seventh day the protruding mass was the 
size of a large hen’s egg. 
On the forty-fourth day the mass was tied off, for fear 
of haemorrhage. 
On the forty-sixth day a protruding mass was again cut 
away. 
On the forty-eighth day a flow of serum commenced, 
which continued until the fifty-third day, during which over 5 
two pints was discharged. During all this time the child 
was bright but fretful, took food, pulse ranging from 120 to 
144. 
On the fifty-eighth day the protruding mass remained sta- 
tionary, its broad base filling the opening, firm, of a light pink 
color, and resembling brain-tissue. Child deaf, walks un- 
steadily. 
On the sixty-eighth day, general health improved, child 
walks alone : all the general symptoms have subsided. The 
mass has the appearance of brain-convolutions. 
On the sixty-ninth day Dr. Hutchinson commenced slight 
pressure, by a cork pad, held by a rubber band passed around 
the head, such as is used around packages of letters, and in a 
few days, without any unpleasant symptoms, the mass passed 
within the cranium. 
On the eighty-eighth day it was covered with membrane. 
On the ninety-eighth day the scalp had nearly healed over. 
On the one hundred and twelfth day the child was en- 
tirely well, but deaf. 
In this case, considering the age of the child, the loss of 
brain-substance was large. During the inflammatory pro- 
cess, while the injured brain-tissue was being discharged, the 
amount of connective-tissue elements produced and cut away 
was very great. 
Dr. S. Weir Mitchell, in speaking of the pathological re- 
sults of neuritis after injury to nerves, says there is “an enor- 
mous development of connective-tissue elements.” 
The length of time in reparation of tissue in this case 
quite corresponds with reparation of nerves after injuries. 
The new and final growth was the reformation of brain- 
matter filling up the space. It was some twenty days in 
completing its structure, and the convolutional character of 
the surface was distinctly marked. My impression is, that it 
would have passed into the cranium without the slight press- 
ure used. 
If, after the section of a nerve, the upper end should be 6 
renewed by tlie formation of a button-like growth, and, if 
reparation is a law of the organism, why should the brain be 
an exception ? Was the brain-tissue reproduced, or the space 
simply filled with amorphous matter ? It was a long time 
before the reproduction of nerve-tissue was accepted ; yet, 
nerve-fibres were reunited and reproduced in the healing of 
wounds and fractures, and in cases of destruction of tissue 
by abscess or ulcerative processes. 
This boy is now ten years old, a bright, active lad ; is 
deaf, and is being educated at the Institution for Deaf 
Mutes in Hew York City. The case was under the charge 
of Dr. Edwin Hutchinson, who conducted it with great skill, 
and whose reported notes I have freely drawn upon. 
The second case is that of a man, a soldier, who at the 
age of forty-one, in September, 1862, was wounded in the 
head at the battle of Antietam. The ball struck the pos- 
terior part of the right parietal bone, crushing it in, leaving 
an opening in the skull one and a half inch in antero-pos- 
terior diameter, and three inches in the vertical line. The 
ball was embedded in the substance of the brain. Forty- 
eight pieces of bone were taken from the brain; the bullet 
was removed ten days after the injury. He was discharged 
from the service and pensioned in 1863, and entered upon his 
occupation as a turner in brass, the wound having entirely 
healed over. For five years he remained in good health, 
without even suffering from headaches. His general health 
became impaired in October, 1868, and he became depressed, 
and finally developed an attack of melancholia. 
He was admitted to the asylum at Utica, February 3, 
1871, where he remained until February 15, 1872, having 
then been well about four months. He was discharged recov- 
ered, and returned home and to his work. Nine months after- 
ward he began to suffer from pain in the head, especially over 
the frontal region. He complained of confusion of mind, 
and asked to be again received at the asylum, dreading a re- 
turn of melancholia. In April, 1873, this condition continu- 7 
ing, he applied for an order, and came to the asylum alone 
with the papers of commitment. June 14th, two months 
after admission, he became profoundly melancholic. He 
gradually failed, and died July 25, 1873. 
On post mortem, an elliptical opening in the right parietal 
bone was found, corresponding to the wound already de- 
scribed. 
Ho attempt at bone-reparation had been made. The 
dura mater extended over the opening, and was firmly adher- 
ent to the scalp. The arachnoid and pia mater were so com- 
pletely renewed that no trace of the injury could be detected 
in their structure or by the presence of cicatrices. 
The convolutions were fully outlined, and resembled in 
appearance the other convolutions of the right hemisphere. 
Vertical sections through these repaired convolutions showed 
the normal proportion of gray and white matter. 
As the pathological result of the attack of insanity, the 
dura mater was somewhat thickened, and showed signs of 
recent inflammatory action. The pia mater of a large part 
of the right hemisphere was opaque, and raised by an effusion 
of serous fluid, containing lymphoid cells and pus corpuscles. 
The whole brain was dry, atrophied more or less, but es- 
pecially the convolutions of the right side. Each ventricle 
contained half an ounce of serum. The brain weighed thirty- 
eight ounces. The walls of the vessels of the convolutions, 
in certain areas, were distended by crystalline deposits of 
cholesterine, and structureless, translucent bodies of an albu- 
minous character. Amyloid degeneration was found in the 
walls of the vessels of the pons Varolii and the medulla. The 
nerve-cells of the outer layers of the gray7 substance were 
contracted and opaque. The fibres of the white substance 
thicker than usual, and the neuroglia lessened. 
In the atrophied gray cortex of the anterior and posterior 
ascending parietal convolutions of the right hemisphere, the 
nerve-elements were much diminished in number, in compari- 
son with the corresponding parts of the left hemisphere. This 
condition was especially marked in regard to the pyramidal 8 
cells of tlie second of the five layers of the cortex. The con- 
nective elements were more dense, fibrillous in their structure, 
and densely colored by carmine. 
In the middle and inferior frontal convolutions, down to 
the convolutions of the Sylvian fissure and the island of Riel, 
there was large infiltration of pigment. 
In this case, as in the other, the brain-reparation was com- 
plete, and the man remained well for five years. The patho- 
logical results of the attack of insanity were similar to those 
ordinarily found. 
Theodore Simon (Virchow’s “ Archives ”) reports two 
cases of what he denominates additional brain-growths, where 
new formations were found superincumbent upon the gray 
matter of the convolutions. In these new growths the gray 
and white matter were normal in their relations and propor- 
tions. They probably originated from slight injuries. 
Pathological history affords a large number of injuries to 
the brain, with loss of brain-substance and subsequent recov- 
ery, though there have been comparatively few cases where 
they have been followed through life, and the brain examined 
after death. 
Among the most interesting cases is that of Phineas Gage, 
which occurred in Vermont, September 13, 1818, and is given 
in detail in the descriptive catalogue of the Warren Ana- 
tomical Museum of Boston. The skull is now in the museum. 
A tamping-iron, a cylindrical iron bar, one and a quarter inch 
in diameter, three feet and seven inches in length, and weigh- 
ing thirteen and a quarter pounds, passed through his head 
while he was tamping a charge for blasting rocks. One end 
of the bar was square, the whole tapering to a quarter of 
an inch at the opposite end. It entered “ in front of the 
angle of the lower jaw, upon the left side,” by the smaller 
end, and passed out through the anterior- and upper part of 
the left parietal bone. It traversed “ the anterior part 
of the left hemisphere, and across the corpus callosum and 
the margin of the right hemisphere, involving the loss of the 
central part of the left anterior lobe, together with extensive 9 
laceration of the middle lobe, the right central lobe, the falx, 
and the longitudinal sinus.” Here was an immense loss of 
substance. 
In this case, as in the boy Galli, a large fungous growth 
appeared in the progress of the case, and was cut away ; there 
was also discharge of pus and broken-down brain-tissue. 
On the fifty-sixth day he was so far recovered as to be 
walking about. 
On the sixty-second day he walked half a mile. 
On the seventy-third day he went to his home, a distance 
of thirty miles. 
On the one hundred and ninth day “the wound was quite 
closed.” 
It will be observed that the progress of brain-restoration 
in these two cases is quite similar. 
He lived twelve years, some two years of which he trav- 
eled with the bar and exhibited himself—then acted as a 
hostler. In 1852 he went to South America and drove a 
stage-coach. In June, 1860, he returned to San Francisco, 
with impaired health, where he worked on a farm, till he 
died of convulsions on the 20th of May, 1861. 
It is to be regretted that the record is silent in regard to 
the condition of the brain. The probability is, that the space 
was so completely filled up as not to attract the attention of 
those who made the post mortem and preserved the skull. 
I have seen three cases of attempt at suicide by shooting, 
where the ball entered the brain and remained there, and 
where recovery took place. In each case the external wound 
was kept open, and pressure prevented during the progress 
of reparation.