has gone on pretty well since the operation.

rather tends to favour its occurrence. This may appear paradoxical, but when we consider that the artery, in this situa

one;

A man,

remarks. He observes that there are two kinds of compound fracture. for instance, leaps from his gig, and breaks his leg. The limb is twisted, the bone protruding, the case apparently a bad "but the surgeon extends the limb, reduces the bone, lays it carefully out upon a pillow, prevents the rising inflammation by cold lotions, or iced water,-and what is the amount of the injury?" The great vessels and different textures are little injured, and the patient will probably do well. If, however, the limb has been crushed, the muscles rent-blood extravasated-the great vessel torn, the appearances to the eye may be the same, but the issue of the case will be very different indeed. The above was an instance of the latter kind of injury, and had not amputation been performed, gangrene, or other fatal termination, would, in all probability, have been the consequence. Passing over Mr. B's reasons for amputating high in the thigh, we come to the question of hæmorrhage. Mr. John Bell, it is well known, denied that the femoral artery could be effectually compressed. It is a different thing, says he, to stop the pulsation, and check the flow of blood. Now, in spite of the authority of Mr. John Bell, surgeons have an idea that they can do both, without any very great difficulty. Sir Astley Cooper, as the story goes, demonstrated this to a young gentleman in the operating theatre of Guy's Hospital, by lifting his thumb from the vessel, and directing the stream of blood, we will not say upon him, at plea sure Mr. C. Bell argues that this prac tical joke of the worthy Baronet's proves nothing at all; the blood being stopped not by the thumb upon the artery, but by the hands grasping the thigh, and so compressing the collateral vessels. This is ingenious reasoning, but we have seen the circulation completely arrested, without any grasping of the thigh at all, the pressure being made upon the artery by the key-compress.

We contend, indeed, that in the high amputation of the thigh, the tourniquet is at times a positive disadvantage, for it prevents the due retraction of the muscles and integuments, is in the surgeon's way, and instead of arresting hæmorrhage,

a kind of hollow between the sartorius and pectineus, we see at once, that by the contraction of these, and the other mus cles, the tourniquet is ineffectual in preventing the circulation through the artery, quite, or nearly quite, effectual in preand through the profunda, whilst it is venting its return through the veins. These remarks apply of course, only to the The consequence is obvious-loss of blood. high operation, for the surgeon who makes a boast of never requiring or desiring the tourniquet in any case, is only depriving himself, most unnecessarily, of a very val

uable assistant.

With regard to the time of operating in these severe cases of gun-shot wound

or

severe fracture, Mr. Bell very judiciously observes that, after the patient has once recovered from the shock of the accident, and has revived from the state of depression, "so that he sees by the shattered condition of his limb, that it must be lost, then the operation ought to be performed, and the sooner the better." Mr. B. pays a merited compliment to the surgeons of the British Navy, but singularly enough, omits their brethren of the Army, which is certainly not at all fair to the latter.

The next case which occupies the attention of the lecturer, is one of distorted limb, where the patient wished to have the defective member removed. This wish of a patient's, Mr. Bell thinks, cæteris paribus, should go for nothing in determining the question; as cases have repeatedly occurred, when in compliance with such request, the limb has been amputated, and the person died. A tailor, for instance, had so crooked a leg, that he could not sit in the proper position on the board. He suffered amputation and died. The case under consideration, was one in which the motions of the knee-joint were much impaired in consequence of an old and ill-set fracture; conjoined with which there were ulcers upon the leg. Mr. Bell taking into consideration the fixed determination of the man to have his leg off, either in that hospital or elsewhere, the utter lameness, and the ulcers which were continually, and would be continually breaking out,

at last consented to amputate. Symptoms of tetanus came on, but disappeared; a bad state of the stump supervened, and at the end of five weeks the patient sank.

Mr. Bell makes one observation, in which we do not quite agree with him, namely "that he looked upon the ulcers of the leg as favourable to amputation." Now it certainly seems to us, that these old sores indicate a state of system far from favourable to any great operation, and in one or two cases where amputation was performed for such sores, we have witnessed an unfortunate result.

Case 3. A man æt. 54, having received a slight scratch upon his little finger, erysipelas showed itself, and was relieved by incisions into the arm and hand, giving vent to serum and pus. The erysipelatous inflammation, however, recurred at intervals, an abscess exposed the joint of the thumb, and another surrounds the elbow-joint. In this case, Mr. Bell is adverse to the amputation, because the slight nature of the original injury, and the occurrence and recurrence of the erysipelatous inflammation are evidence of something defective in the constitution, which might, and probably would, equally show itself in the stump. A young woman in the Middlesex Hospital, was a remarkable instance of this liability to erysipelas. If leeches were applied, an erysipelatous blush extended up the thigh, the same with blisters, caustics, &c. so that the girl nearly died. At last amputation was performed (for disease of the knee-joint) a bad state of the stump was the consequence, ushered in by erysipelatous inflammation, and she narrowly escaped

with life.

We have been led farther into these lectures of Mr. Bell's than we intended to

have gone, but really the interest of the matter, and the engaging manner in which it is treated, cannot fail, we think, to be a sufficient apology.

3. STEEVENS' HOSPITAL, DUBLin.

VAPOUR-BATH IN TETANUS.

Dr. Marsh has published some brief notices of the effects of vapour-bath in this dreadful, and generally fatal malady. The first case was that of a boy, five or six years of age, who was brought into

Ca

Steevens' Hospital, Dublin, labouring under tetanus. The paroxysms were severe and frequent, and the disease had come on after an injury in the great toe. lomel in large doses, with other purgative medicines, having failed to act on the bowels-and opium not giving any relief, the vapour-bath was suggested, and the boy was subjected to it, at a heat not above 90 degrees. He remained in the bath six hours. The paroxysm became less violent and less frequent. A third of a drop of croton oil was given every third hour, which operated violently after the fourth dose. Belladonna, and ol' succini, were rubbed along the spine. bath was daily employed, for several hours each time, and the boy slowly recovered. It was remarked that, on removing the little patient from the vapour-bath, the sore, which had previously been foul and unhealthy, began to improve in appearance, and ultimately assumed a clean granulating aspect.

The

The next case was also one of traumatic tetanus, but unsuccessful. "The uniform effect of the vapour-bath was to abate the violence of the paroxysms, without, however, influencing, in the slightest degree, the permanent rigidity of the muscles."

Calomel

In the third case, the patient was an adult, who was under the care of Mr. Cusack, in the aforesaid hospital. and opium had been given till ptyalism was established; but apparently, without any good effect. The vapour-bath was then tried, and steadily persevered in till every symptom of the disease gradually gave way. In this and the other cases, the patients were enveloped in a flannel bag, to which, at the lower part, a small tin boiler was attached. Underneath this, a spirit of wine lamp maintained an abundant regulated by a thermometer, introduced supply of vapour, the temperature being into the flannel envelope.

Thus, then, two patients were saved out of three, and one of those saved laboured under traumatic tetanus. We conceive that the long-protracted vapourbath, at a low temperature, as above described, is infinitely preferable to liquid baths in the common way, or vapour. baths at a high range, where, of course, the stay in the bath must be comparatively short. This plan does not interrupt or interfere with the exhibition of medicine, and we strongly recommend its adoption.

4. ST. BARTHOLOMEW'S HOSPITAL.

INJURY OF THE HEAD-APPLICATION OF THE TREPHINE.

If any one set of cases is more puzzling than another in surgery, it is-"Injuries of the Head." We verily believe that, if a student were to go the round of the different surgical lectures in this metropolis, he would scarcely find any two agreeing in their practice in these cases. Sir Astley Cooper tells us, that it makes all the difference in the world, whether the cranial fracture be simple or compound. Mr Travers and Mr. Brodie seem to say that it makes no difference at all! Here, then, upon a mere matter of experience, for the comparative danger of one case over another can be known only by experience, sound practical men are at loggerheads. In medicine, alas! there is nothing certain, but death and the doctor's bill.

Case. W. B. æt. 30, was thrown from a cart, picked up insensible, and taken to a surgeon, who bled him, and dressed his head. He regained his senses, and vomited frequently, but soon fell again in a state of stupor, and next morning, Jan. 23d, was admitted under the care of Mr. Earle. At this time, he was drowsy -incoherent--pupils dilated, but answering to the light-pulse small and irregular --extremities cold. Over the upper and lateral part of the left parietal bone, there was a lacerated scalp-wound, but the bone did not appear to be denuded. He was ordered calomel and jalap, and, at 4. P. M. there being some re-action, he was bled. In the evening, 20 ounces of blood were taken from the temporal artery, with some little relief, and, at 12, P. M. was bled again to 3xvj. Next day he had difficulty of articulation, pulse full and frequent, pupils much dilated. V. S. ad

xvj. On the 25th there was paralysis of the right side of the face, and he passed the urine and fæces involuntarily. 26th. Partial paralysis of the right side of the body-coma. The wound was sloughy, and the bone beneath bare for about an inch, and, apparently, dead. In consultation, it was determined to apply the trephine. Upon removing the bone, neither blood nor matter was found upon the dura mater, but this membrane had a blueish tint, as if there were blood de, VOL. VIII. No. 16. 67

posited beneath, and no pulsation of the brain was to be felt. He appeared to recover a slight degree of sensibility after the operation, but soon relapsed. The pupils were greatly dilated-the breathing stertorous-he became violently convul sed, and, at 2, A.м. of the 28th, expired.

Dissection. Dura mater not inflamed, but on removing this membrane, a quantity of blood was found effused over the whole cerebrum. The left hemisphere, opposite the point where the bone had been removed, was flattened, by the deposition of a quantity of dark clotted blood, and the posterior surface of its middle lobe was coated with grumous blood. On making a section of this lobe, it was found to have undergone the process of ramollissement to the extent of about two inches. Besides this, a fracture extended from the left temporal bone, through the anterior inferior angle of the parietal, passing across the groove for the meningeal artery. Between the dura mater and bone, at this part, no less than three or four ounces of blood had been extravasated-Gazette, No. 10.

Mr. Earle, according to the report, considered that, in the earlier part of the case, the symptoms of concussion were present, while, latterly, those of compression supervened. On this point, we cannot exactly agree with Mr. E. for, as far as we have seen of concussion, the patient, though drowsy, is not generally incoherent, nor is the pulse "small and irregular.' Besides, after having been bled by the surgeon, before his admission into hospital, the patient recovered his senses, but relapsed again immediately. This certainly is not the case, with con, cussion, for, having once recovered from this state, the patient can scarcely be said to fall into it again, but rather to suffer from the inflammatory action, set up as a consequence or sequela of the concussion. It appears to us, that this man laboured under tolerably well-marked symptoms of extravasation throughout, although latterly they were aggravated, partly from the re-action in the system, which terminated in the and partly from the disorganizing process, "ramollissement" of the brain. The practice pursued by Mr. Earle appasrs to have been highly judicious.*

*This article had been sent to press,

We shall here introduce a case which occurred at St. George's Hospital, and is illustrative of the difficulty which exists in ascertaining the exact nature of the injury which the brain has received.

A boy was brought into the hospital, Aug. 22d, at half past one, P.M. in a state of total insensibility, having fallen from a height of 30 feet. There were two extensive scalp-wounds upon the right side, but the pericranium was entire, and no fracture of the bone could be discovered. The pupils were rather contracted and sluggish-pulse almost natural-surface cool-breathing much like that of a person asleep, and without stertor. When his name was halloo'd loudly in his ear, he was perfectly unconscious of it, but, whilst some bleeding vessels were being

when we received No. 233 of the Lancet, containing a most abusive tirade against Mr. Earle, for the practice which he pursued. There is so large an admixture

of slang, "cock-sparrows"- -"bats""vampires," &c. &c. that, for some time, we could not persuade ourselves but that we were perusing the account of a mill, at Monlsey Hurst, between "Barney Aaron" and the "Chelsea Snob," or some such celebrated personages. The sapient critic in the Lancet sports we know not how many notes of admiration, at Mr. Earle's considering the symptoms enumerated above as those of compression. Now we have said, and we do maintain it, that the symptoms were those of compression, almost from the very commencement of the case, exasperated certainly, at last, by the inflammation going on in the substance of the brain. If the symptoms did not indicate compression, what, in Heaven's name, did they indicate? Concussion? The man in the mask must be even a greater goose than we take him for, if he asserts that difficulty of articulalation-paralysis of one side--and involuntary discharge of fæces and urine, are evidences only of concussion. Whether the trephine should have been applied earlier than it actually was, may admit of doubt; but the man who can rate a surgeon, as Mr. Earle is rated, for applying that instrument in a case, where dissection shewed "three or four ounces" of blood over the dura mater, and a considerable quantity under it, ought to be ashamed of himself.

secured upon the scalp, he struggled violently, and moaned.

In the evening, he grew restless and fidgetty, and slight re-action came on. He was still insensible, and the pupils were dilated, particularly that of the right eye, but without any strabismus, or convulsive affection, in any of the muscles. V.S. ad 3 viij.

23d. Evidently sinking. The surface is cold-the pulse scarcely to be feltpupils act on the approach of a candle, but the right is still dilated. Towards evening he became rather convulsed, and, at 6, P.M. quietly expired.

Sectio Cadaveris. Mr. Brodie, under whose care the patient was, imagined that the symptoms depended upon extravasation beneath the dura mater. On

raising the calvarium, no blood whatever was found, either above or below this membrane, and the hemispheres were sliced down to the level of the corpus callosum, without any extravasation making its appearance. In the substance of the cerebrum, a little to the left of the septum lucidum, was a small spot, softened, and containing a little blood. This was also the case with the left optic thalamus, and in the lower part of the posterior lobe of the cerebrum, was a cavity about the size of an almond, enclosing extravasated blood. A fissure was found running across the optic fossa of the sphenoidal bone, and the liver was of that granular texture found in dram-drinkers.

It would be difficult to say how far the symptoms, in this case, were owing to compression, and how far to concussion. The want of stertor-the coldness of the

surface, and the almost natural state of the pulse, would seem to evidence the latter, whilst the unequal dilatation of the pupils, and the general intensity of the symptoms, might rather be referred to the former. These are the mixed cases which occur in practice, and bother the student, who has got by rote all the pretty little distinctions, so clearly pointed out in his elementary books.

5. ST. GEORGE'S HOSPITAL.

PECULIAR AFFECTIONS OF THE CRANIAL BONES.

At page 489 of our last Fasciculus we

have noticed some observations of Dr. Abercrombie's and Mr. O'Halloran's upon this head. Two cases have lately occurred at St. George's Hospital, under the care of Mr. Rose, which might well have been appended to the article in question.

Case 1* A woman was admitted for bronchocele, but there was casually observed a tumour on the head. It had been punctured three weeks previously, and into the puncture a probe was introduced, and vent given to some glairy serum. Next morning rigors and severe constitutional disturbance came on, an erysipelatous blush appeared upon the neck, and on the 3d day she died. On dissection the tumour was found to be of malignant structure, and to pass through a circular opening in the parietal bone, and take attachment (though not a firm one) to the dura mater beneath. This membrane was quite sound, and there was no reason to believe that the tumour had originated from it.

Caroline Hollyoake, æt. 20, was admitted Nov. 7th, with extensive disease of the right parietal bone. The outer table was completely exposed for a space about the diameter of a crown piece, but longer, and the edges of the scalp around were curiously tucked in. The bone was rough and blackened, and around it a line of separation had been commenced, but was ineffectual in checking the disease, for the probe passed beneath the scalp, and discovered dead bone for some distance round. The coronal suture crossed the exposed bone in front, and between its serrated edges, which were more apart than they should be, pus was seen undulating in correspondence with the pulsations of the brain. The menses had always been irregular, and for the last three years had ceased entirely. About a year previously she began to be affected with pain in the head, and hysteria, and she first noticed matter amongst the hair,

*Lond. Med. Gazette, No. 1.

nine months prior to admission. An abscess appears to have formed, and the part of the scalp to have been destroyed by ulceration. Besides this disease of the cranium, there was likewise dead bone in the lower jaw. There was no reason whatever to suspect a syphilitic taint -she had never received any blow upon the part-nor could she account for the affection in any way On the 13th, Mr. Rose removed a portion of the blackened outer table by an elevator, and on the 29th he divided the scalp, and removed a still larger portion by means of Hey's saw. Large flabby granulations were exposed beneath, which pulsated strongly ; but whether they arose merely from the diploë, from the dura mater, or partly from one and partly from the other, it would be difficult to say. The patient was going on pretty well-the pulsation had distinctly lessened, and her health was certainly not suffering much, when she was persuaded by her stupid friends to leave the hospital, lest she should be made to undergo any more operations.

At this time the probe passed for some distance across the os frontis, and there was altogether a very large amount of diseased bone on the right side of the

head. What was the cause of all this it would be difficult to say, though it must be owned that the girl was of a puny, scrophulous habit of body. It is curious how little disturbance these affections cause to the sensorium. In the first case,

the patient was scarcely aware of the existence of the tumour, and in the second, there was no paralysis, no affection of the mind whatever. Mr. O'Halloran objects to the use of the trephine, but upon what grounds we know not. If there is a mass of diseased bone in the skull, particularly if the outer table only is affected, it surely must be an object to get rid, as quickly as may be, of this dead and irritating body. If, indeed, there be symptoms of irritation to the brain, as convulsions, paralysis, epilepsy, &c. then we conceive that the surgeon, cæteris paribus, has no choice in the matter, but is imperatively called upon to remove the affected bone.