OBSERVATIONS ON THE TREATMENT OF COMPOUND FRACTURES OF THE SKULL,

736

ternal ear, and of the external auditory fora- be

injured, and

your, experiment fail:

we

fifth seem to have exposed the nerve, and divided .nerve on one side ? I must answer, No; it, without any accident of this kind. and the reason is, that the external parts You must remember that whenI pinched of the ear and the auditory tube are fur- the seventh nerve, about half an hour ago, nished with other nerves, which serve to the animal-gave evident signs of his haoiua keep up the sensibility. You may see a felt me. I then said the sensibility was proof of this in the little animal which is intimately connected with, and dependent before us. Although the fifth nerve has been on, the fifth nerve. Let us now see if this completely divided on one side, yet the sen- be true. The fifth nerve has been, I think, sibility of the parts just mentioned remains completely divided across, and the sensibi. undiminished on that side. This fact shows lity of the seventh, on the same side, should

men, is destroyed by dividing

the

how necessary it is to test all our assertions

accordingly

have

disappeared. [Here the

in physiology by experiment. Authors have Professor pinched and irritated the seventh been in the habit of repeating that the sen- nerve in various ways without the atuma) sibility of these parts is similar to that of giving any of the signs of sensibility which the face, and, like the latter, dependent on he formerly did when the same nerve was the fifth pair of nerves; but I will now de- touched before the division.] This expemonstrate the contrary, and show you that riment demonstrates, as clearly as any exthe sensibility of the external ear and its perimental process could possibly do, that

foramen persists after the complete division

the sensibility of the seventh, or facial nerve, ob- depends on the integrity of the fifth. In my next lecture I propose examining serve beforehand, that if the animal do not show any great symptoms of sensibility the functions of the three nerves which are when I touch the external ear on the side distributed to the larynx, and several quesat which the fifth nerve has been divided, it tions allied to the physiology of the larynx,

of the

nerve

in

question. Here I must

is because that part of his body is naturally but little sensible. [Here the Professor touched the orifice of the ear, on which the animal gave signs of

feeling, though feebly.]

The question

of

OBSERVATIONS

ON THE TREATMENT OF

COMPOUND FRACTURES OF THE

special

sensation

comes

order; but as I have a great deal to say on this part of the subject, I prefer

next in

SKULL, AND THE SUBSTITUTION OF COLD TO THE HEAD FOR VENESECTION.

treating it, ex professo, in a separate lecture ; to-day I shall confine myself to show- By HAMILTON ALDER ROBERTS, Esq., Surgeon, Bangor, N. W. ing you the influence which the nerve of the fifth pair exercises on that of the seventh. You have seen how the seventh nerve is not PERHAPS few subjects connected with sur-

entirely deprived of sensibility, as some gery have more deservedly engaged the atphysiologists assert, although it possesses tention of practitioners, than the management

that property in a degree much, very much, of compound fractures of the skull. On this inferior to the fifth nerve. I have exposed point the most diametrically opposite opi. the facial nerve in this young dog ; it has nions are entertained. Sir A. Cooper, and been carefully isolated from all the sur- Sir B. Brodie, recommended the employ. rounding parts. I now raise it up, and ment of the trephine, or elevator, in all when I pinch it the animal, as you see, gives cases of compound fractures with depres. evident signs of feeling. When the force sion, whether symptoms denoting compreswith which I pinch

sion exist or not; while Desault, Aliernetly, and Dease, have insisted that no attempt should be made to elevate the depressed the proof, has, however, this very peculiar bone unless the symptoms indicating a!) character, that it is connected with the in- injurious degree of pressure are most de. tegrity of the fifth nerve, upon whose influ- cided. The advocates for the employment ence its full and complete exercise depends. of the trephine state, that, if the bone Let us now demonstrate this latter assertion be left depressed, suppuration will most by an experiment. [Here M. MAGENDIE probably occur, and the matter, having no seized a young dog, and having made an means of escape, will produce bad symptoms: incision below the base of the zygomatic also, that, although no injurious consearch, divided the temporal muscle until he quences should immediately happen, the came. down upon the cranium. A portion depressed bone may at a future period of the temporal fossa was then removed, andI cause such mischief as to demand the applithe trunk of the fifth nerve exposed. The cation of the trephine. To the fil’stargumenl operation lasted about twenty minutes.] it may be said; Cannot the surgeon,in You must not (resumed the Professor) in- most instances, prevent inflammation and troduce your instruments too freely withinthe suppurative process by adhering to a the cavity of the skull, least the braini rigorous antiphlogistic treatment’ To the is

increased, it

even

cries, and makes an effort to escape. The sensibility of which you have now witnessed

737

second, that the recorded cases of patients who have suffered, after the lapse of months and years, from the effects of depressed bone, are very few in number, and that it is quite time enough to interfere when these evils come. The trephinists (if I may be permitted to use that term) have, however,

reply to a few questions. Is not the catting away of a portion of bone a serious evil? Is not even the jarring of the trephine likely to increase the shock which that most sensitive and tender organ, the brain, has beforereceived ?Are the dangers of injuring the dura mater, of inducing sloughing of that membrane, and of hernia cerebri, to be despised ? That such severe consequences do frequently follow the application of the trephine cannot be denied, and unless more potent arguments be brought forward to justify thenecessity of having recourse to that instrument, the practical surgeon may feel satisfied that the safest and most jtidicious practice will be to interfere only when urgent symptoms of compression,

to

&c. have failed to overThe following cases of compound depressed fractures mayprove interesting in illustrating the propriety of pursuing this line of treatment :-

which bloodletting come, are present.

CASE 1.—John Williams, æt. 22, a quarryman, fell from a rock to a depth of more than forty feet. He was stunued for some time after the accident, and had lost much blood from the wound. He was brought to Bangor on the 9th of March, 1830, at 12, A.M. An extensive wound, situated immediately above the tuberosity of the occipital bone, exposed to view a transverse fracture, which extended on each side to the lambdoid suture. The inferior portion of bone.was depressed to a distance of nearly three lines, and the pericranium was separated to a considerable extent from the bone. Two branches of the occipital artery, which bled freely, were secured, and the lips of the wound brought together by adhesive straps. The patient is now perfectly sensible, and does not experience much

pain.

Eight r.ar. Twelve ounces of blood were taken from the arm, and an aperient mixture was

prescribed.

scalp almost entirely removed. The discharge from the wound is purulent; of the

tongue clean; bowels open; but little thirst. From this timedaily and rapid improvements took place. The patient was

discharged

cured .,

on

the 25th of March. ,

,

CASE 2.—William Jones, ret. 17, received a blow on the head from a piece of rock on the 26th of November, 1832. There was a wound on the left side of the head,-about

three inches long, commencing alittle above the antitragus, and extending obliquely npwards and backwards. The fracture fol[lowed the direction of the posterior part of the squamous suture, proceeding downwards as far as the meeting of that suture with the lambdoidal. A portion of bonts was driven in, to a depth of the quarter of an inch. There was copious hæmorrhage, proceeding, apparently, from the lateral sinus. The patient is quite sensible. The edges of the wound were brought together, and Schmucker’s lotion was applied to the head.—Vespere. There is great pain in the head; pulse 90, hard ; bowels constipated. An aperient power ordered. The bowels were 27th. Slept well. freely moved. The neighbourhood of the wound is very painful and tumid.—Vespere. Pulse 108, and hard; there is great thirst. The aperient repeated, and a powder, containing 10 grains of nitrate of potash and one-sixth of a grain of tartar etnetic, to be taken every four hours. 28th. There is more pain in the head; pulse fuller and harder, 115 ; tongue covered with a white fur; bowels confined. A pint of blood was abstracted from the arm, and an aperient mixture ordered. The antimonial powders produce much nausea. Cold lotions to be continued. 29th. The patient is much better. Pulse softer, but frequent. The head is not so painful, and the wound discharges pus freely. The bo-wels have been frequently moved. 30th. Has had a good night. -Pulse soft, 76; the bowels continue open. Dec. 2nd. Great improvement has taken place; patient is free from headach and fever; the wound looks healthy; the cold

applications are

very

agreeable.

10th. The patient felt very comfortable 12th. The cold lotions left off, as there is throughout the day, but severe pain in the no longer any heat of the scalp. The patient head came on during the night. The medi- walked a short distance, but had slight cine produced several loose evacuations. giddiness. llth. Has passed a restless night. 18th. Discharged well.

Tongue clean,

The but dry; pulse 84. the wound is very painful, and has a boggy feel. There is tumefaction over the whole of the head. A bloody serous fluid escapes from the wound. Bloodletting repeated, and the aperient mixture continued.—Vespere. There is less headach; bowels freed twice.

scalp around

l2th. Anotlier restless

night.

CASE 3.-Thomas

Thomas,

æt.

16, fell,

(Nov. 21st, 1832,) from a rock, a distance of about fourteen feet ; he continued insensible for half an hour. There was found a wound,

about three inches in length, upon the left side of the head ; immediately under the wound, and corresponding with it in length Puffiness and direction, being an inch beneath 3C

about

738

sagittal suture, there beaten in as to permit the free introduction fracture, accompanied with of a finger. The injury was occasioned by slight depression; the pericranium was a piece of rock, which was thrown out in extensively torn. The patient complains of the process of blasting, falling upon the headach ; pulse 100, hard; cold water kept vertex. The patient was not much stunned after the accident. The wound was dressed constantly applied to the head. 22nd. Pulse not so frequent, and rather with adhesive plaister, and linen cloths, soft; the scalp is very painful. The bowels dipped in cold water, were kept constantly being torpid a purgative was given, which applied to the head. 22nd. The patient makes no complaint. produced one evacuation. 23rd. An aperient mixture prescribed. Pulse weak; tongue clean; but very little 24th. The bowels have been freely moved. heat of the scalp. There is no headach, but the wound conFeb. 3rd. Patient going on well; has tinues painful, and discharges much pus. neither headach nor thirst ; the wound al. Pulse 90. most entirely healed. Dec. 7th. The patient is nearly well; he 8th. The patient discharged cured. has no fever or headach ; the wound is and

parallel

was

detected

to the a

rapidly cicatrizing. 14th. Discharged cured. CASE 4.-Benjamin Roberts, tiet. 16, on the 6th of January, 1836, was struck on the head by a fragment of rock; he continued in an insensible state for a long time, and vomited frequently. Over the supero-posterior part of the left parietal bone there was a contused wound, which was above four inches in length ; the scalp was separated from the bone to a great extent; the fracture extended downwards to the temporal bone; the posterior portion of bone was depressed about an inch. Considerable haemorrhage ensued. The patient was brought to Bangor at 3, P.M., at which time he was quite sensible, and complained much of pain in the head. Cold water applied to the scalp. To take six grains of calomel at bedtime. 7th. The patient continues to suffer from headach, and is very thirsty. Tongue clean; pulse rather quick. The wound looks well; the scalp is painful to the touch, but not much swollen. The bowels have been freely evacuated. To use the cold water

constantly. 8th. The integuments covering the parietal and occipital bones are very painful and puffy ; very little pus comes from the wound ; tongue coated with a thick, creamy fur. A saline purgative mixture ordered. Application of cold water continued. 9th. Patient has had a good night; the scalp is less painful, and the puffiness is quickly disappearing. The medicine has procured several evacuations. 12th. Patient going on well ; pulse soft and regular ; tongue cleaner; healthy discharge from the wound. 23d. Daily improvement since last report. The patient has returned home quite well. CASE 5.-Eleazer Prichard, ast. 17, was brought to Bangor on the 21st of Jan., 1836. A crucial lacerated wound was seen on the scalp, covering the superior part of the left not fractured in one part, so much

parietal bone, which, though to any

great extent, was,

Remarks.-It will be observed that blood.

letting was had recourse to in only two of the foregoing cases. In the first, blood was abstracted twice. This depletion would not, I feel persuaded, have been required had the application of cold to’ the head been assiduously employed in this as well asin the other cases. Bloodletting is, even in the present day, too frequently carried to an immoderate extent; and although the foolish and pernicious practice of using the lancet after every accident (even while pa. tients are in a state of collapse) is almost exclusively confined to the hands of empi. rics, still it too often happens that surgeons, who place too implicit a reliance upon the authority of books, and who are more or less biassed by early prejudices, consider the abstraction of large quantities of blood absolutely indispensable in the treatment of injuries of the head. When reaction has taken place, bloodletting is generally unne. cessary, and if too freely employed is highly injurious, inasmuch as it debilitates the system to such a degree as to render it incapable of struggling with the effects of inflammation, and prevents the surgeon, when inflammation has been fully develop. ed, from pursuing the only means calculated to arrest its progress. Sir A. Cooper and Sir B. Brodie, although they agree in recommending moderate depletion, speak in strong terms against its abuse. The former, in his 11 surgical Leetures," makes the followingremark :" There are some persons who say, you cannot bleed too much in these cases, but such an assertion only proves their want of un. derstanding." He also gives the history of a case in which death was occasioned by excessive bloodletting. Sir B. Brodie states, in his " Observations upon Injuries of the Head," that "Where bleeding has been carried to a great extent, symptoms frequently occur which, in reality, arise from the loss of blood, but which the superficial observer will be led to attribute to the injury itself." As a substitute for venesection, in the great majority of cases, I can most confidently recommend the continued applica-

739

tion of cold to the head. This practice, it is and the tongue was moist; there was no true, has been alluded to, and occasionally pain in the head; his conversation was

works; but, un- quick, even abrupt, and occasionally anipraised, in various surgical fortunately, it has seldom been properly mated, and he exhorted his friends not to greatly neg- fear for him, assuring them that he should appreciated, and is at present I have had such be better to-morrow. His intellectual facul-

lected in this country. repeated opportunities of witnessing its bene- ties appeared to be more than ordinarily ficial effects, that I conceive it to be an im- acute, his replies to my interrogatories being perative duty on my part to urge its more judicious and sensible. He would lie quiet, and apparently heedfrequent adoption. The mode in which I prefer to apply the cold water is as fol- less of all things, for a few seconds, and lows :—A few folds of old linen, moistened then his repose would be suddenly interin the coldest water, are placed (so as to rupted by violent spasms, affecting the facilitate evaporation) lightly upon the head, throat, seeming to threaten immediate despreviously shaven, and are changed as often truction. During the paroxysm he would as possible. Cold water alone is preferable throw the bed-clothes off, and struggle with where the injuries are complicated with himself as if endeavouring to be rid of some. wounds; but in contusions and simple thing which was dreadfully cumbersome, tures of the skull, the water may be ren- I his intellect remaining entire. After a dered still colder by the addition of frigo- minute, or thereabouts, he would relapse rific mixtures. Cold water, as a topical ’, into his former state, the paroxysm being remedy, possesses the most incontestible renewed upon the application of the most advantages; it effectually relieves the pain trifling cause. The slightest agitation of and heat which occur after injuries of the the air, produced either by an attendant scalp, and seldom or never fails in prevent- moving near to him, or the opening of the ing the formation of those very serious con- bed-room door, was sufficient to produce sequences of contusions and wounds, vi7,., the effect, of which he was very sensible. puffy tumours and erysipelas. I have never The agitation of fluids caused a marked found patients to express any repugnance to impression on him, though it did not seem the application of cold ; on the contrary, it quite sufficient to excite a return of the proves so agreeable to them, that they re- symptoms, but on water being offered to quire not to be told to be careful in having him he became ungovernable. The same the cold cloths frequently renewed. Cases extreme effect was produced if a lookingwill, undoubtedly, sometimes offer them- glass were placed before him, when the selves which will demand the abstraction violence of the paroxysm was, indeed, of blood; but, with those exceptions, the awful. The history of the case is this :-About employment of cold applications, active purging, strict attention to diet, and perfect seven months since, (I could not learn prerest, will seldom disappoint us in bringing cisely when), this boy was bitten by a about a favourable termination. strange dog, in the calf of the left leg. The animal ran from a court-yard, and in passBangor, North Wales, Feb. 7, 1837. ing by him bit him, and ran off. Nothing more was ever seen of the dog. The wound, which was trifling, healed in due time, CASE OF HYDROPHOBIA. without much attention being paid to it. Four or six days preceding that on which I To the Editor of THE LANCET. saw him, he had complained of being unSIR :—I take the liberty of forwarding to well, but had, nevertheless, kept to his you the following case of hydrophobia. I work. I am told that he occasionally am, Sir, your obedient servant, spoke of an uneasiness in his throat, for JAMES GEORGE DAVEY, M.R.C.S., &C. which he was recommended by a relative Miid-end Terrace, Portsea, some domestic remedy, as an external apFeb. 2nd, 1837. plication. But what all about him regarded as singular was his aversion to fluids. On Christmas-day last I was desired by His brother told me that " he had not drunk my partner, Mr. Gardiner, to visit a lad of a gill of fluids of any description, including the name of Martin, by trade a butcher, tea, for a period of several days." The first who, he said, I should find labouring under occasion of alarm was on the night of very unequivocal symptoms of hydropho- Christmas-eve, when a lighted candle was bia. On entering the chamber I found him put in the chair, beside his bed, as the poor lying on his back, with his neck and chest boy lay in it, when, it would seem, a exposed, his arms fully extended, and his paroxysm was induced, on his recovering countenance expressing the utmost horror from which 1 have understood he attributed and anxiety. He complained of a torment- the cause of his sufferings to the candle ing restlessness and a distressing sensation having been so near to him, and desired that of impending suffocation, and constriction of it might, on no account, be put within his the throat; the pulse and skin were natural, sight. 3 C 2

frac-