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REVIEWS FROM THE WEST.
210 sometimes among labourers, the treatises on the same subject. Those lower classes of society, the love of who have heard the writer’s lectures approbation is so strong, that when will easily discover a deep tinge of they are drinking together the one who has felt his consequence much his mind and manner in these pages, hurt will even stab his fellow labourer. In looking for this organ yon will not his phrase naturally assuming the always find it very elevated, but it is aphoristical form, of all others, pergenerally very broad in the characters haps, the best suited to medical com. I have been describing. I give the feeling as fundamental, and the organ position. It is much to be regretted, as quite certain. that a man who possesses such ample The doctor then briefly recapitulatof and inves. ed, and exhibited the casts of several opportunities observing in all its varied known to forms, this disease, persons possess feeling tigating in considerable activity. favour the world with should not the opima spolia won in a long and wellfought campaign of the most exten. siveexperience. The materials ofa REVIEWS FROM THE WEST. use work we know he possesses; but his earlier productions having Practical Precepts on Injuries of the met with rather a Wa1’m reception Head. By A. COLLES, one of the from the critics, we believe he has Professors of Anatomy and Siirgery come to a determination not to venI in the Royal College of Surgeons ture his hand once more in the wasp’s nest. No such consideration should in Ireland. Dublin, 1824. deter him from the performance ofa AT the close of the winter course of duty which his acquirements so well lectures at the R. C. of Surgeons in him to undertake, and which qualify Ireland, 1824, the following Tract, on his situation in life, as a public teacher, Injuries of the Head, was printed at in some measure demands of him to the author’s expense, and distributed execute. Should not the example of by him, gratuitously, to his pupils. men in similar circumstances stimulate An offering of friendship from a him to exertion ? Had the energies professor to his class, more than an of a COOPER been confined to the elaborate display of knowledge in- handicraft of his profession, narrow tended for general circulation, can indeed would have been the sphere hardly be said to be a subject for of his labours, while his writings have even
criticism.
Censure, even if deserved, made the latest posterity his debtor. would, we think, be out of place, AVe must conclude this notice abruptly, when applied to a production under in order to make room for the subject such circumstances ; but, in truth, no it, which we shall insert entire; such delicacy is required, in speaking assuring our readers, that our plea. of this little work, for though small sure, in rescuing this little tract from and unpretending, it really contains oblivion, is not greater than our ap. as much useful information as will be probation of the amiable motives in generally found in more voluminouswhich it originated.
of
’
211
the extravasated blood will absorbed in the course of or twenty days. It’at the end of Gentlemen, or twelve days the tumour should The following little work, on Inju- ten continue undiminished, especially if ries of the Head, has been compiled the integuments should begin to inwith the view of facilitating the study and point, you may then make flame once at difficult and ofa subject an incision sufficicnt to give exit to complicated. I request you will ac- the blood ; after which keep the parts cept of it as a mark of my sincere in apposition by compression and banesteem and a return for your kind dage, and they will quickly unite. attention. "
To the Pupils of the Royal Collegee
of Surgeons in Ireland.
and
quiet,
generally be
ten
Believe, gentlemen, Yonr sincere friend,
incised wounds be treated as simiA. COLLES. lar wounds in other soft parts ; they INTRODUCTION.-The plan of this will unite by the first intention. If little work has been borrowed from a the bone be so cut that a scale of it similar publication, by the late Mr. be raised along with the flap of the Dease, the first Professor of the Prac- scalp, replace the parts, and treat the tice of Surgery in our College. I have wound as an incised flap wound of the ventured to make considerable alte- scalp only; such a wound frequently rations in the arrangement, and such heals as if it were a wound of the additions to the matter as have been soft parts. In lacerated flap wounds supplied by the present improved of the scalp, replace the flap and restate of surgery. I have made Mr. tain the parts in apposition by gentle Dease my guide, because every man compression, with bandage, &c. &c. who has read his larger work, " Ob- The contused wounds, if small, apservations on Wounds of the Head," proximate the parts, but do not bring must see that the principles which he them into very close apposition, bethere inculcates are now received as cause a greater or a less degree of established truths, and are acted upon suppuration and sloughing must folas rules of practice. low. Contused flap wounds are to be treated by laying down the flap after INJURIES OF THE SCALP.-Contusion. you have endeavoured to wash clean —A blow of a blunt weapon, in gene- the surfaces. As soon as the process ral, detaches the scalp from the peri- of sloughing is finished, bring the cranium. The separation takes place parts into the closest apposition, and to a greater or less extent around the retain them in that state by adhesive seat of the injury. Into the receptacle plaster and bandages. Should you thus formed, and also into the broken dress the surface of the wound and cellular substance which surrounds the flap separately, the flap would, the cavity, blood is poured from the from day to day, become more thick, ruptured vessels. There is danger of more unyielding, and more narrow; mistaking such an ecchymosis for a so that when you wish (after the prodepressed fracture, because the bor- cess of sloughing) to draw the flap der of it, raised and hardened by the over the surface from which it had blood which is impacted amongst the been raised, it will leave more than cellular substance, resembles the ele- one third of that surface uncovered. vated circumference of a depressed Punctured wounds of the scalp are fracture ; while the central part, soft to be treated as similar wounds in and yielding; allows the finger to sink other sott parts. This class of wounds below the level of the is sometimes followed with a circumscalp. If you open such tumours in scribed painful swelling, accompanied an early stage, you will induce a with inflammatory fever ; these conhigh degree ofinflammation and fever, sequences arise from the inflammatory which will be followed by stipptira- tension of the aponeurosis, and are tion of a very bad character. Hy most speedily removed by dilating the means of cold lotions applied to the wound of this membrane. Erysipelatumour, by the antiphlogistic regimen tous inflammation, with fever, is not
WOUNDS.-Simple
of the scalp are
,
apparently
to
212 an
unfrequent consequence of wounds month, and occasional hlisters, should arising, however, rather constitute the plan of treatment.-
of the scalp,
When covery ;
from constitutional than local causes. the symptoms begin to yield, The treatment should be the same as we may entertain good hopes of re. for erysipelas attendant on wounds we must not then repeat the of other parts. The event sometimes ! evacuations in too quick succession. proves fatal. On examination, after Should this plan of treatment prove death, no traces of inflammation of nnenccessfnl, and should the condition the brain, or any other disease of that of the patient become more and more organ, can be discovered. ’In wounds alarming, we may then think of apply. of the scalp, generally speaking, the ing the trephine ; for in some few
should he en- cases it has happened, that by the moderate the I blow the dura mater had been detach. for a wide space from the cra. local inflammation of the integuments, but also to guard against the more while at the same time a frac. serious danger of the inflammation of ture of the internal table had torn the middle artery of the dura mater, or the internal parts. some one of its sinuses, and thusa CONCUSSION AND EXTRAVASATION.- large quantity of blood had been col. The primary, or immediate coiistitti- lected between the membr ane the tional symptoms of injuries of the head, skull. With the faint and uncertain are loss of sense and volnntary motions, hope of finding such an extensivese. stertorous breathing, slow labouring paration, and such a large collection the surface of the dura mater, we pulse, iaavoluntary discharge of urine and fæces, &c. Every possible variety should apply the trephine. In nene. occurs ill the violence and duration ral, however, this operation affords of these symptoms, from a slight but little chance of relief, because the stunning toabsolatte and almost in- effused blood lies not on the surface stant death. The intensity or durathe dura mater, but is widely tion of the symptoms is by no means over the pia mater, and tenaproportioned to the force of the blow, ciously adheres to that membrane,or severity of the injury. Dissection the usual symptoms of eon. discovers two different states of the cussion and extravasation are com. contents of the cranium in those who bined with epileptic fits, spasms, or conhave exhibited the above symptoms. of any of the muscles of the In some, blood has been widely found carefully examine whether there spread on the pia mater, over one or be not a fracture, and whether !a both hemispheres, or extravasated into splinter of bone has not wounded the the ventricles, or about the base of dura mater. In a few instances of the brain; while in others, we dis- injuries of the head, the patient is afcover no effusion, no rupture, no disin a manner very different that described in the heginninn organization of the brain : the only remarkable appearance which pre- of this section. He has a wild look, sents itself is, that this organ seems much, frequently gets out of not to fill the cranium completely. bed, has a tendency to vomit, his This latter class of patients are said pulse more than naturally quick, his to Lave died of concussion of the breathing neither slow nor stertorous. brain; the former class, of extravasation. Tbe same train of symptoms INFLAMMATION AND SUPPURATION occurs in both these forms of internal WITHIN THE CRANIUM.-Patients who znischief. The same line of treatment have suffered from extravasation or is applicable to both. In case of re- concussion of the brain, may, after covery, these symptoms in general the removal of all the symptoms at, slowly retire ; the sensibility and vo- tendant -on such mischief, be seized luntary motion gradually return. In with symptoms of suppuration within The probability of such a few instances the patient suddenly the cranium. recovers possession of his faculties. a consequence is not to be estimated Venesection, repeated if necessary, according to the severity of the oripurging injections, purgatives by the ginal injury, for suppuration has fol-
antiphlogistic regimen joined, not merety to
ed
nium,
on
of spread
Whenever
vnlsions face,
fected from
talks
i
213
injuries of the head in whichantiphlogistic regimen, constitute the wound of the soft parts, no frac. means most likely to succeed with ture of the skull, had taken place, the generality of’ patients. The tre2iid where the symptoms of roncns- phine should never be employed as a sion had been very trifling and very means of preventing inflammation of iransitorv. On examination after the brain and its membranes. Rigors, death, we generally find a small quan. fever, and the other symptoms said tity of purnlent matter lying (at the to denote internal suppuration, may site of the blow) ou the surface of the arise from a wound in some other dura mater. When we raise this mem- part of the body, from inflammation brane, we find nearly the entire stir- and tendency of the bone to exfoliate, face of the hemisphere covered over or from the ordinary causes of fever; by a yellow purulent fiuid, which ad- therefore be not too hasty, on the first heres so tenaciously to the pia mater appearance of such symptoms, in apthat very little of it will flow off; plying the trephine. Search well for
lowed no
.indeed the colour and consistence of every other cause which may have this fluid would lead m to suppose excited the present disturbance in the that it was formed of a commixture ofsystem ; use the means ordinarily repnsand coagulated lymph. Nausea, sorted to for the relief of febrile thirst, head-ache; quick, full and hard symptoms ; and if, notwithstanding pulse; restlessness, pain, and coi-d- these attentions, you perceive an aged feel of the head, are the constitu- gravation of symptoms, then have retional symptoms said to be indicative course to the operation. This opeof this mischief. The local symptoms ration must necessarily prove unsucin cases Without a wound are, a tu- I cessful in the majority of cases, bemour of the scalp, puffy and tender, cause the inflammation is diffused, but not paini’nl to the tonch. In -cases and the fluid is spread on the pia accompanied with a wound on the mater, not on the surface of the dura. surface, which had been healthy and mater, as had been formerly imagined. In a few instances, however, the matgranulating, will become pale, andflabby; instead of good matter, it ter is formed in a circumscribed spot will only discharge a thin discoloured on the surface of the brain, with adsaiiies, the dressings will stick closely, hesion between the dnra and pia and the pericranium, instead of ad- mater, and occasionally with a splinter hering firmly to the bone, will sepa- of bone forced through these two rate from it, and that even to some membranes into the substance of the distance, around the edges of the brain. The early application of the wound. The symptoms indicating trephine will save such patients; but suppuration within the cranium never if it be too long delayed, this opeappear at an earlier period than the ration will, even in such cases, prove sixth day; generally between the ineffectual, because the matter of the eightlaand twentieth days. We are abscess, being pent up, will irritate not, on this account, to conclude that the adjoining portions of the brain, the inflammation has only begun at and will give rise to the diffused inthis period. Dissection has proved flammation along its surface. Should that matter has been formed within the operation fail of bringing the the cranium, so early as the third and wished-for relief, and only a small fourth days; so that the above symp.. quantity of matter be found on the toms mark not so much the cotnmence.. exposed dura mater, we sliall have ment of the inflammation as the dis- neither any certain guide to indicate turbance which the system suffers the presence of fluid lodged beneath from the matter formed within the this membrane, nor any strong enskull. To avert thi, inflammation and couragement to divide it. Should the suppuration, we must take our mea- desperate condition of the patient urge sure. from the very first day of the you to this measure, you will only injury. Bloodletting largely and re- perceive a very small quantity of seto the rous fluid to flow through the openpeatediy employed, condition of the patient, with a strict ing. After the operation of the treattention to the other parts of the the integuments should be laid
glassy,
’
according
pan,
214 down again, but not brought into such close apposition as to prevent the escape of pus. The constitutional treatment must be regulated by the particular circumstances of each case. When fungus of the brain shoots up, pressure will not restrain it. Remov ing it by ligature is ineffectual-by incision, mortal.
ON FRACTURES
OF THE
SKULL -
Simple (nndepressed) fracture of the skull is not productive of any symptom or condition, by which, when the integuments remain entire, we could
be certain of its existence. Blood issuing from the nose, eyes, and ears, affords a strong presumption offtacture passing across the bones which encompass these organs. In simple fracture, accompanying an incised or lacerated wound of the scalp, we are
particularly required
to
bting
the
toms of compression, we must quickly raise the depressed piece to its proper level. This, in very open fractures, can be sometimes accomplished by the elevator alone. Where there is not room for this instrument, or where the form and circumstances of the fracture require the removal of some part of the skull, we should apply the trephine to such parts, and in such manner as will facilitate the elevation of the bone. In general we shall find it of advantage to make the trephine comprehend the border of the frac. ture. Mr. HEY’S saws will be found of great advantage in removing the edge of these fractures, when of any considerable length. If any depressed piece cannot be prevented from wounding and irritating the dura mater, or if it be perfectly loose and have lost all connexion with the snr.
lips lOundiug parts,
so as
to
be incapable
of the wound into close apposition, ’of re-union, such piece should be en. and procutee their speedy union. To tirely removed. In very small de.
trace the extent of a simple fracture pressed fractures, (such as may deisequally unavailing and unnecessary, serve the name of punctures of the for such fractures too often pass from bone,) where a depressed bit of bone the top, or sides, to the base of the is sunk into the brain, it will perhaps skull, until stopped by the foramen be prudent to postpone ttie operation magnum ; and surely the fracture, if for a few days ; for, if the operation left covered, is more likely to unite be performed immediately after the without much inflammation than if it receipt of the injury, and if we at. be exposed to satisfy an idle curiosity. tempt to seize the depressed fragThe early application of the trepan ment, the first touch of the forceps to a simple fracture must tend to ex- sinks it still deeper into the brain; cite, rather than to avert, inflamma- portions of the brain, from its soft-
tion of the contents of the cranium. The constitutional treatment of such injuries should consist in the most sedulous employment of the means calculated to prevent inflammation of the brain and its membranes.
DEPRESSED FRACTURES.-The symp-
compressed brain do not corin severity with the size of the depressed portion of bone, or the depth to which it is sunk. In severe injuries of this kind, the symptoms are comparatively slight and of short dutoms of
respond
ration. If the case be not urgent, we may postpone the attempt to elevate the depressed piece, until symptoms of inflammation begin to show themselves. Many such cases have had a complete recovery, although the bone remained depressed. In depressed fractures attended with severe
symp-
ness, rise np, and conceal the bone from our sight and touch, whereas if we defer the operation for a few days, we give time for the adhesive inflammation to take place ; this cir. cumscribes the depressed piece, hardens the spot of the brain, and thus enables us to lay hold of the bone more easily and certainly. The older surgeons prohibited the application of the trephine to certain parts of the skull ; but when the circumstances of the case require it, we should not hesitate to apply it even to those pro. hibited parts. Wounds of the brain must be treated on the same principles that regulate our practice in the treatment of the other injuries of the head."
‘
215 FOREIGN DEPARTMENT.
During the
year 1824 admitted.
were
Intermittent fevers Diseases of the brain and its
............
ANALYSIS OF FOREIGN MEDICAL JOURNALS. REVUE MEDICALE-MARS.
ninges.................... Ophthalmia .............. Diseases of the organs of respiration
14
me-
......................
Report of Diseases observed Diseases of the heart and its conat Me Hotel Dieu, in the Clinical necting membranes and vessels Wards of Professor RECAMIER clurDiseases of the alimentary canal ing the last year. Diseases of the liver............ The number of patients admitted Diseases of the urinary passages .
37 1 118
General
......................
10 176 13 5
into the clinical wards of the Farulte Diseases of the organs of generaduring the year 1824, amounted to tion in the female.......... 16 about five hundred and thirty-six, of Diseases of the organs of generawhich number three hundred and tion in the mate.......... 8 thirty-four were males, and two hun- Cases of peritoneal inflammation 6 dred and two females. Of these sixDiseases of the skin ............ 26 ty-six have died, fifty-seven of the Phlegmonous inflammations of the former, or near one-sixth of the numcellular membtane 3 ber, and nineteen females, that is ra- Diseases of the fibrous tissues, ther less than a tenth of their number. muscular and synovial...... 51 Of the five hundred and thirty-six pa5 Diseases of the nervous tissue.. tients admitted, four hundred and Diseases of the lymphatic strue-, tight laboured under acute affpctions, tures (stt’uma)............. 2 of whom forty-two died, that is in the Diseases of the bones (gibbosity) 1 proportion of one-ninth, whilst of the Sinile debility 4 hundred and twenty-eight others who Contusions of a nature .... 11 laboured under chronic diseases, thir- Diseases of a slight not well kind, slight ty-fonr were lost, or a little less than defined ................... 29 a third. From these general results we obTotal 536 serve,-1st, That the mortality has been much more considerable among We shall not follow the subdivision the men than among the women. This which M. MARTINET has made in spemay be attributed to the greater se- cifying the varieties of each of the verity of the diseases among the diseases which he has thus classed toformer. 2dly,The mortality has been gether, but shall proceed to examine much more severe in the chronic than the therapeutique which was adopted, in the acute cases, almost double, and and the alterations which have been was generally owing to the very ad- made in this respect from the estavanced stage of the affection when blished practices. medical aid was first solicited. On The employment of graduated comthe other hand, if we take a survey of pression in the treatment of ascites by the nature of the diseases which have a laced bandage ; the cauterization of reigned during the greater part of the a cancerous nlcer of the lip by the last year, we shall see that affections solution of the nitrate of mercury and of the alimentary canal have been the rapid cicatrization which followmost common, and more so than those ed ; the complete cure of a permanent of inflammation of the respiratory or- contraction of the hands and feet of a gans. Rheumatic compLiints have been girl, principally affected by the use of most in frequency, and after these dis- shower baths, which were employed eases of the encephalon, of the skin at first at 16 degrees R., and afterand of the organs of generation; then wards at 14 degrees ; the fortunate come intermittent fevers, affections ofterminations of several cases of pleu. the bladder, of the heart, and of the ro-pnpumonies, by the internal admi urinary passages, as will be indicated nistration of tartar emetic, of from six to eight grains duringthe twentyby the followingtable. .........
.................
criticism.
Censure, even if deserved, made the latest posterity his debtor. would, we think, be out of place, AVe must conclude this notice abruptly, when applied to a production under in order to make room for the subject such circumstances ; but, in truth, no it, which we shall insert entire; such delicacy is required, in speaking assuring our readers, that our plea. of this little work, for though small sure, in rescuing this little tract from and unpretending, it really contains oblivion, is not greater than our ap. as much useful information as will be probation of the amiable motives in generally found in more voluminouswhich it originated.
of
’
211
the extravasated blood will absorbed in the course of or twenty days. It’at the end of Gentlemen, or twelve days the tumour should The following little work, on Inju- ten continue undiminished, especially if ries of the Head, has been compiled the integuments should begin to inwith the view of facilitating the study and point, you may then make flame once at difficult and ofa subject an incision sufficicnt to give exit to complicated. I request you will ac- the blood ; after which keep the parts cept of it as a mark of my sincere in apposition by compression and banesteem and a return for your kind dage, and they will quickly unite. attention. "
To the Pupils of the Royal Collegee
of Surgeons in Ireland.
and
quiet,
generally be
ten
Believe, gentlemen, Yonr sincere friend,
incised wounds be treated as simiA. COLLES. lar wounds in other soft parts ; they INTRODUCTION.-The plan of this will unite by the first intention. If little work has been borrowed from a the bone be so cut that a scale of it similar publication, by the late Mr. be raised along with the flap of the Dease, the first Professor of the Prac- scalp, replace the parts, and treat the tice of Surgery in our College. I have wound as an incised flap wound of the ventured to make considerable alte- scalp only; such a wound frequently rations in the arrangement, and such heals as if it were a wound of the additions to the matter as have been soft parts. In lacerated flap wounds supplied by the present improved of the scalp, replace the flap and restate of surgery. I have made Mr. tain the parts in apposition by gentle Dease my guide, because every man compression, with bandage, &c. &c. who has read his larger work, " Ob- The contused wounds, if small, apservations on Wounds of the Head," proximate the parts, but do not bring must see that the principles which he them into very close apposition, bethere inculcates are now received as cause a greater or a less degree of established truths, and are acted upon suppuration and sloughing must folas rules of practice. low. Contused flap wounds are to be treated by laying down the flap after INJURIES OF THE SCALP.-Contusion. you have endeavoured to wash clean —A blow of a blunt weapon, in gene- the surfaces. As soon as the process ral, detaches the scalp from the peri- of sloughing is finished, bring the cranium. The separation takes place parts into the closest apposition, and to a greater or less extent around the retain them in that state by adhesive seat of the injury. Into the receptacle plaster and bandages. Should you thus formed, and also into the broken dress the surface of the wound and cellular substance which surrounds the flap separately, the flap would, the cavity, blood is poured from the from day to day, become more thick, ruptured vessels. There is danger of more unyielding, and more narrow; mistaking such an ecchymosis for a so that when you wish (after the prodepressed fracture, because the bor- cess of sloughing) to draw the flap der of it, raised and hardened by the over the surface from which it had blood which is impacted amongst the been raised, it will leave more than cellular substance, resembles the ele- one third of that surface uncovered. vated circumference of a depressed Punctured wounds of the scalp are fracture ; while the central part, soft to be treated as similar wounds in and yielding; allows the finger to sink other sott parts. This class of wounds below the level of the is sometimes followed with a circumscalp. If you open such tumours in scribed painful swelling, accompanied an early stage, you will induce a with inflammatory fever ; these conhigh degree ofinflammation and fever, sequences arise from the inflammatory which will be followed by stipptira- tension of the aponeurosis, and are tion of a very bad character. Hy most speedily removed by dilating the means of cold lotions applied to the wound of this membrane. Erysipelatumour, by the antiphlogistic regimen tous inflammation, with fever, is not
WOUNDS.-Simple
of the scalp are
,
apparently
to
212 an
unfrequent consequence of wounds month, and occasional hlisters, should arising, however, rather constitute the plan of treatment.-
of the scalp,
When covery ;
from constitutional than local causes. the symptoms begin to yield, The treatment should be the same as we may entertain good hopes of re. for erysipelas attendant on wounds we must not then repeat the of other parts. The event sometimes ! evacuations in too quick succession. proves fatal. On examination, after Should this plan of treatment prove death, no traces of inflammation of nnenccessfnl, and should the condition the brain, or any other disease of that of the patient become more and more organ, can be discovered. ’In wounds alarming, we may then think of apply. of the scalp, generally speaking, the ing the trephine ; for in some few
should he en- cases it has happened, that by the moderate the I blow the dura mater had been detach. for a wide space from the cra. local inflammation of the integuments, but also to guard against the more while at the same time a frac. serious danger of the inflammation of ture of the internal table had torn the middle artery of the dura mater, or the internal parts. some one of its sinuses, and thusa CONCUSSION AND EXTRAVASATION.- large quantity of blood had been col. The primary, or immediate coiistitti- lected between the membr ane the tional symptoms of injuries of the head, skull. With the faint and uncertain are loss of sense and volnntary motions, hope of finding such an extensivese. stertorous breathing, slow labouring paration, and such a large collection the surface of the dura mater, we pulse, iaavoluntary discharge of urine and fæces, &c. Every possible variety should apply the trephine. In nene. occurs ill the violence and duration ral, however, this operation affords of these symptoms, from a slight but little chance of relief, because the stunning toabsolatte and almost in- effused blood lies not on the surface stant death. The intensity or durathe dura mater, but is widely tion of the symptoms is by no means over the pia mater, and tenaproportioned to the force of the blow, ciously adheres to that membrane,or severity of the injury. Dissection the usual symptoms of eon. discovers two different states of the cussion and extravasation are com. contents of the cranium in those who bined with epileptic fits, spasms, or conhave exhibited the above symptoms. of any of the muscles of the In some, blood has been widely found carefully examine whether there spread on the pia mater, over one or be not a fracture, and whether !a both hemispheres, or extravasated into splinter of bone has not wounded the the ventricles, or about the base of dura mater. In a few instances of the brain; while in others, we dis- injuries of the head, the patient is afcover no effusion, no rupture, no disin a manner very different that described in the heginninn organization of the brain : the only remarkable appearance which pre- of this section. He has a wild look, sents itself is, that this organ seems much, frequently gets out of not to fill the cranium completely. bed, has a tendency to vomit, his This latter class of patients are said pulse more than naturally quick, his to Lave died of concussion of the breathing neither slow nor stertorous. brain; the former class, of extravasation. Tbe same train of symptoms INFLAMMATION AND SUPPURATION occurs in both these forms of internal WITHIN THE CRANIUM.-Patients who znischief. The same line of treatment have suffered from extravasation or is applicable to both. In case of re- concussion of the brain, may, after covery, these symptoms in general the removal of all the symptoms at, slowly retire ; the sensibility and vo- tendant -on such mischief, be seized luntary motion gradually return. In with symptoms of suppuration within The probability of such a few instances the patient suddenly the cranium. recovers possession of his faculties. a consequence is not to be estimated Venesection, repeated if necessary, according to the severity of the oripurging injections, purgatives by the ginal injury, for suppuration has fol-
antiphlogistic regimen joined, not merety to
ed
nium,
on
of spread
Whenever
vnlsions face,
fected from
talks
i
213
injuries of the head in whichantiphlogistic regimen, constitute the wound of the soft parts, no frac. means most likely to succeed with ture of the skull, had taken place, the generality of’ patients. The tre2iid where the symptoms of roncns- phine should never be employed as a sion had been very trifling and very means of preventing inflammation of iransitorv. On examination after the brain and its membranes. Rigors, death, we generally find a small quan. fever, and the other symptoms said tity of purnlent matter lying (at the to denote internal suppuration, may site of the blow) ou the surface of the arise from a wound in some other dura mater. When we raise this mem- part of the body, from inflammation brane, we find nearly the entire stir- and tendency of the bone to exfoliate, face of the hemisphere covered over or from the ordinary causes of fever; by a yellow purulent fiuid, which ad- therefore be not too hasty, on the first heres so tenaciously to the pia mater appearance of such symptoms, in apthat very little of it will flow off; plying the trephine. Search well for
lowed no
.indeed the colour and consistence of every other cause which may have this fluid would lead m to suppose excited the present disturbance in the that it was formed of a commixture ofsystem ; use the means ordinarily repnsand coagulated lymph. Nausea, sorted to for the relief of febrile thirst, head-ache; quick, full and hard symptoms ; and if, notwithstanding pulse; restlessness, pain, and coi-d- these attentions, you perceive an aged feel of the head, are the constitu- gravation of symptoms, then have retional symptoms said to be indicative course to the operation. This opeof this mischief. The local symptoms ration must necessarily prove unsucin cases Without a wound are, a tu- I cessful in the majority of cases, bemour of the scalp, puffy and tender, cause the inflammation is diffused, but not paini’nl to the tonch. In -cases and the fluid is spread on the pia accompanied with a wound on the mater, not on the surface of the dura. surface, which had been healthy and mater, as had been formerly imagined. In a few instances, however, the matgranulating, will become pale, andflabby; instead of good matter, it ter is formed in a circumscribed spot will only discharge a thin discoloured on the surface of the brain, with adsaiiies, the dressings will stick closely, hesion between the dnra and pia and the pericranium, instead of ad- mater, and occasionally with a splinter hering firmly to the bone, will sepa- of bone forced through these two rate from it, and that even to some membranes into the substance of the distance, around the edges of the brain. The early application of the wound. The symptoms indicating trephine will save such patients; but suppuration within the cranium never if it be too long delayed, this opeappear at an earlier period than the ration will, even in such cases, prove sixth day; generally between the ineffectual, because the matter of the eightlaand twentieth days. We are abscess, being pent up, will irritate not, on this account, to conclude that the adjoining portions of the brain, the inflammation has only begun at and will give rise to the diffused inthis period. Dissection has proved flammation along its surface. Should that matter has been formed within the operation fail of bringing the the cranium, so early as the third and wished-for relief, and only a small fourth days; so that the above symp.. quantity of matter be found on the toms mark not so much the cotnmence.. exposed dura mater, we sliall have ment of the inflammation as the dis- neither any certain guide to indicate turbance which the system suffers the presence of fluid lodged beneath from the matter formed within the this membrane, nor any strong enskull. To avert thi, inflammation and couragement to divide it. Should the suppuration, we must take our mea- desperate condition of the patient urge sure. from the very first day of the you to this measure, you will only injury. Bloodletting largely and re- perceive a very small quantity of seto the rous fluid to flow through the openpeatediy employed, condition of the patient, with a strict ing. After the operation of the treattention to the other parts of the the integuments should be laid
glassy,
’
according
pan,
214 down again, but not brought into such close apposition as to prevent the escape of pus. The constitutional treatment must be regulated by the particular circumstances of each case. When fungus of the brain shoots up, pressure will not restrain it. Remov ing it by ligature is ineffectual-by incision, mortal.
ON FRACTURES
OF THE
SKULL -
Simple (nndepressed) fracture of the skull is not productive of any symptom or condition, by which, when the integuments remain entire, we could
be certain of its existence. Blood issuing from the nose, eyes, and ears, affords a strong presumption offtacture passing across the bones which encompass these organs. In simple fracture, accompanying an incised or lacerated wound of the scalp, we are
particularly required
to
bting
the
toms of compression, we must quickly raise the depressed piece to its proper level. This, in very open fractures, can be sometimes accomplished by the elevator alone. Where there is not room for this instrument, or where the form and circumstances of the fracture require the removal of some part of the skull, we should apply the trephine to such parts, and in such manner as will facilitate the elevation of the bone. In general we shall find it of advantage to make the trephine comprehend the border of the frac. ture. Mr. HEY’S saws will be found of great advantage in removing the edge of these fractures, when of any considerable length. If any depressed piece cannot be prevented from wounding and irritating the dura mater, or if it be perfectly loose and have lost all connexion with the snr.
lips lOundiug parts,
so as
to
be incapable
of the wound into close apposition, ’of re-union, such piece should be en. and procutee their speedy union. To tirely removed. In very small de.
trace the extent of a simple fracture pressed fractures, (such as may deisequally unavailing and unnecessary, serve the name of punctures of the for such fractures too often pass from bone,) where a depressed bit of bone the top, or sides, to the base of the is sunk into the brain, it will perhaps skull, until stopped by the foramen be prudent to postpone ttie operation magnum ; and surely the fracture, if for a few days ; for, if the operation left covered, is more likely to unite be performed immediately after the without much inflammation than if it receipt of the injury, and if we at. be exposed to satisfy an idle curiosity. tempt to seize the depressed fragThe early application of the trepan ment, the first touch of the forceps to a simple fracture must tend to ex- sinks it still deeper into the brain; cite, rather than to avert, inflamma- portions of the brain, from its soft-
tion of the contents of the cranium. The constitutional treatment of such injuries should consist in the most sedulous employment of the means calculated to prevent inflammation of the brain and its membranes.
DEPRESSED FRACTURES.-The symp-
compressed brain do not corin severity with the size of the depressed portion of bone, or the depth to which it is sunk. In severe injuries of this kind, the symptoms are comparatively slight and of short dutoms of
respond
ration. If the case be not urgent, we may postpone the attempt to elevate the depressed piece, until symptoms of inflammation begin to show themselves. Many such cases have had a complete recovery, although the bone remained depressed. In depressed fractures attended with severe
symp-
ness, rise np, and conceal the bone from our sight and touch, whereas if we defer the operation for a few days, we give time for the adhesive inflammation to take place ; this cir. cumscribes the depressed piece, hardens the spot of the brain, and thus enables us to lay hold of the bone more easily and certainly. The older surgeons prohibited the application of the trephine to certain parts of the skull ; but when the circumstances of the case require it, we should not hesitate to apply it even to those pro. hibited parts. Wounds of the brain must be treated on the same principles that regulate our practice in the treatment of the other injuries of the head."
‘
215 FOREIGN DEPARTMENT.
During the
year 1824 admitted.
were
Intermittent fevers Diseases of the brain and its
............
ANALYSIS OF FOREIGN MEDICAL JOURNALS. REVUE MEDICALE-MARS.
ninges.................... Ophthalmia .............. Diseases of the organs of respiration
14
me-
......................
Report of Diseases observed Diseases of the heart and its conat Me Hotel Dieu, in the Clinical necting membranes and vessels Wards of Professor RECAMIER clurDiseases of the alimentary canal ing the last year. Diseases of the liver............ The number of patients admitted Diseases of the urinary passages .
37 1 118
General
......................
10 176 13 5
into the clinical wards of the Farulte Diseases of the organs of generaduring the year 1824, amounted to tion in the female.......... 16 about five hundred and thirty-six, of Diseases of the organs of generawhich number three hundred and tion in the mate.......... 8 thirty-four were males, and two hun- Cases of peritoneal inflammation 6 dred and two females. Of these sixDiseases of the skin ............ 26 ty-six have died, fifty-seven of the Phlegmonous inflammations of the former, or near one-sixth of the numcellular membtane 3 ber, and nineteen females, that is ra- Diseases of the fibrous tissues, ther less than a tenth of their number. muscular and synovial...... 51 Of the five hundred and thirty-six pa5 Diseases of the nervous tissue.. tients admitted, four hundred and Diseases of the lymphatic strue-, tight laboured under acute affpctions, tures (stt’uma)............. 2 of whom forty-two died, that is in the Diseases of the bones (gibbosity) 1 proportion of one-ninth, whilst of the Sinile debility 4 hundred and twenty-eight others who Contusions of a nature .... 11 laboured under chronic diseases, thir- Diseases of a slight not well kind, slight ty-fonr were lost, or a little less than defined ................... 29 a third. From these general results we obTotal 536 serve,-1st, That the mortality has been much more considerable among We shall not follow the subdivision the men than among the women. This which M. MARTINET has made in spemay be attributed to the greater se- cifying the varieties of each of the verity of the diseases among the diseases which he has thus classed toformer. 2dly,The mortality has been gether, but shall proceed to examine much more severe in the chronic than the therapeutique which was adopted, in the acute cases, almost double, and and the alterations which have been was generally owing to the very ad- made in this respect from the estavanced stage of the affection when blished practices. medical aid was first solicited. On The employment of graduated comthe other hand, if we take a survey of pression in the treatment of ascites by the nature of the diseases which have a laced bandage ; the cauterization of reigned during the greater part of the a cancerous nlcer of the lip by the last year, we shall see that affections solution of the nitrate of mercury and of the alimentary canal have been the rapid cicatrization which followmost common, and more so than those ed ; the complete cure of a permanent of inflammation of the respiratory or- contraction of the hands and feet of a gans. Rheumatic compLiints have been girl, principally affected by the use of most in frequency, and after these dis- shower baths, which were employed eases of the encephalon, of the skin at first at 16 degrees R., and afterand of the organs of generation; then wards at 14 degrees ; the fortunate come intermittent fevers, affections ofterminations of several cases of pleu. the bladder, of the heart, and of the ro-pnpumonies, by the internal admi urinary passages, as will be indicated nistration of tartar emetic, of from six to eight grains duringthe twentyby the followingtable. .........
.................