No. 197.] LONDON, SATURDAY, JUNE 9.

LECTURES

BY

MR. ABERNETHY

ON

Operative Surgery ;

Delivered at St. Bartholomew’s Hospital.

On Opemtive Surgery.IN the time of Le Dran, surgery was di-

vided into four parts;1. Synthesis, or the union of parts;2. Diceresis, or the division of parts;3. Eittresis, or the removal of parts ; and1.. Prosthesis, or the sobstitution of parts ;

and a most villanous division it was, for it ledto the notion of surgery being merely anoperative science. The necessary perform-ance of an operation is, or ought to be, anhumiliating reflection, since it contains aconfession that our art is inadequate to thecure of disease. Well, a great deal moremight be said upon this point, if you chooseto go to what John Hunter has said to thesame purpose; but it’s a good division tome nevertheless, for I am going to speak ofthe operative part of surgery, and first Jshall speak of the

Divisioa of parts—which is effected bya knife. And I am sure people will use aknife better, if they reflect upon the na-

ture of the instrument before they begin touse it. It is a compound instrument, inas-much as it is both a wedge and a saw; it is awedge, because it is broader at the backthan at the part you use, and you may cutwith it, but for every fibre you cut you willbruise almost a thousand. Now it’s usedas a saw ; and what is a finely cutting knife?A knife with such an edge as to interceptthe least possible fibre in the interstices, sothat it cuts cleanly; and if you draw such aknife over the surface, using no furtherforce than is necessary, you will make afine clean cut. People often complain of

their knife, when the fault is not so muchof the instrument as of the hand that usesit. The fact is, that with a dnll knife peopleoften cut themselves unawares, when if theyhad tried, they could not have done it, andthen they say, la, who would have thought it!(laughter.)

Well, the use of the instrument; it is tobe used like a pen or a pencil. There arecertain muscles over which we have ac-quired a perfect command, such as the mus-cles of the fingers; and the instrument isused with those muscles as a pen or a pencil,thrown from you by the extenso1’, and drawnto you by the flexor muscles of the fingers.There is a phrase, manu suspensa; it meanswith a light hand, but not an unsupportedhand, as in drawing or writing you make a sortof support for your fingers to rest upon. Mr.Pott used to say, that dissection taughta man the free use of the knife; meaning toconvey that anatomists did not hesitate tomake a free use of the instrument. It ishowever literally true, that by dissectionyou acquire a free use of it; and as a personwho teaches a pupil to write would firstmake him take long strokes, going on gra-dually, till he wrote small hand, so the wayof acquiring a knowledge of dissection is todissect cleanly as you go along, and to dis-sect in the line of the fibres; never mind

cutting away a bundle of the fibres if youare in the line of the fibres, for cuttingaway the fibres in the line of the fibres,makes no disfigurement in the muscle, andthat used to be a cant phrase in the earlypart of my life. Well, you use the knife inthat way, and you ought as much to ex-

pect a draftsman to draw a line in a direc-tion he did not intend, or a penman tomisform a letter, as to expect that a surgeonwould cut a fibre if he did not intend it.

There are two modes of using a knife;one is, by drawing it towards you, and theother is, cutting with the edge turned fromyou ; and this is a very good way of dividingparts in many cases ; as, for instance, whereyou have a breast to wound, you hold thebreast up, and make your incision at theunder part of it, in the first Instance. Well,so much for the instrument. And a saw isa knife : a carpenter in using his saw, will

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not bear upon it; he draws it lightly overthe surface he means to divide, and so oughtyou. Well, these are things for your ownconsideration ; and I say it is a grievousthing to see an operator operating upon afellow being, and not using his instrumentas he should do,-that’s all I shall say onthat point.Now as to this synthesis, or the union

of parts; would any body, any reflect-

ing person of the modern day, believe it v

possible that the old surgeons used to sewup wounds as they would stitch up a rentin an inanimate part And you see even inmodern books of surgery, that sutures shouldbe madefirmly, and so on. Now the wholeof this absurdity has been exposed by M.Louis ; and notwithstanding that MM.Louis and Petit both published on the sub-ject, I see books in which the use of suturesis inculcated. But what are you to do ?Are you to cut a wound, to make a furtherdivision for the purpose of getting a unionof the parts ! Would you aggravate thewound by putting in needles, and leavingforeign bodies in the parts, which would besure to produce an inflammation extendingbeyond the first stage, and which would becertain to produce suppuration ? 0, thisnever should be done. Is there any neces-

sity for dragging parts together? No, notif you attend to position ; it is by positionthat you close wounds. If there was a cutthrough the skin across my arm, when Ibent mv arm, the sides of the wound wouldcome in contact, but if I stretched out thearm, then there would be a gap. In mus-cular wounds it is particularly necessarythat you should attend to position ; you maybring the skin together by drawing it withsutures, but you never can bring the sepa-rated parts of the muscles together ; or

where by force you drag them together,there is always a bag left at the bottom bythe receding muscles. Now where woundscan be closed by adhesion, and sticking plas- Iter only, none but fools would use sutures.They seem to have made strong suturesformerly, by which they dragged parts to-gether, while they stood with a pair of scis-sors in their hands ready to snip them iflock jaw came on. You must not draw partstogether with sutures ; they are useless ifthey are not required, and you cannot havethe use of them without their being perni-cious. Still I don’t carry my antipathy tosutures to the extent to which M. Louisdid, for I know there is a good in them;in the cut scrotum, for instance, a thread ortwo may keep the parts together ; and thereis another good in sutures, which is, thatthey keep the patient quiet ; pin a child’share-lip together ; 0, eaad, the child willnever cry nor laugh, nor do any thing toseparate the parts. M. Louis carried his

abhorrence of sutures to the extent thathe would not use them in the hare-lip ; butI say 1 would not carry my abhorrence ofthem to the extent that ill. Louis did. Nowthe operations of surgery by sutures will beshown to you, and therefore I only tell youwhat relates to the subject as far as princi-ple is concerned.

Well, I believe I had better not say anvthing about instruments, and so on. Aneedle is employed to pass the sutures, andI would have you take care that the edge ofyour needle should be lancet-shaped, that itmay cut easily, and that the thread may bein the wound without distention of the parts.If you don’t give directions as to this point,you may depend upon it the instrument-makers will force upon you a wedge-shapedneedle ; there is a little more consumptionof the metal in making a lancet-shaped one,and therefore if you let the instrument-makers alone, they will always give youwedge-shaped needles, which I would nothave.Now in speaking of the operations of sur.gery, there is no better mode of proceeding,that I know of, than that which was firstadopted by Paulus of .7Eoina, beginning withthose of the head, and regularly descending.

Trephining.—Then about the upper part,the first operation I shall speak of is that oftrephining ; that is, boring a hole in a man’sskull, that’s what’s meant by it. The firstinstrument was called a trepan, then it wascalled a trephine ; there are advocates for theone, and advocates for the other, now-a-days;but I have always been impudent enough tosay, that on many occasions I would puzzlethe very best surgeon in London, by askinga single question ; even Mr. Pott himself,whom I considered one of that character;and the question would be-Why, Sir, doyou ever trephine a man ? Egad, I don’tknow ; because-because, perhaps, he wouldsay-because his skull was broken. Well,but, Sir, I would say, I don’t see you tre-phine a man who has broke his leg; tre-

phining the leg would break it worse. No;0, no, but because there are symptoms.Symptoms ! What symptoms ? Now theanswer to the question is as simple as the

question itself : you never trephine, but totake pressure from off the brain in cases ofinjury. I have, in the course of the lectures,told you, there were cases requiring you totrephine from disease. You may take awaythe external plate of the skull, to let outmatter between it and the diploe. You

may uncover the whole of a part of theskull, to let out matter between it andthe dura mater. But, in cases of acci-dents, you trephine to take away pres.

sure ; and what are the cases of pressure?Why, the bone may be beaten in upon the. brain; blood may be shed beneath the bone,

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or matter may be collected under it ; butdoes every depression of the skull warrant

you in trephining 1 No, it does not appearthat it does. And what are the symptomsof pressure from the direct injury, which arepotent enough to warrant the operation ?Why, the symptoms of pressure are, torporof the brain, more or less, according to the

degree of injury. Now, in the course of thelectures, I have quoted cases in proof of thedifferent propositions I maintain. I havetold you of the bleeding from the meningealartery ; and I related the case of a man whowas knocked down by a crane. He got up,shook his ears, and was not further stunned,but that artery was bleeding ; he thoughthe would go home; but, before he got to hislodgings, he felt very heavy and sleepy ;he went and lay down on the bed, andgradually became perfectly apoplectic; respi-ration went on, as it were, automatically,but he was as insensible as if he had neverbeen sensible. You might have cut him,or struck him, and he knew nothing aboutit. 1 say, therefore, there are symptoms oftorpor; and, in some people, the brain ismore readily affected, and made torpid by aslighter degree of pressure, than in other per-sons ; but I never heard of a case wherethe brain was pressed upon, in which thesymptoms were otherwise than those of

torpor-torpor of the functions of the brain.There was a very curious case, where asailor got a piece of his skull beaten in, inthe Mediterranean ; he was brought to thiscountry before the pressure was removed ;he was in a perfectly torpid state; but whenhe was trephined he got his senses at once.

Well, I believe it is torpor that is thecharacteristic of pressure. Now I particu-larly wish you to distinguish between tor-por which is occasioned by a diminution ofexcitability of the brain, and that statewhich is called concussion. Certain it is,if we had never seen a man asleep, weshould have said, this man is insensible.He don’t see me, nor does he hear me ;that is, lie is insensible ; his mind is eitheridle, or engaged about his own fancy ; he isdreaming, or he is in a state that you wouldcall abstraction-thinking of nothing at all,as the saying is. But he is not insensible ;if you awake him, he will jump up, and thisis the state of people who have mere con-cussion of the brain. The assemblage ofsymptoms, which denote pressure, are these :a greater or less degree of insensibility,manifested by a dilated pupil. When theyare deeply apoplectic, you may put a candleto the pupil, and it will not stir or be

affected ; you may sound a trumpet in theirears, and they will never hear it ; cut them,and they won’t stir. They never vomit:0, that would show a sensibility of stomacli.Circulation and respiration go on, as I have

expressed it, automatically ; the pulse goeson but feebly, and the respiration is pro-portionably slow and stertorous. But, inthe case of concussion, what have you *!Have you any of those symptoms *! 0, notat all ; and yet I grant you, in the firststate, that the jarring of the brain dis-

qualifies it from its functions : a man is

knocked down, he is perfectly pale, and, fora time, you may bleed him, but you cannotrouse him ; still this lasts but for a short

time just while the stunning lasts. Youtake him up, put him to bed, and as soon asthe circulation is diffused, as soon as warmthis extended over the body, he is no moreinsensible than a man in a deep sleep ; youmay rouse him if you call loud enough, butit requires some strength of voice to do

that; and not only is loudness of voice ne-cessary, but you must call out somethingthat really will excite him, something thatinterests him, and then you may raise him.Now look to the other symptoms : Is thereanything in the other symptoms that indi.cate insensibility ? No; and I am per-suaded quite the contrary. The pupil ofthe eve is by no means dilated ; nay, some-times it’s more contracted than usual; thebrow has frowns upon it; there is an ex-pression of uneasiness in the patient; thepulse is frequent-it may be intermitting.As to the intermission of the pulse, I havetold you I don’t put any great faith in that,for it seems to be occasioned by a capricious-ness in the action of the heart ; but, as far asI know, the intermission is much more com-mon in the case of concussion than that ofcompression. Raise the man, and he vomits,which shows a sensibility of stomach.

Well, now, what succeeds to this stun-ning ? 0, it is inflammation. I say, to allmechanical injuries, inflammation succeeds.You may have a bone driven in ; you mayhave matter formed between the bone andthe brain, and you may have inflammationproduced in proportion to the violence of theconcussion ; then when the inflammationcomes on, 0, then indeed, the patient doesnot sleep : sleep he may, occasionally, butwhen he is awake, he will be trying his ut-most to get out of bed, or something of thatsort. He will have symptoms, common

symptoms, of phrenitis come on. Now howcan I prove this to you? Prove it? Prove

it by the recital of cases. I was educatedunder Mr. Pott ; he used to give lectures ;they were lectures corresponding with hisbook ; and I will venture to say, that for

twenty years of my life, there never was aman admitted into this hospital with an in-

j ured head, that I did not attend ; and therenever was one who died afterwards, that Idid not examine ; and therefore as I picked1 up a quantity of cases, and got informationj from them in addition to what I was taught,

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I afterwards put together and published Ithose cases, with what I had to say uponthem. Well, how am I to prove it ? Bythe recital of cases ; and I will tell you oneof the worst, and one of the slightest ofthose cases. There was a man who fell fromthe top of Meux’s Brewhouse, 80 feet inheight, nay, 90 feet, I believe ; he fell uponhis hand, and broke his carpus all to pieces ;knocked off the ends of the radius and ulna ;

injured the cheek, for that also came againstsomething, and the head was jarred: he wasbrought to this hospital like a corpse. Theyput him into a warm bed, passed the warm-ing pan over his body, tried to give him alittle brandy, which, of course, he did notswallow ; it, however, washed his mouth:they put hartshorn to his nose, and by de-grees he came round; warmth returned allover the surface of the body, his pulse be-came exceedingly rapid, and this was thestate in which I found him next morning.He was sweating, secretion was going on,and, as I say, the pulse was exceedinglyrapid; the pulse was what one of the pupilscalled a flutteriug pulse, so frequent that itcould not be counted. He had taken nomedicine, but having got some, and callingout the man’s name, I said to him with aloud voice, " You must drink this stuff; if

you drink it, you may live, and do well; if

you don’t, you must die: drink it, I say."Well,.he drank it. Now I know the waysof those people pretty well, for I have hada good deal to do with them ; however hedied, and his head was examined. The piamater every where was excessively inflamed; I,absolute effusion of blood had taken place, !,and every manifestation of the most violentarterious action of short duration was appa-rent. He could not have lived long fromsuch effects. Well, I say that shows you theworst case that I can remember. A s to con-cussion, I have heard it was a term purelymeant to conceal ignorance ; and so it wasformerly, but as we use it, it is a very de-finable term ; it is, that the brain havingreceived a jar, it is incompetent to performits functions in the ordinary manner. Allthis may happen without any lesion of thebrain. In this case of the man which I have

just stated, there was not a part of the brainwhich appeared to be torn ; but I know youhave cases in which some parts of it aretorn. Mr. Pott says he never knew a manrecover without the abrogation of some partof the organ. Well, I grant there may besome injury done to the brain, but that has no-thing to do with the treatment. They may re-cover. I can only tell you that I have hadvery, very bad cases indeed, and that theyhave all got well, and with the perfect performance of the functions. I have not metwith any of those cases lTr. Pott speaks of.I remember of late years there was a man

who had a very horrible degree of concna-sion, and he squinted afterwards; but I’ll behanged if the squinting did not come onsubsequently to the concussion, and I be-lieve it was from an effect produced uponthe brain, from the reaction of a disorderedstate of the bowels. He went out of the

hospital quite well; but I asked the pu-pils to watch him, and the complaint tookplace as a secondary occurrence ; that is,the squinting took place as a secondary oc.currence. However, whether there be a

rupture of any of the fibres of the brain,tending to produce some local injury or not,it makes no difference to the surgical treat-ment. Inflammation you are to expect, andif you permit that inflammation to go on,

your patient will be destroyed, therefore youmust bleed. To bleed a man who has had aconcussion, in the first instance, when he isfrom appearance killed, would be an ab.surdity; but as soon as warmth has goneover him, you may take away a little blood.I call it a preparatory bleeding. You mustdo that which would lesson the force andaction of the heart and arteries. I don’t callthis a curative measure, it is preventive; itis done with a consciousness that inflamma-tion must succeed, but with a view to mode-rate that inflammation. Of course you wouldclear the patient’s bowels ; you would keephis bowels kindly relaxed. You would lethim lie with his head raised, and supportedup with pillows. You would bathe his headif it were heated ; but when you found a sortof muttering by the patient, and inflamma-tion come on, 0, you would bleed again,apply blisters, and do all those things whichthe principles of the profession enjoin, andwhich I need not further impress on yourminds.

Will this treatment he successful? Yea,verily ; I tell you a case illustrative of it.There was a stout man, a Welshman, of thename of Davis, who was brought to this

hospital with a violent concussion of hisbrain. He was attended by a pupil whowas here at that time, of the name of Shep’herd, and as clear a headed tuan he was as Iever saw. Davis was treated as I tell you,but violent inflammation came on; and a

very violent strong Welshman he was.

Shepherd took 124 ounces of blood from himin twenty-four hours, and he could scarcelycontrol the Welshman even then, but hedared not to bleed any more. Blisters were

put upon his neck, and different parts of hisbodv; his bowels were attended to, but allthis did not seem to subdue inflammatoryaction; perhaps we might say, it had op-posed it. However, about the 5th day hebecame hemiplegic, and Mr. Shepherd camerunning to me, and says, it’s all over withpoor Davis ; lie has lost the use of the rightside of his body; there is some effusion on

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the left hemisphere of his brain : evad, tliat’sjust what I thought, I said ; but I am notsure of its being all over with him. He said,there can be nothing done further to him.1 said, no, unless it be the use of calomel.Well, he got some people to rub mercurialointment on Davis’s limbs twice a day, andin about three days it affected his bowels,and his guts at the same time, for he had aviolent fit of purging come on. Now, whe-ther the mercury did good to his head bythe disturbance it occasioned in the bowels,I have some doubt myself at present, butthe hemiplegia was removed. I remember

going to him and asking him to let me see

his hand, the hand that had been paralyzed,and he put it out as firmly as ever he had donein his life. Well, I can tell you that no-thing but the most delicate nursing broughtthis man round. Then, I say, you are obligedto subdue inflammation, but a great deal isto be done after that; however, Davis didcome round, his senses were perfectly re-stored, and he was discharged in as goodhealth as before he met with the accident,but it was by a great deal of attention havingbeen paid to him.

Then, I say, this is what we are to do;but, would you believe it, there are diversbooks on surgery that seem to recommend a

contrary plan of treatment; they seem todraw a parallel between the state of thebrain, which renders it incapable of itsfunctions, and a palsy from want of energy,and they recommend stimulants. For a longtime I did puzzle myself to know what theplague could be meant by those cases ; andat lost, I found out that they were caseswhere people give themselves a bump onthe head, and that, being nervous subjects,a train of nervous affections come on, and

they called the case a concussion! For in-stance, a young lady in her closet, was

stooping to pick up something; she raisedher head, and struck it against a shelf; shedid not stun herself, but she felt a littlehurt, and a nervous attack seized her. 0,they wilt tell you such strange things, tell

yeu that their brains are turning round, tellyou that their skull is being turned insideout, (laughter,) and all these sort of things,but they are nothing more than nervous

symptoms. 11 ’’ell, all this will be managedby a little stomachic, and taking care of thebov. els. I say, I puzzled myself a long time,to know in what sort of cases a contrarytreatment could possibly be beneficial. Andfurther, I acknowledge that I have alwaystaught what has lately been asserted by aMr. F:eltl, of Newcastle, I believe; he seemsto me to he a very sensible intelligent sur-geon, and he has published a book, discom-mending the free abstraction of blood inthose cases of concussion.Bow there are people who have concus-

sion, who are nervous, and if you bleedthem much you may do them injury. I re-member being called to two females at one

time, who were thrown out of a gig. I re-member I was sent for down to Gravesendto see one, and as far in another directionto see the other. I told the surgeon at

Gravesend what I thought of it; I said, ifinflammatory action or pain in the headcame on, bleeding might be used; but Ireally believed he had used the lancet toofreely ; at any rate, the woman was so ner-vous and fidgetty for two or three days af-terwards, that she was almost fit for a placecalculated for the reception of insane per-sons ; all kinds of fancies, and so on, floatedin her mind. With regard to the othercase, I had myself been attending the wo-man formerly for some disease about theancle ; she went into the country, and rid-ing out in a gig (for she could not walk

well) she was canted out of it and stunned.There there was some degree of delirium,and pain in the head ; she was bled, and gotbetter. Still, however, she complained ofpain in the head, which I believe was anervous attack altogether, and she alwaysexpressed herself greatly relieved by the

application of leeches. She was naturally. weak, and of course rendered more so bythis treatment, when all of a sudden shedeclared she could see nothing, but was to-tally blind. This was what created anx-

, iety, and I was sent for. The gentlemanwhom I met was an intelligent man, and Ialways think those who have seen the wholeI of a case know more of it than any person; can know upon just coming in on a sudden.L I dared not tell him that he ought not totake blood, but I said this blindness is notthe immediate effect of the effusion, other-wise it would have been contemporaneous

with the injury ; and besides, your deple-

tion must have done away with the effectof it. "Then what is it?" he said. To, which I answered, " It seemed to me to bea state of nervous blindness, and that I couldtreat it as such by great attention to her

system, keeping the bowels open, but notin such a degree as to irritate them, givingher alterative doses of quicksilver, giving

her ginger to drink, and so on ; he did this,and she got well. Thus I caution you, that

you are not to treat all people as Shepherdtreated Davis ; such treatment was appro-priate to him, but it would not do for adelicate female.Now I go on last of all to say, that the

ultimate well doing of a person who hasconcussion of the brain, depends uponyour attention to their digestive organs(laughter); and, egad, I have seen hunclredsand thousands of people who, having had ablow on the head and stunned, were per-haps bled, and after getting a dose of phy-

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sic were very well, and no more attentionwas paid to them till they have becomecomplete hypochondriacs, from the state ofthe alimentary organs. There is no hurt ofthe head that does not affect the bowels;but I say the great thing we have to do is,to prevent that action and reaction whichdisturbed nerves have upon the abdominalviscera, and again from the abdominal vis-cera upon the nerves of the cerebrum. Well,now, if the bowels be not attended to, thepeople will go into a complete state of hypo-chondriasis, and therefore I am sure the re-covery of the functions of the brain mainlydepend upon the digestive organs. It isnonsense to suppose that a man who hashad any violent concussion of the brain willhave all the functions of that organ get rightof a sudden. I remember attending a gen-tleman who was a great calculator, and afterhe recovered he said to me, if I read a

paragraph in the newspapers, I understandthe first sentence, but beyond that I haveno comprehension of it ; and he said it wasone twelvemonth before I could do thosesums with the utmost difficulty, that I coulddo with the utmost facility before the acci-dent happened. Therefore there is a greatdeal to be done if you wish to establish

your patient in perfect health, for wherethere is that disturbance in the brain therewill be a disposition to disorder in the di-gestive organs, and that disorder will reacton the brain.

Trephining.—Well, now I have said whatI have to say on the distinction betweencases of compression and concussion, andwhat may be done in either case, so that I

may now proceed to state the kinds of con-cussion you may relieve by trephining ; andof course you may trephine in cases of com-pression of the brain, but not in every oneof these. Surgeons always do, and it is na-tural for people to go into extremes, butthe worst thing of all is party spirit. Weare all partisans, and we do side with oneparty or the other. I, however, have al-

ways said, I shall never sell my soul to anyparty as long as I live ; I shall never giveup my opinion. There is one set of sur-

geons who trephine in all cases, and thereis another set who trephine in none. De-

sault, a surgeon of the greatest experience,never would trephine whatever befel a

skull; for, said he, I have seen some with

very badly fractured skulls recover withouthaving been trephined, but I never sawone recover who had the operation per-formed upon him. Desault practised inthe Hotel Dieu, a most horribly crowdedplace ; I think there were four tiers of beds

along the wall when I was in it, which wasat the time Desault was there, and twopatients in each bed. Now it is not to bewondered at, and it deserves your atten-

tion, that a man in the country may betrephined, and trephined again, and do well;they can do things in the country that can-not be done in London hospitals. But I wantyou to think of it, and to understand it, and Iam aware you will never understand it bylectures ; practical surgery is only to beacquired by experience, but I say the ob-ject is to send students forth into the worldwith a knowledge of what they are to ob.serve, and how they are to make observa.tions, possessing a knowledge of the prin.ciples on which the profession ought to bepractised.Now then, as I saw people going into ex-

tremes, I thought it a good thing to relatehalf a dozen cases of depression, and of greatdepression, which did well without the

operation ; there they are, and you mayread them if you like; but there came in acase shortly afterwards, which I will men.tion. A young man had a fracture, ex-

tending across the squamous part of the

temporal bone, half of it seemed to be juston the organ of murder, (laughter) and itwas the upper part of his skull that was

depressed. Egad, there was no trephiningit, you could not put on the trephine; youcould not raise up the depressed bone. Wedid not know the extent of the injury; therewas an external wound, but it was mani.fest that the parietal bone was depressed onthe upper part of his head, fully the eiglithpart of an inch below the other part of thebone, and this could be felt, as far as wecould trace the inquiry. But the chap hadno bad symptoms at all, and he came to theHospital. Now, said I to the students, hereis a case where you cannot trephine, there.fore you must leave the fracture as it is, andthis will show whether the opinions I havepublished be right or wrong. Here is afracture that produces no bad effect, on theinstant of the injury, nor have any symptomsas yet occurred, now the question is whe-ther there ever will. Well, we gave himsome physic ; but, begad, it’s necessary towatch these cases very attentively. I sawhim generally three times a day; on theday after he came into the Hospital at noon,he was as well as you could have wished himto be ; however, I came down in the evening,and I found that he had got fidgetty andrestless, and was trying to get out of bed, soI took a large quantity of blood from hisarm, gave him a dose of physic, and told himto keep his head supported high with pil-lows, ordering his head to be bathed, andthe next day he was very well. Now, ifthat bleeding had not taken place, if thosemeasures had not been adopted at the timeat which they were used, so as to havesubdued the inflammation, that inflamma-tion would have gone on and killed him;then what would the world have said!

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Why, a partisan would have said, all this is t

owing to your not having elevated the de- v

pressed bone. Now, -suppose the depression thad been elevated, inflammation would still 1:

have come on, and if it had not been subdued yit would have killed the patient; and the rpartisan on the other side would have said, t

all this is the effect of your operation ! It is t

right therefore that you should have an un- I

prejudiced mind, so as to be able to judge afairly in these cases. However, I tell youthat that man was bled occasionally after- I

wards, and that he did perfectly well.Being desirous of knowing whether thepressure might have any particular effecton his brain, I did what Hippocrates wouldhave done, I inquired about his dreams, buthe did not dream at all; he slept soundly, 1but did not dream. I made him stand onhis head to see whether that would botherhim at all, but it did not. I am sure thefunctions of that man’s brain were in noway injured by the depression. John Bellhas published a book upon this, and lieheads one of the lectures in this way," Abernethy dislikes the trephine," makingapartisanofme ! (Laughter.) I am no partisanat all. Abernethy dislike the trephine, in-deed ! I never said any such thing. Now beaware of this, that all fractures of the skullare to be divided like the fractures of otherbones, into simple and compound fractures.And where there is a compound fracture,0, there may be exfoliation, and there maybe a great deal of irritation about the bone,and the action about the bony scalp will

produce irritation in the more internal parts.To show you in the briefest manner I can,what I mean, I will relate to you this case.A woman was brought into the Hospitalone night, who was struck with the leadenhead of a cane upon the parietal bone,which pressed in the scalp and depressed i

the bone. There was a circle made, a Ilittle bigger than a shilling mayhap, butit was depressed about the quarter of aninch, and starred in many pieces. I wassent for in the middle of the night to

see this accident, and I really did not knowwhat to make of the woman. I couldnot tell whether she laboured under symp-toms of compression, concussion, or intoxi-cation. I did not know which was the most

predominant. However, finding that thebone was broken in this way, 1 took it all

away; I put on a small trephine, and tookaway all the starred parts ; then cleaningthe dttra mater, I laid the trephine down,put on a dressing of a little plaster, with alittle bandage to make pressure against thepart that had been cut ; she was bled, a

little physic was given to her, and on com-ing to the Hospital the next day, I said," How is the woman, I hope she has nottaken off the dressing." "We know no-

thing about her," was the reply, for shewill let nobody near her ;" and when I en-tered the ward, then she said, "Ak, nowhe’s come into the ward, you may look ifyou please ;" showing that the woman wasmore drunk than any thing else. However,that case did well. And why is the opera-tion of the trephine so deleterious ? Why,because by performing it you are obligedadditionally to injure the parts. You cut

away the parts; you additionally injure thebone ; you cut, you do additional injury, foryou leave a gap where the dura mater is un-supported ; where the dura mater does notreceive the support from the bone it oughtto do, and the consequence of all this is,that when inflammation comes on in theI brain, as it must of necessity do after a vio-lent injury, there would be such an aug-mentation of the vessels from turgescence,that the brain will be thrust up and pro-truded through the aperture. 0, that’s avery serious thing, and certainly never,never was more judicious advice given tosurgeons, than that which was given by Mr.Minors of Birmingham. He trephined aboy, took away a piece of bone, closed thescalp, bled and puiged the boy, and thewhole united bv adhesion.Now I tell you the cases which bear out

the different lectures ; you are to put themtogether, and govern yourselves accordingly.There was a man who was taken ill in thisway from an abscess in the brain, and whohad neither concussion nor compression,but simply the removal of the integumentsfrom the os frontis. Well, now I tell youjust one other case. There was a man inthe neighbourhood where I lived, who wascleaning an old fashioned carriage belongingto an old lady, an old fashioned lady ; andthis fellow had got on a ladder to clean theglass ; the ladder slipped, and the chap’shead went bolt through the large square ofplate glass of the window. The edge of theglass cut him across the scalp, and turneddown the flap towards his ear : he bled pro-fusely ; he bound his napkin round his head,and ran into the house where I lived. Itied a branch of an artery that was puffingaway very copiously, replaced the scalp, andadvised him to come to the Hospital, for Iknew that if lie was taken to the old wo-man’s house, she wuld be in a most horri-ble state of alarm, so his going there woulddo mischief, and that probably he could notget such good advice and attention at herhouse as at the Hospital, therefore I toldhim to come here ; and here he was, I be-lieve, very kindly and judiciously treated.

Now here there was no stunning, no touch-ing of the bone, it was merely a wound ofthe scalp. He was shaved; it seemed todo well; the wound was in a great measurehealed, but that which came from it was

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fœtid. Then he got symptoms of cerebralirritation; he afterwards got better; thecerebral symptoms came on again, and itwas upon that second attack that he died.He died of inflammation of the brain ; thepia mater was inflamed and thickened to anenormous degree, and the thickening wentinto the ventricles of the brain. I say, then,that that shows the great sympathy existingbetween the containing and contained parts,and it is that which renders the operationof the trephine so far injurious, besidesleaving the gap in the bone, in the case oftrephine, when inflammation is likely to

come on, and effusion.In doubtful cases, said an Irish surgeon of

the name of O’Halloran-and doubtful casesthere must be,-it seems wisest to leave thedepression till the inflammation, which willnecessarily come on, is subdued ; and then’if depression of the bone is found to producetorpor, or, in any way to ’affect the functionsof the brain, when the inflammation, the

consequence of the injury, the consequenceof the concussion, is gone off, why then, saidhe, you may trephine the bone, and you willonly have to encounter that inflammationwhich is the lresu1t of the operation ;whereas, if you trephine immediately, youwill have to encounter the inflammationwhich is the result of the injury, in additionto that which is occasioned by the operation.Now, as to that practice of O’Halloran,he has shown the practicability of it, and Ihave seen it, in many cases, showing it tobe a good practice in doubtful cases; but,I say, there are cases in which you are

called upon to trephine instantly ; and, Isay, that in those cases, much, of course,will depend on the constitution of the pa-tient ; if he be a countryman, I should notmind trephining him-if he lived in the

country ; but, I say, that will not do in peo-ple of unhealthy constitutions, or in thecrowded hospitals of London.

Well, then, to elevate a depressed bone,you trephine, and Hey’s saw may be used.

Thirdly, and lastly, you trephine, to letout matter collected beneath the bone.Now this cannot require the sudden opera-tion after the accident, for you must waittill the matter is formed, and that may beat an uncertain time. Mr. Pott has de-scribed the cases, but, to tell you the honesttruth, I have seen but very few of them,and, therefore, you had better read Mr.Pott’s book. He says of thosp. cases, thatafter a time the person’s head aches allover, that the matter forms beneath thebone, that the bone perishes in conse-

quence, that if there is a wound you see thebone ash-coloured and like a table, that ifthere is no wound there is a puffiness, andthat then you are to trephine. You maymake out the description of the cases, all

that relates to the cause of this operationfor the removal of the pressure, (and that isthe only thing you perform the operationfor,) by reading Mr. Pott’s book, so that Ineed not detain you much longer, and yet Ishould like to finish the subject while weare about it.

Say that you do trephine a person-saythat there is no blood under the skull, areyou warranted in opening the dura mater! 1If it was thrust up into the aperture, if itwas purple, egad, you must do it-you mustgo on ; but I say, 0, that is a horrible thing,because it’s like a protruding wound intothe cavity of the abdomen ; you do a thingwhich must necessarily bring on innamma-tion in the parts which imbed the brain-you must bring on inflammation. Say youmust do it some time after the accident,well, you let out the blood; nay, it may beall over the surface, and you may let out theserum, but you cannot let out the coagulatedblood; for my own part, 1 should be veryaverse ever to divide the dura mater ; but 1will tell you a contrary case which was sentup to me here by a pupil-it was a lucky case:there was a woman knocked down, and herscalp was divided somewhere about the up.per part of the parietal bone ; this happenedin a small town ; two or three doctors weresent for, who, 1 suppose, were not at homewhen the messengers arrived, for they camein afterwards one after the other. The twothat had arrived before him had declaredthat no operation should be performed, be-cause the bone was not broken. The womanwas apoplectic, had a labouring pulse,stertorous breathing, and so on, and this

chap said, these are decided symptoms ofpressure, and I will trephine ; I will takethe responsibility upon myself, and will

trephine. Egad, lie did trephine the woman,and there was no blood under the bone;he divided the dura mater with a lancet, andlet out about six ounces of fluid blood; andas soon as that was done the woman bolted

upright in bed, and cried out—What thedevil are you all about? Why, what are

you all doing! (Laughter.) I think liesaid she raised herself up like a lion, so

suddenly does the brain resume its functions.But this was a lucky hit; it is not a war-rant for the division of the dura mater ingeneral practice.

Well, I have only one word more to say,which is, that there are some cases of injuryto the head which would puzzle the derlhimself I believe, and those are the casesof fractures of the base of the skull. If aman pitch on his head, it is true he gets ahard blow on the top of the skull, but thearch-like form saves that part of the skullin a great measure from injury, and he hasa harder blow on the base of the skull, fromthe weight of his body falling upon his head,

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and which occasions a crack at the bottomof the skull. Well, I say, those cases areattended with a train of symptoms thatwould puzzle any body. They are a mix-ture ; sometimes like compression, some-times like concussion ; in short, they are asort of mixed case, and they generally ter-minate fatally, though I am convinced thatI have seen a case of fractured base of theskull do well. I could tell you the case,but I can assure you that they are not likelyto do well in general. The general opinionof surgeons is, that they are not likely to dowell, and I am sure I am of a similar sen-timent ; but I have to tell you that I haveknown a case of fracture of the base of theskull where the person has recovered to that

degree that he has gone out of the hospital,that he has been taken ill again, that he hasreturned to the hospital and died, and thatupon an examination of his head taking place,it was found he had a fractured base of theskull. Well, I put them down as perplexingcases, but I have told you how the accidentoccurs; I have told you what enabled us todiscriminate that the case I have related wasa fracture of the base of the skull ; and ofcourse in such cases you must pursue themost cautious and judicious treatment fora considerable length of time, till you areassured that’tlie injury is repaired, and thattherefore there is no likelihood of any freshoccurrence of irritation from the accident.

FOREIGN DEPARTMENT.

PATHOLOGY.

Case of Aneurismal Tumour seated in the Arte-ries of the Tibia. By M. LALLEMAND,Professor of Medicine at the Montpel-lier.*

AI. FIRMIN Hoyos, of Bilbao, a sailor, of awarm temperament, was seized at the ageof forty-three with flying pains in the joints,which at last settled in the right knee ; in afew days the pains were completely curedby the application of leeches. After thelapse of twelve or fifteen months, the painreturned in the same knee, just below thearticulation, accompanied by strong pulsa-tions. The patient was induced to leavehis native place, and to come to -Alo--qtpellier.On the road lie consulted a very eminentmedical man at Toulouse, who was unableto decide whether the complaint was aneu..

* Extract from the Repertoire d’Anato-ruie, Tom 11, No. &;.

rism of the inferior articular arteries, fungus

haematodes, or some other disease of thejoint. When M. Lallemand examined thepatient, Le was in the following state: hewas forty years old, but appeared sixty atleast ; great paleness, with a yellow tint;numerous wrinkles on the countenance, in-dicating his pain ; the right lower extremitywasted, especially above the patella; rightknee one third larger than the left, surround-ed by numerous varicose veins, and coveredby a rosy-coloured skin ; leg bent on thethigh; voluntary motions almost annihilated;pain on motion ; complete extension impos-sible ; head of the fibula very projecting ;excessive pain proceeding from the externalside, and following the course of the fibularnerve ; swelling of the varicose veins, andredness of the integument covering them.At the time of respiration, or when the leghung down, the superior extremity of thetibia almost double its size. At the internalside of the tendon of the patella, was an ob-long ilattened tumour, of the form and sizeof half a turkey’s egg, offering to the handvery extensive pulsations, isochronous withthose of the heart, and accompanied by anexpansive movement in every direction ; atthe external side of the patella, in front ofthe head of the fibula, there existed a secondprojecting tumour under the skin, about theform and size of half a nut, offering the samepulsations as the former ; they are com-pletely stopped in both, by suspending thecirculation in the femoral artery, and whenthe iingers were lifted, the patient felt asif fire were rapidly traversing the artery, andproceeding to the knee : this he attributedto the blood.

These researches made M. Lallemandthink that the two articular arteries werethe seat of the aneurism ; but, guided in hisresearches by the patient himself, who hadobserved the complaint with great narrow-ness, M. Lallemand stated, that the iigamentof the patella was much more projectingand larger than that of the opposite side ;that at the internal side there was a smallelevation, which proceeding along the levelof the rest of the tumour, had only appear-ed two or three months. Tn this space thepulse could be felt much more distinctly,and when this small prominence was per-pendicularly compressed with the fore

finger, nearly all the first phalanx sunk intothe tumour, when a circular opening of fourto six lines in diameter could be feit, thecircumference of which was hard and thin :if the thumb were pressed strongly on thl’border of this opening, the tumour yieldedwith a sound exactly resembling that whichis produced by the breaking ofnn egg. Thesmall tumour, situated intemaliy, beingpressed on the same manner, became flat-

tened by degrees, makirg at intervals similar