No.11.] LONDON, SUNDAY, DECEMBER 14, 1823.

SURGICAL LECTURES,CONTINUED.

Theatre, St. Thomas’s Hospital,MONDAY EVENING,

DEC. 8th, 1823.

LECTURE SIXTEENTH.

Injzaries of the Bmin.BEFORE I proceed to mention

these, I will give you a brief ac-count of the nervous system ; a

correct knowledge of which, how-ever, can only be acquired byassiduity in the dissecting-room.The nervous system is composedof the following parts, viz. brain(which is divided into cerebrum,cerebellum, and medulla oblon-gata), medulla spinalis, and twosets of nerves - one set issuingfrom the brain, and the other fromthe medulla spinalis. Besidesthese, there is also the grand sym-pathetic nerve, which may be saidto form a complete system initself.The nerves are freely distri-

buted to every part of the humanframe, and are the means by Iwhich all voluntary and involun-tary motions are maintained. It i

is impossible that a mere descrip-tion of the nervous system, in thisplace, however minute it might becould make you sufficiently ac-quainted with its anatomy; forthis can only be obtained by themost careful and attentive exami-nation of the dead body. It is

necessary, however, for you, atthis moment, to bear in mind, thatan immediate communication ex-ists between the stomach andbrain, by means of the eighth pairof nerves, or par vagum ; for un-less you do this, it is probablethat an important symptom, whichI shall presently mention, attend-ant on injuries of the brain, willbe but imperfectly understood.There is also another circum-stance connected with the brainto which I wish particularly todirect your attention, viz. its beingthe vehicle of the mind ; or,rather, I might say, the mediumthrough which the mind is commu-nicated. The influence of thebrain on the mind, and vice versir,will be amply demonstrated to youas I proceed.Now, when the brain receives

an injury, the symptoms stated tobe the result of that injury are,general loss of sense and volition,if the injury be considerable;

but if not so severe, some portionof sense and volition will remain;for example, when you are called

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to the bed-side of a person thus functions of no organ are so soonsituated, you find him to be what affected by injuries of the brain asis termed comatose. If you speak those of the stomach; this arisea

sharply to him, he becomes from the connexion before ex-

roused for the moment, mumbles plained to you ; vomiting, there-some brief answer to you, again fore, is one of the first symptoms;lays down, and relapses into his though the iseces pass involun-former sleepy state : thus you ob- tarily, yet there is such torpor ofserve partial mental faculties and the intestinal canal, purgativesvolition still remain. This state will not easily excite action, andyou should minutely note, as it there will be found considerablewill greatly assist you in your difficulty in procuring evacua-

after diagnosis; and you must be tions ; the pulse is said to beat la-upon your guard that you are not boriously; for the heart being ai-deceived here ; for a man in this fected, it cannot readily get rid ofcondition very much resembles its contents. The pulse, however,one in a state of intoxication ; and is not slow unless the body be atthis similitude often proves exceed- rest ; for upon the slightest exer-ingly harassing to the surgeon. tion it becomes exceedinglyHe is probably sent for to a per- quick ; the pupils are dilated,son who, it is stated, has received bleeding from the nose, whicha severe injury of the head. He when the patient has been keptfinds him with a very severe lace- lying on his back, often occasionsration of the scalp, together with vomiting of blood; when the in-stupor, and sometimes even ster- jury has extended to the basis oftorous breathing. Not knowing the skull, producing fracturethat the individual was intoxicated there, it is generally attendedat the time of receiving the in- with bleeding from the ears.

jury, the surgeon attributes the These cases are very dangerous,above symptoms to concussion or and persons usually fallvictimscompression, when, after a few to them. In addition to the symp-hours, the person recovers from toms already enumerated, therehis drunken fit, and it becomes is often partial paralysis or hpme-apparent that he received no other phlegia, likewise squinting is oc-mischief than a wound in the casionally produced; the naturalscalp. direction of one or both eyes be-

In addition to loss of sense and coming changed ; permanent, par-motion, the iseces involuntarily tial, or total aberration of the

pass off from the sphincter ani mental faculties may also be ad-

losing its retentive power through ded to the consequences alreadythe sympathetic influence of the enumerated, arising from injuriesgrand sympathetic nerve-the vo- of’ the brain.

luntary power of the bladder be- When asked by what twocomes for the time extinct-the causes concussion and compres-urine is retained, and you are sion are produced, you answer,obliged to pass a catheter for its concussion is simply a shock,removal at the very time when the which the brain has received, moreescape of the ieeces cannot be or less severe, attended with la-controlled. But the involuntary cemtion or not and compression

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arises from either a depressed tion of the carotids than in health,portion of bone, the extravasation they beat more violently, thoughof blood, or the formation of mat- not more quickly, if the patientter; and trom whichever of these be at rest ; if asked what are theit springs, still the symptoms will best marked symptoms of concus-be the same. sion, I should say this increased

In describing the symptoms and motion of the carotids ; the ap-treatment of these diseases more parent tranquil sleep ; the instan-particularly, I will first begin taneous relapse to that state afterwith concussion : when called to having been roused ; the remark-a person whom you find in a state able excitement of the pulse uponof’ stupefaction, but not to a great using exertion, and the insensibi-degree ; regular pulse; tranquil lity having immediately followedand regular breathing ; and the the injury.accident has existed some hours, The diminution of the opera-you will generally be justified in tions of the mind is often so greatpronouncing that the injury has in concussion, even where con-been trifling; but when the indi- siderable voluntary motion re-

vidual has been first seized with mains, that you cannot, even byvomiting, is incapable of using hallooing as loudly as you are

any muscular power from loss of capable, get any other answernervous influence ; a total aber- from your patient, than eh!’ de-ration of the mental faculties ; livered in a gruff under-tone.-Iwith intermittent pulse and have known several very curiousbreathing, these will be found circumstances of this kind ;-onethe diagnostic symptoms of severe case was that of’ a gentleman whoinjury, and the case a dangerous had met with an injury of theone. In simple concussion, head, by which concussion hadwhere the derangement is not so been produced-every endeavourextensive as that just described, to get a word from him was in-and where the patient upon being effectual ; yet, at one period,spoken to raises himself as it when the attendants were all ab-awoke from a sound sleep, and sent, he got out of bed, bolted thewhere some power of volition door, made water, and returnedstill remains, you will find one to his bed again, in the same

of the best diagnostic symptoms manner as though he had beento be the accelerated action of in perfect health: when the ser-

the pulse upon the patient exert- vant went back, he found the

ing himself ; a man in this state door fastened; all their knockingwith a pulse at 70, on being rais- was unavailing, they were obligeded or attempting to walk, will to break it open, and then couldhave it inordinately quickened, not procure from him a singleand instantly beat 130 in a mi- word. Indeed, I do not be-nute ; this is a never-failing lieve the noise of an earthquakesymptom, and where the patient would have succeeded in rousingcan be made to exert himself at him from his lethargy; yet heall, will be found a sure charac- could get out of bed, pass histeristic of the disease. There is urine, and adopt his ordinaryalso in these cases a greater ac- habit of delicacy, by bolting the

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door.-I have caught a man, when accumulation of matter, he lostlabouring under the effects of’ his English entirely, and I couldconcussion, with his feet in a onlycommunicatewithhimthroughchamber-pot, and by the action the medium of an interpreter. Atof his hands, it was evident that last he lost the power of speakinghe was trying to throw water over even in his native language, andhis legs ; upon the servant going he died in consequence of the ac-into the room of the same indivi- cumulation of matter. It is curiousdual, some days after, he was to observe the gradual changefound to be attempting to shave which takes place in the intellec-himself, and having no lather, he tual faculties, as alteration occurssubstituted a pot of spermaceti in the brain; and the gradualointment, and which he had brush- diminution of ideas which haveed all over his face. been more recently acquired, un-

I suppose you have all heard of til at length they become totallythe extraordinary change which obliterated. Old persons are ob-the memory sometimes undergoes served to be fond of relating anec-from the effects of concussion. dotes of their youth, forgettingThe first story of this kind that I incidents of more recent occur-ever heard, was from Mr. Cline : rence; and the change which takesa man was taken to Guy’s, in a place in the intellect from injuriesstate of insensibility, in which of the brain is very similar to thecondition he remained for some effects of age. The patient be-time, but at length recovered; comes, as it were, suddenly old;and when he did so, no person in loses impressions of a recent date,the Hospital could understand his and is sensible only of those whichlanguage ; a milk-woman hap- he has received in his earlier

pening to go into the ward one years. Such is the state of the

day, heard him, and discovered mind, which is very frequentlythat he was speaking Welsh : he produced by compression of thetold her that he knew English brain.well before the accident, but after With respect to the state of theit all knowledge of that lan- brain under concussion, when theguage was obliterated from his concussion is not extremely vio-mind. It had been recently ac- lent, there is merely a change inquired ; the impression was less the circulation of the brain.

strong, and consequeutly the more A sudden shock will so far dis-easily effaced. turb the circulation of this organ,

I witnessed a similar circum- as to produce diminution of thestance in the case of a German, powers of the mind, as well as towho was a sugar-baker in this impair the functions of the body.town, and who had compression I shall have occasion to mentionof the brain arising not from any to you a most extraordinary case,injury by violence, but from pres- in which the functions of the mindsure in consequence of the for- were suspended from an inter-mation of matter. This man could ruption of circulation in the brainspeak English extremely well be- for upwards of thirteen months,fore the compression, but as the the patient having, as it were,

compression increased from the drunk of the cup of Lethe during

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all that period. Any change of the usual manner. On examina-the circulation in the brain alters, tion of the body after death, forin some degree, the powers of he died eight days after the ac-mind and body; but if the agita- cident, the brain was found to betion be very considerable, the lacerated in several places, andpowers of the mind will be for a considerable extravasation of bloodtime suspended. Thus when a had taken place. In general,person is said to be stunned, there therefore, when the concussion isis a sudden alteration of the cir- slight, there will be only an alter-culation in the brain, and a cor- ation of circulation in the brain;responding loss of sensibility: but but when it is severe, there willwhen the circulation is restored be laceration, accompanied with

by the means which I shall pre- extravasation of blood, and the

sently point out to you, the powers symptoms will be found to runof the mind return with those of’ into those of compression. Thethe body. When the concussion first case in which I ever saw theis very violent, a lesion of the brain lacerated from concussion,brain takes place; but when it is was one which occurred at theslight, no appearances can be other Hospital, in the first year ofdiscovered on dissection which in- my apprenticeship, when I was adicate any alteration of structure. dresser to Mr. Chandler. As thisA person may die from another was the first case of the kind I

injury, accompanied with concus- had seen, I preserved a portion ofsion ; and on examination after the brain. The patient had lostdeath, not the least alteration may the power of speech from a blowbe found in the brain. This is on the head; but there was no

not the case, however, where the appearance of any wound or in-concussion is violent. I have be- jury to the skull. Mr. Chandlerfore me a great number of prepa- attributed the loss of speech to

rations, from the brain of patients concussion. On examination ofwho have died of concussion, in the body after death, it was foundmost of which that organ was con- that the anterior lobe of the cere-siderably lacerated, and some brum was torn, the first effect ofextravasation of blood is observ- which injury was the loss of theable within the brain. (Several power of utterance, or rather abeautiful specimens of lacerated paralysis of the muscles, whichbrain, accompanied with extrava- deprived him of the power ofsation of blood, were exhibited to speech, and subsequently com-the class.) These specimens show pression and inflammation, ofthe effects produced by severe which he died. When you areconcussion. I remember a case asked, then, as to the effects ofof a gentleman, an intimate friend concussion, as they may be col-of the late Lord Nelson, who fell lected from the appearances onfrom his horse at the corner of dissection, you will answer, thatSt. Thomas’s Street in the Bo- when the concussion is slight, itrough. He was immediately taken is merely an agitation of theto Guy’s Hospital, where he was brain, by which the circulation isfound to have all the symptoms of altered ; hut when it is severe,concussion, and he was treated in the brain itself suffers laceration,

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which laceration is accompanied inflammation within due bounds.with extravasation of blood. By I shall mention a case in whichthe knowledge of these facts we fatal consequences ensued fromare led without difficulty to the the error committed by the sur-principles of treatment. geon in bleeding his patient to

. such excess, that the slight de-T1’eatment of Concussion. gree of inflammation necessary to

The great danger which we the process of adhesion was re-

have to guard against, in the moved, and the reparative pro-treatment of concussion, is inflam- cess of nature consequently pre-mation of the brain. This prin- vented.ciple must direct our practice ; In these Lectures, Gentlemen,and in order to prevent inflam- I feel it to be my duty to describemation, we must take away a to you Surgery, as it is, and notvery considerable quantity of in the glowing coloars in which itblood. By bleeding largely at is painted to you in books. Youfirst we not only remove existing must be content to practice Sur-inflammation, but we prevent that gery, as it is : not as it is sometimeswhich would otherwise occur. fallaciously represented to you.This practice, however, may be I am most anxious that you shouldcarried to excess. There are omit nothing which may contributesome persons who say you can- to increase your professional skill,not bleed too much in these cases ; and enable you to afford thebut such an assertion only proves greatest possible sum of relief totheir want of understanding. You the sufferings of your patients;must regulate your conduct by but they who blazon forth our pro-the symptoms; observe whether fession, as one which is attendedthere be any hardness in your with undeviating success, are onlypatient’s pulse, and whether he deceiving you. You must hearcomplains of pain in the head, the untoward cases of your pro-if he have still the power of com- fession, as well as those of whichplaining; watch your patient the issue is favourable, in orderwith the greatest possible anxiety; to form a correct judgment invisit him at least three times a your minds of what your protes.day, and if you find any hardness sion really is. It is for theserea.of the pulse supervening after sons, Gentlemen, that I shall neverthe first copious bleeding, take hesitate, coute qui coute, to detailaway a tea-cupful of blood, but to you, and perhaps to the public,do not go on bleeding him large- those cases which have terminatedly, for you would by this means unfavourably. I have a duty toreduce the strength of’ your pa- perform, and I shall never shrinktient too much, and prevent the from the discharge of it. It is byreparative process of Nature. It detailing to you the unfavourable,is necessary that there should be as well as the favourable cases,a slight degree of inflammation, that I can alone perform thatfor without this the reparative duty, for it is by such a courseprocess cannot go on, and the alone that I can point out to youpatient cannot recover ; but it the rocks which you are to avoid,will be your duty to keep this as well as the haven in which you

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are to endeavour to anchor. The him, but 1 judged it necessary tocase to which I last alluded, was bleed him again largely; and Ione of concussion, accompanied took blood in smaller quantitieswith slight laceration of the brain, from him day after day, watchingwhich occurred in the other Hos- the pulse with the greatestpital. The gentleman under whose anxiety, and bleeding him onlycare the patient was, thought it so far as to reduce the hardnessright to bleed him, and that he of the pulse without diminishingcould not bleed him too largely. too much the powers of his body.He accordingly bled, not only from The whole quantity of bloodday to day, but twice a day. The taken from this gentleman, byconsequence of this mode of treat- bleeding from the arm, openingment was, that the patient became the temporal artery, and the ap-perfectly pale, was in a state of plication of leeches, as far asconsiderable dejection, not of the this could be estimated, amount-mind, but of the powers of the to about two hundred and eightbody, and died without any symp- ounces of blood. One hundredtoms of inflammation, ten days and eighty ounces were takenafter the injury. On examination from the arm ; yet such was theof the body, it was found that hardness of the pulse that at thethere was a slight laceration of’ last bleeding there was some de-the brain, with some degree of gree of inflammation in the brainextravasation of blood, but that remaining.not the slightest attempt had been You are to use bleeding as amade by nature to heal the wound. means of preventing inflamma-You are aware that the brain tion, but you are not to resort to itheals, like any other organ, by as a matter of course, the mo-the process of adhesion ; but in ment you are called to a patientthis case, the quantity of blood under concussion. A man fallstaken from the patient was so from his horse, and the instantlarge, that the slight inflammation he is picked up from the ground,nece3sary to the adhesive process some surgeons think it necessarywas removed. and the process of to take the lancet from their poc-restoration conseqnently prevent- ket. This conduct is quite irra-ed. Still it is often necessary to tional; for suppose the pulsetake away blood, after the first could scarcely be felt at the wristlarge bleeding, but it must be of the patient, and the surgeontaken in small quantities, and you were in such a case asked whymust watch the patient with the he proceeded to bleed; what

greatest possible anxiety, for the would his answer be! z The pro-symptoms can alone regulate bability is that he would have noyour practice. Sometimes it is answer at all ready, or he wouldnecessary to take away large perhaps say that he bled him be-quantities of blood. I was called cause the accident had broughtto a gentleman who had fallen a great quantity of blood to thefrom his horse in riding to Lon- brain, as if the shaking of thedon. 1 found him insensible on head could have any effect in

my arrival. Mr. Constable, who producing a determination ofattended him, had already bled blood to the brain. It is not with

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this view that we bleed in concus- emetics of considerable use; thesion, but in order to prevent in- vomiting produced by them doesflammation. I have seen many good. I have always considereda patient who would have died the efforts of nature to relieveif a large quantity of blood had herself after injuries salutary;been taken at the time of the ac- and thus the vomiting which iscident. This was the case with excited in cases of concussion,the gentleman who was attempt- acts beneficially by relieving theing to shave himself, whose stomach of its contents, as the

symptoms I described to you this accident generally happens to

evening. When I first saw him, persons in a state of intoxication;his pulse was scarcely percepti- and also by propelling the bloodble. I took a little blood from to the brain, and thus restoring thethe arm, and he was immediately powers of life. But the vomitingseized with convulsions, like an excited by nature restores theepileptic fit, which I thought patient to his senses for a shortwould have proved fatal. I time; he is sometimes relieved,closed the arm, and I would not but without continuing so long;upon any account have taken he looks about, and lapses intosix ounces of blood from him at his former state of aberrationthat moment. Some time ago I of mind from which he had re-

saw a man, at the other Hospital, ceived merely a temporary relief.who had received a blow on the When emetics are exhibited ashead. He was pale and deject- a remedy in concussion, thereed, and his pulse could scarcely is only one thing that I fearbe felt. I said to the dresser you from their use, when there is anymust not bleed this man at pre- extravasation of blood in thesent; there is rather too little ac- brain; or any tendency to apo-tion than too much. Wait till the plexy, then they should be em-pulse rises, and then bleed him. ployed with caution ; and it is onIn the evening reaction took that account that I wait for three

place; the pulse rose, and the or four hours after the accidentdresser then very properly bled before I order them.him. Inflammation was by this With respect to the exhibitionmeans prevented, and the man of cathartics, the bowels shoulddid well. The principle upon be kept open by calomel purges,which you should act, Gentlemen, followed by the infusion of senna,is never to do any thing in your and sulphate of magnesia. The

profession without a good reason, calomel should be given aboutwhich, whatever may be the result two hours after the accident; andof the case, will leave your con- it will be useful to give to thescience clear. A surgeon who patient at the same time, a quan-bleeds without being able to as- tity of’ mild fluids to drink ; as bysign any other reason than that this means a disposition to purg-his patient has received a blow, is ing is kept up, counter irritationnot fit to practice his profession. is, as it were, produced, and theThe next remedy I come to is blood is drawn from the brain to

EMETICS. the intestinal canal. SubmuriateI must say that I have seen of mercury, with lemon juice

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squeezed in water should be to you but from the recollectiongiven. Perspiration on the sur- of some case that has occurred toface of the body is very desirable, me. I was very intimate withand for this purpose antimonials a Mr. T., of Yarmouth, where Iare employed. The Pulv. I pec. used to spend a good deal of timeCom. (Dover’s powder) is not when a boy; after my apprentice-generally used to produce mois- ship was finished, I went down toture of the skin, on account Qf the this place, and I found Mr. T.

opium it contains, as it confounds labouring under the effects of con-the judgment, and prevents your cussion ; the mind was not in theseeing what are the effects of the least affected ; he had received

opium, and what those of the a blow on the forehead from a

disease; for opium produces the bludgeon, and he was afterwardssame disturbance to the brain as frequently seized with sickness attakes place in concussion ; there- the stomach. I cal1ed on him ;fore it is not often employed. and when I went into the room,Counter irritation is of use, but I said, 1 came to ask you hownot until other means have been you are: in approaching me heresorted to ; the object of blisters was obliged to put his handker-is to sub(lue the inflammation chief to the mouth to prevent thewhen other means have failed. I contents of his stomach goinghave known a patient, with pain over me. In his walks he hadin the head, sickness at the frequent vomitings : a relationstomach, loss of strength, and who was at Yarmouth twelve

throbbing of the carotids, who months after this, said to him,had been often relieved by blood- that he had better have the tre-

letting, for about two hours only phine applied, and the portionafter it was done. A person, under of hone removed ; to which hesuch circumstances, I have known readily consented. After thebenefited by the application of a operation his symptoms were notblister; on the principle not of relieved; he remained just the

increasing but subduing action, same ; or I should rather say thatfrom an excess of which the ill he was not relieved, for he did notconsequences are to be feared. continue long in the same state;For the symptoms after concus- he soon got worse and worse:

sion, the trephine used to be em- his bowels became costive ; the

ployed ; but it now becomes a powers of the mind affected, andquestion whether it ever ought to he died in consequence of thebe resorted to as a means of relief operation, though he had livedunder those circumstances. To two years after the injury, beforethis I say, if you were to trephine, it was performed. Mr.B.. nowyou ought to be trephined your- in Yarmouth, was living with himselves in turn (a laugh). BVhat at the time, and he could tellwill trephining (to ? ’! Probably more of the particulars thangreat harm, by disturbing the myself; but this I know, that hebrain ; and if not, no good can was not benefited by the opera-possibly result from it. Now for tion, but injured by it. But for athe proo’s : first, that it does no more direct proof that it is dan-good. Gentlemen, I never lecture gerous, Dr. Farre told me that he

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knew a person who was subject Ito epileptic fits after concussionof the brain, and that he was ex-tremely anxious to be trephined.The operation of trephining wasperformed, and he died soonafterwards. Do not think, Gen-tlemen, that I mention this as anuncommon case; but this usedto be the plan adopted withalmost all the patients admittedinto these Hospitals during myapprenticeship; they were all,submitted to the operation ; in-flammation of the membranes ofthe brain supervened, and nearlyall died ; recovery being veryrare. But do our patients nowdie from the effects of concussion 1No; by bleeding and depletionwe rarely lose a patient; perhapswe have fallen into the contraryextreme. After the expiration ofmy apprenticeship at these Hos-pitals, I went over to Paris to seethe practice of Desault, at theHotel de Dieu ; and there Ifound that never, under any cir- Icumstance whatever, did he tre- Iphine ; and that he was moresuccessful than those who were

constantly doing it here. Tre-

phining in concussion is now so

completely abandoned, that in thelast four years I do not know thatI have performed it once ; whilstthirty-five years ago I should haveperformedit five or six times ayear.But I believe that I have omittedone circumstance; and that is totell you to pay strict attention tothe mind; excessive anxiety mustbe prevented; for if’ you sufferthe mind to be disturbed, you dolittle or nothing towards the re-covery. I was very much struck,about twelve ’months ago withan instance of this: a boy wasbrought to me from the north of

England who had lost a portionof the skull just above the eye-brow ; and I was asked (for itwas for this purpose that I was

consulted), what protection shouldbe given to the denuded brain.On examining the brain, I dis.

tinctly perceived the pulsation wasregular and slow; but at thistime he was agitated by some

means or other; directly, theblood was sent with increasedforce to the brain : the pulsationbecame more violent; theref’oreif you omit to keep the mind freefrom agitation, your other meanswill be unavailing.

Lastly, the treatment of Chil-dren. As you cannot ahnaysbleed them from the arm, youmust give the submurias hydrar-gyri (calomel), with mild drink,so as to purge them; leechesmust be applied to the temples:you must open the jugular vein.for the symptoms after con.cussion, or pain in the head, orsickness at the stomach, you mustmake an incision through the

scalp, put issues in, wash themwith spirits of wine and water;for this is better than any thingelse I know : and use the showerbath two or three times. ’Theseare the best means for givingpower to the nervous system andbringing the action of the braininto a healthy state.

Theatre, St. Thomas’s Hospital,WEDNESDAY EVENING,

Dec. 10th, 1823.

’ LECTURE SEVENTEENTH.

WEare this Evening to con.

sider, Gentlemen, COMPRESSION