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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, turn aliorum, turn proprias collect as habere, et interse comparare.-MORGAGNI De Sed. et Caus.Morb., lib. iv. Proœmium.

WESTMINSTER HOSPITAL.

THREE CASES OF INJURY TO THE HEAD.

(Under the care of Mr. HOLTHOUSE.)EACH of the three following cases presents features of in-

terest. In the first, a certain amount of relief was obtainedby the application of the trephine ; but death ensued eventuallyfrom inflammation of the membranes of the brain. The secondcase was probably one of fracture of the skull through thepetrous portion of the left and possibly of the right temporalbone, involving in a slight degree both facial nerves. Thisseems more likely than that both these nerves should havebeen damaged at their central origin, especially as no othercranial nerves were affected. The third case is interesting, notonly on account of the original injury and the symptoms whicharose from it, but from the man’s condition three years after-wards. Contraction, it will be seen, had occurred in the for-merly paralysed muscles.CASE 1. Compound comminuted fracture of the frontal bone,

with depression and escape of brain-substance; application ofthe trephine, with relief ; death on the eighth day from menin-gitis.-George B-, carman, was admitted on the morning ofthe 12th of March, 1867, with a gaping, lacerated wound, twoinches long, immediately above and parallel with the righteyebrow, produced by the kick of a horse. There was freearterial haemorrhage, and on mopping the blood from thewound, portions of brain-substance were found adhering tothe sponge. The bone was extensively bared and shattered,and one portion depressed and overlapped by another in sucha way that no instrument could be got beneath it to raise ittill a small piece of the overlapping bone had been removed bythe trephine. The depressed piece was then found to be socompletely isolated from all its connexions that it was re-

moved, together with two other smaller fragments similarlycircumstanced. Lint dipped in tepid water, with oil-silk out-side, was then laid over the wound, and wet rags were appliedto the forehead.

Condition an hour after admission.-Right upper lid muchinfiltrated with blood ; both pupils dilated; pulse slow andfeeble, 60; was conscious when roused, and answered questionsabruptly; could partly extrude his tongue, and there was noparalysis. Just before the operation he vomited a large quan-tity of beer, and was so strong and resistant that chloroformhad to be given before the trephine could be used. After theoperation he was faint and much exhausted from his previousstruggles. Pulse 120, very feeble. Pupils contracted. Strongbeef-tea and milk diet.March 13th.--He had quite rallied, and was rational when

roused from the semi-comatose condition in which he lay.Wound not unhealthy; forehead hot; pulse frequent and feeble.Took his food well, and got out of bed to make water; noaction of the bowels, and no more sickness.

l5th.-Yesterday, five grains of calomel were given him,which brought away two copious greenish stools, and to-dayhe was decidedly better-i. e., less drowsy, perfectly con-scious and sensible, and rather disposed to talk. He took hisfood well, called for the chamber when he wanted to relievehimself, but complained of headache and pain in his eye.Pulse 110, feeble. Wound looked healthy. Repeat calomel,three grains, to-night.16th.-He passed a restless night, and wandered a good

deal, but seemed better this morning; quiet and disposed tosleep, and perfectly intelligent when spoken to. Foreheadnot unnaturally hot; wound granulating healthily; eyelid stillecchymosed, but less swollen; pupils of normal size, and sen-

sitive. Tongue dryish; bowels acted once in the night. Pulse90, feeble, and intermittent three times a minute. Yesterdaythe house-surgeon reported it intermitted every fifteenth beat.He took his food well, and once asked for wine-his favouritebeverage. Had coughed a good deal, especially when he wastaking food.17th.-Though quite rational when spoken to, he talked a

good deal to himself, and confessed to feeling " very queer."The forehead was somewhat hot, and the feet cold. Pulse 110.He took his food less readily. Was restless up to two A.,11,,afterwards quiet. The bowels acted once during the night.Continue calomel, three grains ; mustard plasters to feet.

18 th.-He bad a "fit" of screaming and convulsions lastnight, which lasted a full hour, and some spasmodic move-ments of the face this morning, and was now unconscious, anddeclined taking food. He passed his evacuations under him.Pulse very feeble.19th.-He had a succession of convulsions throughout yes-

terday, affecting sometimes one side, sometimes the other (ac-cording to sister’s account). When seen by Mr. Holthouse itwas the left half of the body which was convulsed. He wasnow evidently sinking ; respiration rapid and audible ; pulsevery frequent and feeble; sphincters relaxed. He died at5.30 F.NT.Examination of the head tuenty-one hours after death.-

Blood was infiltrated into the deeper tissues of the scalp inthe right frontal and parietal regions. On removing the cal-varia, which was unusually thin, the dura mater was seen tobe much congested, and the superior longitudinal sinus gorgedwith blood; a thin layer of the latter existed between thebone and dura mater in the frontal region, and also in theright middle fossa of the base of the skull. There were notraces of inflammation of the dura mater or of the arachnoid.No effusion into the cavity of the latter; but beneath it, be-tween the sulci of the convolutions over both hemispheres,were yellow purulent or semi-purulent deposits, which becamemilky on approaching the base. On removing the brain, thepart corresponding with the wound was of a rusty colour, andquite broken down. On making thin vertical sections of theanterior lobe, commencing through the lacerated and broken-down brain-substance, and proceeding backwards, extensivebruising was seen, with yellow discoloration of the white sub-stance, which extended as far back as the posterior part of themiddle lobe, with diminishing faintness till all traces of injuryhad disappeared. The fluid in the lateral ventricles was clear.No other injury or morbid condition was observable in thebrain. The fracture of the skull involved nearly the wholebreadth of the frontal portion of that bone, as well as theorbital, which were split transversely ; so that after the re-moval of the calvaria, a piece, 3" long by 4 "’ broad at its widestpart, could be removed immediately below the sawn surface.The roof of the right orbit was smashed; but the fragmentswere held in position bv its periosteal linin and were notdepressed. (There was but a very small ecchymosis beneaththe conjunctiva of the eye, just over the insertion of the ex-ternal rectus muscle, and none at the back of the globe.) Thefracture of the right orbital plate extended inwards in a trans-verse direction across the body of the sphenoid and the roofof the left orbit, and outwards as far as the posterior part ofthe middle fossa. No subconjunctival ecchymosis existed onthe left side.CASE 2.--Frederick B--, aged nineteen, carpenter, was

working under an arch on Jan. 2.5th, 1867, when it fell in, anda quantity of bricks striking him on the head, he wasknocked down, and slightly stunned, in which condition hewas brought to the hospital, copiously bleeding from bothears, chiefly the left, and slightly from the nose. His facewas pale, and his feet cold ; but hands warm, and circulationnot greatly depressed. He was quite conscious, and answeredquestions put to him, complaining of pain in his head. Therewas no vomiting, or involuntary action of the bowels orbladder. Low diet, beef-tea, hot bottles to feet, and blanketsover the body.

Jan. 26th.-Reaction was perfectly established ; all bleedingfrom the ears had stopped. He complained of but little painin the head. Pulse 72, of normal power. General conditionfavourable.30th.-Continued to improve, and complained only of

deafness.Feb. 2nd.—Was up. The deafness, which affected chiefly

the left ear, still continued, and there was evident indistinct-ness of speech. Left meatus and membrana tympani were sobesmeared with blood that the condition of the latter could notbe ascertained. Right meatus was covered with a fetid

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sanious purulent discharge. Ears to be syringed with warmwater.7th.-After syringing and examining the ears in sunlight,

blood was seen behind the left membrana tympani, pushing itslightly forwards into the auditory passage ; but no rent oropening could be discovered in the membrane. The rightmembrana tympani was slightly nebulous and thickened, but noblood occupied the tympanic cavity. A fetid sanious pus be-smeared the meatus. The ticking of a watch was heard bythe right ear at a distance of three feet; but by the left only on’

contact. On analysing the defect of speech, it was found tobe in an imperfect articulation of the labials : thus, he had adifficulty in pronouncing his own name, and all words beginningwith B or P, M or Y. V and F he had less trouble with, andhe remarked that the want of power was more in the upperthan in the lower lip. He could not whistle or spit, and com-plained of the food getting between his cheek and his teethon the left side. There was defective power in all the musclessupplied by the left facial nerve, and in a slighter degree alsoin those of the right : thus, he could not wrinkle his forehead,or frown, or close his eyelids, even on the right side, so stronglyas he ought to do. There was no defect of deglutition, or ofabduction of either eye, and none of sensation anywhere ; butthere was slight tinnitus in the left ear, and a little headache.13th.-He was slowly recovering the power of the facial

muscles, and spoke less indistinctly ; but it seems he had

always lisped a little.l9th.-He was discharged convalescent, with an injunction

to report himself in two weeks, which, however, he failed todo.

It ought to have been mentioned that there was no distor-tion of the features, and no deviation of the point of thetongue, or of the uvula, when these parts were specially ex-amined as to this deviation.CASE 3.-Charles W-, aged thirty, carman, was admitted

into the Westminster Hospital, January 7th, 1864, with afracture of the basis cranii, from falling off a cart loaded withstraw. He was unable to rise, and quite unconscious, andwhen brought in was pale and cold, and his pulse very feeble.He vomited several times, and his bowels acted freely andspontaneously. There was bleeding from his left ear, but noscalp wound or other apparent injury about the head.

Jan. 8th.-His skin was warm and moist. Pulse 80, soft.Was perfectly conscious and rational, and complained of nopain. There was no perceptible paralysis, but profuse serousdischarge from the right ear, and slightly from the left. Lowdiet; beef-tea.9th.-The serous discharge from the ear still continued, and

there was slight facial paralyses of the left side, but he wasable to close the eyelids.

llth.-Paralysis more marked ; unable to close the eyelidsof the left side ; features much drawn to the right. Serousdischargp. continued, but not so abundant, and it evidentlycame from the left ear, and not from the right. The error of

supposing it came from the right ear arose from his lying onhis right side, and the pillow being saturated where his headlay ; but it was now evident it came from the left, and randown the back of his neck, wetting his shirt-collar, and after-wards the pillow. His bowels have acted twice freely fromcastor oil, and with relief. Mercury with colocynth pill, tengrains, to be taken at night.

12th.—Discharge still continued from the left ear, and theparalysis was the same ; no constant cephalalgia, but occasionalparoxysms of sharp pain. Though the sister said he was quiteconscious when brought to the hospital, and asked for thenight-chair as soon as admitted, he himself recollected nothingfrom the moment of the fall till he found himself in the hos-pital.16th.-The serous fluid was standing in a puddle in the

concha of his left ear as he lay on his right side. No materialchange in the symptoms, but expressed himself as feelinghungry, and asked for some meat and beer. Could close thelids feebly, and was quite deaf with the left ear.23rd.-Had been up the last two or three days, and felt

quite well and very hungry; asked to go out for exercise. Thefacial paralysis continued, and was observed to vary slightlyfrom time to time, so that on one day he could close the lids,and on another could not do so; the features were considerablydistorted, and the discharge from the ear, though less abun-dant, still continued.30th.-He was discharged to-day at his own request, the

discharge from the ear still continuing in small quantity, andbeing slightly fetid, the paralysis and deafness remaining thesame; the general health, however, was good.

Jan. 22nd, 1867.-Has just been discharged from Mr.Brooke’s care, under whom he has been for another fall on hishead, less severe than the former, but followed by a slightbleeding from the left ear.

Since he was in the hospital, three years ago, he has hadotorrboea constantly, and the discharge is fetid ; he hearsnothing, he says, with that ear (watch not heard in contact).The distortion of the features is gone, and he can close both

lids equally well; but when he laughs, or puts in much actionthe facial muscles, those of the left or formerly paralysed sidecontract more than those of the other. He obstinately refusedto allow the ear to be examined with a speculum.

MIDDLESEX HOSPITAL.OUT-PATIENT CANCER DEPARTMENT.

(Under the care of Mr. NUNN.)THE diagnosis in some forms of ulcer found on the lips and

tongue and genitals is occasionally rendered somewhat difficultby an outward resemblance between the cancerous and thesyphilitic ulceration and induration. The following cases havebeen selected as illustrating the above proposition :-Solomon U--, aged fifty-two, December 20th, 1866.

" Has an ulcerated gaping notch in the upper lip to the left ofthe median line. He has twice undergone excision : on the firstoccasion by a private practitioner; on the second, by one of themost distinguished hospital surgeons in London; and he-attended during nine months at a cancer hospital. Theulceration has extended to the alveolar border of the upperjaw behind the sore on the lip ; the ulceration of the bone, infact, corresponds to the ulceration of the lip." This history ofthe case is syphilitic; the appearance of the sore is cancerous.Thirteen years previously the patient was bitten on the lip,at the part now affected, by a loose woman. The bite wasfollowed by a sore, which remained open during three years ;it then healed, continuing sound for five years, at the end ofwhich period the sore broke out afresh, the patient allegesfrom the irritation of a pipe; it has remained unhealed eversince, having been twice operated on, as just stated.The patient was put by Mr. Nunn on an antisyphilitic treat-

ment, consisting chiefly of biniodide of mercury and iodide ofpotassium ; the result being a considerable improvement in theappearance of the sore. The patient ceased to attend aftera few weeks, but not before Mr. Nunn felt thoroughly convincedof the syphilitic nature of the ulceration. Mr. Nunn expresseshis belief that the woman who inflicted the wound on the lipof the patient with her teeth, was suffering from constitu-tional syphilis; that a modified syphilitic sore was the result ofthe infection of the wound, and that, by subsequent modifica-tion of the poison in the patient’s system and latency, a lupoidulcer was developed of the same character as lupus, the conse-quence of hereditary syphilitic taint; although the relation-ship of lupus to hereditary syphilis is unhesitatingly denied bysome writers. In the above case, the long history, and thesituation of the sore on the upper lip, favour the view that thesore was not cancerous.

Charles S-, aged fifty-two, a smith, was sent to the hos-pital by Dr. Slight, of Brewer-street, Regent-street, for Mr.Nunn’s opinion as to a sore on the lower lip to the right sideof the median line.-Feb. 21st, 1867 : " The sore is about thesize of a threepenny-piece, and has hardened edges; a glandbelow the jaw is enlarged ; the patient is quite free from anykind of sore on his genital organs. The sore has existed duringone week." The probability of every source of contagion wasexamined. It appeared that the patient was in the custom oftaking up from the work-bench any tobacco-pipe that mightcome to hand. The straightforwardness and candour of theman, in his replies to searching questions, left little doubt ofa tobacco-pipe being the medium of his infection with syphiliticpoison. The short history of the sore in this case eliminatedthe question of cancer in calculating its origin. In the courseof a few weeks constitutional syphilis declared itself; and anote of the case, May 9th, states that an attack of iritis wassubsiding at that date.- M-, admitted Jan. 25th, 1866, with sore on the lower

lip to the right of the median line. The sore had an induratedbase about the same size as that in the case above recorded.There was an enlarged gland below the jaw. The patientstated that his mistress had sores on the inside of the mouth.This patient suffered shortly afterwards from constitutionalsyphilis. He applied to the cancer department of the hos-pital, under the fear that he had cancer of the lip.