Case 3. P. C. a strong Irish labourer, fell, July 12th, 1826, from a scaffolding thirty-five feet in height. On admission he was quite insensible; pulse scarcely to be felt; pupils much dilated; respiration unembarrassed. He rolled about in bed, often groaning and putting his hands to his head, and lay with the thighs drawn up towards the abdomen and head bent upon the breast. Scalp apparently uninjured-considerable hæmorrhage from the left ear. Head to be shaved-calomel and jalap. The pulse continued weak and not above forty all day, and he remained in a dosing state. 13th, Much the same, save that there is some heat of scalp. Hirud. xij. temporibus-cold lotion to the scalp -purgative enema, as the calomel has not operated. In the evening the pulse got up to fifty, and was stronger; the bowels had been opened, and though he was roused once, he relapsed into a lethargic state. Emplast. canthar. nucha. 14th, Ratber more sensible; pupils more contracted, but he was still restless. Calomel and jalap-aloetic enema. In the evening the pulse got up, and he was bled to eight ounces with relief. 15th, Sensorial functions very imperfectly performed; pain in the head; pulse quicker; bowels not opened. Aloetic glyster to be repeated, with house medicine-ten leeches behind the ears-calomel and antimony three times a day. From this time he continued slowly to improve under local bleeding, blistering, purges and antimonial medicines. Aug. 5th, He could walk in the garden with assistance. Aug. 15th, He was discharged. "He could then walk alone--he was quite deaf in the left ear; his intellects were much impaired; his countenance was a complete blank; in short he was little better than an idiot." Since then his faculties are in a slight degree restored.

Remarks. Was this a case of pure concussion? We think it was not. The bleeding from the left ear-the subsequent deafness in that ear-the extreme slowness of recovery, and the injury done the intellectual functions seem clearly to indicate compression on the brain. In fact we think it extremely probable that a vessel was ruptured, most likely the meningeal, that part of its contents escaped by the ear, and part coagulated on the surface of the brain producing the symptoms narrated above. Then comes the question of trephining; if the scalp be injured in any one place, there is some sort of guide to the surgeon,

ments were much tumefied. The pericranium was divided by a crucial incision, and the dura mater exposed, this being a part originally unprotected by bone. Effused blood was found pressing on this membrane, and removed. A considerable hæmorrhage occurred, The boy was now able to answer questions, and the pupils contracted on the application of light. Leeches, cold lotions, purgatives, and other very proper means were employed, and the boy recovered. When all swelling of the integuments had subsided, it was found that there was a very considerable portion of brain un protected by bone. We think the treatment was very judicious, and that the removal of the extravasated blood from the dura mater, contributed mainly to the successful issue of the case.

but if, as here, the scalp be uninjured, and the bone unbroken, it might be dangerous practice to dig in search of coagula upon the dura mater.

Before closing this short article, we may also notice a case of compound fracture of the cranium [in the Lancet] from Guy's Hospital, The boy (12 years of age) had received a kick from a horse on the head, by which the bone (parietal) was comminuted, and the scalp irregularly wounded. The symptoms of compression were present, as stertor, slow pulse, dilated pupils, insensibility, &c. Under these circumstances, Mr. Bransby Cooper operated and removed the depressed portions of bone, by means of Hey's saw and the elevator. The patient very soon experienced relief. The pulse rose in a quarter of an hour, and consciousness returned. In the evening, there was reaction, and blood was abstracted. A brisk dose of calomel was given. The patient rapidly recovered. This was certainly the kind of case which promises most success under an operation, viz. fracture and depression of bone-laceration of integuments; in short, a compound fracture of the skull.

7. CONGENITAL DISLOCATION OF THE HIP-JOINT.•

[Hotel Dieu ]

It is well known that the most frequent kind of dislocation to which the hip-joint is liable is that of the head of the femur upwards and backwards on the dorsum of the ileum. It is also well known that of this dislocation there are two varieties—the first is the result of accident -the second is consecutive, the result of scrophulous ulceration in the joint. But M. Dupuytren in the memoir now before us, proposes to add to the list a third variety of this same dislocation, which, as it is found at birth, he terms "congenital."

The signs which characterise it, are shortening of the limb-presence of the head of the femur on the dorsum ilei-prominence (saillie) of the trochanter major (?) — retraction of almost all the muscles of the upper part of the thigh towards the crest of the ileum, where they form around the head of the femur a kind of cone, the base towards the os innomi. natum, the apex towards the trochanter-the almost entire denudation in consequence, of the tuber ischii-the rotation of the limb inwards— the obliquity of the thigh proportioned, of course, to the age and development of the pelvis the meagreness of the limb, out of all proportion to the trunk and upper extremities, which are really well developed and the imperfect motions, particularly of abduction and rotation. The upper part of the trunk of persons thus affected is thrown backwards whilst the lumbar portion of the column projects as much forwards; the pelvis is placed almost horizontally on the femurs, and the ball of the feet alone touches the ground. In walking we observe them incline the body strongly towards the limb which is to support the weight, at which moment the head of the femur of that side is seen distinctly to rise on the dorsum ilei, in consequence of the superincumbent weight and sinking of the pelvis, and then they drag painfully

* Baron Dupuytren Répertoire, No. 3, Tome 2me, 1826.

forwards the opposite limb, the head of the femur of which is perceived not to rise but to sink in consequence of its own weight drawing it down, This series of phenomena then is repeated each step the patient takes, and although locomotion to him is not so painful as it appears, still he is incapable of making any thing like a long journey.

In the recumbent posture, most of the symptoms of the dislocation in a great measure disappear, in consequence, no doubt, of the relaxation of the muscles and removal of the weight of the trunk. In this position of the body the surgeon can by a slight effort elongate the limb and shorten it again, that is, he can pull the head of the femur downwards or press it again upwards to the extent of two or even three inches, according to circumstances.

Let us look to the history of this complaint. Even at birth the prominence of the haunches, the obliquity of the femurs, &c. are perceptible, but in these cases the attention of the parents is seldom much directed to the malformation till the child begins to walk, and indeed even then its aukward efforts are attributed in general to weakness, &c. till the end of the third or fourth year, when the parent is at last convinced there must be something wrong. As the pelvis begins to be developed (for it is a curious fact that the growth of the pelvis is never affected in these patients) the symptoms which we have enumerated above become more marked, especially in females, and a person not acquainted with the true nature of the malady would consider it the consequence of scrophulous disease of the joint. But the previous history, the absence of all pain, swelling, abscess, fistula or cicatrix, and the simultaneous affection of both sides are sufficient to correct this At the same time it must be remarked that these individuals are for the most part of a lymphatic and scrophulous habit.

error.

As the age of the person increases, and the superincumbent weight becomes of course greater, the heads of the femurs rise on the dorsum ilei till at last they almost touch the crista, the obliquity of the bones is increased, and the difficulty of motion proceeds at last so far as to incapacitate the patient from all active exercise.

As this of course is not a fatal disease, the opportunities for cultivating its pathology must be comparatively rare. In the cases which he has examined M. Dupuytren has found the acetabulum almost entirely obliterated or even entirely wanting; the head of the femur a little flattened on its internal and anterior surface, and a sort of cotyloid cavity' to lodge it, formed on the dorsum of the ileum, as happens in unreduced accidental dislocations. In one or two instances, he has seen the ligamentum teres elongated, and in some places worn apparently from the pressure and friction of the head of the femur.

The Baron puts some questions to himself and the reader as to the etiology. He asks, can the dislocation be consecutive to a disease which assailed the fœtus and disappeared before birth? Or can it be the result of an ante-natal accident? Or lastly, can it be owing to an original imperfection of the acetabulum, in other words, can it be a congenital malformation? He seems to incline to this position, but like a

skilful disputant he has dealt his blows so equally to all his men of straw, that it is almost hard to say which is up or which is down.

M. Dupuytren makes some very sensible remarks on the treatment, which of course can be but palliative. As the weight of the trunk is the main agent in aggravating the displacement, repose is obviously indicated; but it is not necessary to confine patients to the recumbent posture; for in the act of sitting there is no stress on the femurs, the body resting entirely on the tuberosities of the ischia. Let these individuals then choose a profession which they can exercise when seated. Our author advises, likewise, the use of the cold bath, and the application of a bandage which encircles the pelvis, confines the trochanters, and keeps them of an uniform height, thus binding the ill-adapted parts together, and preventing that continual motion to which they are exposed. This practice, though it certainly will not cure the complaint, will give a great degree of support to the hip-joints, and prevent the progress of the displacement.

In the course of eighteen years, M. Dupuytren has met with twenty cases of this kind, seventeen or eighteen of which have been females. There is a plate appended, which shows the characters of this congenital dislocation very satisfactorily.

8. DISSECTION WOUND.

[Mr. Shaw-Middlesex.]

This was the case of a medical gentleman, who, while sewing up a subject that had died of peritonitis, grazed with the needle the middle finger of the left hand. He did not notice this scratch at the time, but awoke the next morning (7th January) with pain and stiffness of the fingers and hand, the former soon extending up to the axilla. To these symptoms were added head-ache-dull heavy coldness of the other hand and of the feet. Feeling nervous and depressed, he took two table-spoonfuls of brandy in a cup of coffee, and then went out to visit some patients. The pain increased, and he had alternately a kind of hysterical fit of laughing and crying. Returning home his breathing became oppressed, with a sense of constriction in his throat, and difficult deglutition. He took some more brandy, as the sense of coldness augmented. By mid-day he had taken three quarters of a pint of brandy. A medical friend advised him to discontinue the stimulantto take some calomel-and to apply some leeches to the chest. Mr. Shaw visited the patient about one o'clock, and found the wrist and hand of a livid colour-a similar patch on the inside of the arm-the finger swollen-but the wound scarcely perceptible. "His counte nance was very extraordinary, his expression being that of a mixture of hysterical alarm and intoxication." The patient said he was a dead man, and felt that nothing could save him. Mr. Shaw gave immedi ately eight grains of calomel and six of colocynth, with two grains of opium, wrapping his arm and hand in a lotion of laudanum and liq.

* Med. Journal, Feb. 1827.

plumb. acet. dilut. Laudanum was ordered to be kept poured over the cloth as it dried.

Being a little composed Mr. S. left him, and returned in an hour. The patient was still composed, and he ordered a linseed-meal poultice made with a very strong solution of opium, to be applied to the hand and wrist. In the evening, Mr. Griffiths and Mr. Shaw visited the patient. They found him low and dejected, but quite composed. The hand and arm were not so much inflamed as in the middle of the day. Ten grains of Dover's powder and four of calomel to be taken immediately, followed by a draught of camphor mixture, carbonate of ammonia, and laudanum. The draught to be repeated every four hours. On calling next morning, they were not a little surprised that the "dead man' had gone to a considerable distance, to attend a woman in labour! They returned at 3 o'clock, and found their patient sitting comfortably in his parlour. At seven in the evening, he was so well as to give Mr. Shaw a clear and connected account of all that had passed up to the time of Mr. S's first visit. He had not even a head-ache, after so much brandy, though unused to spirits-the hand and arm shrivelled, white, and free from pain. His bowels had been freely opened. He was advised to take some Dover's powder and opium, and a glass of brandy in gruel for supper. Next day he was out seeing his patients, and had no farther inconvenience.

were

We agree with Mr. Shaw that, although this gentleman had a rapid recovery, he had also a narrow escape. Indeed there can be no rational doubt that a specific principle had been absorbed in this case, for it would be preposterous to attribute all the phenomena to "thecal inflammation." They were far more like those which follow the bite of venomous animals, and we think they were of the same nature.

The treatment must be modified by the symptoms. With the deadly coldness and nervous dejection presented in the above case, stimulation was evidently the proper remedy. But a general rule cannot be founded thus. Had this gentleman presented symptoms of violent reaction and inflammation, the stimulating plan would have been improper, and even moderate depletion might have been justifiable. Here, in short, as in all other cases, we must be guided by the symptoms. High excitement must be controlled-nervous depression counteracted, by cordials and stimuli.

9. ANEURISM FROM VENESECTION.*

[St. George's.]

Two cases are related from the practice of Mr. Brodie at St. George's, of aneurism of the brachial artery following venesection. The first case, that of J. Rogers, will be found already detailed, at page 194 of our last number. Of the second case we shall give some particulars.

H. Chambers was bled in the West Indies in 1820, soon after which a pulsating tumour appeared at the bend of the arm, which by degrees attained the size of a large walnut. In April, 1820, a surgeon tied the brachial artery above the tumour. This diminished in size, and the

Med. and Phys. Journ. for February, 1827.