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duce at pleasure, and without pain or fur-ther inconvenience. Had never made useof a truss. Early on the morning of the7th, whilst raising a heavy weight; the her-nia came down suddenly, and to a much

greater extent than at any previous time.He paid no attention to it for several hours,when it became painful, and he attemptedto reduce it. At this time he was also ad-vised to rub the swelling severely, as a

means of returning it. He remained dur-

ing the day and the following night withoutapplying for advice, suffering at times mostexcruciating pain. On the morning of the8th, the day following, he applied to Dr.Duffin, of Weymouth Street, who sent himto the Hospital, where he presented himselfabout eleven o’clock, with the followingsymptoms :-a large swelling, of the size ofa fist, occupied the right side of the scro-tum, extending upwards to the external

ring ; it was tense, and the integumentssomewhat inflamed. There was no tender-ness of the abdomen,- but on handling thetumour he complained of slight pain. The

patient stated, that his bowels had been

very slightly opened in the course of thenight.He was put to bed, and bled at the arm

till he fainted. Attempts were then madeto reduce the bowel, but without success.He took a large dose of castor oil, and abladder filled with ice was applied overthe tumour ; this was continued until theevening, during which, occasional applica-tions of the taxis were employed. Up tothis time he had complained of little or nopain, and could readily allow of pressureboth on the abdomen and tumour. Aboutseven o’clock he became somewhat restless,had slight hiccup, and tendency to sickness.Little hope of reducing the hernia beingnow held out to him, he assented to theoperation, which was accordingly perform-ed by Mr. Wardrop ; the sac was found tocontain a large knuckle of intestine, whichwas of a dark purple colour : there wasalso a considerable effusion of serum. Thestricture, which was found at the externalring, was divided, and the protruded bowelreadily returned. The patient died earl}in the morning’ of the next day, havingbegun to sink soon after the operation. On

opening the abdomen, the small intestineswere found generally inflamed, but theintestine which had been protruded wasalmost of a black colour, softer in consis-tence than natural, with considerable thick-ening of its pariete$.

ST. THOMAS’S HOSPITAL.

CASES OF FRACTURE OF THE CRANIUM.

CASE 1.-Compound Fracture if the Skull, withDepression, unattended with symptoms of Com-pression of the Brain.-Operation, and FatalTermination.

b this case there were no symptomspresent, indicative of compression of thebrain, although the bone was extensivelydepressed. Mr. Travers, however, adoptedthe same plan of treatment as in the casereported last week, where symptoms of com.pression did exist, and for the reasons statedbelow, which are strictly in accordancewith the principles inculcated by SirAst]eyCooper. It is perhaps unnecessary to re.mark, that the practice of operatng in eesrycase of compound fracture, of the skullwith depression is strongly objected to bymany surgeons: it is a practice, however,generally pursued at these Hospitals.

J. Williams, aged 13, a robust, healthyboy, was brought to the Hospital on Sundaynoon, November llth, in consequence ofhaving received severe injury to the head,about half an hour previously. The acci-dent was occasioned by the falling of a

brick wall, the remnants of a fire, whichoccurred in Queen Street, a few days be.fore : lie was buried in the ruins, and wastaken out in an insensible state. Whenadmitted, he had in a great measure reco.vered his sensibility; the surface of the bodywas cold and damp, pulse feeble and iire-gular, countenance pallid, pupils dilated,but obedient to the stimulus of light. Hevomited once, and complained of pain in thehead. On examining the head, two trans-verse lacerated wounds were observed,about three inches in length, extendingacross the vertex towards the right ear:the edges were separated, and dirt was

mingled with the blood, in the wounds. Atthe lower wound a portion of bone couldbe felt very sensibly depressed, and thesame also with the upper wound to a lessextent.

It was deemed advisable to send for Mr.fravers, who arrived at the Hospital abouttwo hours after the patient’s admission ; atthis time reaction had taken place, the pulsehaving become more regular, and the surfaceof the body warmer. Mr. Travers, havingexamined the wounds, and readily disco.vered the depressed bone, remarked, thatalthough there were no symptoms of com.pression, yet he considered it proper to re-move the depressed portions of bone, for it- vas highly probable that they would act asirritants and produce inflammation of the

477

meninges, when it would be of no avail tooperate.The boy having been removed to the

theatre, the operation was commenced byenlarging the lower wound downwards andbackwards,when the depressedbone was ren-dered very apparent. A portion of the poste-rior superior angle of the right parietal bonewas seen to be fractured transversely, to theextent of about two inches in length, and aninch and a half in breadth ; the bone wasconsiderably depressed below the level ofthe surrounding portion, and was drivenunder at the upper part. A small portiononly was detached, which was removed. Itwas evident that the depressed bone, fromthe circumstance of its being driven under,and firmly wedged in, could not be re-

moved without cutting away a portion of thesound bone ; this was accordingly done,with Hey’s saw, but not wichout much diffi-culty. This having been at length effected,the elevator was used, and considerable forceemployed, in order to raise the bone, whichwas done by piece-meal ; a small part of theinner table of the skull, which remainedafter the use of the elevator, was taken awayby means of dressing forceps, and this wassucceeded by a copious discharge of venousblood. The bleeding was at first attributedto the supposed circumstance of the longitu-dinal sinus being wounded, but subsequentlyit was discovered that the blood proceededfrom a large vein, passing to the sinus: adossil of lint was applied, and the bleedingwas easily restrained. The whole woundwas covered with simple dressing, and theboy put to bed; absolute quietude beingenioined.

Monday 12th. We learn this morning,that shortly after the operation the patientslept; in the evening the pulse was stronger,but compressible, and he complained of painin the forehead ; there had been no furtherbleeding from the wound. The pulse was80, early this morning, and slightly inter-mitting ; he had, however, passed a quietnight: the lint was removed from thewound, and no bleeding ensued. A dose ofcastor oil was given, as the bowels had notbeen moved. At noon, when seen by Mr.Travers, there was considerable alterationin the patient’s condition ; the pulse at thistime was small and weak-the skin mode-

rately warm-the pupils natural, but therewas a dull expression of countenance. Heanswered questions, somewhat unwillinglyand hesitatingly : there had been some

bleeding from the wound. The oil havingbeen rejected, and the bowels not yet actedupon, Mr. Travers directed an enema to beadministered, with four grains of calomel, afew hours after, if required.The lad continued in much the same state

for several hours, then gradually sunk, anddied at six o’clock in the evening.

Post Mortem Examination.

This was made on the following day byMr. Ward. Externally, there was nothingremarkable to be observed: on removingthe calvarium, the vessels of the dura materwere seen to be congested generally, andthere was a wound of this membrane, cor-responding to the fractured portion of theskull, of about half an inch in extent, and ata short distance from the lateral sinus.The pia-matral vessels were gorged-notwith black blood, but with a fluid resemblingblood, which had undergone a partial de-composition ; the membrane was readilydetached from the surface of the brain.The substance of the brain presented nomorbid appearance. No other part of thebody than the head was examined.

CASE E 2.-Compotind Fracture of the Skull, withdepression, unattended by symptoms of Cam-pression of the Brain.—Operation, and FatalTerntination.

In this case, there was less extent of dee

pression of bone; it was however elevated,in accordance with the principle laid downin the former case, by Mr. Travers. Thetermination of this case will be found to bevery remarkable, symptoms of high nervousirritation supervening on the second dayafter the operation, and eventually provingdestructive. Dissection, as usual, revealingnothing in this disorder of function.

S. B., pet. 12, of spare habit, was broughtinto the hospital at the same time with thepreceding case, the accident having oc-curred from the same cause.When admitted, a circular portion of the

scalp, about two inches in diameter, wasfound torn from the cranium, and reflected ;the bone was denuded of pericranium to

some extent. There was a fractured por-tion of bone, of about the size of a sliilling,very evidently depressed, at the upper andback part of the left parietal bone. The

pulse was small and irregular, the skin cold,the pupils natural; he was perfectly sen-sible.

In addition to the injury of the head, therewas a lacerated wound at the outer angle ofthe left orbit, extending some way abcveand below : the globe nf the eye was not in-jured. There were bruises in various partsof the body, especially on the right sideof the chest and hip.Mr. Travers having examined the case,

and Mr. Tyrrell also, (who was accidentallyat the hospital,) it was agreed upon to per-form an operation for the removal of the de-pressed bone, and this was readily effectedby the elevator, the bone not being im-

478

pacted, as in the former case. The duramater was uninjured. The wound was

dressed with simple dressing, and a few

strips of adhesive plaster lightly applied.12. The patient has slept well during

the night; he is quite sensible, and com-plains of pain at the back part of the head ;the skin is hot, tongue white and moist,pulse 90, and somewhat sharp. He took adose of castor oil early this morning, whichhas operated freely; the wound at the eye ehas discharged some blood.

13. This afternoon, the patient began toexhibit symptoms of nervous irritation,being very restless and fidgetty ; he was,however, perfectly sensible. The bowelshad been very much disturbed by the castoroil exhibited yesterday. Mr. Travers, con-sidering the symptoms to be referrible to astate of undue nervous excitement, and notdependent upon inflammatory affection, di-rected an opiate injection to be adminis-tered, and a dose of castor, with aether, tobe given every four hours. A blister to beapplied to the nape of the neck, with threeleeches to the temple.

14. The opiate injection procured somerepose, and the patient is, upon the whole,somewhat less irritable ; the pulse is small,and upwards of 120. The leeches were

applied, but not the blister ; the castor andaether were rejected, and therefore discon-tinued. There is nothing remarkable inthe appearance of the wounds, to which abread and water poultice is applied.

15. The patient, to-day, may truly besaid to be labouring under the highest pos-sible nervous excitement; he is talking in-cessantly to himself, and has been doing sothroughout the night, almost without cessa-tion ; the pulse is exceedingly rapid and

small ; the bowels have not been movedsince Tuesday night. Ordered to take five

grains of calomel immediately, and a salinedraught, with five minims of laudanum,eve v four hours.

The symptoms continued unrelieved

throughout the day and night, and he diedearly on the following morning.

Post Mortem Examination.

The body was examined a few hoursafter death. There was some discolourationof the integuments around the immediateseat of injury. The calvarium having beenremoved, which was accomplished withmuch difficulty, the dura mater was foundto be perfectly healthy, but a circle of rup-tured blood-vessels was apparent at the

part corresponding to that portion of theskull whence the external pericranium (aswe have described) was detached. It seemedthat a far more intimate vascular connexionthan natural had taken place between theinner surface of the bone and dura mater,

and this occasioned the principal diffi-

culty in raising the skull cap. The sur-face of the brain was. equal ; there was noappearance of any previous compressionhaving existed. The arachnoid tunic and

pia mater were even less vascular thannatural, as was also the substance of the

! brain, which was, however, soft generally.We might perhaps except one portion op-posite to the depressed bone, which wascertainly more than usually vascular through.out its cineritious structure. No further

examination was made.

CASE 3.—SIMPLE FRACTURE OF THE CRANIUM,’I WITHOUT DEPRESSION, ENDING FATALLY

’i FROM EXTRAVASATION OF BLOOD ON THE

I BRAIN.

Sinaular Chionic Disease of the Brain.W. M., a boy apparently about 15 years ofage, was admitted into the Hospital on theafternoon of the thirtieth of November, hav.ing fallen upon the pavement from a consi.derable height, whilst employed in cleaninga window. He was picked up, in a sense.

less condition, and brought to the Hospitalsoon afterwards : he vomited once or twiceon his way thither.When admitted his face was pallid, the sur-

face of the body cold, and the heart’s actionwas so feeble that the pulse at the wrist wasa mere thread : the pupils were dilated andfixed ; in fact all the powers of the bodywere prostrate. Upon examining the headcarefully no wound could be detected; butthe scalp was much swollen, apparentlyfrom the extravasation of blood : this wasmore especially the case at and about the

junction of the right parietal with the occi-pital bone, there was also some swellingabout the left temporal bone. No fractureor depression of the bone at any part couldbe found.The means first employed were those cal.

culated to produce what is called reaction,and consisted in the application of warmthto the surface of the body, and the exhibitionof a small quantity of brandy and water, fromtime to time.‘

Dec. 1. The boy now lies in a state ofpartial stupor, from which he is easilyroused, and then tosses about in a wild, irre-

gular manner, apparently without being atall conscious : he cried last evening, but has

not spoken. The left radial pulse is about7’4, weak, and somewhat irregular; the

This treatment -was directed by the

dresser, Mr. Oates, and not by Mr. Travers,cis it has beet wilfully mistated. The pa-ltient came into the Hospital about three o’clock on the Friday afternoon, but teas notseen by Mr. Travers until the,fuliau:ingmnrn-, ing.

479

right radial pulse is scarcely perceptible ; -the pupils are dilated, but fain’tly obedientto the stimulus of light; the bowels havebeen freely relieved by a turpentine enemaexhibited during the night. There is no

pain evinced when the right arm is smartlypinched, but the opposite limb has full sen-sitiveness ; and, singular enough, when thisis pinched he moves the right arm.Mr. Travers saw the patient at nine

o’clock this morning, and directed the ap-plication of leeches to the temples ; theenema to be repeated. Five grains of calo-mel had been given by the dresser.Dec. 2. Sunday. 3 p. m. There is not

much alteration in the symptoms of yester-day ; the pupils dilate on the admission of

light; the left radial pulse is now small andquick, about 100 ; the dresser informed usthat it has varied much during the night,being at one period very rapid and at ano-ther time slow.

3. Noon. The boy remains in the samecomatose condition ; the pulse at the leftwrist is small and quick ; the right pupil isdilated and the left is contracted, and thelatter dilates when light is thrown uponthe eye. The bowels were relieved at nineo’clock this morning.At three o’clock this afternoon, Mr. Tra-

vers saw the patient, and divided the scalpvery freely at the part we have describedas swollen on his admission, under the sup-position that a slight depression of the bone,which had not yet been perceived, mightexist. No fracture or fissure, however,was detected. The boy was roused, andsensible of pain during the operation, butspeedily fell into the same state of partialstupor, as before. The cellular membrane Iof the scalp was found to be loaded withextravasated blood : the subsequent bleed- Iing from the cut was not considerable. Itwas not deemed proper, by Mr. Travers, to ’,,adopt any further means.

4. The lad was much the same at’noon,to-day, as yesterday; but, at about 4 p. rn.,lie became very restless ; tossing himself toand fro, as if suffering much pain ; the

pulse became more feeble, and the counte-nance anxious. Nothing further was done ;Mr. Travers considering it to be a " lostcase."

5. Noon. He is now quiet ; the pulse isupwards of 120, and feeble ; one pupil iscontracted and the other dilated No fur-ther means have been employed .6. Noon. Evidently in a dying state. He

expired in the evening.Examination of the Head.

This was conducted by Mr. Mackmurdo :upon denuding aod examining the skull

carefully, a fissure was found, commencingat the coronal suture on the left side at the

point where it is crossed by the anteriormeningeal artery, and passing downwardsand along the os frontis, to the right exter-nal angular process. In addition to this wasa second separation of bone ; the coronalsuture from the point above mentioned, atwhich the first- fissure commenced, was

I asunder to within a short distance of thesquamous portion of the temporal bone ;and here the fracture, leaving the courseof the suture, took an oblique directionbackwards, for a short distance.

Tracing the inside of the cranium with thefinger, a slight irregularity of bone was feltat the upper part of the os frontis: upon thedura mater, corresponding to this part of

" the bone, was a small clot of blood, and thiswas the only morbid appearance observedon this membrane. When the dura materwas detached, then the mischief which had. ensued became apparent: there was veryextensive extravasation of black blood upon

the brain, at the upper part and side of thel m,.dclle lobe of the right hemisphere. Thusfar, of the result of injury ; but continuingthe dissection, a singular chronic disease ofl the brain was discovered :-on separatingthe hemispheres, in lieu of the corpus cal-losum was seen an opaque whitish cyst,

- which readily burst and discharged a con-siderable portion .of serous fluid. This1 cyst was placed at the under part of theleft hemisphere, immediately above the la., teral ventricle ; in fact, the lower part of

the cyst was partially the covering or roofof the lateral ventricle. It was nearly ofthe size of.a pigeon’s egg, smooth, polished,and vascular on its inner surface. The leftventricle was greatly distended, containingseveral ounces of serum ; there was no ap-

pearance of the corpus callosum, or of thefornix ; the floor of the ventricle being co-vered by a thin membrane (the velum inter-positum?) The brain was now removed and

put in spirit for the purpose of hardening it,and thus allowing of a more minute exami-nation, when the right ventricle was foundequally distended with the left, and it wasnow also distinctly ascertained that therewere no relics of the corpus callosum. A

slight portion of the fornix was perceptibleon the right side, and also its anterior

pillars.The upper part of the spinal marrow, we

omitted to say, was examined, but nothingmorbid was detected ; n ) other part of thebody was inspected. We find upon inquiryof the boy’s parents, that he was a lad ofweak mental powers, retaining his childishhabits and pursuits to an advanced period.He had of late, however, filled a situation oftrust, being accustomed, as his mother states,to take care of sums of money, which he didwith accuracy and fidelity. She remarkedalso, that he was frequently in the habit of

480

laying his head. down, even when he sat attable, but never complained of pain. Hewas a patient in Guy’s Hospital more thaneighteen months ago, on account of injuryto the neck from a blow, and he felt for aconsiderable time afterwards stiffness aboutthe part.

OPERATION OF LITHOTOMY BY MR.TRAVERS.

Ou Friday last, Mr. Travers performedthe operation of lithotomy on a boy four

years of age. The gorget was used on thisoccasion, and a calculus of about the size ofa hazel nut extracted: the patient is doingwell.

ABUSES AT ST. THOMAS’ S HOSPITAL.

A ST. THOMAS’S PUPIL.

To the Editor of THE LANCET- - ,

SIR,—It is with regret I am compelledto have recourse to the plan made use ofby my brother chips, at the other Metro-politan Hospitals ; but since abuses are get-ting to such a height here, I must crave

permission for a corner in your valuable

publication. The first thing 1 have to men-tion is, with regard to the Sectio Cadaverum.It is shameful to think that so much moneyhas been stolen from us, (for so it mayjustly be termed,) since it was paid for theprivilege of attending these examinations;yet day after day occurs without a singlenotice being’ stuck up. Some little time

- since, Dr. Williams thought proper to havenotice given, but within one week this im-proved plan of proceeding stopped. I think,Sir, it would be no bad plan to suggest,that these examinations might take place inthe Demonstrating Theatre, against the door’of which, as well as in the Surgery, a noticeshould be posted, as each pupil might thenhave an opportunity of witnessing the mor-bid appearances with satisfaction to himself,for in so small a place as the Dead-housethere is such cramming and pushing thatall cannot conveniently see. Another thingI beg to propose is, that a certain time befixed for these examinations to take place.With regard to the attendance of the sur-geons of this establishment, I must, thoughunwillingly, complain of Mr. Green and Mr.Travers ; I am sure no student can conscien-tiously complain of Mr. Tyrrell’s neglect, hebeing regularly at his post within a minute ortwo of twelve o’clock, whereas the other twogentlemen seldom make their appearancetill one, and often after that time. It wasa short time since proposed, by a few stu-dents, that the anatomical lectures shouldbe delivered half an hour later, as there

would be then more time to attend to thesurgical practice of the Hospital, and thesurgeons would probably be more punctulin their attendance ; but since the altera-tion has taken place, I am sorry to say thedelay in making their appearance has, onthe contrary, increased.

Trusting that what I have said may havesome influence towards the acquisition ofthe rights of myself and fellow students, Ihave the honour to remain,

, Sir, your obedient servant,A ST. THOMAS’S PUPIL.

December 14, 1827.

TO CORRESPONDENTS.

MANY communications have been received,and for which we return thanks. Severalof them will be most useful.

We should feel greatly obliged to "X."if he would be more explicit on the subjectmentioned towards the close of his letter.

11 R.L. Y." will perceive that the "cases"were not wanted ; we entreat him, how-ever, to keep his eye on the whole of theparties. It is our duty to look out forsqualls.

Several Students belonging to the St.Bartholomew’s and Webb-street Schools,complain of the disgusting conduct duringlecture, of four or five ignorant puppies,who are constantly annoying the class bythrowing pieces of paper, orange peel, andother missiles, at such pupils as are desirousof attending to the discourse of their

’ teachers. Why not give the fellows a duck-ing under the pump 1 At all events, if thenuisance should be continued, we will pub-lish the names of the offending parties.The statement of " An Eye-witness"

will not be forgotten.Mr. LAWRENCE’S reply to Messrs. Cooper,

Travers, and Butter, has been received, butis unavoidably postponed. It shall, how-ever, certainly appear in our next number.

THE LANCET.

ON Saturday, Jan. 5, 1828, a STAMPEDEDITION of this Journal will be published,(price is.) which may,be sent, FREE oF

POST, to any part of the kingdom ; alsoto the BRITISH COLONIES, on paymentof three half-pence, at the General Post-Office. Orders for this Edition should beforwarded, as quickly as possible, to theLondon N ewsme1l.