ranging it, for such an impression; thus in the case of the eye, or of the ear, the first movements which follow a noise, or strong light are certain automatic and in. voluntary actions of the muscles subservient to the organs of vision, or of hearing; the object of which actions is either to mitigate, or to increase and concentrate the external impressions. Now these actions are under the influence solely of the medulla oblongata; but the perception of the impressions belongs to the brain, and to the brain alone; for the brain is the organ of the faculty which wills, and of the faculty which perceives and judges. We are therefore not to regard the medulla oblongata and spinalis as the seat of special and general sensation; they are, so to speak, points of transition, or organs intermediate between the external part on which the impression is made, and the brain which perceives the impression; the function of the medulla being rather to excite a train of movements (those of general locomotion), destined to withdraw the individual organ, or to approximate it to the external agent, or, at other times, to modify and alter the condition of the organ itself; in short, to determine and regulate those special actions which are necessary to the accomplishment of the functions of sense.

MM. Majendie, Dumeril, and Serres, suppose that the trigeminal nerve is fundamentally the real nerve of all the special senses; that it bestows, by a mode of influence which we do not understand, the special sensibility on the optic, olfactory, auditory, and gustatory nerves; and that frequently, especially in the lower animals, it takes the place, and exercises the functions of these nerves. The following are the chief arguments adduced in favour of these opinions. 1. In the mole, there is no optic nerve, but instead of it, there is a twig of the fifth pair; in fishes, there is no auditory nerve; in the cetacea, no olfac tory nerve; and yet these animals have in all probability a certain degree of the corresponding sensations. 2. When the

fifth pair is divided, all the special senses are destroyed, or at least enfeebled; when the special nerves alone are divided, the animal still retains in part the capability of perceiving odours, tastes, sounds, and light; but if the fifth pair is divided at the same time, these sensations are utterly and entire y annihilated. 3. Certain of the special sensations may be produced in other ways than the contact or impression of their ordinary stimuli; thus, for example, sound may be heard, although the external ear be plugged up, if a watch be applied to the head, or put between the teeth. 4. The occurrence of amaurosis, anosmia, and agenstia, from neuralgia of the trigeminal nerve. In answer to these arguments, we may state that division of the fifth pair does not immediately and instanter destroy any of the special senses; that a certain interval elapses, and during this interval, certain changes have taken place in the texture of the parts on which the nerve was distributed; thus in regard to the eye, the cornea becomes opaque, the conjunctiva inflamed and the humours muddy: the same results follow any injury or disease affecting this nerve; very different, however, is the effect of the division of the optic nerve; the sight is gone instantaneously and for ever. As to hearing the ticking of a watch, when put between the teeth, it is easily explicable on the well-known laws which regulate the transmission of sonorous vibrations; in a similar manner can we understand that those animals which have no external ear, as seals, moles, fishes, &c., may yet have the sense of hearing. And again; can we not hear the noise of our own voices, even when the ears are firmly plugged, and excluded from any atmospheric impulsions on the tympanum? We readily admit, that the 5th pair is intimately connected with the functions of the four special nerves; but this connexion is indirect, and arises from the trigeminal being the nerve of general sensibility, and of common mcbility to the hand and face; and when it is destroyed, or disused, certain morbid

enforced, since, from the predisposition the great susceptibility to every passing impression, moral and physical, and the little resolution which such individuals are capable of exerting, we find them constantly returning to a state of mental aberration, and presenting a life spent between intervals of sound mind and healthy actions, and the feelings and the actions of insanity.

The former class of cases again requires a steady perseverance in antiphlogistic measures, limited, however, in general, to local depletion, and such other means, as do not depress too much the strength of the general system.

29th March, 1832.

XLI.

ANEURISM BY ANASTOMOSIS. Dr. MACFARLANE in his Clinical Reports makes the following remarks on the subject of nævus, and relates three cases not devoid of interest.

"That species of aneurism by anastomosis to which the appellation of nævus is applied, is a disease now often met with in children. During my attendance at the Infirmary, I have seen above thirty cases, the majority of which were treated as out-patients, and have had opportunities of comparing the merits of the different plans of cure which have at various times been adopted. In shortly noticing the size and other external characters of these tumours, I was careful also to preserve a description of their exact situation; and I find, in reference to this point, that more than two-thirds of them were confined to the anterior aspect of the body, and that considerably more than a half were situated on the head and face. All of these, except one, were observed at birth,-grew with greater or less rapidity, and varied in extent from about quarter of an inch to fully three inches in diameter. They all projected more or less beyond the level of the surrounding parts: and, in a few VOL. XVIII. No. 36.

cases, ulceration of the thin integuments with which they were covered took place, giving rise to troublesome hæmorrhage. In three of these there was gradually projected from the ulcerated surface a fungous tumour, which rapidly increased, assumed a pyriform shape, bled on the slightest touch, and appeared to possess all the characters of the original disease. When ulceration does not take place, then the superjacent skin, by the morbid enlargement of the subcutaneous vessels, is gradually and unequally elevated; but it is seldom that the diseased mass extends more than an inch beyond the level of the adjoining healthy parts. I have seen two cases, however, in which the disease did not increase in breadth, but continued to project, while the integuments were entire, so as to form livid and pendulous tumours."

CASE 1. Aneurism by AnastomosisLigatures-Convulsions.

A child, nine months old, had a tumour, about the size of a grape, over the anterior superior angle of the left parietal bone, which had all the characters of aneurism by anastomosis. A needle, armed with a double ligature, was passed under its base, and each half of the swelling was tightly tied, so as to cut off its supply of blood. The child was teething: it cried bitterly, and was fretful and uneasy for several hours. During the following night it had an attack of convulsions, which continued for fifteen minutes, and returned with undiminished violence after an interval of two hours. The ligature was immediately removed, and the convulsions ceased. In four days the tumour sloughed, and a cure was speedily accomplished.

CASE 2. Aneurism by Anastomosis cured by temporary Ligature.

Dr. Macfarlane was induced by the circumstances of the preceding case to leave the ligature only for a short period in another instance.

A child, 8 months old, was brought to the Infirmary to have a pyriform tumour 44

removed from the edge of the under lip. It was, when observed at birth, about the size of a split pea, of a livid colour, and on a level with the surrounding integuments. It remained stationary for the first three months, after which time it began to increase rapidly, and to project in a pendulous form. The integuments were entire: the apex of the tumour, which was about the size of a walnut, was irregular and doughy; whilst the neck, which was not larger than a quill, was hard and smooth, and the pulsations of its vessels were distinctly perceptible. A broad ligature of tape was firmly applied, close to the base of the tumour, and removed in 24 hours. With the use of cold this temporary ligature was perfectly successful, the tumour sphacelating, and the lip cicatrizing.

We apprehend that this practice is more likely to succeed in cases like the preceding, where there is a narrow and distinct pedicle, than in others where the origin of the tumour is more diffused. It is sometimes difficult to include the whole of the disease by the ligature applied in the most efficient manner. Indeed, Dr. Macfarlane's third case is one in point.

CASE. 3. Aneurism by Anastomosisincomplete Ligature.

W. H. aged seven months, had a soft, unequal, purple-coloured tumour, about the size of half-a-crown, on the anterior surface of the left arm, two inches above the elbow-joint. It was elevated a little above the surrounding parts; and when firmly compressed, an obscure thrilling or slightly pulsatory sensation was perceptible. It was tied with a double ligature, as in the last case, and in six days the tumour separated. The exposed surface, which had at first a sloughy appearance, soon became clean and florid; and, except a small spot in the centre, it was evident that the diseased structure was completely destroyed. Here, however, a large spongy tumour formed, which was of a dark colour, and bled profusely. Pressure by means of a compress and bandage, the free application of nitric acid, caustic, &c., were

ineffectual in checking its progress. The actual cautery was at length had recourse to; and by four applications of it, the morbid growth was destroyed, and a cure accomplished.

Whatever is capable of exciting inflammation in these vascular tumours, and of producing either ulceration or consolidation of their loose texture by the effusion of lymph, may put a stop to their progress, and ultimately lead to a cure. For this purpose I have used vaccination with success in five cases; and in one case, where the disease extended over the whole surface of the lower eye-lid, and where neither the ligature nor the knife could be employed without producing deformity, I succeeded in exciting inflammation of the tumour, by introducing a seton close to its base, and retaining it till partial suppuration was established. In another case, where the discase was confined to the inside of the lower lip, the seton proved unsuccessful, and ligatures had to be employed.

There can be no question that the ligature, when applicable, is the least tedious and the most certain method of removing nævi. Next to the ligature probably comes excision. Vaccination we have tried, and seen tried without success. It is a pretty rather than an useful plan of treatment, at least we have found it such. We have not ourselves seen any bad consequences from the operation. Erysipelas followed in one child, but it did

well.

XLII.

INJURIES OF THE HEAD. "WHEN a large quantity of blood is ef fused under the scalp, its evacation by incision is seldom required, unless for the purpose of ascertaining the state of the bone, and that only when symptoms of compressed brain exist. The extravasated blood will be slowly absorbed, and the detached scalp regain its former connexions, while the removal of the fluid by puncturing the tumour, will not unfre

quently give rise to troublesome and extensive suppuration."**

Nothing can be more true than this observation. Most surgeons must witness cases of fluctuating tumour of the scalp after injury. For the most part there is little or no pain, nor any fever. But fever may be accidentally present, and from certain circumstances there may be some tenderness. The surgeon is then induced to puncture the swelling, fluid blood issues, and a troublesome suppuration in the cavity ensues. We have seen this mistake made with this result. If the fluid collection of blood be small, it is well known how much it may simulate a depression of the bone. Blood is injected and coagulates in the surrounding cellular membrane, and the yielding fluid portion counterfeits depression. This mistake also is not uncommon. We know not whether fluctuating tumour of the scalp, apparently from blood effused, be common in newly-born children, but we have seen one instance of this description. The infant was one or two months old, the fluctuating tumour as large as an apple, and situated over the pariental bone; there was no pain, no cerebral disturbance: The labour had been difficult. But we will give Dr. Macfarlane's case.

CASE 1. Concussion-Effusion under the Scalp-Cure.

A stout labourer, thirty-eight years of age, was struck on the left side of the head by a brick, which fell from a considerable height. He lay in a state of stupor for nearly an hour, when his sensibility was gradually restored; and in a short time longer he was able to return distinct answers to the questions put to him. He complained of vertigo, headach, and nausea, which were removed by venesection, and smart purging. On examining his head, the scalp was found distended by fluid blood. The swelling, which appeared to be covered by the tendon of the occipito frontalis muscle, commenced at

* Dr. Macfarlane's Reports.

the injured part where the integuments were not wounded, and gradually extended from the left to the right side of the head, and from the superciliary ridges to near the foramen magnum of the occipital bone. By the use of a strong lotion, composed of the murias ammoniæ and vinegar, this extensive effusion of blood was slowly absorbed, and without the occurrence of a single unfavourable symptom, the parts were restored to their former state in less than a month.

Dr. Macfarlane relates two cases of concussion, both of which were cured. In the first there was probably some extravasation, as the symptoms of concussion did not soon pass away, and on the day after the injury there was slight stertor. The symptoms did not disappear in less than a fortnight, though very active antiphlogis tic treatment was employed. Dr. Macfar lane remarks that the symptoms of concussion often run so gradually and insensibly into those of inflammation that it is difficult to pronounce upon the boundary between them. This is true. There is, however, one good practical rule-to sin on the side of depletion. If the symptoms do not subside in a reasonable time, it is probable that either extravasation of blood or inflammatory action is present. Inflammation never proceeds to any extent without fever-a frequent pulse, skin more or less warm, secretions more or less altered. This is the grand diagnostic mark of inflammation, and one that can seldom deceive.

Dr. Macfarlane observes, that bleeding from the ear is oftener met with in fractures of the base of the cranium, than in simple concussion of the brain. Out of four cases of concussion in which this symptom was present, and witnessed by Dr. Macfarlane, two proved fatal, and on inspection neither fractures nor laceration of the lateral or cavernous sinuses could be detected. Dr. M. considers, therefore, that both venous and arterial blood may be discharged from the ears as from the nose by laceration of its own blood-vessels.

All who have seen many cases of injury of the head, will corroborate Dr. Macfarlane's view of the subject.

on extravasation of blood. For, as he remarks, it does not necessarily follow that when a small portion of the brain is lace

"W. B., æt. 50, was admitted on the 31st of January, 1832, having received several severe blows on his head ten days before, which produced immediate insensibility, vomiting, and bleeding from the left ear. He lay in this state for several hours, and then recovered so far as to be able to answer questions, though rather incoherently. In a short time, however, the stupor began again to increase, and, on his admission, the existence of partial compression was distinctly marked. He was dull and drowsy, and when asleep his respiration was stertorous. It was only after shaking him, and speaking to him with a loud voice, that he could be induced to open his eyes, which had a vacant expression, the pupils being dilated and torpid. For the first two days no answer could be obtained to any question that was put to him, but after the repeated application of leeches and blisters to the head and neck, and the use of purgatives, he became more sensible, his pulse rose from fifty-two to eighty in the minute, but he was still incoherent. Calomel was given as an absorbefacient. When the gums were affected, the improvement became more decided, and, in ten days from his admission, the symptoms of compression had altogether disappeared. His mind, however, continued imbecile; his memory was much impaired; he could not recollect the names of his children, or of any of the objects around him with which he was most familiar, and he complained of deafness, headach, and vertigo. When dismissed on the 18th of February, his memory was partially restored, but a degree of fatuity still remained."

Dr. Macfarlane observes, with reference to the preceding case, that the symptoms which developed themselves subsequently to the subsidence of the primary symptoms of concussion, depended in all probability

diate. The collapse produced by the injury may prevent the flow of blood from the divided vessels at the time, and they do not bleed until reaction is established. Be this as it may, nothing is more common than to observe the symptoms of concussion to diminish, and symptoms of compression to come on, unattended with any evidence of inflammatory action. If, indeed, the extravasation is extensive, there is usually no pause, the symptoms of concussion being mixed in the first instance with those of compression, or merging indistinguishably into them.

It is not unfrequently said, and in works on surgery it may be seen, that patients may die from concussion alone. We must confess that we are very sceptical on this point, and whilst we are well aware that the thing does occasionally occur, we be lieve that the occurrence is extremely rare. That patients die without ever rallying from the state of collapse is most true, but in all the cases of this description that we have witnessed, there was more or less destruction of the organization of the brain, or effusion of blood, or other destruction of parts.

Dr. Macfarlane has met with three fatal cases of concussion attended with laceration of the brain, the laceration corresponding in none to the part of the skull on which the blow was inflicted. These injuries were confined to the upper and under surfaces of the cerebrum, and to the central commissure; the effusion of blood was considerable, and in one of the cases it was injected into the substance of the brain to some distance around the injured part.

Dr. Macfarlane thinks that secondary hæmorrhage may occur in the brain as elsewhere, and details a case in which he believes that it occurred. He is more confirmed in his opinion from the circumstance of a very similar case having been