the one by the breech or head, and the other transversely, are about one to sixteen. According to the same register, the proportion of twin to single births is about one in eighty; and, in about four cases out of five, the twin children have been of the same sex. When the case is one of triplets, we might expect to find the head of one presenting, the breech of another, and the third lying across at the fundus uteri; at least, in three cases which I have personally witnessed, this has been the situation. The proportion of these cases of plural births may be about one in 12,000. Twins are not usually so large individually as single children, but together they weigh more. Dr. Clarke's calculation gives us about eleven pounds and a half the pair. Besides the three cases of of the ovum laid open. e. The funis umbili calis, twisted round the neck and arm; this is not usual. f, The cervix uteri, perfectly developed. g, Ös uteri, displaying its glands, 3 enlarged under pregnancy. h, Vagina. triplets, I have personally known one of quadruplets; which are exceedingly rare. Dr. Hull, of Manchester, met with a case in which there were five children at a birth, thrown off prematurely: they all five together weighed about eleven pounds and a quarter. These foetus are preserved in the Museum of the College of Surgeons in this city, and the preparation was put up by my friend, Mr. Barlow. I believe this is the only well-authenticated case of the kind on record. CLINICAL LECTURE ON FRACTURE OF THE SKULL. Delivered at the Middlesex Hospital, BY SIR CHARLES BELL. I SHALL not say a word upon the dissection before you (that of a leg which had been amputated the day before, for a tunor of malignant growth in the tibia), beCause I will not break the connexion of the lecture; but I beg you to look at it to-day, and on another occasion I will offer a few remarks respecting it. Fracture of the Parietal Bone-Trephining. -In continuation of the subject which last engaged us-fracture of the skull try to recollect the chief circumstances attending the case of Thos. Garlic, a young man, 24 years of age. It appears that he was struck by some part of a steam-engine in motion. I know not the form of the part of the engine, or the velocity with which it descended, but it was remarkable that the blow occasioned only a momentary insensibility, and that the patient walked into the ward. The integuments were open, the skull was fractured in the parietal bone, and there was a slight depression. In the meantime, no symptoms were apparent-the mind was collected, the senses perfect: he had lost a considerable quantity of blood from the integuments, and blood oozed from the fracture. The pulse was frequent from the first (this, by the by, is a contradiction, as to there being no symptoms): I found his pulse up to 120. This was subdued by the means employed. On the second day the pulse began again to rise, and continued rising; and more distinct symptoms of inflammation came on. A consultation was called, and the operation of trephining was determined on. Why was it determined on? We are met that I may explain why; and the subject is an important one for you to reflect upon. The edge of the fractured bone was rough externally; and such being the case, it indicated that it must be sharper still internally, that, in all probability, this rough or sharp edge was pressing upon and irritating the membranes of the brain. This plan [presenting it] will shew you where the trephine was applied. It was necessary to soothe the patient during the operation; which is of the utmost consequence; because struggling and outcry are attended with great forcing of the blood to the head. The operation was, therefore, performed with all possible gentleness and precaution, so as to keep the poor man quiet, and this principally, you are aware, by avoiding much interference with the integuments. The day after the operation stupor came on, and that stupor gradually increased with a rising pulse, so that it was counted 150: this was attended by loud snoring, and at ten P. M. by convulsions. The action was greater on the left than the right side of the body; the left arm and leg became rigid and cold; the right eyelid hung down, and he died twenty-four hours after the operation. On examination after death, a thin clot of blood was found under part of the bone. There was no blood under the dura mater, which some of you conceived, from the symptoms, to be the condition. There was, however, an effusion of lymph and purulent matter, not only upon the hemisphere of the brain under the part operated upon, but also extending to the other hemisphere. There was serum in undue quantity in the ventricles, and under the tunica arachnoides at the base of the brain. This history, and these appearances in the dead body, imply that the patient died of effusion consequent on inflammationand that inflammation propagated from the wound and local injury of the brainrather than of the concussion and general injury. This being the last of the cases of fracture of the skull which I have to place before you, let us endeavour to recapitulate— or I would rather say, let us consider-the subjects which should most interest you, as leading to a just view of the pathology of these cases. Concussion. Let me advise you, in studying this subject, to endeavour to distinguish the state of concussion. You understand it to be the effect of a vibration from the blow, which goes round the skull and through the brain, affecting the wholean effect which will be immediate. An injury to the brain, a part so abundantly supplied with blood, has, as I have already stated, certain and immediate consequences: and you will notice the stages proceeding from this condition. It has three stages-insensibility, excitement, and effusion: the insensibility is the direct effect of the injury; the excitement is consequent upon the rising of the inflammation from the injury; and the effusion results from the inflammation. You see the man at first lying like a person dead; lift him up, and he scarcely breathes: you feel his pulse, but you can scarcely perceive it; he is cold and insensible; he is like one in danger of instant death. But, by and by, there is a flushing of the face, an increased action in the arteries of the temples; increased heat of the body: these are symptoms of inflammation; and with the rising of the inflammation, there is a return of sensibility, in a certain degree, too often to be followed by a deeper insensibility than at first, differing from the insensibility which was before noticed by the stertor in the breathing, an effect, therefore, of effusion-an effusion which implies the compression of the vessels of the brain, and a certain interruption to their activity. If he recover from this condition, he is still subject to another effect of inflammation-that of the deposition of coagulable lymph; and if he sur vive this, he is too apt to be deprived of some functions; to be prone to disordered health, and to singular changes in temper or disposition. I hope you have attended to a very interesting case of inflammation, and its consequences, after concussion, in a woman who was placed downstairs, from her violence and outery disturbing the other patients. I am sorry to say that the account of it is not before us. Inflammation.-The next head for remark in studying this subject, is inflammation of the brain. You remember that there is inflammation in this organ from injuries, similar to that idiopathic inflammation which you learn from your medical studies,and marked with all thes symptoms of high action in the vessels of the head. But we have to notice that there is an inflammation different from that, in as far as it is not marked by the same distinct symptoms, but yet is sufficiently apparent when you see the effects in the dissection of the body. Thus, from a blow upon the head, from a depressed bone irritating the brain, from the presence of a dead bone irritating the surface of the brain, you have a deep abscess or suppuration in the substance of the brain, with adhesions around it, and all those consequences which you know must have resulted from inflammation. Inflammation, then, is present during life, but there are none of those symptoms which you learn to enumerate under the head of idiopathic inflammation -no flushing of the face, throbbing of the temples, or general excitement, or violence; but, on the contrary, the man is torpid, or sleepy: you can rouse him for a time, but by and by you cannot, and so he falls into a deeper insensibility, and dies. When you dissect him you find, as I have said, a well of matter in the brain, and all the effects of deep and great inflammation. Thus you perceive it to be necessary that the surgeon should study most carefully that partial and insidious inflammation which is attended with destruction of the brain itself: and while we are on the head of inflammation, may I entreat you to remember that in its commencement you will often be deceived by a seeming amelioration of the symptoms; that is to say, the man comes in, perhaps, with compression of the brain, perhaps with concussion, and he lies insensible? By and by, the friends are agreeably surprised to find that he sits up in bed, that he points to them, and converses with them, and they think he is about to get better, to survive the accident; but presently he falls into what I described before as a state of deeper insensibility. So in the history of almost all cases, we find the surgeon pleasing himself with the effect of his operation of trephine. The man is carried out of bed in a state of insensibility; the integuments are opened; the trephine is employed; the bone is raised; and, behold, his patient is greatly improved, for he gives tokens of sensibility, almost of restoration of sense; but too often this is not the effect of raising the bone, but results from the excitement of the operation, the struggling of the patient, and the degree of inflammatory action excited. Excitement from inflammation deceives us; we consider that there is an amelioration of the symptoms, when in truth it is a state which continues but for a time, and is the forerunner of death. Compression.-The third head, which should engage your attention, is that of compression of the brain. You are to consider that it is not, as the word implies, compression of the brain itself, but such an encroachment upon the vessels of the brain as prevents them ministering to the functions of the organ. You know very well that muscles will not continue to act unless they have the circulation through them; the eye will not continue to be sensible unless the circulation be perfect through it; and so with regard to the brain, if you take away too much blood by bleeding, you have faintness; and if the blood be prevented passing freely out of the brain, or through the brain, you find insensibility, with some variety in its cha racter, proportioned to the cause. When, from defect of circulation, for example, there is deliquium, there is not that stertor which you find accompanying insensibi lity with a full pulse. When a clot of blood occupies the brain-case, in proportion to the volume of the clot there is an encroachment on the cavity, and an embarrassment of the circulation. The ves sels cannot act freely, the organ suffers from the want of circulating blood, and the symptoms of compression are present. On this head I would have you to notice a statement which is often made, both in this hospital and elsewhere. Cases are put down as relief from compression on the brain. I will state what occurs. There is a dead portion of bone, for example, and under that dead portion there is a teaspoonful of pus upon the surface of the dura mater. The operation is performed; a portion of bone is taken away, and a little matter is permitted to escape. By and by the patient recovers, or is remarkably improved in symptoms; and the case is put down as the effect of pressure removed from the brain. Now I cannot give credit to this; for if I see effusion in ten times the quantity-if I see a clot of blood ten times larger than this, without producing any symptom, how can I acquiesce in the belief that a little matter, not more, perhaps, than half a tea-spoonful, taken away, should remove, as the term is, pressure from the brain? sure. By taking off the dead bone in the more common case, and freeing the membranes from the presence of matter, you sometimes see, happily, all the symptoms removed. I am ready to acknowledge the fact, but I cannot acquiesce in the reasoning, and I think we must take a new element into the argument: in short, I conceive that we remove irritation, not presI remember Mr. Cline narrating, during a consultation, that he had trepanned a man who had received a blow on the head with some sharp point (I forget what), and who fell into a state of insensibility, and remained long in that condition; but being trepanned, there appeared a small point, like a thorn, projecting from the inside of the circular portion of bone. By the operation the senses were restored. You will excuse me giving these remarks upon the three divisions of our subject-concussion, inflammation, and compression: I fear they are conditions little understood. FRACTURE OF THE SPINE, RIBS, LEG, AND DISLOCATION OF THE HUMERUS. Now let us turn to a subject of equal interest-fracture of the spine. Let me entreat you to omit no opportunity of studying the injuries of this part; for you know that the spine is equally important with the skull, and that it has its importance from the same causes-nmely, that it contains within it a vital organ. Study it, therefore, I entreat you. First make yourselves masters of the anatomy, and then of those subjects which are continually presenting in practice: the lateral distortion of the spine; the scrofulous inflammation of the bodies of the vertebræ; the effect of injury in producing inflammation, and thickening of the theca and membranes of the spinal marrow; and lastly, fracture and dislocation: fracture of the spine should more immediately engage your attention. You remember the structure of this column; that it is a beautiful combination you remember that the bone is light and of parts producing firmness and elasticity; spongy, and that the strength of the spine principally resides in the ligaments. So strong, in fact, are the ligaments of the spine, as contrasted with the bone, that the bone will break before the ligaments give way; and this is especially the case with the lower vertebræ when a man is crushed down and the column bent. years of age, a labourer." I am almost Now the case is this: "Joseph Neal, 40 tempted to stop and comment at that word, for certainly no philosopher could good sense, under such an affliction, and ever exhibit more temper, calmness, and under the anticipation of immediate death, than this poor man; I was struck with his unpretending Christian piety;-a labourer, whole demeanour, with his good sense, and then, admitted on the 8th November. The attendants, those who came with him, state, ground above gave way, and covered him. that whilst he was digging a drain, the removed; it amounted to three cart loads. As soon as it was possible the earth was When he was extricated, it was found that he had fracture of the spine; several of the the humerus, and comminuted fracture of ribs were broken; there was dislocation of respiring; in short, like a dying person. the leg. He was cold and pale, and scarcely Being brought into the hospital, he was comfortably placed in bed, the leg attended to, the shoulder reduced, and this reduction was effected without any force; and indeed, when the bone was reduced, it was very easily dislocated again, by motion of the arm, conveying the impression that and ligaments. His symptoms altered but there was great laceration of the tendons little, although he lived eighteen days, and he died apparently of gradual exhaustion. The prominent characters of his sufferings hips downwards, inability to retain the were, loss of sense and motion from the was drawn off by a catheter for the first fæces, incapacity to pass the urine, which few days, and afterwards dribbled away. On examination of the dead body, there vertebra; the displaced portion of the bone was found fracture of the twelfth dorsal pressed on the spinal cord, without having burst through the theca. The spinal marof inflammation was apparent; several of row was softened, but no further evidence the ribs were broken on each side of the chest. The shoulder joint was examined, but no appearance connected with the dislocation found, the capsular ligament being entire. But the state of the fractured leg was very different: here there was no attempt at a process of union; no callus had been thrown out; the effused blood even in every respect such as is exhibited in a was not absorbed, and the fracture was recent injury. The result of active pleuritis was found on the right side of the chest, and the membranes were there thickened and adherent. The left lung appeared as if it had been compressed by air or fluid: it was dense as muscle; (I suppose liver would be a better term, hepatized; however, here it is said " it resembled muscle, and could not be inflated.") "In the abdomen nothing particular was observed, except extravasation of blood in the cellular texture, about the fractured portion of the spine. The bladder was thickened, inflamed, and emitted an exceedingly foetid odour." Now I understand that you have been debating this subject in your Society—I mean the necessity of nervous energy to support inflammatory action-and I fancy I will be wise to leave that inquiry altogether. Is there a little influence of hypothesis in this account of the case? It would appear that the upper extremity, the shoulderjoint, went through, in this short time, all the processes of restoration; that the membranes of the chest underwent the usual changes, by the coagulated blood being absorbed, and coagulable lymph deposited; but that in the lower extremity no re-action took place, no inflammatory process, and that the joint resembled one on which an injury had recently been inflicted. I say, all that is very remarkable; but still we take it with some little reserve, in as far as I see it is a matter debated among you, whether or not the injury to the spine took off the nervous energy from the part, and was the cause of the absence of the usual effects of injury. You see the question would embrace this-whether the constitutional power of the body depends upon what is termed the ganglionic or sympathetic system, or results from something emanating from the cerebrum and spinal marrow? However, I am inclined to attend to matters of a little more practical importance. You find that the spine is broken, that there is a fracture of the bodies of the vertebræ, not by a blow, but by the neck being bent down and crushed; that a person receiving a weight upon his shoulder, the spine is broken down, and instead of the ligamentous connexion giving way, the bodies of the vertebræ themselves are fractured, and they are broken at the lower part of the back. Why? If you have to mend your whip or your fishing-rod, and splice it; and if it breaks again, it will be close to where you have spliced it. The reason is this: by the splicing you have destroyed the elasticity and motion at that part, and therefore the motion is thrown The cases read by Sir Charles Bell at lecture are in general drawn up by the house-surgeons. proportionally more on the point next to it. Now when you consider the texture of the thorax, and that all the dorsal vertebræ are, as it were, surrounded and sup. ported by the ribs, so that there is a greater consolidation of the vertebræ of the back; and that they are more firmly braced together than those of the neck or loins, you see that when the body is crashed down from a weight bearing on the shoulder, the injury must fall with accumulated force upon the point immediately contiguous to that which is so spliced, as it were. This is the reason why injury, by the forcing down of the shoulders, takes place at the lowest dorsal vertebræ. There has been a notion prevalent, that fracture of the spine affords a fair case of analogy with fracture of the skull; but there are very important differences. When a man has suffered a fracture of the skull, you know, just as in the last case you were considering, that there is a piece of bone driven in; but as to the brain, it is a small portion of the organ that is bruised, compared with the whole mass. When, how. ever, the spinal marrow is bruised by the intrusion of the fractured bone, and cer tainly if the intrusion be such as to deprive the lower part of the body of sense and motion, it is the whole of the spinal marrow that is injured. How, then, can you hope for restoration? The idea enter tained is, you will observe, that when the arch of the vertebra is broken down and thrust in, you may, upon the analogy of a fractured skull, make an incision, and draw out the depressed bone. My first objection is, that it is very seldom, indeed, that there is an actual forcing in of the posterior part of the spine, the ring of bone: generally it is a fracture of the body of the vertebra; and it occurs in the manner that I have explained to you. But even suppose it were a depression of the posterior part of the ring of bone, you would surely not think of operating unless symptoms of paralysis of the lower extremities implied injury of the spinal marrow: and if the pressure not gradually applied, you know, but produced by the force of the intrusion of the part-has the effect of destroying sensation and motion in the lower part of the body, how can you expect restoration? The analogy does not hold; because in cases of fracture of the skull, you take away pressure from a small part of the brain; but here, there is pressure of the whole of the spinal marrow, that is to say, the spinal marrow is irretrievably crushed, and in this very case you see it is so. The sheath is not burst-the spiculum is not sticking into the spinal marrow, as it sometimes is; but by the separation of the parts, there has been such a bruise of the spinal marrow, that it does not recover. |