the region of the os hyoides, and carrying it from thence in a curved direction to just below the projection of the left malar bone. A crescentic flap was thus formed, the convexity looking downwards, and the two extremities extending from the chin to the prominence of the cheek. The flap was detached from the subjacent parts by a rapid dissection from below upwards, by which the maxillary bone and the tumour were perfectly exposed. A common saw was then made to work upon the jaw between the right canine tooth and contiguous incisor, and with some little difficulty the bone was cut across. The other division was made a little before the last molar tooth, and beyond the limits of the disease, which was done with the chain saw. The diseased parts were soon dissected out, several small vessels secured, and the integuments brought together by seven separate sutures. All has hitherto done well, and the wound is now nearly healed.

On examining the tumour, it was found to consist of a fibrous mass, alternately reddish and white, enveloping all the portion of bone that had been removed. This had acquired a spongy texture and considerable size, resembling the medullary sarcoma, and communicating at intervals with the dental alveoli, the whole being encased in a thin envelope of firm consistence. The characteristic appearances were particularly well marked at the extremity of the excised bone corresponding to what remained attached to the ramus of the jaw, a circumstance calculated to inspire well founded dreads of the incomplete eradication of the disease. The reporter is of opinion that the disease began in the internal periosteum of the maxilla, and is fungoid and malignant in its nature.

The reporter remarks that M. Roux intends removing the remaining diseased part of the bone at a future opportunity. He thinks that an incision directed obliquely on the ramus will enable the chain saw to work easily and effectually. The reporter also eulogises the idea of not dividing the angle of the lips as is usually done, but beginning

the incision below it. The chain saw is not forgotten in this gentleman's laudatory observations. If the disease was really fungus hæmatodes, we would not give much for the patient's chances of a cure.

III. DISEASE OF THE TESTICLE.
CASTRATION.

We are disposed to notice this case, to shew that the French surgeons are yet far behind us, in the diagnosis and treatment of diseases of the testicle, and we believe of malignant tumours in general.

Case. Jacques Byard, ætatis 28, a carpenter, was admitted into La Charité on the 21st of December, 1829, with considerable enlargement of one of the testicles. It was oval in shape; very heavy; about four inches it its long diameter, from above downwards; the skin was tense, shining, unadherent; the cord was unaffected. The disease had been coming on eight months, and was attributed by the patient to a blow. This had been followed by violent pain which disappeared spontaneously, but was succeeded in the course of a week by a little towards the centre of the testicle, and continued to advance. For a month the patient had suffered from lancinating pains, "the almost pathognomonic symptom of cancerous affections."

Now, although the case was to all appearance a very unfavourable one, most well-informed English surgeons would have given the patient the chance, which a moderate mercurial course affords. We may in general, by carefully considering the symptoms and accurately sifting the history, form a tolerably correct opinion on the nature of most cases of diseased testicle. But still a degree of uncertainty must in the majority of instances impend over the diagnosis, and the most experienced surgeons are every now and then deceived. Unless then the malignant character of the affection be indisputable, we hold that it is generally better to submit the individual to a gentle course of mercury, conjoined with sarsaparilla or tonics if the health be bad. By this proceeding we shall seldom do harm,

and occasionally we save a testis which would otherwise have been removed. This we know to be the practice and opinion of the best surgeons in this country. However, these considerations had no weight on M. Roux, and on the 26th of December he performed castration. Two ligatures were placed upon the cord, which was cut across by means of scissors the wound was dressed simply and the patient did well. Our readers will see that in their mode of performing this operation the French are yet behind us. The vessels of the cord are always tied separately here, and M. Roux's mode of cutting the cord with scissors, is surely awkward looking, and if we may venture to coin a word, unsurgical. On making a section of the amputated testicle, it was found to consist chiefly of a dense, compact structure, of lardaceous consistence, but reddish and fibrous in appearance. It seemed as if the gland of the testis had become hypertrophied, without preserving everywhere its natural texture. In the centre were scattered some whitish, tubercular-looking masses, of different dimensions. The reporter would be inclined to say that the white matter was of medullary character, but he does not positively affirm it. These statements strengthen our criticisms on the practice of proceeding immediately to the operation. We do not pretend that mercury would have cured this disease; we think it would not. But still we cannot before operation see into a testicle, and where there is a chance, it is, cæteris paribus, right to give it.

LI.

ST. GEORGE'S HOSPITAL.

INJURIES OF THE HEAD. THERE is scarcely a more interesting subject to the surgeon, whether he be of a purely practical turn, or inclined to indulge in the speculations of physiology, than that of the injuries to which the cranium and its contents are exposed. Like all the other great points of surgery, it has emerged from the gloom,

which the comparative ignorance of the earlier ages of physic threw around its accurate and sober investigation. The labours of Le Dran, of the French Academicians, and particularly of Mr. Pott, were of essential service in pointing out the proper methods of study, and in explaining symptoms which were previously shrouded in darkness and in mystery. The peculiar talents of Mr. Pott substituted, indeed, a fallacious light for the former shadow; but this has been sobered down by the practical and eminent men of our own times, by Abernethy, Cooper, and Brodie. We do not pretend that the knowledge and treatment of injuries of the head have been reduced to rules of unerring certainty, or deny that much difficulty and doubt impend over many of these cases. But we are confident that the treatment is generally based upon rational, consistent, and intelligible principles, and that a great deal has been done, if more remains to do. The road to knowledge in medicine and surgery is only through the medium of cases. The general notices of facts which we find in essays and books, are rather calculated to illustrate doctrinal points, than convey any accurate information in themselves; and, as an able writer has observed, they admit of the bias of theory and the warp of system, with more facility than cases more closely and circumstantially related. Thus we perceive the value of hospital reports. If taken with care and detailed with fidelity, they are calculated to prove beneficial to the public; but if the source is poisoned, if the reporter sin through malice or incompetence, the profession are quaffing, like Darius, not a wholesome beverage, but a foul, muddy, and polluted draught. Under the best of circumstances, errors will creep in, and men who would not willingly deceive, have nevertheless, through the fallacies of the human mind, and the weaknesses that vanquish the wisest, proved the unconscious instruments of deception. This alone, independent of the prevalent false faith of these days, will always furnish false facts in abundance, for theorists to stumble, rogues to cheat, and honest men to grieve.

It must be allowed that written cases, however minutely observed and carefully recorded, afford an inadequate and imperfect representation of what actually occurs in practice. It is a defect inseparable from this method of communicating information, and although it may be partly remedied by the care and attention of the narrator, it can never be altogether obviated. We must take reports, then, for what they are worth, and after we have allowed for all their imperfections, enough of good and usefulness remains to render them excellent media for diffusing knowledge. We shall dedicate the present report to cases of concussion, uncombined with perceptible fracture.

CONCUSSION.

Perhaps the simplest case of injury of the head is that in which a person receives a blow upon the part, is stunned for a short space of time, and after his recovery from the state of insensibility, experiences no farther symptoms of consequence. There is much variation in one particular symptom which has often been alluded to-the non-remembrance of the mode and time in which the accident occurred. An individual suffering what appears to have been a trifling injury will present this loss of memory, whilst another, who has seemingly been hurt more severely, will not. As a general rule, the more acute the injury and the more complete the state of concussion, the more perfect is the oblivion respecting the accident.

Some authors have stated that the pupil is dilated in concussion. It frequently is so, but not always. We have seen it contracted, and it varies in a short space of time in the same individual, being contracted and dilated in the course of a few hours. It is almost always sluggish, but in some few cases it would seem to be little, if at all affected, especially if the patient is recovering from the state of insensibility.

CASE 1. Concussion-Pain in the Head. John Nevinton, ætatis 35, admitted July 19th, 1828.

Was knocked down when rather intoxicated, and his head struck the ground. In a quarter of an hour afterwards was admitted in a state of insensibility-pulse low and faint-skin cold pupils dilated. He had been bled in this condition by a chemist.

In two hours after his admission he was sensible, and able to reply to questions. The pulse had risen to 80, and was full; he complained of pain in the forehead; had no recollection of the occurrence of the accident. He had house physic, and in the evening, the pulse being fuller and the pain in the head more severe, he was bled to 3xij.

He was relieved by the bleeding, but continued drowsy, although roused without difficulty. The pulse was full and slow. On the 23d there was much uncomfortableness about the head-pulse full, sharp, and remarkably slow-pupils rather sluggish. On the 24th, he complained of dull, aching pain across the brow-the pulse was slow, and presented a trifling irregularity. He was bled to 3xvj. and took salts in infusion of roses. He was relieved. On the 28th he was ordered a little ammonia, but it occasioned more pain in the head, which he compared to the skull

being opened and shut," accompanied with throbbing in the brow; the pulse was 50, rather vibratory. He was again put on salts and salines; on the 8th, leeches were applied behind the ears; and, on the 11th, a blister was placed behind the left. The pain in the head gradually diminished-it subsided; and on the 18th of August he was discharged cured.

CASE 2. Concussion-puffy Tumour of Scalp simulating depressed Bone. Eliza Macpherson, ætat. 5, admitted Dec. 16th, 1828, under Mr. Brodie.

This little girl experienced a fall upon her head on the 8th of December, by which she was stunned, and after which she vomited. She then recovered her senses, and was brought to the hospital on the 16th on account of a swelling of the scalp, which the surgeon told the mother would require at least half a dozen incisions.

This formidable tumour requiring such active surgical treatment, was a fluctuating swelling extending over the greater part of the left side of the occiput, without any pain in the part or in the head, without any redness of the skin or marks of inflammation in the cellular membrane, and finally, without a single symptom of general disturb ance. It was evidently a case of effusion of blood, remaining fluid beneath the scalp. Near the left sagittal suture was a depression, which might well have been considered as produced by fracture. It depended on effusion into the soft parts around.

The treatment consisted in the application of spirit lotion, and one or two aperient powders. It is needless to say that no incisions were made, and on the 23d the swelling, fluctuation, and appearance of depression were all gone together, and the child was as willing and able to run home as if nothing whatever had happened to her.

CASE 3. Slight Concussion-Puffy Tumour of Scalp.

Joseph Drew, æt. 26, admitted June 12th, 1830, under Mr. Babington.

On the left side of the head, about two inches above the ear, was a circumscribed hard tumefaction, exceeding a crown-piece in circumference, with a soft and boggy kind of depression in the centre-not much tenderness on pressure no loss of sense-pulse quiet. Fracture of the lower end of the radius. Had fallen in the morning from a hay-loft, seven or eight feet from the ground. Was stunned for ten minutes, but did not vomit. The case was clearly one of puffy tumour of the scalp.

We need scarcely mention the treatment; suffice it to say, that on the third day the tumour had disappeared.

CASE 4. Severe Concussion-Puffy Tumour of Scalp-Bleeding from the

Nose and Mouth.

John Smith, a groom, æt. 28, admitted June 25th, 1830, under Mr. Brodie.

At half-past ten o'clock this morning a horse with a gig ran away, and both passed over him. He was stunned for

a short time, and when carried home was immediately bled to nearly a pint, when he vomited. Blood issued from his nose and mouth in considerable quantity.

Half-past 11, a. m. Great ecchymosis about the left eye and left half of forehead-sensation, communicated by the effusion of a depression on the latter-left clavicle broken, with various other bruises. He is partially insensible, but answers questions if long and loudly hollaed to-moans much-surface cool-pulse feeble.

After his admission he vomited two or three ounces of dark blood, and in the evening he vomited some more. His symptoms continued the same.

On the next morning, his pulse having risen, he was bled to xij. and one of the cups shewed the usual inflammatory appearances in the blood, but the other did not. The pulse was from 70 to 80, full, the tongue dry and brown in the centre. The pupils were contracted, but contractile-he was constantly moaning-could answer ques tions when aroused-but did not know where he was, nor how nor where the accident had happened.

Lot. frig. capiti.-H. sennæ.

On the 27th he was much improved, and the effusion of blood beneath the scalp was less apparent; the peculiar depression was almost gone. He had vomited no more blood. The fracture of the clavicle was attended to, and although he complained for some time of pain in his head, and was very unmanageable, the unfavourable symptoms gradually passed away, the clavicle united with a little riding, and on the 21st of July the patient was discharged from the hospital cured.

CASE 5. Severe Concussion-Inflammation of the Absorbents of the Leg. Thomas Fox, æt. 11, admitted April 16th, 1830, under Mr. Keate.

One, p. m. Was thrown from a horse at full trot, an hour and a half ago, and is said to have fallen backwards and struck the occiput. Was picked up in a state of insensibility, and has so remained; has vomited several times, and has been bled to viij.

Calomel and black draught.

In the evening he could give peevish answers to questions when sharply put to him, and next morning was more sensible still, asking for the chamberpot, and complaining of pain in the forehead. Pulse 60, soft, occasionally irregular-pupils sluggish, and more dilated-bowels freely opened.

H. senna. Hirud. x. ponè aures. H. sal. c. vin. ant. t. m. xv., mag. sulph. 3j. 6tis hor.

On the 28th there was little change; the pulse was 56. On the 29th he lay like a child with hydrocephalus-the pupils were contracted, yet the eyes were open and staring-no stertorhand often carried to the head-no replies made to questions-pulse ranging from 56 to 60-bowels open under him. Next day he continued in the same state; the pulse was 56, and had been 48 in the morning; herpes had appeared about the lips and chin.

Emp. Canth. nuch. et servetur ope. Ung. Hyd. fort.

On the 1st May he was more sensible, and could put out his tongue, which was moist-pulse 48-motions no longer passed beneath him. He was ordered support in the shape of beef

head symptoms now disappeared very rapidly, and the inflammation of the absorbents became the object of attention. It was treated with salines, and cal. gr. j. pulv. ipec. c. gr. iij. twice daily. On the 11th, the nitrate of silver, in substance, was applied from the knee to near the groin, over the track of the inflamed absorbents. The leg and foot were swollen, red, and very tender to the touch; the pulse was quick, the tongue red, and the bowels loose. An abscess formed in the cellular membrane of the dorsum of the foot, and was opened-the patient was put upon cinchona - and the abscess over the little toe was evacuated-on the 24th he was convalescent—and on the 2d June he was discharged. He was affected with deafness, which he had not before the accident, but he said that he remembered having been thrown from the horse.

Tensive pain across forehead, with a feeling of great weight there-noise of hammering in the head-heaviness of eyes, preventing his seeing perfectlyvacant aspect vertigo and giddiness on attempting to stand. On making him attempt to walk, which he cannot do without support, his legs totter under him, crossing each other with the toes turned inwards-disposition to nausea-occasional chilliness succeeded by heat. Pulse somewhat hard and fulltongue white, coated-bowels opened by medicine-urine high-coloured.

Just above and behind right ear, a tenderness on firm pressure, and, perhaps, a little more fulness than natural.

One month ago fell from a low twostory window, and struck his side, and the posterior part of the head, where the tenderness is now. Was stunned for ten minutes, when he recovered. On the next day he had pain in the head and swelling, for which he was bled and cupped; leeches were also applied to the side. He recovered, and weakness only remained. Five days ago