thinks, that though the nerve was enlarged, it was not diseased; the enlargement and pain proceeding from the ulcerated state of the parts in the leg. Here Mr. Swan introduces a passage from Morgagni, to show how violent the pain is when the nerves are in a state of ulceration. The case was an aneurism in the right groin, which extended backwards so as to produce ulceration in the sciatic nerve.

"In the last month the pains became most severe, not only in the tumour, but sometimes beneath the internal malleolus ; in which place only, violent as the pains were, the foot was sensible, being in every other part deprived of feeling and motion. In all this month he neither had an interval of ease nor any sleep until his strength failed; then for some days he lay half asleep, and so died. "On examining the limb, the nerve was so much eroded, that a few fibres hardly remained by which the superior and inferior parts were joined together."" 76.

VIII. Tumours in the Nerves. These may be distinguished by the excessive pain which pressure occasions, and from its shooting generally in the exact course of the nerve, though Mr. Charles Bell, in his Operative Surgery, relates an exception to this rule, where a tumour in the ham did not, when pressed on, cause any particular pain, but rather a sense of pricking numbness down the leg. On dissection the sciatic nerve was found to enter into the substance of the tumour. Mr. Swan thinks it better to cut out the portion of nerve in which the tumour is seated, than to dissect the tumour out of the nerve. Here Mr. Swan instances cases from his own and the practice of others, illustrative of the foregoing observations.

IX. & X. Divided Nerves. If a nerve have been divided, and the external wound is healed by the first intention, very little pain is felt in the nerve, and sensation gradually, though slowly, returns. An open ulcer, however, connected with a wounded nerve, is generally very painful, and sometimes produces violent symptoms; consequently it is a matter of the greatest consequence, when a nerve is divided, to effect union of the parts around it by the first intention.

"When a nerve has been divided, and the external wound has healed, and there are marks of inflammation about the cicatrix, as a slight redness, tumefaction, and tenderness on pressure, it frequently happens that this inflammation is communicated to the nerve, and causes great pain, which is generally aggravated by any motion of the part.

"The best method of treatment will be to apply leeches near the parts, and evaporating lotions, and to keep them constantly at rest. "I need not say how necessary it is in all diseases to pay proper

attention to the state of the digestive organs, and that it is so most especially in all diseases and injuries of the nerves." 98.

In the following case, the sciatic nerve was wounded by a fracture of the thigh bone-an accident, Mr. Swan thinks, of not very unfrequent occurrence.

"John Wright, about seventy years of age, got a fall about the beginning of May, and injured the left hip. I saw him for the first time on the first of June. The knee and foot were turned completely inwards; and if this position of the limb was changed, it was always soon resumed: the thigh could be raised by an assistant towards the abdomen as high as usual, but could not be rotated much the limb was shortened about an inch; the trochanter major was not far from its usual situation, but behind it there was a rounded tumour, which was apparent, and could be distinctly felt, so as to convey the exact resemblance of the head of the thigh-bone: when the hand was placed about the trochanter, and the limb was moved, a crepitus could be felt the limb had the exact appearance of the dislocation backwards. He complained of very violent pain for some time, much more than is usual; but for the last two or three weeks he lay in an almost insensible state : he was in a very debilitated state before the accident, but after it he never had any appetite; so that he sunk from complete exhaustion on the twenty-fourth of June.

"The next morning I examined the part where the injury was received.

"On dividing the integuments, a small quantity of a dark-coloured fluid escaped: all the parts for some distance appeared one confused mass, from the quantity of coagulated extravasated blood. The thigh-bone was broken through below the capsular ligament, and another portion was broken off below this, in an oblique direction, so as to leave the trochanter major nearly perfect; this portion lay behind the trochanter, and when covered by the integuments had a rounded feel like the head of the bone: another small portion was likewise completely detached. All the portions of bone were surrounded by coagulated blood, which appeared to have become organized, for in several parts of it were found osseous deposits: the head of the bone appeared inflamed, and was coated with coagulable lymph. Nearly all the cartilage lining the acetabulum was absorbed.

"The sciatic nerve was much enlarged, and likewise surrounded by coagulated blood; and in one place a portion of coagulum, about the size of a filbert, adhered very firmly to it; and when it was examined, portions of a whitish substance might very distinctly be seen in it, so as to convey the idea of this part having taken on the structure of newly-formed nerve: at this part some nervous fibrils had been lacerated." 103.

The appearances of the limb in this case differed from what are usually presented in fractures of the neck of the thigh-bone. They might, without great care, have been

mistaken for dislocation of the bone backwards.

Under such

a mistake how greatly would the patient's sufferings have been aggravated by extension of the limb!

XI. The eleventh chapter of Mr. Swan's work is on punctures or partial divisions of nerves. This accident may be suspected when every acute pain accompanies the infliction of a wound, especially if the pain extends in the course of the nerve accompanied by convulsions or other symptoms of great nervous irritation. We shall abridge an interesting case of punctured nerve, communicated to Mr. Swan by Dr. Wilson of Grantham. Dr. W. was called to a woman labouring under strong convulsions. She had been bled two days before by a gardener, considerable pain being experienced at the time, shooting from the wound up to the shoulder. The wound was somewhat inflamed, and a thin liquor oozed from its lips. While making the examination, the woman became strongly convulsed. With the view of interrupting the communication from the diseased point to the sensorium, a tourniquet was applied above the part. A remission of the spasms soon followed, and an anodyne was administered; but the convulsions, after a short interval of ease, recurred as before, and another application of the tourniquet produced no good effect.

"As I had no doubt," says Dr. Wilson, "that the cause of the disorder was an injury of a cutaneous nerve in the operation of venesection, I determined to endeavour, by a transverse incision, to divide the nerve above the injured part, and to destroy its connexion with the sensorium; I therefore made an incision while the convulsions were most violent, of about an inch in length and small depth just above the orifice: no mitigation of symptoms was perceived; but on making another incision above the former one, somewhat deeper and longer, she cried out immediately, to the astonishment of the attendants, I am well, I am quite well, I can stir my arm;' which she began to move, and continued to do so with great delight for some time in various ways. She had no return of the spasms, and very soon got well." 109.

When a nerve has been wholly divided, each portion immediately retracts to some distance. When partially divided, the divided portions retract in the same manner, though not in the same degree. Each nerve being composed of different fasciculi, and these fasciculi generally communicating together, it follows that if a fasciculus be partially divided, or wholly divided where it communicates with its neighbour, an unnatural distention of parts will take place, accompanied with considerable pain. This will be still more the case if a nerve be wholly divided, with the exception of one fasci

culus, which one will be greatly on the stretch. Still, as nerves must be totally or partially divided in almost all the accidents and operations to which the human frame is liable, it is difficult to account for the comparative rarity of any serious accidents succeeding these lesions. That the wound of a nerve may be the entire and immediate cause of the symptoms, independent of inflammation, or any thing else that could irritate the nerve, the following case, from Sabatier's Medecine Operatoire, is brought forward by Mr. Swan to prove.

"This slight operation,' he says, 'was very painful, and was soon followed by convulsive motions, which extended themselves through the whole of the wounded extremity, and then through the rest of the body: these symptoms were not accompanied by any tumefaction, and were very often renewed. The patient could neither walk, nor ride in a carriage. This state having continued a long time, notwithstanding the use of antispasmodics and quieting remedies, I advised a division of the saphenus nerve, but it was not consented to; nevertheless the nervous symptoms gradually diminished, and the patient partly recovered her health, after five or six years almost continual suffering.' 114.

Mr. Swan would advise, in cases of injured nerve from bleeding, that several leeches be applied to the neighbourhood of the part, and afterward evaporating lotions. Should these disagree, poppy fomentations and poultices are to be tried, keeping the limb as quiet and easy as possible. He has no doubt that the greater number of injured nerves in venesection are rendered troublesome by too much exertion of the arm inducing inflammation. We have had reason to believe, that the state of the atmosphere has sometimes an effect in festering venesection wounds-at least during the severe winter of 1812-13, in Holland, a great number of men who were bled for pneumonia, and who used no muscular efforts at all afterward, had the wounds inflamed, and that without any suspicion of bad lancets or improper modes of opening the veins. Mr. Swan relates the following case to show that if a nerve be wounded in bleeding, and the external wound heals by the first intention, the wound of the nerve will not be of much consequence.

"I bled Mrs. D. in the median cephalic vein; she complained of very acute pain at the time I made the puncture, and it continued for several hours.

"As I was certain from the manner in which she complained that I had wounded a nerve, I was very careful in binding up the arm well, so as to keep the lips of the wound in exact contact, and at the same time told her of the necessity there was for keeping her arm

entirely at rest. The wound healed by the first intention, and the pain did not return." 116.

Mr. Swan is of opinion that in whatever way nerves are wounded, the lesions are repaired by Nature alone. It is therefore right, when an accident of this kind happens in venesection, to wait for a while and try palliatives. But if the irritation induce convulsions, as in the case related by Dr. Wilson, and threaten life, an operation should be attempted in order to cut off the communication between the brain and the wounded nerve. Mr. Swan quotes two cases from M. Larrey, in elucidation of this principle, although the accidents did not arise from venesection.

"The first was that of a man who was struck by a ball, which crossed the right arm, and wounded the biceps and coraco-brachialis muscles, and the radial and internal cutaneous nerves. On the eighth day he began to have great pain; and it was wished to divide a bridge left by the wound, in which were found some branches of the internal cutaneous nerve, but the patient refused to have it done. The next day his local pains were very acute; he had convulsive motions of the hand and fore arm, heat in the whole system, and locked jaw; he was very restless, and in continual agitation. The rapid progress of the symptoms determined Larrey to divide the bridge, and cut the bottom of the wound, where he found several nervous bridles. This operation was very painful; but two hours afterward the patient was much relieved, and in the space of two days all the symptoms disappeared.

The second was that of a man who received an injury from a spear on the right side of the forehead. The point of the spear had slided obliquely from below upwards and inwards under the pericranium, so as to make a deep fissure in the frontal bone: one of the superciliary nerves was grazed by the cutting side of the spear. "Nine days passed without any alarming symptoms, and it was considered as a simple wound; but in the night between the ninth and tenth days tetanus came on, with convulsive motions of the corresponding eyelids, and a loss of sight in that eye: there was a little mental wandering, a very acute pain, locked jaw, and a very marked disposition to emprosthotonos.

"Emollients were immediately applied to the wound, and diaphoretic and opiate draughts were given without effect; the complaints went on increasing, and in twenty-four hours would have been at their greatest height. The wound was then examined with a probe, which gave very acute pain; this determined Larrey to divide from below upwards with a bistoury the whole of the superciliary muscle, the nerves, and vessels: the patient was immediately relieved, and in less than twenty-four hours all the tetanic symptoms had disappeared." 120.

Mr. Swan next extracts a case from Sabatier, which he thinks may throw some additional light on the subject of