artery, so situated as not to admit of being included between two ligatures." The secondary hæmorrhage, after an interval of ten weeks, certainly does not impugn the accuracy of this statement, which is, indeed, verified, beyond all doubt, by Mr. Fleming's case. It is highly probable, as Mr. T. remarks, that, in the first of the above cases, had the operation of tying the carotid trunk been practised distinct and at a distance from the original wound, and had this remained undisturbed, the coagulum would have been gradually absorbed-suppuration would have been prevented-and the case would have terminated like that of aneurism, with the separation of the ligature. Mr. Travers does not appear to have been aware of Mr. Fleming's case, as he talks of the want of a precedent for the operation which he has performed. We can refer him to the Journal mentioned below, for the details of Mr. Fleming's case, as published by Dr. Coley.

5. INJURIES OF THE HEAD..

æt. 30, received a kick from a horse on the head, Nov. 1st, 1825. On admission into the St. Louis, immediately after the accident, the following symptoms presented themselves. Insensibility; a transverse wound, three inches long, over the right eye-brow, with depression of the bone to the depth of an inch; the depressed portions were joined so exactly at an angle, that it was impossible to introduce an instrument between them capable of elevating them. Venesection-sinapisms to the feet. In an hour the patient recovered his sensibility and speech. Nov. 2. Some excitement, lids contracted, pupils sensible to the light. As there were no symptoms of compression, M. Richerand decided on not applying the trephine. All went on well till the 13th; the wound had nearly cicatrized, but the contraction of the eye-lids remained. Some degree of pain and stiffness of the lower jaw now took place, but, on the 15th, the man left the hospital, which, on the 1st December, he re-entered. The wound was then about an inch in length, the jaw could scarcely be opened, and the limbs were becoming rigid; this tetanic state made progress, and on the 15th he died.

Dissection, 24 hours after Death. The fraginents of bone had pierced the dura mater, and were compressing the anterior lobe of the brain, which, at this part, was reddened and diffluent. This softening was greater in the cineritious than in the medullary substance, Arachnoid tunic, at the anterior and superior surface of the lobe, thickened, and covered with a sero-gelatinous layer of pus.

Remarks. Here the inflammation and disorganization of the brain seem obviously to depend upon the compression and irritation produced by the depressed fragmeuts of bone. In the next case, however, which we shall notice, the mischief was still more extensive, although the pieces of bone were removed.

M. Paillard. Clinical Report from the St. Louis. Révue Med. Sept.

Case 2. *** æt. 16, received a violent blow, Aug. 1st, 1825, on the left side of the frontal bone, near the eminentia, from a grinding stone, which broke in pieces. On his admission, directly after the accident, the bone was found fractured, and a splintered piece, the size of a five-shilling piece, driven into the brain. The fragments of bone were removed by means of the circular forceps, and some of the cineritious substance of the brain issued with them. Copious venæsection-and the wound was dressed simply. Insensibility. In the evening, another free bleeding. Next day, the patient was perfectly sensible, and could answer questions. Much soft bloody-looking cerebral matter issued from the wound-venasection. The discharge from the wound now assumed a gangrenous appearance. The patient, on the fifth day from the accident, fell into a comatose state, but survived till the 26th, when he sunk.

Dissection. The fracture had extended no further than the wound. The tunica arachnoides covering the convexity of the right hemisphere was much inflamed, and covered with a layer of pus; this was the case, also, at the base of the brain. The left anterior lobe of the brain was almost entirely destroyed; what was left was in the suppurative state.

We shall now record another case, where fracture, with depression, is stated to have taken place, without any symptoms of compression supervening.

Case 3. Boulogne, æt. 22, a carpenter, of athletic constitution, fell on his head from a high scaffold, Sept. 1st, 1825. On admission into hospital, he was insensible; there was felt, over the right superciliary ridge, a depression about six lines deep, arising from the complete separation of the depressed portion of bone from the cranium. The integuments were bruised, but not broken. On being bled, the sensibility returned. Sept. 2. The man had a little pain in the head, and fever. V.S ad 3xx. At the end of a month the patient was cured. The swelling of the integuments had subsided, but the depression still remained, about the depth of six lines.

To these cases we shall add one which occurred, some little time back, in a public hospital, and under our own observation.

W. S. æt. 12, of a strumous habit, fell from a scaffold, 60 feet high, on the 1st Sept. 1826. He was stunned by the fall, but was recovering, when a medical gentleman came up, and took away fourteen ounces of blood on the spot. On admission into hospital, he was quite sensible, and the pupils contracted and dilated. At the upper and left part of the head there was a scalp-wound, and the parietal bone beneath was found to be fractured into several portions, which were depressed. Cerebral matter issued through the wound. This was dressed with lint. For the three next days, there was little alteration-the pupils contracted and dilated, though not so readily as they should do; the lad was sensible, and could answer questions. Sept. 5. Re-action, in some degree, took place the pulse got up-he would not answer questions-the pupils became more sluggish. V.S. ad 3xij. with much relief to the

symptoms. He soon, however, relapsed into his former dozing statethe pulse became 140 or upwards-convulsions appeared-the pupils became dilated, and delirium occurred at night. Sept. 8. The pupils again contracted more readily, but opisthotonos, chiefly, however, confined to the muscles of the back of the neck, was developed. Sept. 9. He gradually sunk. During the progress of these symptoms, pus and cerebral substance, blended together, were discharged pretty freely through the wound. The treatment consisted in frequent small bleedings, cupping between the scapula, and the exhibition of haustus sennæ and liquor antimonii tartarizati.

On dissection, the fracture was found to be chiefly in the left parietal bone, but extending into the right. The dura mater was lacerated to the extent of an inch or more, and beyond this laceration it adhered to the arachnoid. Below the laceration there was a cavity in the brain containing mingled pus and cerebrum in a diffluent state. Pus effused over the hemispheres of the cerebrum-pus and serum near the junction of the optic nerves.

We shall now make a few remarks on the subject of injuries of the head. Our impression decidedly is, that at this present moment, surgeons trust too much to nature, and too little to the instruments of their art. In Mr. Pott's time, almost every man who got a broken head was trepanned as a matter of course. This, no doubt, was bad practice. Mr. Abernethy published his work on injuries of the head, and the trephine was almost banished the surgeon's instrument-case. Indeed, Mr. Samuel Cooper, in treating of fractures of the cranium, with depression, again and again warns his readers-" that existing symptoms of dangerous pressure on the brain can alone form a true reason for perforating the cranium." Surgeons are beginning to discover that this is bad prac tice also. If the bone is depressed, and there are as yet no symptoms, we are told that it is too early to apply the trephine, but when symptoms do come, sad experience tells us, alas! that it is too late. Now, when we consider that these symptoms are, for the most part, not the symptoms of mere compression, but of irritation and inflammation, excited by the presence of a foreign body, we should be led to expect their occurrence, not so much immediately on the receipt of the injury, as after the lapse of a certain period of time. And such, in by far the majority of instances, is the actual state of the case. We are convinced that the term compression, has done infinite mischief; it has led to false reasoning and consequent bad practice. Mr. S. Cooper, for instance, in his arguments against the use of the trephine, makes use of the following piece of sophistry: "indeed, it is not easy to conceive that the pressure which caused no ill effects at a time when the contents of the cranium filled its cavity completely, should afterwards prove injurious, when they have adapted themselves to its altered size and shape." Page 505. If it were always mere pressure, perhaps it would "not be easy to conceive it," but the cause of the mischief generally being irritation, it is not only "easy to conceive" the after occurrence of symptoms, but every one who is not wilfully bliud may see the thing happening every day. What,

If the frac

then, is to be our rule in the application of the trephine? ture, with depression, be a compound fracture, we should certainly say that the trephine or elevator is indicated, even though no symptoms are present. It may be true that some cases of this kind will do well without operations, but these are "rari nantes," and we do assert that no surgeon is justified in thus exposing his patient to the risk which he infallibly runs. The opinions of Sir A. Cooper on this subject, of whose experience it would be useless for us to say any thing, are, we think, so just, that we cannot avoid transcribing them here.

"If the fracture be compound, the treatment must be very different; because a compound fracture is followed, very generally, by inflammation of the brain; and it will be of little use to trephine when inflammation is once produced. It might be thought that it would be time enough to perform this operation when inflammation had appeared; but this is not the case; for if the inflammation comes on, the patient will generally die whether you trephine or not."-Sir A. Cooper's Lectures, by Tyrrel, vol. i. p. 305.

Sir A. Cooper's practice, when called to a case of this kind, is this: Whether symptoms of injured brain exist or not, he generally uses the elevator to raise the depressed bone, if possible. If the elevator will not do, the worthy Baronet applies the trephine, but this he uses "very rarely.”

The case we have detailed as occurring at one of our hospitals illustrates well what we have said on this subject. A boy falls from a height of 60 feet, the scalp is torn-the bone depressed, and brain issues through the wound. The depressed bone is not elevated-the irritating body not removed. What is the consequence? Why all goes on well for a few days; then symptoms of irritation and inflammation shew themselves, and the patient sinks. On dissection, the membranes are found inflamed, and the brain ulcerated. Can there be a better case than this of the danger of not trephining?

There is, however, another kind of fracture, with depression, viz. that where the scalp is uninjured, and the fracture consequently simple, in which the use of the trephine may admit of doubt. Bearing in mind that the symptoms do not arise so much from compression as from irritation, it may, we repeat, admit of doubt, whether the conversion of the simple into a compound fracture, by the operation, and the consequent admission of atmospheric air into contact with the brain, may not prove a greater source of irritation than the mere presence of the sunken bone. Sir A. Cooper, for whose opinions we have the highest respect, observes—

If the fracture be simple, and there is no wound in the scalp, and no symptom of injury to the brain, it would be wrong to make an incision into the part, and perform the operation of trephining; for, by making such an incision, you add greatly to the danger of the patient, as you make what was before a simple a compound fracture, and, consequently, greatly increase the danger of inflammation, which rarely follows fracture with depression, where the fracture is simple." Even

if, in this case, there be symptoms of injury to the brain, Sir A. Cooper would not immediately trepan, but would take away blood and purge freely, and then see how far the symptoms may arise from concussion of the brain, and not from depression.

Whether this be the best practice or no, we are not quite prepared to say. Case 3, which we have related in this paper, as far as it goes, confirms this view of the subject. The man had considerable depression of the frontal bone, but the scalp was sound. He had not a bad symptom. On the first kind of fracture, however, compound, with depression, we think there can be no manner of doubt as to the propriety, nay, the necessity of trephining. We cannot conclude without referring the reader to the very able paper on this subject, published by Mr. Wise, in the Extra Limites department of this Journal, for April, 1825.

6. OPHTHALMIA.*

Mr. Mackenzie, who is one of the surgeons to the Eye Infirmary of Glasgow, has published a paper on this subject, of which we shall give a short abstract. He divides the ophthalmia occurring in adults, from atmospheric causes, into the catarrhal, rheumatic, and catarrho-rheumatic. These are German distinctions, too little attended to, Mr. M. thinks, in this country, and essentially necessary for the proper treatment of the disease. "The appropriate treatment of the rheumatic ophthalmia is not at all adapted to the catarrhal; while the remedies which, in a few days, subdue the catarrhal, will only exasperate the rheumatic."

The catarrhal genus affects the conjunctiva-the rheumatic affects the "fibrous sclerotica and surrounding fibrous membranes"-the catarrhorheumatic affects both the conjunctiva and the sclerotica, the symptoms being a union of those accompanying both. We fear Mr. M. will have some difficulty in persuading the routine practitioners of this country to adopt his minute classification. Thus in conjunctivity, as a genus, there are four species-the atmospherica-contagiosa-leucorrhoica-gonorrhoica.

The inflammation in the first species (catarrhal ophthalmia) which is the most common of all forms of ophthalmia, in adults, is almost entirely confined to the conjunctiva and meibomian follicles. The secre

tion of the membrane is increased, and becomes opake, thick, and puriform, though in many cases it remains translucid. The redness is chiefly in the conjunctiva lining the eye-lids, in mild cases, while the vessels on the white of the eye can be moved in every direction, by pressing the eyelid against the eye-ball with the finger, "shewing that they reside in the conjunctiva." In severe cases chemosis takes place, and general antiphlogistic treatment is insufficient-the cornea may burst, and vision be destroyed, if local means are neglected. Mr. M. attributes this accident more to mechanical pressure of the distended

* Mr. Mackenzie. Med. and Phys. Journal, No. 4.