related by Mr. Brodie, in his excellent paper in the Medico-Chirurgical Transactions, a paper of which a full analysis was given in this Journal.

CASE.-Death apparently from Secondary Hemorrhage.

F. C. æt. 35, fell, Jan. 1, 1827, from a considerable height upon his head, and was carried home insensible. In three hours he had so far recovered as to be

able to answer questions, but he lay for several days in a state of drowsiness, from which, however, he could be easily roused. On the 8th he was admitted into the Infirmary. His pulse was sixty-five and feeble; his eyelids were half shut, and the pupils slightly dilated; but his respiration was natural and free from stertor. No wound of the scalp or fracture of the skull could be discovered.

On the 9th, he had three severe attacks of convulsions, the last of which was followed by immediate and complete insensibility; his pulse sunk to fifty in the minute: his breathing became laborious; his pupils dilated and immoveable; and his urine and fæces were passed involuntary. He died on the 11th.

On inspection, a considerable portion of the dura mater was found detached from the cranium. Two lacerations of the substance of the brain were discovered, both being situated on the upper surface of the anterior lobes. That on the left side was covered by a firm coagulum, about the size of a walnut; while, from the right, nearly three ounces of blood was extravasated, and spread over the surface of the hemisphere. This blood was fluid, and had every appearance of having been recently effused.

"The coagulum on the left side was probably formed soon after the injury, any farther hæmorrage having been prevented at the time by the free blood-letting, and other depletory measures which were employed. On the 9th day from the period when the injury was inflicted, an increased determination of blood to the head took place, which was occasioned by the attacks of convulsions, and a renewal of the hæmorrhage was the consequence. The effused

blood extended over the right hemisphere, and to this occurrence the sudden coma and death of the patient were to be ascribed."

This case is very illustrative of Mr. Brodie's opinions. That able practical surgeon is inclined to believe, from the cases which he has witnessed, that convulsions is produced by slight extravasation, or other source of pressure, coma, stertor, &c. by a more extensive or powerful compression. It was evident from the symptoms of the patient until the last attack of convulsions, that there was some source of pressure or of irritation. The small coagulum on the left side was this source. The convulsions thus occasioned were the cause of the larger and fatal extravasation, which fully deserves to be considered a secondary hæmorrhage.

Dr. Macfarlane relates a case of secondary suppuration on the surface of the brain after injury of the head. There is nothing in the case to distinguish it from the many of a similar character that have been published. The rigor occurred on the 15th day, and the patient died on the 19th. She was not trephined. The injury was fracture of the cranium without depression. Pus was found on the anterior lobe of the left hemisphere of the cerebrum, and also between the cerebrum and cerebellum.

We notice the succeeding case more at length, because it involves a contested principle, that of trephining or not trephining in cases of compound fracture of the cranium, independently of the existence of symptoms of disturbance of the brain.

R. A. æt. forty, admitted February 1st, 1832, at 6 P.M. having on the preceding evening, at ten o'clock, been assaulted by two men, when he received several blows on his head with a bludgeon. He was stunned for a short time, but soon recovered so far as to be able to walk home. In the course of an hour he vomited two English pints of blood, after which he was said to have become drowsy. At the time of his admission into the Infirmary, he was perfectly collected, but irritable and peevish, and complained of intense pain in the head. The eye was suffused; the pupil variable; the pulse sixty, and of good strength. On the forehead, about an inch and a quarter

above the middle of the left supra-orbital ridge, there was a lacerated wound, through which a portion of the frontal bone, about an inch in diameter, was observed to be fractured, and slightly depressed. He was immediately bled to twenty-four ounces; and on visiting him at nine, P.M., about three hours after his admission, Dr. M. found that his pulse had risen to eighty, and that he had a slight rigor. The depressed bone was firmly fixed, but at one point the pulsatory motion of the fluid blood, which filled up the fissure, showed that the fracture extended through both tables of the scull. On enlarging the wound by a crucial incision, and dissecting back the flaps, Dr. M. raised up the depressed bone with the clevator, and removed it in five separate pieces, along with a small coagulum. From the oozing of blood, the small size of the opening in the cranium, and the restless state of the patient, who was secured with some difficulty, it was impossible to ascertain whether the dura mater was injured or not. The edges of the wound were retained in contact by a suture, and the usual dressings, with a double-headed roller, applied. A bladder containing a refrigerative mixture was applied to the head, and a purgative exhibited. For the first nine days, the most active antiphlogistic measures were employed. Besides smart purging, nauseating doses of emetic tartar, &c., one hundred and twelve ounces of blood were detracted by venesection. On the 14th, an abscess burst in the left ear, after which no unfavourable symptoms occurred. The wound healed slowly, the pulsations of the brain became gradually more obscure, and he was dismissed, cured, on the 19th of March.

"In such a case," says Dr. M. "nearly all the surgical authorities of the present day condemn the practice of applying the trephine, and removing a sound portion of the cranium, that the depression may be elevated, unless symptoms of compressed brain exist. They approve of the removal of such loose and detached splinters as can be readily laid hold of by the foreceps, or raised by the elevator: but until symptoms of compression appear, either from the effu. sion of blood, or the occurrence of suppuration, they are, with one or two exceptions,

unanimous in condemning the trephine. On the contrary, Pott recommends that the cranium be perforated, and the depressed bone elevated, not with the view of remov. ing existing symptoms, but as a preventive of ill consequences. Sir A. Cooper, and Mr. Brodie, appear less hostilely opposed to this practice, than the rest of their contemporaries. The former gentleman says, 'I generally use an elevator to raise the depressed bone, but rarely apply the trephine;' whilst Mr. Brodie is of opinion, that, when the depression is slight, and the symptoms trifling, the trephine should be applied only when the injured bone is exposed, in consequence of a wound in the scalp. Considerable diversity of opinion also exists as to the cause of the suppuration, which so frequently occurs in the neighbourhood of a fractured and partially-depressed bone. The majority assert that this suppuration does not arise from the depressed bone, but from the violence inflicted on the brain by the original injury; and that, of course, the application of the trephine cannot prevent the formation of the pus, but, on the contrary, by the additional injury which it produces, the inflammatory mischief will be greatly aggravated: they have recourse, therefore, to active antiphlogistic treatment, which they maintain is generally successful in warding off the impending danger; and assert that the trephine ought not to be applied, till, from the accumulation of matter, unequivocal symptoms of compressed brain manifest themselves. To wait for this occurrence, is to delay till the chances of success from surgical interference are almost hopeless. We have no means of ascertaining the exact situation of the purulent collection, or whether it lies above or below the dura mater; and we shall often fail in evacuating it, even after the trephine has been employed. I have seen it spread over an entire hemisphere; and when it is so situated, and so extensive, the disorganization of the brain, resulting from its accumulation and diffusion, will frequently lead to a fatal result, even although it should be evacuated by an operation: but this cannot be accomplished when it is collected under the pia mater, a situation in which Sir Astley Cooper states that it will be ge

nerally met with. It does therefore appear, that if we can, by a cautious use of the trephine, remove the fractured and depressed bone, soon after the injury has been inflicted, we shall succeed in relieving the brain from a source of dangerous irritation, and be enabled more effectually to combat the inflammation, and ward off the suppuration, which so frequently ensue; and that, upon the whole, the result will be more fortunate than were the operation deferred till suppuration had commenced, and symptoms of compression were present. I have seen, during the last six years, five cases of compound fracture of the skull, with partial depression, treated in the infirmary, according to the Abernethian plan, but unsuccessfully. There existed at first no symptoms of compressed brain; it was therefore considered imprudent to have recourse to the trephine, the usual antiphlogistic means being alone trusted to. In from six to fourteen days, a rigor took place, followed by headach, drowsiness, and stupor, until at length stertorous breathing, slow pulse, dilated pupil, coma and death, supervened. In two of these cases, the trephine was applied, and a small quantity of pus, collected exterior to the dura mater, was evacuated, but without the slightest relief to the compressed brain. On dissection, the greater part of this fluid was discovered between the dura and pia mater, and between the pia mater and brain; and in these two, as well as in the other fatal cases from suppuration, the inner table of the skull was more extensively fractured than the outer one, and an irregular portion of it thrust down on the brain. Finding that these unfavourable results are of such frequent occurrence, when the operation is deferred till suppuration is established, I have been long of opinion with Mr. Brodie, that, in compound fracture of the cranium, the early removal of the depressed portion of bone by the trephine, when it cannot be accomplished by the elevator, is the safest, and likely to become the most efficient practice. I have only had an opportunity of trying it in one case, and in this the result was successful."

Thus it will be seen that Dr. Macfarlane agrees with Sir Astley Cooper and Mr. Brodie in thinking immediate elevation advisable in cases of compound fracture of the cranium, attended with depression.

XLIII.

MR. MIDDLEMORE ON THE PURULENT OPHTHALMIA OF INFANTS. THERE is a sensible paper on the Ophthalmia Neonatorum in our valued contemporary, the Medical Gazette. We shall notice some of Mr. Middlemore's remarks on the causes and treatment of the disease. With respect to the first, Mr. Middlemore appears satisfied that it is always to be found in morbid vaginal discharges of the mother, there being at the same time some defect in the children themselves, or in the management of them, predisposing them to the disease, or aggravating it when present. Those morbid vaginal discharges may be gonorrhoeal, gleety, or leucorrhoeal; in short, they may be various, without corresponding, or at least recognizable, varieties in the character of the induced ophthalmia. This seems to be the pith of Mr. Middlemore's theory of causation.

"Infantile purulent ophthalmia more frequently attacks the progeny of the poor than the offspring of those in better circumstances; it is more common in premature children and twins, and is most obnoxious to those who are weak and delicute in constitution; it is also observed to be very prevalent in Foundling institutions-those, I mean, that receive infants deserted by their parents immediately after birth; whence I infer, that delicacy of constitution, want of cleanliness, defective nursing, and a vitiated and unwholesome atmosphere, are powerfully predisposing causes."

Now leucorrhoeal is very common in women of the middling and upper classes, but in their children ophthalmia is very uncommon. This proves, without further argument, that other circumstances are necessary to render the leucorrhoeal discharge operative in producing the ophthalmia. Cleanliness and clothing, and pure

air and vigour, are probably the most essential protectors against contamination; but whether differences in the maternal discharge are operative in rendering the infant more or less liable, is a question that we cannot pretend to solve. It certainly does appear, that a person with gleet may or may not communicate gonorrhoa to the female with whom he is connected, and it is also likely that what is termed leucorrhoea, that is a mucous discharge from the vagina, not consequent on venereal infection, will occasionally, but not commonly, infect the male. We are not well acquainted with the laws that regulate the infecting power of vaginal discharges. But let us pass to Mr. Middlemore's method of treatment. It is rather judicious than novel.

In slight cases, an astringent lotion and a dose or two of magnesia will effect a cure. The majority of cases are not so slight, and much depends on obtaining the management of them at an early period. In such a case, at such a period, we may use a solution of alum and a slight aperient. The eye should be washed every half hour, or, if necessary, oftener, with a well made ivory or pewter syringe, the point not too sharp; the extremity is to be placed between the lids, at the outer angle of the eye, and should pass it, for a short distance, almost parallel with the surface of that organ, and not so obliquely as to hurt the eye-ball, or oppose the conjunctiva as an obstruction to the issue of the fluid. The eye is thus to be syringed with a little warm milk and water, after which a weak solution of the sulphate of zinė or alum (gr. iij. ad 3j.) may be thrown in, and repeated, with the same preliminary washing, every second hour. Mr. M. recommends the nurse to apply a little fresh butter, or sweet oil, or mild ointment, along the tarsal margins, whenever the child is about to sleep, a precaution which renders unnecessary the tedious bathing the lids. This should be combined with a dose of magnesia, or, if the child be jaundiced, as sometimes happens, of hydrargyrus cum cretâ.

The inflammation may be severe, with chemosis, &c. Mr. M. then recommends the application of a leech to the root of the nose, or upper lid of each eye, according to circumstances. Of course great care must be taken to prevent the bleeding from proving too considerable. If the lids are much swollen, with obstructed circulation, and if any vessel be particularly large, it may be opened with a lancet, and the bleeding encouraged by warm water.

If the case has proceeded farther, the cornea having ulcerated or sloughed, the chemosis diminished, and the conjunctiva become comparatively pale, “it would be right to use a solution of the nitrate of silver (two or more grains to the ounce) two or three times a day, the eyes being frequently bathed with zinc lotion. If suppuration of the eye-ball has taken place, the surgeon should not be too tardy in puncturing the cornea, and discharging the contents of the eye-ball.

Mr. Middlemore protests against "the harsh applications" of Dr. Vetch, particularly the undiluted liquor plumbi acetatis. He also thinks that, at the present time, there is an "extraordinary partiality for the early employment of stimulants." He would not wish them used till the proper time, that is, till the acute stage has passed by. Mr. Middlemore cannot coincide with Mr. Guthrie, in using the unguentum argenti nitratis in the earliest stage of the purulent ophthalmia of infants.

As Mr. Middlemore's strictures are levelled against stimulating applications generally, when employed in the early stages of ophthalmia, we may be permitted to make this remark-that at Mr. Guthrie's Ophthalmic Hospital, stimulants are not found to be productive of those mischiefs which their opponents attribute to their employment. For the results of Mr. Guthrie's treatment, we can safely refer to a report from the Ophthalmic Hospital, published in a late number of this Journal. The cases there detailed are satisfactory evidence of the advantages, we put it broadly, the great advantages, of stimulating early in certain conjunctival inflammations.

sat, falls blighted. The brilliancy of mirrors is dimmed after reflecting their image, the edge of burnished steel is deadened, as is also the shining beauty of ivory. Hives of living bees are quickly deprived of their busy vitality. Copper and iron become rusted, in consequence of being exposed to the contact of the malignant fluid. Dogs that taste it become mad, and their bite infuses with it an incurable poison. They say, that even that small animal the ant can discover the vicinity of a menstruous woman, and that it throws away the provisions it chanced to be carrying at the moment of making that discovery, not taking to them again. This evil of such a nature and magnitude happens to women every thirty days; but prevails to a greater extent every third month. Some, however, have the menses oftener than monthly, others have them not at all. These latter, however, do not bear children; for this periodical flux is the matter which assists the male in the act of generation. Plin Secund. Natural Histor. tom. ii. lib. 7, cap. 15, art. 13. In the law of Moses, the secretion incident to the function seems to have been considered more in the light of an infirmity of nature and of offensiveness to our senses, than as being possessed of the malignant properties ascribed to it by other ancient writers.-Levitic. xv. 19 -38. Isaiah, xxx. 22. Ezekiel, xviii. 6. In hot climates it is indeed probable that the menstruous secretion is very liable to become acrimonious under certain circumstances of inattention to the duties of cleanliness. Hence, no doubt, the origin of the strict regulations contained in the Mosaic ritual, and imposed upon the females of the Jewish nation during and for some days subsequently to the period of the function. The personal habits of the native women of India are such as lead to the same conclusion. The frequency of their ablutions is such as scarcely to be credited, excepting upon the most veracious testimony."

ancient philosophers. It was, indeed, a benefit to the human mind, when Lord Bacon broke the neck of antique sophistry. It is generally believed that the menstruous fluid contains no fibrine. There have not been an adequate number of experiments to determine this satisfactorily. Mr. Brande's analysis appears to deserve most confidence.

"Whilst engaged (says he) in observ. ing the colouring matter of the blood, I received from Mr. Wm. Money, House Surgeon to the General Hospital at Northampton, some menstruous discharge collected from a woman with prolapsus uteri, and consequently perfectly free from an admixture with other secretions. It had the property of a very concentrated solution in a diluted serum, and afforded an excellent opportunity of corroborating the facts respecting this principle, which have been detailed in the preceding pages. Although I could detect no traces of iron by the usual mode of analysis, minute portions of that metal may, and probably do, exist in it, as well as in the other animal fluids which I have examined; but the abundance of the colouring matter in the secretion should have afforded a proportionate quantity of iron, if any connexion had existed between them. It has been observed, that the artificial solutions of the colouring matter of the blood invariably exhibit a green tint, when viewed by transmitted light. This peculiarity is remarkably distinct in the menstruous discharge. I could discover no globules in this fluid, and although a very slight degree of putrefaction had commenced in it, yet the globules observed in the blood would not have been destroyed by so trifling a change."

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