also remarks upon the modifications of diseases, or convalescence from them, that are sometimes, apparently, the result of a prior syphilitic infection.

In conclusion, Dr. Marston says the effect of the Mediterranean climate upon the syphilitic diathesis is very inimical, especially during the summer months.

SECT. II.-SPECIAL QUESTIONS IN SURGERY.

(A) CONCERNING THE HEAD AND NECK.

ART. 97.-On the Treatment of Damaged Brain from
Mechanical Injury.

By Mr. PAGET, Surgeon to St. Bartholomew's Hospital, &c. (Medical Times and Gazette, Feb. 21, 1863.)

In a clinical lecture on a case of fracture of the base of the skull, among many excellent remarks, are these:

66

What is the treatment of fracture of the base of the skull ? As regards the fracture, all we can do is to leave it alone. Occasionally, recovery will take place. As regards the damaged brain, do nothing but shut out all possible sources of mischief. For instance, keep away all possible causes of excitement. Just as we would keep a hurt joint quiet, so we ought to keep a hurt brain quiet. When the patient even looks or thinks, or is roused up, it is like moving the injured brain. In private practice it is difficult to keep the patient quiet, but in hospitals this can be more easily managed. The friends of such patients almost insist on something being done. This question of treatment may be illustrated by the way in which we treat an injury elsewhere, as, for instance, a bruised muscle. There is nothing to do but to keep it at rest. Would it occur to any one to bleed here? And yet it occurs to men of sense to bleed because a man has hurt his brain. What good would it do in injury to a muscle to give mercury? And yet it seems not unusual to give mercury in injuries to the head. Of course there are cases in which there are distinct indications for this kind of treatment. Its adoption as a matter of a routine in injuries to the head is to be deprecated. If (Mr. Paget said) the surgeon is not prepared to give mercury in bruised muscle, he has no ground whatever for giving it in injury to the brain. If, however (he continued), his patient had had symptoms of inflammation, he would proceed to treat it, but as yet he had had no symptoms of the kind. Delirium, convulsion, or other symptoms of celebral disturbance, are not sufficient alone to establish the diagnosis of inflammation of the brain. The signs to be relied on are those that would indicate inflammation elsewhere-the pulse full and rapid, breathing rapid, skin hot, and the organs of sense acute, and the pupils acting more rapidly. If these symptoms are not present, we

ought not to bleed or give mercury, on account of delirium or convulsions, or other symptoms of celebral disturbance.

"What we ought to do is, as before mentioned, to keep away from the patient all possible sources of excitement. We ought also most carefully to attend to the bowels and to the digestive organs. We should keep in mind that the patient can digest little, and, therefore, give but little, and that generally fluid. If the general health should flag, then we should give wine."

*

*

"In reference to treatment of inflammation following injuries, Mr. Paget said, that if the symptoms set in soon after-e. g., within the first two or three days of an injury, or of an operation-we might bleed or depress the patient, or at least refrain from stimulating him. But when the symptoms set in later-e.g., as in this case, on the eleventh day-then clearly the inflammation was an asthenic one. It was analogous to erysipelas setting in some days after an operation. If, after an amputation, we find tenderness and swelling of the stump within two days, we may treat it with depressing means, apply leeches or told lotions, or, perhaps, rather, merely keep the patient quiet, and refrain from stimulants and full diet. But if on the eleventh day the stump were to inflame, we should treat the patient with good diet and stimulants. Just so in injuries to parts we cannot see. If after ten days signs of inflammation set in, we ought to give wine, just as we ought in erysipelas of the scalp setting in at that time. In fact, we ought to be guided by the time when the symptoms set in, as well as by the symptoms themselves. The man's breathing was more frequent, but it was more shallow; his pulse was quicker, but it was more feeble; so that everything indicated stimulants. That the treatment was unsuccessful does not necessarily show that it is wrong. In fractures of the base of the skull, if we save one in twenty, we should do very well indeed."

ART. 98. On the Water Cure in Puriform Ophthalmia. By M. CHASSAIGNAC, Surgeon to the Hôpital Lariboisière,

Paris.

(Medical Circular, April 15, 1863.)

M. Chassaignac published a paper on this subject in 1847, from which, and likewise from a subsequent communication of M. Velpeau to the Academy of Sciences on the same subject, it appears that this treatment was resorted to in 71 cases of puriform ophthalmia, and that in no instance was loss of sight observed, or spots on the surface of the cornea. This result is especially deserving of attention, inasmuch as at the Foundling Hospital, where M. Chassaignac carried on his researches, the cases of ophthalmia amounted to 250 or 300 in a total of 600 patients, and that omitting the instances in which death was induced by the disease, blindness followed in 8 or 10 of the children.

Since that period M. Chassaignac and several of his former

pupils, MM. Léon Rieux, A. Fournier, and Bricheteau, have frequently ascertained the undoubted efficacy of the ocular douche in the puriform ophthalmia of children and adults. Thus the Bulletin de Thérapeutique informs us that the method was recently resorted to by M. Bricheteau in thirty children, twenty of whom were more than two years old, and were perfectly cured in an average of ten days; the remaining ten were new-born infants, and here again the treatment was perfectly successful, vision being in all cases preserved in its integrity. At the Hospital of La Maternité, M. Danyau also follows this course of treatment with results deserving of notice.

66

During the first quarter of the year 1862," says M. Nivert, an Interne of that Institution, in an appendix to M. Bricheteau's memoir, "600 births took place at La Maternité; 139 of the infants became affected with inflammation of the conjunctiva, the ophthalmia being puriform in 20 per cent. of the cases. Cold-water douches were prescribed in every instance, and in the severest only was a collyrium of nitrate of silver (5 gr. to the ounce) applied to the eyes. The intensity of the inflammation was not uniform. 39 were mild cases; in 61 the symptoms were more important, and 35 were of the most aggravated character.

The following were the results attained:-72 children left the hospital in a perfectly satisfactory condition, after complete restoration of the eyes; 45, when discharged, still preserved a morbid degree of vascularity of the conjunctival surface, but were obviously doing well; 17 infants were removed by their mothers, during the progress of treatment, and before any material improvement had set in; 5 only died; they were, moreover, born prematurely; and were carried off by scleroma, or gastro-intestinal complications."

Whether, in these cases, the douche is merely a more powerful detergent than common injections, or, as M. Chassaignac believes, a local modificator of great energy, no doubt can be entertained as to its efficacy. We shall, therefore, briefly state the mode of operation recommended by M. Chassaignac.

The only instrument required is to be found in the poorest dwellings, and consists in the tin-funnel used for watering the floor. To the pipe is adapted an India-rubber tube, and the apparatus being previously filled with water, is suspended to the ceiling or to a nail immediately above the child's head. The stream of water is then directed to the bridge of the nose, and to the open eye, the strength of the douche being gradually increased. In hospital the reservoir is attached to the cross-bar above the bed, and contains four pints of water; the extremity of the tube is supplied with a cock, and the water runs through a waterproof cloth groove into a tub placed on the floor.

The douche should last from eight to twelve minutes, and be repeated as often as may be required by the severity of the symptoms, or the nature and abundance of the morbid secretions. M. Chassaignac uses water at the temperature of in-door fountains, or of wells in summer, and has also recourse to astringent collyria, two or three grains of nitrate of silver, or of sulphate of zinc, to the

ounce of water, for instance. In order to prevent agglutination of the eyelids, it is further desirable to lubricate the palpebral margin with some greasy substance, such as glycerine or cucumber cerate.

ART. 99.-Diphtheria of the Conjunctiva.
By Dr. JACOBSON.

(Schmidt's Jahrbücher, No. 2, 1862.)

This disease is said by Jacobson to be characterized by the transformation of the conjunctival tissue into a bloodless yellow grey or grey-white mass, which penetrates to various depths, and so has different appearances. The membranous formation offers nothing characteristic, but varies in individual cases. He describes the anatomy of a case ending in death, after measles, of a child ten months old. "In the microscopical investigation, the extended membrane appeared to be composed of an amorphous granular matrix, swelling up in acetic acid. In this matrix were distributed crowded large and small fat particles, and separate from them there were, moreover, irregular, angular, pale cellular formations without nucleus, some of the size of the pus-corpuscles, and some smaller. These might be considered as shrivelled pus-cells breaking up, and partly as detached fibrinous particles. The epithelium was wanting as far as the pseudo-membrane reached; it was partly preserved on the sclerotic conjunctiva, but irregularly disposed, dimmed, and very granular; the uppermost layers seemed to be wanting. The reticulation of connective-tissue corpuscles of the palpebral conjunctiva of the tarsus and of the submuscular connective-tissue was engaged in an extension, increasing in intensity from the deeper parts towards the surface; and, indeed, in the nearest surrounding parts of the smaller arteries and veins there always appeared the largest accumulation of cellular elements. Towards the surface one saw a dimming of the tissue by molecular fat particles, increasing progressively, and with it a decay of the cellular elements was connected. The most superficial layer appeared irregularly indented, formed of degenerating tissues infiltrated with granular matter. The cells of the Meibomian glands were almost wholly free of fat. On the transition fold and the sclerotic part of the conjunctiva the condition was nearly similar, only the degeneration on the surface did not appear to have yet taken place here, and therefore the epithelium was partly preserved. The epithelium of the cornea, as far as it was still maintained, showed a very granular appearance, hazy, and somewhat brownish in colour; the layers adjoining them were likewise dimmed with little fat particles, and the corneal corpuscles showed an increase of nuclei. In the ulcerating parts were found detached shreds of sloughing corneal lamella; the increase of nuclei and the granular infiltration extended rather deeper."

ART. 100.-A Case of Intra-orbitar Aneurism, cured by Ligature of the Carotid, after failure of Digital Pressure. By Mr. ERNEST HART, Surgeon to the West London Hospital. (Lancet, March 15, 1862.)

The following case appears to be unique in the surgical literature of this subject. It is an instance of traumatic arterio-venous aneurism of the frontal branch of the ophthalmic developed within the orbit.

CASE. Richard T

a boy, aged 11, quarrelling in the street with another lad, received a blow from the forked end of an iron rib of a parasol at the inner angle of the left upper eyelid, about four years since. Rapid swelling of the eyelid followed. In a few minutes a considerable effusion of blood into the eyelid had occurred. It swelled to the size of a pigeon's egg, and became purple in colour, altogether obscuring the eyeball, since the lid could not be raised. The wound bled very freely. By the aid of pressure the bleeding was arrested. Subsequently, under the influence of time, cold lotions, and leeches, the swelling of the eyelid subsided, the eye remaining somewhat bloodshot. No ill effects were apparent.

The boy returned to school, and went on as usual. He used to complain afterwards of headache and singing in the ears; but it was not until the end of 1860 that the attention of his mother was drawn to a swelling in the site of the original wound of the lid, which beat with a perceptible pulsation. This gradually increased in size; the lid became protuberant, the eye projecting, and somewhat unduly vascular in its conjunctival surface. He was brought to my house on the 19th of January, 1861.

There was an aneurismal swelling at the inner angle of the orbit, just below the margin of the bone; it pulsated strongly. There was a perceptible thrill, and a very loud, whizzing bruit could be heard over all the left side of the head and temple. This bruit was continuous through both systole and diastole, but louder during diastole. Hence I inferred that there was a communication between the artery and vein, and that this was an arteriovenous aneurism, resulting from the transfixion of the frontal branch of the ophthalmic artery and its satellite vein by the forked end of the piece of iron. There was no scar perceptible where the external wound had been. The eyelid was swelled, and some dilated vessels coursed over the ocular conjunctiva of the globe, which was itself more prominent than that of the opposite side. The general health of the lad was good. He complained of a whizzing noise in the head, like that of a steam-engine at work, and he suffered from headache.

After causing my diagnosis to be verified by Mr. Erichsen, I resolved to apply digital pressure to the left carotid artery, with the view of obtaining a cure in the same way as we are in the habit of doing in treating aneurism in other parts of the body. Although entertaining the highest opinion of the capabilities of this always innocuous treatment, I had not any great hopes of its success in this case. That method is most effective to cure where a definite sac or diverticulum of the blood exists, and where, by retarding the circulation, the deposition of layers of fibrin on the roughened walls of the sac may be obtained. Here, however, there was but a small sac, situated between the artery and vein, and communicating with both. I had put the boy under chloroform to facilitate the perfect examination of the aneurismal disease; and by passing the finger between the eye and the

XXXVII.

11