the 13th, 14th, and, 16th, his bowels were opened by pills of calomel, extract of colocynth and croton oil: sulphuric acid and acetate of lead with opium were administered; by which means the hæmorrhage was speedily subdued, and on the 25th of March all traces of the petechiæ had disappeared.

The blood drawn was the richest in coagulating and colouring matter Dr. B. ever beheld. Even after standing for twenty-four hours, it threw out only a few globules of serum.

Dr. B. has related this case for the purpose of noticing a coincidence which may perhaps (should it fall under the observation of others) throw some light on this obscure disease. The subject of the present case has been for years liable to ob structed bowels, with occasional violent pain there and vomiting, requiring the administration of powerful purgatives; and though now all hæmorrhage has ceased from the bowels, yet there is still disease existing there. The abdomen is tense and very painful on pressure; the pulse is frequent; the tongue white; the thirst great, und there is either constipation or watery diarrhoea. About a year ago, Dr. B. had an opportunity of examining the body of a female of intemperate habits, who fell a victim to purpura hæmorr hagica. The only morbid appearance discovered (besides the incorporation of blood with the cutis in various parts of the body) was extensive ulceration of the cæcum and right extremity of the colon.

XL.

BATH HOSPITAL.

Several instructive cases of injury of the head have been reported from this hospital in the Provincial Medical Gazette; passing over the first, a fatal and not very unusual instance of hernia cerebri, in consequence of wound of the dura mater, we are led to take notice of the following, because it involves a practical question in surgery, or rather illustrates a position on which we have often dwelt.

I. COMPOUND FRACTURE AND DEPRESSION OF THE SKULL-OPERATION-RECOVERY.

William Wilmott, sixty years of age, fell from a height of fourteen feet in a quarry, and struck his head upon the angle of a block of stone. He was admitted into the hospital shortly afterwards perfectly sensible, with his skin cold, and the pulse small and weak. At the upper and posterior part of the parietal bone was a small wound which bled freely and communicated with the bone, which was fractured and depressed. An oval piece, about an inch and a half long and half an inch in breadth, was indented, one side remaining on a level with the rest of the skull, the other being depressed a quarter of an inch. The depressed part was so firmly wedged down, that it could not be raised until the level edge was completely divided by Hey's saw, when the bone was removed, and, as usually happens, the fracture proving much more extensive in the internal table than the external, several other fragments were taken away. The dura mater was unhurt, and no extravasation existed between it and the bone.

The patient passed a restless night, and was purged and bled to eighteen ounces next day. On the 20th of August, (the accident happened on the 18th) there was a copious discharge of watery fluid from the surface of the dura mater, but the wound had in great measure closed by adhesion. There was a good deal of pain in the back of the head, intolerantia lucis, pulse 70, tongue moist. He passed a restless night, and on the 21st, was bled again to sixteen ounces. Want of sleep, and pain in the head, with a pulse rather slow than quick, viz. from 58 to 64 in the minute, continued to be the more prominent symptoms, and on the 25th, he lost six ounces more blood. A thin, clear discharge flowed for some time from the surface of the dura mater, but the wound healed slowly, and the patient was discharged in good general health, on the 9th of October. The pulse at this time was still slow, and he suffered from giddiness in the head and dimness of vision.

This case is really a fine illustration of Sir Astley Cooper's precept of operating in compound fracture, with depression of the cranium, whether there be present symptoms or not. Of course we cannot pretend to affirm in a positive manner, that under other treatment than that which was adopted a different result must necessarily have followed, but we do believe that in all probability it would. Cases apparently similar have occurred where the broken bone was not interfered with, and the consequence has been, the supervention of fatal inflammation and suppuration on the surface of the dura mater, or in the brain, as, for instance, in the case reported at page 234.Cases have also occurred where the operation which was neglected or rejected in the first instance, has perforce been had recourse to at the secondary period when inflammation has come on, sometimes with success, oftener, much oftener without it. On these and on other accounts, we think that Mr. Norman, under whose care the present case was, acted scientifically and judiciously in applying the saw, and raising the depression, even although it produced no symptoms of pressure at the time. With respect to the giddiness in the head and the

weakness of vision that remained when the man was apparently recovered, we believe that these dregs, if so we may term them, of affections of the head after injury inflicted, are by no means uncommon. It is not at all unusual to find a patient complaining for months and months of violent pain in the head, "a solitary symptom after all other symptoms have vanished."

II. FRACTURE OF THE CRANIUM WITH SLIGHT DEPRESSION-WOUND OF THE MENINGEA MEDIA-OPERATION--DEATH.

We are tempted to take notice of this case also, because it has a practical bearing, and is one that will every now and then be met with by the surgeon.

A lad of 16, was brought into the hospital under the charge of Mr. W. Brown, on the fifth of November, having fallen on his head from a hay-loft fourteen feet high. Immediately above the ear was a very slight

scalp wound, and although he was stunned, he was far from completely insensible, desiring the attendants not to cut his clothes in removing them. By the end of an hour, a material change had taken place; he had vomited several times-his respiration was stertorous, though not in any great degree his pulse was weak, and had become more frequent-the pupil of the right eye dilated, that of the left in its natural state, and acting freely on the access of light-he was much less sensible, but still expressed pain, when firm pressure was made in the seat of injury. Mr. Brown, who saw him two hours after the accident, divided the scalp by a T shaped incision immediately above the ear-exposed the bone-found a fissure extending from the vertex through the lateral and posterior parts of the parietal and temporal bones towards the basis, with a trifling depression below-applied the trephine and Hey's saw, and removed the depressed piece.

The finger now passed into an extensive collection of coagulated blood, beneath which the dura mater could be felt deeply depressed and detached from the bone in a circle of two or three inches in diameter.— The coagulum was removed to the amount of four or five ounces, aud the dura mater seen to be uninjured. As fast, however, as it was removed it re-accumulated with rapidity. The source of the hæmorrhage was discovered to be a tolerably large branch of the meningeal artery, pouring out blood with a vigorous jet, some way within the anterior margin of the bone. After some time had been allowed to pass in the fruitless expectation that the bleeding would cease, a tenaculum was carefully passed under the bleeding point, so as not to perforate the whole thickness of the dura mater, and the vessel then secured by ligature. The surface of the dura mater which had not at all risen, was next cleared from blood; the integuments closed by a few points of suture, the head turned to the injured side, and covered with cloths kept wet by cold water. He lost much blood during the operation and was rather more sensible after

it, whilst the states of the pupil, respiration, and pulse had also undergone an improvement. In the evening re-action took place, and six ounces of blood were abstracted; at eight p.m. the dura mater had regained its natural elevation, the breathing was easy, the pulse, 96. He was purged, but next morning the pupil was more dilated and immoveable, the pulse 132, the patient restless. Another purgative was given, and after its operation he seemed to be relieved. However, no material amelioration ensued; the insensibility continued, as did the restlessness; the pupils and especially the right, were dilated; the pulse was rapid, always above 130, and early in the morning of the 11th, he died.

Dissection. The fracture extended from the upper and posterior part of the right parietal bone to the basis cranii, passing through the squamous part of the temporal, running round the petrous portion, which was loose, and terminating in the body of the sphenoid bone. The dura mater, where it had been detached from the bone, "was alive," and covered by a thin but very firm layer of pale red coagulum. The ligature, which was loose in the wound, had been applied to one of the principal divisions of the meningea media, and had not been passed through the whole thickness of the dura mater. The principal injury to the brain was on the side opposite to the fracture, consisting of contusion with effusion of blood

under the pia mater, and into the superficial parts of the brain at several points.There were few traces of inflammation, and those almost wholly confined to the upper part of the hemispheres, where the arachnoid was opaque, and the vessels of the pia mater injected in patches of small extent.

The

head, which produces a scalp wound, and does not completely stun him. In the course, however, of an hour, he sinks into a condition of total, or almost total, insensibility, accompanied with stertor and the other symptoms said to indicate pressure on the brain. Now what state of things can such a series of phenomena point out? Concussion? No, for that would not increase, but be greatest at the time of the accident.Compression from broken and depressed bone? Surely something more, for that too would be an injury acting at once, and not supervening in a gradual manner. symptoms are those of pressure, and the pressure is evidently produced by extravasation of blood, because it increases gradatim and before inflammation could possibly be set up, just as the blood would pour out of a ruptured vessel. Under these circumstances the surgeon finds a scalp-wound, enlarges it and discovers a fissure. Now we do say, that in such a combination of things, not only is the surgeon right in trephining, bnt, cæteris paribus, he is bound to do it, for although the extravasation may not be there, the probabilities are strong that it will. In this sort of case it seems to us that the surgeon then ought to trephine, and that whether he finds the extravasation, or whether he does not, he has done his duty. The case, however, is materially altered, when the fissure or fracture of the skull is

We

absent, the other symptoms and the order of their occurrence being still the same. know that there is pressure, that that pressure is probably from extravasation, but we have not the fracture to guide us to the spot, we want the characters graven as it were, on the tablet of the skull, telling us "here ye generally is) a scalp wound, the bone may may search and find." There may be (and even be denuded, and yet the effusion may be quite on the opposite side of the skull, and trephining, if performed, must be worse than useless. In such a case, and unhappily it is not uncommon, a fearful uncertainty prevails, and a trying question there is for the surgeon to determine.

Here also we think that Mr. Norman acted very properly in applying the trephine, even though success did not consecrate the operation. A boy receives a fall upon the

XLI.

ual and regularly progressive emaciation of the body went on from this time till the day of his death, (24th of May, 1829) with the exception of a few weeks, which will be presently noticed.

The following highly interesting and melancholy case is calculated to teach humility -to inculcate charity-and to moderate pride, as far as the medical art and its professors are concerned.

The subject of the case was a young officer, about 25 years of age. He had been serving with his regiment, in a part of continental Europe by no means unhealthy, in the year 1827, and was then apparently in good health. It is probable, however, that he may have lived rather freely about that period, and for some time previously.

In the Autumn of the above year, and without any apparent cause, or deviation from usual health and habits, he was suddenly affected, after some riding exercise, with paralysis of the right arm and leg, with out any loss of consciousness, or any intellectual disturbance. He was lying on a sofa when the surgeon arrived, who asked him what was the matter, as he appeared in good health? The answer was, "don't you see that I am paralytic." The paralysis, however went off in about six hours from the commencement, without bleeding, but only with some aperient medicine. The next day he was bled, in consequence of some threatenings of a return. He had no more paralytic affection during the remainder of his life-upwards of 18 months-and he did military duty on his voyage home, in the year 1828. As far as could be collected from the patient and from the medical attendants, there had been derangement of the digestive organs, both before and ever after the above attack. Be this as it may, grad

VOL. XI. No. 21.

After his return to England, he was under the care of a surgeon in London for a local complaint-and afterwards he was attended occasionally in Yorkshire by another What were the opinions of these practitioners cannot now be exactly ascertained. Some of them at least, viewed the complaint as that of disordered function of the stomach, liver, and bowels. The patient was able to take some considerable degree of exercise, amounting even to hunting and shooting, in the country, during the Autumn and Winter of 1828. According to his own account, the progress of emaciation was, for some time, suspended in the country.

In the month of February, 1829, the gentleman presented himself to me, at my own house, and the degree of emaciation which then obtained instantly raised in my mind the idea of mesenteric disease. After giving a very slight history of his complaint, he observed that the essential and distressing symptoms were, 66 a constant fermentation in his stomach, with acid eructations, flatulence, sense of distention in his bowels, progressive emaciation, and debility." He was stripped, and examined in my own library. The emaciation was indeed, alarming. On laying him on a sofa, the abdomen was so extenuated, that I could feel the aorta from the cœliac artery to its bifurcation. I thought I felt enlarged mesentric glands, and my first impression was, that mesenteric disease obtained. The chest sounded well in all parts, and the respiration was loud and distinct throughout the whole thorax. The heart beat strongly, but not over a larger space than usual-the pulse was 80 and weak. There was no disturbance of the intellectual functions, nor of any of the senses the appetite was rather craving than otherwise-and the bowels were reported to be irregular, sometimes relaxed, sometimes confined. The tongue was moist, and slightly furred at the root. The patient had

been losing weight, at the rate of from three to five pounds weekly, for a considerable time previously, and the cravings of nature were such, that he took more nutriment, in the aggregate, than a man in health.

As I said before, the impression on my mind was, that the patient laboured under mesenteric disease. A mild aperient was prescribed, and again he presented himself. On examination, no mesenteric glands could be felt, and he informed me that he had passed some lumpy stools. I prescribed mild aperients, and a bitter infusion, with a very small proportion of the sulphate of quinine. I advised him to moderate the quantity of his food; but, on this point, he seemed determined to be the guide of his own conduct. During the first week of this plan the progress of emaciation stopped, and he lost but a quarter of a pound. During the preceding two or three weeks he had lost from four to five pounds weekly. In a week or two more, the "fermentation in his stomach," which was the great source of his grievances, almost entirely ceased ;-but, upon the whole, the emaciation advanced. As the patient now made known his resi dence, I had an opportunity of examining the state of the evacuations from the bowels. They were exceedingly variable-sometimes light or clay-coloured-sometimes dark and lumpy-sometimes slimy-sometimes entirely healthy and formed-but, generally speaking, fetid in smell, and deviating from a state of health. The pulse hardly ever varied from 80 in number, being weak, small, but regular. I candidly confess-and I confessed to the relatives of the patient at the time, that I was at a loss to form any accurate knowledge of the nature of the diaease. I did the best that my judgement prompted for checking its progress, but I was unsuccessful. My avocations prevented me from keeping notes of the case; but I think it was about the beginning of April that another physician was called into consultation He was equally at a loss to form any thing like a determined diagnosis of the disease. We both suspected that some mischief had been going on in the brain, from the period of the paralytic seizure in Portugal; but it appeared to us quite evident, that the immediate cause of the progressive emaciation and atrophy was in the digest

recommended an

ive apparatus.* Dr. increase of the quinine (to the amount of four or five grains in the day) with alterative aperients. On this plan to the surprise of the patient, as well as of ourselves, he gained, in 14 days, 7 1-4 pounds in weight-and began to drive out daily in his cabriolet. In the succeeding week, he lost 53 pounds!He thus went on, sometimes stationary, but generally, loosing flesh and strength, his appetite continuing tolerably good, and the evacuations from the bowels frequently healthy, but more frequently otherwise.

One evening in the latter end of April, he sat at the window of a drawing-room while the easterly wind prevailed and got a chill. He next day complained of pain, or at least uneasiness, in the back part of his head, and there was an acceleration of pulse, with some febrile symptoms. The bitter tonics were discontinued, and some saline febrifuges prescribed. As the head symptoms rather increased, we had the patient cupped on the back of the neck and kept in bed.About this time, my colleague, on examining the abdomen, thought he felt something like a tumour pulsating near the origin of the renal arteries, and mentioned this suspicion to the parent of the patient. A surgeon was added to the consultation; but nothing could be detected in the abdomen. As the

pulse was quick and hard, and the patient complained of some uncomfortable sensations about the head, we agreed that 6 ounces of blood should be drawn from the arm. It was much buffed and cupped. In the course of the same night, the region of the left parotid gland became swelled and inflamed. Next day he complained of an indescribable sensation of distress whenever he attempted to turn himself from one