P.S. We believe the late Talma died of this disease, and that Dupuytren would have attempted the operation of gastrotomy, had it not been for the debilitated state of the patient.

8. CHOREA. DR. M’ANDREW.*

It is now beginning to be acknowledged that Dr. Hamilton's plan of purgation will not always prove successful in chorea. That the disease depends upon irritation in the primæ viæ, in most instances, we have little doubt; but the causes of this irritation would not produce the disease, if there did not exist a morbid sensibility, or susceptibility, in the nerves of the alimentary canal. By purgation, therefore, we only perform half our work. We clear away all irritating matters; but we do not remove the morbid sensibility of the parts to which the irritants had been applied. On this account, the best practice is to follow up the purgative plan by tonics-or, at least, to combine or alternate them. The case of Dr. M'Andrew was a girl, nine years of age, admitted to the South London Dispensary in March, 1826, her complaint having begun in January, in the form of slight convulsive movements in both sides of the body. These were always increased by mental agitation. She had occasional head-ach and diarrhoea. Her brother is subject to epilepsy. She herself had now the usual symptoms of chorea, but not in a severe degree. Purgation by calomel and jalap was assiduously employed, and leeches were applied to the head; but a month's treatment on this plan produced merely an increase of the convulsive movements. Ether, valerian, and opium were now conjoined with the purgatives, but under this treatment also the patient got worse. She could now scarcely stand or walk. The head was ordered to be shaved, and the tartar-emetic ointment applied, which brought out a copious crop of pustules. The convulsive movements on one side now subsided, The pustulation was extended to the spine, and with beneficial effects. The bowels were kept open by calomel and jalap. She ultimately, though very slowly, recovered.

It is evident that the purging plan failed here entirely, and the cure is to be attributed to the counter-irritation on the head and along the spine. This removed the morbid sensibility of the nerves, on which the disease generally depends. We repeat it, that purgation is only half the cure. Tonics, sedatives, and counter-irritants must be alternated or combined with purgatives.

9. M. LISFRANC'S CLINICAL REPORT. LA PITIE.

1. Carcinoma of the Eye. We notice this more for the purpose of recording M. Lisfranc's mode of extirpating the organ of vision, than for any great interest that attaches to the case itself.

Case. Ann Vigé, æt. 21, of strumous habit, had suppression of the

* Med and Phys. Journal, No. 4, New Series.

* Hôpital de la Fitié. Révue Medicale, August, 1826.

menses at the age of seventeen, after which she was subject to ophthal mia of the left eye. In Nov. 1825, she received a blow on this organ, which caused much inflammation, and, indeed, deprived her of vision. On entering the hospital, on the 25th February, the eye was found to be irregular-the sclerotic of a deep livid hue-pus collected behind the transparent cornea, from which there arose a fungous projection-violent lancinating pains. Extirpation of the eye was determined on, and performed by M. Lisfranc, in the following manner.

The patient being seated, with her head reclining on the breast of an assistant, M. Lisfranc, placing the finger and thumb of the left hand on the external angle of the lids, drew out the integuments; then with the right hand introducing a straight bistoury horizontally beneath this angle, he passed it half an inch across, turned it forwards, brought the point out through the skin, and so made the instrument cut its way out. Then, with a hook, drawing out the globe of the eye, he plunged the bistoury between this and the walls of the orbit, on the inner and upper side, so as to divide the great oblique, and carried the instrument round to the point from which he started. It may be observed that the assistant opens the lids alternately, and not both at once, as is commonly done. The optic nerve and cellular tissue were divided by curved scissors, and the lacrymal gland cut out by the same instrument. M. Lisfranc, during the operation, avoided wounding the eye lids, by making the fore-finger of the left hand a director for the bistoury. Little blood was lost.

On the 5th day there was much pain in the head, with tumefaction of the palpebræ. These symptoms were dissipated by abstinence, a free bleeding, the application of 30 leeches to the temple, and a poultice to the part. The patient left the hospital on the 15th, quite cured.

2. Hernia and Perforation of the Stomach, &c. F. Duvenot, æt. 63, who had always been accustomed to carry heavy weights upon her stomach, had redness and pain about the navel, which, after a fall on the 20th March, 1826, became much aggravated, and ended in abscess, that burst spontaneously. On admission into hospital, April 4th, there was found, in the place of the navel, an abscess about the size of a fivefranc piece, which discharged fetid matter. On introducing a probe, this was found to end in a cul-de-sac. The patient had spasms-the eyes were sunken-the extremities cold-tongue red and dry-pulse feeble and irregular. On the next day the discharge was more fetid, and smelt of fæcal matter, the probe passed to the depth of three inches. On the 12th, after the exhibition of a ptisan, pressure was made on the stomach, and the fluid was seen to issue through the opening. She sunk on the 18th.

Dissection, 20 hours after Death. The pylorus was found to have contracted adhesions with the umbilical tumour, and it had a perforation half an inch in diameter; the valve was almost entirely destroyed by ulceration. There was a very free communication between the stomach and duodenum. Ulcerations in the jejunum, ileum, and cæcum.

Herpes Zoster. In our last we took notice of the treatment of Herpes zoster by M. Geoffroy, at La Pitié, namely, cauterization by the nitrate of silver. M. Lisfranc has detailed three other cases in which this plan was tried, and with the effect of dissipating the eruption very rapidly.

3. Wounds of the Scalp, with or without sub-aponeurotic Inflammation. M. Lisfranc observes that, in scalp-wounds, unless the soft parts be very much injured indeed, the surgeon brings the divided edges together, and endeavours to obtain union by the first intention. Seeing, however, that in a great number of cases so treated, the union is only superficial, that purulent matter is collected at the bottom of the wound, and that depôts frequently form in the neighbouring tissue, giving rise to serious consequences, M. Lisfranc has adopted another, and, in his hands, more successful method. After cleansing the wound, &c. he brings the edges, not into close contact, but within two or three lines of each other, by adhesive straps, the interval is then lightly filled with charpie; over thisthere is put some common dressing, with holes for the free exit of matter, then charpie, and a bandage over all. If pain and tumefaction should occur, the dressings are removed, and merely a little charpie is introduced into the wound, which is covered by a poultice. He adduces several cases in illustration; we shall notice one or two.

Case 1. Gindon, æt, 32, robust, received a wound on the head, about two inches in extent, on the 9th January. He was bled, and the lips of the wound brought together, On the 11th he entered La Pitié. On the 12th the wound was found partly cicatrized, its edges tumid and painful; the pulse was frequent. On tearing off the cicatrix, a small quantity of matter escaped; the wound was kept open by lint and a poultice. On the 14th suppuration was established, and the wound dressed. On the 2nd February he was discharged, cured.

Case 2. M. Monty, æt. 67, received, Dec. 11th, a wound, two inches long, over the right parietal bone. On entering the hospital on the 12th, the pulse was quick and hard-intense cephalalgia. 13th, Venesection -the wound was dressed with charpie, simple dressing, and bandage. Jan. 16th. Discharged cured.

The practitioner, however, is not always fortunate enough to meet with cases thus early. Perhaps before he is called, extensive aponeurotic inflammation and suppuration have taken place, and an excitement of the system, which is, at all times, of a serious, and not unfrequently of a dangerous character. In cases of this kind, then, the cicatrix must be broken up, free vent given to the confined matter-poultices applied, and strict diet and antiphlogistic measures, if there is any determination to the stomach or any other organ, are to be employed.

Case. M. Débété, æt. 68, had a fall, in which he received a wound, two inches long, in the upper part of the scalp. On entering La Pitié, 4 days after the accident, the wound was found partly cicatrized-the edges tumid, oedematous, and of an erysipelatous redness-pressure

gave great pain. Pulse quick-violent cephalalgia-extreme dejection. The cicatrix was torn up, and a poultice put on the part: bleeding, general and local, by leeches was employed, and, on the 10th September, the patient was well.

Several other cases follow, but they are of a precisely similar character, and to use the homely adage, "Enough is as good as a feast." We would now make a few remarks on the practice of which we have given an account. We think, then, that, with proper precautions, union by the first intention, in many cases of scalp wounds, as in other wounds, may be obtained with perfect safety to the patient. The error, in our opinion, in a great majority of instances, lies, not in endeavouring to produce union at first, but in continuing to force it on when the parts are manifestly not disposed to it. In scalp wounds where the vitality of the parts is not much injured, let union be attempted; if, however, there arise pain in the part, if the edges become puffy, and an œdematous condition shew itself around the wound, let not the surgeon, as is often the case, be continuing his straps and his compresses, but let the dressing be torn off, and a ready exit be given to the serum or the matter which is surely collecting. We say serum, for we have observed that a not uncommon consequence of scalp-wound, is an oedematous condition of the surrounding tissue, situated, for the most part, under the aponeurosis of the occipito-frontalis muscle; this ædematous condition of the cellular membrane between the occipito-frontalis and the pericranium is commonly attended with intense cephalalgia-great febrile action, and even delirium, and, if it be not relieved, it will, in all probability, end in extensive suppuration. A free incision down to the pericranium relieves the tension and mitigates the symptoms, and in one case, which occurred under Mr. Brodie, at St. George's, an erysipelatous attack, which appeared after the incision, was remarkably mild and speedy in its termination.

We conclude, then, that, whilst we do not entirely agree with M. Lisfranc, we think his plans, with the modification we have mentioned, very judicious, and we repeat, that the "adhesive" plan is often blindly followed up in this country.

10. DR: GREGORY ON VACCINATION.

[Small-pox Hospital.]

In the November Medical and Physical Journal, Dr. Gregory has made some remarks on the best mode of introducing the vaccine virus, in order to insure its effects. He thinks the most general cause of failure is the use of dry lymph on points or glasses. Another source of failure is an unfit lancet. This instrument should be clean and sharp, otherwise the virus is thrown back upon the shoulder of the instrument, and not a particle enters the wound. The skins of children differ much in the degree of toughness. Failures Dr. G. has observed to be more common where the skin is tough. It is desirable that the lancet should not only be extremely sharp, but have a broad shoulder. The skin should be put well on the stretch by grasping the arm firmly, and fixing

the skin between the finger and thumb of the left hand. "In the hollow thus formed there is ample room for as many insertions as may be desirable." He thinks that

six or eight punctures should be made, allowing them all to be effectual, in order to make the proper impression on the constitution. The form is thus:

The lymph should be taken from a vesicle before it begins to subside. After the tenth day, the virus is scarcely fluid. It cannot be safely taken after the 8th day, including the day of insertion. We should say not after the sixth or seventh day. We generally take it on the fifth or sixth day. A fifth-day vesicle, he observes, will not generally afford virus for more than one subject. "An eighth-day vesicle (even when very tumid) cannot be relied on for more than six or seven subjects." The younger the lymph (fourth or fifth day) the greater is the degree of intensity. The propriety of inserting a numerous crop of punctures becomes very evident, Dr. G. observes, not only for the purpose of sa. turating the system more effectually, but for enabling the vaccinator of a public establishment to open a new vesicle for every third or fourth operation. The number of punctures here recommended will not add to the local inflammation, if they are made in the manner above described. The greatest number he has hitherto made was twenty; and, although the constitution sympathises more decidedly in such a case, the local irritation is not, cæteris paribus, greater here than under common circumstances. In a few cases he has observed a pretty copious eruption all over the body, of a ́lichenous character, disposed in crescentic forins, and receding in two or three days.

To ensure the success of the operation, the child should be in perfect health. It should never be vaccinated during hooping-cough. The vaccination sometimes fails, "from the prior occupation of the system by some other internal disorder." The most proper age, Dr. G. thinks, for the operation, is between the second and fifth month. If these instructions be attended to, our very intelligent author assures us that—

"Then the charm is firm and good."

11. ANEURISM AT THE BEND OF THE ARM, OCCASIONED BY VENESECTION.

The first case of this kind which we shall notice is related by Mr. Dalziell, R.N. in the 4th Number of the Edinburgh Journal of Medical Science.

Case 1. In the early part of February, 1825, A. Craighton, æt. 57, a seaman, was bled by a surgeon in Lancaster, soon after which a tumour formed at the bend of the arm, and continued to increase. Compression was tried, but it gave so much pain that it was laid aside. On the 7th May, Mr. Dalziell, was called in, and found the arm swollen and œdematous; at its inside, near the tendinous aponeurosis of the biceps was a pulsating tumour, about the size of a lemon; much pain in the limb; VOL VI, No. 11.