5. HOPITAL ST. LOUIS. URTICARIA TUBEROSA INTERMITTENS.

BY DR. CAZENAVE.

DAUBENTON, aged 33 years, entered the St. Louis Hospital, on the 2d December, 1825, and was discharged on the 1st November, 1826, after a sojourn of 333 days. Four years previously he caught the itch, of which he was cured by the usual means. After taking a warm bath, at the completion of the treatment, he was seized with a violent rigor succeeded by intense heat, and ultimately profuse perspiration. At the same time, the left elbow and left knee swelled, and presented a number of irregular nodosities, of vivid red colour, and accompanied by insupportable pricking heat. This par oxysm (for so it deserves to be called) lasted eight hours, and then ceased, leav ing the parts above-mentioned covered with dark-coloured patches, that disappeared under pressure. On the succeeding evening, at the same hour, Daubenton was seized with a similar paroxysm in all respects, which lasted six hours.

The swellings and nodosities in this paroxysm were on the opposite side of the body. From this time, he was regularly seized, every day, with an attack similar to the first, except that almost every part of the body became, in succession, the seat of the swelling, irritation, and eruption. Ulcers formed on the ankles, and he was soon confined to bed, in a most miserable condition. At the end of a fortnight he was carried to the HOPITAL DE BEAUVAIS, the paroxysms having now augmented in duration and intensity. The tumefaction of the lower extremities was now permanent and enormous, the skin being almost black. Venesection, blisters, sulphureous baths, were employed in this hospital, by which the complaint was much mitigated; but, as soon as he began to move about the wards, he relapsed as bad as

ever.

After four months residence in hospital, he went out in the above-mentioned condition. He came to Paris, and, after a few months, repaired to the HoPITAL ST. ANTOINE, where he stayed nine months, undergoing a variety of treatment, with the effect of reducing the disease from a quotidian to a tertian, and sometimes a quartan form. This melioration was attributable to bark, which he took in powder. He went out of hos

pital in this state, and contracted a syphilitic complaint, of which he was cured in the HOPITAL DES VENERIENS, the original malady still continuing, though considerably mitigated. The unhappy Daubenton now supported a miserable existence, by working during the early part of the day, betaking himself to bed every evening, under a paroxysm of the pristine affection. At length he presented himself at the ST. LOUIS, and there the periodical accessions of the disease, as already described, were unequivocally ascertained. The paroxysms generally lasted four or five hours, accompanied by the swelling and eruption above-mentioned. On minute examination, during the remissions, no organ of the body appeared to be dis ordered in function or structure. Having now again become affected with itch, he went through the usual regime for that malady, and was cured of it. The sulphate of quinine was then administered, in doses of eight grains per diem. The paroxysms were stopped by this remedy, and he remained eight days free from complaint. He procured wine secretlycommitted a debauch-and again the original malady returned. This relapse was accompanied by inflammatory symptoms, which obliged them to omit the quinine, and prescribe antiphlogistics for a fortnight. Again the quinine was administered, and, in twelve days, the paroxysms were stopped. The intermission lasted a month, when the disease returned, without any appreciable cause; but in a much milder form. M. Biett now determined to employ arsenic; and Fowler's solution was administered, at first in doses of five drops per diem. The paroxysms ceased after the fifth day of this treatment. The remedy was ob liged to be suspended for eleven days, on

account of some enteric affection, but the original malady did not appear in that

interval. The solution was then recommenced, and continued for 26 days, at six drops the dose. The malady returned no more, and the patient was retained six weeks in the hospital, after cure, in order to be sure that he was free from complaint --BIBLIOTHEQUE.

The above we conceive to be a very interesting case, and certainly it does credit to the arsenic, which, in this, as in many other periodical affections, is even superior to the quinine.

6. ROYAL INFIRMARY OF EDINBURGH.

FRACTURED RIBs.

Some time ago, a person, who styled himself ERINENSIS, took to writing letters in the Lancet, which, though frothy and superficial enough, still had a degree of talent and wit in them, and might have made excellent briefs for a second-rate Irish barrister at the Old Bailey. Such, however, was the success of this gentleman from Dublin, that Edinburgh, determined not to be behind-hand, sent forth her champion under the designation of ScoTUS, who followed his predecessor "haud passibus æquis." Whether the REPORTS of Scorus be true or false we cannot pretend to say; if, however, they are the latter, there are plenty of channels now open to the medical officers of the Royal Infirmary to expose their misrepresentations, and it is their own fault if they do not take advantage of them. In No. 228 of the Lancet the following case is related.

W. G. æt. 68, broke his 6th and 7th ribs, near the angles, by a fall on the 25th September last. He applied no bandage, and walked about as usual until the 3d October, when he entered the infirmary, under the care of Dr. Hunter. He had then severe pain in the side, dyspnoea, pulse 100, bowels costive, tongue white. V.S. ad 3xxx. with relief. On the next day the stethoscope indicated "an alteration in the pulmonary tissue" in the situation of the fracture. On the 6th he was bled to 3xvj. and this not giving relief, a second bleeding was practised, after which he went on well until the 11th, when he had a rigor in the night, and inflammation took place in the vein which had been opened. Incisions were made into the arm, as it was generally swollen, and it was enveloped in ice, by which means, aided by bleeding and salines with antimony, the pain and swelling of the limb gradually subsided, and little remained except a short cough, and pain in the side. On the 21st, he had severe dyspnoea, which was relieved by a blister, but returned, on the 23d, with excessive pain in the neighbourhood of the fractured ribs. On examination, there was found an inflamed, circumscribed, and fluctuating tumour, reducible by pressure and position apparently into the cavVOL. VIII. No. 16.

60

ity of the chest. On the 4th November Dr. Hunter, after a short consultation with his colleagues, made an opening into the pleura, between the 6th and 7th ribs, where the tumour was most prominent, and gave issue to a "few ounces" of healthy purulent matter. The Doctor, we are informed, passed his fingers between the fractured ends of the ribs, and distinctly felt their rough extremities, no attempt at union having taken place. A piece of oiled lint was introduced into the wound, the discharge from which progressively diminished, until the 25th of December, when it had entirely cicatrized, and the patient is to leave the hospital in a few days.

We agree with the reporter, that this is not to be considered as a case of empyema, or as in any degree affecting the question of paracentesis thoracis in that formidable disease. We are not quite satisfied, however, that the formation of matter, in this case, depended exclusively on the fractured ribs, for, if so, it ought to have given note of its existence sooner. It evidently showed itself subsequently to the inflammation of the veins of the arm, and every one who has seen many of these cases of phlebitis, after bleeding, must be aware, that inflammation and the deposition of matter in the pleural cavity is by no means an unfrequent result. We do not mean to deny, that the fracture may have had a share in the production of the disease, but we certainly are of opinion, that the affection of the veins had also a share, and that a considerable one, in its developement.

7. MEATH HOSPITAL, DUBLIN.

DRS. GRAVES AND STOKES ON CUTANEOUS DISEASES.

Every one knows the difficulty of curing cutaneous diseases; which is about as great as the anxiety of patients to have cures speedily effected. Accordingly skin-doctors are in as great demand as so. It spine-doctors-sometimes more is wonderful how much may be done by the milliner in concealing a distortion; but an unsightly eruption on the face, the os sublime by which Heaven is said to have distinguished man from all other animals, though, in reality, a monkey's

face looks more upwards than that of the philosopher, is a terrible defect, and the removal of it is eagerly sought, even at the expense of some more important malady.

We are informed by the physicians above-mentioned that, at the date of their reports, they had, in the Meath Hospital, a young girl, labouring under the severest form of psoriasis, affecting not only the scalp, face, and extremities, but almost the whole surface of the body. A most abundant desquamation of silvery white scales was constantly taking place, so that handfuls of them could be gathered in her bed every morning. Her skin was almost universally of a bright red colour, and was very itchy-pulse 100, and strong -thirst-but otherwise healthy. She was twice bled-put upon low diet-and leeches were repeatedly applied to the most inflamed parts of the surface. In the mean time, she took daily, a pint of decoctum sarse, with two drachms of supertartrate of potash. When the inflammatory symptoms had subsided, sulphur was exhibited internally, with warm baths containing sulphuret of potash. The disease diminished for some time, and then made a stand against the doctors. Jar-ointment, and afterwards the

ung. hydrarg. nitrat. were employed, with good cleansing of the surface, and sulphur internally continued, by which means a complete cure was ultimately effected.

"In squamous diseases, more limited in their extent, we have successfully used a similar method of treatment; except that in such cases general bloodletting may be often dispensed with, as the repeated application of leeches to the affected parts is sufficient to subdue the active inflammatory stage of the disease. The only difficulty which occurs in the treatment of squamous diseases, is to determine the proper period for leaving off the local antiphlogistic applications, and changing them for stimulants. The latter, if applied too soon, will aggravate the disease, and when this is found to be the case, they should immediately be laid aside, and the application of leeches, poultices, and cooling lotions again be resorted to."

case

Hitherto Drs. Graves and Stokes have met with no case of scaly disease, which has resisted this simple method of cure. They have also extended these principles to the treatment of chronic pustular siderable success. and tubercular diseases, and with conA similar treatment they have found efficacious in a of sycosis menti-and they have used it, with marked advantage, in porrigo of the scalp, or tinea capitis. Recent cases of porrigo, they say, yield readily to the application of leeches to the head, with poultices repeated till the inflammation of the scalp is subdued. This may be known by the decrement or disappearance of the heat, redness, and soreness of the scalp. As the formation of pustules depends on the inflammation, their developement will cease with the removal of the cause; and the cure may then be readily effected by the use of the tar and citrine ointment. It is

hardly necessary to remark, that the preliminary steps of lulling the pain, shaving the head, and applying poultices, alkaline solutions, &c. till the scabs are softin very chronic cases, they have found it ened and removed, are necessary. Even best to commence by leeching the head; but recent cases require, of course, more antiphlogistic treatment than chronic.

a

In many cases of scald head, where circumstances have prevented leeching in the first instance, poultices, with an ounce of the liq. acet. plumbi, have been substituted with advantage. In children, this will often succeed in reducing high inflammatory action. In one case, however, the continued application of the acetate of lead produced something like colica pictonum. The following remark is worthy of attention. "There can be no doubt that the sudden drying up of cataneous diseases has occasionally produced dangerous internal complaints. This danger does not seem to attend their cure by the antiphlogistic treatment, which, when prudently conducted, diminishes the tendency to inflammatory action in the constitution, and does not, like merely topical applications, destroy it in one part, only to re-appear in another."

1. ANEURISM.

In a late sitting of the Westminster Medieal Society, Dr. Barry furnished a subject for discussion-namely, that of internal aneurism. The reason for the internal consideration of the subject was humourously enough grounded on the distinction between physic and surgery. Thus, till an aneurism points above the clavicle or below Poupart's ligament, it is, of course, the property of the physician-but the moment it overleaps these boundaries, the surgeon claims it as his prescriptive right! True it is, that the surgeons sometimes invade the domain of the physician. Cooper and Abernethy ought to be prosecuted and fined by the College of Physicians for digging into the abdomen-a soil in which they had no right to plunge a spade; while Wardrop and many others have passed the line of demarcation, in an opposite direction, and have threatened to tie up the ventricles or auricles of the heart itself, when affected with aneurism! We have a plea for canvassing the opinions and practices of both parties-because, like Tyresias, of old, we have served in both capacities.

If aneurism were as common in ancient as in modern times, it is wonderful that it should have escaped the observation of Hippocrates and Celsus. The latter clearly understood the difference between veins and arteries, and observed that wounds of the latter would not heal. "At arteria incisa neque coit, neque sanescit ; interdum etiam, ut sanguis vehementer erumpat, efficet."-Lib. ii. But the word aneurism does not occur in his writings. He describes varices of the veins of the leg, and directs them to be cut out, having first placed a ligature

above and below the tumour. In wounds of the veins, too, he directs a ligature above and one below the wound, and then the vessel to be entirely cut across. "Venæ, quæ sanguinem fundunt apprehendendæ, circaque id quod ictum est, duobus locis delegandæ, intercedendæque sunt."-Lib. v. It must not be said that Celsus here means an artery when he speaks of a vein; for he has minutely described the differences between these vessels, not only in their coats, but in the kinds of blood which they contain.

If this opinion be doubted, we have the authority of Sprengel on our side. Etius seems to be the first who distinctly notices aneurism, when speaking of Philagrius. He says that that bold surgeon excised the aneurismal tumour in toto, having first tied the artery above and below. Paulus Eginetus, and almost all the surgeons of the middle ages, followed the above method; which afterwards fell into disuse. Lanfranc was the first to recommend the actual cautery to the aneurismal opening in the artery, which advice was adopted by Fallopius. Marcus Aurelius Severinus appears to have been the first who tied the femoral artery close to Poupart's ligament, for an aneurism at the top of the thigh. Thus, till the sixteenth century, the treatment of aneurism was by ligature, and, in some rare cases, by excision of the tumour. At this epoch, John of Vigo tried compression and styptics, which were employed by Ambrose Paré, Fabricius Hildanus, &c. About the middle of the seventeenth century, the tourniquet was employed by some surgeons, to check the flow of blood into the aneurismal sac, while various contrivances were adopted, to make pressure on the tumour itself. Passing over these, it appears that Dominique Anel was the first to propose, and Lacorta to perform the operation of tying the artery both above and below the aneurism, without making any opening into the latter. Then came the operation of John Hunter, so well known, and still so universally adopted. But we cannot always, as in popliteal aneurism, disease-nay, we cannot always get at tie the artery at a distance above the the artery at all, between the aneurism and the heart. This consideration led Dessault to propose, and it is said (by the younger Sprengel) to perform, with success, the ligature beyond the tumour. This operation is reported to have succeeded in aneurisms of the axillary and external iliac arteries, but we cannot find the proofs, DESCHAMPS followed the example of Dessault; but in the two operations which he performed for aneurism of the external iliac or inguinal

* De Efficaci Med. Lib. 1. p. 11. p. 51.

artery, he completely failed. The same want of success attended Sir Astley Cooper, and it only remains to inquire, whether those performed by Mr. Wardrop, on the principle of Dessault, promise a more fortunate result. Of the four patients operated on by Mr. Wardrop and Mr. Lambert, two are dead, and in one of these, no aneurism, it has been

shown, was found, nor any trace of ligature having been applied to the carotid artery. The first case, the old lady, is still living, and dissection has not yet cleared up the true nature of the malady. Of the case operated on by Mr. Lambert, we gave our opinion in a former Number. From seeing the preparation and the drawing, we are still of opinion, that it was aneurism by dilatation of the carotid artery,

a disease not necessarily fatal in itself. The patient died of hæmorrhage, from ulceration of the coats of the artery.

Of the last case operated on by Mr. Wardrop, we gave an account in our last Number, page 534. Dr. Barry's diagnosis of the disease may be seen in the same place, where he stated the innominata to be considerably dilated, as also the aorta within the pericardium and at its arch, where it pressed upon some of the bronchia. Dr. Barry also stated his opinion, that the left carotid was "uniformly-dilated." From these and other considerations, Dr. Barry pronounced the disease to be fatal in its results, and that no operation on the right carotid could be of any service. Nevertheless the subclavian was tied, and in the LANCET, We find the most flourishing accounts of the patient's subsequent health. She had lost her cough, her dyspnea, all painand could go up stairs as well as ever. But Dr. Barry, in the Westminster Society, stated from an accurate examination of the woman, that the dyspnea, instead of being removed was increased since the operation-and in short, there cannot be a doubt that, although the tumour or dilatation of the vessels was prevented from proceeding in an outward direction, it had been making progress in another and more dangerous direction, which would terminate ultimately (if it went on) by suffocation.

Thus the pa tient had been relieved of pain, occasioned probably by the pressure of the aneurism on some nerve or nerves, but had got an increase of dyspnea, which

we consider a far more formidable symptom, and one which was likely to produce more suffering in the end.

From this exposé, we believe the Profession will be disposed to place little hope in the ligature ultra tumorem.

When, indeed, an internal aneurism has

protruded beyond the clavicle or the groin, there can be little rational hope of cure by any means. The cause of want impossibility of arresting the current of of success, may fairly be attributed to the blood through the aneurism, on which arrest the great hope of success must depend. Now the epigastric and circumflexa ilii arteries must always keep up a stream through an aneurism, where the ligature is applied beyond the tumour, in the groin or thigh-and the carotid, and several other arteries must also keep up the current in an aneurism of the innominata; so that the chance of success is diminished almost to a cipher. The only tangible artery, as we stated in a former Number, where ligature ultra tumorem offers any prospect of cure, is the carotid, because, from the common trunk of that vessel, no branch goes off till it divides at the top of the neck. In an aneurism, therefore, of that artery, situated too low for ligature citra aneurismam, there is a fair excuse for tying the vessel ultra tumorem. In any other situation, we fear the operation will be useless-perhaps, worse than useless.

P. S. Just as we had penned the above, Mr. Wardrop's additional report, dated the 5th December, came to our view. In this communication, Mr. Wardrop impugns the statement made by Dr. Barry, above alluded to, and he tells us that at the end of August, Mrs. Denmark was so well that Mr. Chapman, who examined her, declared to Mr. Lawrence that, had he not been previously acquainted with the nature of the case, "he could never have discovered that aneurism of any of the large vessels of the heart had ever existed." Lancet, Dec. 8. Mr. W. further informs us that the patient's countenance had "lost entirely that anxious expressive look which was formerly so observ. able." And bringing up the account to the date of his report, (5th Dec.) says, "she has regained a nearly perfect staté of health." The operator avers that, six weeks prior to the above date of report,