No.506.

LONDON, SATURDAY, MAY 11, 1833. [1832-33.

CLINICAL LECTURES ON SURGERY,DELIVERED AT THE

HOTEL DIEU, PARIS,BY

M. LE BARON DUPUYTREN,

During the present Session, 1833.

[Revised (before translation) by the Baron himself in thefasciculi of his "Lecons Orales de Clinique Chirur-gicale," published periodically by G. Bailliere, Paris.]

FUNGUS HaeiB1ATODES.

. THE erectile tissue does not always pre-sent itself in the simple state described inthe last lecture, being often mingled withcancerous matter. To this combination itis that I apply the term fungus l1aema.todes. Sometimes the cancerous matter

predominates; sometimes, on the contrary,it is the erectile tissue. This difference inthe proportion of the two elements is farfrom being a subtlety of description, or oftrivial importance respecting the treat-

ment, for, according to the predominanceof one or other of these structures, thedisease will have a different termination.If it be the erectile tissue which is in excess,complete ablation will almost assuredlyeffect a cure. If, on the other hand, thescirrhous structure be in greater proportion,its degeneration is the more sudden, a re-lapse more liable to occur, and extirpationwill be far from procuring favourable re-sults.

Fungus haematodes is in some cases si-tuated at the bottom of a cyst of variablesize, and sometimes filled with a largequantity of serum, which renders deceit-ful the first aspect of the part affected.

CASES 1 and 2.-neynorrrs in the stibsta)ice

n/’ the Left Breast.-Fuugws Hccmatodes.-Lxtirpatiorc.A young woman, above twenty, affect-

ed with a tumour in the substance of theleft hraast, entered the Hotel Dieu earlyin August, 182!): she attributed the dis-

case to the strong pressure to which thepart had been subjected two years before.The tumour was as large as a clenchedhand, was painful, and presented markedfluctuation, but the superincumbent inte-guments were sound. M. Breschet hav-

ing plunged a bistoury into the wound, aconsiderable quantity of blood escaped.The hemorrhage recurred twice in 48

hours, when it was arrested by means ofagaric and compression. On the 7th ofAugust the agaric fell off, and the edges ofthe wound were seen gaping, and givingissue to a bleeding voluminous fungus.On the 8th of August, a crucial incisionwas made over the tumour, and when thiswas laid bare, the finger was introducedbetween it and the surrounding parts. Itwas then found that the tumour was con-tained in a cyst intimately adherent to theadjacent parts, the tumour itself beingreadily separable from the containingcyst. The interior of the sac was care-

fully examined, and found to be free fromdisease. The point of the cyst from whichthe fungus seemed to arise, was extirpat-ed altogether. Its interior was then filledwith charpie and a light retaining band-age. This was all with a view to cause the

suppuration and adhesion of the parietesof the cvst.The separated tumour was of the size of

the clenched hand, composed of a sub-stance like brain, but of much greater con-sistence, and traversed throughout by aninnumerable quantity of tangled vessels.An abundant and dense cellular tissue,almost fibrous in certain points, containedthe various elements of the tumour, which,after its ablation, assumed a pale colour,

II forming a striking contrast to its rednessbefore the operation.""In a second case, a female residing in

Paris was affected with a rather volume-nous tumour in the substance of the breast,On the supposition of its being scirrhous,the operation was recommended. Thefirst stroke of the bistoury, however, gave

All further details respecting this nteresttugcase, ate unanenuntaNy omitted by the FrenchReporters.—En. 1-.

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issue to an enormous discharge of trans- movement of general expansion, especi-parent serosity, which showed the error of ally when the disease is of long standing.the first diagnosis, and seemed to indicate These pulsations cease completely whenthat the swelling was formed by an hyda- the artery is compressed between the tu-tid cyst. The serosity being all discharged, mour and the heart. The finger now per-a simple dressing w as applied, but in a ceives in some parts of the tumour afew moments an abundant hemorrhage "bruit" or thrill, like that produced bytook place. The dressing was immediately the friction of dry parchment. In otherremoved, the opening enlarged, and, on points the finger penetrates to a sufficientcloser examination, a bleeding tumour, depth without meeting any resistance.composed of erectile tissue and cancerous All this pulsation, which resembles thematter, in other words a true fungus hse- aneurismal closely enough, depends on thematodes, was discovered at the bottom expansion and contraction of the littleof a serous cyst of rather ample size. arteries which proceed to the diseasedThe tumour was at once extirpated, but, part.

’

it seemed, not completely, for in some " r. rr , . , ’

days after, another hemorrhage occurred CASE 3.-Fti.Tigus Hœmatodes of the Rightthrough the wound made in the operation. Leg.—Trial of Compression.—Ligature ofThe opening was accordingly again en- she Crural Artery.-Retnrra of the Disease

larged, and all the diseased points in the in Severa Years.—Amputation.—Recovery.depth of the sac were completely removed. -Examincitiott ot’ the Limb.After this there was no further hemor- Fungus haematodes is a very seriousrhage, and the wound healed without in- disease, which can only be cured by extir-terruption. The patient, who has per- pation, where that is possible, or by am-fectly recovered, has since suckled several putation. One of the elements whichchildren, and continues to enjoy good enters into its composition, the erectilehealth. tissue, may readily, under certain circum-

Remarks. stances, be modified favourably, by the.

ligature of the arteries whose ramificationsThe cysts in which fungi of this kind are keep up its circulation. But the other

sometimes developed, are externally fibrous element (the scirrhous cancerous ence-

and cellular, and adherent to the surround- phaloid) forms a powerful obstacle to theing tissues; internally they are complete- success of this mode of treatment. Never-

ly serous, and hence the secretion already theless the ligature of the artery may con-mentioned. Sometimes it is from a single siderably retard the progress of the dis-

point of the cyst the fungus arises, and ease towards complete degeneration, and,to this alone it adheres. Under other consequently, prolong, and render sup-circumstances, it adheres in almost its portable, the life of the patient.entire extent to the internal surface of I have seen this employed with greatthe cyst, which itself is intimately united advantage in the following case. Rwith the parts in the midst of which it is astat. 39, pale, thin, and tall, without anydeveloped. In this case the cyst is fibro- previous disease, except a tinea of somecellular, or entirely fibrous. years’ duration, was at 32 affected by a tu-

Placed beneath the skin at a greater or mour which developed itself at the innerless depth, and without affecting or alter. and upper part of the right tibia beneathing this membrane in the least, the fungus the knee-joint. On placing the hand onhaematodes may readily lead the surgeon this swelling pulsations were perceived,astray. It sometimes offers the insidious synchronous with those of the heart. Oncharacter of a manifest fluctuation, and his admission to the Hotel Dieu, in 1819,when we open the supposed abscess, in- (the tumour having been previously treatedstead of pus, we sec a discharge of blood, with cataplasms, leeches, and a blister,or of a reddish humonr, which is sooner or without any relief,) the tumour occupiedlater succeeded by a bleeding fungus. It the superior external and anterior part of theis an affection rarely or never seen, except leg, being about as long as the palm of thein young suhjects or adults. Sometimes hand, not circumscribed, the investingafter blows or external violence of various skin red, the pulsation ceasing on the

kinds, or after rheumatic or gonty swell- compression of the crural artery. On the

ings. In the place which is to become idea that the tumour was produced by athe seat of the cliscase, there occurs a dilatation of the capillary vessels, andpainful tumour, the skin being sometimes perhaps also by a commencing alterationred, violet, and still oftener colourless. of the soft parts of the bones, the treat-Pulsations are soon perceived, at first ment was commenced by the applicationdeep-seated, isochronous with the beatings of compresses steeped in Goulard’s lotion,-of the heart, and giving no " bruit." Now and the tourniquet was applied on the tractand then they are accompanied with a of the femoral artery. The vessel, how-

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ever, rolled away so from the pad that formed by the extraordinary developmentcompression produced no effect, and by of the superior extremity of the tibia.the 30th of March having done not the The rotula hidden in the substance of theleast good, it was determined to tie the engorged and indurated tissues did notcrural artery, an operation which was ef- appear increased in size; immediately be-fected in the usual manner on the 16th o. neath it commenced the tumour, present-March. Next morning the tumour was ing anteriorly in the most prominent partfree from pulsation, diminished in size, one or two softened points, where the os-and the limb regained all its sensibility seous tissue which seemed to form theand mobility. The thirteenth day the liga- shell, allowed the pulsations to be felt dur-ture fell off, and next day some pulsation ing life, pulsations doubtless produced bywas perceived in the tumour, and that greatly enlarged vessels, or by the shocknight hemorrhage occurred to the amount these communicated to the body of the tu-of two cupfuls. This was arrested by the mour. The two inferior thirds of the legcircular compress applied by the patient were sound, though the adipose tissuehimself. A second hemorrhage took place seemed more abundant than usual. Theon the twenty-second day, and was again part of the same limb above the rotulachecked by the coolness and courage 01 was in the same state. The projectingthe patient. To be brief, he left the Hotel and softened points above mentioned afterDieu on the 30th April, with only a slight the separation of the limb . became col-trace of tumefaction, free, however, from lapsed and flaccid, and presented manifestany pulsation. He had regained some fluctuation. Here and there the thin, ex-strength and plumpness, and the limb had tended, and shining skin showed blueishresumed its normal size. lines. Anteriorly it appeared ready toSeven years after this operation the dis- break, posteriorly it was separated from

ease began to resume its progress. The the subjacent parts by abundant andlst August, 1826, the patient again en- slightly infiltrated adipose tissue.tered the Hotel Dieu ; there then existed At the part where the tumour ceasedat the upper part of the right leg a tumour inferiorly, the skin abruptly resumed itswhich extended from the junction of the natural aspect. The subcutaneous cellu-substance and condyles of the femurs to lar tissue was scanty anteriorly, wherethat of the upper and middle thirds of the tumour was entirely osseous. It herethe leg. This tumour was much more contained no fat, but behind, between thevoluminous before than behind; the veins gemelli muscles and the lower extremitycreeping beneath the skin were much di- of the flexor muscles of the leg, there waslated—the skin itself fine, and threatening a moderately thick layer of fluid andto break in various points. The circum- whitish fat. The muscles of the thighference of the tumour was thirty-two cut across at about their lowest quarter,

. inches, the flexion of the knee impossible. were in the natural state, and had expe-The general health was good, though the rienced no alteration, whether in theirpatient was thin, pale, and even of a colour or their density; they were sur-slightly yellow tint. rounded by a great quantity of adiposeOn the 5th August amputation was per- cellular tissue. The gemelli muscles were

formed ; this being the only chance of, pale, soft, and thin, especially the parts ofcure remaining for the patient. The ope-’ them corresponding with the external and ration was performed in the usual manner, anterior part of the leg. The popliteala vast number of vessels bled, and twenty- artery was of the ordinary size, but wasfour ligatures were at once applied. After ossified in several points. The articular

being put to bed, another artery even re- arteries seemed very small. The anteriorquired to be tied. It is unnecessary to tibial recurrent was, on the contrary, verypursue the details of the treatment of the voluminous, as well as the whole of the

stump, or to narrate the consecutive symp- arteries corresponding with the upper parttoms, which did not differ from those in Qf the tibia, numerous branches being di-ordinary cases. Suffice it to say, that on rected towards and penetrating this bone.the 25th day after the operation, he was Lower down the arteries resumed theirdischarged with the stump nearly healed, normal state. The venous system of theand in a satisfactory state of general diseased limb was much increased. Thehealth. I deep-seated veins were nearly doubled inThe removed limb was carefully dis- size. The internal saphena was as large

sected, and a model of it in wax placed in as the little - finger, and although verythe anatomical museum of the School of flexuous, not having the nodosities re-

Medicine. In its greatest circumference marked in varicose vessels. In fact therethe tumour was thirty-two inches, viewed seemed to be no morbid alteration of theexternally before dissection, the ampu- veins, solely an increase of size, enormoustated limb presented an enormous volume! vessels, which, in the natural state, were

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ui twigs, springing from the entire ex-tent and the substance of the tumour en-velopiiig it in their windings, and pro-ceeding to the inner side of the knee,where they united in a common trunk.The great sciatic nerve was quite healthyto the posterior part of the joint, and con-tained in its substance a moderately largebranch of the ischiatic artery. It wasmore voluminous than was natural. Atthe point of its bifurcation the neurilemawas lifted up by the infiltration from thesurrounding cellular tissue, which seemedto be united with the nerve, which herewas in a state of incipient, lardaceous, de-generation. The lateral ligaments, pro-digiously thinned, were converted intoabsolute membranes. The inner surface ofthe tibia had commenced to become carci-ilomatotis. The posterior ligament re-

tained the fluids contained in the articu-lation, and thus formed a tumour of aninch and a half in projection. Elsewherethe ligaments were in the same state as inwhite swellings.The inferior extremity of the femur was

of ordinary size, but its tissue was softened,and readily cut with the scalpel. A sec-tion made perpendicularly to the axis ofthe leg, displayed the tissue of the bonein an advanced state of ramollissement,but also not increased in size.The tibia was inmnensely developed, and

as if inflated at its upper extremity. Sawedopen in a direction perpendicular to themedian line, and the interior of the tu-mour thus laid open, it was divided into Icompartments like a pomegranate. The

largest and most anterior of these cellswas filled with a matter like gelatine.The parietes of the cavity were lined bya highly developed vascular net-work.Some of the other cells contained gelati-nous matter like that in the first; otherscontained a yellowish, others a blaclcish,fluid, the apparent result of a putrid solu-tion and carcinomatous degeneration ofthe parts. Lastly, some of the cells werefilled with albuminous layers formed bycoagulated blood in old aneurismal tu-mours. The cartilages, which were al-most intact, were separated from theosseous surfaces, and were moveableamong the surrounding destruction.[Two additional cases were here de-

scribed, but they are so closely similar tothat now given in detail, that their inser-tion is unnecessary. Amputation was per-formed in both cases. In the first the pa-tient sunk in a few days ; in the secondthe operation was successful.]Fungus hæmatodes, to which a crowd

of names has been applied — such as

spongy inflammation, pulpy medullarysarcoma, sanguine or vascular sarcoma,

- &c., is, from its component elements, a

very dangerous affection. The ligature- ’ of the principal trunk may, where the, cancerous matter is not predominant, re-. tard the progress of the malady towards7complete degeneration. This proceeding,however, cannot be compared to extirpa-I tion. The perfect ablation is then theonly true chance of success presented tous in the treatment of this disease. Often,nevertheless, the disease recurs, althoughno suspected part has been left behind, asin the majority of the amputated cases.

In these cases we must admit that themalady depends on an internal cause.

We must not forget, too, when perform-ing our operations, that the smallest por-tion of the fungus left behind, suffices forthe reproduction of the disease. An En-glish surgeon once having amputated’thethigh for a similar tumour, perceived asmall prolongation towards the inner partof the stump. He thought, however, thatthe inflammation and suppuration woulddestroy it. His error was fatal to the pa-tient. The tumour having extended, vainattempts were made to extirpate it. Am-

putation was again performed, and thewound healed, but the patient died of ex-haustion soon after. In concluding this

lecture, we should not forget to remarkthat carcinomata of the eye, or of otherparts, where a multitude of veins and san-guineous cells have been founded, areoften confounded with fungus hæmatodes.These tumours have, however, no analogybeyond the discharge of blood when theyare cut into, or when they open sponta-neously. There is, in fact, not only spe-cific, but a natural difference betweenthem.

REMARKS ON THE INFLUENZA, OR

CATARRHAL EPIDEMIC OF 1833.

By ROBERT VENABLES, M.B., &c.

THE disorder which his been prevail-ing, and still continues to prevail, so ex-tensively among the inhabitants of themetropolis and surrounding neighbour-hood, has given rise to much speculation,as to whether or not it be only the pre-cursor of some more pestiferous disease.The apprehensions upon this subject havenot been much allayed by the greaterseverity of form, or the occasionally morefatal character, lately assumed by thisaffection. It may possibly, however, provemore generally advantageous to inquireinto the nature and circumstances of theepidemic itself, than to indulge in vainand unfounded speculations upon the kind