No. 347.

LONDON, SATURDAY, APRIL 24. [1829-30.

LECTURES ON SURGERY,MEDICAL AND OPERATIVE,

DELIVERED AT

St. Bartholomew’s Hospital;

BY MR. LAWRENCE.

LECTURE XXXIX.

Affections of the Skin continued-LeprousScaly Eruption-Cancer of the Hand,External Organs of Generation, and,4axillary Glands - Chimney Sweeper’sCancer-Tuncour of the Cellular Mem-brane—Warts— Corns—Bunions.

I HAVE a specimen here, Gentlemen, whichMr. Lancaster was kind enough to bring tome to show you, of a scaly incrustation, form-ed in leprous eruption. This is a specimen ofthe kind of masses of scaly depositions thatsometimes take place in these and similaraffections. It was taken from a patient ofabout twenty years of age. On one side,you observe some of the young scales, andon the other you see the extent to whichthey may go, when no means are taken tokeep the skin clear from this cutaneous erup.tion. (The,largest mass must have been ofthe size of a goose’s egsr, and the smallestabout that of the bole of a teaspoon.)Now the skin, Gentlemen, is subject to

, Cancer; and this affection is arrangedunder the order tubercula of cutaneous

nosologists, because cancerous diseases inthe skin commence with a small induratedenlargement, called a tubercle. In fact,cuncer of the skin goes through the sametwo successive changes which I have hadoccasion to describe to you in speaking ofcancerous affections generally. There are,in the first place, induration and enlarge-ment-the scinhous condition; and thereis, subsequently, the state of ulceration. Allparts of the skin are not equally liable toc-ancer; the integuments of the face, andperhaps those of the eyelids, are the mostso. We occasionally see it on the external

organs of generation in both sexes; some-times on the hands ; these are the partsmost commonly affected. The scrotum isliable to a peculiar kind of this disorder,from certain local causes which I shall haveoccasion to mention to you hereafter.When cancer attacks the integuments of

of the face, ic begins with a small indura-tion, and enlargement of a certain spot,which may be called a tubercle, and whichthe patient supposes to be a wart. It is un-inflamed, possesses the colour of the naturalskin, and is not particularly sensitive. Inthis state the affection may remain for a veryconsiderable length of time ; however, itsooner or later ulcerates, and the ulcerationformed on this tubercular enlargement ofthe skin, does not penetrate very deeply—does not assume any very unfavourable ap-pearance. It secretes a matter which formsa thin brownish incrustation over the part ;on being exposed to the air, a thin crust, orscab, forms over it, and in this state thething goes on for a considerable time, with-out much attracting the attention of the pa-tient. The disease however gradually ad-vances, and the ulceration ultimately attainsconsiderable magnitude. We now find thatthe margin of the sore is elevated, ragged,but still presenting more or less of the cha-racter of sound integument. There is nogreat excavation. The secretion does notseem to possess any very acrid or offensive

quality, and the disease, in fact, will go onin this form, without any very rapid in-crease, without any very serious alteration,for a great many years. Slowness is its pe-culiar characteristic ; and, in the majorityof instances, it does not affect the absorbentglands in the way cancer does when ittakes place in the female breast, for instance.We see this affection more frequently, per-haps, in the eyelids, than in the other partsof the face. In the month of December,1825, I removed the principal part of theeyelid of a gentleman on account of thisaffection. At that time the disease had al-ready existed about five years, and had noteven then completely destroyed the underpalpebra. It consisted of a tubercular en-largement of the skin. The tubercles, ofwhich this enlargement consisted, presented

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the appearance and colour of the sound skin, ous, they admit, to a certain extent, of cure;having over them a few red and varicose for it seemed here, that the disease had com-vessels. The affected part might be said to menced in the ala nasi, that a considerablebe twice the natural thickness of the palpe- portion of the ala nasi had cicatrised over,bra, and over this there was a tubercular and that, indeed, when the patient was inulceration, which, beginning at the internal, the hospital, a disposition to cicatrise pre-had gradually eaten its way about two-thirds vailed in that part of the ulcer towards thetowards the external angle of the eye. It opening of the nose; but on the other partsdid not extend so much on the mucous sur- it seemed to spread, so that there appearedface of the eyelid, as it did on the external to be no encouragement towards any otheror cutaneous surface. Indeed, the disease attempt to cure than that of operation. Iseemed to be essentially an affection of the remember seeing an operation performed,integuments of the eyelid, and not of the where this affection had destroyed bothmucous membrane. Now this affection had eyelids, and where it went partly into thegiven the gentleman no very great inconve- orbit close to the globe, which had not be-nience-had not been attended with much come affected, however, except from expo.pain; but the sharp edge of the eyelid, sure to the air. In this case, the diseasewhere it was ulcerated, had occasion- had existed seventeen years, and even thenally irritated the globe of the eye, so the absorbent glands were not diseased.as to produce a good deal of uneasiness. The great advantage which is often de-Various local applications had been tried rived from arsenical preparations in thosein this case, but none of them with anv ef- ulcerations of the face which I mentioned tofect, and I therefore extirpated the part, you tinder the name of lupus, has ledta thewhich I was enabled to do completely. It application of some of these preparations inwas, however, necessary to take away nearly cancerous affections of the face ; but theythe whole of the inferior palpebra, includ- are not here of equal efficacy, nor is their

ing the punctum lachrymale, and aconsi- application’ equally safe, for by applyingderable portion of the lachrymal duct. The them, you sometimes produce a degree of *wound healed very favourably, and the stimulus which increases the mischief, andgentleman, now at the distance of four causes the affection to spread more rapidly.years from the performance of the opera- For this reason, it is necessary that yoution, remains perfectly well. The part is should carefully distinguish ulcerations inquite sound, and no inconvenience is expe- the face of a cancerous nature, from thoserienced from the removal of the inferior which come under the head of lupus. The

punctum. In the last summer, I had a pa- tubercle which we consider cancerous is’tient in the hospital, about forty-eight hard at its commencement and uninflamed ;years of age, in whom a cancerous affection that is, it has the same colour as that ofexisted on the left side of the nose. At that the natural integuments : the tubercle ofperiod it was partly seated over the ala of the lupus is softer, and of a bright-red colour.nose, and extended to about an inch and a The cancerous tubercle is single, that is,half in length, by about from a third to half the affection is confined to some one spot;of an inch in breadth. The margin was irre- but in lupus there are generally two or

ularly elevated, and the sore produced thin more spots of the skin affected. The mar-

discharge, but in no very great quantity, gin of the ulceration in cancer is hard, but itThe ulceration in this individual had existed retains the same colour as that of the sur-six years. I extirpated the parts in this rounding integuments, and the ulcerationinstance, and took away the whole of them, generally presents a smooth red surfaee,by cutting at a short distance from the seat and is particularly characterised by its slowof disease ; the wound healed very favour- progress; it does not eat deeply, nor de-,ably, and 1 have heard nothing of the patient stroy the parts rapidly. In.lupus, thesince. I had here an opportunity of ex- margin of the skin surrounding the ulce-

amining the state of the affected skin. You ration is of a bright red ; the ulcerated’will suppose that the entire depth of the skin surface itself is generally yellow, some-

had been destroyed by the ulcerative pro- thing like that of a phagedenic sore, and,cess; I found, however, on examination, the destruction extends rapidly; so thatthat the whole of the skin had not been pe- it will destroy an ala of the nose, or anynetrated, but that it had acquired an addi- other part, within a short period of time.tional thickness-an additional stratum, as it Ve sometimes see ulcerations of a cancer-were. The natural structure, indeed, was ous nature affecting the external organs ofrather thickened and hardened, and it formed generation in thefemale affecting either aa sort of fibrous substance shooting up to- portion of the integument, or a portion ofwards the surface. In this instance there the thin covering which lines the externalwas no affection of the absorbent glands, and opening, and sometimes parts of both. Itthe result of this case clearly shows, that al- is here important ta be correct in distin-though these complaints are called cancer- guishing the affection, for such ulcerations

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are liable to be mistaken for venereal com- had been felt. After some time, I was sur-plaints, and treated by means which are inca- prised to hear that this lady had very sud-pable of rendering any service in cancer. denly been taken ill ; that her attendantsThe ulcer (and I have never seen it in could not make out what was the matterits tubercular state) is generally deep ; with her, and that in about a fortnight afterthere is a considerable excavation ; it has the time of my last seeing her, she had died.a red appearance, like raw flesh, the mar- I have not seen any instance of cancerous

gin of the sore presenting a kind of sharp affection occurring about the female organs ofcut edge. The secretion is of a thin ichor, generation in which I have deemed it at alland very great pain is experienced in the right to remove the parts ; in the presentpart. I have generally observed in those instance the situation was such as would notcases, that the glands in the groin are af- have admitted of their removal, provided thefected. The disease is slower in its pro- glands had not been affected ; but the stategress than the venereal ulceration ; at the of these seemed to me to preclude all idea ofsame time it proceeds more rapidly than extirpation.cancerous ulceration seated on the face. An affection, we sometimes find com-The only treatment that I have found of mences on the skin of the hands, probablyany advantage, has been the palliative, or deriving its origin from the local irritationssoothing treatment: soft poultices applied to which the hands are so liable, proceedingto the part; lotions of opium and water, or to an indurated enlargement and warty con-Battley’s liquor opii sedativus, and the ad- dition of the skin, and going into a state ofministration of opium internally, to quiet disease which we cannot describe by any otherthe pain. I had a lady under my care lately, name than that of cancer, an affection havingwith a cancerous ulceration seated just at the same untractabfb tendency-the samethe inferior edge of the mons veneris, characters which belong to cancer. I hadbounded below by the upper part of the some time ago a man under my care in theclitoris and nymphæ, and above by the mons hospital who had an affection of the hand ofveneris. When I first saw it, the affection this kind; he was 55 years of age; he camehad existed for two years, and had formed a from the county of Sussex, where he hadconsiderable, deep excavation; there was an lived as a labourer and had enjoyed goodexcavation into which I could put my thumb, health. He had warts over different parts ofjust under the mons veneris. The surface the hand and forearm ; and one, which wasof the sore was foul and unhealthy ; some situated towards the first joint of the thumb,parts having the appearance of ash, pre- had been more troublesome than the rest.

senting ’ash-coloured sloughs, some having Under the care of some old woman, or somegreen appearance, and so forth. I found, practitioner in the neighbourhood, I forgetthat for some time a succession of stimulat- which, a succession of caustic and acridappli-ing and heating applications had been made cations had been made use of, by which theuse of to this sore, under which the lady had part had been brought into a painful state,experienced very considerable aggravation and the affection had become a very formid-of her sufferings, and owing to which, pro- able disease. When he came to the hospitalbably, the sore had got into an unfavourable he had the whole of the integuments coveringstate. Caustic, mercurial fumigation, and the back part of the first bone of the thumbother means of the same kind, had been ap- and extending to the metacarpal bone of theplied, under an idea, probably, that it had fore-finger, considerably enlarged, in a tu-something of a venereal character. When berculated state, inflamed, of a bright-redthese means were laid aside, and when the colour, and ulcerated at a variety of points.soothing plan was adopted, the painful state There were several excavations reachingof the wound and the inconvenience altoge- deep into the’parts, and giving issue to a thinther were materially alleviated. In this fœtid ichorous discharge. In other parts thisinstance, the absorbent glands on both sides enlargement of substance presented more ofwere enlarged and indurated; in other re- the character of a wart ; that is, an irregu-spects the lady appeared in good health ; lar rouoh surface, which seemed to be partlyshe had not lost flesh, she had good health, ulcerated. The margin of the diseased skinand all the organic functions were very well was enlarged and tuberculated, and the dis-performed. She remained under my care ease appeared to extend by the gradual giving’for some time; and when I last saw her, way of the part, and subsequent ulceration.she came to me apparently quite in good The character of the discharge, in this in-health, and looking very well. The ulcera- stance particularly, pointed out the naturelion had then considerably increased; the of the disease. Although the patient wasexcavation would have held a large walnut, healthy, and there was no reason why anybut it had a tolerably clean surface. The common ulcer should not have discharged aindurated glands on the right side had sup- uatuial healthy pus, yet that which nowedpurated, ulceration had tormed, from which from this ulceration was of a watery consist-a copious discharge flowed, and some pain ence, of a lightish yellow appearance and

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very feetid. It did not present any of those different to those which we see when it takescharacters which usually belong to a dis- place in the mammary gland of the female,charge of pus from a healthy ulceration. and some other parts (in fact we should ex-There was considerable enlargement of the pect, from the difference of texture, it wouldglands of the axilla ; they formed a tumour present some modifications), yet that in itsabout the size of a pigeon’s egg. When in- essential nature, and in its destructive cha-quiry was made respecting tIns tumour, the racter, so far as regards the texture in whichpatient said it had existed long before the it is developed, and so far as regards thedisease had assumed its formidable appear- life of the individual, it is exactly similar toance on the hand. This was- a point par- cancer when it occurs in other situations.ticularly investigated with reference to the Chimney-Sweepers’ Cancer.—I have men-question, whether it would be right to re- tioned, that in the scrotum there is a pecu-move the part by amputation or not. If liar cancerous disease occurring in certainthe swelling in the axilla had been regard- individuals, and the affection I allude to is,ed as a cancerous affection of the glands what is called chimney. sweepers’ cancer;seated, there, it would have constituted an and this is an important form of the affec-objection perhaps to the operation; but tion, because it shows that a malignant dis-viewing it as a tumour which had existed ease, in all its principal features, very closelythere before the appearance of cancer on the resembling cancer, may be produced in askin of the hand, it would not be regarded person otherwise healthy, simply by localin the same light. The swelling in the irritation, for chimney-sweepers’ cancer isaxilla was soft, it was not hard ; and, fur- the result of the irritation of the soot lodg-ther, that it could not be the result of ing in the rugm of the scrotum. This dis-this affection of the hand, was account- ease does not exist, however, in what areed for by its having been there longer called climbing-boys ; that is, in boys whothan the disease had existed in the hand. are actually employed in cleaning chimneys;I had resolved to perform the operation of it takes place in adults ; it takes place inamputation in this case, for the complaint those who, in following their avocation, havewas decidedly cancerous, but it was sug- their skin as much in contact, however, withgested that some local means might be tried ; the soot as the climbing children. It is veryin fact, cinnabar fumigation was suggested uncommon under puberty, and perhaps thereas a local measure. This was tried, and the never has been an instance known of it;effect was, a great aggravation of the inflam- and in truth it very rarely occurs under

matory state of the skin, and a smart and the age of thirty. The disease commences

very serious attack of erysipelas of the arm, in the scrotum, by the formation of an indu-forearm, and shoulder. When that had gone rated enlargement of the integuments, whichoff I amputated the hand, removing it at the we call a wart, and which, in common lan-wrist. The wound made by the amputation guage, and especially in persons who followhealed very well, but the forearm conti- that calling, is denominated a soot-wart—anued much swelled, and was subject to occa- tuberculated enlargement and induration ofsional attacks of inflammation, so that it a portion of the integuments of the scrotum.was necessary to apply leeches and various In this state it often remains for a very con-other means, and we did not think the man siderable length of time. The cuticle, mayin a fit state to go out of the hospital until be separated ; a little discharge may takeseveral weeks after the performance of the place from the part and form an incrustation,operation, which I think took place in the and this may be picked off, or removedmonth of July, 1827. In the month of March, accidentally. However, sooner or later this1828, he returned to the hospital with a part ulcerates, and an ulcerative affection isgreat enlargement of the swelling in the established in the scrotum, its principalaxilla. It had now acquired the size of a characters corresponding with this disease;small apple ; it was hard, and the integu- that is, there is a deep excavation, there isment adhered to it. There could be no a hardened basis, and very commonly andoubt that this was a cancerous affection of elevated and everted margin, and the ulcera-the axillary glands ; however, it was thought tion thus produced exudes very copiously aexpedient to give the patient a chance of foetid, ichorous discharge-an ichorous dis-the removal of the disease, and I removed charge of a peculiarly offensive nature.the affected glands, which adhered so Sometimes the affection consists not so.

closely to the vessels that about an inch and much of a state of ulceration as in a warty,a half of the axillary arteiy was laid bare by or rather a fungoid, excrescence of thethe operation. The parts afterwards healed affected part, what we should call a soft,very readily. No long period elapsed before vascular kind of wart, which produces thehe returned again to the hospital, and ulti- same kind of offensive ichorous dischargemately he died of the disease in the axilla. that the ulcer does. Whether the affectionYou see, therefore, that although cancer of takes place in one or in the other of thesethe skin may present appearances somewhat forms, it will extend over the whole scro-

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turn, and gradually pass to the perineum. not appear that the disease very frequentlyAfter it has lasted for a certain time it will spreads to the testes. You may find thatextend to the testes, and the glands in the the integuments of the scrotum have becomegroin will become indurated, and pass into so thickened that you cannot move thema state of ulceration. The affection is upon the testes, and hence you might beattended with very severe pain ; in that disposed to judge that the testes themselvesrespect it resembles other cancerous dis- are involved ; yet in such instances you wilteases, and the patient in whom it occurs, find them sound. I remember a case ingenerally exhibits marks of an unhealthy which I took out both testes, the sper.constitution; they are persons of an ema- matic cords being healthy ; they were com-ciated appearance ; they have a peculiarly pletely imbedded in the surrounding in-sallovv, dark, and earthy appearance of the durated integuments, but when they wereskin; and it has been even observed, that cut into they were both completely sound.their cutaneous perspiration has generally The mere circumstance, therefore, of thea very offensive smell. The progress of this testes adhering to the diseased parts, anddisease by its local effects, and the serious seeming to be involved in them, would not,disturbance it produces in the constitution, in my opinion, be a circumstance againstultimately destroy the individual. I am the operation ; and the ultimate conse.

not aware, however, whether or not in this, quence of such a case is so certain, ifas in other cancerous affections, internal left to itself, that, even in a doubtfulorgans become affected. There is a short one, I should rather have recourse to theaccount of this disease published by Mr. operation than leave it untried. A morePott, but in which lie does not advert to that important question is, how far the ope-circumstance at all. ration may be advisable or justifiable if the

Neither local remedies, nor internal medi- glands of the groin have become diseased.cines, have any effect whatever, in arresting There is a paper by Mr. Earle, in the twelfththis complaint; in that respect it corre- volume of the Med. Chir. Trans., on thesponds with cancer generally. Local reme- subject of this affection ; and he there saysdies may soothe, tlielocal application of opium that the swelling in the glands of the groinmay lessen the pain ; local applications may will subside after the disease has been re-

destroy or remove the fcetor of the dis. moved by operation. So that the mere ex-

charge, but I am free to say to you that we istence of a swelling in these glands, is nothave no power by external remedies, or local to be deemed a sufficient reason against theapplications, to stop the destructive progress performance of the operation. I have seenof the disease, although we may remove or this take place in the way Mr. Earle de-lessen particular symptoms by either inter- scribes; that is, I have seen the diseasenal or external means. In fact, the only removed, and the swelling of the glandseffectual mode of treatment in these cases is subsequently subside. I should, however,extirpation; and whenever the disease can make this distinction, if the glands are

be completely removed, whenever you can swelled without being indurated, I think

carry the incision, necessary for the removal the operation may be performed, but if theof the disease, beyond the parts actually af- glands are hardened as well as swelled, Ifected, so as to cut into the sound structure should doubt the propriety of the operation;around, you may remove the disease, with of course, if ulceration of the glands shouldgreat confidence in the efficacy of that pro- have occurred, I should think that a conclu-ceeding. If we leave behind any parts that sive reason against the operation.have become indurated, and still more any Painful Sitbeutaneous Tumour.—Thereparts that would become ulcerated, we can- is an affection, Gentlemen, which I oughtnot be surprised that the disease should re- to have mentioned to you in speaking of theappear, butif we can take away every portion diseases of the cellular system, and that is,that is diseased, so as to carry the incision the formation of a small tumour immediatelyinto parts completely sound, then the ope- under the skin, just in the cellular mem-ration is a safe and an effectual remedy. It brane under the skin; a tumour, which hasdoes not matter how far the disease may been noticed incidentally by various writers,have extended to the integuments, for you but which I believe has only been profess-will understand that if it should have in. edly noticed and described by Mr. Wood, ofvolved the whole of the integument of the Edinburgh, who in the twelfth volume of thescrotum or of the perineum, we may fre- Edinburgh Med. Trans., lately published,quently take it away ; for, although we has described it under the head of a pain-should denude the testes, or a portion of ful subcutaneous tumour. It is a small hardthe penis, the surrounding integuments tumour,. so small that in general it does notwill be drawn together by cicatrisation, and present a conspicuous external appearance,cover those parts. It is a question how situated immediately under the skin, looselyfar such parts should be removed, if the connected to the surrounding parts, and overtestes have become involved Now, it does which the skin itself can generally be moved.

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The principal character of it is the severe interfere with some motion, or with somepain which belongs to it, and from which office to which those parts are destined;Mr. Wood has called itpainful subcutaneous and they frequently occasion an unpleasanttumour. This pain, however, is not a con- appearance, so that people are desirous ofstant attendant on the swelling ; it gene- getting rid of them; in accomplishing which,rally takes place in paroxysms, and these there is no great ditficulty. Perhaps theparoxysms are so severe that one should al- simplest and shortest way of proceeding is,most compare the pain with that experienced to pare off the thickened cuticle which covers

by persons afflicted with tic douloureux. The the prominent wart ; cut it off by successivepatient often complains that the pain is most layers ; shave it till you come to the sur-

iptolerable ; it will attack him in the night, face of the skin, and till you, perhaps, drawand destroy his rest; perhaps at other times blood in two or three places. When youthe person may experience no inconveni. have thus denuded the surface of the skin,ence. These small subcutaneous tubercles rub the part thoroughly over with the ni..

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are the seat of slight attacks of pain, when trate of silver, and one effective operation ofthey are struck or hurt ; at the same time this kind will generally destroy the wart ; ifthe patient often experiences for weeks and not, you cut off the black spot which haseven months together, no kind of inconveni. been occasioned by the nitrate of silver, andence from the affection. These tumours last apply it again ; or you may apply acetic acid,a length of time without acquiring any great and thus you will get rid of it. You maymagnitude, seldom extending to a larger resort to extirpation ; that is, by making ansize than that of a pea, or a horsebean ; and incision on each side of the wart and cuttingMr. Wood mentions one case in which the it out.tumour had lasted for thirty years; it was Corns.-Corns are an affection of the skin,on the anterior part of the ancle, and had arising from inflammation of a portion ofthen acquired only the size of a horsebean. the toes, or feet, in consequence of pres-On examination of these tumours, if you sure by the covering of those pdrts ; this in-make a section of them, the structure ap- flammation being attended with an unnaturalpears to approximate a good deal to the na- secretion of cuticle in the part; the con-ture of cartilage. It is not quite so hard, tinuance of the irritation thus produced, oc-is slightly transparent, and consists of a ho- casions a growth of an unnatural appear-mogeneous substance, which makes a noise ance, so that, ultimately, a very hard, hornywhen cut through with the knife. It is sup- substance Is produced, and that hard, hornyposed that the tumours are developed in, or substance, by its pressure, increases the in-are connected with, twigs of the subcutane- flammation of the skin, and brings on a stateous nerves ; and, indeed, the author of an of the parts attended with very great in-anatomical work mentions this circumstance, convenience, and indeed great suffering toI do not know that any actual development the patient. The skiu, at first, is preter-of these tumours in the nervous twigs has naturally sensitive, in consequence of thebeen observed, so that I cannot say they are friction, and then in this preternaturallytumours of the nervous system. There is sensitive state of the skin you have a hard

only one mode of treating them,-we must body of horny substance formed, which iscut them out; the operation is safe, perfect- pressed upon by the shoe, or boot, cover-

ly easy, and perfectly effective. ing the foot, and which usually occasionsWarts.-Warts consist of enlargements great inconvenience. In some individuals

of a portion of the textures of the skin with- a great variety of parts, all the prominentout inflammation, accompanied by thicken- portions of the toes, are occupied by thising, and induration of the cuticular covering disease ; and when such individuals persistof the skin. I have already had occasion to in wearing shoes, or boots, which pressspeak to you of those warts which are upon the parts, they suffer great pain fromformed about the generative organs of both the affection. This pain and inconveniencesexes, as a kind of venereal affection ; but are experienced more particularly at certainwhat I am now about to allude to are, warts times of the year, and those are the periodswhich appear in’, other parts of the body. of the year when the feet naturally becomeThey come without any obvious cause ; in heated in consequence of exercise, and thethe hand particularly. They are often seen temperature of the atmosphere.in young subjects-exist in very consider- Treatment.—The palliative cure for corns,able numbers, and will disappear about as you may call it, consists in cutting awaythe time of puberty, without any particular the indurated cuticle, so as to remove it

application, or any obvious reason. When from the inflamed skin, and thus get rid ofthey are so situated as to produce no par- this mechanical source of irritation. If theticular inconvenience, and not to occasion feet are first soaked in warm water, so as to

any deformity, they may be safely left to moisten the indurated cuticle, you take athemselves. They sometimes are, however, sharp instrument, a sharp knife, with whichso seated about the hand and fingers, as to you can easily pare away the morbid cuticle ,

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which has accumulated, and in doing this, the measures already described for remov-after you have removed the greater part ing it. So far as the inflammation goes,you will generally come to a sort of single you have only to adopt the usual antiphlo’point, where the cuticle seems to have ex- gistic means, and take pains to protect thetended deeper than at the other parts. In- part from any irritating pressure by the bootdeed it appears that, at one point, the dis- or shoe. ’ ’

ease extends deeper than it does elsewhere,and this has been called the root of the corn. LECTURE XL.It is said you may actually lift up, and take Affections of the skin, continued.-Chilblainaway altogether in a mass, the portion of - Onychia - Paronychia - The nailthe cuticle that forms this root of the corn, growing into the flesh-Ntvvi materni.but I apprehend that is not easily to be

done; however, if you cut away the thick- THAT peculiar affection of the skin, gen-ened cuticle in this way, and then cover the tlemen, which is called in English chilp

part over with soap plaster, spread on blain, arises, as the name implies, from theleather, and direct the patient to wear large action of cold upon the surface of the skinand, soft shoes, great relief will be expe- -the affected part being chilled-having itsrienced, and the cuticle will recover its temperature reduced. The Latin name isper-.natural texture. If, however, considerable, nio. As chilblain is the result of the influenceinconvenience be still experienced, you may of cold, it occurs in those parts of the bodyproceed to a further measure for a more where the circulation is the most feeble andeffectual remedy; that is, after shaving exposed ; that is, in those which are most re-away, as nearly as possible, all the dead mote from the heart; the fingers, the toes, theparts which are about the surface, rub the knees, the tip of the nose, and the extremity.surface over with the lunar caustic, and then, of the ear. It also happens most frequentlyperhaps, you will have no re-formation, if in young subjects, in whom the organizationyou avoid external and exciting causes; at has not yet attained its full vigour, or powerall events this simple process will afford of resistance to external influences. Whenthe patient a very great alleviation of his I say that this complaint arises from the ap-sufferings. plication of cold, you must not understand

Bunions.—There is an affection, some- that it is immediately produced by cold ; itwhat allied in its nature to corns, which, is necessary that the part should have itshowever, in some respects, is different- temperature reduced, and be subsequentlythis is a kind of swelling, called bunion. heated ; that there should be an alternationThey form, usually, in the connexions be- of cold and warmth ; and it is in this cir-tween the first joint and the metatarsal cumstance that the origin of chilblain is tobone of the great toe, a part particu- be found. Indeed, we observe that chil-larly liable to pressure by the shoe, or boot. blains, in general, do not happen during theThe portion thus affected is swelled, and period of the most intense frost ; they areattended with more general tumefaction more numerous and troublesome when thethan that of a corn; but there is another temperature of the atmosphere is renderedcircumstance attending it, there is a hard- milder by the succeeding thaw. It was ob-ened and thickened state of the cuticle served by Larrey, in the winter campaignover the most prominent part of this swell- of the French in Russia and Poland, that aing, which constitutes bunion. I believe few days before, and a few days after, athe swelling of the bunion itself consists of famous battle there, when the thermometeran inflammation of a bursa mucosa, situated was from ten to fifteen degrees below zero,between the skin and the prominent part of no particular suffering was experienced aboutthe joint in question; a bursa mucosa, which the hands or feet, but that a few days afterin point of situation is analogous to that the battle, a thaw took place, so that the ther-which is over the patella or the olecranon, mometer rose many degrees, and a greatand that, by irritation upon the part pro- number of cases of mortification of the feetduced by the pressure of the boot or shoe, occurred ; indeed nearly all the soldiers suf-a state of inflammation arises with effusion fered more or less. These circumstances leadinto it, for, in fact, if you open such a swell- us to the modes by which the occurrence ofing, you will find, invariably, than fluid es- chilblain may be obviated. And, in the firstcapes. When this is in a state of iiiflamma- place, the extremities of the body being mosttion, you may apply the same remedies as subject to chills, warm clothing of those partsyou would apply in any other inflammation is of great importance : in the next place,ofbursae, that is, leeches or poultices. N ow, when any part, such as the hands or feet, hasthis may become the foundation of a corn, been greatly chilled, it should not be sud-ar)ditmay,from the cause which produces it, denly raised to a high temperature; it shouldpass into a continuance of abscess, and matter not be plunged into warm water, nor broughtmay be discharged from it externally. If a too near to a fire; on the contrary, meanscorn forms in this situation, you must,adopt should be taken to restore it to its,natural ..

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heat, gradually. The great object is to pre- I with a livid edge or surface ; and, in fact, itvent such parts from experiencing sudden is the existence of ulcerative absorptionvicissitutdes of heat and cold. without any attempt at repair. Very greatThe affection which we call chilblain, ex- itching attends it, and it is a source of much

ists in various stages ; there are different inconvenience. The best application to ul..degrees of change in it. In the first, or sim- cerated chilblains, in the first instance, is aplest form, we have common inflammation of soft poultice ; and, subsequently, in orderthe skin ; what nosologists have called to promote the restorative action, which iscrythema ; that is, mere redness and vascu- very deficient, you should employ local sti.lar congestion, without any other change. muli, and the two best are, the red precipi-There is, to be sure, some effusion into the tate in the form of ointment, and the nitratesubjacent textures ; so that swelling is ano- of silver in the state of solution. There isther accompaniment. When the part is consi- yet a third and more serious degree of thederably swelled, its motions may become affection, in which we see a portion of - theimpeded; when the fingers, for instance, skin actually lose its vitality, and becomeare the seat of the affection, the whole of converted into a slough ; and when a consi-them may be so much swelled that you derable part of the body is exposed to severe.cannot employ them in writing, for example. cold, you will have this sloughing extend toThere is a great heating and itching in con- the entire limb. The treatment here falls,junction with the swelling ; and these make under the general principles I mentioned toup the early symptoms of chilblain. Now, you in speaking of mortification.the heat and itching are not quite the same Inflammation occurs sometimes (and ge..in degree during the whole twenty-four hours; nerally in consequence of injury to the in-.there is some period at which, perhaps, the teguments) at the extremities of the fingers.parts become warm, and then the heat and and toes, on their dorsal aspect, at the originitching are more particularly troublesome. of the nail, and thus technically called

Treatment.—In the more active state of Onychia. Onyx, ovvz, is the Greek word forthis condition of chilblain, relief from the nail ; onychia, then, is used with referenceheat and itching will be obtained by cold to a disease of the part which forms the’

applications, although, often, persons have nail. This inflammation is attended with.suffered so much from cold that they do not the formation of matter under the fold oflike such a proceeding. Experience, how- cuticle, which is reflected from the semi-ever, has established the fact, that applica- lunar termination of the skin. The mattertions of a stimulating nature are useful ; the passes under the nail, detaching that part of-camphor-lipiment, spirituous lotions, strong the skin which crosses its.root, so that a freshsolutions of salt, and a great variety of nail is formed. The formation of mattersimilar remedies, have been rubbed.over the sometimes takes place under the nail, so

parts, with considerable benefit. The most that it is no longer held in its situation, ex-advantageous remedy of this kind was recom- cept where attached by the cuticle, and thenmended by Mr. Wardrop, in a short paper you may easily remove it, in order that ahe wrote on some affections of the fingers new nail may have liberty to grow.aud toes, in the fifth volume of the Med. - Paronychia.—Matter may form in vari-Chir. Trans. This remedy consis!s of one ous parts about the nail, not immediately inpart of the tincture of cantharides, and six the situations I have mentioned to you, andof the soap liniment; to be used three or those formations of matter are sometimesfour times in the course of the day. In called paronycleia. Para, wapa, means near,this stage of chilblain we do not always find paronychia signifies merely a formation ofa vivid red appearance, but frequently when matter near to, or about the nail. This isthe chilblain is not in its most advanced what is sometimes called panaris, or pana-state, the kin is very livid, indicating, in 1’itiuJ1t, in Latin, and in English, wltitlmv.fact, that the action of the capillary system There is no great difference between panu-is very imperfect. After this condition of ris, onychia, paronychia, panaritium, andinflammation has existed for some time, ve- wliitlo%v ; they all merely designate forma-sication will occur, and the skin will ulcer- tions of matter about the nail.ate ; this is the state which is called, in Nail growing into the flesh.—when thecommon language, broken chilblain. The integuments about the nail become injuredcuticle becomes elevated into a livid or by wounds, or any other cause, it often hap-brownish vesicle ; that is, there is livid or pens that considerable pain ensues, andbrownish fluid under the cuticle, and when local irritation is produced, by the pressurethat breaks, the skin itself is observed to be of the hard nail against the denuded portionof a livid 1me; it soon ulcerates, and the of skin; under certain’ circumstances, and,ulceration thus formed is of an unhealthy, not uncommonly, a very painful fungus arisesunfavourable appearance, very slow in heal- from the portion of integument which hasing. Sometimes it is of a brownish appear- been thus denuded ; and in the various

ance, with bloody points interspersed, and offices for which the fingers and feet are

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employed, the parts become pressed, so as to remedy the inconvenience. There are in-occasion the patient a frequent recurrence stances, however, where the evil is too con-of pain ; thus great inconvenience is fre- siderable to be got rid of in this slight way,quently experienced from a very trifling and where it is found necessary to take awaycause. Under such circumstances it is ne- a portion of the nail; after which youcessary to introduce very carefully, with a can remove the fungus, and the irritation.very fine probe, a thin piece of lint (which we The nail will afterwards take the propercall tbe jiue of the lint), just between the direction, and if care be taken that the per-edge of the nail and that part of the in- son do not again wear tight shoes, the eviltegument on which it presses ; in this way will not recur. Dupuytren recommends thewe generally remedy the inconvenience. In removal of that portion of the nail whichthe great toes of the feet a similar, but a presses upon the skin, by means of a pair ofmuch more serious state of things arises, scissors, and the mode that he recommendsfrequently in consequence of the pressure of is this ; to have a pair of pretty strong scis.tigbt shocs. The soft parts which are seat- sors, one blade of which shall be quite sharp;ad at the side, particularly on the inner side, put the sharp point just under the edge ofof the nail of the great toe, are pressed the nail, carry it along under the nail, byagainst the nail by the tight shoe or boot; a quick motion, up to the base, or to wherethey become irritated, inflamed, or thicken- you wish to cut it through, then make a per-ed, and from some slight external injury a pendicular cut, and afterwards take a stronghigher degree of inflammation is produced ; pair of forceps, and forcibly tear off that partmatter forms, the integuments become de- of the nail. This seems rather a rough sortprivedof their cuticle, and then the same of proceeding, however I have done this;kind of fungus, which I have already men- and it has not been found to be so very-tioned, arises. In this case the thickening painful; the pain is merely momentary andof the integuments, from the inflammation soon gone. When you have thus got ridand production of the fungus, will go to of the mechanical source of inconvenience,such an extent that a considerable portion of you will probably find that the thickenedthe nail becomes completely imbedded in state of the skin and integuments will sub--them ; and this is what,in common language, side of itself; if not, rub them over withis called, the nail growing into the flesh. lunar caustic, and in proportion as the nailNow, a mistaken notion has been entertained, grows, see that it grows in a proper di.that the state to which I have just alluded, rection. Now, I am told there is a mode ofarises from some wrong form, or some wiong taking away a part of the nail equally effec-direction, of the nail; and thus the curative tive with this, but which is not done inefforts have generally been directed towards quite so rough a manner.. Mr. Wardropremoving or getting rid of the nail, or giving has informed me, that there is a gentlemanit what is considered a more proper direc- practising that part of surgery wliielibelongstion. As these efforts proceed entirely from to the fingers and toes, at the west end ofa mistaken view of the case, we cannot the town, who has observed that the nail iswonder that they should altogether fail. imbedded in a dense cuticle, and, therefore,.The truth is that the nail is not in fault in that you can cut through the nail, withoutthese instances ; the mischief arises from going into what we call the quick, so as notthe pressure of the soft parts against the to draw blood. The object is, with a sharpnail, and then a state of perpetual mechanical instrument merely to cut through the nail, andirritation is produced from the constant pres- he says if you do this you can lift it out verysure of the nail against the inflamed skin. easily from its bed of cuticle, without draw-A great point, of course, therefore, what- ing blood. If that can be done it is cer-

ever else you do, is to keep off the source tainly a more eligible method of proceeding.of mischief, and not to wear any tight cover- The mode in which persons attempt to easeing, such as a shoe or boot, and, further, to themselves, by cutting away pieces of theallow no pressure to be produced from any edge of the nailis not sufficient in agreat manyother cause. In many instances, particularly cases, and 1 believe is sometimes calculatedthose that are not of the worst kind, you can to produce inconvenience rather than a cure.put a stop to the evil by the simple measure When the evil is removed, for the time youI have recommended,of putting under the nail will prevent its recurrence by a properevery day, or every second or third day, a mode of cutting the nail. Now, in theportion of lint. When you do this you will fingers we generally cut the nails so as tounderstand that the object is merely to inter- bring them to a sort of semicircular edge,pose a quantity of soft lint between the irri- but when the nails have been affected as Itatedskin and the nail ; you are, therefore, not have mentioned, they should be cut square,to push in a great deal, for that would aggra. and do not let the sides be cut away.vate the mischief; then take care that the Nœvi Materni.—Under the name of ntevishoe shall be loose, and you will commonly materni are included various original de-fiud that this simple mode of proceeding will fects or peculiarities in the structure of

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some portion of the skin. The name naevi mouse, because it had got no tail. " Oh !"materni, means simply maternal spots, and he said, " it had once a tail, but somebodyis founded on the generally received notion, cut it off." (Laughter.) I saw a child,that these peculiarities of the skin arise that a gentleman sent to me to lookfrom some influence of the mind of the at, the greater part of whose body wasmother on the offspring. It has been sup- covered over with hair ; the legs and oneposed, for instance, that if a pregnant arm, and a great part of the trunk, were al.woman is terribly frightened by any strange most entirely covered with hairy spots. Thesight, there is a great probability that the child was otherwise very healthy, and thechild will bear some mark on its body, skin in those parts did not seem materiallymore or less allied to the object that occa- unhealthy. In a great number of thesesioned the fright; or, again, if the pregnant naevi materni, there seems to be a peculiar,woman should have a great desire, or, as the unnatural, state of the vessels of the skin.gossips call it, a longing for anything, and The peculiarity consists in vascular enlarge.especially if that desire cannot be gratified, ment. Sometimes you may have a few ves-it is a vulgar belief that the child will be sels ramifying on the skin in a peculiar,marked; and thus, if you may believe branching form, something like the spider’smothers and nurses, marks upon children web, and hence called spider’s nœvus. Notare representatives of all manner of things uncommonly you will see portions of thewhich mothers may have been longing for, skin discoloured, red, brown, livid-some-whether meat or drink, whether it be beef times of a deep, sometimes of a lighteror pork, whether it be raspberries or grapes, sliade ; and this extends irregularly over a-

or the Lord knows what. (Laughter.) This considerable part of the face ; being some-notion seems to have been very prevalent, times called claret-marks, from the simi..for a term which refers to " mother’s long- litude in colour to claret-wine. In theseings" has been long applied to them in cases you will often see large vessels rami-France, and one which means " mother’s fying quite on the surface of the skin, andspots" is well known in Germany. We some- in some instances of this kind, I havetimes find slight elevations, irregular in figure, known persons liable to the occasionalof a rough granular surface, varying in point bursting of these vessels, and, consequently,of colour,-reddish, brownish, or yellowish, to very copious haemorrhage from them; butand not uncommonly having on them particu- the marks 1am now speaking of are gene-larly long hairs, and these spots are called, in rally of a stationary kind ; they do not in-common language, moles. They generally crease, they lemain throughout life the same.remain, during life, of their original size, and The na&vi,however, which are mostcommonlydo not increase. It might happen that a the subjects of surgical treatment, consistmark of this kind might be so situated as to of peculiar vascular groups, seated either inproduce deformity ; if so, extirpation would the skin itself, or in the adipose tissue im-be very simple. There are some instances, mediately under it. The cutaneous nævihowever, of their growing after birth, and are those which are seated in the skin, con-attaining a very large size; of which the sisting of a soft, bright, scarlet elevation,specimen I now show you is an example. the surface of which is finely granulated;This was cut off the lower part of a lady’s they appear to occupy a certain portion ofback, and had the appearance of a mole, mea- the texture of the skin, upon which you’suring about a foot flong, and about a foot have this bright-scarlet colour; you wouldacross ; consisting of a kind of fibrous warty think it not displeasing in appearance. Theseexcrescence, and having a dirty brownish naevi are generally a little irregular, notcolour during life. It was removed by Mr. rising high above the surface of the skin.

Abernethy; I remember assisting in the 1 he subcutaneous nævi consist of a softoperation a vast many years ago. It did swelling under the skin, imbedded in thenot go deeper than the skin ; what is under adipose tissue ; the skin itself may beit is merely adipose substance. Sometimes completely sound. More commonly towardsa portion of the skin is brown, or reddish the centre of the nsevus, you have more

originally, and thickly covered with hair, or less of a blue or livid appearance, some

just like the coat of an animal. Alittletime of the vessels appearing to approach nearerago, I remember there was a boy in the to the surface of the skin. Not unfre-foul ward, in undressing whom, to exa- quently, you have a portion of cutaneousmine some syphilitic eruption, a portion nævus m the centre, and a portion of theof his chest- was discovered with light- subcutaneous tumour extending around it;brownish hair upon it, just like the coat of so that when I speak of cutaneous andan animal, It was about an inch one way, subcutaneous naevi, you are not to sup-and an inch and a half the other. In look- pose that they are essentially different ining at it, I said," What is that you have on their nature, for they may be combined

your chest ?" ’’ Oh !" said he, " that is a together. You may have a nævus, of which

vn4ause, Sir." I said it could not be a a part is of that bright, soft, scarlet state:

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of the skin which I have mentioned, while rhage may occur; or they sometimes ulcerate

the rest is a tumour under and around it. after attaining a certain size, and this con-These kinds of swellings are soft and com- dition of ulceration, if it becomes exten-

pressible-in fact, you find that by pressing sive, will frequently, in the end, destroy athem you diminish their bulk, and squeeze considerable portion of the morbid growth,something out of them, and that when you and lead to a kind of partial natural cure ofremove the pressure, they slowly recover the affection. I have mentioned to you,their former size. Sometimes they are that pressure will diminish the size ofrather warmer than the rest of the skin ; naevi, and that they recover their formerthere is, sensibly, more of heat in them. magnitude when the pressure is removed ;These nævi, like the others I have men- this diminution is produced by squeezing outtioned, may remain stationary-that is, you the blood. What they contain, and what issee them of a certain size at the birth of the removed from them by pressure, is blood ;child, or they may acquire a certain size and, moreover, it is arterial blood. In thesoon after the child is born, and they do not cutaneous nsevus, which is quite on the sur-grow afterwards. More frequently they are face of the body, and where the vessels aresmall at the time of birth, and then begin to covered only by the thickened kind of cuti-increase, and often grow very rapidly for a cular coat, you have the bright-scarlet tinttime. With respect to those that are per- of the arterial blood ; the colour of the ves-maneut, they do not always remain in the sels immediately shows that it must be.

samecondition; they undergocertam changes arterial blood which is contained within.,according to the state of the system, and But in the deeper-seated tumours, wherethe peculiar circumstances affecting the iu- there is greater thickness of the skin, fromdividual in whom they arise ; so that a the blue or livid appearance, you mightgrowth of this kind will sometimes be more suppose it was venous blood ; you will.firm and dense, the vessels apparently more find, however, on performing an operation,filled than at others. It is these cutaneous it is arterial blood. I may mention further,nævi that are particularly likened to vari. as a proof of what kind of blood is containedous objects-strawberries, raspberries, and in these vessels, that if you cut into any,so forth; and really the likeness is not portion of one of them, the arterial bloodso bad. I have been many times told by flows out with a velocity and degree of vio-persons of information and intelligence, that lence that you would hardly believe to beamark on a lady’s back, for instance, gets of possible, unless you saw it ; an immensea red colour, and of a considerable size, and stream of the most florid arterial blood,then shrinks and drops away at a certain comes out, which you cannot restrain, with-season in every year. Now there are cer- out pressing firmly the whole of the partstain changes of condition which may have that are injured by incision. When yougiven rise to, or which may support, this come to make a section of this kind of tu-notion. I have mentioned to you that the mour after removing it, it exhibits a cellularnævi are usually small in bulk, and often so appearance ; and a prevailing notion hastrifling at birth as to be overlooked till some been entertained, from this circumstance,time after the child is born, and that then that it is made up of the general structurethey may increase very rapidly. They may of cellular substance, with blood-vesselsbe of the size of a pin’s head at birth, and ramifying through the cells. Now I be-afterwards reach the size of your hand, or lieve this idea of cellular structure to be-anindeed there is hardly any limit to their erroneous one. As far as we are able to see,growth. They are most commonly on the I believe the apertures that are visible, arehead, frequently on the scalp, but there may the mouths of blood-vessels, for they are allhe many on all parts of the face, and some- circular, with a smooth lining like that oftimes they occupy a considerable portion of blood-vessels. It appears to me, therefore,the cheek, the ear, and the lip. I saw a case that the nsevus consists of an aggregation ofof a young man at this hospital, who had the blood-vessels ramifying and combining intohalf of one lip, and the corresponding por- a kind of tumour. Whether these are ar-

tion of that side of the cheek, completely teries or veins, I do not uudertake to deter-filled up with this unnatural sort of growth, mine, but certainly during life they containIt was covered on the outside by the skin, arterial blood; and if you cut into them,and by the mucous membrane of the mouth arterial blood Piows out with the greatestinternally. The uaevi occur about the neck, profusion ; hence the name which is popu-more rarely upon the extremities, and some- larly given to them is by no means a badtimes they are found on the trunk, In those one—that of bloody tumour ; and they arethat grow, (as they consist essentially of described by Beer under the title of tumeurlarge vessels npar the surt’ace of the body,) it sanglante, which is similar to our Englishwill happen frequently that their vessels term of varicose tumour. Baron Dupuy-will give way ; they are hable to be rup- tren has given his notion of the structure oftared by accident, and thus profuse haemor- these nsevi, and his idea is, that they consist

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of the same kind of texture which exists na- of a higher temperature than the rest of thetllrally in certain parts of the body. Thus body, it has been thought that cold applica.there are certain parts of the body in which tions and pressure might be useful, and a caseyou find the structure occasionally flaccid, has been mentioned of an extensive nxvusand of which the utmost distention may in a child which was reduced in this way.be occasioned by an influx of blood. These It must, however, be observed, that thereparts admit of a sort of action which is are very few parts where the) pressurecalled erection, and their structure has been can be applied. The tumours very frequentlycalled by the French tissue erectile; such are grow on the face of children who are in.that of the penis, clitoris, nipple of the female, tractable, and therefore I cannot myself placeand some other parts. Dupuytren considers much reliance on pressure, which sometimesthese nasvi unnatural erectile productions, proves rather injurious, than otherwise, to

and hence he calls them tumeurs erectile the part to which it is applied. Excision ishis observations on the subject may be found an obvious, and, at all events, an effectual,in an interesting and valuable work on tu- mode of getting rid of this complaint. 111mours, which was published under Baron adopting this, you must observe that the

Dupuytren’s own direction. There are, cer- rule is, that of taking away the whole oftainly, some points of resemblance between the unnatural growth; you must cut intothe structure of these tumours and that of the the sound portions all round, and not beerectile tissue of the body, but I should ob- inclined to save either skin or any otherserve, that we do not know enough of either part, and be careful that no portion of theto be prepared to assert or deny the propo- morbid production be left behind, because,sition. I should also observe, that this for. if you leave any, you will have the growthmation is to be found, not only as a congeni. reproduced ; and if you cut into it in thetal structure, but that it may take place course of the operation, you will haveafter birth in certain parts of the body ; and profuse haemorrhage, such as, until youwhen this latter is the case, very often have seen it, you can form no idea of.the tumour, though not precisely corre- You must, therefore, cut freely round thesponding with those which I have men- soft parts, so as to take away all the morbidtioned, has another character, that of pul- growth ; and though you have copious hæ-sating—having a pulsation synchronous with morrhage in cutting into the sound parts,that of the arteries. This is a circumstance yet you have by no means that profuseI have not observed in the naevus maternus; bleeding which you would have if you werethat is, in the congenital tumour; at least to cut into the morbid tumour. Very com-in the generality of them it does not exist. monly, however, in cutting out these naaviI have already spoken of the observations of you have a degree of haemorrhage, which, forDupuytren, and the circumstances on which a moment, makes one suppose the child-he founds his notion of the nature of these for these operations are generally performedtumours. They are what John Bell calls on children-will die, so much blood is lost; ianeurism by anastomosis, and what others and I may mention here, that the operationin following him, have called by the same of excision, on this account, is in some mea-name. Hence it has been observed, that sure limited to naevi of a moderate size; forthe majority of naevi materni are of this where the operation is performed for thoseformation; but I cannot say that I think of a large description, there is really dangerthey do consist of anastomoses of blood-ves- of death under the use of the knife. Mr.sels, nor do I think they are to be considered Wardrop took away a large naevus from someas aneurisms, for there is no resemblance part of a child as quickly as he could; itbetween them and what we call an aneurism. was one of considerable size, and there was

Treatment.—The same principles of treat- a very profuse bleeding from it ; in aboutment are applicable to the affection, whether a minute or two the child was defunct; and,it consists of a congenital peculiarity of na- upon examining the parts, one of the vesselsture, or of an accidental formation after that was opened was found to be largebirth. If the naevusmaternus be stationary enough to admit the largest quill. When- if it do not increase in size, there can be you consider how these vessels, therefore,no reason for interfering, or meddling, with are increased in size, you cannot wonder atit, unless it be a source of deformity ; though, such an occurrence. In order to avoid theas they are frequently found on the face, danger of haemorrhage from the use of thethat often becomes a reason for removing knife, it has been proposed to tie these tu-them, as also do the various magnitudes mours round their bases with ligatures, andto which their increase may lead. A va- to draw that very tight, in order to produceriety of methods of treating those nævi, mortification of the unnatural part. In gene-when it is wished to reduce their size, ral, the bases of these tumours are hardlyor to take them away altogether, has been sufficiently projecting to admit of being tiedproposed. In consequence of observing in this way; but sometimes, when they arethe occasional circumstance of their being seated in the cellular membrane, you can

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seize them, pull them up, and pass through upon them, and been satisfied that the in-them a needle with a double ligature. When terruption to the flow of blood through themyou take out the needle, you have a liga- very materially stopped the pulsation ofture left for each half of the tumour, which the swelling. This operation was attended,you tie tightly. This is an effectual mode for the time, with an interruption of theof preventing the danger of haemorrhage, pulsation, and a reduction of the swelling;You might suppose that the process by but the effect was short, and the tumour gotthese ligatures, if the naevi were of large worse again; in fact, this girl suffered sosize, might be attended with danger in other much afterwards, that she wished me to per-respects. I have seen a good many in- form whatever operation I liked for her, withstances, however, of treating them in this a view of relieving her. I accordingly sub.way, and I have never known any bad sequently cut round the basis of the tumoureffects produced. I have used the ligature, upon the finger, so as to divide the wholein some instances, where the nsvus was so of the soft parts, except the flexor and ex-large that I could not have dared to use the tensor tendons, and in doing this there wasknife, and the result has been successful. a pretty considerable haemorrhage, for all theLigature, therefore, is safe. It has been enlarged vessels had been cut through. Thisproposed, both in cases of nievus and of had the effect, I will not say of entirelyaneurism by anastomosis, to tie the arte- stopping the affection, but certainly of bring-rial trunk that goes to feed them, to pre- ing it into a state in which she suffered novent growth, and effect their reduction. Now, more inconvenience from it. And I maygenerally, we find that vessels come into mention here, that a notion was entertained,these tumours from all quarters, so that it thatif all the soft parts, except the tendons,would be difficult to accomplish this pur- were cut round, there might be a doubtpose. However, this would be more easy whether the end part of the finger wouldin parts about the head, where the carotid not mortify; but after dividing and tyingartery, for instance, is the principal trunk. the arteries, the distal ends, the oppositeMr. Wardrop tied the carotid artery of a ends of the arteries, coming from the ’tipchild, where there was a considerable nsevus of the finger, bled so freely that I wason the head; the tying of the artery had obliged to tie some of them. The circula-a considerable effect upon the tumour, but tion in the small vessels along the perios-the child, who was much reduced from the teum, went on in such a manner as to be

previous effects of the disease, died after- quite sufficient to sustain the vitality. Thenwards, but more from a continuation of those there is another principle of treating theseeffects than from the operation itself; so naevi, where we do not like to disturb themthat the advantages of tying the artery in with the knife, or by the application ofthat instance could not be well estimated. ligatures, for sometimes the form and situ-In consequence of this attempt, the opera- ation of them are such that a ligature can-tion of tying the artery was tried by Du- not be applied. This method consists in

puytren, in the case of a very large use- imitating the process of natural cure, whichvus, situated near the ear. By pressing consists of inflammation and ulceration, per-on the carotid artery, it was found that the haps partial sloughing, and sometimes con-size of the naevus was reduced, and hence solidation of the tumour, that is, by thethe natural inference was, that if the artery application of caustic to the tumour. Thiswere tied the reduction must be permanently has been proved by Mr. Wardrop : he re-accomplished. Dupuytren tied the com- commends the application, to the centre ofmon carotid artery, and for a few days the the tumour, of a portion of potass, or rub-operation seemed to correspond entirely bing the tumour over with the nitrate ofwith the wishes of the operator; the tu- silver; but potass is the most effectual;mour became livid, flaccid, and much re- and he says, if you produce a certain inflam-duced, but after a little time it swelled out mation in one point of a structure like this,again, and grew as fast as ever ; so that I the same process will naturally diffuse itself

fear, according to the experience we have at throughout the whole, and thus that youpresent, the plan of tying these arteries, or may get an obliteration of a naevus which iseven the vessels that supply the parts of the too large to be taken away by the knife. Notbody that are thus diseased, cannot be much long ago he sent me a patient to look at,relied upon. I remember the case of an with a very large naevus on the face, whichenormous aneurism on the finger of a young I thought too large for excision, or the ap-girl, on whom Mr. Hodgson operated. This plication of the ligature ; he has since toldwasnotana;vus; the tumour came subse- me that he applied caustic in this way to thatquently to birth; it was a swelling occupy- case, and that the cure is going on verying the lower part of the finger, with a pul- favourably, and that he had tried it in ano-sation in it, and an increased temperature. ther instance. At all events, you may knowMr. Hodgson tied the radial and the ulnar from these facts, that the caustic may bearteries in that case, having first pressed safely tried.

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. Another method has been proposed, andin some instances adopted with great suc-cess, which is, that of vaccinating the nevus,in children who have not undergone vacci-nation, You introduce the vaccine matterall over and around the part, and the objectis to produce considerable inflammation inthe substance of it. I have tried this, inone instance with partial, in one or two in.stances with complete, success ; and I haveseen one case where this treatment entirely Ifailed, and where I was obliged to extirpatethe nwvus, which was situated on the scalp.

LECTURE XLI.

Pascular system—Hœmorrhage.—Distinc-tion between Arterial and Tlenozzs Hae- limorrhage.Wounded Arteries.—Natural ’,process for the suspe?isiort of flz terial

Haenzon"hage; SU1’gical means for thesame. ’

Loss of blood, or, as it is technically called,laremorrhage, is a consequence attendanton wounds ; it is frequently dangerous,sometimes fatal ; and is always alarmingto the patient, and to those who are around,who are ignorant of what ought to be doneon its occurrence. The danger of bleed-ing is not confined to the very time at

which the injury is received, nor immedi-ately after it; for the bleeding, which di-

rectly follows the wound, may stop, but thehaemorrhage may be renewed at some dis-tance of time, and the patient may die. It istherefore of great importance, to adopt im-mediately such effective means for treat-

ing wounds of blood.vessels, as shall pre-vent dangerous consequences. Ancient sur-gery was very defective in this respect, foralthough we find in Galen, and other writers,some incidental mention of tying arteiies,yet it does not seem that the practice wasadopted generally ; it appears, indeed, tohave been rarely employed, and not to havecome into that common use which weshould expect would have been the case, ifthe nature of so simple and effective a modeof proceeding had been generally understood.Thus we find, that for the purpose of arrest-ing haemorrhage, the olden surgeons em-

ployed compression, the application to the

wound,of substances possessing, or supposedto possess,styptic properties, and even theactual cautery. Now, we cannot wonder thatthey should have been afraid of performingany of the great operations, when theirmeans of preventing loss of blood wereso very imperfect ; when the only way inwhich they could prevent a person from

bleeding to death, after amputation, for ex-ample, consisted ill burning the stump to acoal, in order to sear up thp orifices of thedivided vessels. The celebrated French

surgeon, Ambrose Pare, has the honour, if

not of inventing, at all events of re-Intro-ducing into practice, or of bringing into ge-neral employment, the plau of tying woundedvessels ; and when we consider how impor-tant this improvement is, when we considerhow beneficially operations might have beenperformed with the advantage derivable fromthis method of arresting haemorrhage, andhow infinitely better the treatment of woundsmight have been, under this mode of pro-ceeding, we cannot be much surprised thatthis surgeon should have considered- theidea of employing ligatures as a kind of

inspiration. But the processes adopted bynature for arresting haemorrhage, and themanner in which ligatures act in accomplish-ing the same purpose, in fact, all the cir-cumstances connected with bleeding, andthe mode of its. arrest, have been verycarefully investigated in modern times, sothat we may consider this part of surgery asbrought very nearly to a state of perfection.

Distinetion between arterial and venous/N!(M’/7<o’g’e.&mdash;Arterial haemorrhage is dis-tinguished by two circumstances ; first, bythe colour of the blood, which is of a brightscarlet, and, secondly, by the circumstanceof its being thrown out of the wound, ordivided vessels, in jets.A wounded artery is said, technically, to.

bleed per saltum, which signifies by leaps,orjunips. Now, we must not understand thisphrase quite in the literal sense, for theblood is not exactly thrown out in a series of,single projections ; the stream of blood froma wounded artery, like that from a woundedvein, is uninterrupted ; but the stream riseshigher, or is projected further from the bodyat each time that the left ventricle acts.

There is no interruption to the stream ;there is a constant flow, but it is thrownforward more forcibly at every contractionof the left ventricle of the heart. The quan-tity of blood lost, in a given time, and the’effect which that loss will produce onthe system, depend chiefly on the size ofthe wounded vessel. A complete division,or a large wound, of the femoral or bracliial,arteries, of the common carotid, or external,or internal carotid art4ries, generally pro-duces so great a loss of blood as to be almostimmediately fatal. This observation youwill not understand to be invariably anduniversally applicable, for bleeding from awounded vessel is, in some measure,modifiedby the nature of the division of the externalparts. If the external wound be free, so as toallow of an easy escape to the blood, then awound of large arterial vessels will be sud-dealy fatal ; but if the external wound hesmall, so that the exit of the blood is im-peded, then the event may be different. Iremember to have seen a case, in which thebrachial artery was cut across on the insideof the arm, at the same time that a very free

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division was made of the external parts; the haemorrhage from all the Test havingthere was a considerable loss of blood occa- been arrested by a naturalprocess. Yousioned, and the individual fainted; but the will then naturally inquire, how it is thatorifice of the injured artery was tied, and the bleeding from a wounded artery stopsthe patient did not die from hemorrhage, spontaneously 1 What the course is that isSometimes from a wound of one of these adopted by nature for arresting the flow ofvessels, the patient dies almost immedi- blood under these circumstances ? 1 The ori-

ately, whilst in other instances death does fice of the divided vessel contracts, becomesnot take place so suddenly. In a case smaller and smaller, and ultimately seems towhere the ligature came off the femoral close entirely. This natural contraction ofartery after amputation, the gentleman in the orifice of the divided artery, is favouredwhom it occurred, made a noise which by exposure to cold, or by the application ofroused the nurse, who was in his room, but cold water-by sponging ; so that, when weby the time she had reached his bed he was have exposed the part to the air, such as adead; a profuse flow of blood had taken place wound made in removing a breast, or in am-from the femoral artery, and the gentleman putation, we shall find, perhaps, that theprobably died in the course of one or two bleeding has entirely ceased from it, while itminutes. I remember an instance of a liga- is thus exposed ; but when we unite theture giving way that had been applied to the parts, when we bring them together, and,femoral artery of a lady, in whom the artery more especially, when the wound is coveredhad been tied for aneurism ; and in that case by a considerable quantity of dressing anddeath did not ensue till about an hour after clothes, so as to produce heat, haemorrhage willthe giving way of the ligature. recur in the arteries that had ceased to bleed.When an artery of the second order is At the same time that the divided orifice of

wounded or divided ; for instance, when the vessel contracts, the blood coagulates ineither of the three arteries of the leg, the the extremity ; a clot forms which resists theanterior, or posterior tibial, or the peroneal, efflux of blood from the artery. A thirdor either of the three arteries of the fore- circumstance has been mentioned, as contri-arm, the radial, ulnar, or interosseal, or any buting to the natural suspension of haemor-of the primary branches of the external ca- rhage, namely, the retraction of the dividedrotid,-profuse hemorrhage ensues. A con- arteries within the cellular sheath which sur-,siderable quantity of blood is lost in a short rounds them. This has been observed in

time, but the patient faints, and the bleed- experiments on animals; and 1 should re-ing stops-death does not ensue immedi- mark to you that those changes, on whichately, and the patient recovers: haemorrhage the natural suspension of haemorrhage de-may come on again at a distant period, re- pends, take place more powerfully in thepetitions of the bleeding may occur, and brute creation than they do in the humanthus the patient may be ultimately lost from subject. The brachial, the femoral, thethe repeated losses of blood. When arteries common carotid arteries, may be divided in.of smaller size are divided, the blood flows the dog, generally with impunity. A con-more or less freely for a time, but the h&aelig;- siderable gush of blood will take place frommorrhage ceases spontaneously, and no per- a division of those vessels, but the flow soonmanentillconsequences ensue. Itmaysome- stops, the orifice is closed, and the woundedtimes happen that a wound of an artery of animal recovers. Under such circumstancesthe second order, such as the radial, ulnar, it is found that the ends of the divided vesselsor interosseal, or one of the arteries of the have retracted. You are aware that arteriesleg, may not be attended, ultimately, with are generally surrounded by a loose cellularfatal consequences, although no measures are texture. This cellular texture is so veryadopted to restrain the haemorrhage. The loose that it admits of the ends of the ves.,bleeding may stop, and the orifice of the ar- sels,where they are divided, being withdrawntery may be obliterated by a natural process to a considerable distance from each other;.without any recurrence of hasmorrhage. In under such circumstances the blood is in-,the case of amputation of a limb, we see an jected into the cellular sheath ; and a coagu&middot;.exemplification of the remark I have now lum forms, which assists in arresting h&aelig;mor-made. We find it necessary then, perhaps, rhage. Now, it is difficult to say whetherto tie from one to six arteries, but the rest, this process takes place in wounds of thewhich of course must be extremely numer- smaller arteries, or not; indeed, I appre-ous in a wound of this kind, cease bleeding hend, it is pretty clear that the cessationspontaneously, undergo certain changes, and of hemorrhage from small arteries doesno further haemorrhage from them takes place not depend on that process ; for we observe,Sometimes in the amputation of the thigh in the case of amputation for example, awe need only tie the femoral artery. I now ofblood from an artery taking place.when,have known iu the amputation of the fore- that which was a considerable stream gradu-arm, perhaps only one artery tied, or only ally diminishes, till at last it stops altogether,one tied in the same operation on the leg, though the orifice of the bleeding artery re-

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mains within our view, and, therefore, has pletely, and neglect even the most ob-not at all retracted. We see, however,where vious means of arresting the flow of blood.arteries are seated in textures of a dense and It often happens, that haemorrhage from aunyielding kind, that when wounded they wound, even though a considerable vesselbleed more obstinately ; haemorrhage does should have been divided, might be stoppednot stop so suddenly, as when it arises by simple pressure of the finger ; yet personsin the softer parts which admit of the will see the blood flowing from a wound, andcontraction of the arteries ; thus in re- will not take that means of stopping it.moving a portion of the mammary gland, we Pressure with the finger on’the immediateoften see very small vessels continue to bleed aperture of the vessel, or on the wound, iffrom the denser part of the gland, so as to it be small; or tying round the wounded partrender it necessary for us to put ligatures a handkerchief with a degree of force, will,’on them, the denser substance preventing at all events, arrest the bleeding for the mo-the orifices from retracting, which they ment ; it is a temporary stop to the bleed.would do, if situated in some softer parts. ing, till more effectual means can be em.The same thing is observable in wounded ployed. Heretofore, when the applicationarteries of the skin; they do not retract of the ligature was not understood, pressurethere, but continue bleeding. It is not un- was one of the principal means used; not aslikely, therefore, that this retraction of the a temporary mode of stopping bleeding, butorifices of divided arteries may, in certain for the purpose of permanently arrestinginstances, contribute to the suspension of haemorrhage. Sponge, or portions of lint,haemorrhage. Such are the circumstances, were laid on the orifice of the vessel or

then, contributing to the spontaneous ces- wound, and these were bound firmlv upon’sation of haemorrhage; the contraction of the part by bandage, this pressure beingthe orifice, the coagulation of blood within continued until the wounded vessel was sup-that orifice, and the retraction of the ends of posed to be united. It is very difficult tothe vessel within the cellular sheath. Now apply pressure to a wound of a consider.by means of these processes, in many in- able artery, in such a way as to prevent thestances haemorrhage ceases naturally, even flow of blood through that vessel, which isin the case of complete division of arteries of necessary in order to accomplish the effec-considerable magnitude, tual cure of the wound. It is difficult toThe surgical means which are adopted, to apply pressure in such a way as to keep, per-

stop the flow of blood from divided arteries, manently, the degree of force on the wound-may be arranged under three heads&mdash;pres- ed part necessary to accomplish this pur-sure, styptics, and ligature. I should, pose. There are but few’situations in whichhowever, have observed to you, respecting an artery is so situated, as to admit of itsthe natural means of suspending haemor- being effectually compressed ; and if werhage, that the changes on which that effect use a degree of force with the bandage suf-depends, are materially favoured by the ficient to bring each part of the wound toge-state of faintness which is produced by the ther, we shall so injure the condition of theloss of blood. The diminished force with whole limb, as probably to bring it into awhich the blood is projected into the arte- state of mortification; at all events, theries under the state of faintness, assists bandage will’produce irritation-producethe natural process by which haemorrhage is inflammation and swelling generally of thestopped. The coagulation of blood, particu- limb; thus it will bring on a state of thelarly in the orifice of the divided vessel, is wound in which the disposition to bleedingproduced more readily in a reduced state will be augmented rather than diminished.of the circulation ; tor this reason, the Again, slight motions of the limb will becondition of faintness may be considered sufficient to disturb the actual pressure uponas one of the natural means by which hm- the wounded artery; so that for these va-morrhage is stopped ; and hence, under or- rious reasons, pressure can by no means bedinary circumstances, we should not be at regarded as an effective means of arrestingall alarmed by the occurrence of fainting- the flow of blood from an artery of consider-we should not immediately attempt, as per- able size. It is found, indeed, so far inse-sons are apt to do, to rouse the circulation cure, and so far ineffectual, that it has beenby the administration of stimuli. Under generally abandoned by surgeons as a meanssuch circumstances, we should rather regard of arresting h&aelig;morrhage. There are, per-the occurrence of faintness as part of the haps, some few instances in which pres-natural process by which haemorrhage may sure may be employed, but it is by no meansbe arrested. to be regarded, generally, as a right modeNow, in the alarm which persons natu- of proceeding in all cases. In the case of

rally, and almost instinctively, feel on an the wound which we make in the temporaloccasion of serious haemorrhage, those who artery, for instance,-in opening that vesselare ignorant of anatomy and physiology, for the purpose of taking away blood, as itseem to lose their presence of mind com is situated on a bone, it can be’ pretty ef.

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hetually compressed; and this is such a

case as we may find pressure answer the

purpose in. In the case of a BmaH wound ofan artery-of a large artery, it is sometimesfound that pressure will answer the desired

purpose. Now, as an example of this, I

may mention the wound that is occasionallymade in the brachial artery in the operationof phlebotomy. I remember seeing an in.stance, in which there was every reason to

suppose the brachial artery was punctured ;that is, when the vein was opened in bleed.ing, it was observed that there came out ofthe vein a stream which was partly of abright scarlet, and partly of the livid colourof venous blood. These two componentparts of the stream were so strongly marked,that there could be no doubt on the subject.However, in this case, the quantity of bloodwhich it was desirable to take was not ob-tained, even with this additional apertureinto the artery. The bleeding stopped ofitself before as much blood had flowedout as it was wished to take in this par-ticular instance. In this case, a compresswas placed upon the wound; large por- Itions of folded lint were applied over Ithese, by degrees increasing them in size, soas to make what is called a graduated com-press over the wound. Another compress Iwas made upon the trunk of the brachialartery, above the situation of the wound.These were firmly bound on the part by abandage, which was applied from the wristupwards over the whole of the limb. Suchwas the mode that was adopted for the pur-pose of producing pressure in this instance ;the pressure was completely effectual; no

further loss of blood took place, nor did anyfurther aneurismal swelling occur. Theremay be, therefore, some few instances whichmay constitute exceptions to the rule reo

specting the eligibility and efficacy of pres.sure, as a means of restraining bleedingfrom a wounded artery. It is said, that pres-sure may be adopted when bleeding takesplace from a number of small vessels. Ibelieve you will find generally, under suchcircumstances, that the most advantageousmode of proceeding will be, to exposethe wound freely to the air, and spongeit well over with cold water; you willgenerally succeed in stopping it in thatway. It has also been said, that pres-sure may be adopted where bleeding takesplace from the surface generally; this, infact, is hardly an example of arterial h&aelig;mor-rhage. It sometimes happens, that thebhod seems to flow from the whole of the l,denuded surface; it flows from the capilla-riea of the part. Now, it is probable thatpressure may be used effectualIy to restrainthe bleeding there ; but you will immediate-ly perceive, that this is a different case fromthose to which our observations are applied,

different to wounds of arteries ; and I maystate to you generally, that pressure is neversecure, nor in any respect an eligible modeof stopping bleeding, when it proceeds fromany arterial trunk of considerable size. Asa temporary mode of restraining haemor-

rhage, we may mention pressure. on the ar-terial trunk of the limb above the situationof the wound ; thus, if the wound have beenreceived in any part of the thigh, you maypress on the femoral artery, where it

passes the crural arch of the groin. Withthe same view we employ the tourniquetwhen we perform operations. These are

modes of omptoying pressure temporarily, inorder to prevent the bleeding for the moment,On this subject I may state to you, thatpressure applied in this way, is a completelyeffective mode of stopping h&aelig;morrhage;and I may mention this, because a veryingenious and lively writer, a man of muchtalent and ability, took great pains to im-

press the world with a belief (I meau thelate Mr. John Bell) of a contrary kind. Hisdoctrine was, that we could not succeed instopping bleeding by pressure upon the ar-terial trunk. He said, when pressure wasmade with the utmost force on the arteryin the groin, the blood still flowed throughthe attery, as if no pressure had been made.Now I really do not know how he came tostate this ; for I know that you can press theiliac artery between the finger and thumb,and completely put a atop to all circulationthrough it. Again, in amputation of theshoulder we trust to pressure, for the pur-pose of stopping the flow of blood throughthe subclavian and other vessels in that part,and we find that the pressure is perfectlyeffectual. In cases of wounds, either of thearm or leg, where bleeding has occurred,and we suspect the occurrence of it again,we frequently leave a tourniquet looselyplaced round the limb, so that if neces-

sary, it may be tightly applied afterwards,that is, should the bleeding return ; butthis can only be a temporary proceeding,for it produces swelling of the lower part ofthe limb, a very painful state of it, and, in-deed, a condition in which, if pressure werecontinued, would terminate in mortification.This kind of- pressure is, therefore, onlyto be applied as a temporary mode of arrest-ing bleeding.

Great reliance has been placed on theoperation of substances called styptics inarresting bleeding. The exposure of a

wound to the open air, and the applicationof cold to it, by sponging it with cold water,have a powerful influence in checking bleed-ing ; and thus far these may be consideredas styptics. But when we speak technicallyof styptics, we have ill our minds certainmedicines which are supposed to act bycontracting the orifices of the divided ves.

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sels, and in this way, to have the effect of ed, that will subsequently prevent any hse-stopping the flow of blood through them. morrhage. The ligature which we- maySubstances of an astringent nature, particu- apply, separates of itself from the vessel, atlarly alum and sulphate of zinc, are perhaps various lengths of time from its application,

those on which the most reliance has been from four or five days to three or fourplaced. Oil of turpentine has been used for weeks; and when we come to examine thethe same purpose. Perhaps there are no end of the vessel on which the ligature hassubstances that are to be considered as been applied, we find it is firmly closed,more powerfully styptic than a saturated so- and, in fact, not only that the orifice haslution of alum, or of the sulphate of zinc. closed, but that the portion of tube, ex-

We cannot, however, rely upon these, or tending from the orifice up to the situationany other of the substances supposed to pos- where the first branch is given off is contract-sess styptic properties for arresting the ed, has its tube obliterated, and has shrunkbleeding, from an artery of considerable into a firm, solid substance. Such is the

magnitude. They may, perhaps, check effect of the application of a ligature to an

bleeding from small vessels, and that is all artery; so that you observe it is very effec-the virtue we can allow to them; it would tual, not only as the immediate means ofbe extremely unsafe to trust to those pre- arresting haemorrhage, but also of pre.ventives in a case where an artery of any venting the future recurrence of bleeding.consequence, such as the radial or ulnar, Now, when we apply a ligature to an artery,or we might even say, perhaps, one of the supposing we employ ligatures of the ordi-digital arteries, were concerned. There are nary kind, such as are commonly used, andcertain cases where the divided vessel, in suppose we apply the common degree of

consequence of its being deeply seated, and force employed in tightening them, thein consequence of its being so placed, that effect we find produced is, that the two in-we cannot get at it without cutting or inter- ternal coats of the vessel, namely, the in.fering with parts of importance, in conse- ternal and middle, are divided-are cutquence of the swollen or inflamed state of through. When you take off the ligature,some of the parts&mdash;there are certain occa- after having drawn it in this way, and looksions of this kind where we should depart at the vessel where it has been applied,from the usual rule of not employing styp- the vessel appears as if you had cut throughtics ; but then the employment of such the internal and middle coats with a knife;means constitutes an exception to that rule the external or cellular coat being of a muchof proceeding ; on such occasions I should, more tough and resisting nature, is not di-for my own part, be inclined to employ vided by the application of the ligature ; anda saturated solution of alum ; and the mode indeed that is so firm in its texture, that youT should adopt, would be to dip lint into cannot divide it by any degree of force youthe saturated solution of alum, sponge the can apply to a ligature. Now, you willwound clean, lay a portion of the lint on easily see this effect produced by tying athe part from which the bleeding proceeds, ligature round an artery, (The lecturerthen put another portion over it, and make then applied ligatures to different parts ofsuch a compress externally, as by means of arteries wllich he had on the table, to demon-a bandage applied over the whole, would strate the fact.) The effect of the appli-subject the part at one and the same time to cation of the ligature, then, when it is ap-the effect of the styptic, and that of pres. plied with that degree of force that is drdi-sure also ; under such circumstances, per- narily used, is to divide the inteinalandmid-liaps the proceeding might be effectual. I dle coats of the vessel, the external cellularhave known a bleeding that might have been coat remaining entire, and of course sur-troublesome, stopped by the application to rounded by the ligature. Then you have anthe part, of lint dipped in a solution of alum incised wound, for you may so’ call it, of thewith armenian bole, both of which are sup. internal and middle coats of the vessel, andposed to possess astringent properties. Lint you have the edges of that wound kept indipped in a mixture of this kind may be contact by the application of the ligature.applied over a wound ; the blood will form The same circumstance takes place here,a cake under it, and the lint is allowed to as in the instance of a wound in any other ofremain till the danger shall have gone by. the soft textures of the body ; that is, co-The only safe mode of proceeding, how- agulable lymph from this wound is effused

evpr, to restrain bleeding’from wounded ar- on the internal and middle coats of the ves-teries, is the application of a ligature. You sel, this becomes organised, and forms thewill readily understand, that if the orifice of medium of communication by which thean artery be firmly tied, no blood will pass sides of the vessel are firmly held together,through’It. It is, therefore, an effectual and are, finally, permanently closed; it isjuststop to the bleeding ; and the application of the same process as that which takes placethe ligature is followed by those changes in in any other soft parts when they are wound-the end of the vessel that has been wound- ed. Coagulating lymph is first thrown out,

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that becomes organised, and forms the me- form which is called, in the trade, dentists’dium of a solid and permanent union be- silk, which consists of a firm dense texture ;tween the divided parts. The accomplish. so firm, that a piece of a very small size youment of this process, in the case of a cannot break by pulling with the finger andwounded artery, is assisted by the coagula- thumb. I here show you a piece, which istiou of blood in the extremity of the artery. of a small size, but quite large enough forThe blood being at rest in the extremity of all ordinary purposes, and yet so firm,the vessel, being no longer ;in a state of that vou would have a difficulty in break-motion, coagulates, and the coagulum that ing it. with the finger and thumb. It

is thus formed, protects the extremity of the is what the people in the trade call dentists’artery from being,disturbed during the time silk. But itis not necessary that you shouldthat the effusion of the coagulable lymph, employ silk; common stout thread willand its subsequent organisation are going answer the purpose. Heretofore, before theon. The coagulum of blood in the end of process by which the buspension of haemorthe vessel prevents the coagulating lymph rhage, and the mode of uniting divided ves-from being washed away; it prevents the sels, were understood, it was very com-effused lymph from being disturbed by the monly recommended to employ large andimpetus of the circulation, it is therefore an flat ligatures, and not to draw them veryauxiliary to the process on which the orga- tight ; to draw them merely so as to ap-nisation depends, as it prevents disturbance, proximate the sides of the vessel without ac-allowing the process to go quietly on. But tually cutting them. Indeed it appears thatthis internal coagulum is not absolutely the fact of the division of the internal andessential to the closure of the divided vessel. middle coats by ligatures was not noticedWe find this coagulum extends up to the until the time of Desault. Dr. John Tltam-first branch of the artery, which is given off son, by whom this fact has been stated inabove the situation of the wound. Now, it this country, mentions, I think, that he bad

may happen that a vessel might be wounded learnt it from Desault, and it was not statedclose to the origin of a branch, or it may be here, I think, till the present Dr. Johntied close to the origin of a branch ; in that Thomson, the professor of medicine in thecase no coagulum forms in the inside of the University of Edinburgh, mentioned it. Youvessel, and yet the wound is uuited. But it will observe, therefore, that the recom-must be observed, that the process is more mendation of the employment of large liga-precarious under such circumstances, it is tares with the injunction to draw them onlymore liable to be interrupted ; the instances so tight as to bring the sides into contactin which subsequent haemorrhage takes without injuring the middle and internalplace, are more common under such cir- coats, proceeded on an ignorance of the pro-cumstances. Now when we see the mode cess which takes place in arteries which havein which this process is carried on and ac- been tied. I will not venture to say that aii

complished, we can easily determine what artery might not be cut completely through.kind of ligatures should be employed in tying by a ligature under such circumstances.arteries, and what should be the mode re- There are conditions of an artery where de-sorted to in using them; your object is, of position has taken place, where a kind ofcourse, to produce a simple and clean cut of cartiluryinous substance has formed, wherethe internal and middle coats of the vessel ; the structure of the artery becomes changedfor that purpose you should use small, round, in such a wuy as to lose more or less of itsand firm ligatures, for a ligature of that kind natural elasticity or power of resistance-will produce a neat and clean cut. If you where it becomes more brittle; it may b8use a large ligature, you not only divide the perhaps, therefore, in large arteries of aninternal and middle coats, but, at the same altered structure, when tliey have beentime, you bruise them, and you produce au thus changed, that by the application of aextensive detachment of them from the ex- ligature in this way, we might cut throughternal coat. You will find that, in some of all the coats of the vessel ; but speaking ofthe specimens which I have just tied by a the circumstances under which you will haverough and strong string, the internal and to apply ligatures generally, in consequencemiddle coats have been considerably sepa- of a wound, whether from an accidental cir-rated from the external coats ; and, in fact, cumstance, or operation, or otherwise, I canof you were to use a ligature of this kind, venture to state to you, that the smallest ofand put it on a large artery, it is by no these silk ligatures I have now sent round,means impossible that you, might partially may be applied with the utmost force youinjure the external coat with it. The liga- can apply to them with the finger and thumb,tures then you employ, may be made of without any risk of dividing the externalany substance you like, provided they pos- coat, th(,u,;h, at the same time, they willsess these properties: small in size, fitm, completely divide the internal and middleaud round. Silk ligatures will, perhaps, coats of the artery. The ligature should beanswer the purpose best, and especially that applied to the artery ulone, and ’without in-

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ocludinn, any other parts. If you include the !surrounding parts, such as nerves, veins, orany other substances, you cannot calculateso confidently on producing the particulareffect you wish to accomplish; and if youinclude nerves and veins within the hga- I

ture, you run the risk of serious ill con-sequences of another kind. It is desirable,therefore, in all cases, to apply the ligatureto the artery alone. This can be easily done Iin arteries of a large size, because they aresurrounded by a cellular sheath, which ad- mits of their being drawn out from theirordinary situation, by a common pair of

forceps, or by a tenaculum. You take theend of the wounded vessel, draw it out, andapply the ligature immediatelv in contactwith it, perhaps separating with the nail of!the finger, the vein and nerve from the ar-1 itery, if they should be closely accompanyingit; so that you may leave the artery bare. Anordinary pair of forceps is used for this pur- Ipose, or the instrument called a tenaculum,which is a pointed instrument, semicircularin its shape. I now show you modificationsof the tenaculum. There is one that bearsthe name of Professor Assalini, which ad-mits of being so employed as to take uparteries when you have not got an assistantwith you ; by laying hold of the arteries it-will retain its grasp. There is a spring, bywhich the branches of the tenaculum are

’kept together, and it will take up a verysmall artery indeed. Here is another ofthe same kind, where the branches of thetenaculum are kept together by a slide.There is a single sharp point on one side,and a little socket on the other, by whichthe orifice of the bleeding artery may bevery completely held. There are different;modifications ofthe same sort of instrument.

With respect to arteries of such a sizeas do not admit being drawn out by the te-naculum, you should use the forceps for thatpurpose. In instances where the arteriesrun into the substance of a muscle, or intoother substances, and create a difficulty inlaying hold of them, you may find it neces-sary to transfix by the tenaculum somepart of the surrounding textures, and thentie the artery with as little of them as

possible. Having secured the artery inthis way, you generally cut off one eud ofthe ligature close to the knot, leaving theother end hanging out of the wound; andwhen, by the process of ulceration, the liga-ture is detached, it falls away of itself. It Iis expedient, in general, to leave the ligature ’in this way uutil it is thus naturally detach-ed. In cases of ligature applied to an artery fof a-large size, if you were to draw the,ligature away, vou might interfere with the Iprocess which is calculated to close theorifices. The ulceration of the external cel- ilular coat Qf the artery, by which the liga- i

’ture is detached, takes place sIowly. Ihave mentioned that it sometimes takes

place in four or five days, and sometimescontinues so long as three weeks-seldom

beyond that. If you find that it goes on

beyond that, you may then safely draw iti gently, and it will come out. Attemptshave been made to get rid of the irritationwhich ligatures produce in wounds, by cut-ting off both ends of the ligature close tothe knot; and I have done this in manyinstances after amputation, castration, fe-moval of the female breast, operation for

aneurism, and various other operations; andhave not. in any instance, seen any ill

consequences result from cutting off bothends close to the wound, and leaving theknot covered in. In many instances the

wound will unite, and the knot seems

to remain without creating any irritation ;in some other instances, after the cica-

trisation of the wound, a small spot arises[ on the cicatrix, slight ulceration takes

place, and the knot comes away. In everyinstance where you have an expectationthat the wound will suppurate, you may cutoff both ends, because the knot will comeaway with the suppuration. If the woundis likely, however, to unite by adhesion,perhaps the safest and best method is to cutoff one of the ends, and leave the other hang-ing out of the wound.

I have some further remarks to make onthe subject of wounded arteries, which Imust defer till our next meeting.

-

CLINICAL LECTURE

BY

Dr. ELLIOTSON.

Delivered at St. Thomas’s Hospital.

EPILEPSY.

TnE subject, Gentlemen, which I havechosen for this morning’s lecture, is a case ofepilepsy, admitted into Henry’s ward, on the10th of December. The man is twenty-eightyears of age, and has been a victim to thedisease about three years. The fits havesometimes recurred very frequently, but onehad not taken place for two months before

his admission. Ever since the first attack,he had experienced pain over the forehead;and during the last twelve months, his eye-sight had gradually failed; so that, at hisadmission, he could not read a large hand-! writing, and his pupils were very muchdilated, and the irides not influenced bvlight. There was also tremor of the handsand tongue, and the head was hotter than