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No. 742. LONDON, SATURDAY, NOVEMBER 18, 1837. [1837-38. LECTURES ON THE THEORY AND PRACTICE OF MEDICINE; NOW IN COURSE OF DELIVERY AT THE THEATRE OF ANATOMY AND MEDICINE, WEBB-STREET, SOUTHWARK. BY MARSHALL HALL, M.D., F.R.S. L.&E., &c., &c. Inflammation considered as a curative means. Examples shown in apoplexy, and in the formation of artificial anus. Dupuytren’s treatment of artificial anus. New opera- tion for the treatment of prolapsus uteri described. Report of the Royal Academy of Medicine on the operation. Cure of nævus. Good effects of adhesive inflammation in the obliteration of nævus. Examples of cure rapidly obtained by this means. Advantages of this mode of operating over excision and the ligature. Explanation of the operation. The erectile tissue is replaced by the solid tissue of organised lymph. GENTLEMEN :-I now introduce to your no- tice a final topic connected with the subject of inflammation : it is that of, XV. Itifli-immatio2i as a Curative Means. Without inflammation the art of surgery could not exist. Every operation implies the resources of Nature in healing divided parts. This is accomplished by the imme- diate adhesion of contiguous surfaces, union by thefii-st intention; or by the gradual fill- ing up of cavities, granulation. Inflammation, as a curative measure, is sometimes employed by Nature, sometimes by Art. A coagulum of blood is formed in the sub. stance of the brain, in apoplexy : in the first place, albumino-fibrine is thrown out, i forming a cyst which lines the torn cavity of the cerebrum, and inclosing the coagulum; in the next place, the coagulum may be gra- dually absorbed, leaving a cyst replete with serum; in the third place, this serum may be absorbed, the parietes of the cyst ap- proach. adhere, and the cyst is obliterated, nothing but a cicatrix remaining. I have already noticed the operations of Nature, in conducting the pus of hepatic abscess to the surface, and in ultimately discharging it from the system. Another fact, of equal interest, is that of Nature’s operations in the formation of pre- ternatural antts: the peritoneum lining the abdomen, and the peritoneum covering the intestine, unite by layers of effused albu- mino-fibrine ; the strangulated portion of the intestine sloughs, but the abdominal cavity is safe ; the patient is not destroyed ; but he is left a prey to a loatlisome malady. We shall see how Art, guided by Genius, com- pletes what Nature had begun. The cure of artificial anus was devised by Dupuytren. The state of the intestine, in that affection, is thus represented by that distinguished surgeon : s
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Page 1: LECTURES ON THE THEORY AND PRACTICE OF MEDICINE;

No. 742.

LONDON, SATURDAY, NOVEMBER 18, 1837. [1837-38.

LECTURESON THE

THEORY AND PRACTICEOF MEDICINE;

NOW IN COURSE OF DELIVERY AT THE

THEATRE OF ANATOMY AND MEDICINE,WEBB-STREET, SOUTHWARK.

BY

MARSHALL HALL, M.D., F.R.S. L.&E.,&c., &c.

Inflammation considered as a curative means.Examples shown in apoplexy, and in theformation of artificial anus. Dupuytren’streatment of artificial anus. New opera-tion for the treatment of prolapsus uteridescribed. Report of the Royal Academy ofMedicine on the operation. Cure of nævus.Good effects of adhesive inflammation in theobliteration of nævus. Examples of curerapidly obtained by this means. Advantagesof this mode of operating over excision andthe ligature. Explanation of the operation.The erectile tissue is replaced by the solidtissue of organised lymph.GENTLEMEN :-I now introduce to your no-

tice a final topic connected with the subjectof inflammation : it is that of,XV. Itifli-immatio2i as a Curative Means.Without inflammation the art of surgery

could not exist. Every operation impliesthe resources of Nature in healing divided

parts. This is accomplished by the imme-diate adhesion of contiguous surfaces, unionby thefii-st intention; or by the gradual fill-ing up of cavities, granulation.

Inflammation, as a curative measure, issometimes employed by Nature, sometimesby Art.A coagulum of blood is formed in the sub.

stance of the brain, in apoplexy : in thefirst place, albumino-fibrine is thrown out,i forming a cyst which lines the torn cavityof the cerebrum, and inclosing the coagulum;in the next place, the coagulum may be gra-dually absorbed, leaving a cyst replete withserum; in the third place, this serum maybe absorbed, the parietes of the cyst ap-proach. adhere, and the cyst is obliterated,nothing but a cicatrix remaining.

I have already noticed the operations ofNature, in conducting the pus of hepaticabscess to the surface, and in ultimatelydischarging it from the system.Another fact, of equal interest, is that of

Nature’s operations in the formation of pre-ternatural antts: the peritoneum lining theabdomen, and the peritoneum covering theintestine, unite by layers of effused albu-mino-fibrine ; the strangulated portion of theintestine sloughs, but the abdominal cavityis safe ; the patient is not destroyed ; buthe is left a prey to a loatlisome malady. Weshall see how Art, guided by Genius, com-pletes what Nature had begun.The cure of artificial anus was devised

by Dupuytren. The state of the intestine,in that affection, is thus represented by thatdistinguished surgeon :

s

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The instrument by which Dupuytren con-trived to effect the cure, is portrayed in thesubjoined woodcut:

It will be observed that one of the bladesof this instrument is received into a groovein the other; its edge is dull, indeed one

line in breadth, so that the intestine is heldand c-rushed, not severed, when seized by it.The first blade is passed into the upper, thesecond into the lower portion of the intes-

tine, and it is gradually but firmly closed.The adjacent parts of the peritoneum uniteby albumino-fibrinous exudation; the tex-tures seized by the instrument slough thecavity of the abdomen is preserved entire,whilst the canal of the intestine is madecontinuous. The external wound is healedwhen the passage of the faeces has becomefree. All this is admirable.The cure of hydrocele is efl’ected by

changing the form of inflammation in thetunica vaginalis, from that which pours outserum to that which pours out lymph.Sometimes the cavity is obliterated by adhe-

sions ; sometimes its internal surface is

changed by the deposit of lymph, or in thecondition of the vessels. This change is in-duced by some proceeding which excitesa higher degree of inflammation ; by an in-jection, by a seton, by removing a portion ofthe peritoneum, &c.

It has sometimes occurred that, for wantof inflammation, the broken extremities ofbone, in the case of fracture, have notunited. It is then usual to excite this ac-tion by means of a seton, or other similarmeasure.

Cure of Prolapsus Uteri.Another application of the principles of

inflammation to the cure of a distressingmalady, was proposed by myself, and suc-cessfully made by Dr. Heming. The objectwas to cure prolrtpsus uteni. It occurred tome that this might be accomplished by di-minishing the calibre of the vagina, so thatthe uterus might be supported in its placeat its upper part. The vagina, being linedby mucous membrane, could not be readilyexcited to contract adhesions with itself; Iproposed, therefore, to remove one or twoslips of that membrane, and draw the oppo-site edges into contact by suture ; adhesionwould take place, the canal would be firmlycontracted, and the prolapsus of the uterusprevented. All this was eflectually accom-plished in one case, the details of which Ipublished some time ago. Several yearsafterwards, the case was examined byMr. Vincent; the uterus was still retainedin its proper position. Recently this ope-ration has been successfully repeated byM. Velpeau and M. Berard, jun. In theyoung, I would propose that the slip ofmucous membrane removed from the highestpart of the vagina be broader than that re-moved from below.The object, in this operation, is to con-

tract the vagina. It is accomplished bychanging a mucous surface, opposed to ad-

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hesive inflammation, into a surface of an- pletely remedied. The descent of the pouchother character, on which this form of of the rectum was lessened.inflammation is readily excited. The principle upon which this case wasThe mode of performing this operation is treated, is illustrated by a fact detailed to

represented in the subjoined sketch, me by Dr. Holland, of Queen-street, May-The first case of this operation was pub- Fair. A pessary, introduced in a young

lished so long ago as 1831. The subject of person to support the uterus, subject to bethe case was a poor woman, whose bread completely prolapsed, induced great inflam-depended upon the labour of her hands. mation. This was followed by such firmHer sufferings, from the prolapsed state of contraction of the vagina, that the uterusthe uterus, were often extreme, and she ever afterwards remained in its properwas frequently disabled from engaging in situation.her various occupations. This subject has recently occupied theFor several years there had been com- attention of the surgeons in Paris, and seve-

plete prolapsus of the uterus; to this were ral notices have appeared in the Reports ofalso conjoined a partial descentof the blad- the proceedings of the Academie Royale deder at the anterior, and of the rectum, form- Medécine, and in the Parisian journals, re-ed into a pouch, at the posterior part of this lative to it. I think an account of theseprolapsus. The os uteri protruded at least discussions cannot cannot fail to interesttwo inches beyond the os externum. the members of our profession in England.

It occurred to me, that, if the canal of the The first of these notices, of which Ivagina could be considerably, permanently, shall give an account, is that of two com-and firmly reduced in its diameter, the ute- munications made to the Academie on therus would be supported in its place, and llth August, one by M. Velpeau, the otherprevented from resuming its prolapsed situ- by M. Berard, jun.ation; and that this might be done by re- " M. Velpeau communicated the case of amoving a portion of its mucous membrane woman, about fifty years of age, who hadalong the anterior part, and by bringing and for a long time been affected with prolapsusreturning the denuded surfaces in contact, uteri. There was also cystocele, pushingby successive deep sutures,until they should the uterus backwards. An operation wasunite by cicatrix. performed according to the plan of MM.

This operation was performed by Dr. Marshall Hall, Heming, and Ireland,Heming. The uterus being protruded as though with the following modifications :-much as possible by the efforts of the pa- In order to effect a considerable tightening,tient, two parallel incisions were made three shreds of the mucous membrane ofthrough the mucous membrane, from which the vagina were removed, one anterior, thethe sides of the os uteri, along the course of other two lateral, beginning at the os exter-the protruded vagina, to the os externum, num ; each of these shreds was ten lines inthe portion of this membrane situated be- breadth, and two inches and a half in length.tween these incisions, was then removed, A difficulty is usually found, after removingleaving a space of one inch and a half in the shreds, in making the suture. M. Vel-breadth, and of the entire length of the peau took the precaution to fix the threadvagina, completely denuded. A suture was previously. The operation was not attendedthen inserted near the os uteri. This suture with any untoward event; the haemorrhagebeing tightened, the os uteri was obviously and pain were very slight, and cicatrizationpushed upwards. A second, a third, and ensued by the first intention. Some colicother ligatures, were then inserted in the pains, arising from the retention of somesame manner, at short intervals, to the os faecal matter, were subdued by laxativeexternum ; each ligature, on being tighten- medicines. The patient was cured twoed, moving and supporting the os uteri months ago, and the cure promises to be

upwards. permanent. The operation is at once freeThis operation was attended with little from pain or inconvenience, and appears

pain ; the only sensitive parts of the mem- most effectual.brane being those near the os uteri and os M. Maingault objected, that, in the caseexternum. of young women likely to become mothers,The patient was directed to keep quiet in this operation would involve serious incon-

bed. The bowels had been opened. An veniences.opiate was given. No pain or fever follow- M. Velpeau observed, that this objectioned. In four or five weeks the denuded parts might appear well founded at first sight,had firmly united, and, shortly afterwards, but that there were facts to show that cica-the ligatures came away. trices of the vagina may yield sufficientlyOn examination, six, eight, and ten weeks during labours to admit of the passage of the

after the operation, the os uteri could be foetus.just felt, in situ, by the finger passed M. Bérard, un., related the case of athrough the vagina ; the vagina was firmly woman, in which he performed the samecontracted along its whole course, operation with entire success. Out of threeThe prolflpsus of the uterus was thus com- instances in which he had himself been the

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operator, two persons were completely adopt it in England, but Al. Ditpuytreu, incured. France, described it with much more accu-

Since that day M. Bérard has repeated racy, and ought justly to be considered asthe same operation. He proposes to desig- the first who gave rules for its performance.nate it by the term Elytroraphie."’ Thus, from the success obtained in cases ofTo this brief account of the proceedings prolapsus ani, it has led to a belief that the

of the Academie, I beg to add that of a same benefit might be expected in cases ofclinical lecture by M. Velpeau, published prolapsus uteri, by contracting the vagina.by Dr. Dufresse, in the " Journal Hebdoma- The first idea of this operation is due todaire," for August the 29th, tom. 3, No. 35, M. Girardin, who described it in a memoirp. 275 :- which lie presented to the Societe de Méde-" There came under my care (says the pro- eine de tllctz, or de 7V«ne;/. He proposed

fessor) a woman, aged 58, of dark com- to contract the vagina, and if necessary evenplexion, and well formed, affected with pro- completely to obliterate it in women in

lapsus uteri to such a degree that this organ whom the catamenia had ceased. He foundprojected through the os externum. The many opponents to his ideas, which werecervix was neither inflamed nor ulcerated. rejected. The manuscript remains unpub-The patient experienced no pain, and she lished, the journal of the Society havingcould reduce the tumour herself. given only an analysis of it, which I have

This affection is rather an infirmity than now before me.a disease. It may, however, become a These ideas have since been renewed, re-source of serious disease, in consequence of duced to rules, and adopted with success.the dragging which is produced by it on the M. Dieffenbach, of Berlin, has employedparts contained with the pelvis. It may this method. In 1831 many of our youngalso be the cause of peritonitis, inflamma- surgeons went into Poland, and they ad-tion of the cellular membrane of the pelvis, dressed letters to the 11 Gazette Medicale,"and, consequently, of abscess ; and the in- in which they gave an account of many casestestines may be drawn into the cut de sac of procidentia uteri, in which there had beenwhich is thus formed. It may also be the performed all operation similar to thatcause of strangulated hernia; and, lastly, of adopted by M. Dupuytren for the cure ofulceration of the neck of the uterus. prolapsus ani.The surgical means which have been Two years ago M. Langier tried to cure a

hitherto applied are only palliative. They case of prolapsus uteri, which came underconsist of pessaries, by the use of which his care, by contracting the vagina. I be-the patient is subjected to numerous acci- lieve this case has not been published.dents. There is considerable variety in M. Tanchon was acquainted with thisthe form of these pessaries ; some are method, but kept it a secret; he has pub-oval, others elliptical, or "en gimblette." lished nothing upon it; he has only put inThey are with difficulty retained in their his claim against that of the English sur-proper situation, and are ill calculated to geons, who wish to consider the priority insupport the uterus. They imbed themselves reference to this operation, as due to them-deeply in the parietes of the vagina, and selves.produce inflammation, in consequence of M. Dieffenbach is contented with remov-which it is frequently necessary to with- ing the folds of the vagina near the inferiordraw them. Others have the form of a orifice.° bilboquet." It has a stem, which projects M. Langier cauterized a broad strip ofout of the vagina, and produces much in- the mucous membrane with the nitrate ofconvenience when the patient sits down. mercury.This is often broken, and then the cup re- MM. Marshall Hall, Heming, and Ire-mains in the vagina, where it becomes land, in England, have performed the ope-covered with a calcareous concretion. Pes- ration with complete success. Their methodsaries have also been known to perforate the consists in removing an elliptical shred of

recto-vaginal septum, and the sores thus pro- the mucous membrane from the internalduced to become fistulous. There are, be- surface of the vagina, an inch in breadth,sides, " pessaires 6lyti-oides." These are and several inches in length. The woundwith difficulty kept in the vagina. is then united by the interrupted suture. InThe insufficiency, then, of these means, some cases two such shreds have been re-

and the inconveniences which follow their moved, one from the left, and the other fromapplication, justify the efforts that have the right side.been made to obtain a radical cure ; which In the case which I have described, thehas been effected in some cases. catamenia had subsided, for a long time.

There is one principle only, but this is The uterus projected two inches exter-effected in various ways. It has been nally; the tissues were not hypertrophied,founded upon that which is adopted for the nor had they undergone any other alterationcure of prolapsus ani. This consists in of structure.contracting the orifice of the anus to a The plan which we propose is as follows:greater or less extent, Hey was the first to -First, to remove the anterior column of

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the vagina, from the inferior part to the

superior, before reducing the prolapsus ;then, to reduce it, and remove from thelateral parts of the vagina, both right andleft, and along the whole length of thiscanal, a band of the mucous membrane ;and, lastly, to unite the anterior wound bythe interrupted suture.

In our opinion it is much better, whenthe procidentia is not very considerable, toinsert the sutures before removing the an-terior shred of mucous membrane, so thatthe threads may be situated about a linefrom the edges of the wound. Nl’e advisethis to be done, in consequence of the paincausing the parts to contract, when the ex-

cision is made before the sutures are in-

serted ; and, in many cases, when this hap-pens, it is exceedingly dimcult to insertthem. In the dissection of the anterior shredconsiderable caution is necessary lest thevesico-vaginal septum be completely cut

through.The woman who forms the subject of

this communication, experienced no incon-venience ; and some days since she walkedin the wards of the hospital, and in the gar-dens, without the least tendency to a returnof the prolapsus. We may now, therefore,calculate upon almost certain success by anoperation."What I have to add is a little amusing.

It seems M. Girardin has written to theAcademie to remind its members that in182 he had proposed to cure prolapsusuteri. It is added that M. Girardin " avoulu par cette communication assurer al’operation son origine et maintainer à lachirurgie Francaise (!) la priorite de Fin-vention, sinon de son execution."

It seems that the profession in France re-.mained steady in their opposition to thismeasure, and that M. Girardin slept uponhis mere proposition. I do not imagine,therefore, that either will gain much by anyattempt to deprive me and Dr. Hemingof whatever merit there may be in havingboth devised and executed this simple,this painless, almost bloodless, yet impor-tant operation. To compare our opera-tion to that of Hey, or that of Dupuytren,for prolapsus ani ; or to those of M. Dieffen-bach, and M. Langier, for prolapsus uteri,neither of which could succeed, is equallyfutile. As to M. Tanchon, who could keephis mode of proceeding secret, he does notdeserve a moment’s notice.Without attaching too much importance

to it, I cannot but regard this operation as avaluable addition to our curative means.

Prolapsus uteri is frequently a great cala-mity. The mode of cure proposed is atonce effectual, and free from either pain ordanger if properly performed.

Cure of Nævus.

Thgre is one other application of the prin-

ciples of inflammation to the cure of disease,which I also proposed soiiie 3 cat-s ago, andmust briei!y notice ill tlis plice. It occur-red to me that if I could change the vascu-lar texture of certain forms of nævus intofirm lymph or cicatrix, I should effectuallycure that congenital disease. The planswhich I proposed in order to accomplish thisobject, are represented below :

The circle to the left represents a nasvuspunctured from one point, in various direc-tions, by means of a needle of considerablesize, with cutting edges ; the middle circlerepresents a naovus absolutely divided bytwo operations ; the third, a nsevus piercedin several parts by a needle and thread, thelatter being left to excite inflammation.Little pain is inflicted, scarcely a drop ofblood is lost, no scar is produced ; the depo-sit of lymph is effected very slowly ; but itis only necessary to repeat the operationoften enough, at due intervals, and to waitlong enough for Nature’s processes. Thecelebrated Professor Lallemand, of Mont-pellier, has quite recently proposed a pre-cisely similar mode of proceeding ; the onlydifference being that that gentleman sug-gests the propriety of leaving the needlesthemselves in the nsevus, for a time sufli-cient to induce the deposit of lymph.

In February, 1831, observed, " the dan-ger of liaemorrhagy from the excision, theexcessive pain of the ligature, and the ex-tensive scar left by vaccination (as thesehave been respectively employed for thecure of naevus), induced me to considerwhether some less objectionable mode ofoperation in these cases might be devised.

I communicated my suggestions to seve-ral eminent surgeons some years ago. I amnot aware, however, that the plan proposedhas been subjected to the test of experi-ments by any of them.About nine months ago I was afforded

the opportunity of examining a case of thiskind, and of superintending the operation,by my valued friend, Dr. Heming, of Ken-tish Town.This operation consisted in introducing a

couching needle, with cutting edges, at onepoint of the circumference of the naevus,close by the adjoining healthy skin ; fromthis point the instrument was made to passthrough the tumour, in eight or ten differentdirections, so as to produce slight incisionsthrough its textures, parallel with the skin,but not so as to pierce the tumour in anyother part. The first point of puncture wasmade the centre of the several rays of slightincisions, effected by merely withdrawing,

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and again pushing forward the little instru-

ment, in the manner and in the various di-rections just described.The naevus was oval, and rather larger

than a shilling; the couching needle wasintroduced at one point, passed as nearly aspossible to the opposite edge of the tumour,without piercing it, and then in various di-rections, until eight or nine punctures, orrather incisions, traversing the texture ofthe tumour, but not the skin, had beenmade.A little pressure was then applied over

the tumour by means of strips of adhesiveplaster.

There was no pain, and of course no hre-morrhagy, and as the skin was only punc-tured in one point there could result no scar.

I expected that inflammation would takeplace, and that a cicatrix would be formed,which, from its solid texture and progres-sive contraction, would obliterate the tex-tures of the tumour.For some time, for several weeks, little

appeared to have been effected. There waslittle or no change in the appearance of thenaevus of any kind ; indeed, it was almostconcluded that the plan had failed, that thevitality of the part had been too low to

yield the degree of inflammation requiredfor the cure.

What a short time did not effect, however,a longer period accomplished completely.Half a year after the operation the tumourwas found to have disappeared, and thecolour of the skin to be nearly natural; theskin itself was preserved perfectly freefrom any appearance of scar.

It is plain that the operation might be re-peated at longer or shorter intervals, andwith more or less numerous punctures, ac-cording to the degree of force apparentlyrequisite to induce the given degree of in-flammatory action for the obliteration of thetumour.

. The mode of treatment might also possi-bly be adopted for the cure of some of thosecongenital marks which disfigure the face,the instrument being cautiously introducedunderneath, and parallel with, the surfaceof the skin. If the loose vascular or cellu-lar substance were thus obliterated, thecolour would disappear.But at this time I would confine myself

to the consideration of the cure of naevus.To obviate the occurrence of haemorrhagy,ofpain, andofscar,is of sufficient importancein itself, to attract the attention of surgeonsin the treatment of this affection. But, be-sides this consideration, nævus sometimesoccurs in situations, as in the tongue, theeyelids, and not admitting of any other modeof operation. It does not appear that pres-sure forms any necessary part of the treat-ment. The cure in the case detailed wasgradually effected long after pressure hadceased to be employed."

) In December of the same year, I added- Dr. Heming, to whom I am already sodeeply indebted, has again afforded me anopportunity of observing the effect of punc-ture in the cure of nævus. The case wasdoubly interesting, from combining ulcera-tion with the ordinary circumstances of thataffection.The tumour was oval, about one inch and

a half in length, and three-fourths of an inchin breadth. The central part was under-going the ulcerative process; around theulcer the nævus existed in the form of aring, about one-sixth of an inch in breadth.The edges of the ulcer were ragged, andslightly phagedenic; the surface of theulcer was mali moris, and had bled fromtime to time. The naevus rose about aneighth or a tenth of an inch above the sur.face of the skin.A common broad needle, with cutting

edges, was passed through the substance ofthe naevus, at its base, and under the ulcer,from side to side, in every direction. Se-veral punctures were made, but one wouldhave been sufficient.In the course of one week the ulcerative

process had undergone the most interestingchange into the adhesive. No better or

more beautiful illustration could be present-ed of the Hunterian doctrines. The raggededges became smooth and white; the ulce-rated surface covered with a film of coagu.lated lymph. In a few days more the wholeulcer was completely healed.As a much slower process, the deposit ofcoagulable lymph encroached on the edgesof the r&maiuing ring of naevus, which, inthe space of one month, had become reducedto one-third its original breadth.At this period it was thought right, in

order to accelerate the process of oblitera-tion, to repeat the operation. But on exa-mination, the process of obliteration ofthe ring of naevus was going on so beauti-fully, that we determined to leave it fordaily observation. The deposit of coagu-lable lymph, with obliteration of the vessels,gradually encroached upon the breadth ofthe ring of naevus, and destroyed its red.ness and tumour. Each successive weekinduced an obvious change. The wholeprocess was so distinct, and so peculiar,that, however a shade of doubt might becast upon the foymer case, none could pos-sibly subsist in regard to the nature of thecure in this.That every kind of vascular naevus, and

even some tumours, morbid growths, andulcers, may be cured by this simple opera-tion, I have no doubt. Such a mode of obli-terating vascular texture, and of changingvascular action, must have numerous appli-cations in surgery. I have thought it, there-fore, incumbent upon me once more to drawthe attention of the profession to this sub-ject."

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For the following case I am indebted toMr. Wallace, of Hackney-road :" Miss W-, three years of age, had from

her birth a nævus occupying the apex andseptum of the nose, which produced a veryunpleasant appearance; its surface project.ed, and had the resemblance of a ripe rasp-berry.On the 14th of May, 1835, I punctured

the naevus in every part with needles, andrepeated the operation on the 28th.At the end of a fortnight I observed a

manifest diminution of the vascularity.On the 24th of June I again punctured it

as before. From this time it has been gra-dually diminishing in vascularity and ele-vation of surface, and now, after six months,there is not the least appearance of nævus

remaining, the part resembling, with regardto vascularity, any other part of the face.Mr. Wallace observes, it will be remark-

ed, that the seat of this nævus was such asto render the knife, the ligature, or the

caustics, altogether inapplicable ; the scarinduced would have been a greater defor-mity than raspberry-like nsevus itself. Theprogress of the cure was extremely slow.Not having seen the case recently, I toldDr. Marshall Hall, yesterday, that I believ-ed a point still remained of the original hue,but having visited my little patient thismorning, I find that since my last visit thatspot also has gradually and entirely lost itsvascularity. It is important to rememberthis slow progress of the cure, in order to

prevent undue expectations and cousequentdisappointments. It is more than six monthssince the first acupunctu rations were per-formed.

I must admit that I know not what other

plan of cure could have been adopted in thisinstance. This mode of cure must, there-fore, be deemed of great value, and not theless, because it is attended with scarcely anypain, hasmorrhage, or other inconvenience."As this operation has met with no little

opposition, I must be allowed to detain youwhilst I adduce two or three other cases.The first is a case for which I am indebtedto Mr. Doubleday, of Blackfriars-road. Mr.Doubleday observes,-" The child of Mrs. Palmer, residing at

37, Garden-row, London-road, was broughtto me at the beginning of November, 1834,with a diffuse swelling between the eyes,encroaching upon the left orbit, and of thesize of a large nutmeg. On applying pres-sure the tumour almost disappeared, butthe moment the finger was removed, it re-turned to its former size. The mother stat-ed, the first time she saw her child after itwas born, she observed a bruise between itseyes, but her mind was made quite easy bythe medical man who attended her, assur-ing her it would disappear in a few days.Five weeks after this she noticed a small

swelling, and at the expiration of three

weeks more, making altogether two monthsfrom the birth of the child, it had acquiredthe size I have stated.The case presented a good example of an

increasing nævus, situated in the cellularsubstance. I suggested to the mother alittle delay, that 1 might consider of thebest mode of treating the disease, duringwhich it increased so much in size, that shebecame very impatient to have somethingdone. Some time before this case presenteditself, Dr. Marshall Hall kindly explainedto me his method of treating naevi, and Iconsidered it an excellent opportunity ofputting his plan to the test of experience.Accordingly, on the 5th of January, 1835,in the presence of Dr. Hall, I carefully in-troduced a couching needle into the centreof the naevus, and moved it from side toside, so as thoroughly to break down thenet-work of vessels. This operation wasrepeated on the 21st of February, 27th ofMarch, 1st of June, 1st of July, 8th of

August, and on the 1st of September, 1835.There was not any diminution of the tumouruntil after the third operation, after whichit gradually decreased in size; although, Ibeg particularly to observe, the nævus didnot totally disappear until upwards oftwelve months after the first puncture.On the 17th instant the little patient was

sent to Sir Astley Cooper, who wrote thefollowing note to Dr. Hall : -

" My dear Sir,-There are no appearancesnow which indicate the existence of thenaevus. Yours truly,

" ASTLEY COOPER." ’

I have only further to observe, that I be-lieve I performed the operation more fre-quently than was necessary. It is length ortime that is required, and it will be impor-tant to observe the dates in this interestingcase.

I need hardly point out the advantages ofthis mode of removing naevus over excisionand the ligature ; it is only necessary torecal to mind the haemorrhage induced bythe first of these operations, the pain in-flicted by the second, and the scar whichresults from both."

Other cases of naevus have been success-fully treated by the same means, by variousother medical friends. Mr. Vickers, of

Baker-street, showed me a diffused arterialnævus, which involved the left nipple, in alittle girl. It was cured by the operation.The prog-uess of the change induced wastraced from month to month, long after thesecond,-nay, for three or four years.There is now nothing left but a few vessels,as fine as hairs, which will doubtless dis-appear in their turn.

Another case of naevus of a venous struc-ture was shown to me by Dr. Bull. It was

situated in the upper eyelid, in the innercanthus. No knife, no ligature, no caustic

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256

could be applied. It was cured by repeatedoperation with the na*vus needle.

I need not adduce more facts. I regardthis mode of treatment as the only recom-mendable one. All othe1’s are, in my opi-nion, barbarous. By the means which Ihave described we have only to operate fre-quently enough, and to wait long enough, andwe shall cure every kind of nsevus, where-ever situated, without hasmorrhagy, with-out pain, without present danger, and with-out future disfiguration.

All this is accomplished by exciting ad-hesive inflammation,-by replacing the erec-tile tissue of the naevus by the solid tissueof organised lymph.

DISCOVERIESIN

OVOLOGY AND EMBRYOLOGY,MADE BY

MR. JOHN MILLER,MECHANIC, LONDON.

To the Editor of THE LANCET.SiR:-I throw myself for publication on

the liberality of your Journal, which hasbeen so often boasted of as a vehicle for thecommunication of science. In the year1827 I attended Dr. Birkbeck’s Lectures ouAnatomy, at the Mechanics’ Institution. Iwas then following the trade of a plastererand modeller. Those lectures kindled inmy bosom the love of anatomy. I deter-mined to leave my trade, and follow it. Ioffered my services as a porter to the dis-secting-rooms but could not get employ-ment. Mr. Green of St. Thomas’s Hospitalgave me employment in making casts forhis museum, for about twelve months. Ithen commenced to form a collection of myown. The subject I chose to investigatewas embryology, and the connection of theplacenta with the uterus. I have examinedthe uteri of sixteen women who have diedundelivered. In 1835 there was no prepa-ration in London to prove the connection ofthe uterus with the placenta, or the placentawith the uterus, except the preparationmarked No. 3535 in the Hunterian Museum.The account of it was drawn up by Mr.Mayo, in the presence of Mr. Stanley andMr. Owen, and all three concurred in think-ing that the preparation established all thepoints of the structure which are describedin it. I would beg the attention of luid-wifery teachers to that preparation.The paper on the structure of the uterus

and placenta by Dr. Robert Lee, in the"Phil. Trans.," drew my attention toanother method of injecting, by making twoinjections to run at one time, the one in thehypogastric arteries and veins, the other in

the arteries of the funis, with differentcoloured injections, so that it might be seenwhere each terminated. I have succeededin this. An artery as large as a crow’squill is seen to pass, filled with injection,from the uterus into the placenta. Thelarge decidual vein round the margin ofthe placenta was filled with injection. Inthis vein there are three openings, as largeas goose-quills, into the veins of the uterus.These three veins return the whole of theblood from the placenta into the uterus. Inthe greater number of the uteri that I haveexamined, I have never seen more than fourvenous openings, and never less than three.There is also another set of vessels, called

the decidual arteries, and the decidual veins.They go to the uterine layer of the deciduaand stop there ; so do the veins. They formthe short curling vessels of Hunter. Sepa.rate portions of this uterus were dissectedby Mr. Green, Mr. North, and the late Dr.Hugh Ley, who saw the same appearances.I have the preparation now.

I have also been successful in injectingother uteri. In Magendie’s "Physiology,"p. 509,1829, he says :-" In animals, amongthe small vessels which go from the uterusto the placenta, there is not one which hasthe appearance of a vein." In my collec-tion I have what shows the reverse; theveins and arteries are injected. In London-there are twenty teachers of midwifery, andthere is not among their collections a pre-paration to show the connection of theplacenta with the uterus. This is teachingphysiology ! What do the readers of thisJournal think of it? Three out of that"number have given me every opportunity ofexamining that subject. I should be un-grateful if I did not give each of them aspecimen as soon as possible. Would it bebelieved that some of the teachers in thehospitals in London, with their favourites,would have examined gravid uteri and yetnot let me know of it, although they kuewthat I was investigating that subject? Theyhave thought, by having mosey, and beingteachers, that they could not he denied asight of my collection when they applied tosee it. I asked them " Why I was not atthe hospital to see the gravid uterus exa-mined, as well as their favourites ?" I toldthem that I knew the reason. My coat wasnot fine enough. But the tailor made thecoat only, and God made the man. If thechairs of teachers were got by talent only,a poor mechanic, like me, in investigatingnature, would know where to go to pursuehis studies. The chairs, however, are mostlygot by intug’ue. Allow me to prove this.The painter is known by his paintings, andthe sculptor by his works. Why not thephysiologist by his? Have the physiolo-gists nothing to discover ? What have theteachers in London done for the last tenyears ? Have they no preparations to pro’


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