-No.2.] LONDON, SATURDAY, JAN. 15, 1825.

SURGICAL LECTURES,DELIVERED BY

MR. ABERNETHY.

Theatre, St. Bartholomew’s Hospital.

LECTURE 14.

Varicose Ulcers.

GENTLEMEN,Sir EVERARD HOME, speaking of

ulcers depending on a varicose stateof the veiris, recommends that theveins should be tied, but it is a prac-tice which appears to me extremelydangerous, being frequently followedby inflammation of the part and greatconstitutional irritation. Mr. BRO-DIE, finding that ligatures on the veinsproduced these bad effects, was in-duced to try what their division woulddo. For this purpose he makes useof a curved knife with a cutting con-vag edge, which is first introducedhorizontally under the skin and vein ;the b’ade is then turned upwards, andthe vein divided as the knife is with-drawn. This is a part of new surgery,however, into which I shall not now

enter; you must read Mr. BRODIE’Spapers for yourselves, for I cannot giveyou any information on the subject de-rived from myown personal knowledge.Mr. BRODIE states, that he found thedivision of the vein below the sore

more successful than the division above;now this does not at all accord withSir EvEHARD HOME’S notions. In

short, it is a subject I do not under-stand myself; as far as I know, noharm results from the practice ; as tothe good done by it, you must decide

for yourselves, I am not competent togive you any information on it ; andany observations which I might nowoffer on the subject, would be derivedfrom the opinions of others, and notfrom my own personal experience.

I have been talking of local dis-eases, as they may occur in any partof the body, in consequence of anundue action in the arterial systemof the part, or as a consequence of in-creased morbid action of the alisorh-ents of the part, and have now to speakof something wrong in the nervoussystem of the part.

Nervous Affections.When any disease, however, comes

on in a part, I do not believe any onesystem in particular is affected, butthat everv system of the part suffers ;the vascular, absorbent, and nervoussystems are equally wrong, and yetwe name the disease from its most

prominent character ; as for instance,in local diseases, when the vascularsystem is affected, you may have in-flammation, ulceration, and somethingwrong in the nervous actions of the

part, and these derive their name fromthe characteristic circumstance of thedisease. When the nerves are affectedlocally, it most frequently depends ongeneral disturbance of the whole ner.vous system. You may have numb-ness in a part and local pain, but ingeneral these, together with weak-ness and twitching of the muscles(for here I must connect the muscularand nervous systems together), de-

pend on something wrong in the ner-vous system. In short, I believe everydisease is original1y nervous. Disor-der of the nerves is first excited, andthis leads to increased action of thevessels, and increased action of theabsorbents of the part. Some diseasesaffect the vitality of the part. There

will be acute pain and increased vas-cular action in the part, such as in

34

inflammation, gout, and rheumatism,and these will move all of a suddenfrom one part to another. I say,therefore, that these diseases are ori-ginally nervous. Egad ! the pain willbe one instant in one part of the body,and then the-next in another; anddoes not this show that an affectionof the vitality of a part, capable ofsudden shifting and changes, is anaffection of the nervous system? I

say that there is a certain disorder ofthe nerves of the part antecedent todisease in the part. Suppose thatthere is disturbance in any part, youcannot say that it is disease; it beginswith irritation, and therefore I object

. to the word disease in that sense.

Functional disorder precedes any. change in the structure of the part,

but I believe it to be originally nervous.I say to persons who come to me

with weakness of the muscles, spasm,and irritation, occurring in any partof the body, that it is the result of

something wrong in the nervous sys-tem as a whole. I could quote plentyof cases illustrating this, showing thatlocal irritation and disease are theeffect of something’ wrong in the ner-vous system. This is very well ex-

emplified in the complaints which at-tend dentition in children, where thenervous irritation sometimes difior-ders all the parts of the body ; thereare convulsions, weakness of the mus-cles, the arms are turned out andsometimes inwards, and so on. Thelarynx also becomes affected, and ah !persons lose their voices all of a sud-den, all through an affection of thenerves of the part.Then again the nerves of a part

may be influenced by something ope-rating on the trunks of the nervesleading to those parts ; as in injuriesor affections of the spinal column, allthe nerves in the parts supplied frombelow the part of the medulla spinalisinjured, will be deprived of their sensi-.bility. Again, affections of the nervesof the cerebrum may produce localaffections in every part of the body.We cannot conceive disease to bemerely local ; there must always bea plurality of parts affected. Thesubject is one difficult to explain ; butwhat I want chiefly to call your atten-tion to, is, a painful affection of the. nerves of a part called

Tic Doulourpux.It was a rare thing, in the early part

of my life, to see many cases of rlis.ease produced by increased vascularaction, which are now common; andso it is with diseases depending on anundue nervous action in a part; forI do not think there was such a thingas tic douloureux ever dreamt of in mytime. How this comes, I don’t know.There has been a great increase of me-dical men, it is true, of late years, but,upon my life, diseases have increasedin proportion ; that is a great comfort.(A laugh.) As to the disease, it is at-tended with the most intense pain;there is no increased vascular actionin the lip or cheek, for they look asusual ; there is no increased vascularaction generally, nor any error in theabsorbent system ; but, as to the pain,it is most excruciating; ah ! often he-yond endurance. I have seen peoplewith this disease perfectly free from

pain one instant, and who, whilsttalking or doing something else, havebeen suddenly seized with the most

racking and excruciating pain imagi-nable. I remember one young womanin particular, who, when the parox-ysms of pain came on, would tearhandfuls of hair from her head, andrequired three strapping young mento hold her : so tormenting is the pain,so formidable are the effects which itproduces. Well, it is a very curiousdisease ; and some persons have beenled to divide the nerves of the part,but I say, you might as well expect tocure a man with gout of the pain in’his great toe, by dividing the nervesgoing to the toe, as to cure a personof tic douloureux by the division of anerve, In both cases the complaint isperfectly constitutional. You may seea person with gout, who is almost un-able to move with the pain ; but pro-duce a shock on the nervous system,by telling him that the house is on

fire, and he will scamper about like alamplighter. As SMOLLETT tells us,in one of his novels, of Captain Sis-MAGUNDO, who went into a house andcried out to an old gentlemen with the-gout, "Mad dog, mad dog!" when hejumped up, and ran out of the house,even into a pond of water opposite.

In this complaint, one part alone isnot affected; the disease flies fromone part to another, and the division

35

of the nerves does no good. Can it bEcured ? Undoubtedly, if you can tran.quillize the disorder of the nervous

system. But how is this to be done ?

Why, I don’t know, nor do 1 believeany body else knows. As I say to

patients who call upon me with thesekinds of affections, If I could quietirritable nerves, strengthen weak ones,and regulate the distribution of thenervous energy, then I could cure atlthe diseases you would bring to me.This may be wrong, or let it be

otherwise; I know of no other me-dium through which these affectionscan be cured, than that of the nervoussystem ; and I believe, that if th pa-tient be put on a rational plan of

diet, and his digestive organs got intoa right state, these affections will notcome twice, at least if the patient re-main in good health. I have seen

many cases of this kind, and feel

strongly convinced as to the truth ofwhat I say. I once lodged in thecouutry during the summer, where Iused to see a man go by the windowevery day, making all the wry facesin the world ; one day having themouth and chin drawn up, another,grinning like a " Cheshire cat." Now,this expression won’t do for THELANCET. (Here the whole class laugh-ed, in which the lecturer himself

heartily joined.) 1 wondered what allthis meant. At last he called on meone day, because I suppose I was a

London surgeon, to consult me. Hewas a respectabie farmer, and a well-educated man. He asked me whetherit was possible for him to be cured?Most undoubtedly, I told him. Regu-late your diet and bowels ; take a lessquantity of wine than you have beenaccustomed to (for he was iu comfort-able circumstances) ; in short, keepyour system as quiescent as possible.By attention to these circumstanceshe became quite well, as you will seeby the following anecdote, which heafterwards told nie:—"I returned,"he said, "to the country, (for he wasa man of fortune, and farmed his ownestate,) and met a surgeon in themarket, who had formerly attendedme. 1 said to him, Doctor, I will buysixpennywoi th of pears, and lay you abet that 1 eat my half of them beforeyou will yours.’ " Whether he gainedthe bet or not I don’t know, but the

surgeon was astonished, and said tohim, " I thought that you could notventure to eat pears." To which hereplied, "Six weeks ago, I couldsooner have done as Mucius SCÆVOLAdid, thrust my right hand into thefire, than have taken a cold pear intomy mouth." Now, I have seen severalcases of this kind.The most severe case which I ever

saw, was in a physician of this town,who suffered for many years the mostexcruciating agonies, and at last died.The nerve was so cut about, thathe said himself, when he shaved orwas shaved, the skin was quite in-sensible. The pain in these cases is

mostly produced in the trunk of thenerve, not in the branches. I donot myself think division of these ofany use, but rely on the constitutional-treatment of the disease.

I once divided a nerve in a lady’sfinger, for tic douloureux. The painwas so great that she could not put herhand into her pocket; she had crampsof the muscles, and spasms, and in factI was afraid that she would have lock-jaw. The complaint continued formany years, gradually augmentingin severity ; and I thought the case

one to vindicate the division of thenerve. The temperature of the armwas above the natural standard, thepain extended up the whole course ofthe radial nerve, but it began Bfromthe extreme point. I cut down on

the nerve, exposed it, divided it, andtook away three quarters of an inchof the nerve on the second joint ofthe finger. It was a long time beforeshe was physiologist enough to findout that the division of the nerve haddone her any good, for she had all

the pain for some time after, as beforethe operation. The arm above the

part where the nerve was divided wasparticularly sensible, and the painwas referred to the end of the finger,She became, however, a little better;the arm regained its natural tempera-ture ; the pain subsided, and she lostall those general nervous feelings towhich she had for so long a time beensubject. But this unfortunate girt’iied a vear afterwards, of extensivedisease iu the abdominal viscera. Now1 say. that I have seen several cases

! of this kiud, and I am conviucfd that. the treatment of tic douloureux should

36

be constitutional treatment, and suchas is calculated to allay the irritabilityof the nervous system. It seems to

me as truly a constitutional disorderas either gout or rheumatism. In the

physician’s body, whose case 1 men-tioned to you just now, no organicdisease could be found in any part.In many cases which have been exa-mined, no organic change could befound ; the complaint consisted infunctional derangement, and not inany structural change.

Well, I proceed, for you see my ar.rangement is, to speak first of general- diseases, which are named from theirmost prominent character, and then oflocal’diseases, such as affect the vascu-lar, absorbent, or nervous systems ofparts. I shall now speak of those dis-cases which occur generally through-out the body, such diseases as are

found to affect the various structures,as the bones, joints, &c. Here I can-not enlarge on the subject, for myobject in these lectures is to supplythat part of surgery which is not in-cluded in the anatomical course. Itmatters not what I begin with, I mayspeak first of

Tite Diseases of the Skin.And here I may not go into the sub-

ject scientifically, or satisfactorily toyourselves or the public, but J will tellyou what I know about it. The newnames which are used to denominatethe affections of the skin, bother me ;.and I am in the habit of saying of’them as HUDlBRAS says of rlietori-cians : -. For all the rhetoricians’ rulesTeach nothing but to name the tools."But they do not tell you how to curethe disease. In diseases of the skin,many are of the papular kind, otherspustular, and some vesicular. The

eruptions which are red and slightlyprotuberant, are called papular erup-tions, aad are made an order in theclas; of .diseases of the skin. Someend in a hind of suppurative inHam-mation, and arc called pustular erup-tions. Others end in an effusion underthe cutic de, atid are named vesicu-lar. Some. are attended by none ofthese effec, s, but produce au altera-tion in the B, ’LK°>le corering of the skin,a,.xzd are calli deprosy. It is all right

to have these names, for the sake ofdistinction, but persons go farther,and subdivide them into genera andspecies, give them break-tooth and

puzzling names, in consequence of

every insignificant appearance, whichdo not at all signify the nature of thedisease, and are therefore unneces-

sary. They mav lead to nice dis-tinctions of the disease, but if carriedto no ulterior object are of no usewhatever.

’There are causes which act on theexterior of the body, as cold and wet,which weaken the circulation of theskin, that may lead to cutaneous dis-ease ; and many medical men, in orderto keep up a certain degree of energy

’ in the action of the skin,employ tonicsin cutaneous diseases. The decoctionof the elm bark is one very much used.

! But I think the great cause of all va--iatioiis in the states of the skin, is tobe met within the DIGESTIVE ORGANS.CUVIER, speaking of the alimentarycanal, says, that it is an internal sac. of skin, ;that the skin is inflected andt lines the intestinal canal. You may7have perceived that diseases of the

skin arise in general from irritation of

the alimentary ct.nal, making allow-ance that weakness and defective cir-culation may sometimes be the causeof them. The main cause, however,is to be found in the state of the DI-GESTIVE ORGANS. I beg you to re-

mark the strong sympathy which exists; between the skin and the alimentarycanal. Watch the state of the skin atthe time you give an emetic; a fewminutes after a person has taken it,the skin becomes cold and shrivelled,like what is called goose-skin; butas saon as he begins to throw up, theskin is covered with cold clammy, andafterwards with hot burning, sweats;a simultaneous change in the state ofthe skin is taking place with that of thestom’ch. A person shall eat heartilyof muscles, and in ten minutes after-wards the whole skin shall be coveredwith rash. What other inference canhe drawn from these facts, but thatthere exists the greatest sympathybetween the skin and the stomach.You can see no other general causeswhich produce cutaneous disease butdisorders of the digestive organs. It

might be granted, perhaps, that thereexisted a sympathy between the skiu

37

and the lungs. I thought at one timeevidence of this existed—it may be

granted, however; hut the greatmeans of curing cutaneous diseases isby tranquillizing the state of the ali--

mentary canal. I have continuallyobserved in patients with these affec-tions, that as the digestive organswere set to rights, so the cutaneousdiseases were cured. In some in-stances, where the people have hadscabs all over the body, by attendingto the state of the alimentary canal,the scabs have entirely disappeared,and firm sleek skin has been producedin the spots which were covered bythem. But I grant that a deficiencyin the circulation of the skin, pro-duced by exposure to wet, cold, andthe changes of temperature, may becauses of cutaneous disease. Manycases of this kind have been admittedinto the hospital, with various formsof cutaneous disease, and have beenall cured by keeping them in bed,the warm bath, cleanliness, regulatingtheir diet, and paying attention to thestate of the digestive organs. There areother cutaneous diseases which willbe benefited by external applications,and the use of the diluted sulphuric Iacid, but the main object is to set thedigestive organs to rights.

I do not want to speak of cutaneousdisease generally, but only of the Isurgery of cutaneous diseases, of thesurgical app’ications which are ne- Icessary in these affections. Whenthe skin is red, irritable, and coveredwith scabs, what are you to do? Whyyou will be obliged to allow of a freedischarge from the surface of the skin,or else you will never do any good.For this purpose you apply poulticeswith light dressings to the part, andthese soften and remove the scabs.The scabs form a source of irritationto the parts, and the discharge isconfined beneath the scabs, and pro-duces irritation. Poultices soften thescabs, and cieanse the sore of an irri.tating suhstance, when they often getwell. Cleansing the surface then, 1bold to be good ; for if an acrimoniousdischarge is confined to the surface onwhich it is poured out, ee;ad! what can

you expect but that a sore will formbeneath it? To cleanse, to dry, to

amoint, then, are three points to beattended to in those diseases of the

skin which do not require dressings.Where dressings are employed, the

great secret is to cleanse them of theacrimonious matter, and to dry themwell before the ointment is applied.I find it necessary to explain thesepoints well to the patient, on the prin-ciple of common sense. You see

dressings sometimes put on to wet

sores; why you might as well applywater upon a greasy surface as oint-ment to a wet surface; therefore, theparts must first be well dried. Tocleanse, to dry, to anoint, are threepoints to be performed in the treat-ment of cutaneous diseases. In auirritable state of the skin, the princi-ple on which 1 think anointing good,is that, as there are on the surface ofthe skin myriads of follicles or oilbagswhich form the natural ointment tothe skin, so it is deprived of this oint-ment at the time when it is mostwauted.The best medicated pomatum, for so

I call it, is hog’s lard rubbed downwith the liquor pJumbi subacetatis, thisis the name of it I believe ; I mean.Goulard’s extract, in the proportiouof one drachm of the latter to an

ounce of lard. There are many dis-eases of the skin in which the unguen-turn hydrargyri nitratis is of use;it should not he applied too sharp;

two-thirds or three-fourths of lard, toone-third or one-fourth of the oint-

ment. 1 have seen many cutaneousdiseases cured by the unguentumhydrargyri nitratis. Tar ointment andtar water are also good applications.This leads me to speak of washes,which produce certain good effects illcutaneous irritation, a solution of sul-phate of zinc and of Goulard’s ex-

tract are good washes. Also water

impregnated with sulphuretted hydro-gen, by a solution of sulplfucet ofpotass, formerly called hcpar sul-

phuris, and the tar water, frequently: do great good.Affections of the Skin producing

Uleei-s.-Nu%v, there are many ulcersoccasioned by disease of the skin.Tubercles form first, and these pro-duce ulcers ; the ulcers orig inating inthe cutaneous disease. A morbidaction in a part is mtal,liylmd, it

spreads, and becomes an ulcer. Thereis one fornt of cutaneous disease, lsru-ducing ulcer, called the

38

Porrigo Lupina.This begins by a chain of tubercles,

which are in proximity to one another.The feel of the skin is like a cord ex-tending from one point to another, andit seems as if the disease was in theabsorbent vessels. These spread andcontinue till they form a foul sore. Inthe early part of my life, I was taughtthat this disease was sure to be curedby mercury, which altered the state ofthe action of the part. I have seenit used to salivation, and not’cure ; yet I

a certain quantity is useful in this dis-ease, to regulate the secretions, andalter the state of the digestive organs ;with this view, its exhibition will befound of use.Under this head of ulcers, may be

classed the

Herpes Nasi, and Herpes exedensNasi.

The herpes nasi is the ulcer whichbegins in the nose, and communicatesitself to the surrounding parts. Thefirst sore is getting well when anotherclose to the old one breaks out. Thusthe disease, as JOHN HUNTER says,wears itself out in one situation, butthe surrounding’ parts become affectedby it. Thus the healing of the sore inone part shows that the disease is

curable ; and I am persuaded that itis kept up by disorder of the digestiveorgans. I remember a striking caseof this : A woman, whose appearancewas so much disfigured that she couldnot go into service, was admitted as apatient into the Hospital. Being ex-tremely disfigured, and unable to geta place in service, I said to the stu-

dents, you see such and such a case,(alluding to the ulcers of this girl,) forGod’s s sake, let us see what will hap-pen by paying attention to the stateof the digestive organs, and not to

dressings. Well, by regulating her

diet, and the state of her digestiveorgans, the disease was cured; andon going round, the students were

perfectly astonished; for a sore thatbefore was irritable and spreading’had now got quite well. Such was thesuccess of this simple treatment.Now, there is another disease which

disfigures the countenance most hor-ribly, and which now and then comesunder our notice ; it is what is called

Noli me tangere, or herpes exedensnasi. The sore goes on to the de-struction of the parts, till the patientdies. I know no disease of a moreterrific nature than this. So muchfor the treatment of cutaneous dis-eases in general, but I believe thatthey are in all cases kept up by a de-ranged state of the digestive organs.

I shall now speak of some diseasesin particular, and first of the

Itch.

And what is the itch ? it is a vesi-cular eruption which, some say, con-tains a small insect that produces theirritation. I do not waut, however,to discuss this subject. A pimple ap-pears on the surface of the body,which bursts, and the discharge fromit is applied to a new surface onwhich another pimple appears, andso on. Then it begins at a point,spreads all over the body, and some-times forms scabs, in which case it isexceedingly difficult to know whetherit is itch or not. Well, brimstone isan infallible cure for the itch, and indubious cases I often say to the pa-tients, "Tryit"; if it is the itch, it isan expeditious mode, and will cure itin twenty-four hours; and if it is notitch, it will not be made worse. Inthe itch you order an ointment to beused, composed of equal parts of sut-phur and lard rubbed down together,coloured, if you like, with a little cin.nabar, and scented with a few dropsof oil of r03emary. This is the itchointment, and you order a good quan-tity of it to be rubbed in, full half apound at a time, and what 1 say is,Now, sir, all you have to do is to

anoiut your whole person by the fire-side, at. bedtime, with this ointment,particularly the parts affected; then

put on a suit of under garments, goto bed, and remain there till the samehour the next night; then take a,warm bath, clean yourself well, whenall the itch will be gone, but you mustbe very careful to destroy all theclothes which you have before worn.But there are many diseases like itch,but which are not itch, dependeut ondisorders of the digestive organs. A

gentleman came to me and said, thathe wanted to have my opinion as to adisease which he had been told wasitch. If it is itch, be said, it has becu

39

very expensive, for it has already costme 6001. Egad! I said, you have,paid your medical men very liberally.Six hundred pound! At last it cameout, that he had destroyed his whole Iwardrobe three times over. On examination, I found that it was notitch. I gave him some medicines toset his digestive organs to rights, andhe was soon cured. I have seen manysimilar instances.There is another infectious disease,

called

Tinea.

This is a papular eruption whichinfects the heads of children, inocu-lating the surrounding parts, andforming a zone of papular eruption,called the Ring-worm. I have nowto describe the various species of Por-rigo.

I have heard of so many nostrumsfor this complaint, that 1 am quiteweary of them. When the disease

gets to the surrounding parts, youshave the head, wash the sores veryclean, and having well dried them

you apply some simple ointment. Theointment, which 1 order, consists oflard and white precipitate, and is calledI believe, Unguentum Hydrargyri Al.bum, it is made of one dram of theprecipitate to an ounce of lard.feel confident that the stubbles of hairkeep up the irritation in those cases,and, therefore, great attention shouldbe paid to the keeping the head quitebare and free from all hair. Now,where the disease has been of longcontinuance, and is kept up by a dis-ordered state of the alimentary canal,keep away all dressings, and try toput the digestive organs into a soundstate. In these cases scabs form onthe head, and by the discharge -accu-mulating on the head a large mass offilth would be formed, which wouldpuzzle a man to say what was the ori-ginal nature of the disease. I remem-ber a case of this kind, where a largeconical scab had formed on the headof a person, and some physicians saidit belonged to this order, and othersto that, but they all agreed it was a

very curious case, and said we will havean artist to draw it. But 1 said tothe dresser, Simply lay a bread-and-water poultice on the part, and attendto the state of the digestive organs,

! and, egad! before the artist came the’ scabs were gone, and the patient was! cured. (A laugh.) I mention this to showyou, how sores of years’ standingmay be cured by an attention to thestate of the alimentary canal. You areto judge whether what I mention toyou in these lectures is correct, bythe result of your own observations.I only tell you what is the result of myexperience.

LECTURES

ON THE

PRINCIPLES AND PRACTICE

OF PHYSIC.

BY DR. ARMSTRONG.

Theatre of Anatomy, Webb Street.

I LECTURE II.

IN this Lecture I shall notice two

affections, namely,

1. The acute and sub-acute inflam-mation of the Spinal Cord, and itsMembranes.

2. An affection of the Brain, closelyresembling phrenitis, but which, beingdifferent in its pathology, requires avery different treatment; it is whathas been called Brain Fever or Deli-rium Tremens.

Acute or sub-acute inflammationof the spinal cord and its membranesfrequently occurs with inflammationof the brain ; and I am inclined tobelieve, that if in all cases of iiiflani-mation of the brain and its membranes,which terminate fatally, we minutelyexamined the spinal cord and its mem-branes, we should very frequentlyfind the vestiges of inflammation eitherin one or in both of these parts. In-flammation of the spinal cord fre-

quently, however, occurs without in-flammation of the brain ; it happensalso more frequently from peculiarthan from common causes : for in-stance, malaria has a very remarkableieffect upon the spinal cord; so muchso, that I have scarcely ever seen thesplllal cord examined in patients who’

I