No. 505.

LONDON, SATURDAY, MAY 4, 1833. [1832-33.

CLINICAL LECTURES ON SURGERY,DELIVERED AT THE

HOTEL DIEU, PARIS,BY

M. LE BARON DUPUYTREN,

During the present Session, 1832-3.[Revised (before translation) by the Baron himself in the

fasciculi of his " Lecons Orales de Clinique Chirur-gicale," published periodically by G. Bailliere, Paris.]*

* The present number, or " fasciculus," was

published in Paris on Saturday last, 27th April.

ON ERECTILE TISSUES.

Their Anatomical and Physical Characters.THE occnrrence, in the morbid state, of

the very remarkable tissue which I havetermed the erectile, had never been ascer-tained until I made it known and describedit in my lectures on pathological anatomy.

In the normal state this tissue is metwith in the genital organs of the majorityof animals of both sexes, especially in theurethra, the corpora cavernosa, and theglans ; on the head and neck of a greatnumber of the gallinacese, on the buttocksof several apes, and elsewhere in manyother animals. It is of a red colour, ofvarious shades, and of different consist-ence, according to the condition underwhich it is observed. Its temperature ishigher than that of the other tissues. Itis provided with a fibrous and elastic en-velope by which it is limited and circum-scribed, and its development limited orpermitted. Internally it is based on co-lumns of fibres interwoven with each other,and forming a net-work which gives firm-ness and support to an infinite number of Iarterial capillaries intricately involved witheach other, and scarcely susceptible of in-jection without being lacerated, of capil-lary veins still more difficult of injection,and of nerves that impart to this tissuea sensibility which is the primary sourceof its properties and distinctions. This

erectile tissue is filled with arterial blood,the material and immediate agent of thedifferent functions which it fulfils. Lastly,scarcely developed in infancy, when itsfunctions are not yet aroused, this tissueacquires its greatest development at theepoch of aptitude for procreation, one ofthe chief agents of which function it be-comes. In debility and disease it loses itsredness, heat, sensibility, and other pe-culiar properties, and in old age it is al.tered, withers, and changes its nature.

This tissue is the type and model ofa multitude of accidental tissues, whichoriginal or acquired vices of organisationmay give rise to in almost every part of ourbodies, producing tumours of various vo-lumes, which participate more or less inthe properties of the natural erectile fa-

bric, differing chiefly in the comparativeweakness of their fibrous sheath, and morescanty supply of nervous branches. Theskin and subcutaneous cellular tissue arethe special seat of these morbid produc-tions, which nevertheless are always metwith in every other part of the system,and especially on the face and cranial in-teguments. They form the base of themajority of the spots and tumours termed" envies," longing or mother’s marks (nsevimaterni). Sometimes an entire organ isthus invaded; I have thus seen the wholeof the concha of the ear, and a portion ofthe adjacent parts, converted into a trueerectile organ. In other cases these pro-ductions are situated either in the inter-stices or in the actual substance of variousparts. Sometimes they seem to be theresult of the degeneration of a naturaltissue, and the dilatation of its capillaryweb, while in other persons they seem taform absolutely new organs, developedamong other parts. In the former case

they are thoroughly confounded with thehealthy structures; in the latter they areseparate, and compress them, and are

rendered distinct from them by the inter-position of a moderately light cellularenvelope, by which their periphery is cir-cumscribed.The accidental erectile tissues are red-

dish or brownish, ordinarily granulated on

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their surface, and implanted in the skin, thesubcutaneous cellular tissue, or among themuscles. Their form is that of collapsedor projecting tumours, and the skin whichcovers them is sometimes scarcely altered.They are the seat of movements isochro-nous with the arterial pulsation, and

pressure reduces them to a very small vo-lume. Habitually soft, the least irrita-tion renders them tense, and remarkablyswollen. If cut into, hemorrhage is ex-

cited, which it is often very difficult toarrest. These erectile tissues do not dis-

appear spontaneously, their tendency be-ing, on the contrary to increase. Likethe natural tissues of the same character,these also undergo, at the same epochs andby the influence of analogous causes, a

strongly-marked development, or alter-natives of tension and relaxation, corre-sponding with the state of health, ofstrength, or of debility, in the individualaffected.

Treatment of Erectile Tumours.Several plans of treatment have been 1

employed for these tumours. I shall con-fine myself here to the subject of their com- Ipression, cauterization, ligature, and ex- itirpation.

CASE I.-Erectile Tissue; Aneurismatic Di- I

latation of the Arteries of the Ear, Temple,and Occiput.—Ligature of the Carotid Ar- jtery. ID--, setat. 20, was admitted to the

Hotel Dieu on the 9th of April 1818. Hewas of weak constitution, tall stature, thin,and bilious. He was a cart-maker bytrade. When born, he clearly showedtwo little alteratic--qs of the skin, such asare commonly called " wine marks," onthe external fold of the concha of the

right ear, which, however, was not deform-ed, and merely seemed a little larger andthicker than natural, where the spots ex- isted. Slight itching was the only incon-venience they occasioned. This itching,however, often led to the excoriation ofthe part, and the consequent efliusion ofblood of a florid colour. He continued inthis state until the age of twelve, when,simultaneously with the development cfthe genital organs, the ear increased insize, and the colour of the spots changed,from red to violet. Three years later it Ihad doubled in dimensions, and pulsations were then first noticed. In eight monthsafter their occurrence, a first hemorrhagetook place, occasioned by an attempt toforce his hat from his head, and the flow ofblood was only stopped by very carefulcompression. It enfeebled the patient, andcaused a transitory decrease of volume andabatement of pulsation in the tumour, but

the ear soon regained its former state. Hewas-now obliged to abstain from all theamusements of his age, as vigorous exer.cise, or any indulgence of diet, led to theincrease of the swelling and its pulsa.tions. Compression with a light cap wasthen tried, but its effect was merely tran-sitory, and ceased when the compressionwas removed. In some time after, a se-cond considerable hemorrhage took place,spontaneously, which, however, subsidedof itself. £ A surgeon then recommendedthe application of compresses steeped inastringent fluid, which was done, but withno advantage, for a third hemorrhage soonafter happened. Some months later therewas a fourth, which was arrested by agaricand compresses.

It was remarkable, that in all these he-morrhages the blood, although vermilion,and evidently arterial, did not escape byjets, but in waves, and as it does from acut fungus hæmatodes. Terrified at these

repeated accidents, the patient entered theHospital of Sens on the 5th of August1817. The affected ear was then threetimes larger than the other, was of thethickness of a finger, and the scalp of thesame side presented numerous little tu-

mours of the same character. MM. Po-puius and Retif, the directors of the hos-pital, first tried compression on the courseof the arteries of the ear, temple, and occi-put ; but the patient being unable to endurethis, they decided to attack the malady byligature, and, to practise this operationsuccessively on the temporal, anterior au-ricular, and occipital arteries, an opera-tion, based on one performed fifteen yearsbefore at the Hotel Dieu of Paris, and theobject of which was, to intercept, succes-sively, all the sources of blood by whichthe tumour was nourished. The ligatureof the first of these vessels diminished alittle the volume of the ear, but the pulsa-tions continued, though their impulse wasnot so great. The edges of the woundwere brought together and kept in contact,and the ligatures came away from the 12thto the 14th days.Twenty-one days after the first opera-

tion, a hemorrhage suddenly occurredfrom a little opening in the helix, whichhad never been healed after one of the

early ruptures. Strong compression suc

ceeded in overcoming it. The blood wasred, and arterial, as at first. In a fcw daysmore, there was a sixth hemorrhage fromthe same place. On the 23th day, a gan-gre.zsgrensus eschar, the size of a silver* crownpiece, formed between the helix and anthe-lix. This eschar fell off’on the 35th day. On

) *- 11’e use this and similar expressions, in orderto assist our foreign readers.—ED. L.

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the 43rd, the occipital artery was tied, but Iwith no better results than attended thefirst operation. Finally, still pursuing thedisease, the practitioners I have namedattempted the ligature of the external ca- rotid artery, the common source of all the ’,arteries of the ear, temple, and occiput.It seems certain, however, from the ac-’ count they themselves have sent me, thatthey tied, not the external carotid, but the,origin of the superficial temporal, whichwas extremely dilated. However this may be, the operation was neither more norless advantageous than those previouslyperformed, and the patient quitted the Ihospital of Sens after a stay of threemonths. Having returned home, and soon finding all his symptoms aggravated, he then sought admission in the Hotel lDieu of Paris.

On admission here, the symptoms werethe same, increased in intensity, with thosealready described. It was found, then, ’,that compression on the primitive carotidartery suspended all pulsation in the tu-mour, and caused its collapse and decolo-ration. Moreover, the patient’s health wasvery good, and he made ro complaint.He heard well with the diseased ear. Suchwas the condition of, our young patient.His affection, however, was by no meansa simple one. The eye and finger enabledus to distinguish in the diseased mass twovery different elements, which are some-times combined, but are generally sepa-rated in the maladies they produce. Thefirst occurred in the form of large, sinuous,unequal, knotty, full, and compressibleconduits, creeping on the temple and ear,to which they gave a knobbed aspect,arising one from the other, like arterialramifications, as large as the little-fingerin the greatest, and as a crow-quill in thesmallest, branches, which could be tracedinto the substance of the skin.

The origin, situation, direction, and di-vision, of these vessels, and, above all,their pulsations synchronous with thoseof the heart-the violence of which seem-ed every moment to threaten lacerationand dangerous hemorrhage, sufficientlyindicated that they were formed by thearterial system of the ear, temple, andoccipital region, dilated beyond measurein its trunks, branches, and finest cuta-neous ramifications. ’ Everything elsewhich in this singular malady did not

immediately belong to the arterial dila-tation, was formed by the erectile acci-dental tissue described at the commence-ment of this lecture. This second elementof the disease in the case before us, filledup the spaces in the arterial net-work,imparted to the parts. affected their violet

colour, elevated temperature, and doublemovement of expansion and collapse.The consideration of the history of the

case, and of the instant condition of the

patient, decided me in the opinion thatthe ligature of the carotid artery was theonly plan which offered a probability ofsuccess. Nevertheless 1 entertained the

presentiment that this operation woulddo more to remedy the aneurismal dilata-tion of the arteries than the new erectiletissue, and the event fully justified this

opinion. The primitive carotid artery was

thus tied, however, on the 8th of April:-

! The patient being placed in the hori-zontal posture in bed, an oblique incisionwas directed from above downwards, and! behind forwards along the inner edge ofsterno-mastoid muscle, to the extent ofthree inches. The cellular tissue was di-vided cautiously with a bistoury, guidedby a grooved sound ; the sterno-mastoidheld aside by one assistant, and the larynxmoved to the opposite side by another.The artery was now laid bare, and care-fully isolated from the jugular vein andconcomitant nerves. A grooved soundwas next placed beneath it, and a singleligature, formed of four threads of flax,waxed and disposed like a riband, wasglided along the sound and below the

artery by means of a needle-shaped stylet,which, with the director, was then with-drawn. In no other artery is so muchcaution required, in the separation of con-comitant nerves and vessels as in the ca-rotid, on account of the organs to whichare distributed the nerves which surround

’ it-namely, the heart, the lungs, and thestomach, the action of which mav be in-stantly suspended, or deeply and imme-diately altered, by the ligature of the nervesin question.

It was easy to perceive at this stage ofthe operation, that on pressing the arterybetween the point of the index finger andthe ligature, the ear collapsed, and its

pulsations ceased, without producing theleast embarrassment of the functions ofthe important organs awhile since men-tioned. This test was several times re-

peated, after which the ligature was

finally tightened. At this moment the

patient experienced intense pain in a

small molar tooth of the right side, whichdid not exist before the operation, andwas certainly determined by it, though itis impossible to explain how..The volumeof the ear was not quite so much dimi-n;shed as we expected, doubtless owingto the retention of the blood in the areolæof the erectile tissue. The patient wasdressed, compresses steeped in Goulardsolution were applied to the ear, and

charpie placed between it and the head.

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In the operation itself, but a few seconds break the plaster mould to pieces, and se-were employed. Nevertheless the patient, parate it from the temple to which it ad-fatigued during the day by the incessant hered. I now devised another apparatus,questions of indiscreet pupils, was, in the from which I expected better success. Itevening, attacked by violent headach, was a kind of double hinge which couldand he vomited his bouillon. Bleeding embrace the ear, and be compressed towas consequently performed, and some any extent by knots, fixed by a strap totorpor of the arm of the opposite side the head. But this, though more effica-having been noticed, foot-baths, impreg- cious than the plaster, was still equallynated with mustard, were directed. Next unsuccessful in effacing the erectile tissueday the headach was less, but the ear which survived the arterial pulsation. Towas painful, as if pricked by needles, and cure this part of the disease, the tissue it-the patient again vomited a bouillon. The self was either to be removed, or its or-functions of the brain, heart, and lungs, ganization changed. The extent of thewere, however, untroubled. (Absolute diet, affection was here, however, too great toSeltzer water, and foot-baths, as before.) allow of extirpation, and to change theThird day, headach gone, no more vomit- nature of the tissue was beyond our power.ing, functions of sight, taste, hearing, and We, therefore, determined to leave to it-smell, quite perfect. No pulsation in the self the erectile affection, which, when un-tumour, or in the temporal, auricular, or accompanied by the arterial arrange-occipital arteries. The volume of the ear ments we had succeeded in removing,was diminished, but it was red and hot. occasions but very slight inconvenience.It was exactly compressed. This case is of the utmost interest inOn the fourth day a soup was taken every point of consideration; it demon-

with pleasure, and without any inconve- strates the facility and freedom from dan-nience. On the fifth, the first dressing ger of the ligature of the primitive carotidwas removed, suppuration was established, artery, and proves the efficacy of this ope-and the wound was dressed simply. On ration in the aneurismatic affections of thisthe sixth, the patient was doing very well, vessel. It shows that if the ligature of thethe ear merely causing some stingings, carotid is not equally effectual against thebut free from pulsation, and more col- morbid erectile tissue, it at least controls itslapsed. Tenth day it was diminished progress and diminishes its dangers. The

by one-third. The excoriation, which sequel of the case is, moreover, before us.before the operation used to bleed, now In fifteen years after the operation, D-suppurated well. In the evening, fever, presented himself at the Hotel Dieu, inheadach, and dyspno2a, for which a vene- February 1833. Since the ligature of thesection was practised. Eleventh day, the carotid artery, the tumour of the ear hadbad symptoms of yesterday all gone. made no progress. There had been no

Twelfth, the ligature has fallen off, with- hemorrhage. He suffers no inconve-out hemorrhage, having cut through the nience except when he takes severe exer-parietes of the artery. cise, and this he carefully avoids. In thisOn the 18th day, the erectile tissue, case, then, the operation has been indis-

which had previously diminished, seemed putably beneficial; but we cannot, how-to have resumed a movement of expansion ever, deny that under a vast number ofand retraction, although no beating was circumstances it has totally failed. Thisperceived in the adjacent arteries. Com- depends on the intercommunication of

pression was exactly applied to the ear. vessels proceeding from various trunks,30th day. Movements perceptible to and the development of further anasto-

the eye.-43rd. The ear which for several moses after the operation. Still, howeverdays had been compressed between two uncertain this be, I think it should be em-masses of charpie was exposed. Slight ployed whenever the erectile tumour is somovements were visible, but only in some situated that neither cauterization, com-points. No pulsation in the temporal pression, nor extirpation, can be practised.artery. In the evening dyspnoea, with I should add, too, that when the erectilehard and frequent pulse. Twenty leeches tissue is not combined with carcinoma, theapplied to the thorax.-44th day. Pa- disease increases with less rapidity aftertient better. No more pain of the chest, the operation.and wound of the operation entirely healed. ,-

I now made an attempt to apply a more CASE 2.-Erectile Tumour of the Lower Lip.uniform pressure, by the application of —Trial of Compression.plaster of Paris, after evacuating the ear Compression has been recommended inby continued manual pressure. My ex- the treatment of these cases. The major-pectations were, however, disappointed, ity of practitioners, however, reject it, fromfor so enormous was the force of expan- its want of exactness, the violent pain it

sion, that three times successively did it always excites, and the fact of its some*

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times occasioning local inflammation, and well as the surrounding parts ; there wasan immediate increase of the disease. We even reason to dread an affection of thecannot adopt these opinions, which are bones. The tumour on the thigh wascontradicted, as a general assertion, by double its original size, but free from ulce-numerous examples of cures so obtained. ration. Amputation was first thought of,Thus, in six weeks, a child I attended was but fear of a relapse, and the tumour ofcured of one at the angle of the eye. It is the thigh, led us to prefer cauterizationthe method, too, which I shall pursue in with the acid nitrate of mercury, in orderthe case now before us. This man, aetat. to change the nature of the ulcer, and leadabout 40, was in very good health, when, to its cicatrization.about nine months since, he received a On the 7th of March this operation waskick from a horse on the lower jaw; first performed, and the surface of the coresoon after a little tumour showed it- touched with a hair pencil steeped in theself on the lower lip, and quickly in- acid nitrate of mercury. The cauteriza-creased in size. An able surgeon whom tion was painful, and did not seem to pro-he consulted tied the two coronary arteries duce any very good effect, for next morn-and a branch of the labial. The tumour ing the ulcer was still more like hospitalfirst diminished, but soon regained its ori- gangrene, and the eschar soft, greyish,ginal size. The compression we propose and foetid. Nevertheless, a second caute-to exercise will be applied by a kind of rization was practised on the 14th ofdouble valve, like a pair of castanets, which March, with somewhat better effects. Anwill embrace both sides of the lip, and the abscess now’supervened in the upper partpressure of which can be regulated by a of the right thigh, and obliged the suspen-screw. If this plan do not succeed, we sion of the process, which was resumed onwill extirpate the tumour. the 9th of April, and continued every fifth

CnsE 3.—Ulceration from Erectile day to the ninth turn. The success sur-CASE 3.—Ulceration from Erectile Tumours passed our expectations, and by the end of

oj’ the Foot and Thigh.—Treatment with May, the ulcer of the foot was healed.Caustic. Other phenomena were meanwhile pass-Caustics are sometimes beneficial, as the ing in the thigh, the tumour of which, af-

following case will demonstrate. Mr. ter the fifth cauterization of the foot, hadWardrop also advises this method, which become ulcerated, and the ulcer seemed tohe deems capable of producing an ulce- advance as that of the foot cicatrized. Anrative inflammation in the tumour, which issue was now made in the arm, and cau-effects its destruction. terization employed with the second ulcer,A child æt. eight months was born with which was cured by five applications. On

two red spots, one of which occupied the the 25th of July she was quite well.entire dorsal surface of the knee, first me- The destruction of erectile tumours bytatarsal bones of the left foot, and extended chemical caustics may thus be sometimesbetween the two first toes to the plantar effected; but this mode of cauterizationsurface of the foot, an inch of which it is far less certain than the actual applica-involved : the other was situated towards tion of a hot iron, which constitutes onethe external and middle part of the left of our surest methods. This, however, isthigh, and was of the size of a franc piece. rarelyresorted to, on account of the terrorThese tumours remained stationary for it excites, and because excision acts with

.

some time, but at the third month, that of equal efficacy and less inconvenience. Wethe foot increased in size, and superficial may, however, have recourse to the actualulcerations showed themselves between cautery when the tumour is too extended,the toes. At first no hemorrhage occurred, too thin, too much combined with thebut the general health soon became im- healthy tissues to permit its extirpation.paired. The ulceration extended to the The bistoury then is the most certainsole of the foot, and after five months’ method which can be used. In some

progress, the child was sent to Paris in cases scissors are sufficient. We should inthe following state. A fissure existed be- this operation not lose sight of the fact,tween the toes continuing to the sole of that the further we go from the morbidthe foot, being about two lines deep, with tissue, the fewer vessels have we to tie,a greyish, flaccid, and fungous surface, the danger of hemorrhage being great in thewith elevated, turgescent, hard, and violet- event of cutting the morbid tissue. Whencoloured edges, formed of the remains of situated on an isolated part like the fingererectile tissue. The ulceration resembled, or lip, milder means having been em-in fact, hospital gangrene, and its sub- ployed without success, we may remove estance was apparently composed of dege- with the tumour the base which supportsnerated erectile tissue and cancerous mat- it, as we do for cancerous ulcers, and thenter. The purulent sanies was dread- reunite the edges of the wound. Erectilefully fetid; both the toes were swollen, as tissues having a remarkable tendency to

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reproduction, we should in our operations I This tumour had appeared early in life,take the utmost care not to leave the advanced slowly, and without pain. Four.smallest portion behind. Observing this years previous to his admission lie re-

rule, I have removed tumours of this kind ceived several blows on it; and a surgeon,from almost every part of the body, and then consulted, made an incision whichwith constant success. gave issue to pure blood. Since then no

[The following analysis of some cases accident occurred until a few days beforethus treated will illustrate all the practical admission, when a quantity of earth fellpoints desirable to be studied.] upon his head. The disease, in fact, was

evidently incurable; nevertheless, on theCASE 4.—Erectile Tumour of the L’ip.— repeated urgings of the patient, an ex-

Exeisima. ploring puncture was performed, whichThe first cited was a child at eight. The afforded arterial blood, but the hemor-

erectile tumour was on the lower lip and of rhage was readily arrested. In a few days,the size of a bean, its base apparently ex- however, fever, nausea, vomiting, and

tending into the muscular substance of the pain, supervened. On the fourth day, anlip. The age and indociiity of the child erysipelas of the scalp, face, and right sideprecluded the treatment by compression. of the neck, appeared, with a small con-The operation of excision was accordingly tracted pulse. On the eighth, the erysipe-performed. By means of a straight scis- las extended to the upper part of the chest.sors, two rectilinear incisions were made Having rallied from this immediate at-in the form of a V, the apex towards the tack, he was doing pretty well, when,base of the lip, and the wound was subse- on the twenty-first day, hemorrhage oc-quently united by two needles and a con- curred, and the fever reappeared. The

necting suture, as in the operation for legs soon became infiltrated, he fell intohair lip. In thirteen days the patient was delirium, and died on the thirtieth day.discharged, with the wound neaoly cica- In order to examine the tumour moretrized. The little tumour, when cut into, completely, an injection was pushed intowas exactly like the spongy portion of the the carotid artery, which in a few secondsurethra. filled the cells of the tumour, and returned

by the jugular vein. Another injection,CASE 5.—Erectile Tumour of the Scalp urged by the veins, rendered sensible aNeck.—Exploring Puncture; Erysipelas; great number of very large veins on theHemorrhage ;° Death.—Examination of the surface and in the vicinity of the tumour,Tunzour.-Serotis Cyst irz the Skull, entirely which dissection showed to be composeddestroying the Rig.’2t Lobe of the Cerebel- of two very distinct parts. One formed aliini, without signs during life. considerable mass, presenting three dif-The next case was a very striking one. ferent tissues; lst, reddish, like the mus-

A man, ast. 40, had at the right side of the cular fibre, but extremely friable, and de-head, a tumour which covered a portion void of linear disposition ; 2nclly, a fibro-of the parietal, frontal, occipital, temporal, cellular tissue, forming the greater part ofand mastoidean regions, and the upper the tumour, infiltrated by serosity, tra-

part of the lateral portion of the neck. versed by large veins and much smallerProjecting about two and a half inches in arteries; 3rdly, in some places a fibro-its centre, it declined gradually towards cellular tissue, redder and more vascularits circumference, and was all over covered than the second. It was in the hetero-with hair, like the scalp. On shaving the geneous mass that the abscesses hadhead the skin was found healthy, and di- formed—the red and villous parietes ofvided into three portions, one, superior which, had supplied the hemorrhage ob-and anterior, separated from the others by served during life.a transversal line, seemed formed by an The second part of the tumour, muchorganized matter of sufficient consistence smaller than the former, occupied the mas-a second, in the centre, offering indistinct toidean region, and was only the appen-fluctuation; and a third, lowest down, agi- dix of one still larger, situated within thetate by movements of expansion and con- skull, and jutting onwards through thetraction synchronous with the systole and opening observed during life. This tu-diastole of the heart. The most atten- mour was a serous cyst, developed in thetive examination did not enable us to dis- substance of the right lobe of the cere-cover in the other parts of the tumour bellum, which lobe had entirely disappeared.similar movements. Posteriorly, on the It was united to the inferior occipitalmastoidean portion of the temporal, all fossa by cellular and fibrous adhesions.irregular opening, armed with bony points, Its cavity was intersected by vertical andwas perceptible to the touch. We thought horizontal partitions which gave it a eel-also that we could perceive an alteration lular aspect. The cells were filled withQf the zygomatic arch., . serosity, and membraniforrn remains, sus-

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pected to proceed from the death of somehydatids. Besides these leading diseases,it was found that the zygomatic bone hadbeen dislocated from the external angularapophysis of the frontal bone, and that it ihad experienced a fracture which had be-come consolidated. The veins adjacentto this bone were all varicose, and formedby themselves a soft tumour which ex-isterl in this situation.

It cannot be denied here, but that thecerebellar cyst preceded the other dis-eases, and that the pulsatory motions wereproduced by its projection externally, butit is difficult to understand how this ex*

traordinary lesion could destroy an entirelobe of the cerebellum without occasioningany alteration in the cerebral or generalfunctions.

CASES 6, 7, 8, 9.—Erectile Tumours on theFace and Head.—Excision.

The next case was remarkable for thedifficulty of its diagnosis. The tumourwas situated in the furrow which separatesone cheek from the nose : it was the sizeof a nut; free from pain; no change ofcolour of the skin; diminishing in volume,though not disappearing, when compressed;devoid of pulsation; and containing in itscentre a hard nucleus, which occasionedpain on pressure. It was manifestly eithera lipomatous or an erectile tumour. The

operation could alone decide, and it was

accordingly extirpated with great care.

There was considerable hemorrhage ar-

rested by compression. In the subsequenttreatment the nitrats of silver was veryfrequently and freely applied, and in fiveweeks the patient was well. The tumourwas of the erectile kind, and the hardnucleus alluded to was composed of bonymatter.

In three other cases excision was alsoperformed with success. The first was achild, xtat. two years; the tumour smalland pediculated, and situated at the ex-ternal commissure of the left eyelids. Itwas removed with a curved scissors, andcured in eight days. The second was acase of small erectile tumour on the head,precisely where the hat should be placed.Excision remedied the evils it gave rise to.The third case was a tumour of the lowerlip, which was cured by excision in eightdavs.

If extirpation is in the majority of casesthe best means of curing these erectile tu-mours, we still should not resort to theoperation when the tumours are stationary;free from pain, and occasion no incon-venience.

This tissue, which is often congenitalmay supervene without known causeor be provoked by external violence o

continued pressure. It developes itselfas I have said, in all parts of the body,but especially in the lips, doubtless on ac-count of their spongy and vascular texture.They have been seen on the fore-arm,arrn, thigh, scalp, ear, cheek, labia ex-

terna, in the substance of the skin, mus-cles, periosteum, bones, kidneys, liver, &c.Lastly, they may successively invade anentire limb, as in the case of Lemortier,in which the skin, muscles, and bonesthemselves, were affected, from the fingersto the shoulder.

CASE OF

ALVINE CONCRETIONS

DISCHARGED THROUGH THE

PARIETES OF THE ABDOMEN.

By FREDERIC GRANGER, Esq.Surgeon, Bristol.

ON the 20th of November 1831, 1 wasrequested to visit Mrs. W., a widow lady,aged forty-two years, of spare make anddelicate habit, residing about four milesfrom Bristol. I found her suffering in..tense and continued pain in the abdo.men, more particularly in the right iliacregion, increased by pressure, with thirst,heat, anxiety of countenance, a hardquick pulse, vomiting, constipation, inshort, presenting every character of acuteenteritis.

I learned that in the afternoon of thepreceding day, she had returned from awalk, cold and shivering, with slightspasmodic pain at intervals in the partparticularly referred to, which had con-siderably increased during the night, with-out any remission for some hours before Isaw her. My inquiries respecting her dietdid not elicit any error committed. Theliberal and repeated abstraction of bloodfrom the arm (which was highly cuppedand buffy), the application of leeches tothe abdomen, with aperients, injections,&c., and rigid antiphlogistic treatment,removed the acute stage in a few days,and in about three weeks my patient (al-though very much debilitated) had lost the.more urgent symptoms, but still com-

plained of some degree of pain and ten-derness in the part originally affected,and on minute examination a tumourdeep-seated was sensible to the touch.The occasional application of leeches af.forded temporary alleviation, but the tu-mour gradually increased, accompaniedby rigors and frequent lancinating pains,indicating the formation of matter. Alin-