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VELPEAU was received with a nearlyequal degree of affection, arising not only !from his popularity, but probably as atestimony of the sympathy so generallyfelt for the ill-treatment he received atthe last concours.

The jury, as we have before said, wasdetermined on the 16th of June, when thepreliminary measures were gone through. eOn the 17th one of the candidates, chosen Iby lot, was accompanied by the jury to the ’,Hotel Dieu, at four o’clock, when he ex- Iamined his two patients, and on returningto the School of Medicine, commenced hislecture about half-past five. This was re-

peated by each candidate in turn, and

composed the first trial., We now propose to give as complete a

view as our limits will permit, of the lec-tures delivered by the principal candidates,and shall then notice the thesis and argu-mentations founded on them, summingup the whole by a review of the anteriortitles possessed by each. In this mannerwe hope to give a good idea of an institu-tion, which, though capable of abuse, is yetaccompanied by high advantages. We e eom-mence with the lecture of M. SANSON.

LECTURE BY M. SANSON.

The two patients who fell to the lot ofM. SANSON were placed in No. 19 SalleSt. Marthe, and No. 12 Salle St. Jean,Hôtel Dieu, and afforded subjects for the

. following lecture !

First Patient.—CARIES OF LUMBARVERTEBRÆ.

GENTLEMEN,The first is a child eight years of age,

of a lymphatic temperament; his skin isfine and white ; the abdomen much de-veloped; the hair light-coloured; in a

word, he presents the characteristics ofwhat may be called a scrofulous beauty.The family of this child is, according toall account, healthy, and he himself hasenjoyed a good state of health until withineight months of the present time. At thatperiod the patient first experienced somepain in the region of the loins, which re-mained for some time ; I cannot exactlysay how long, as the answers of the childwere not very precise upon this point ;the pains were not accompanied by anyfeebleness of the lower extremities, on

symptoms of any organic affection. Aftea few months a tumour made its appear.

ance at the upper part of the thigh, andwas at first accompanied by pulsations,which have since disappeared. The swell-ing gradually increased in size, and is nowas large as two fists united together, occupying the inner and upper part of thethigh. When examined by the hand,there is an evident feeling of fluctuation,and its volume is influenced by the posi-tion in which the patient may be placed-Thus, when the child lies down on hisback, the tumour becomes less tense thanin the upright posture, and if we press thehand flat on the thigh, the contents aredisplaced, and ascend into the iliac fossa ; ;hence we may conclude the existence of alarge cavity filled with a liquid matter. Ishould remark that the skin is not adhe-rent to the surface of the tumour, but ixmoveable on all points of it. The child,as was before remarked, seems to enjoy

’’! still a good state of health; he is not

- affected with diarrhoea or sweating ; his

, appetite is good; sleeps sound ; he walkswithout experiencing inconvenience, andthe affection is as yet completely local. The’ sister of the ward says he has coughed for

the last three months; this led me to ex-

r amine carefully the state of the chest ; on- auscultation we could not discover any,t symptom of the presence of tubercles in_ ! the lungs ; the respiration, on the con-

; trary, was healthy; there was no matityupon percussion at any point of the tho-rax; the only anormal sound was somemucous râle indicating a chronic catarrh,but this was slight, and the expectorationwas not by any means abundant.What, we ask, is the nature of the dis-

ease under which our patient labours ? It

may be laid down as a’general rule, thatwhen you have a tumour presenting itselfat the upper part of the thigh, after a con-tinuance of lumbar or dorsal pains, theexistence of caries of the vertebral columnis very probable. The diagnosis is some-times, however, accompanied with diffi-

culties ; in the present case, indeed, weare assisted by a leading symptom, for wehave a slight gibbosity of the lumbar ver:tebræ, and hence we are justified in con-cluding that the vertebral column is af-

fected ; we should however, in all cases,wait for the formation of an abscess, beforewe give a decided opinion, because, inmany circumstances, as in the case of afall on the loins, accidental injury, &c., we

have often the symptoms of vertebral dis-ease, although no caries exists. But ourpatient was not affected by any accidentof this kind, and the pains commenced

} without any appreciable cause.Let us begin by endeavouring to deter-mine the origin of the disease in the pre-sent instance. Rachitis is a very frequent

534

cause of softening of the vertebral column,

Band this often produces the angular ciir-vature; so much so, that many practitio-ners regard the angular curvature as a

characteristic of rachitis; hence muchdoubt on the origin of the atIection mustexist, until caries has actually set in.But we have to remember that rachitis Ihas a set of symptoms by which it is dis- Itinguished ; it is a general constitutionaldisease, not a local one; rachitic childrenare feeble, and mostly sunk in a state ofabattement and depression of spirits; theyexhibit an indifference to what passesabout them, while, at the same time,there is a precocity of mental powers,which is very remarkable; the gastricorgans are usually affected in this disease;the mesenteric glands are engorged; thechild has often diarrhoea, with a slow fe- ver, or an acceleration of the pulse towardsevening; he is pale, the lower jaw pro-jects, and he gradually gets thin, and pinesaway. Now we remark none of thesesymptoms in our patient; his health hasbeen good, and we have, besides, anotherproof that his affection does not derive itsorigin from rickets, because we find thecharacteristic signs of an abscess by con-gestion. We have, therefore, in the pre-sent case, a formation of pus in the cellei-lar sheath surrounding the lumbar nerves,or psoas muscles, and passing down as faras the thigh, where it presents itself; thismatter is of an inflammatory origin. Wefirst had pain in the part for a consider-able period, and then the formation of pus,which is now making its way to the exte-rior along the sheath of the muscles; thedisease, in a word, is caries of the vertebralcolumn, with abscess bv congestion.But we do not find here the symptoms

which most commonly accompany cariesof the spine. In most cases the diseasecommences by vague pains in some onepoint of the vertebral column; these be-come worse, and the patient soon experi-ences some difficulty or loss in the powerof the locomotive system. Thus, if thedisease commence in the lumbar region,the curve of the spinal column beginsthere, and the patient’s movements are

embarrassed in consequence of the influ-ence which this change of form exerciseson the action of the nerves; the generalposition of the patient is very character-istic of the affection under which he suf-fers ; the head and neck are thrown back,and the legs are bent in such a way as toproduce a most uneasy position. If youremark the child when he walks, thereis no action of the thighs, he seems to

walk merely with the lower leg. Whenthe bodies of several vertebrae are engagedin the disease, the spinal marrow may be

pressed on in a moderate manner, andcertain symptoms, as subsultus tendinum,convulsive movements of the muscles, in-dicate this complication ; the patient feelsa weakness of the lower extremities ; ifhe sit down, or attempt to lift up any-thing from the ground, he is compelled tobend the limbs gradually, and dip downwith a slow motion. The child whom wehad to examine did not present any ofthese accidents ; he walked well, as hasbeen remarked, and did not show any im-pediment of motion.Whence arises this exception from the

accidents usually accompanying caries ofthe spine ? The reason is that he has

several of the bodies of the vertebrae af-fected at the same time ; when one only isdiseased, the curvature which results is! angular, and the pressure exercised on the! spinal marrow is, consequently, more

sudden and violent, giving rise to convul.sion, paralysis, or retraction of the limbs.The compression of the spinal marrow is! not the only cause of the disorders whichwe sometimes witness in the organs of lo-comotion ; inflammation may come in asan accessory cause, extending from thebodies of the affected vertebrse to the

membranes, and from the latter to thespinal marrow itself. We have, therefore,in the present case caries of the vertebra’,and abscess by congestion. The caries

occupies many vertebrse together, for if weexamine the state of the spinal column wefind a gradual bend, quite different from

, the sudden angular curvature when one- vertebra only is destroyed; and this cir-I cllmstance fully explains the little or no

difficulty of motion which our patient ex-periences, his upright posture in walking,and the freedom from all unpleasant ordangerous accidents.! The question now arises, What is the cause’ of the disease in the present case ? The

exciting causes of caries of the vertebral

; column are in general difficult to discover.Our patient’s father is a tailor, and his! children have been accustomed to spend, their time in a low, ill-ventilated shop.3 This may be the origin of the scrofulous affection under which he now suffers, and-although the cause is not very wellsmarked, yet the bad habit of body con-1 tracted by living in an unwholesomeplace, is suflicient to excite the disease.- In what state is the vertebral column, The affection sometimes commences in) the bodies of the vertebrae, and then wea have them only inflamed. If it persist3 for some time, the weight of the body3 begins to act on the altered and softenedbone, breaks it down, and a curvature1 more or less prominent is the consequence.e But in our patient we have not only in.

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ftammation of the hone, bnt suppuration Ialso. The disease is not confined to a

simple ramollissement; the spongy tissue Iof the bones has become fungous, purulentmatter. is secreted by them, and a largecavity exists, filled with that fluid. If wehad an opportunity of examining the stateof the parts which transmit the pus fromthe seat of the disease to the exterior, weshould find a long channel, hollowed outthrough the cellular sheath surroundingthe muscles : the channel is lined through- i

out by a membrane which constantly se-cretes pus, and is called by surgeons puro-generative (puro-genié). In its structureit resembles somewhat that of the mu-cous membranes.Ilow does the disease terminate ? (Here I

M. SANSON entered into an extensive ex- Iamination of the different ways in whichcaries of the spine may end, and of whichwe need give but a very faint outline.)The affection in the first place may goon and become daily worse; the inflam-mation extends to the membranes of the

spinal marrow, and to the medullary sub-stance itself; we have then the develop-ment of a new set of symptoms ; motionbecomes irregular and interrupted, andparalysis is finally established. The pa-tient is now confined altogether to bed,his health is completely destroyed, thelong-continuecl pressure brings on gan-grene of the buttock, &c., and death en-sues. In many cases, however, the puru-lent collection opens by a small abscess inthe thigh; the opening is often very mi- (nute, but this does not prevent the en- <

trance of atmospheric air into the cavity.’. iThe patient soon presents severe typhoid i

symptoms, from the degenerescence of the ’purulent contents of the abscess; his lungs

-

are attacked, and, on examination, wefind tubercles, which perhaps we did notbefore suspect or discover; diarrhoea, nowsets in, and he soon sinks in a state ofexhaustion. In other more favourablecases the termination is of a different Icharacter. The tissues surrounding thediveased and carious vertebrce furnish abony matter, and the destruction of thehard parts is, in some degree, repaired ;’.the pus becomes concentrated and dries,the abscess contracts, and its sheath is i

gradually changed into a kind of canal, Iwhich no longer secretes puriform matter,and is at length totally healed, or theabscess may open externally, and ter-minate like any other abscess in a dif-ferent part of the body; however, in mostcases where the abscess thus opens spon-taneously, it becomes nstulous, or thepatient dies.

Let us now consider the treatmentwhich should be. adopted in the present

case. If we look to the general health of

our patient, we find it very favourable;his constitution is good, there is little or nopain, and we may say that he is in a pro-mising state, and that the affection underwhich he labours is as simple as itis capable of being. He has, in fact,no fever of any kind, he does notsuffer from diarrhoea or hectic perspira-tions, and there are no symptoms of con-stitutional derangement. The pain in thelumbar region has considerably dimi-nished, and the abscess has not yet openedexternally. There are, however, on theother hand, some unfavourable conditionsin the present case; thus, for example, ifthe extent of the caries, by destroying! several of the bodies of the vertebr&aelig;, hasthe effect of preventing any injurious pres-sure on the spinal marrow, yet a greaterquantity of osseous tissue is necessarilyaffected, and the labour of regenerationwill be more difficult or uncertain; and

again, although on examination of thechest we found no signs of the existence

of tubercles, yet, from the child’s generalappearance and temperament, we mayfear their formation at a subsequent, period. Hence the prognosis in the pre. sent case must be guarded, and the

, chances of a cure are, perhaps, less nu-; merous than those of a fatal termination.. Sometimes the caries of the vertebralcolumn is superficial, and we may attack- it with a reasonable hope of attaining ai successful result; but not so in the case

of our patient. The disease has alreadyexisted for too long a time, and the lesionis too profound. What then are we todo? It may be remarked, in the first

place, and as a principle of treatment, thatthe affection is originally an inflammatoryone, and hence the antiphlogistic treat- ment should form the principle we oughtto have in view. When I mention anti-

phlogistic treatment, I do not refer ex-clusively to blood-letting or debilitatingmeasures; these only form a part of it re-garded as a whole. I allude to another

and an important branch, viz., the revul-sive -part, which is included in the termantiphlogistic treatment, and not to thesanguineous, which, in most cases, is not’i to be thought of.

The first means I would employ is the, moxa; this is a most powerful and effi-eacious external irritant, and we may ap-ply it over various points of the spine, soas to multiply the foci of irritation, ac-

t cording to the method recommended by- Baron LARREY ; he has often placedthirty or forty mox&aelig; along the spine, and

this application has been attended witht verv remarkable success.t At the same time that we attack the

536

disease by local measures, we should not’neglect general constitutional treatment. :Our first and principal object should be to ’correct the scrofulous temperament, which iis strongly’marl,,ed in the patient; this isto be done by the treatment with which Ievery one is familiar: the child shouldhave good, nourishing, easily-digested food;he should live in a wholesome atmosphere,exposed to a fresh healthy air; he shouldtake gentle and constant exercise, &c.,and we may aid these means by the ad-ministration of bitters, if indicated.

So much for the general treatment.Now what treatment is applicable to theabscess ? Here a variety of opinions existsamong surgeons: some open the abscess Islargely, and expose the cavity as much aspossible; but this method is liable to grave Iobjections, and is often followed by verysevere and dangerous accidents; however,I find I have not much time to dilate uponthese, as the period allotted to this pa-tient is very fast drawing to a close. Thesecond method is that recommended byBaron BOYER, and which consists in open-,ing the abscess by a single incision, di.rected obliquely, so as to prevent, if pos-sible, the entrance of air into the cavity;but this opening always persists; the at-

mospheric fluid penetrates into the ab-scess in spite of every precaution; andbesides the inconveniences thus produced,we have added those arising from the re-tention of altered pus. M. LARREY pro-poses to traverse the abscess horizontally,from side to side, with a red-hot needle,so as to evacuate the pus, and at the sametime enable him to close the wound im-mediately afterwards.

Finally, M. DUPUYTREN, fearing theaccidents which so frequently result froman artificial opening, has come to the re-solution of leaving them to nature. Thisis a practice which I think we ought notto follow; in permitting the pus to accu-mulate in too great quantity, we run therisk of having an immense abscess, whichmust complicate the case in a very unfa-vourable manner.As for myself, I would either make se-

veral small incisions, or would open theabscess, after the method of BOYER,obliquely, and as the contents becamealtered in quality, would increase the ex-tent of my incision, and lay it completelyopen. There are various other points re-lative to the treatment, which we mightconsider with advantage. But the timecompels me to pass to my other patient.Second Patient.&mdash;LYMPHATIC ENGORGE-

MENT OF THE BREAST.

Our second patient, Gentlemer., was afemale, thirty-seven years of age; she

bears marks of a lymphatic temperamentof body ; several of the cervical ganglia,for example, are tumefied. She has nowinhabited Paris for seventeen years, andduring that time enjoyed a pretty goodstate of health.Some time ago her menses became sus-

pended, and remained so for the space ofthree months, after which the left mammabegan to swell; the menstrual dischargehas since then returned with its accus-tomed regularity, but the breast remainsswollen and engorged ; it became verylarge and hard; this produced consider-able alarm in the patient’s mind, andabout six weeks ago she entered the hos-pital, ready to submit to an operation ifnecessary. We proceeded immediately to

examine the external aspect and relationsof the tumour; the first thing with whichwe were struck, was the regularity of formit presented; the nipple was concealedin the substance of the tumour; the skincovering it was altered in colour, andadherent to the surface of the gland; thislatter body was very hard, solid, and re-sisting to the touch; it did not, however.adhere to the parietes of the chest, for it

could bo moved about in all directions,and raised up upon the hand. On exam-ining the state of the lymphatic systemin the neighbourhood, we found some

slight engorgement in the axilla, and thetraces of lymphatic tumours under theclavicle ; on the right side, the axillaryand subclavicular spaces were perfectlyfree from any swelling, &c. What is thedisease with which this woman is affected?(Here the speaker entered into a minuteexamination of the different tumours whichmay occupy the breast, comparing themwith the case before him, and pointingout the characteristic differences.) Thetumours to which the mammary gland is

liable are numerous, and very different inkind. The present swelling might, for

example, be produced by the presence ofan encysted tumour; but the latter usu-

ally offers a round or globular tamefac-tion, and is not marked by the densityand hardness which characterize the dis-ease before us. It might be a chronic in-flammation of the mammary gland itself,and this is an affection which is very oftenmistaken for scirrhus. There are nurie-rous examples on record, where the breasthas been extirpated for a cancerous affec-

. tiou, which was afterwards discovered tobe nothing but a chronic inflammation.With respect to our patient, we may re-mark that scirrhus is generally develolzedin a slow and gradual manner, while

her disease is comparatively of short du-ration; the scirrhous tumour is also less: smooth and even; it presents a much

537

greater degree of hardness, and is usually 1more adherent; the tumour with whichthis woman is affected is, as 1 said, round,and we do not feel any inequalities on itssurface. The simple adherence of theskin to the subjacent tissues is not suff-cient to prove a cancerous nature; be-

sides, the woman is now quite free frompain of any kind. The sunken appear-ance of the nipple might, at first sight,seem a suspicious circumstance, but wefound the same disposition on the otherbreast. From a review of the symptoms,and a consideration of the history ojthe case, I would say that our patienthas had a chronic inflammation of thecellular tissue of the mammary glandthis has affected chiefly the external cel.lular tissue surrounding the organ, and iis not improbable that the interstitial tissueis also engaged in the disease.The state of the lymphatic ganglia may #

be also taken as an additional proof of the ‘non-scirrhous nature of the disease; theyare not, as we before remarked, affectedwith the degree of hardness peculiar toscirrhus; besides, they do not occupy thesituation which the glands enlarged in

consequence of a cancerous disease of thebreast, usually do. These are commonlyfound situated in the region of the axilla,while the engorged glands in our patient Iwere placed under the clavicle. I there-fore think the disease, in the present in-stance, is a simple inflammation of thecellular tissue surrounding the breast, andis by no means of a cancerous or malig-

‘

nant nature.

As to the treatment, amputation is evi-!dently an unnecessary operation, and not Bto be thought of. The diagnosis is, con-sequently, less grave, and the therapeuticmeans should consist simply in the em- ployment of antiphlogistic measures. A number of leeches should be placed roundthe circumference of the tumour. There isa remark, besides, whicli I had forgottento make, relative to the diagnosis. Thewoman says her breast was larger beforeher entry into the hospital than it is atthe present moment, and that its volumewas reduced by the use of cataplasms;this is an additional argument of someweight against the idea of a scirrhous en-gorgement. 1 would therefore continue

ithe cataplasms, as they have alreadybeen useful, with local antiphlogistics, and Imight perhaps assist their action with theinternal administration of mercurials. Theresolutive power of iodine is well knownto every surgeon; it would therefore he

proper to employ frictions of iodine or

mercury over the surface of the gland;but the former medicine requires to beemployed with care, as it often produces

very considerable irritation of the skin.

) General warm-baths might be advantage-ously administered, and, finally, compres-! sion. (Here the speaker entered intoseveral practical considerations on theimportance of compression.) This is ameans of the utmost utility in obtainingthe resolution of several tumours, and hasproduced excellent effects even in cases ofcancer. Where the case is nothing but a

lymphatic engorgement, compression maybe used with wonderful success ; the man-ner of employing it is simple, and we can-not follow a better than that proposed byM. RECAMIER, by whom it was first in-

troduced to the notice of practitioners. Itis necessary to remark, that we should hecareful in managing the compression andwatching its effects, especially in cases ofscirrhous engorgement, otherwise we mayaggravate the disease, and hasten the can-cerous degeneration of the tumour. The

utility of this method is, as I have said,decided; I have seen engorgements, hav-ing many characteristics of scirrhus, com-pletely dissipated hy compression.Here the president announced to M.

SANSON that his hour had terminated.(To be continued.)

THE LANCET.

London, Saturday, July 5, 1834.

DUBLIN-COLLEGE WITNESSES.

IN a recent notice of medical affairs in

Dublin, it was stated that an attemptwould probably be made by the College ofSurgeons of that city to prevent the exa-mination of Mr. READ and Mr. TAGERT

before the Committee of the House of

Commons. It was also stated that those

gentlemen were selected for this duty bythe heads of the College itself; and thatan apprehension that their evidence

might not precisely correspond with theobjects for which they were appointed,

was the cause of their contemplated de-t tention in Dublin. With respect to thewishes of the College on the subject, thiswas quite correct. The College has, how-’ ever, adopted a plan for carrying its

; i intentions into effect, somewhat different

from that which we anticipated it would