rine hemorrhage should be controlled by rest in the recumbent posture, cold application to the hypogastrium, and the internal use of the acetate of lead.

When any of these tumours pass through the os uteri into the vagina, they may be removed by the ligature or by the knife. If the root is soft and slender, the tumour may easily be twisted off by the forceps. In the course of the last twenty years, Dupuytren states, that he has removed two hundred uterine polypi by excision. Hemorrhage has only occurred twice in all the cases, and in both instances it was permanently arrested by the tampon. In eight or ten cases, after the application of the ligature, death took place from the absorption of pus into the system.

Where the root of a tumour is large and vascular, I am of opinion that a ligature should previously be passed around it, at as great a distance from the os uteri as is compatible with the removal of the disease."

132.

This paper is a highly valuable one, and deserves attention. As the talented author is now lecturer on the practice of midwifery in the school of St. George's Hospital, the pupils of that school will enjoy the advantage of receiving the lessons of one of the most philosophical professors of midwifery in this country.

IV. CASES OF WARTY TUMORS IN CICATRICES. BY CESAR HAWKINS, Esq. Surgeon to St. George's Hospital, and Lecturer on Surgery in the Hospital School.

This is the second paper of the volume. Mr. Hawkins very properly points out the confusion that arises from the vague signification attached by various persons to the term malignant. A morbid growth or morbid alteration of structure may be incurable, that is, may be incapable of those actions that lead to its removal. Another morbid growth may not only be incurable, but may contaminate contiguous or distant parts through the me dium of absorption or the absorbents. It is clear that the two conditions are widely separated, and ought to be so. But in practice, the same term, malignant, is too frequently applied with the effect of confounding or des troying the distinction.

But morbid changes of structure are not simply incurable without contaminating neighbouring parts, and malignant by contaminating such parts and the general system-they sometimes possess the power of contaminating contiguous structures, but not of poisoning the system at large. As Mr. Hawkins justly observes

"We want some word for those diseases which do form a new structure capable, apparently, of contaminating the surrounding parts, so that the removal of the whole of the altered structure is necessary, but which do not, as far as I know, produce any contaminating influence upon the absorbent glands, and have no tendency whatever to reappear in a distant and unconnected part of the body. Such a disease is familiar to most surgeons in the skin of the face of elderly persons, and is often, but I think erroneously, called cancerous and malignant, since if the new structure at its basis be completely taken away, there need be no apprehension of any return of the disease, either in the same part or else where or at least if the new structure really possesses the nature of cancer, it must be clearly understood that the disease is cancerous and malignant in the very lowest degree. Of this kind also is the disease which I purpose to describe by the recital of a few cases which have fallen under my observation, and which, as far as I know, is not described in any surgical writings." 21.

"

If we recollect rightly, Sir B. Brodie published a case of the disease Mr. H. is now describing in the London Medical and Physical Journal. It was facetiously styled in some of the medical journals of that time, "a case of cat-o'-nine-tails tumor." Let us see what the characters of this dis

ease are.

"The tumour," says our author, "which I will call the WARTY TUMOR OF CICATRICES makes its appearance in some old scar, many years after the injury which has produced it has been healed, whether a burn, a cut, or a laceration of the skin; and it arises equally from a flogging or a scald, in which the skin alone has been injured, or from a cut, or gun-shot wound, which injures also the tendons or bones below the skin, and makes a more complicated cicatrix. There appears in the first place a little wart, or warty tumour, in the cicatrix, which is dry and covered with a thin cuticle, but which soon becomes moist, and partially ulcerated, like the warts of mucous membranes, from which a thin and offensive, and semi-purulent fluid is secreted. In this stage it gives no pain nor inconvenience." 21.

Case 1. This illustrates the stage above described. A man had been repeatedly flogged in India, and in the cicatrix left by the lashes several warts sprang up, which coalesced to form a tumor; the probe passed between the warts to the basis of the disease. Around the tumor the skin was of a dark and livid colour, and studded with several smaller warts. Sir B. C. Brodie removed the tumor, then about the size of a small apple, eleven years after the infliction of the last flogging, and no return of the disease ensued.

In the second stage of the disease, proceeds Mr. Hawkins, the growth of the tumor becomes more rapid, the warty appearance being in some measure lost, a more solid substance projecting from the diseased skin, which bears much resemblance to the fungus of fungus hæmatodes; the formation of fresh warts being still seen around the tumor, and preceding the change which has been alluded to. The tumor is very vascular, and bleeds when touched, but its irregular surface still allows the probe to pass through its structure, except where it is most firm.

Case 2. A man, æt. 45, was admitted into St. George's Hospital, April 18th, 1827, under the care of Mr. Jeffreys.

There was a large tumor connected with the skin of the back, somewhat, elevated, and with the edges overlapping the surrounding skin, which was drawn in and puckered round the tumor. The tumor was about five inches in diameter, and the skin appeared to be partly connected with the spinous processes of the dorsal vertebræ, and with the spine of the scapula. The tumor was warty and irregular, and had an ulcerated surface, discharging a thin, sanious matter. The man's countenance was sallow, the appetite however not impaired, the bowels in general constipated, and his sleep at night disturbed by shooting pain in the back.

Twenty-seven years previously to his admission this man had been flogged, and had suffered for eighteen months from the effects of that punishment. The cicatrix, however, remained quite well, until six months prior to his admission, when a piece of wood falling on it and grazing it, a small lump soon afterwards appeared in the part, and ulcerated. The tumor progressively increased till it attained the dimensions and the character which have been described.

The tumour was removed nine days after his admission by an operation, four days after which he died of phlebitis, that would seem to have commenced before the operation was performed.

Case 3. Susan Farrington, æt 28, admitted into St. George's Hospital Oct. 23d, 1833, under the care of Mr. Hawkins.

The left leg and foot had been severely scalded when she was a child. The sore was more than a year in healing, and the surface of the cicatrix had, since then, frequently ulcerated. The last recurrence of ulceration had been four months prior to her admission, and two months and a half before that time, the sore had displayed the characters we shall describe.

"There was a prominent tumour, about two inches and a half above the surrounding skin, which was four or five inches long, and extended more than twothirds round the leg. The surface had the usual irregular warty appearance of these tumours, and discharged a very fetid pus. The cicatrization of the former scald extended from the toes to very near the knee, and was wrinkled towards the tumour. The tumour allowed the probe to pass through it very readily, and when thus examined in various directions, there seemed to be no softening of the periosteum of the tibia, nor of the fascia of the leg.

She had latterly become thin and out of health, with a furred tongue, and quick and weak pulse, and more or less restlessness, from excessive pain and irritation in the tumour." 26.

The patient at first improved a little under the judicious treatment of Mr. Hawkins. But then the tumor rapidly extended, and amputation was proposed, the extent of ulcerated surface rendering excision of the tumor impossible. The patient would not at first consent, but she subsequently altered her determination, and the limb was removed below the knee. The stump healed, and no return of the disease has taken place.

"It will be seen (says Mr. Hawkins), on examination of the preparations, that the tibia was perfectly healthy, excepting an addition of new bone from common inflammation, and that the disease had not extended through the fascia to which it adhered. The drawing was taken about three weeks before the operation, when the tumour began to lose some of its distinctive warty appearance, by becoming somewhat sloughy on the surface, and by the warts becoming more solid and smoother in their prominent extremities, so as to resemble fungus hæmatodes, or the fungous kind of cancerous tumours.

I allude especially to the perfectly sound condition of the tibia, because I believe many gentlemen, who saw the leg, were of opinion the bone must have been diseased, and must have given origin to the tumour. I have placed, however, upon the table the cast of a case of a prominent fungus of a different kind, which is occasionally formed over carious bone, and which ought to be carefully distinguished from the tumour which I am endeavouring to describe. This fungus grows to the same height as the warty tumour, and resembles it in some measure in appearance, but even in the cast perhaps the difference may be perceived between them. In this exuberant growth from the cancellous structure of a bone, the projections are more like granulations; they are softer and redder than the warty tumour, and none of the peculiar changes in the skin around can be detected, which, I believe, uniformly precede the growth in question; on the contrary, the circumference of the diseased parts has the appearance of a common ulcer of the skin, and if the carious part of the bone on which the prominence depends be carefully dissected out by the chisel, the ulcer in the skin will readily heal.

But while I wish to assert the origin of the warty tumour from the texture of

the skin, I am perfectly aware that a disease of some bone may be added to the alteration of the skin, as was shewn in the last case, or as the following case may also prove." 29.

Case 4. John Colley, æt. 45, admitted into St. George's Hospital, July 10th, 1833, under the care of Mr. Babington.

Twelve years ago, he cut the heel through the tendo Achillis so deeply, as to expose the bone. The wound healed in three months, but the ankle and instep continued stiff. Two years afterwards an ulcer formed in the cicatrix, and never subsequently cicatrized completely.

On his admission, a warty ulcer existed around the heel, at the bottom of which exposed bone could be felt. The tibia was enlarged, and the joint stiff. The leg was amputated, and the patient did well. On examining the ankle, the bone of the heel was found inflamed, and rough and scabrous, as in common inflammations, but without any appearance of the disease having caused any other alteration of its structure.

"It appears then that the tumour may be easily and safely removed from any part of the body. In the leg, indeed, the removal of the whole limb must generally be preferable where the tumour is at all extensive; but if its size admits of excision, there need be no fear of the disease being re-formed in any texture except the skin. Still, however, if there be any doubt whether the bone below may have become carious, or otherwise diseased, from the proximity of the tumour, a portion of it may be taken away without adding to the length of confinement." 30.

Case 5. John Callcott, æt. 49, admitted into St. George's Hospital May 28th, 1828, under the care of Sir Benjamin Brodie.

He had a yellow, wart-like fungus, about the size of a crown-piece, which rose above the skin, and through which some bone was felt; this was situated in the centre of some old cicatrices. He had received a blow on the shin from an anchor, twenty-seven years previous to his admission, which was followed by a large abscess, out of which some dead bone had been taken while in a naval hospital, after which the wound healed. Fourteen months ago he received another injury, which was also succeeded by an abscess, at the bottom of which the bone was exposed. The exposed bone was believed to be dead, but as it was not loose, he left the hospital till it was in a fit state to be removed; soon after this the fungus formed, and he was re-admitted, when the tumour seemed to be connected with the bone or the periosteum, or both. June 5th, the tumour being removed with the periosteum, to which it was fixed, a portion of the bone which seemed to be more vascular than usual was taken away with the trephine, so as to expose the medullary canal. The vascularity did not extend more than a quarter of an inch in depth, and the bone was not otherwise altered. The wound healed well, and the man has since continued free from disease.

Mr. Hawkins observes, what must, indeed, be obvious, that the knife is much preferable to caustics, as a means of removing these morbid productions. The knife is at once the less irritating, the more expeditious, and more certain of the two. We have hitherto seen the ulcer arrested in its progress to its termination, by the aid of surgery. To complete the picture, it is necessary to study it unchecked by art-to observe its ravages, and the mode in which it destroys the patient.

"After," says our author, "the tumor has become solid and prominent, a

new action takes place in it, and the tumour ulcerates and sloughs alternately, with a great deal of pain and suffering, and it is destroyed down to its basis, so as to present the appearance of a foul excavated ulcer, except in its circumference, where the skin is raised, thickened, and everted, and from time to time warts are generated, which again ulcerate and slough, till the patient becomes gradually worn out by suffering, but without having at all the sallow and peculiar aspect of a person dying of a malignant disease; and on examination of the body, no disease of the absorbent glands is found, nor is there, as far as I know, any sign of malignant disease in the interior of the body. This termination of the disease I witnessed in the following case. 23.

Case 6. James Sturgess, admitted under the care of Mr. Hawkins, Jan. 18th, 1832.

Sixteen years previously, he had a severe burn of the back, the cicatrix of which extends from the sacrum to the scapula. The sore healed, and the cicatrix continued sound till eighteen months before his admission, when "a small pimple" made its appearance. He picked it off; an ulcer formed, and it progressively extended. On his admission, the tumor which previously existed had disappeared, and an excavated ulcer, eight inches by six in diameter, was left in the loins.

No treatment availed to check the disease, which was too extensive for excision. In July, the patient died exhausted. The disease, even then, had in no part destroyed the fascia of the back, and, except in one or two places, where the sloughing had been most severe, the cutaneous basis still remained, although very thin.

"I shall be glad," concludes our author, "if the remarks I have thus presented to the Society, enable any surgeon to recognize this disease in its early stage, when it may be removed by the knife, without wasting time in the use of remedies, which seem to exert no substantial influence over its growth, and, if unsuccessful, will do much harm. The excision of the tumour, or warty ulcer, may thus prevent the necessity for the amputation of a useful limb, as in several of the cases I have related, or prevent the patient from being worn out by a disease that might have been eradicated, while its size still allowed of the ope

ration.

If, again, the surgeon has dissected out such a tumour, or has removed a limb, when the tumour was too large to admit of separation, still it will be a great point to quiet his own and his patient's anxiety, by a confident assurance that the disease is not in the least malignant, as cancer is malignant, but is, on the contrary, entirely local in its origin, and does not contaminate even the adjacent parts, except in a very trifling degree, so that no future mischief need be apprehended." 34.

On the whole, this must be regarded as an useful and interesting contribution to surgical pathology.

V. CASES OF FRACTURE OF THE NECK OF THE FEMUR, WITH THE APPEARANCES OBSERVED AFTER DEATH. By J. HowSHIP, Esq. &c.

These cases are possessed of interest, because they are attested facts that bear on the vexata questio-whether fractured neck of the thigh-bone, internal to the capsule, does not admit of ossific union.

There are two ways of putting this important question-first, it may be asked if bony union ever takes place, or, secondly, it may be inquired if the