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whales, and other gigantic cetacea ? Thearms. The slow-worm (anguis fragilis)among the serpents has no arms without,but what rndiments of them do you findwithin ? The scapular arch for the sup-port of arms to be developed among thesauria. So that analogy appears to con-firm what the structure only suggests,that these members developed from thesides of the trunk in the cephalopods, forprogressive motion through the sea, arethe first rudiments of the anterior rather than of the posterior extremities of higheranimals, and that they shift their positionforwards and backwards on the trunk ofcephalopods, like the legs of fishes, whichare not yet fixed to the vertebral column.The jaws (K 5, a, b) are very per-

fect in the cephalopods, and have theform of horny mandibles (K* 5) so com-

mon in the lower vertebrata, as in thechelonian reptiles and birds. They are

curved, short, strong, of a dense texture,with sharp cutting edges in the naked

species, and are destructive instrumentsamong the young crustaceons and tes-taceous animals on which the cephalo-pods chiefly feed at the bottom of the

deep. In the nautilus their edges are

more broad, tuberculated, and consolidat-ed with calcareous matter. In the vesti-bule of the ear, these animals have a coni-cal calcareous body of a soft chalky con-sistence, as we commonly find in thelowest classes of vertebrata. And thesurface of their tongue is covered with

regularly-disposed, recurved, sharp, hornyspines, which are common on that part,both in the invertebrata and in the verte-brated classes. The cirrhi, or arms (K* I, d)developed from the oral disk, which formsthe circular lip of the cyclostome fishes,are provided with circular cups or suckers,(K*4), as we see on the tentacula of someannelides. These suckers (K*- 4, a, b, c)of the cephalopods have their circumfe-rence supported by a cartilaginous ring,which presents numerous minute verysharp teeth (K 4, a, c), moveable, and di-rected towards the centre of the suckerso as to aid that organ in attaching itselfto the surface of soft animals. Some-

times, as in onychia, these cartilaginousdisks are drawn out to the conical form ofcurved claws, as we see also on the oraldisk of lampreys. These are principalforms of the skeleton and of the hard ptitqwhich present themselves in the class of

cephalopods, the last and highest of theinvertebrated division of the animal king-dom.On Monday I shall proceed to the ske-

leton of fishes.

HOTEL DIEU, PARIS.

CLINICAL LECTURES ON SURGERY,DELIVERED BY

BARON DUPUYTREN,

During the present Session, 1833.[Revised (before translation) by the Baron himself in the

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

LIGATURE OF THE EXTERNAL ILIAC

ARTERY. .

TIIE ligature of the external iliac arteryapparently presents greater difficultiesthan that of the subclavian. It is not, infact, without some feeling of fear, that wereflect how the vessel must be sought, asit were, in the abdomen, to be tied; how-ever, in practice, this operation is gene-rally less diflicult, and not more dangerous,than the other. The parietes of the ab- domen are divided in the high operationfor stone; they are divided, in almost

every operation, for hernia; why notthen open them without fear, in order tocure a disease, certainly as dangerous asany of the preceding ones ? The placewhere the incision should be made, and the

disposition of the peritoneum, enable us to) expose the artery, and avoid injuring theserous investment of the bowels.

Several methods may be employed; thefirst consists in opening the parietes ofthe abdomen parallel to the direction ofthe artery, commencing at the pointwhere it passes under the crural arch,

and ascending along the external edge ofthe rectus, toward the umbilicus. In thesecond method, which is that of ABER-NETHY, the abdominal parietes are dividedparallel to the crural arch, and about halfan inch above it. The process of Sir A.

COOPER consists in making a curved in-. cision above the arch, commencing from’ the anterior superior spine of the ileum,and terminating near the external ring.

BOYER has proposed to make an incisionof two inches, just above the arch, one

extremity of which shall be at the samedistance from the spine of the ileum as

!! the other is from the spine of the pubes;r i the tendon of the great oblique musclebeing opened parallel to Poupart’s liga-. ment, the operator pushes aside the chord,and soon comes down on the iliac artery;but this incision, made exactly over thedirection of the artery, does not permit usto tie the vessel more than an inch abovethe arch; hy turning the lower angle of

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the incision toward the iliac spine, weshould gain more room, but then we shouldfall into the method of COOPER, with allits inconveniences. The incision, prac-tised after the first method, gives an

opening parallel to the vessel, but this

opening is limited to the separation al-lowed by the lips of the wound, whichrenders it very difficult to find the artery,or to perform the manoeuvres necessary forplacing the ligature round it. Besides, inmaking this incision, we run the risk ofopening the peritoneum, which, in pro-portion as it is distant from the arch, ad-heres more closely to the abdominal pa-rietes. The incision made parallel to thecrural arch being perpendicular to theiliac artery, renders all parts of the ope-ration more easy, in addition to which itfalls precisely on the line where the peri-toneum abandons the parietes of the ab-domen to be reflected on the pelvis, andin the midst of loose fatty cellular tissuealways found in this situation; it also

gives greater facility for detaching theperitoneum, and exposes the patient tomuch less danger of having this mem-brane opened; however, if continued toofar toward the ring, it may divide the! epigastric artery. i

The ligature of the artery, by one orother of these methods, may be mademore or less high. In tying the vesselhigh, we get at a distance from the tu-mour, hut we increase the danger of

wounding the peritoneum ; in taking upthe artery low down, we avoid the dan-ger, but then ligature is placed so closeto the aneurysmal sac, and to the originof the epigastric artery, that the formermay be attacked by secondary inflamma-tion, and open into the wound, while thelower tube being traversed hy the bloodof the epigastric artery, may re-establishthe circulation and pulsations of the aneu-rysm. In each of these different pro-cesses, the artery is isolated from thevein and nervous plexus, which lie on itsinner side, with the finger rather thanwith any instrument; the laxity of thecellular tissue fortunately renders this’operation easy, which might otherwise bedangerous if practised with a cutting in-strument. It is much more easy to findthe termination of the external iliac arteryin the woman than in the man. In theformer it is situate more superficially, onaccount of the peculiar form of the femalepelvis; but whatever be the sex, the ope-ration is more easy in thin than in fatindividuals. The following case will giveus an opportunity of applying some ofthese principles.

CASE.-,42i.eurysm of the Temoral Artery.- Trial qf Pressure and Cold on the Ex-ternal Iliac.

Berger, an old soldier, now a stone-

cutter, 45 years of age, in the month ofJune 1815, made a sudden effort to lift upa heavy plank, one extremity of whichrested on his left groin; he immediatelyfelt in this part considerable pain, hut as itwas of short duration, he continued hisoccupation for several days ; however, inabout two months Berger perccived asmall tumour in the left groin, about twoinches below the crural arch : it was per-fectly indolent, and therefore attracted noattention from him. By degrees the tu-mour enlarged, up to June 18] 6, when thepatient, having made some fresh exertion,it suddenly increased to the size of a hen’segg. About three weeks before his entryinto the hospital, the poor man fell on theedge of a copper vessel, and by some fa-tality the weight of his body was broughtto bear exactly on the tumour, which en-larged so rapidly from this period, thathe judged it prudent to enter the hospi-tal in August 1816.The tumour, placed as I have said, in

the left groin, over the femoral artery, hadat this time the form and size of a large

’ pear, with the base turned upward, and’ the point downward and inward. It com-

I menced a little above the arch, and ex-tended down for four inches: beingtwo inches and a half in breadth, it didnot present any pulsation in mass, but

alternate dilatations and contractions,quite isochronous with the movements

of the heart. When the external iliac

was compressed on the branch of the

pubis, all kind of movement in the tu-

mour was suspended, and at the sametime it became sensibly diminished. ifthe femoral artery was compressed in themiddle of the thigh, the pulsations, on thecontrary, became more strong and vio-

lent. When the tumour itself was com-

pressed, it disappeared altogether, and we

could feel that its parietes were very un-equal, and of the consistence of cartilage.On the least suspension of the pressure,the tumour recovered its ordinary volumeand tension in two or three beats of theheart; besides, it was perfectly indolent,and the skin was not in the least disco-loured. It was impossible to doubt thatthe tumour was an aneurysm of the fe-moral artery, and as it had latterly madesuch rapid progress, it was equally certainthat it was necessary to do somethingspeedily.Two methods of treatment were appli-

cable to this case,-compression and theligature. If pressure were unsuccessful,

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it would at least favour the success of the It was applied on the 20th of Septern-ligature ; we therefore decided on apply- ber, and we soon perceived this advan-

ing pressure to the tumour, aided by cold. tage in its use, that it accommodated itselfBeing convinced, by experience, how easy to all the movements of the body, byit is to compress the external iliac artery which means the compression was render-on the horizontal branch of the pubes, 1 ed sufficiently fixed and exact to havecaused an instrument to be made by one attained with certainty the proposed ob-of our most intelligent cutlers of such a ject, if the patient had been gifted with anature, that one end pressed on the sa- little more courage and endurance. The

crum, the other upon the iliac artery. ice was applied again, and the action ofThe machine being applied about half an the truss was regulated by means of ainch above the arch, the circulation was strap passed under the thighs, but it couldperfectly suspended in the artcries below not be borne by the patient longer thanthis point, as well as in the tumour, upon the former one, and ten days after itswhich we placed pounded ice in a blad- application Berger demanded the opera-der. All the surrounding parts were tion with great earnestness. In vain I

guarded from the action cf the ice by attempted to impress upon his mind thefolded cloths; but we soon found the im- advantages of a means hy which he mightperfection of this instrument. The pulsa- hope a cure without an operation; hetions of the tumour, which were suspend- constantly refused to employ the pressure,cd when the instrument was first applied, and, at length, wearied by his entreaties,soon reappeared whenever the patient I appointed a day for the operation. In

coughed or spoke, or made the slightest the intermediate time we endeavoured to

motion; and even when the pressure was calm the state of nervous excitement intoexact, it excited such uneasiness, that the which the compression had thrown him,patient was unable to support it above fif- and we made such dissections and experi-teen minutes at a time if the ice were at tticuts on the dead body as were calculatedthe same time used, while without the to render the operation on the living moreice it could be borne for half an hour. successful.These pains, which -were evidently due to ( At this time the tumour was diminishedthe pressure of the crural nerves, ceased to one-third of its size, and the force ofin about five or six minutes after the ap- the pulsations remarkably decreased. On

plication of the machine. It was fre- the 9th and 10th of October the patientquently altered, but as it always had the experienced pain in the inner side of thefault of not following the motions of the tumour, and extending along the thigh topelvis, and of gliding off the horizontal ! its middle; they ceased oil the 13th, butbranch of the pubes, when the patient there still remained some pain in the backmoved in bed, it could not exercise an part of the thigh, corresponding with theefficacious pressure, direction of the sciatic nerve.

This compression was continued with- As the patient was habitually costive heout intermission to the 18th of September, was ordered on the 1-ith and 15th emol-hut it became so painful that we were licnt clysters, which brought away onlycompelled to abandon it; however, the ’ two small stools of dark and hard matter;tumour was sensibly diminished. The as the operation was two 1)3 performed onpatient was permitted to get out of bed the following day, I prescribed an ouncefor a few days, and experienced on getting of the sirup of diascordium, which procuredup some uneasiness in the left knee-joint, a tranquil sleep for six hours.which disappeared in the course of forty- ! The instruments used during the opera-eight hours. tion were various straight and convex

In spite of these difficulties I did not bistouries, a straight bistoury boutomiee, agive up the hope of conquering the dis- grooved sound, two needle-shaped styletscase by means (.f compression. A new threaded with waxed threads, forceps,machine somewhat analogous to Cowper’s sci3sars, several small cylinders of linen,truss-bandage was made; it consisted of and sponges.an elastic steel plate, forming about five- The patient lying in an horizontal posi-sixths of a circle ; one extremity was fixed tion, an assistant was placed by his side,on the right haunch ; the other, which was in order to suspend the course of themore straigh t, and twisted a little upwards blood in the lower extremities, by pre,-and to the left, was furnished at about six sure on the termination of the ventralinches from the extremity with a pad cor- aorta, if such should be necessary.responding exactly with the point where I now commenced an incision, begin-the external iliac artery passes over the ing about an inch below the superior an-horizontal branch of tlie puhis. The whole terior spine of the ileum, which ranaction of this instrument depended on its parallel to the crural arch, and extendedelasticity, to the inguinal ring; the spine, tendon,

517

and muscles, were successively dividedwith great caution, and I soon came

down on the cellular tissue, which wasyellow, slightly injected, remarkablydense, and containing a great numberof lymphatic glands, with which it ad-hered strongly to the external iliac artery;this occasioned some difficulty in exposingthe vessel, for we were compelled, notonly to remove this cellular tissue, layerhv layer, but also in order to favour thisdelicate dissection, we were obliged to

divide the crural arch by several small

perpendicular incisions; when the arterywas cleared externally of the cellular tis-sue, and separated internally from theiliac vein by means of the index fingerwith great caution, it was elevated on

both index fingers, while an assistant

passed underneath it a hollow sound. Whenthe artery was compressed on this sound,all pulsation was suspended in the tumour.A ligature was now placed, almost an inchabove the diseased part, bv passing astylet through the canula ; a ligature of re-serve was placed half an inch higher up,by the same means ; the artery was raisedby drawing gently the two ends of theligature, while the index finger of the lefthand was pressed on the knot. This ma-noeuvre again suspended the circulation;the vessel was tied at once, and the pulsa-tions of the tumour immediately stopped.A 1 emarkable circumstance occurred

during the operation ; white the patientcontracted forcibly the muscles of theabdomen, the edges of the wound werealmost brought into contact, and the peri-toneum, pushed forward by the intestines,presented itself under the blade of the

bistoury; we were thus compelled to

direct an assistant to push back the in-testine and peritoneum with his fingers,while he kept the edges of the wound open.The inferior ligature was placed at the

lower angle of the incision; that of re-serve in the upper angle. The woundwas covered with linen spread over withcerate, and above this were placed severalfolds of fine lint. Triangular compressesand bandage completed the dressing.Thus terminated, without much diffi-

culty, the ligature of the external iliac

artery, and if we were to judge from theeffects which followed the ligature of thesuhclavian, we had cause to hope that thepatient would soon be perfectly cured.Hut, instead of this, a long series of acci-dents set in, which I propose to explain toyou at length; first, because they are es-sentially connected with the case, and,secondly, because they show how neces-sary it is to follow up an operation by ju-dicious treatment. The details shall be

comprised in another division.

A LECTURE

ON A

PECULIAR KIND OF INJURY OFTHE SHOULDER-JOINT,

Delivered at the Westminster Hospital,BY MR. GUTHRIE.

GENTLEMEN,—The observations I amabout to make, constitute an essay which

I reserved for a time, in the hope it mightfind a place in the first volume of the Trans-actions of the Royal College of Surgeonsof London. But as my expectations in

. this respect have hitherto proved vain,and as there is at present in the hospitalan example of the kind of injury I wish toillustrate, and which affords you ari oppor-tunity of judging of my opinions, I havethought it right to deviate from my origi -nal resolution. It is possible, that whenattention is particularly and generallydrawn to the subject, an opportunity maybe found of ascertaining by dissection theexact nature of an accident which hascaused me much anxiety, and which mayhave been a source of inconvenience evento those who arc best qualified to form ajudgment on these subjects. As I wish onthis point to he fully understood and fairly

represented, I will, if it be agreeable tothe gentlemen who take notes for themedical journals, and they think it worththeir while to accept the offer, give theman opportunity of copying my own re-

marks on the subject—in fact, the verypaper I now hold iii my hand. I have nointerest in any journal, save that whicharises from cidlity; and there is an oldsaying, that " civility begets civility."Louisa Chapman, eleven years of age,

fell on her shoulder 0n the 8th of Octoberlast. This child’s shoulder is, as Mr.W HJTE aptly calls it, out of drawing. Thereis a considerable prominence on the insideof the anterior part, beneath the coracoidand acromion processes, and in the situa-tion of the small tuberosity of the hu-merus. This projection is so manifest, asto be seen at a distance; and when exam-ined, it might be mistaken for the head ofthe humerus displaced into this situation,and constituting a partial dislocation, if itwere not for two circumstances. 1st, Thatit is not the whole head of the humeruswhich is felt projecting internally; neitheris it round, but, on the contrary, it is dis-tinctly a rough and irregular protuberanceof bone. 2ndly, That a portion of thehumeius may be felt in the glenoid cavity.

If the thumb or forc-finger of the left-hand be placed on the internal protu-