No. 53.

LECTURES

ON THE

PRINCIPLES, PRACTICE, & OPERATIONS OF SURGERY,

BY PROFESSOR SAMUEL COOPER.

Delivered at the University of London,
Session 1832-1833.

LECTURE XXI., delivered Nov. 21, 1832. GENTLEMEN,-On Monday evening I was describing some of the characters of carbuncular inflammation; I mentioned, that, soon after the formation of the tumour, one or more livid vesicles make their appearance on its surface, and that, when this had occurred, you might be certain, that sloughing of the cellular membrane underneath the skin had taken place. When such vesicles burst, they are followed by one or two inadequate openings, that is, openings quite insufficient for the discharge of the contents of the tumour. If you now delay making a proper incision, several small ulcerated apertures are gradually produced, so as to give the surface of the carbuncle a perforated, or sieve-like appearance. From these a thin, greenish, sometimes bloody and sanious matter, is discharged, but the mortified cellular membrane remains behind, the openings not being free enough for its discharge. The matter flowing from a carbuncle is frequently whitish, resembling a mixture of flour-and-water, and Sir Astley Cooper considers this as one of the characteristics of the disease. If the process, adopted by nature, answer for the discharge of the sloughs, it is with slowness and difficulty, for it is only by the tedious effects of ulceration that it can be effected, by which the skin is destroyed, and a deep ulcer left, at the bottom of which you will occasionally see the denuded fascia, tendons, and muscles. Such is sometimes the depth of the ulcer: nay, instances are recorded, and one of them is mentioned by Mr. Liston, in his Elements of Surgery, in which the cervical vertebrae were exposed at the bottom of a formidable sore left after the detachment of the sloughs.

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The undischarged matter of a carbuncle lies in the cells of the sloughy cellular membrane, where it was originally formed, and is not diffused in those of the surrounding cellular tissue, as in bad cases of phlegmonous erysipelas; indeed, a carbuncle is truly a circumscribed disease.

Gentlemen, I may next observe, that carbuncles are chiefly seen in persons, whose constitutions have been broken or permanently impaired by excesses and dissipation: you will rarely see them except in elderly persons, or persons above the middle age. In this respect, carbuncle differs from a boil, which occurs principally in young persons. It is alleged, that carbuncles may arise from stimu lation of the skin, in various manners; but then we must suppose the previous existence of a peculiar state of the system creating a kind of predisposition, without which the irritated part would not have been attacked with carbuncular inflammation.. Carbuncles are attended with severe constitutional disorder; rigors, intense headache, considerable gastric disturbance, clammy perspirations, palpitations, faintings; a weak, faltering, pulse; extreme prostration of strength; and, after a certain time, with symptoms very much like those of typhus fever, with a tendency to disturbance of the intellectual functions, coma, and sometimes actual delirium. Carbuncles are rarely seen on the limbs; their usual seat is the back of the trunk. I have seen two or three cases, where carbuncles formed on the head; perhaps their most frequent situation is between the scapula, or near those bones; they are common too over the glutai muscles and the nape of the neck. John Hunter mentions having seen buncles on the limbs; but this must be looked upon as uncommon.

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Carbuncles, gentlemen, as you all know, are amongst the symptoms of plague; but those which form in the plague are not like the common kind observed in this country. The carbuncle of plague destroys the skin more quickly and completely; it forms a large black patch, and not small apertures; and it attacks

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