we have before alluded; as well as a desire to absorb the whole credit;-seeing that it would have been easy for him to have compared the original with the translation, and to have corrected any thing "rebutting" in the style; or any inaccuracy in conveying the meaning of the author; and we must say, in conclusion, that whilst we hail with unallayed pleasure this edition of the works of one of the shining lights of medical science, we are by no means satisfied that the best possible selection has been made of Editor.

Observations on Aneurism, and its Treatment by Compression. By O'BRYEN BELLINGHAM, M. D., Edin. Fellow of and Professor in the School of the Royal College of Surgeons in Ireland, etc. etc. etc. John Churchill. London: 1847.

In this interesting brochure, Dr. Bellingham gives us a brief history of the treatment of Aneurism by Compression, and the various improvements in the mode, accompanied by an abstract of the cases that have been reported in which compression has been used; the instruments employed, and the theories upon which compression has been supposed by different writers to cure aneurism.

"The author's views respecting the pathology of aneurism, particularly the exact manner in which the disease is cured, differ from those usually taught;" and he has endeavoured to prove that "the cure of aneurism is accomplished in a similar manner, whether the ligature is employed or compression is used, or whether the cure has been brought about by Nature's unaided efforts." That the latter is true, is highly probable, from the uniform simplicity observed in the processes of Nature on other occasions, and the explanation of our author, which we shall notice presently, is at least plausible. The employment of cutting instruments upon the living body, where it can be avoided without incurring other or greater evils, is always to be deprecated, and every plan which holds forth a reasonable hope of relief without such a resort, is entitled to calm and impartial consideration. The result of all the experiments for the cure of aneurism by compression, has not been such as to warrant our confidence in relying upon it in the generality of cases; but if

it can be shown that a false theory has been entertained on this subject, under the guidance of which an erroneous practice has been pursued, the case becomes altered in its aspect most essentially.

The objections that have been urged against compression by authoritative writers are principally the following:

1st. Uncertainty of success, from the impossibility of applying sufficient force to bring the sides of the vessel into contact, so as to cause adhesive inflammation and consequent obliteration of its cavity, in many instances from its being surrounded by soft and elastic tissues that take off the pressure.

2d. Impossibility of continuing the pressure long enough to be effectual, in consequence of the extreme suffering of the patient from compression of the large nerves which accompany all the principal arteries.

3d. Danger of sloughing, in consequence of the long continued pressure.

All these evils have undoubtedly been experienced, and the question is, whether, according to Dr. Bellingham's theory, and the practice founded upon it, success can be attained without such risks.

"Surgical writers appear," says Dr. B., "to have been under the impression, that in order to cure an aneurism by compressing the artery above the tumour, it was essential to interrupt completely the current of blood through the vessel-in fact, to to apply such pressure as would act like a ligature, cause inflammation of the coats of the artery at the part, and obliterate the circulation in the vessel at the point to which compression had been applied.

"When it was considered absolutely necessary for the success of compression, that such an amount of pressure should be applied as was almost certain to produce sloughing of the part, and very certain to occasion intense pain and suffering; and when, in addition, this was to be prolonged through five successive nights and days, (as in the case reported by Mr. Guthrie) we can readily understand why patients refused to submit to it, and we can easily account for the disrepute in which the practice fell; and for the unwillingness of surgeons to adopt this treatment, in preference to the simple operation of placing a ligature upon the femoral artery. It would, however, appear that it is not at all essential that the circulation through the vessel leading to the aneurism should be completely checked, but rather the con

trary it may, perhaps, be advantageous at first, for a short period, by which the collateral circulation will be more certainly established; but the result of this case, if it does no more, establishes the fact, that a partial current through an aneurismal sac will lead to the deposition of fibrine in its interior, and cause it within a few hours to be filled and obstructed, so as no longer to permit of the passage of blood through it. Pressure, so as altogether to obstruct the circulation in an artery, must necessarily be slower in curing an aneurism, as it must, in some measure, act by causing obliteration of the vessel at the part to which the pressure has been applied; whereas a partial current through the sac enables the fibrine to be readily entangled in the parietes of the sac in the first instance, and this goes on increasing until it becomes filled; the collateral branches having been previously enlarged, the circulation is readily carried on through them."

Several cases are narrated by the author, wherein these results of moderate compression were proved to have taken place, by post mortem inspection of the parts.

That aneurism may be cured in the manner recommended by Dr. Bellingham is admitted by eminent living surgeons, but the priority of the practice as well as the theory is not so readily accorded to him. Mr. Wilde, the able editor of the Dublin Quarterly Journal, awards the credit to the late Mr. Todd of that city. Professor Syme of Edinburgh, whilst he denies to Dr. B. any just claims to originality, condemns the practice as inapplicable to aneurism of the large arteries generally, although he admits that, in certain cases, where for special reasons the ligature cannot be used, compression should be tried.

If the doctrine contended for, however, and which it is not difficult to test, shall be established by sufficient observation, we can see no reason why compression should not supersede the knife and the ligature in nearly all cases, and should Dr. Bellingham's earnest advocacy be productive of so good and desirable an improvement, he will indeed have earned a proud claim to our gratitude.

The following remarks, extracted from Chapter X., present a resume of the positions assumed by Dr. B. :

"When we consider how many writers have devoted their attention almost exclusively to the subject of aneurism, and how much talent has been engaged in illustrating its history, patho

logy, and treatment, it appears strange that the process which nature herself sets up for its cure should have been so much overlooked hitherto by surgeons; and although this process was daily, I may say, passing under their eyes, that the exact mode in which it was accomplished should have attracted but little attention, and no attempts should have been made to imitate or assist it.

In almost every case of aneurism, where the disease has subsisted for some time, we find a larger or smaller amount of solid matter deposited in the sac, which is composed of the fibrine of the blood, arranged in regular concentric laminæ.

Examples of the spontaneous cure of aneurism, in which the sac is completely filled with fibrine deposited in regular concentric layers, are not very uncommon.

Again, in cases of valvular or other disease of the heart, when a considerable impediment exists to the circulation through its chambers, we know that the fibrine of the blood will separate from its other constituents, and form the bodies improperly termed polypi, (which are sometimes so closely interwoven with the carnæ columnæ and chorde tendineæ as to be with difficulty detached,) which, by closing the orifices, or obstructing the action of the valves, not unfrequently prove the immediate cause of death.

These familiar facts all tend to prove

1st. That nature herself sets up a process by which, under favourable circumstances, the cure of aneurism is effected.

2d. That the mode in which she effects this, always in internal aneurism, and frequently in external aneurism, is by the deposition of the fibrine from the blood in the sac of the aneurism, until it becomes filled.

3d. That the fibrine in such cases is deposited in regular concentric laminæ, the oldest or first formed next the sac, those most recently formed nearest the centre.

4th. That a current of blood through the aneurismal sac is a necessary agent in bringing about this result.

5th. That any obstruction to the current by which its velocity and amount are diminished will accelerate the deposition of fibrine in the aneurismal sac.

6th. That once this process has commenced, if the same agents continue in operation, it will go on until the sac becomes filled, and no longer permits of the entrance of blood.

Writers upon aneurism hitherto appear to have been more. intent upon solving unimportant points connected with the distinction between true and false aneurism; or in ingenious speculations as to the comparative frequency of aneurism from dilatation of all the coats of the artery, or from rupture of the internal

and middle coats, than in investigating the mode in which a spontaneous cure of the disease takes place. Indeed so little notice is taken of this process in some modern works, that one would suppose the authors were either ignorant of the facts just stated, or looked upon the phenomena as too unimportant to dwell upon.

Before proceeding further, there is a point upon which I wish to make a few remarks. In the details of the cases of aneurism treated by compression which have been published within the last three years, the writers speak of the coagulation of the contents of an aneurismal sac, or of developing a coagulum in it by pressure upon the artery at the cardiac side, as if a coagulum or clot, and the concentric laminæ of fibrine which form in aneurisms, were identical: indeed, from the loose manner of expression adopted, it is sometimes difficult to tell whether the writers are aware of the distinction between them. This is the more remarkable, because the two substances in appearance, colour, and consistence, present a remarkable contrast; the one being soft and loose, of a very dark colour, not deposited in any regular order, and composed of the red globules and fibrine of the blood; the other being solid and firm, of a paler colour, deposited in regular concentric lamina, and composed of fibrine alone, or with a very small proportion of the red globules. The former is commonly found in the auricles of the heart, and in the large veins which open into them, and is familiar to every body; the latter constitutes the solid matter, which, in greater or less quantity, fills the sac of old aneurisms.

It is obvious, therefore, that the mode in which these two different deposits are formed cannot be the same. To cause the deposition of fibrine in an aneurismal sac, it is essential that a stream of blood should pass through it for a period that will vary according to different circumstances; but its deposition will be promoted or encouraged by diminishing the strength of the current in the artery leading to it, and by lessening the amount of blood which passes through the sac. This, it is easy to understand, can be readily accomplished by compressing the artery at the cardiac side of the aneurism, and the pressure need not be so strong as to occasion very great pain to the patient.

On the other hand, to bring about the coagulation of the contents of an aneurismal sac, the blood must remain at perfect rest for a considerable time; if a current continues to pass through the sac, the blood in it will be replaced by another portion before there is time for its coagulation; for although a coagulum or clot will quickly form when blood is removed from a vein, it is not so easy a matter to bring about its coagulation in an aneurismal sac in a living subject. To effect this, very considerable pres