Periscope. Dissection of a Subject cured of Aneurism by Compression. the society-is, that it exhibits the results of compression some time after a cure had been effected, and when the patient had remained well in the interval. As this patient had been twice the subject of aneurism, both of which were treated by compression, the preparation upon the table has still more value, exhibiting, as it does, the results of compression in two aneurisms cured at different periods. As the treatment of aneurism by compression appears to be now an established practice in every case where the situation of the aneurismal sac permits of pressure being applied to the artery leading to it, there is no necessity to trouble the society with observations upon its advantages over the ligature. I shall therefore confine my remarks in a great measure to points illustrated by the dissection in the present case. 323 which follows Brasdor's operation for aneurism. If this There is a point connected with the employment of presIt was some time since, and perhaps with reason, urged sure in aneurism to which I have not before alluded, but against this method of treating aneurism, that the period which is illustrated by the dissection in the present case; which had intervened since its reintroduction was, too it is that the mode in which compression effects the cure of short to allow a positive opinion to be pronounced as to aneurism seems to be more simple, and to require (if I may the permanency of the cures, or the contrary. Here, use the expression) less assistance from nature than the li however, we have demonstrative evidence that in fifteen gature. For instance, when a ligature is placed upon, an or sixteen months from the date of the cure of an aneu-artery in the usual situation at a distance from the aneurisrism of the femoral artery by compression, the tumour has mal sac, to prove effectual it must cause the obliteration of completely disappeared, the contents of the sac have been the vessel at the point to which it is applied: the blood, absorbed, and the artery at the seat of the aneurism has contained in the sac, or that which finds its way into it by become quite impervious, so that it would be utterly the anastomosing branches (as there is no vis a tergo) coaguimpossible for pulsation to return, or for an aneurism to lates, and the main artery of the limb comes eventually to form again at the part. Indeed from the mode in which a be obliterated both here and at the site, of the ligature ; : cure is effected by compression, it seems hardly possible whereas, after a cure by compression, the artery is obliterafor the pulsation to return, though many instances have oc- ted only at the seat of the aneurism. Indeed for this reason, curred where pulsation has returned after the application of the application of a second ligature higher up the artery, in: a ligature. cases where secondary hæmorrhage had occurred, almost ; necessarily fails, and we can hardly be surprised at gangrene attacking a limb, the main artery supplying which is obliterated at three points in its course. Upon a former occasion I laid down the proposition, that to cure an aneurism by compression, such an amount of pressure is never necessary as would cause inflammation and adhesion of the opposed surfaces of the vessel at the In addition, the cure of an aneutism by compression is point compressed. An examination of the preparation more likely to be effectual, and ought to be more permaupon the table fully bears out the correctness of this nent, than one treated by ligature; because in the former proposition, as we see the femoral artery upon each side case the sac becomes gradually filled by fibrine, or the vesto be pervious and uninjured down to the site of the ori-sel leading from the sac is completely obstructed, and no ginal aneurismal sacs, at which points only its channel is obliterated. longer permits of the passage of blood, although all pressure is removed; whereas, after the application of a ligature, a I also laid down the proposition, that it is not necessary loose coagulum of blood alone remains in the sac, which to carry the pressure so far as completely to intercept the does not fill it, and may or may not extend into the main circulation in the artery at the point compressed, but that artery; the parietes of the sac must therefore necessarily the consolidation of the aneurism will be more certainly shrink considerably, and the artery supplying it must be brought about, by allowing a feeble current of blood to pass closed up before the sure can be pronounced to be perthrough the sac-in fact, that to apply compression success-manent. That this sometimes requires a long time to be fully, the velocity and force of the current through the ar-effected, is shown by the pulsation having returned after tery leading to the aneurism are to be diminished, while a considerable interval in cases where the ligature had been : the amount of blood passing into the sac is to be lessened, used. by which the deposition of fibrine will be encouraged, until the sac no longer permits of the entrance of blood. A cure will then be effected in the manner in which nature, under the most favourable circumstances, brings about the spontaneous cure of aneurism. The only objection which it appears to me can be urged: with any fairness against the treatment of aneurism by pressure is, that it will probably prove more tedious than the ligature. Admitting this (although in several of the recorded cases it was less tedious), yet when we take into ac This process is necessarily slow and gradual, and must count its perfect safety, its almost absolute certainty; and: take some time to be accomplished; but when the cure is on the other hand, the risk, the danger, and the uncertainty rapid, and is brought about after the application of pres- of the operation by ligature, (particularly in the case of cersure for a few days only, (as happened in one of the aneu-tain arteries) we cannot, I think, hesitate to give it the prerisms under which this patient laboured,) the period is ference. apparently too short for such a result. Here the cessation There appears to be, but one form of aneurism in which of the pulsation in the aneurism, in all probability, de-compression is liable to fail-viz., where the tumour is pended upon the formation of a coagulum or clot in the formed by general dilatation of all the coats of the artery aneurismal sac during the action of the compression, in fact, where no true aneurismal sac exists; but in such a which, on the pressure being discontinued for a short interval, was impelled by the strong current of the blood into the vessel leading from the sac, and was so firmly impacted in it as completely to obstruct its channel; the circulation was then determined to the collateral channels, and a cure was effected in a somewhat similar mode to that case it is very probable the ligatute would equally fail: If the blood is very poor in fibrine, the treatment is likely to prove much more tedious than usual, or might even fait, as little or no deposition would take place in the sac under such circumstances, and the formation of a coagulum even would be interfered with by the rapidity of the circulation, 324 Periscope-Dissection of a Subject cured of Aneurism by Compression. In such cases, before we commence applying pressure, we should endeavour to improve the condition of the blood, and to increase the quantity of fibrine in it by medicines and by proper attention to diet and regimen. sufferings which they produce they are rarely used by modern surgeons." It has been urged as an objection to this mode of treating aneurism that it is not only tedious but painful. I do not mean to deny that pressure is not painful; indeed it is not unlikely some patients may find it so irksome as to call for the operation, the pain of which they consider will be only momentary, and of the danger of which they are ignorant. But after the pressure has been employed for a time, the pain diminishes materially, and there are modes of applying compression which occasion comparatively little suffering, but to which I need not here more particularly allude. I may, however, mention one which was employed in the present case, which could be continued for almost any length of time without occasioning pain, and which the patient preferred to every other mode. This consisted in a pad made of a piece of bandage rolled up, and laid upon the femoral artery as it passes over the ramus of the pubis, upon which a weight; sufficient to diminish materially or to check the pulsation in the aneurism, was placed, and Mr. Gibson of Philadelphia (in his Treatise on Surgery) maintained in that position by the patient as he lay in observes-"Compression is now rarely resorted to, expebed, with the thigh flexed upon the pelvis. It was an ac- rience having proved its general inefficacy. The process cident which obliged me originally to have recourse to this has been found, moreover, even when successful, so exproceeding, the instrument employed having gone out of tremely painful and tedious, that few patients can be inducorder upon a Sunday, when there was no possibility of hav-ed to submit to it, or to persevere sufficiently long to accoming it repaired, it occurred to me to try the effect of this simple means. A four-pound weight was first used, this was subsequently changed for a seven-pound weight, which was found to answer remarkably well. I mention it here, merely because the same mode of applying pressure is stated to have been employed with advantage in a case reported some time subsequently, in which no allusion is made to its having been used previously-an omission which I am sure was accidental on the part of the reporter of the case. Mr. Guthrie (in his work on Aneurism) observes-" The application of pressure by means of a spring pad has been tried, and has sometimes though very rarely, succeeded. The process is long, the pain great, and their is danger of the part sloughing; the pain, indeed, is so great that few persons can be persuaded to submit to it, and those surgeons: who have tried it once will not again put it in competition. with the ligature." The cases of success which have followed the employment of compression, M. Begin (in the article Aneurism in the Dctionnaire de Medecine) observes" Are few compar-ed to the number of instances in which it has been tried. The difficuties in this method are inherent in it, and can be overcome by no instrument. No matter what precautions we employ-no matter upon what part we apply the compression, or with what care we graduate the pressure, it soon becomes painful, and in the great majority of cases unsupportable. The greatest courage and the firmest resolution are not equal to it." plish a cure. That it operates partly upon the principle of the ligature (when it does succeed) there can be no doubt, by compressing the sides of the vessel, causing the effusion of lymph, and finally obliteration of the channel, so as to force the blood to abandon the sac, and pass off by the collateral branches." Many other authorities might be enumerated; the foregoing are, however, sufficient for the present purpose. But we have seen that in the mode in which compression is employed now (for the cure of aneurism) the obliteration of the As their appears to be some misconception abroad respect-artery at the point compressed is never aimed at indeed ing the modern method of treating aneurism by compression, the amount of pressure necessary is not even so great as and as it is frequently stated to be nothing more than the re- completely to check the current through the artery leading vival of an old mode, I will take this opportunity of saying to the sac; neither is pressure applied to the aneurismal a few words upon these points. That it could hardly be the tumour itself, either of which proceedings would necessarily mere revival of an obsolete and abandoned method must be ap- occasion so much pain that few patients would be found willparent to any unprejudiced person from the success which has ing to submit to it; and the latter would probably do much attended its employment in so many cases recently: where- more harm than good, and might occasion the rupture of the as formerly, success was the exception to the general rule; sac and the conversion of a circumscribed into a diffused aneuand that it is not the mere revival of an old mode of treat-rism. Nor is the application of a tight bandage round the ment is proved by the written testimony of the authors them-limb, with or without a compress upon the aneurismal sac, selves who put it in practice. advisable-indeed it would probably act rather injuriously For instance, the older practitioners who employed com- than otherwise, by interfering with the return of the venous pression in the treatment of aneurism aimed either at oblit-blood, or with the establishment of the collateral circulation, erating the vessel at the point compressed, or they applied particularly with the enlargement of the articular arteries the pressure directly upon the aneurismal tumour, or they about the knee, which always increase remarkably in size, made general pressure upon the aneurism and entire ex-after the filling up of the sac, in cases of popliteal aneurism. tremity by means of a compress and roller carried round the limb. As might have been anticipated, they very seldom succeeded-indeed so seldom that the plan came, not only to be entirely abandoned by surgeons, but it is discountenanced in every standard work on surgery, and represented to be tedious, painful, and doubtful, and uncertain in the extreme, in proof of which I shall delay to quote a few authorities, whose remarks, I may observe, refer only to the most eligible site for the application of the pressure-viz., between the aneurismal tumour and the heart. In conclusion, it may, I think, be laid down from what precedes, that the ancient and modern methods of employing pressure are essentially different; and although the two proceedings bear the same name, their is really no more resemblance between them than between the old operation for aneurism (in which the sac was laid open and the artery tied above and below it) and the Hunterian method, in which the vessel is tied at a distance from the sac and in a situation where its coats are healthy. The PRESIDENT could not feel surprised, he said, at the Mr. Samuel Cooper (in his Surgical Dictionary) speaking demonstration of applause from the cross benches-though of compression, observes-" In order that pressure may suc- contrary to rule-upon the delivery of Dr. Bellingham's ceed, the coats of the vessel at the place where it is made highly valuable remarks on a system of treating aneurism must be sufficiently free from disease to be susceptible of the which solely belongs to our own day. Dr. Bellingham, he adhesive inflammation. Few patients (he remarks in considered, was entitled to the highest credit for having another place) can endure the pressure of such an instrument pointed out the true principles by which we should be guidquarter of the time, when put on sufficiently tight to afforded in the employment of pressure, which it had hitherto any chance of obliterating the artery, and on account of the been deemed necessary to apply in such a way as to com Periscope-Dissection of a Subject cured of Aneurism by Compression. plefely obliterate the main trunk,-a proceeding which, as shown by Dr. Bellingham, so far from being necessary, is decidedly injurious. The object to be obtained by pressure is not to obliterate the artery by causing adhesion of its sides, but to obstruct and retard the flow of blood through it to a degree that will permit a firm coagulum to form in the sac, and thus to force the blood by the collateral vessels into the lower part of the limb. There is at the museum of the Richmond Hospital (the President observed) one of the most beautiful preparations perhaps extant of the collateral circulation after the successful operation of tying both femoral arteries in the same individual for popliteal aneurisms. These operations were performed by the late Mr. Todd. There is just now, also, in the Richmond Hospital, he would remark, an exceedingly interesting case under the care of Dr. Macdonnell, who tied the artery of one limb three or four years ago for popliteal aneurism. The man returned some time since with the same affection in the opposite limb, and pressure was employed, he was happy to say, with the most fortunate results, for their is now neither pulsation nor tumour to be found in the ham. As Dr. Macdonnell was present, he hoped he might trespass on that gentleman for a more full statement of this case. A great advantage attendant on this mode of treatment (the President observed) is, that when the patient complains much of pain at any particular point, the instrument may be shifted to another on the line of the artery. 325 two months-never returned, and the tumour has now diminished by absorption fully two-thirds its original volume. The man remains in the hospital at present more from the degree of interest attached to the case, and for the purpose of observation, than any other reason, for the cure may be looked on as perfected. Dr. Macdonnell would be happy to exhibit him and the instruments employed to any of the members of the society. The PRESIDENT said that he had asked Dr. Macdonnell's patient on one occasion, when he complained of pain from the pressure used, whether he would prefer the treatment he was under or the operation; and the man's reply was, that he would much rather submit to the operation; but here the society must remember that this was the choice of an ignorant man who knew nothing of the dangers of such an operation. He would venture to say that there was no surgeon present who would not give the preference to the mode of treatment by pressure in all available cases, so that one should be very slow to give way to the complaints of patients under these circumstances. Knowing, too, as we now do, that pressure is not to be applied to the extent of obliteration of the artery, the compressing means may be removed for a time and again replaced. He looked upon this method of treatment therefore as an improvement of the highest importance, but the value of which, it appears strange, our English neighbours seem to be very slow in appreciating. Professor HARGRAVE fully agreed in the opinions generally Dr. MACDONNELL had great pleasure in laying before the expressed in favour of the treatment of aneurism by comsociety the heads of the case alluded to by the President. pression in every instance in which that method could be It was one, he said, highly interesting indeed, and corrobora-made available, and it was of the utmost importance, he tive of everything that could be said in favour of this new considered, to work out completely the establishment of the method of treatment in external aneurisms. He fully con- practice, the truth and value of which it is not possible to curred in opinion with Dr. Bellingham, that the practice was gainsay. The practice had clearly been revived in this entirely new, and one of the greatest improvements effected country, first by Dr. Hutton, and afterwards so ably acted in surgical science since the days' of Hunter. In his (Dr. on by Dr. Bellingham. Yet, as he had just observed, the Macdonnell's) opinion, all the credit arising from this very problem still remains to be worked out to its clearest demonimportant addition to the science must be traced to the happy stration; for even in Ireland itself doubts exist the minds results of a case treated in this way by Dr. Hutton in the of provincial practitioners in reference to facts which had year 1842, and it was his belief that there are few names emanated from this very society. There are, undoubtedly, with which an advancement in surgical science could be certain cases in which compression will not answer, an more worthily associated than Dr. Hutton's. Dunne, the instance of which had been mentioned to Dr. Hargrave a subject of the case, at present under his (Dr. Macdonnell's) few days ago by a gentleman who is a pupil. The subject care, about five or six years ago, got a large aneurism in the of this case had been a patient in George's Hospital, London, left popliteal space, but at this period the case presented no some months ago, but was of so irritable a habit that he feature of particular interest. The ordinary operation at could not endure the treatment, so that the artery had to be Scarpa's angle was performed, after which the man com-cut down upon, and a cure was thus finally effected. With pletely recovered, and Dr. Macdonnell saw nothing of him regard to the remarks of Dr. Macdonnell respecting the until about six months since, at which time he came to him employment of partial pressure, that point, he might observe, saying, that a few days before, in lifting a heavy weight, had been investigated in an interesting manner in a case he perceived a snap, accompanied with intense pain, in the detailed by Sir Charles Bell which had occurred in a black. popliteal space of the leg, opposite to that formerly operated In tying the vessel below Paupart's ligament, pulsation was on. He soon after felt a small pulsating tumour, which had observed to have returned even before the patient was rebut little increased in bulk when first seen by Dr. Macdon- moved from the table. Sir Charles, turning to those prenell, who, at this time, recommended the man to come to sent said-" It cannot be helped; all that it was posthe hospital, but he put off coming on some excuse or other sible to do had been done." The man was therefore put to for two or three months. On admission now, however, he bed, but died some days after of diffuse inflammation. Sir was submitted to the treatment by pressure, the heads of Charles, feeling great anxiety to ascertain the cause of the which were simply these. A single instrument was applied return of pulsation, found on examination the very rare at the groin, but owing to the imperfection of its construc- irregularity of a double superficial femoral artery, coming tion, it by no means commanded the circulation, for pulsa-off below pouparts ligament; there had been notwithtion was still to be felt at the ham; nevertheless, during its standing this, a perfect coagulum formed in the aneurismal use, and while a more perfect instrument was being made, sac, thus establishing the fact, that only half-cutting off the he felt satisfied that the case was progressing, as the aneu- the supply of blood is sufficient to effect a cure. A prepararismal tumour was manifestly becoming firmer. As soon as tion of a similar irregularity is contained (Dr. H. observed) a second instrument was procured, and the original one im- in the museum of our own college. He believed it and proved, it became possible, by using them alternately, one the one described by Bell were the only two instances of the applied at the groin, the other about the middle of the thigh kind on record. In reference to the symptoms indicative of to command the circulation completely and extinguish pulsa- the thoracic aneurism which proved fatal in the communication in the aneurismal tumour; and by using them as long tion then before the society, he would allude to the single at a time as the patient could bear, sometimes for six or one of pain, which may now be considered as diagnostic of eight hours consecutively, pulsation at the ham entirely it, when much anxiety exists as to the true nature of the ceased in about two days, and has since-now a period of affection; a parallel case was presented to his own observa 326 Periscope. Dissection of a Subject cured of Aneurism by Compression. tion in the person of a strong, tall carpenter, of most regular [jected arteries in this case is contrasted with those now and moral habits. For some months before his death he exhibited to the society by Dr. Bellingham, the difference complained of nothing but intense, almost continued pain, is seen to be this, that in the preparation there is obliterareferred to the inferior angle of the left scapula, circum-tion of the femoral artery to the extent of about half an scribed to a spot, the size of a shilling; also of an uneasy inch at each side, while in Dr. Bellingham's case the vescord-like constriction round the edge of the thorax, for sels are pervious all through. The effect produced by a which he was bled, with permanent relief. The stethos-slower current of blood to allow of coagulation in the ancopic phenomena indicated healthy lungs and heart, and a eurismal sac had been the same in both, but was obtained normal condition of the thorax. No treatment relieved this in that treated by Dr. Bellingham by safer means. The pain; the man had been seen during Dr. Hargrave's atten-popliteal arteries both in Dr. Bellingham's and Mr. Adam's dance on him by Dr. Morgan and by Mr. Crampton. His preparations were obliterated to an equal extent. Nobody death was sudden; as he was sitting up in bed he fell back could have supposed, he said. that the autopsy would have and instantly expired. The post-mortem examination shown so trifling a difference in the anatomical characexhibited the lungs perfectly healthy; the heart slightly ters of the vessels. He had seen a case of aneurism high loaded with fat; the left pleural cavity was full of blood up in the femoral artery treated by Dupuytren by compres and serum; a long rent was found in the costal pleura, sion of the iliac, but the man had not patience to submit to through which the blood had issued from a ruptured aneu- the treatment, and called for the operation, which was perrism, situated in the commencement of the descending aorta, formed. the bodies of three of the vertebræ-the third, fourth, and Mr. McCoy would make a few observations in reference fifth-were eroded; some of the intervertebral cartilages to the case mentioned by Mr. Adams, as one of the most also were destroyed, which permitted the blood to circulate remarkable perhaps on record in favour of the treatment in the spinal canal: this pathological specimen (Dr. Har- of aneurism by pressure. He would not go into a particugrave said) is to be found in Dr. Bevan's museum in Peter-lar detail of the case at present, as he had the honour to street. Again, he would call on the surgeons of this city to lay it before the society in full in 1843, in a paper he read work out this practical problem, as the character of surgery on the subject of the present discussion, but though there emanating from this society and this college had been was not an objection yet raised against meddling with an impugned. aneurism, not a discouraging circumstance attending the Mr. ADAMS entirely agreed with Dr. Hargrave, that disease that was not to be found in that case. The man much of the improvement in the treatment of aneurism by was of intemperate habits and reckless character; he compression of the main artery leading to the aneurismal had had a popliteal aneurism to which he paid no attensac was to be considered as due to the exertions of Irish tion until one day going up a ship's side he felt something surgeons, although he would not be understood to say that give way; the revenue surgeon was sent for, and Mr. the principle of compression had not been adopted previously. Adams and he (Mr. M'Coy) accompanied him, when it He would go so far back as the time of Mr. Todd, who had was found that the aneurism had become diffused, and pointed out the advantages to be derived from the employ-nothing seemed possible to be done for his safety but to amment of compression preparatory to the application of the putate the limb; this was accordingly done, and the man ligature, in order (as Mr. Todd said) to prepare the col- recovered in the usual time. Two or three years after this, lateral channels for the reception of the increased quantity the revenue surgeon was sent for again to see this man, of blood thrown upon them as the result of the operation. and he (Mr. M Coy) accompanied him. An aneurism was Dr. Cheyne had also told Mr. Adams that the full report of found an inch and a half below Poupart's ligament, on a case of popliteal aneurism, successfully treated by compres- the same side as the previous popliteal aneurism-it was sion at the Richmond Hospital by Mr. Todd, was placed by the size of an egg, and pulsated strongly ; an operation that gentleman in Dr. Cheyne's hands, and was intended for was deemed inexpedient for many reasons, and it was depublication in the next volume of the Dublin Hospital Re-termined to try pressure, and Mr. McCoy was directed by ports, but which the lamented death of Mr. Todd prevented. his master, Dr. Duggan to apply it. Mr. Todd had the kindSubsequent to that time also, a case occurred under the care ness to lend him his own instrument for the purpose-it was of the late Dr. Duggan, which would most likely be re- accordingly put on, and carefully attended to from day to membered by Mr. McCoy. The case of Scarlet a tide-day, and finally the tumour diminished in size, became waiter in the revenue, in whom a neglected popliteal aneu- solid, and a perfect cure took place, which to-night he had rism became diffused, rendering amputation necessary, after the gratification to hear was permanent to the present time, which the man recovered. In two or three years after the after a lapse of five or six and twenty years. Here was a man got aneurism of the femoral artery of the same limb, case where two aneurisms had come on after a considerable which was perfectly cured by compression with the instru- interval on a very large vessel,-the second occurring ment used by Mr. Todd, and which Dr. Duggan borrowed. where that artery bifurcates into two nearly equal trunks; The same man had been in the Richmond Hospital about where, from position, it was difficult to apply or maintain two years ago from a complaint in the hip-joint. He might the necessary pressure properly, and in one he (Mr. McCoy) also remark, that Dr. Harrison had a case treated by com- could safely say, who was never a day perfectly sober pression in Jervis-street Hospital; in fact, in almost every during the whole treatment. Every one conceded honour hospital in town, cases of the kind had occurred; so that the to him who introduced any improvement into surgical pracquestion plainly resolves itself into one respecting the rela- tice, but in his opinion a far higher honour was due to him tive merits of the operation by the ligature and the treat- who promptly laid it before the profession through the ment by compression, for as to the applicability of the latter press for the benefit of society in general-he thought Dr. practice, their could be no possible doubt. The President Hutton and Dr. Bellingham entitled to that honour in this had alluded to a case of double popliteal aneurism, the in- instance. For himself he did not claim or desire any credit jected preparations of the arteries of both limbs of which, he for being the first to draw the attention of the society to might remark, is contained in the museum of the Richmond the chances favourable to the treatment of aneurism Hospital. In this case both arteries had been tied by the by pressure, as it was merely from the contingency of late Mr. Todd many years before the patient's death, which there being a disappointment in part of the business intook place under his (Mr. Adms) care in the Richmond tended for an evening's sitting of the 8th April, 1843, that Hospital from cancer of the stomach, and with the assis-induced him to go home for his notes and read them at the tance of his friend Mr. Smith, he had made a beautiful pre-meeting, as the secretary may remember. Among the exparation from the case. When the appearance of the in-Icellent observations delivered by Dr. Bellingham, there Periscope.-Gangrene of the Vulva treated by the Actual Cautery. 327 Dr. Macdonnell begged to add that every man of any experience is aware that aneurism has been treated by compression for a great many years past, but the difference between all former cases and Dr. Hutton's is this, that the conclusion drawn by the profession from the previous cases was that compression was a practice to be condemned. These cases did not fructify, Dr. Hutton's has, and upon it the practice of compression in external aneurism has, he might say, been founded, and it will be the means of establishing fully this great improvement in the treatment of this disease. was one opinion he expressed of considerable practical importance, and to which he (Mr. M'Coy) was disposed to give his full assent-namely, that it is not necessary to use such a degree of pressure on the artery going to an aneurismal tumor as to entirely obstruct the passage of blood through its canal, to ensure a successful issue; when the femoral artery is tied for popliteal aneurism it is no uncommon occurrence to find soine pulsation on the following day, perhaps in the ham; Mr. Liston had a case some time ago which was cured, and in which the pulsation of the tumour continued for twenty-four days. Mr. Colles was of opinion that when pressure is applied to the artery at some dis- Dr. Williams would by no means be understood to derotance from the tumour, it should be sufficiently firm to bring gate in the slightest degree from the merit due to Dr. Hutthe sides of the vessel in contact so as to induce adhesion, ton. He had accidentally become acquainted with Mr. while if the pressure be applied to the aneurismal tumour Todd's case, to which Mr. Smith had given such accurate itself, it should be applied as loosely as possible. Mr. testimory; and he (Dr. Williams) felt it only right to McCoy then alluded to cases of brachial aneurism, and a re-mention what he knew himself on the subject. He would markable one of palmar aneurism, which he had himself observe, in conclusion, that if possible he should produce succeeded in curing by the very slight pressure of gradu- the notes of the case, but he wished to state that it was ated compresses of lint bound on with sticking-plaster, possible, after a lapse of so many years, that he might not after failure by firm compression in some of them, the par- be able to get at them; he would again say, however, that ticulars of which he had laid before the society on a for-this circumstance by no means interfered with the question mer occasion. of priority of claims in reference to the subject under dis DR. HUTTON felt it necessary to make one or two observa-cussion. The whole matter, he thought, was somewhat tions in reply to some remarks that had fallen from the pre-analogous to the question which lately occupied so much vious speakers. He believed that the case alluded to, and to attention on the continent-namely, Callison's operation which Mr. M'Coy had borne testimony, had not occurred at for artificial anus, which had, in the first instance, been the Richmond Hospital-at least no account of the circum-universally condemned, but when Amussat took it up and stance had ever reached him, nor was he aware that such demonstrated its practicability, it became universally rea case had been published. As to the question of priority of cognized; for his own part, he considered a man entitled publication, Dr. Bellingham had in the handsomest manner, to so much the more merit for taking up and establishing he said, mentioned his (Dr. Hutton's) name in connexion as a valuable and practical method of treatment one which with the subject, and he felt assured Dr. Bellingham would had previously got a bad name, and was, in fact, looked on not hesitate to admit that his (Dr. Hutton's) case, as also as a failure. Mr. Causack's, had first appeared in print. Dr. Belling- Dr. Benson considered that the chief praise in the revivham had, in the opinion of all, worked out the matter al of this mode of cure was due to him who showed that in the most admirable manner. To him was due, principal- the cure of aneurism could be effected by merely lessening ly, credit of having improved the practice; for himself the current of blood at the point of pressure. So long as he certainly claimed the credit of its revival, but he fully obliteration of the artery there was supposed necessary, so admitted that he had adopted Mr. Todd's principle of treat-long must failure be the consequence. ment. DR. BELLINGHAM said that Dr. Hutton's case occurred six months, and Mr. Cusack's two or three months, previous to his; therefore there could be no question about priority. PRACTICE OF MEDICINE AND PATHOLOGY. GANGRENE OF THE VULVA IN AN INFANT DR. WILLIAMS did not mean to enter into a discussion of the practical part of the question under consideration, but as regarded what had been stated in reference to Mr. The subject of this case was of the age of two years, of Todd's case, he believed there was no doubt of its accuracy. the lymphatic habit, but otherwise in a healthy state. At Shortly before that gentleman's death he (Dr. Williams) the time that it was admitted into the hospital (Des Enfans had been a pupil in the hospital, and the notes of the case Malades) it had a gangrenous patch on the inner side of the had come into Mr. Cusack's possession, by whom they labia majora, completely encircling the clitoris. No appawere given to himself, and, to the best of his recollection, rent cause could be discovered. The child had been tolehe still had them. The case had certainly occurred at the rably well nursed, and did not appear in the least in a Richmond Hospital; whether it had ever been published condition likely to give rise to mortification. When seen or not, he could not undertake to say. Mr. McCoy had in-the next day the gangrene had made considerable progress, advertently stated that it was. wherefore M. Guersent determined to lose no time in the Mr. Smith would be even able, he believed, to mention endeavour to check it. As an external application, he to the society the exact date at which Mr. Todd's case touched the diseased part with an iron heated to whitness; occurred; it was in the year 1825, the year in which he internally he exhibited wine and quinine. In spite of this had the honour of being bound to the learned President. treatment the sloughing gained ground, and a second and He (Mr. Smith) was at the time a very young man, but deeper cauterization was had recourse to. From this mowas sufficiently acquainted with the general fact, that li-ment the disease was arrested; the eschar speedily detachgature was the established mode of treatment for aneurism. ed itself, and disclosed a healthy granulating surface. The Mr. Todd's death took place in six months, he said, after child continued the quinine for some time longer, and was the date of his (Mr. Smith's) apprenticeship. He could discharged cured. point out the precise ward in which the patient lay, and This form of disease is not uncommon in the crowded also the position of his bed, which was placed next the fire-hospital for sick children in Paris, and, like the cancrum place, and behind the door. He had watched the case at-oris, appears to depend upon a general vitiation of the tentively to its termination, which turned out to be com-fluids, induced, mainly, by deficient ventilation; the action pletely successful. The instrument employed was a sort of the cautery was decided in this case.—Gazette des Hoof combination of tourniquet and truss, pitaux, No. 66, |