17

THE LANCET.

London, Saturday, March 20, 1830.

THE DUBLIN WAX-WORKS.

THE newspapers, we presume, have made

most of our readers acquainted with the

munificent donation of the Duke of Nor-thumberland to the Royal College of Sur-

geons in Ireland. The manner in which

this godsend may be disposed of to the bestadvantage by the College, has since, we

perceive, become a question of public, aswell as of private discussion. In this, as in

every other instance in which men delibe-rate, differencss of opinion may be expected;but that doctors should disagree, is so muchn matter of course, that the discrepancies inthe " consultations " of the College, and ofthose who have volunteered to favour them

with advice on the subject, can excite no

surprise. So far as we have been able tocollect the scattered and contradictory intel-

ligence of report, there would seem to be a

preponderance of opinion in favour of the

project for establishing a museum of anato-mical and pathological wax-works, bearingthe name of the illustrious donor. It would

be rather a difficult matter to divine the

grounds which directed the attention of theCollege to beeswax or its preparations, if thegordian knot were not solved by the rumourof their benefactor, having intimated a wishthat his five hundred guineas should be

transmuted into waxen figures, or some

other pretty things of that description. We

believe it possible, indeed, to convert waxinto other forms, besides those of plastersand cerates, which may be subservient to

pathological purposes. In some museums

on the Continent, for example, this sub-

stance has been wrought into likenesses of

healthy and morbid structures, which, weunderstand, are very beautiful or very terri-ble to behold, just as the case may be, of aparturient Venus, or an old cancerous gor-gon. For these and all other artificial de-

vices, by which a knowledge of the humanbody in a state of health and disease maybeacquired, none can have a higher admiration

thanouTselves; the contents of such collec-tions display, in a striking manner, the tri-

umph of art over dissolution, by preserving’for posterity those rarer forms of diseasewhich might otherwise perish, or only existin the imperfect delineations of verbal de-scription. The great estimation in which

such preparations are held, would seem,

however, to have given an obviously inju-rious direction to the art by which they havebeen prepared. They have, in fact, beenlooked on as too valuable for every-day use,

and of too difficult execution to be attemptedby ordinary hands. Hence they are almost

exclusively consigned to the shelves of publicinstitutions, and the secret of their prepara-tion is confined to a few individuals belongingto those establishments supposed to possessa superior degree of manual dexterity. In

one branch, at least, of this useful art, we

conceive a great improvement might be

made, by rendering its cultivation more ge-neral than it hitherto has been, amongst the

members of the profession. We allude to

the manufacture of vascular preparations,which are seldom made or found in the

possession of students, though most of thempossess whole tomes of anatomical cari.

catures called plates, so decidedly inferiorto vascular preparations. We see no reason

why these extremely useful means of ac.quiring knowledge, should not be diffused

more extensively among pupils; why, an

attempt to make such preparations shouldnot, in part, be substituted in our anatomicalschools for the ordinary, but less profitablesystem of destructive dissection in presentuse ? The scarcity of subjects might, we

anticipate, be opposed to the practicabilityof this suggestion ; but this objection doesnot apply to all places, nor even to thosein which subjects are notoriously scarce. It

is allowed on all hands, that pupils dissectmore or less, let the price, or scarcity of sub-

18 THE DUBLIN WAX-WORKS.

jects, be what it may ; and some parts, at for any extraordinary exertion, or expense,least, they might prepare, with great im- in hastening on to completion a -collectionprovement to themselves, instead of throw- which will, in a short time, become completeing them away. It -would, in the first place, under proper management. But as yet,induce the student to conduct his dissections the groundwork of the kind of museum towith more precision, which, according to the which we allude, a HOSPITAL OF CLINICAL

present method, are but too often performed SURGERY, seems not to have been so much

with unprofitable negligence ; while, in the as thought of by that body. Yet it is the

second place, those parts which he may kind of appendage to the College, of which

carefully prepare, would serve ever after- it is at present most in need, and in thewards to refresh his knowledge of anatomi- establishment of which all its energies, bothcal minutiae, which frequently elude, in the moral and pecuniary, should be concen-

lapse of time, the grasp even of the most re- trated. It is, therefore, between a museumtentive recollections. We have no doubt, of this kind, and one of wax, that the Col-that the introduction of such an improve- lege must make its election; and if its

ment would amply remunerate the enter- members only allow their judgment to di-prise of its promoter, in any of our private rect them, the one on which their choiceschools of anatomy, and tend materially to will fall, may, we conceive, be -readily anti.facilitate, as it would to render permanent, cipated. Suppose they had, at this moment,a knowledge of anatomical science. Were one of the choicest colleetions of wax-works

the question between the introduction of a in Europe, safely deposited in Stephen’ssystem of teaching of this kind, and the Green, what, we beg leave to inquire,establishment of a museum of wax-works, would the College be the better for it as awe conceive that the College would be school of practical anatomy and surgery ?

consulting more the advantage of its pupils, Unless the artist, whom they may employ,by deciding in favour of the former, than of takes it into his head to turn Prometheus,the latter proposition. and to make new men, he can really pro-

But this is not the problem which the duce nothing in the way of anatomy-no-College has to solve at present; for being thing in the line of morbid structure-

determined on having a museum of one nothing in the style of obstetrical illustra-kind or other, its nature is the subject to be tion, one millionth part as instructive as thedetermined. Now the quality of museums originals, furnished by the dissecting-room,is extremely various; but there is one kind the clinical ward, and the lying-in-hospital,of pathological museum infinitely more va- For our own part, we never heard of anyluoble than all the rest put together, and advantage derived to anatomy or surgeryof which, in the present state of its circum- from these wax-works, nor ever saw anystances, the College of Surgeons in Ireland person who was made wiser than before bystands much more in need than of any other looking at them. The only advantage,collection of curiosities. With anatomical, therefore, which the College would derivehuman and comparative, as well as prepara- from such a collection, would consist in the

tions of a pathological description, the Col- empty eclat or reputation of its possession.lege is tolerably well supplied ; it cer- As to its being of any use to students, thattainly has more of such things than are is quite ridiculous; for, except glancing atreally made use of, and there is no reason to the show" in company with a member, theydoubt but that the collection will go on in- would have nothing further to do with it.

creasing in the same rapid manner as it has It would merely be drawing an idle mob ofheretofore. In fact, we see no great necessity visitors about the College, to the great hor-

19THE ANATOMY BILL.

ror and tribulation, we have no doubt, of into the details of a plan for the establish-our admirer, Sir Peter Courtenay, whom Mr. ment of such an institution, but we as little

Pearson’s cameleopard has already nearly doubt that if once erected it would supportkilled, but whom the increasing demand for itself, as that its erection might be attemptedadmission to see the new collection of wax- with every prospect of success by the Col-works, would positively send to his grave lege of Surgeons in Ireland. To those who

in less than three months. object to the proposition on the score ofLet the College, therefore contrast such practicability, we would say, has not the Col-

an unprofitable spectacle, such an empty lege accomplished the more arduous and ex-pageant, with the practical advantages of a pensive project of establishing and support-clinical hospital of surgery, before they ex- ing itself? If then it has done so much,pend one shilling of this donation or of any overcome these greater difficulties, is it too

other pecuniary resources possessed by them, much to suppose that in the course of time,which might, be laid out even on the pur- it might, by proper exertion, accomplish thechase of a plot of ground for such an estab- institution of a small surgical hospital ? It

lishment. That the College should be asso- is at least a part of our politico-economicalciated with some such an establishment, is, creed, founded on observation of all aroundwe think, an axiom which cannot be dis- us, that every thing of this kind is practi-puted. It is certain that no school can rise, cable to practical men. The fault in general,or has yet risen, to eminence without the in such cases, is not to be found so much in

assistance of such an institution. It would theundertakingasintheundertakers. Shouldbe pedantry, or perhaps impertinence, to the College, however, decide in favour of apoint out to its members illustrations of this museum, we take this early opportunity ofproposition both at home and on the Conti- bespeaking for its projectors, in considera-

nent. Even a small hospital, properly con- tion of their " miss-mollyish " recommen-ducted, would confer greater benefits on dation, the appropriate office of arraying thescience and humanity, in one year of its ope- " pretty wax-dolls" in fanciful flounces and

ration, than a museum containing all the petticoats.wax that ever was collected on Mount Hybla. We are aware that it may be objected to IT is confidently reported in the parlia-this suggestion that the sum received, even mentary circles that the ANATOMY BILL isthough aided by all the resources in the to be brought into the House of Lords, dur-power of the College, would be unequal to ing the present session, by a nobleman ofthe erection and support of a hospital. Such the highest rank and importance. If this

an objection is, we apprehend, an exaggera- question is to be again discussed in Parlia.tion of fear, rather than the result of a ment, we hope that its agitators will pre-

knowledge of the subject. It has been viously have the decency to submit theirshown, speculatively, by Mr. Kirby, in a intended bill to the consideration of the

pamphlet published some years since, that members of the medical profession, by whomthis great object was within the power of the alone. the subject is fully understood. At

College to accomplish ; and it has lately been all events, let us have a law founded in

experimentally proved, at Edinburgh, that a equity, one which shall apply to the bodieshospital with a very trifling quota of " cha- of the rich as well as to the bodies of the

ritable assistance, is competent to its own poor. Above all things let it prohibit, undersupport, if the fees of pupils are appropriated the severest penalties, the horrid and filthyto that great and benevolent purpose. Our traffic now carried on between resurrection-

space at present does not permit us to enter ists and their employés.

20 REVIEW OF WARDROP ON ANEURISM.

On Aneurism, and its Cure by a New Operation, dedicated by permission to B.the King. By JAMES WARDROP, Sur-geon to His Majesty. 8vo. pp. 117.

B’London: Longman and Co. 1828.

WE believe it may be laid down as an axiomin medicine, that the more closely the ope-rations of Nature are investigated, the

greater will be our progress towards perfec-tion in the sole end of medical inquiry,namely, the cure of disease. The whole

history of medicine fully demonstrates thetruth of this position, and when we narrowour consideration to the subject of the workbefore us, we find it as clearly proved ; wefind that the treatment, nay, that each stepin the progress to the present improvedcondition of the treatment of aneurism, hasbeen suggested by the observation of somenatural process. Now, too, we find the

limits within which our remedial meanswere supposed to be restricted, pushed still Ifurther by a more complete analysis ofNature’s operations, and a legitimate induc-tion from facts; facts, the greater numberof which had been heretofore observed,but which had remained wholly uninter-

preted and unapplied to any practical pur-pose.

It is needless to speak of the paramount,importance of the subject to be considered,inasmuch as it consists in the treatment of a

variety of disease until now regarded as ne-cessarily and speedily fatal, and wholly be-yond the resource of art. The object ofthe work, on the examination of which weare about to enter, is to elucidate the newlydiscovered principles on which the authorfounded his anticipations of success in thetreatment of that form of disease, and tocollect the reports of cases in which the

treatment proposed has been successfullypursued.

Nunc ad inceptum. The contents of

an aneunsmal sac, on being examined, willbe found to be formed of coagulable lymphdeposited in laminae, and, if a spontaneouscure be effected, ‘ though there are no lessthan five ways in which it may take place,the principle which Nature employs for thecure is, in all, the same ;" in all, consistingin the deposition of lymph.

" The different modes which have beersuccessfully employed in the treatment o:

aneurism, are all in strict imitation of thenatural or spontaneous processes of cure.

" As it is the force of the circulationwhich causes the enlargement in an aneuris-mal tumour, as well as its ultimate rupture,and as the coagulating process, or the for-mation of laminated coagulable lymph withinthe sac, proceeds according as the force ofthe circulation is diminished ; hence is tobe explained the rationale of Valsalva’s sys-

tem of treatment." 11 The great languor ofthe circulation which is induced under itsinfluence, will enable the coagulating pro-cess to go on, &c,"

Again; It appears to me that the suc-cess in such cases of aneurism," (thosetreated by compression), " ought to be at-tributed to the pressure acting above or be-low the tumour, rendering the circulationin it more languid, and thus contributing to.the formation of coagulum, in like manneras in the other modes of treatment."

Turn we to Hunter’s operation, or ratherto so much of the observations on it as is

requisite to our present purpose."

When the Hunterian operation for thecure of aneurism was first contemplated, itwas, no doubt, undertaken on the principle,that it would be followed by a complete

’ stoppage-of the circulation of the blood in, the tumour. But in some of the cases ope-rated upon by Mr. Hunter, and related by

Sir E. Home in the Transactions of the So-ciety for the Improvement of Medical andChirurgical Knowledge, Sir Everard states,that the tumour in the ham continued topulsate for a considerable time after the

ligature had been placed on the superficialfemoral artery ; and the important conclu-sion Sir Everard drew from that fact was,’ That simply taking off the force of the cir-,culation.from the aneurismal artery is suf.ficient to effect a cure of the disease, or, atleast, to put a stop to its progress, and toleave the parts in a situation from which the-actions of the animal economy are capable ofrestorin them to their natural state.’ " .

‘ The knowledge of this fact, so distinctlystated by Sir E. Home, did not lead, how-ever, to any practical inference, further than

pointing out, that the circumstance of cir-culation in the tumour being carried on evenafter the artery was tied, ought not to beconsidered as an objection to Mr. Hunter’soperation." I shall, however, have occasion to point

out the importance of this pathological fact,and to endeavour to demonstrate, that itenables us to establish a new principle foroperating in aneurisms so situated ai hi-therto to have been considered beyond thereach of art, and to which the Hunterian

principle of operating is totally inapplica-ble."

21WARDROP ON ANEURISM.

The author, in the next place, proceeds the vessel was tied beyond it,- the swellingto the diminished, a circumstance which was ascer-

" Revival of Brasdor’s operation.-Those tained by the skin covering it, and which wasaneurismal swellings, so situated that the tense, and ready to burst, suddenly formingknife of the surgeon could not reach the into wrinkles." This phenomenon is sim-vessel between the tumour and the heart, ply and fully explained thus :-" The fluidhave hitherto been deemed incurable. blood can find in such case a ready exit into" Brasdor, indeed, a professor in the an-

blood . , in cient school of surgery in Paris, upwards of the trunk, whence it came, and thus againforty years ago, made a proposal in his lec. passes into the circulation ;" - - - ’‘ and astures of another mode of operating for aneu- nature immediately finds a new channel,rism, which was, to place a ligature on the there is no more blood impelled into theaneurismal artery on the distal, in place of tumour afterwards." We agree fully withthe cardiac side of the sac, as recommended

an opinion

founded on this fact, and statedby Hunter.

" by Hunter.

..

at a subsequent part of the work, viz., thatDeschamps first performed this operation it gives to this operation, pro tanto, asu-

°‘ under the most unfavourable circum- periority, especially in large aneurisms, overstances." He was followed by Sir Astley that in which the ligature is placed onCooper. Both cases terminated fatally ; in the cardiac side of aneurism, inasmuch asthe latter, however, the tumour was ob- the blood, in the latter case, ° cannot beserved to have decreased considerably in pushed through the capillaries into thesize for some time after the operation. veins. It must remain in the sac, and must

" These were the only cases in which this either be absorbed, or be evacuated by amode of operating had been adopted from process of inflammation and ulceration ofthe time of its proposal by Brasdor, until the sac."about three years ago, when I had myself an

the sac."

opportunity in a case of aneurism at the root Our observations on the cases in whichof the carotid artery, of putting it to the test the operation of Brasdor has been perform-of a fair trial. ed, shall be very brief. They are four in

" With regard to the principle on which number, and have, each of them, at the pe-the operation of Brasdor cures an aneurism, riod of its performance, been placed in mi-the operation of Brasdor cures an aneurism, riod oi its performance, been placed in mi-I would first observe, that the changes , ,

’ -

which such an operation produces both in nute detail before the profession. One,the artery and sac, are precisely those which which was that of an unhealthy old female,nature employs when she cures the disease died of diseased heart, and general dropsyby a spontaneous process." resulting from it, in several months after

_

The atfthor next goes on to say, that, in the operation. Another died of haemorrhagecases where no arterial branch passes direct- in two months after having been operatedly into the aneurismal tumour, or comes off on ; this, the reader is aware, is not unfre-from the trunk between the tumour and the quently a result of the Hunterian operation,ligature, no sooner is a ligature tied on the and cannot serve in any degree to attachvessel beyond or at the distal side of the discredit to this mode of operating. The

aneurism, than the collateral vessels dilate "post-mortem" examination of the case

and perform the functions of the obstructed shows clearly, that but for this accidental

trunk, as after the Hunterian operation. circumstance, the result would have beenWe have already seen, that languor of most successful. 11 With regard to the

circulation is alone necessary for the conso- hæmorrhage which took place in this case,lidation of an aneurism. This indication it is important to remark," says our author,may certainly be easily expected to result " that the blood in this instance flowed from

from the application of a ligature beyond the the distal, and not from the cardiac orifice

tumour; but who would not have feared the of the artery ; the aneurismal sac and por-occurrence of such a degree of distension, tion of the vessel between it and the liga-as should probably cause the parietes of the ture being plugged up with coagulatedsac to burst? Yet this apprehension, which lymph, and having become quite imper-constituted the strongest objection to the vious." The consolidation of the aneurism

operation, is, as we have seen, wholly un- was complete, and this, be it remembered,founded ; the direct contrary takes place- was, as in all cases, the object for which theInstead of increasing immediately after operation was performed, The remaining

22 REVIEW OF WARDROP ON ANEURISM.

two individuals were completely cured, and I foreign publications of character. We mayare, we believe, still living.though years have instance a work of some promise, at presentelapsed since they were the subjects of opera- being published at -Paris, viz., the "Diet.tion. Three, then, of the four cases, entirely de Medecine et de Chirurgie Pratiques."justify the operation, affording incontestable In the article on aneurism, in one of theproof that it is equal to the cure of, inas- published volumes of that dictionary, thoughmuch as it has cured, a form of disease the work of Mr. Wardrop is quoted, we arehitherto consigned to Nature’s unaided di- still surprised to find it stated, to be a ne-rection, and, in consequence, almost inevit- cessary condition for tying an artery beyondably, to the tomb. To show more clearly the an aneurismal tumour, that no branch inter-

importance of the practice, let us glance for vene between it and the ligature. Such,a moment at the condition previous and certainly, had been the almost universal

subsequent to the operation, in any one of opinion previously to the publication of ourthe cases which terminated favourably. Of author’s researches. " The complete stop.one of the sufferers it was said, " The poor page of the circulation was, by all, deemedwoman is much emaciated, and her degluti- a ’ sine quâ non’ to its success. Suitabletion and respiration, which have been much cases for the operation, under such circum-impaired for some months, are now almost stances, must have, therefore, been extreme-annihilated." Many physicians and sur- ly few ; and this may be considered the rea.geons (the names are given) assembled son why it has been so seldom practised :’yesterday, " and after considering the case, The successful results, however, of thewere of opinion that an operation would be foregoing operation, together with discove-

fruitless, in consequence of the advanced ries from dissections, have led me to ada step further, and I trust that I shall

stage of the disease ; and, moreover, from now be enabled to communicate the know-the magnitude of the tumour, it would be ledge of a principle for the cure of many.impossible to find the carotid artery. This aneurisms, which have hitherto been con.morning my medical friends wrote to me sidered beyond the reach of art."

saying, that as Covis (the woman’s Our author, however, is not quite correctname) had not swallowed for the last nine when he states that " the complete stoppage ofdays, her respiration was becoming more the circulation was by ALL deemed a sine quaalarming, and her voice had almost failed non to the success of the operation: ’ Mr.her, they wished I might now attempt to Lambert, in his account of the ease of Mrs.secure the carotid on the distal side of the Apostle, published in number 186 of THF,aneurism." Such was the condition before LANCET, March 24, remarks, "There couldthe operation : mark the sequel. ’° Imme- be no doubt that the disease was aneurismal,.diately after tightening the ligature, and and apparently affecting the lower part of thebefore the wound was dressed, she swallowed right common carotid artery ; but, whetherten ounces of wine and water, and such was confined to that vessel, or extending into theher relief, that she actually thanked me for arteria innominata, was to me a matter ofthe benefit I had conferred on her, and, it conjecture,* ‘ ’. This, however, is not.allowed, would have prolonged the conver- of the moment which at first sight it appearssation." -Again, in a month afterwards, we to be ; for, as I shall have occasion presentlyfind it stated of the same person, " she is to remark, the operation of tying the arteryin perfect health, &c." Who that has read above the tumour is expedient in EtTHER

this, will not be disposed to exclaim, case."-LANCET, Vol. 11., p. 802." Here is, truly, the triumph of surgery Mr. Lambert goes on to observe, "And theover death !" applicability and expediency of tying an

-

THE NEW OPERATION. artery beyond the tumour in cases where theTHE NEW OPERATION. ordinary method, from peculiarity of situa-

To this we are desirous of directing the es- tion, could not be adopted, were amply de-pecial attention of,the reader, more particu- monstrated by Mr. W’ardrop’s two cases.

larly, as although of greater . -

be- But I am not without hope that tins opera-larly, as although of greater importance, be- . I am not without hope that this opeia-° ° tion may be rendered still more serviceablecause of far more extended application, than that it will be found available in cases hither-

, the operation which we have just noticed, it to regarded as utterly beyond the reach ofhas escaped the observation of some late surgical aid. I mean in aneurisms of the

23WARDROP ON ANEURISM.

arteria annominata. If we suppose a case " In a case of aneurism of the innominata;

of aneurism of the arteria innominata mani- Mr. Mackelcan found that nature had nearlyfesting itself by a tumour at the lower part completed a cure of the disease on this prin-of the neck, let us inquire what would be the ciple. The carotid iitery was plugged up,effect produced by applying a ligature to and the large aneurismal swelling was filledthe right carotid artery, in such a case. The with a coagulum, leaving only a compara-impulse of the blood would certainly be di- tively small channel for the blood to passminished, and more especially at the upper into the subclavian artery. I have seen

part of the sac, the course in which the dis- some cases, and several are on record, whichease is extending ; the obvious effect of an illustrate the same important pathologicalinterruption to the ingress of blood in an fact, and prove beyond a doubt that bloodaneurismal tumour, is the formation of a can coagulate in an aneurism so as to

coagulum, and such I apprehend would be strengthen the parietes of the sac, and ulti-the case in the disease under consideration. mately fill its cavity, without the circulationThe diminution of the quantity of blood en- through the sac beiug, in the first instance,fering the tumour, and the reduced impetus either suddenly or entirely interrupted.of the fluid, would, I believe, allow of a de- " It was a knowledge of this fact that ledposition of coagulum in the upper part of the me to perform the operation I am about tosac, and thus we should (if I maybe allowed relate. In the patient, nature had alreadythe expression) build up the sac at that instituted a curative process, by diminish-part where the disease was extending, and ing the circulation in the carotid artery, andprevent its proving fatal from rupture. That when I found this alone not sufficient to

the curative process in an aneurismal tumour arrest the enlargement of the aneurism, Iwill go on, notwithstanding that the circula- then determined on placing a ligature ontion of the blood is kept up to a certain ex- the subclavian, and in so doing, conceivedtent, is an acknowledged fact." p. 804. that 1 was strictly imitating the process

which nature herself had commenced. IUpon precisely similar views was the was thus led to act on a new view in this

operation of tying the suhciavian undertaken operation, and was naturally induced to con-by Mr. Wardrop, in the case of Mrs. Den- sider the important question, To what extentmark.*

-

is it necessary to diminish the momentum of

It has been established, at a former part the circulation through an aneurism, before

,.

’ part the blood contained in it will coagulate ? Ifof this article, that complete cessation of I were able to ascertain this, it is evidentcirculation is not necessary to the coagula- that I could at once point out with accuracytion of the contents of an aneurismal sac,- those aneurisms in which it would be prac-" A knowledge of this circumstance alone

ticable to cure the disease by tying the ar-" A knowledge of this circumstance alone ticable to cure the disease by tying the ar-would, we might suppose, have led to the tery, or arteries, at the distal side of theadoption of Brasdor’s operation, in those tuinour, Now, in examining the cases where.aneurisms in which the circulation of the nature had performed a spontaneous cure,blood in the tumour could only be partiallv on the principle of forming by deo-rees z’ a

arrested ; and thus would have led patholo-barrier to the circulation in the sac by an

gists to inquire, what was the necessary obstruction in the vessel beyond it, it ap-gists to inquire, what was the necessary obstruction in the vessel beyond it, it ap-

5 to f i*) circulation ’ the peared indisputable, that a process ot coa-degree to which the circulation in the tumour peared indisputable, that a process of coa-must be diminished, in order to admit t the sutation in the aneurismal sac must havemust be diminished, in order to admit of the begun i the momentum of blood in itmust be diminished, in order

to admit of the begun when the momenturu ofbtoodiu it

coautilation of its contents, .

, ,. could have been but very sfightty diminish-But by far the most interesting and could more alteration having taken place incondusive arguments to elucidate the im- the circulation than what might be supposedportant point, which I am so desirous to to be the effect of an enlargement of theestablish for the cure of aneurism, are to be to be the effect or an etilar-ement of theestablish for the cure of aneurism, are to be calibre of the arterial tube, at the daeaseddeduced from the observations which

calibre of the arterial tube, at the diseaseddeduced from the observatious which have part ; either can it be supped that the.been mage on the spontaneous cure of the part ; neither can it be supposed that the

disease ; and the spontaneous circumstance, vessels which were obliteratecl, in the casesdisease; and it is a curious circumstance, to wich I allude, could have undergone any..., , _, to which I allude, could have undergone anythat the natural or spontaneous process does a sudden not on the principle of does thing like a sudden or instantaneous ubstruc-tiot eiteet a cure on the princiofe of the . .

Hunterian operation by completrly arrest- tion on the contrary, whatever the processarrest- have been, the arteries seemed to Laveing the passage ol’ the blood into the ssc, may have been, the arteries seemed to havebut the passage of the blood into the sac, undergone a gradual obatruction, indicated.but is in stuctconfornnty with the principle b the slow diminution in the force of their.but is in strict conformity with the principle by the stow dtmmuticn in the force of theirof the operation I am now endeavouring to ptilsatio-i. y . That a very moderate degree f

.

of the operation I am notv eadeavourina to pulsation. That a very moderate degree otestablish,-that is, by the formation of a establish,-t.iat is, Iry the iormatiou ot a diminution in the impetus of the btnodofbarrier in the artery beyond, or at the distal diminution in the impetus of the blood ofbarrier in the artery beyond, or at tlie distal aneurismal sac is adequate to allow the

tide of the aneurism. process ,. the contained bloodcoagulating process ot the contained blood——————————————————————— to go on, seemed therefore to me proved

* LANCET, No. 186, page 803. from the pathological facts which 1 have now

24 REVIEW OF WARDROP ON ANEURISM.

stated ; though still, the exact quantity ne--cessary to effect this purpose remained amatter of conjecture."-pp. 60-63.We happen to recollect a case, operated

on some years ago by Mr. Charles Bell,which, in our opinion, supports strongly thearguments here adduced. A negro hadpop-liteal aneurism, for which Mr. Bell, assistedby the late Mr. Shaw, tied the femoral

artery. On tightening the ligature, it wasobserved that there was no effect producedon the pulsation in the tumour, as is usualin such cases. Mr. Bell, however, satisfiedthat he had performed the operation pro-perly, determined on awaiting the issue

without interfering any further. The man

died some time after of an internal, or vis.ceral, inflammation. On examination of thelimb on which the operation had been per-formed, it was found that the femoral arteryhad divided, above the situation of the liga-ture, into two branches, which again becameunited into one trunk, higher up than theaneurism, so that the blood conveyed byboth passed through it. One of the brancheshad been tied; the other was pervious, yetthe aneurism was found to be completelyconsolidated. Now, in the case where thereis but one arterial trunk, and that it is tiedfor aneurism, we know that some blood

continues to pass through the tumour byanastomosing vessels. In the instance de-tailed, there must have been a portion sup-plied to the aneurism by the same medium,together with the further addition of that

conveyed directly through the additional orsecond femoral artery. The latter quan-tity may be fairly regarded as equal to halfthat which originally circulated in the aneu-rism. From this it necessarily follows, thatin the case before us consolidation of theaneurism was procured; in other words, thatthe disease was cured, though the circula-tion through it was diminished only by aportion less than half. But what need isthere of any such calculation ? Is not one

of the circumstances noticed in the last

extract from our author, all-sufficient on thishead, namely, that when the disease is

spontaneously cured the coagulation mustcommence, while there is no diminution ofthe quantity, and scarcely any retardation ofthe course of the blood ?

The principle of the operation proposed is

very happily illustrated by the author withreference to the case in which he has per-formed it,-namely, aneurism of the arteriainnominata :-

« Let me suppose, by way of illustration,that the right carotid and subclavian arteriesinto which the innominata is divided, are ofequal diameters; it appears from those caseswhere the spontaneous cure had commencedin the aneurism of the innominata, that the

closure of one of these great branches wasnot alone sufficient to allow of the completeconsolidation of the tumour. Suppose,therefore, that besides the carotid, the cir-culation through the subclavian artery wasarrested at the point where it emerges frombetween the scaleni muscles, a very con-siderable diminution in the circulation ofblood in the tumour would then be produc-ed, and the arteria innominata, in place ofhaving to transmit blood through the carotidand subclavian vessels, would only have to

supply those branches of the subclavianwhich come off nearer the heart than thepoint where the ligature had necessarilybeen applied. Suppose, further, that thesebranches, which are usually four in number,when taken collectively are equal in diameterto their trunk, it will then follow, that if the

right carotid be impervious, and the sub-clavian be obstructed at the point alreadymentioned, no blood will pass through theinnominata, except such a quantity as issufficient to supply the four open branchesof the subclavian, and which quantity willbe about one-third only of the mass thatwould circulate through the iunominata,were its two great branches not obstructed ;hence, the blood contained in an aneurism of

’ the innominata, would have its circulationdiminished nearly two-thirds."-pp.64,65.

If itbe objected, that the four open branchesof the subclavian, by their enlargement, allowas much blood to pass through the innomi-nata as used to pass before the ligature wasapplied, it is answered by pointing to im-portant dissections by Sir Astley Cooper,which show, that though a few branches con-veniently situated ultimately perform the

functions of the obliterated vessel, in the

first instance the current of blood is diffused

over all the contiguous branches in the ratioof their different sizes.The principles here briefly stated (for a

full development of which we refer to thework itself) have been, on one occasion,submitted to trial by the author. All the

circumstances connected with the case havebeen so amply detailed during their progress,in this Journal, that we consider it unneces-

25. WARDROP ON ANEURISM.

sary to make any detailed re-statement of a short time subsequently to the perform-them here. We shall merely remind the ance of the operation. Depletion was re-reader of a few particulars. The symptoms sorted to without any effect in checking theunder which Mrs. Denmark, the patient, progress of the disease. Some constitutional

suffered, were, as in the preceding cases, of symptoms set in, under which the patientthe most distressing kind. °° Her nights sank.

are restless, and disturbed ; she sleeps but We are prepared to hear it inquired, whyfor short periods, and is often. obliged to get not have tied the carotid artery at this pe-out of bed, she has great difficulty of respira- riod? To this question, in the justice oftion, which, on the slightest motion,increases which we entirely concur, let our authorto such a degree as to produce a sense of answer-

impending suffocation, &c. &c." The sys- " However firmly I had adhered to thetem of Valsalva was enforced for some time original opinion I had formed of the seat of £with, at first, some amendment; this, how- this aneurism, there were some surgeons inever, was temporary, the tumour and con- whose discrimination and judgment I had

sequent sufferings began rapidly to increase. the greatest confidence, who were dubious., . , / of the precise seat of the tumour. SuchIt was evident that the only hope of pro- doubts in a case of so difficult a diagnosis,tracting the life of the sufferer rested in the together with a consideration of the severityperformance of the operation. and danger of tying the carotid artery, evenNo pulsation was felt in the branches of under the most favourable circumstances,

the carotid artery, from which circumstance Wf ere, to tml sufficient reasons for not per-it was inferred that thus was supplied the forming that operation.

condition which we have before seen stated The result of the " post-mortem " examin-to be necessary for expecting consolidation ation is of vast importance. It proves howof the aneurism on tying the subclavian. well justified was the author’s confidence inIn some days, however, after the applica- assigning the seat of the disease, and stampstion of the ligature to that vessel, the pul-’ their appropriate value on the rules which hesation returned in the carotid artery. Not- has given for forming an accurate diagnosis,withstanding this circumstance, the tumour without which, of course, no operation cangradually diminished, so as at length to be be safely performed. We may observe, thatscarcely perceptible, and the greater num- previously to the publication of this book, nober of the general symptoms were wholly attempt had been made by any surgeon, toremoved. Thus, though the author had not assign the means by which a correct judg-expected the removal of the disease, the ment may be formed of the exact situationscircumstances which his researches had led of aneurisms occupying the lower part ofhim to regard as indispensable thereto not the neck. This circumstance, and their ac-being present, we see clearly that the con- curacy as proved by the dissection of thedition of the patient was changed from one case alluded to, induce us to regard the

of agony, to that of quiet and freedom from " diagnostic rules" as among the most in-any distressing symptom, at the same time teresting and important parts of the work.that her life was prolonged for a period of We have not space to do more than merelymore than two years. In so far the result indicate the case operated on by Mr. Evans,of the operation must be regarded as most of Belper, which is contained in the ap-

satisfactory. The individual was living at pendix. That gentleman supposed that thethe period of the publication of the author’s aneurism was seated at the root of the caro-work. As she has died since then, we refer tid artery. We, however, are of opinion,for the concluding particulars of the case to that it was situated in the innominata. Tothe second volume of THE LANCET for last this opinion we are forced, particularly byyear, in which they are exclusively contained. one circumstance, viz. the obliteration ofIt will there be found that Mrs. Denmark the arteries of the arm. Mr. Evans says,died September 13, 1829, i. e. twenty-six , I think there can be no doubt that themonths after the operation. A few months obliteration of the arteries of the arm was

previous to her death, a tumour, now occu- accomplished by inflammation, extendingpying a new direction, was observed. The from the aneurismal sac to the internal

carotid, as has been seen, became pervious membrane of the subclavian artery, and

26 EXTRA-UTERINE PREGNANCY.

thence to the brachial artery." To this ex- gree, that no deposite can be formed underplanation, we cannot assent; we consider it any circumstances. These physiologicalto have been produced by obliteration of an considerations confirm strongly the opinionaneurism situated in the innominata; but of the inutility of Vatsalva’s system, enter-" sub judice lis est," and the question can- tained by surgeons of eminence, and, in ournot be set at rest at present. judgment, very much enhance the value ofWe cannot omit noticing the author’s opi- the resources advocated in the present

nions, as to " when the new operation may work ; which, vchilst it contains the mostbe adopted." He states that the first sub- conclusive evidence of the brilliant talents

ject for inquiry, in deciding this question, and scientific labours of its author, presentsis " whether blood continues to circulate to the profession evidence, not less conclu-through both divisions of the innominata, or sive, ot the extent of that base malignity,only through one of them 1" In the former grovelling ignorance, and cold-blooded andcase, when the aneurism has not attained so heartless prejudice, by which it has been

great bulk as to produce very distressing endeavoured to overshadow the lustre of

symptoms, or to threaten rupture, he would Mr. Wardrop’s splendid researches, and to

be satisfied with adopting Valsalva’s sys- render them unavailable to the sufferingstem, in the hope that, ultimately, one of the of afflicted humanity.trunks might be obliterated." Should how-

ever this not ensue, " the propriety of tying **°°*

one of the divisions of the innominata is tobe considered, and how far such treatment

CASE OF EXTRA-UTERINE PREGNANCY.

ought to be adopted in a patient whose csse ANNA M. PACCHINI, aetat. 30, of Cassanois in other respects hopeless, future experi- in the neighbourhood of Bergamo, was inence can alone determine." " July 1807, delivered of her first child, andence can alone determine." b ecame pregnant for the second time duringWith regard to the treatment of Valsolva, 1808 ;; this second pregnancy had advancedwe freely say that we are not satisfied of its without any unusual occurrence, to the

efficacy in procuring the consolidation of sixth month, when, without any assignableaneurism under any circumstances. We cause, the movements of the child suddenlyhave seen that, in all the cases detailed in ceased; none of the symptoms, however,Mr. Wardrop’s book, it had been tried were

observed which usually accompany theMr. Wardrop’s book, it had been tried and of the child. On the 9th of March,found wanting. We know that many sur- 1809, she being then at the end of the ninthgeons, of great experience, place no confi- month, was taken in labour, whi3li was ex-dence in it. Among them may be instanced tremeiy painful, and, after a long duration,the Baron Dupuytren, who has said that suddenly terminated with a crepitousncise inthis treatment is prejudicial : for that after the abdomen, after which the labour-pains andthis treatment is prejudicial ; for that, after all *be other symptoms of parturition imme-reducing the patient to the last extremity, diately ceased; only a slight hæmorrhagewithout the slightest benefit, he had the ; followed ; and in about six days the patientmortification of seeing many of the patients was sufficiently well to leave her bed ; herso treated, become attacked bv some inflam- breasts were distended with nulk; the

.’

, lochial discharge was also perfectly regular.matory affection, when he commenced, ever lochial discharge less in perfectly before

, ller abdomen was less in size than beforeso cautiously, to increase the quantity of II the iabour-pains. but a tumour was percep-food, in order to bring them into a con- tible in the right iliac region, though itHition fit for undergoing an oper-.tion. Such caused not the least inconvenience. For

are the facts. It may be said, Does not the two years she enjoyed very good health ;

perseverance in the system produce languor menatruation was regular, though some.of the circulation, and is not that sufficient what deficient in quantity. A remarkableof the circulation, and is not that sufficient phenomenon was, however, observed, viz.,for establishing the consoUdation ofaneu- that she had au irresistible aversion to con-risin ? True; but lano-uor of the circulation nexiou with her husband (una insuperabileis not the mily effect piolueed by depletion aversione alle unionicongiuyali). In June,and abstinence-that favotirable effect is ! 1811, after scme over-exertion she was

counterpoised by anntEaer. The deposition of suddenly seized with violent pain in the ab-- domen, which ceased, however, under thelymph is the immediate means of consolids- applicatson ef emollient fomentations, andtion ; the treatment under consideration the internal use of almond oil. From thislessens the quantity of lymph to such a de- period, lowever, up to the year 1815, she

27SECOND CÆSAREAN OPERATION.

had every month two or three similar attacks, ° contracted. The wound was cleaned, andwhich were generally produced by the least united in the usual method by sutures. Theexcess in diet; at the same time she began patient, who had evinced great courage dur-to waste away, --,tnd had daily accessions of ing the operation, was removed to her bed,fever. On the ist of May, 1815, she was and had some red wine given her ; shortlysuddenly seized with excruciating paiu in afterwards, she was seized with sicknessthe lower part of the abdomen, with tenes- and vomiting, which ceased under the usemus ; this attack ceased after a copious stool, of ammonia. Soon after tle operation, acontaining several small bones, mixed with small quantity of blood escaped through thefaecal matter. Dr. Rensi, of Bergamo, sub- vagina. On the l3th she was tolerablysequently examined them, and found them well, and had made water. The lochial dis-to be the phalanges of the fingers of a foetna. charge was regular, and some bloody serumFrom May till October, she had repeated at- had oozed from the lower angle of the wound.tacks of violent pain and tenesmus, which On the 14th she was rather feverish and

always terminated in the evacuation of foeta) restless ; the abdomen was tympauitic, very_

bonea; those of the head, however, re- tender on pressure, especially in the left iliacmaiued, and were still felt in the right iliac region ; the wound had a healthy appearance,region. On the 12th of October the patient but had discharged very little. The lowest

having a more violent attack than ever, on suture was accordingly divided, in order toexamination the head was felt a few inches give a free passage to the fluids which might,above the anus, and M. Batti, a surgeon who perhaps, have accumulated in the abdomen.happened to be present, succeeded in ex- At the same time, six leeches were applied,ttacting it. After this no attack of colic pain calomel and camphor given internally, andreturned, and the patient perfectly reco- an injection of milk made into the ree.vered her health, but died in the beginning turn. Towards the evening, all unfavourableof January from pellagra. The post-mortem symptoms had disappeared; the fever wasexamination was objected to,-Annal. Urai less, and there was hardly any tenderness.wersali di Medicinà, Dec. 1819. On the 15th the patient was still better ; the

____ lochial flux was rather profuse, and mixedwith much coagulated blood; the wound

CÆSAREAN SECTION PERFORMED TWICE also discharged a great quantity of offensiveON THE SAME WOMAN. ichor. No secretion of milk had taken

. S. L., setat. 26, who, in her childhood, place. The wound was now dressed withnad been subject to rachitis, was, on the a decoction of cinchona and tincture of10th of May, 1826, taken with labour-pains, myrrh. The patient having been costive forwhich continued during the day, and in the two days, the gtBster was repeated. On the

evening, at about eleveu o’clock, caused the 16th she had a copious stool ; the pain in theTuptuie of the membrane. On the morning left side had almost entirely disappeared.of the llth, M. Enge1trum, of Amsterdam, During the following days the wound beganfound the os uteri dilated, and the head to heal, and on the 12th day after the ope-presenting ; the ossa pubis were mal- ration, cicatrisation had so far advanced, thatformed; the’ antero-posterior diameter at the patient was allowed to leave her bed forthe brim was not more than two indies and half an hour. On the 30th day, the wounda half, and the other diameters were also pro- was perfectly closed ; the uterus appearedportion ally small, the head was very high, and to have returned to its natural size, and theredid not seem to descend ; the pains were was no discharge through the vagina. The

strong, though short. In the course of the day cicatrix of the wound was 3 inches in- no alteration took place ; the pulse was quick length, and from two to five lin(-s3in hreadth.and full, the face flushed, and the patient ap- Ou the 15th of June, she regularly menstru-peared to he very much exhausted. She ated. About two months after the opera-was bled and had a glyster, with twenty tion, she began to resume her former occudrops of tinct. opii. The blood was buffed. pation as washerwoman, but was soon obligedOn the morning of the 12th she was again to give it up, as a ventral henna formed,bled, and as this also was not followed by partly in consequence of her omitting toany progress in the labour of’tlie chiid, the wear a bandage, which had been recom-Ciesareau operation was performed in the mended to her. In October, 1815, she in-evening. -’I lie incision was made through iormed M. Lut;eltrum that she was againthe skin and muscles in the right side of the pregnant, and a consultation was according-abdomen, about an inclr and a half below ly held on the 12th of April, by M.Engel-navel ; the uterus immediately protruded, trum and three other accoucheurs, when itand its anterior paries was divided, from was determined upon performing the Caesa-its fundus down to the neck. The child reau section again, as scon as the first symp-was extracted by the feet, and the placenta, toms of labour should appear. She was atwhich was attached on the lelt side, re- that time in the sixth month of pregnancy;moved with it. The uterus immediately the abdomen was very pendulous; ; the cica-

GANGRENE OF THE FOOT.28

trix of the wound had almost entirely givenway, the hernia had attained a very largesize, and the movements of the child weredistinctly felt through it. The generalhealth of the patient was good, except thatshe from time to time suffered from inflam-matory headach, which was relieved bvrepeated bleeding. Towards the middle ofJune, she complained of violent pain allover the abdomen, and especially in the

cicatrix ; the epidermis in some parts of theabdomen became detached, and in the be-ginning of July an ulcer was formed there.On the 19th of July, the first symptoms oflabour took place ; on the following morn-ing, the os uteri was dilated, and it wasascertained that the child was alive ; it

presented with the arm. The operation wasperformed in the same manner as before;the incision through the uterus divided partof the placenta, but the haemorrhage waseasity arrested by compression ; the uteruswas observed not to contract so soon or sopowerfully after the child had been extract-ed, as on the former occasion. A shorttime after the operation, the patient beganto be sick, vomited, and complained of greatpain ; the countenance was pale and altered;the pulse was small, and body covered withcold sweat ; the abdomen was very painful,and the os uteri did not appear to contract atall. Aromatic fomentations were made, andstimuli given internally. These remedieshad no effect, and the patient died in theevening, thirteen hours after the operation.On examination, the uterus was found but

little contracted ; the edges of the formerwound on the left side of the uterus wereclosed, but not by cicatrisation of the wounditself, but by the peritoneal lining of theuterus. The wound itself had, properlyspeaking, not cicatrised, for its greaterpart was not united at all, and the edgeswere kept together only in consequence ofthe general contraction of the uterus.The child died eight weeks after the ope-

ration, from atrophy ; the one extracted bythe first operation is still alive.-Waarne.ming wegens eene ten teeveden naale ver-

,rig-te Keiserschneede aan eene en degelvdevooun. voor 7. N. Engeltrum, Amsterdam,1828.

In this case, we think, that the ope.ration was by no means called for, and,in this country, would never have even beerthought of. It is possible that the chilcmight have been extracted alive with tbf

long forceps, but if not, it would have beersurely rbetter to perforate the head, than t(have recourse to a measure which oughnever to be resorted to, except when thlives of both mother and child are in danger

GUY’S HOSPITAL.

GANGRENE OF THE FOOT AND LEG FROM

COLD.

FRANCIS MALOY, about 50 years of age,and a poor-looking object, admitted underMr. Key, January 20th, with gangrene ofthe right foot and leg, extending likewisenearly half way up the thigh. Says he isby trade an itinerant tinman ; that the dis-ease first appeared about a week before hisadmission, first in the feet, and then gra-dually extended up the leg and thigh; hasbeen exposed greatly to the cold, and hisfeet have, at various times, been so be-

numbed, that he could scarcely feel them ;he would then warm them at a fire, whichproduced a " tickling sensation." The footand leg are of a dark-livid hue, the’cuticle,in many places, peeling off; the thigh is ofa bright-red colour. He does not seem tosuffer much pain, and appears such a simplefool, that he answers" yes" to every ques-tion put to him. Ordered poppyfomenta-tions to the foot and leg ; cold ammonia lo-tion to the thigh ; to take ammon. carb. gr. x,three times a day.

25. Considerably benefited by the use ofthe fomentations, &c. ; the inflammation hasnot extended higher np the thigh, and is notof such a bright colour ; sleeps well at night;tongue clean at the edges, but white in thecentre, and moist; pulse very feeble at thewrist, and about 65 beats in a minute ;bowels open. Continue med. et applic.

28. Obscure feeling of fluctuation in thethigh and middle of the leg; pulse exceed-ingly feeble ; bowels rather relaxed. Applya poultice. Omit ammonia.

R Inf. Serpent. :3ij. ;1’. Opii, 3iss. ;

, Pulv. cretæ compo v. M.

take one table spoonful twice a day.Feb. 1, On Saturday the dresser opened

two abscesses, one in the thigh the other inthe leg near the calf; a considerable quan-tity of pus was evacuated. To-day there isa large sloughy-looking ulcer at the back of

the leg, the cellular membrane hanging inflakes. When the leg is elevated, four

small wounds, of very unhealthy aspect, areseen on the foot; the wound in the thigh

likewise looks sloughy ; discharge fcetid andconsiderable; tongue red; bowels open twice

; a day; pulse 60, and very feeble. Ordered,Infus. rosæ, 3iss. ;Quinine sulph. gr. iij. bis die.Wine, 3vjii.

-

) Linseed-mealpoultices to the thigh.t Spirit wasta to the sound surface.

7. Considerable discharge from the ulcers.Has improved considerably since last report;