Eleven opened behind the peritoneum, ten into the peritoneum, four into the left pleura, three into the vena cava inferior, one into the lung, one into the colon, one into the pelvis of the kidney, one into the posterior mediastinum, one into the chest, two died suddenly without rupture of the sac, two from jaundice, and one from each of the following causes: -heart disease, scarlatina, phthisis, diarrhoea, exhaustion, hydrothorax, anasarca and ascites, senile gangrene, and rupture of sac by vomiting. The terminations of twelve cases are not given.

Cerebral aneurism. The cerebral arteries are, according to Mr. Crisp, more frequently the subject of aneurismal dilatation than others of a similar size. This he attributes to their unsupported state from the absence of a cellular sheath, the frequency of concussions of the skull, and the irregularity of the circulation in the brain from mental or bodily excitement. The eight cases of cerebral aneurism that are reported in the table all occurred in males. Five of the aneurisms were seated in the basilar, three in the cerebral arteries. They varied in size from a pea to a common apple. Three of the patients were under twenty years of age, and the remaining five between thirty-five and sixty. In the three that were seated in the cerebral arteries, death took place by rupture of the sac and extravasation of blood; in the remaining five, those seated in the basilar artery, sanguineous apoplexy, cerebral congestion, encephalitis, hemiplegia, and pressure on the medulla oblongata were the causes of death.

Dissecting aneurism. The following is the condensed account that our author gives of his views on dissecting aneurism.

"This variety of aneurism is much more frequent in women than in men, and most of the patients are advanced in years. It is not difficult, I think, to understand why this form of the disease should occur more frequently in the aged, when we consider the state of the arterial tunics at this period of life, their connecting media, from increased dryness, being more readily destroyed. I have performed several experiments on the coats of arteries of persons of different ages, which have fully confirmed this opinion. Thus, if a small syringe, Anel's, is filled with water, and its nozzle inserted into the layers of the fibrous coat, or between it and the cellular coat of an artery taken from an old subject, the fluid will be rejected a considerable distance between the tunics. If, however, the experiment be made on a young subject, considerable difficulty will be experienced in separating the laminæ, and the water will only divide the coats to a small extent. I am, however, at a loss to account for the greater frequency of this disease in females, and I will not at present attempt an explanation. The lower part of the ascending aorta is the most common seat of these ruptures, and the blood is generally discharged into the pericardium. Thus, 15 cases terminated in this manner, and 4 died of the following-senile gangrene, tuberculated lungs, dropsy, and orthopnoea; in 2 the cause of death is not given. This lesion is generally attended with acute pain, great collapse, sense of suffocation, and constriction of the chest; there are no positive signs, however, which can indicate its existence. In some cases death takes place at the time of the rupture; in others the cellular coat of the aorta and its pericardial covering form a barrier for a few days to the passage of the blood into the pericardium; whilst in a third variety a new channel is formed by the splitting of the coats; and in one instance this channel appeared to be lined with false membrane, the patient living for a considerable time after the rupture. Seven of the patients died suddenly, seven lived from one to twelve days after the accident; another survived a month; another lived several months; and in a third the period is not named. The coats may be separated on one side of the artery only, or the splitting may ex

tend to the whole circumference of the vessel. In some instances, the blood, after dissecting the coats, again found its way into the artery; in two cases only did the rupture occur in the abdominal aorta, and in three others the blood passed along the coats of the thoracic to the abdominal aorta, being discharged above into the pericardium. From the experiments I have made I am disposed to think that an artery, containing a large quantity of bony and atheromatous matter, is not so likely to be affected with this form of aneurism, as one which is nearly free from deposit, the adventitious substance tending rather to prevent the splitting of the coats." (p. 168.)

External aneurism. We shall now give an analysis of the statistical data that Mr. Crisp has collected on the subject of external aneurism, in reference to the comparative frequency of this disease in different arteries and at different ages, and in the results of this ligature.

The observations made by our author on the general treatment of external aneurisms, on their spontaneous cure, and on the employment of pressure in those cases to which it is applicable need not detain us, as he gives nothing with which the profession is not already familiar. Indeed his observations on the employment of pressure in the cure of aneurisms, a subject of the greatest interest, and one to which the attention of surgeons is peculiarly directed at the present time, are very incomplete, evincing less acquaintance with the principles on which the modern treatment by pressure is conducted than we could have expected. Mr. Crisp's account contrasts very unfavorably with the very excellent and practical Essay lately published on this subject by Dr. Bellingham of Dublin, to which we would refer our readers as containing a most masterly account of the treatment of aneurism by compression. Mr. Crisp's observations on another mode of treatment that is also beginning to attract some attention, both in this country and abroad-we allude to the galvano-puncture-are also far too cursory and superficial. Short as they are, however, they are not free from error, the introduction of this plan of treatment being attributed to M. Petrequin of Lyons, instead of to a countryman of our own, Mr. Benjamin Phillips, who was the first to direct the attention of the profession to this subject, in an essay published as far back as the year 1832.

Secondary hemorrhage. The statements of different observers vary considerably in respect to the frequency of this accident after ligatures. Lisfranc states as the result of his inquiries into the details of 180 operations for aneurism performed according to the Hunterian method, that secondary hemorrhage occurred in 32; being in the ratio of 1 in 6. Portal in his recent work on the Ligature of Arteries, has collected 600 cases of the ligature of the principal arteries, in 75 of these secondary bleeding occurred; of these 31 were cured, 30 died from loss of blood, and 14 from other accidents. The treatment adopted in 31 cases was as follows: the plug was used in 13, torsion in 4, a second or third ligature in 9, bandaging or cold applications in 3, and amputation of the limb in 2. will be seen by this, that according to Porta, secondary hemorrhage only occurs in about one twentieth of the cases, instead of in one sixth, as stated by Lisfranc. This discrepancy may very probably be reconciled by the fact that Lisfranc has only included in his estimate cases in which the vessel has been ligatured for aneurism, whereas Porta speaks of the results of the ligature for wounds as well as for disease. Mr. Crisp finds that of 256

cases of ligature of the larger arteries for aneurism, 21 patients died of hemorrhage, and in 8 cases the termination was of a mixed character, but bleeding to a certain extent had occurred, and therefore had some influence in producing the fatal result. The deaths lately from hemorrhage amounted to rather more than one twelfth, including the doubtful cases to barely a ninth; whilst the general mortality is 22 per cent., the general mortality of Porta's cases being 27 and a fraction per cent. All these operations were for the cure of spontaneous aneurism, and cases of the distal operation, of ligature of the aorta, the innominata, and of the subclavian, on the anterior side of the scalenus are included. If these cases were omitted, the rate of mortality would be considerably diminished.

The following is the time of separation of the ligatures in 150 cases of operation for the cure of aneurism, nearly all of them spontaneous. In two cases of ligature of the common iliac, the ligatures separated on the 18th and 35th days; of the internal iliac, on the 21st and 42d days. In 33 cases of ligature of the external iliac, on an average on the 22d day. In 54 cases in which the femoral was tied, the ligature remained on an average 18 days. In 30 cases of ligature of the subclavian, 17 days; in 21 cases of ligature of the carotid, 21 days; and in 8 cases of the brachial, 14 days.

Aneurism of the innominata. Of 20 cases of aneurism of the innominata, 15 of the subjects were males, and 5 females. Aneurism of this vessel seldom burst internally,-not one of the 20 cases terminating in this manner;-1 burst externally, 3 proved fatal by pressing on the trachea, 1 on the right bronchus. Serous effusion into the pleura, pericarditis, and exhaustion carried off 3 others; 6 were subjected to surgical operations, and in 5 the cause of death is uncertain. The application of the ligature to this artery has, in every case, been unsuccessful, and few surgeons would, we think, at the present day be found who would venture under any circumstances to have recourse to this operation. There are only three instances of cure of aneurism of the innominata on hand. This occurred to Mr. Porter, who attempted to tie the artery, but on cutting down upon it, he did not think it safe to apply the ligature; strange to say, the patient recovered, pulsation ceasing entirely in the sac. Another case was treated successfully by Mr. Luke, by small bleedings frequently repeated, and digitalis; and the third was a case in which the right carotid was tied by Mr. Evans; the patient was well nine years after the operation.

15

Aneurism of the subclavian. Twenty-six cases of aneurism of this artery are on record; of these 25 were males, and only one a female. occurred in the right, and 8 in the left subclavian; in 3 the situation is not mentioned. The artery was ligatured in 23 of these 26 cases; of these operations 11 were successful, and 12 terminated fatally. In 4 of these unsuccessful cases, however, the artery was tied internal to the scalenus; in 2 the innominata was ligatured, and in 2 the sac was punctured, so that if these eight cases be included, the mortality from ligature of this artery when the operation is performed at an early period of the disease, and in the third stage of the vessel, is not very great. We may mention that all the cases in which the vessel has been tied internal to the scalenus have terminated fatally.

The results of the ligature of the subclavian artery for axillary aneurism

form a striking contrast with the preceding statement. Of 14 cases in which the ligature was applied to the subclavian for this disease, 11 were successful.

Carotid aneurisms. Of twenty-five cases of this disease, thirteen were males and twelve females. The frequency of the disease amongst females is a remarkable fact which we have not seen noticed by any other writer, and which Mr. Crisp attributes to the exposed state of the neck of females, and its consequent liability to injuries. Of these 25 cases, 21 were operated upon. Ten of these operations were successful, and eleven had an unfavorable issue. Five of the operations were performed on the distal side of the sac; of these three were successful, and in two the life of the patient was prolonged. The principal sources of danger after the ligature of this vessel are, as Dr. Miller and Dr. Norman Chevers have shown, referable to engorgement of the lungs or to cerebral disturbance, and though Mr. Crisp doubts the accuracy of Dr. Chevers's conclusions with regard to the frequency of the cerebral disturbance after ligature of the common carotids, there remains in our minds no doubt of the fact, after perusing the evidence that he has adduced in support of it.

Iliac arteries. Only two cases of aneurism of the common iliac are mentioned in the table; both occurred in males: one was a varicose aneurism, in the other the aorta was tied.

Aneurism of the external iliac occurred in nine patients, all males. In two cases the common iliac was tied: in the first, death occurred on the eighth day, from hemorrhage; in the last, the operation was successful; and in four it was ligatured successfully.

With the exception of the popliteal, the upper third of the femoral artery is the most frequent seat of external aneurism. Mr. Crisp has collected 66 cases of aneurism in this situation, 61 of which occurred in males and but 5 in females. A remarkable fact connected with this species of aneurism is its frequency in sailors: of 39 patients whose occupations are given, no less than 12 being sailors. In these 66 cases the external iliac was ligatured 43 times, in two instances the femoral was tied also; 36 of these cases terminated favorably; of the 10 unsuccessful, 3 died from hemorrhage; 2 from sloughing of the sac; 2 from pressure; and 1 from gangrene; another from tetanus, and a third without apparent cause. The femoral artery alone was tied in 12 cases: of these 9 were successful, and in 5 cases amputation was practised with success.

Popliteal aneurism. The table contains 137 cases of aneurism of the popliteal artery. Of these, 133 were males and 4 females; in 44 cases the left side was affected; in 40 the right, in 42 the situation is not named; and in 11 cases the aneurism was double. Of these 137 cases, 119 were cured and 18 died. In 110 cases the Hunterian operation was performed in 91 with complete success, and 7 others terminated favorably after amputation, the ligature having been previously used. The 11 patients affected with double popliteal aneurisms were all cured, the ligature being used in 10 and pressure in one.

Circoid aneurism, or aneurism by anastomosis. Forty-five cases of this disease are arranged in a tabulated form: 24 of these were males, 16 females, and the sex is not stated in 5 cases. In 38 cases the disease was seated in the head, neck, and upper extremities. The lower part of the rectum, perineum, nates, scrotum, leg, knee, and foot, were affected in

the remaining seven; 22 were cured, 6 benefited, 11 died after the operation, and 4 were not operated on. In 16 cases of this disease, seated about the head and face, the carotid was ligatured; and in 3 patients both carotids were tied. The ligature alone was successful in 5 cases; in 7, benefit was derived; and the disease was afterwards removed by pressure, caustic, or incision. In the 3 fatal cases, the patients did not appear to die from the immediate effects of the operation.

Our author next devotes a page or two to some cursory remarks on the important and interesting subjects of aneurism of bone and fungus hæmatodes, and gives two or three short chapters on ruptured, torn, and wounded arteries, which, as they are not the result of personal observation, need not detain us; these are followed by a mere sketch of the diseases of the veins, with which the work concludes.

On the whole, we regard Mr. Crisp's book as a valuable addition to our surgical literature. Our remarks on various parts of it show that we think it might have been made better than it is; but, with all its imperfections, we consider it as highly creditable to its author. It can have no pretensions to be considered a complete treatise on the diseases of the bloodvessels, many of the most important of these affections being treated only in a superficial and incomplete manner. Its principal value consists in the Table of Aneurisms which the author has, with great industry and care, constructed from various sources; and by the analysis of which new light is thrown on several points connected with aneurism, and the result of the ligature of arteries. The value of this collection would, however, have been much increased had the cases been arranged in a systematic manner, and not put down merely in the order in which the author met with them, without any attempt at classification or arrangement. If called on for a new edition, Mr. Crisp will add greatly to the value of his work by enlarging his statistics still further, so as to include the records of foreign as well as of British pathology and practice; and by paying more attention to some of the points on which we have taken the liberty to remark.

Om Torsk hos Barn.

ART. XII.

Af Dr. FR. TH. BERG, Ofverläkare vid Stockholms Allm. Barnhus, &c.

On Thrush in Children. By Dr. FR. TH. BERG, Physician in Chief to the General Children's Hospital in Stockholm, &c.—Stockholm, 1846. 8vo, pp. 157.

We have in former notices of the labours of our Swedish brethren, awarded, we hope, due praise to their steady pursuit of the legitimate objects of medical science; the work now before us, is a further proof, that we have not overvalued their merits. Dr. Berg's modest little volume has afforded us great satisfaction. We have admired the diligence and perseverance requisite for so many and such varied experiments and observations, while the candour and good faith with which these researches are recorded is a guarantee for their perfect accuracy

It is true that the malady of which our author treats is regarded by many, as a disease of no great importance in a practical point of view;