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affected. The questions of age and sex, of the total duration of the disease, the length of life after operation, the frequency of recurrence, with the period at which this or secondary deposits took place, are carefully examined. Two cases also are recorded of the disease, which came under Mr. Pemberton'3 own observation. On the whole, the paper is one of great merit.
Of the twenty-one pages occupied with "Reviews," the greater number are taken up with notices of Dr. Laycock's 'Principles and Methods of Medical Observation and Research,' and Professor Bennett's 'Introduction to Clinical Medicine,' no fewer than fifteen pages being allotted to the former work. These reviews appear to have been written with the object of canvassing the merits of the present rival professors of clinical medicine, and the former rival candidates for the chair of Practice of Physic in the University of Edinburgh. While we fully concur with the Reviewer, that "few men are so well qualified as Professor Bennett to write an introduction to clinical medicine," still, we think that under the circumstances it was scarcely necessary to adduce, as a reason for noticing Dr. Laycock's work, that it emanates from a school which has of late years acquired great preeminence in the teaching of clinical medicine, owing mainly '' to the zeal, energy, and ability of Professor Bennett." We have already* expressed our own views on the merits of Dr. Laycock's Lectures, which were far from being in terms of approbation ; yet we cannot agree with the Reviewer in his sweeping conclusion, that "his doctrines cany with them their own condemnation." On the contrary, as we have already stated, we are of opinion that they contain much that is sound and good, and only regret that the work bears the stamp of too hasty composition. Dr. Laycock is accused of inculcating too strongly the study of logic by the clinical student, and at the same time of being illogical in his own arguments; but we cannot avoid the impression that the Reviewer has made a very bad attempt at logic himself. There are two points also in his remarks to which we must take decided exception. First, Dr. Laycock's "astounding announcement" that "man is but a link" in the chain of created beings, is spoken of in terms of derision. The author seems not to be aware that this opinion has been supported by many of those most competent to judge (such as Linnaeus, Cuvier, Illigor), and that Dr. Laycock is backed up by the first comparative anatomist of the age. Professor Owen, in a recent paper read to the Linnaean Society, makes man a distinet subclass of the class mammalia.f Secondly, it is stated as a "scarcely credible fact, that a Professor in the University of Edinburgh, in the year 1856, should think it necessary to advocate what he terms "physiognomical diagnosis," as worthy of the serious "attention of the student." There are few, we believe, of much experience in the profession, who are not in the habit of attending more or less to this subject. The peculiar physiognomy in phthisis and in cancerous diseases is generally acknowledged; its
• Brit. and For. Med.-Ch;r. Review, vol. xix. p. 159.
important indications in the different species of renal disease have recently been pointed out by Dr. Todd ;•" and to these examples we might add a host of others. We should be the last to detract from the value of physical diagnosis; yet, while we admit that perhaps Dr. Laycock hardly assigns to it the position which it deserves, we do think that the present tendency is to place too much confidence upon it, to the neglect of those general symptoms and phenomena of disease on which onr forefathers had solely to depend, and which are often of the greatest importance.
The "Reviews" also contain short notices of Dr. Clay's 'Handbook of Obstetric Surgery,' 'The Treatment of Cancerous Diseases by Caustics,' by Mr. Langston Parker; Dr. Fuller's work 'On Rheumatism,' and Griffiths and Henfrey's 'Micrographic Dictionary.'
Des Anivrysmes et de leur Traitement. Par Paul Broca, Agrog6 a la Facult6 de MSdecine de Paris, Chirurgien des Hopitaux, &c.— Fori*, 1857. pp. 938.
Aneurisms and their Treatment. By Paul Broca, <fec. <tc .
A New work of some nine hundred pages, on the nature and treatment of aneurism, will perhaps be considered by some surgeons in the present day, an unnecessary and superfluous addition to the monographs we already possess on this important and oft-occurring malady. It is therefore our duty to examine how far M. Broca has proved his labour not to have been superfluous, while we also endeavour to ascertain whether the volume before us, the result of that labour, can be considered unnecessary.
"I have been obliged (says our author in his preface) not only to illustrate the modern methods, but to reconsider every method that relates to the treatment of aneurisms. This will account for the unusual length of the work. To be certain not to travel out of facts, I have collected, analysed, and grouped together nearly 1100 cases of aneurism. I have given special attention to conditions observed after death. I have thus acquired accurate notions on the modes of action of the different methods of treatment, and I have been able to describe many important phenomena with which authors until now have not even been occupied."
M. Broca almost apologises for bringing himself to the notice of the profession in a form so massive; and though some of his chapters might certainly have been curtailed without diminishing the value of his volume, we have every reason to rely upon the industry of the author, to feel satisfied that his conclusions have been matured in a large field of observation, and to pronounce that his industry and observation have produced a work the practical nature of which must make it one of high standard reference.
• Clinical Lectures on Urinary Diseases, p. 180.
M. Broca divides his volume into two portions. The first relates to the Pathology of Aneurism; in the second, by far the largest share of the book, he most fully investigates the various methods of treatment.
Commencing with a wish to define what lesions are to be considered aneurisms, in their pathology and in their treatment, M. Broca naturally investigates what should be intended by the word aneurism, and to what conditions of diseased or altered bloodvessels the term ought to be strictly confined.
The confusion that has arisen in the definition of aneurismal tumours of which M. Broca complains, is owing, he thinks, to the circumstance that surgeons have rather been guided in their nomenclature by the symptoms of a tumour, than by its pathological conditions; and consequently any tumour possessing pulsation concurrent with the heart's action, has been considered aneurismatic in its nature. He wishes, therefore, to limit the term "aneurism" to tumours which are circumscribed, filled with liquid or coagulated blood, communicating directly with the canal of an artery, and limited by a membrane usually termed the sac. And though he states that this definition is alone capable of distinguishing aneurisms from other tumours of an arterial origin, he candidly confesses it will not sufficiently answer all practical purposes, —because certain sanguineous and pulsatile tumours may possess no sac at a certain period, but may become ultimately encysted—because it is often impossible during life to know whether such tumours are diffuse or surrounded by a membranous sac—and because, in either case, the therapeutical indications are the same as in diffuse aneurism.
Diffuse aneurism is the variety M. Broca first considers, dividing it into three kinds, the "true diffuse form" of Chelius being entirely excluded from this division—
1. The first, resulting from wounds of arteries, he terms "Anevrysmes faux primitifs." - 2. The second, occasioned by simultaneous rupture of all the arterial coats, "Anevrysme par dechirure ou par epanchement." 3. The third, resulting from rupture of an aneurismal sac and extravasation of a portion of its contents, "An6vrysme diffus des auteurs Anglais." He says, with respect to the first, that to apply the term "diffuse aneurism" to the mere escape of blood from a wounded artery into the surrounding tissues, is confounding the wounded artery, the haemorrhage which follows, and the infiltration of blood which takes place subsequently, with the traumatic aneurism which takes place sometimes— but sometimes only—after the accident. In fact, that after the wound of an artery, he observes, "it is true the pulsations of the extravasation continue, or reappear after having ceased—the external wound has cicatrised—and the tumour presents ultimately the progress and anatomical characters of an aneurism." "This only occurs when the escaped blood becomes circumscribed in a cavity, and enclosed in a membrane newly formed; previous to this the tumour constitutes but a simple escape or infiltration of blood." The second variety, resulting from laceration of the coats of an artery, resembles in many respects the first, but there is no external wound, and the extravasation occurs among the deeper and the more superficial structures—cest Id loute la difference.
These two divisions M. Broca excludes from the class " Aneurisms." For as in the one, so in the other—to speak correctly—if there is not yet a sac, there is then no aneurism. This is, however, about to occur, and ultimately the extravasation becomes a definite aneurism, by the surrounding tissues forming a circumscribing wall, which limits the extent of the cavity, and occasions a boundary to the extravasated blood. And to these species of aneurism M. Broca proposes to apply the term "primitive diffuse aneurism" (anevrysme diffus primitifs).
The third variety, the diffuse aneurism of English authors, M. Broca considers analogous to the foregoing, and refuses the name of aneurism to this secondary condition. For, says he, reasonably enough, when the rupture of an aneurism gives place to an extensive extravasation— when an aneurism of the aorta bursts into a serous cavity—the aneurism is extinguished (eclipse) by this grave complication; and no one can view the distension of the pleura or the pericardium by blood, resulting from the rupture of the aneurism, as the aneurism itself. So when an external aneurism bursts, one should not give to the diffused extravasation the name of aneurism.
"Cette tumour, dans laquelle l'anevrysme n'occupc plus desormais que la seconde place, ne peut pas etre consideroc comme un anevrysme. . . . But I he continues) the rupture of the sac may be very limited—blood escapes in a very small quantity—and we sec succeeding all the phenomena which accompany a very slight laceration of an artery. A second tumour, of variable size, and also of variable shape, but always circumscribed, now surmounts the primitive ancurismal tumour." (p. 8.)
Then, he asks, ought we tb refuse the name of aneurism to a tumour modified by this one circumstance, that at a single point of its boundary it is deprived of its sac? No; English surgeons say in such a case that an aneurism has become diffuse. M. Broca adopts this distinction; and to mark the variety from the primary diffused form, he designates it the consecutive diffuse aneurism (anevrysme diffus consecitlif). Diffuse aneurisms, he adds, differ from other aneurisms in one respect only—in the absence of a membranous sac; in all other respects they approach each other in resemblance; and though pathological anatomy rightly distinguishes between them, in practice it is but proper not to reject them altogether from the class of aneurisms.
To complete our observations upon M. Broca's ideas relative to diffuse aneurism, we must follow our author a little further.
Diffuse aneurisms, he says, resemble ordinary haemorrhages into the cellular tissue in origin and in nature; but they are distinguished by their circumscribed form, and by the presence of a tumour. It may appear strange at first sight to give the name of diffuse aneurism to a tumour which in its character is circumscribed. But, he adds, compared to ordinary diffuse haemorrhages, diffuse aneurism, it is true, appears "circumscribed"—compared to aneurisms which are ordinarily surrounded by a membrane, it well deserves to be termed "diffuse."
The varieties of true aneurism are next considered, or rather we should say, in the words of the author, all other aneurisms which for their common character must be limited by a membrane termed the "sac." The nature and the connexions of this sac serve for the foundation of his classification; and after alluding to its communications either with an artery alone, or with an artery and a vein, he enters into the considerations of the varieties which result from these separate lesions.
Of cystic aneurism (Anevrysme Kystogemqw), M. Broca mentions two interesting specimens which were presented by M. Leudet to the Anatomical Society of Paris. Corvisart was the first to describe this variety. It is said to commence as a cyst with dense cartilaginous or calcareous walls, containing fatty or atheromatous matter, and attached to the coats of an artery. In its growth, or after a certain duration, it opens into the artery; and as the orifice increases, the septum between the cyst and vessel becomes absorbed, and the aneurismal pouch is formed. M. Broca, sceptical himself as to their true character, had the opportunity of examining the specimens alluded to above—and which appear to illustrate the formation aud progress of several of these cysts—but he adds, honestly, "Je suis dispose a admettre la realit6 des an6vrysmes kystog6niques;" though be objects to the term, and states his reasons against such a condition being looked upon as aneurism resulting from a cyst connected with an artery; he rather supposes that at one stage of the disease there had been a tumour produced by the solidification of an aneurism, and that this may have softened aud broken down. He says, however, that there are a fe* facts tending to establish the primary existence of these cysts, and their subsequent communication with their corresponding arteries. Nothing in our experience enables us to confirm or condemn M. Broca's conclusions; we have not been able tosatisfy ourselves that aneurism is ever the result of such cysts as he examined and describes.
The varieties of traumatic aneurism, and of spontaneous, true, false, and mixed aneurism, next occupy the attention of the author; but there is little here to detain us, however much we are inclined tcyccommend the perusal of the original to the reader.
Of varicose aneurism and its varieties, M. Broca speaks very fully. He points to William Hunter as having been the first to describe the true nature of the arterio-venous communication, and with true liberality pays him a well-merited compliment. It was to this Arteriovenous communication that Cleghorn, of Dublin, first gave the name of aneurismal varix. One interesting case in illustration of the varieties of these traumatic conditions, is cited by M. Broca. A sharppointed knife thrust into the thigh transfixed the femoral artery, and entered the vein, but did not pass through the latter. The openings in the vessels remained patulous, and produced two very different enccts. The edges of the corresponding openings of the vein and nrtery united