PART II.

CRITICAL ANALYSIS.

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I.

A Treatise on the Diseases of Arteries and Veins, containing the Pathology and Treatment of Aneurisms and Wounded Arteries. By JOSEPH HODGSON, Member of the Royal College of Surgeons, London. London, 1815. 8vo, pp. 603.

Engravings intended to illustrate some of the Diseases of Arteries, accompanied with Explanations. By JOSEPH HODGSON, Member of the Royal College of Surgeons, London. Folio, 1815.

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HE Royal College of Surgeons in London proposed, as the subject of the Jacksonian Prize for the year 1811, "Wounds and Diseases of Arteries and Veins." There was much propriety in the selection of this most interesting subject; for there is not, perhaps, any other in which the superiority of modern surgery stands more highly displayed; and certainly there is no one in which the skill, enterprise, and science of British surgeons have been more successfully exerted than this. Indeed, we hardly know anything more brilliant in the history of surgery, than the improvements which have been made, in our own days, by British surgeons, on the operations and treatment of aneurisms, and of wounded arteries. So lately as when we first began our studies, surgeons still hesitated to tie up the main trunk of an artery in the extremities, and when the necessary attempt proved successful, instead of reckoning their success a thing of course, and referable to the wise and almost unerring provision which nature had made for continuing the circulation in the limb, by the collateral and anastomising vessels, they con

jectured only the existence of a lusus, or higher division of the arterial trunk.

Of the causes of secondary hæmorrhage, of the process of nature in the cure of opened arteries, and of the effect of the ligature which they daily used, their conceptions were still crude and imperfect. We have, not long since, known tapes nearly an inch broad applied to the artery in aneurism, in the fear that such ligatures as the surgeon trusted to in his ordinary operations, should, cut and ulcerate the vessel; not to speak of the serre arteres, and other ingenious pieces of mechanism for keeping the sides of an artery in compressed and flattened apposition, with which the French and Italian surgeons are still amusing themselves.

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The British surgeon now knows so well the powers and resources of nature, that there is not an arterial trunk within his reach that he has hesitated to tie; and he has thus successfully thrown a slight and single ligature round the femoral, the carotid, the external, and even the internal iliac artery. He knows now, that a large, broad, and flattened ligature is the worst, precisely for that reason, on account of which it had been thought the best and most secure; and that one of the reasons, for which he now employs a small thread, is to cut and wound the artery, he was formerly so anxious to save. He has ascertained, that, by this division of the internal coats of the artery, it becomes permanently closed and cicatrized by adhesive inflammation; that everything which interferes with this process, and which, instead of it, has a tendency to produce the suppurative or ulcerative inflammation, becomes a cause of secondary hæmorrhage; and, therefore, that the vessel must be separated as little as possible from its attachments; that no foreign body must be interposed for greater security; that the ligature itself should be small, that it may, as a foreign body, offend the least possible; he cuts off one end of it to lessen its bulk still farther; he has even risked cutting away both ends close to the knot, and closing the external wound over it; and he has talked of removing the entire ligature almost as soon as he has tied it, believing that its principal use has been effected when it has divided the coats of the artery, and produced in them a disposition to adhesion. Lastly, instead of slitting open the aneurismal tumour, as was the general practice little more than twenty years ago, he simply secures the artery at some distance above the tumour, and the direct impulse of the circulation being thus interrupted, he trusts to the establishment of a new and devious circulation, and to the consequent condensation and absorption of the aneurismal contents. To all these improvements, British surgery has almost an exclusive claim; and the

Jacksonian prize was adjudged by the Royal College to Mr Hodgson for an Essay, which has laid the foundation of the very excellent treatise now before us. In separate parts, the author treats in succession, 1st, of the diseases of arteries in general; 2d, of aneurism; 3d, of wounded arteries; and 4th, of the diseases of veins. Besides being the subject of inflammation, ulceration, and sphacelation, like other structures, the arteries are liable to other and peculiar morbid changes, to cartilaginous and steatomatous thickenings of their internal coat, and to a deposition of atheromatous and calcareous matter. And these changes are very commonly the forerunners of the more for midable disease of aneurism. But, before entering on the subject of aneurism proper, Mr Hodgson directs our attention to the cases of preternatural dilatation of the arteries. This disease is different from aneurism, as all the coats of the vessels are uniformly dilated, without any breach of their continuity. Its most frequent scat is the ascending portion, and arch of the aorta, though it has been observed in the thoracic and abdominal aorta, and at the divisions of the carotid and iliac arteries. The pouch or sac which is thus formed, is commonly thickened, and covered with atheromatous and calcareous depositions ; but this dilatation seldom it ever is found to contain those lamellated coagula which are so gencrally discovered in the true aneurismal sac; which last, on the contrary, is not often found interspersed with calcareous or ossific deposits like those pouches or dilatations, in which all the coats of the artery are entire. A true aneurism may be, and sometimes is, found engrafted upon a sac of simple dilatation.

Our readers are aware, that the observations of Scarpa have led to the conclusion, that, in aneurism, the formation of the tumour is preceded by a rupture or breach of the internal and middle coats of the artery, and that the sac is formed by the consequent dilatation of the outer coat, and cellular sheath of the vessel.

After having ascertained the fact, therefore, that the whole circle of an artery is found to be preternaturally dilated, in a great many cases, without laceration or destruction of any of its coats, it seems to us a mere affair of arbitrary definition, whether such cases shall be called aneurism or not; and especially, it seems to us, that Mr Hodgson, after describing this case of preternatural dilatation as a distinct disease, and beginning his sec-. tion on aneurism with a definition, limiting its interpretation to the case in which the internal and middle coats have given way, would have saved to himself, and to his readers, some little confusion, by maintaining this distinction throughout. Instead of

which, he resumes the consideration of dilatation with integrity of the coats of the artery, and reasons upon the subject in a way which leaves us, in some degree, at a loss to know whether he would class it with aneurism or not. Thus, he begins with stating the question, "Does aneurism ever consist in a general or partial dilatation of all the coats of an artery, or is it constantly produced by the destruction of all, or most of the coats?"

That disease, indeed, already described by him in a separate section, and said to consist in a preternatural dilatation of the whole circle of an artery, and not in a partial or lateral distension of its coats, Mr Hodgson continues to disunite from aneurism. But the case of a partial dilatation of the coats without rupture, he seems inclined to consider as less separable from ordinary aneurism; and he maintains, that, in a great proportion of aneurisms, the disease has commenced in a partial dilatation of the coats of the artery, although, in the progress of the disease, the internal coats do at length give way. In the generality of cases, indeed, he allows with Scarpa, that the formation of the aneurismal tumour is preceded by rupture of the internal and middle coats of the artery. But very many, he contends, have their origin in previous, general, or partial dilatation of all the coats.

"Those aneurisms which are situated at the origin of the aorta, are generally formed by dilatation of the coats of the vessel. The internal surface of the sac, in most instances, exhibits some of those morbid alterations which are peculiar to the internal coat of an artery. The mouth of these sacs is generally larger than any other part of the cavity, and there is not that circumscribed margin between the artery and the sac, which is constantly met with where aneurism is formed by destruction of the coats of the vessel."

Mr Hodgson has seen this partial dilatation, in almost all the arteries which are subject to aneurism. Such dilatations frequently precede the formation of aneurism in the arteries of the extremities. The cases and observations brought forward by Mr Hodgson, as well as the disputes which have always existed amongst anatomists on this subject, leave no doubt as to the existence of these pouches, and dilatations of the coats of an artery without any rupture; and all that our author seems to contend for is, that many aneurisms have their origin in such general and partial dilatation.

1st, Numerous aneurisms are formed by destruction of the internal and middle-coats of au artery, and the expansion of the external coat into a small cyst, which giving way from distension, the surrounding parts, whatever may be their structure, form the remainder of the sac. 2dly, Sometimes the disease commences in the

dilatation of a portion of the circumference of an artery. This dila. tation increases until the coats of the vessel give way, when the surrounding parts form the sac, in the same manner as when the disease is in the first instance produced by destruction of the coats of an artery."

The original question, however, proposed by Mr Hodgson, "Does aneurism ever consist in a general or partial dilatation of all the coats of an artery; or, is it constantly produced by the destruction of all or most of these coats?" seems thus rather to be gotten rid of, than answered.

It seems, however, to be our author's conclusion, that, although aneurism has often its origin in such dilatation, the case of dilatation ought not to be considered as one of aneurism, till the internal and middle coats of the artery have given way. There is one thing peculiar to this restricted case of aneurism which deserves notice, the deposition of the fibrous portion of the blood in concentrical laminæ upon the internal surface of the sac. "It is almost universally found in aneurisms in which the coats of the artery have given way, but in those sacs which consist in a general and partial dilatation of the coats of the vessel, I have never met with it."

Aneurism, and those diseases of the coats of the arteries which precede its formation, occur much more frequently in men than in women. And the following table exhibits the comparative frequency of aneurisms in the two sexes, in different cases of the disease, in which our author has had an opportunity of seeing his patients during life, or of examining the parts soon after death.

Having considered most of the questions connected with the

nature and formation of aneurisms, and having pointed out the

Females.