Professor Harrison remarks, " I do not recollect a case of this sort of circumscribed aneurism, from the infliction of a simple wound, in which it has been necessary to open the sac or tie the artery below it; I am, therefore, disposed to place full reliance on the practice of simply laying bare the vessel as close to the tumor as circumstances will permit, and tying it with a single ligature." Professor Colles, whose experience and great opportunity for observation render every practical remark of his worthy of attention, thus expresses himself on this subject in his course of lectures on the Theory and Practice of Surgery: " I have operated repeatedly, and with success, for the cure of circumscribed brachial aneurism, in consequence of injury to the artery in performing venisection; I have also frequently assisted others in operating for the same cause, and with the same result; and I never yet found it necessary to open the aneurismal sac, or to look for the vessel below the tumor, or to apply more than one ligature around the artery, which, I think, ought always to be tied as near as possible to the seat of the disease; for in this species of aneurism the coats of the vessel have not undergone any morbid change, as is generally the case in aneurism of the inferior extremity."*

Mr. Cusack has treated three cases of circumscribed aneurism at the bend of the elbow from wounds in venisection, by compression.† The compresses were applied chiefly upon the tumor, the compressing force was moderate; the limb was bandaged with the " gantelet," from the fingers upwards, according to Genga's method: blood was taken from the patient by venisection, digitalis administered, and absolute rest and low diet enjoined. The two first cases terminated favorably under this treatment; during the treatment of the third case, the circumscribed aneurism became diffused. Scarpa adopted this mode of compression for the cure of circumscribed brachial aneurisms. The method of treating aneurism, by compression of the artery leading to the aneurismal sac, has been successfully employed by Dr. Hutton in a case of circumscribed aneurism of the brachial artery at the bend of the elbow: the patient was a servant aged thirty-four; he had been bled by a " country bleeder" for a pain in the chest. On his admission into the Richmond Hospital, the aneurismal tumor was circumscribed and about the size of a pullet's egg; it pulsated strongly and presented the usual characters of aneurism. Dr. Carte's compressing apparatus was employed; " with this the patient maintained the compression during six hours in succession; at the end of this period all pulsation had ceased and never returned."* If, however, these methods should fail in obliterating the sac of a circumscribed brachial aneurism, the surgeon may tie the artery leading to the tumor with a single ligature; and in addition, compression of the entire limb, from the fingers as far as the elbow, should be employed.

* Surgical Anatomy of the Arteries, pp. 185-6 † Dublin Journal, vol. i. pp. 117, etc.

* Medical Press for May 16, 1849.

Surgeons are now generally agreed as to the proper mode of treatment in cases of diffused false aneurism of the brachial artery; the single ligature, which may be sufficient in the circumscribed aneurism, is not to be depended on in this form. When the wound in the vessel is large, when the extravasation of blood becomes considerable, when the tumefaction of the limb extends upwards along the arm, and occupies also the upper portion of the fore-arm, accompanied with pain and discoloration of the integuments, compression will be worse than useless, and the single ligature on the artery leading to the wound will not suffice; the free anastomoses of the vessels about the elbow-joint will allow the blood to flow freely from the wounded artery, and the hemorrhage will continue without control. In a case of this description, therefore, the only operations which can with confidence be relied on, is to cut down with a free incision upon the wounded vessel, to turn out the coagulum of blood, and to tie the artery above and below the wound. In speaking on this subject Professor Harrison observes : " I now believe that very few cases of diffused aneurism, either of this or any other artery, will admit of cure from the simple operation and application of a single ligature to the artery above the injured part, but that it will be almost always necessary to lay open the tumor by a long incision, which should include, if possible, the original wound. When the injured vessel shall have been exposed, it may be raised by a probe, either introduced into it through the wound, or the aneurism-needle can be passed around it, and the artery tied first above and then below the opening."* Professor Porter observes: " But there is still another case; and let us suppose a limb, into which a quantity of blood has been extravasated, not sufficient to cause a gangrene of the part, but still too abundant to admit a hope of its being absorbed. Here, I apprehend, the surgeon lias no choice; he must cut down, turn out all the coagula he can reach, in this way getting rid of that which would be a subsequent source of irritation, and then tie the vessel above and below the aperture."†

* Surgical Anatomy of the Arteries, pp. 180, &C. † Porter on Aneurism, p. 138.

We are anxious, however, to impress upon the mind of the student, that in cases of simple puncture of the brachial artery, as in venisection, or where there is no extensive effusion of arterial blood to create alarm, there is no necessity for immediate operations. The constitutional disturbance consequent upon the wound, and the alarm into which the patient is thrown from the agitation and terror betrayed by the unsuccessful operator, at the instant when he is aware of the mischief he has done, added to the shock sustained by the alarm and precipitancy of a hasty operation performed under such circumstances,—all contribute to induce such a state of the patient's system as to render it very unfavorable for the healing of the wound, and secondary hemorrhage has been known to result from such unnecessary interference. In cases, therefore, not demanding immediate operation, the student is recommended to apply judicious compression by means of graduated compresses laid carefully one over the other upon the wound, so as to correspond to the orifice of the bleeding vessel, and to surround all by means of a figure of 8 bandage, coiled round the elbow a sufficient number of times to secure the compresses in their proper situation. Another form of bandage has been preferred by some surgeons: it is called the " gantelet" of Genga; it consists of narrow strips of bandage with which each finger was enveloped separately; these met above the wrist, from which point a broader roller was carried round the fore-arm, and round the elbow over the compresses which had been previously applied; the bandage was also carried round the arm up towards the axilla. This mode of treatment by compression, in conjunction with proper position, absolute rest, low diet, etc, has proved in such cases decidedly successful, and until it fail, the operation is unnecessary and may be mischievous.

With regard to the treatment required for aneurismal varix, and for the varicose aneurism, we have already observed that it is seldom that either of them requires any operations: the method of compression already alluded to, either upon the diseased part or upon the brachial artery leading to it, may be employed with considerable advantage. Dr. William Hunter advised that nothing should be done in the way of operation in these cases where there should be no considerable alteration in the tumor. Sir A. Cooper entertained the same objection to the operation. If, however, the disease should continue to increase in size, if a thinning of the integuments over the tumor, or over the sac, as in the varicose aneurism, should occur so as to threaten an effusion of blood into the limb, or from an ulcerated opening in the integuments, the surgeon will be obliged to tie the brachial artery, not with a single ligature passed round the vessel leading to the aneurism, but having cut into the sac and having turned out the coagulum, he should tie the artery both above and below the wound in the vessel.