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SURGERY.

orming this ligature a single knot moderately drawn, and over itanother single knot, are perfectly sufficient.

Of Aneurisms.

The term aneurism was originally meant to signify a tumourformed by the dilatation of the coats of an artery ; but by modernpractitioners it is made to apply not only to tumours of this kind,but to such as are formed by blood effused from arteries into thecontiguous parts. There are three species; the true or encysted,the false or diffused, and the varicose aneurism. The causes pro-ducing aneurisms, in general, are a natural disease of the arteries.Thus a partial debility of their coats may readily produce the dis-ease ; or they may arise, especially in the internal parts of thebody, from great buddy exertions. They are likewise producedby wounds of the coats of the arteries, as now and then happens inblood-letting at the arm ; or from acrid matter contained in aneighbouring sore ; or from the destruction of surrounding parts,by which the natural support is removed. Aneurisms have fre-quently been mistaken for abscesses and other collections of matter,and have been laid open by incision; on which account great at-tention is sometimes required to make the proper distinction. Inthe commencement of the disease the pulsation in the tumour iscommonly so strong, and other concomitant circumstances so evi-dently point out the nature of the disorder, that little or no doubtrespecting it can ever take place ; but in the more advanced stagesof the disease, when the swelling has become large and has lost itspulsation, nothing but a minute attention to the previous history ofthe case can enable the practitioner to form a judgement of its na-ture. Aneurisms may be confounded with soft encysted tumours,scrophulous swellings, and abscesses situated so near to an arteryas to be affected by its pulsation, lint one symptom, when con-nected with strong pulsation, may always lead to a certain deter-mination that the swelling is of the aneurismal kind, viz. the con-tents of the tumour being made easily to disappear upon pressure,and their returning on the compression being removed. Thewant of this circumstance, however, ought not to convince us thatit is not of that nature ; for it frequently happens, especially in theadvanced stages of aneurisms, that their contents become so firmthat no effect is produced upon them bv pressure, lienee thepropriety, in doubtful cases, of proceeding as if the disease wasclearly of the aneurismal Kind. In every case of aneurism, theuse ot pressure has been indiscriminately recommended, not onlyin the incipient period of the disease, but even in its most advancedstages. In the diffused or false aneurism, as pressure cannot beapplied to the artery alone, without at the same time affecting therefluent veins; and as this, by producing an increased resistanceto the arterial pulsations, must force an additional quantity ofblood to the oriiice in the artery ; no advantage is to be expectedfrom it, though it may he productive of mischief. In the earlystages of encysted aneurism, while the blood can be yet pressedentirely out of the sac into the artery, it often happens, by the useof a bandage of soft and somew hat elastic materials, properly liltedto the part, that much may he done in preventing the swellingfrom receiving any degree of increase ; and on some occasions, bythe continued support thus given to the weakened artery, com-plete cures have been at 1 ist obtained. In all stub cases - , there-fore, particularly in every instance of the varicose aneurism, muchadvantage may he expected from moderate pressure, but pres-sure, even in encysted aneurism, ought never to be carried to anyreal length ; for tight bandages, by producing an immoderateegree ca reaction in the containing parts to which they are ap-plied, instead of answering the purpose for which they were in-tended, have evidently the contrary effect. Indeed the greatestlength to which pressure in such eases ought to go, should he toserve as an easy support to the parts affected, and no farther.' Inperforming the operation for aneurism, the first step ought to heto obtain a full command of the circulate n in the inferior part ofthe member by means of the tourniquet. This being done, thepatient should be so placed, that the diseased limb, on beingstretched on a table, is found to be of a proper height for the sur-geon; who, as tlit* operation is generally tedious, ought to heseated. The limb being properly secured by an assistant, theoperator is now with a scalpel, tig. 17, to make an incision throughthe skin and cellular substance along the whole course of the tu-mour ; and as freedom in the remaining parts of the operation is

here a matter of much importance, it is even of use to carry thisexternal incision half an inch or so both above and below the far-thest extremities of the swelling. Ail the effused blood ought thento be wiped off by means of a sponge; and the softest part of thetumour being discovered, an opening ought there to be made intoit with the lancet large enough for admitting a finger of the opera-tor’s left hand. This being done, and the finger introduced intothe cavity of the tumour, it is now to he laid open from one extre-mity to ihc oilier, by running a blunt pointed bistoury, (fig. IS,)along the linger trom below upwards, and afterwards from abovedownwards, so as to lay the whole cavity fairly open. The cavityof the tumour being thus laid freely open, all the coagulated bloodis to betaken out by the lingers of the operator, together with anumber of tough membraneous lilaments commonly found here.The cavitv of the tumour is now to he rendered quite dry, andfree from the blood which, on the first opening of the swelling, isdischarged into it from the veins in the inferior part of the mem-ber: the tourniquet is then to be slackened to discover not onlythe artery itself, but the opening into it, from whence the bloodcollected in the tumour has been all along discharged. The open-ing into tlie artery is now to be secured, which is best done byobliterating the arterial cavity entirely by ligatures. After the ar-tery seems to be secured, it often gives way. ami fatal haimorrha-gies ensue; nor is the patient free from this danger for a long time.In one of Mr. Hunter’s operations the artery gave way on the26th day. It is to this difficulty of procuring adhesion betweenthe sides of the artery that a great part of the danger of this opera-tion is to he ascribed.

Of Fractures.

Fractures are not in all instances easy of detection. Pain, swell-ing, distortion, loss of power in the injured member, shorteningof the limb, and a peculiar crepitating sound upon the part beinghandled, are described as the signs denoting a broken hone; these,however, are all, excepting the last, which cannot in every casebe perceived, in a greater or inferior degree, common to bruises,sprains, dislocations, and injuries independent of fracture. Whena bone is simply divided, without any protrusion of its broken ends,lacerations of considerable blood-vessels, or any oilier circumstanceto render the accident complicated, the practice of the surgeonis obvious and easy. In wounds of soft parts, we have seen, ad-hesion is insured by merely bringing their divided edges together;in like manner, though'much more tardily, junction will be el-fected between the divided extremities of a fractured bone, by re-placing and preserving them in even and steady contact. Thehealing of wounds is not accelerated, but oil the contrary retarded,by the several contrivances and interferences of the older surgeons:so by the cruel practice of tight compressing, bandaging, and theuse of machinery, in fracture, not only unnecessary pain is oc-casioned to the patient, but I he process of cure, instead of beingfacilitated and hastened, is considerably impeded. Nature, h*either case, will not he interfered with. The time which hone 8take in uniting is proportioned to the age and health of the indi-vidual. In persons of middle age and tirm constitution, a simpl efracture of the arm will for the most part be fully and firmly unitedin a little more than a month from the accident. Fractures of ll |flshoulder and thigh-hone are, under the same circumstances, abotdsix weeks or two months in healing; while the smaller bones, a 8the clavicle, the ribs, the iibtila, and the hones of the hand, seldoi"occupy in their cure more than three weeks. In simple fracture 8 'provided the parts have not been unduly irritated, either by muc* 1motion after the accident, or try tight straining bandages, thesynip'toms of intlammation will subside in a few days. Sometimes, <-‘ 8 'pecially when the surgeon has been called late, it is necessarysubdur the local irritation by solution of lead, the application otleeches, and other means used in common inflammation, and tl> cseit is often necessary to continue for several days. Now and th eait will be found expedient to bleed trom the arm. These req l,1 Jsitions must be determined by the good sense and judgementthe surgeon. It is impossible to- lay down abstract rules for cp 11 'duct. To bleed, however, merely because a bone is broken, 18 ,practice equally unmeaning and erroneous with that.before all lK ' c __to, with regard to wounds in a soil part The following insti -11 ?.,lions of Mr. J. Hell, are especially applied to a broken leg, hutbe found applicable with proper exceptions to fractures in S enc , r j{J