again began to diminish, and the pulsation became more obscure, so that on the fourteenth day it was not much larger than half its bulk at the time of the operation, and no pulsation could be detected in any portion of it; merely a slight vibration in some parts which seemed to be produced by the pulsations of the contiguous vessels which were now enlarged, particularly the inferior thyroid artery.

The redness of the skin, however, continued to increase and that of the scapular portion of the tumour to become more and more of a purple colour, til, at last, ulceration commenced on the most prominent part. Several considerable-sized portions of coagulated blood were discharged along with some healthy pus through the ulcerated opening; and on the 20th day after the operation, the ulceration of the integuments had closed, and nothing of the tumour remained, but some wrinkling of the skin, and a considerable degree of thickening of those parts on which the base of the tumour had rested. These continued to diminish, and at the end of the fifth week, from the time of the operation, the neck had nearly resumed its natural form, a slight degree of inequality only remaining; the ligature had come away, and the patient's general health, to the management of which the greatest care had been bestowed, appeared now to be completely re-established.

This case appears to me to prove satisfactorily,

the possibility of the success of this mode of operating for aneurism, and of the important advantages which are likely to be derived from it, more especially in those cases which have hitherto been considered beyond the aid of surgery.

The operation may also, under particular circumstances, be preferable to tying the ligature between the aneurism and the heart, even in cases where that operation is practicable. For as in that which I have just narrated, had it even been possible to have tied the artery between the tumour and the heart, how much more dangerous and difficult would the operation have been, and how much greater would have been the risk of secondary hæmorrhage at the place of the ligature.

The only circumstance which must be considered as indispensable to the success of this mode of operating is, that there be no vessel arising, either from the sac itself, or from the artery between the sac and the ligature, sufficiently large to keep up the circulation of the blood through these parts, and thus prevent its coagulation. I say sufficiently large, for it is perfectly ascertained that after the common operation of tying the artery between the tumour and the heart, pulsation to a certain degree often continues for some time, notwithstanding which, neither the gradual process of coagulation in the tumour is prevented, nor the subsequent

contraction and condensation of the aneurismal sac and insulated portion of the artery.

When an aneurism is cured spontaneously, it is evident that in general the process must in like manner be slow; and that the circumstance of the circulation through the tumour being rendered languid, equally suffices to admit of the blood coagulating, as if circulation was completely stopped.

These considerations lead me therefore to hope, that the operation of tying the artery beyond the aneurism, will in many instances be successful, even though the current of blood through it be not completely stemmed. To ensure, however, this being done, the ligature should be made as close to the tumour as possible, in order to preclude the chance of leaving a branch between the tumour and the ligature, which would carry on the circulation; and I can even conceive cases wherein it might be practicable to tie such branch separately, so as effectually to prevent the circulation being carried on through the aneurism.

Charles Street, St. James's Square,

July 1, 1825.

APPENDIX.

DESCRIPTION

OF

MR. BREMNER'S INSTRUMENT

FOR CARRYING A LIGATURE ROUND DEEP-SEATED

"ARTERIES.

VARIOUS Contrivances have at different times been proposed for conveying ligatures around the subclavian and other deep-seated arteries; but the great defect to which all the instruments that have been invented for this purpose are more or less subject, is their being formed either of unyielding materials, and consequently, incapable of bringing the point into view on the side of the artery opposite to that at which it enters; or, when of sufficient curvature for carrying the point completely round the vessel, their form precluding the possibility of entering the point at the commencement of the operation.

The instruments which have been constructed with flexible materials, such as a spring, are found either to want strength, or elasticity, both which properties are absolutely necessary to an instrument in every way fit for the purpose intended.

If deficient in strength it cannot admit of pressure sufficient to enable it to find its way through the cellular membrane surrounding the artery; and when sufficiently strong to do this, it must want that elasticity which is necessary to allow of its taking the form required in the different stages of the operation. A spring capable of describing a circle, the area of which shall be equal to the circumference of such an artery as the subclavian, cannot exceed in thickness that of a common watch-spring, and then, only, when the metal possesses the highest possible temper; for, if the spring be thicker than that of a watch, it cannot, when of the required curvature, be drawn into a straight canula, without breaking it. Elasticity, therefore, and strength are two indispensable properties in an instrument that must be projected from a straight canula; and that now to be described possesses these in an eminent degree.

Mr. Bremner's Instrument consists of a flat canula (aaa Plate V. Fig. 1), within which are contained three distinct but parallel springs (b b), each spring being of the best possible temper, and capable of being made straight, or of assuming their original curved form, without either breaking or setting; when drawn within the canula, they are confined nearly in a straight line, and when projected from it assume their natural curve, and thus a ligature attached to their extremity (c) may be carried round any artery. It is necessary