Observations on aneurism : selected from the works of the principal writers on that disease, from the earliest periods to the close of the last century

Front matter

Given l)'^' A

Class

Book c o:s^coitD,

Preface

The Council of the Sydenham Society having done me the honour to intrust me with the editing of a volume to consist of selections from the more important ' Scriptores Minores/ on Aneurism^ together with Extracts from those systematic works that contain observations of peculiar interest and originality on this subject, not to be found in detached Memoirs, I am unwilhng to let it go forth without giving some explanation of the reasons which have influenced the selections that have been made, and making a few remarks on the arrangement that has been adopted in it.

In making a selection from the very numerous Memoirs that have, at various times, been published on the Pathology and Treatment of Aneurism, I have endeavoured, as far as possible, to be guided by the fact of the Essay under consideration, containing either the original indication, or the fullest and most accurate account of an advance in the Pathology, or an alteration or improvement in the Treatment, of the disease ; and I think that it will be found, on a closer examination of this volume, that each one has been chosen in accordance with this principle. The same rule has been strictly attended to in making the Extracts from the works of the more systematic vi PREFACE.

writers ; those portions merely having been selected that contain the original views of the author^ or that are necessary for a complete and continuous history of the subject.

The Memoirs and Extracts that have been selected have been translated or reprinted without any comment or annotation, a precise reference being given to the title, date, and page of the edition that has been consulted; in addition to which a reference to the date of the first edition of the work (if there have been more than one) is appended in the margin.

Those selections that were originally published in the Enghsh language have been reprinted with the utmost attention to accuracy, the proofs having been carefully compared with the originals; they will, therefore, it is hoped, be found to be free from errors.

In rendering the very barbarous Latin of several of the German and Italian writers on Aneurism into English, I have had a somewhat difficult task to perform; but I trust that it will be found that I have succeeded in giving the correct meaning of the very complicated sentences of some of these writers, though this may occasionally have been accomplished at the expense of the style.

The Extracts from systematic works commence with those from the writings of Galen, and the first Memoir that has been selected bears the date of 1681. The two or three monographs that were published on Aneurism before this period consist merely of compilations from, or of criticisms on the opinions of the older writers, and consequently contain but little worthy of repubhcation ; all the information that was possessed on the subject of Aneurism, as on most others, before the close of the 17th century, being contained in systematic works.

PREFACE. vii

The selections have not been brought down any later than the close of the last century, as it was thought that most works of any importance that have appeared since then would probably be either in the possession, or within the reach of the greater number of the members of the Society ; and, moreover, that it was desirable to avoid the invidious and delicate task of making extracts from or of reprinting the works of living authors. It likewise appeared to be more in accordance with the objects of -the Society to confine the selections to the older and scarcer works.

The Bibliography contains a reference to all Memoirs and detached Essays of any value that have been published on the subject of Aneurism within the period to which the work is confined. Those detached Cases also that are of more than usual interest have been included in it. In order to prevent its being made unnecessarily extensive, those systematic works only have been referred to that contain views of more than ordinary interest or importance. An abstract of the contents of those memoirs or papers that have not been reproduced in the body of the work, is appended for convenience of reference.

The following is the arrangement that has been adopted in this work. The volume has been divided into three parts : the First containing those Memoirs and Extracts that relate more particularly to the Symptoms, Causes, and Pathology of Aneurism ; — the Second, those that refer to the Treatment of this disease; the materials of each of these parts being arranged chronologically ; — whilst the Third Part consists of the Bibliography. In this way it was hoped (as the selections are for the most part of such a character as to admit viii PREFACE.

of this arrangement) that the work would be rendered more readily available for the purposes of reference than if the materials of which it is composed were merely put in chronological order, without attention to their nature and character. This plan has the additional recommendation of rendering the history of each part complete in itself.

I cannot conclude without expressing my sincere acknowledgments to Mr. B. Phillips, as well as to Mr. Dalrymple and Mr. Fergusson, for the very valuable advice with which, as members of the Council of the Society, they have favoured me in the execution of my task.

J. E. E.

London: Nov. 1844.

Part I.— Symptoms, Pathology, And Causes. Page

2d Cent. Galen ...... 3

6th Cent. Aetius . . . . . . 4

1728. J. M. Lancisi — De Aneuiysmatibus Opus Posthumum . . 14

1733. A. Monro — Remarks on the Coats of Arteries, their Diseases, and

particularly on the formation of an Aneurism .' . 81

1736. Petit — Observations Anatomiques et Pathologiques au sujet de la

Tumeur qu'on nomrae Anevrysme . . . . 89

1 749. A. Haller — De Aortse Venseque Cavse gravioribus quibusdam Morbis 98

CONTENTS.

1 757. W. Hunter — The History of an Aneurism of the Aorta, with remarks on Anem-isms in general

1760. D. Monro — Cases of Anem-isms, with remarks

1761. W. Hunter — Further Observations upon a particular species of

Aneurism .....

1769. W.White — Two Letters on the Varicose Aneurism

1770. T. Armiger — A Letter on the Varicose Aneurism

1770. W. Hunter — A Postscript to the preceding

1789. M. Baillie — Of uncommon Appearances of Disease in the Blood vessels .....

101 115

160 171 173 174

PART XL— TREATMENT.

6th Cent. Aetius .....

7th Cent. Paulus ^Egineta ....

1594. J. Guillemeau . . . ' .

1681. Morel — Observations sur la Cure des Anevrismes .

1681. RoYER — Lettre a Mons. I'Abbe Bourdelot, &c. &c.

1681. BouRDELOT — Lettre de I'Abbe Bourdelot, &c.

1688. Saviard — Sur un Anevrysme de I'Artere crm-ale

1714. D. Anel — Suite d'un Memoire, &c.

1728. J. M. Lajncisi — De Aneurysmatibus Opus Posthumum

1 733. J. Macgill — A History of the Operation for an Aneurism of the Arm

1733. A. Monro — Reflections on the Aneurism occasioned by bloodletting

CONTENTS. xi

PAGE

1 744. L. IIeister — De Genuum Structura eorumque Morbis . . 232

1745. MoLLiNELLi — De Brachii Aneurysmate e Isesa inmittendo Sanguine

1748. H. F. Albertini — Animadversiones super quibusdam difficilis Res-

pirationis Vitiis . . . . . . 237

1753. FouBERT — Memoire sur differentes especes d'Anevrisme faux . 242

1753. MoRAND — Sur un Moyen d'arreter le Sang des Arteres sans le secours

de la ligature ..... 250

1761. Lambert — Extract of a Letter to Dr. W. Hunter, giving an account

of a new method of treating an Anem-ism . . . 264

1766. J. BuRCHALL — An Aneurism of the thigh perfectly cured by the

operation, and the use of the limb preserved . . . 266

1772. C. GuATTANi — De Externis Aneuxysmatibus manu chirurgica me-

thodice pertractandis. Historiae duse Aneurysmatum, &c. . 268

1773. W. Bromfield — Surgical Observations, &c. . . . 347

1774. C. Leslie — An Account of the operation for the Aneurism being

performed upon the femoral artery vsdth success . . 348

1779. P. Pott — Remarks on the necessity, &c. of Amputation in certain cases 351

1779. B. Wilmer — An Aneurism of the popliteal artery, with some remarks

on Aneurism in general .... 354

1781. A. Murray — In Aneurysmata Femoris Observationes, &c. . . 359

1786. E. Home — An Account of Mr. Hunter's method of performing the

operation for the Popliteal Aneurism . . . 373

1787. Supplement to the Account, &c. . . . . 381

1793. An Account of Mr. Hunter's method of performing the operation

for the cure of Popliteal Aneurism . . . 385

1797. J. F. L. Deschamps — Observations sur la Ligature des principales

Arteres des Extremites, a la suite de leurs Blessures, et dans les Anevrismes, particulierement dans celui de I'Artere poplitee, &c. . 404 xii CONTENTS.

PAGE

1797. GujSrin — Rapport des Commissaires nommes par la Societe cle

Sante de Bourdeaux pour I'exaraen d'un Memoire sur I'Anevrisme 467

1799. B. Lacoste — Rapport des Meraoires et Obsei-vations du Cit. B. Lacoste, &c. sur uii Anevrisme vrai alapartie superieure de I'Artere femorale gauche, par le Cit. Deschamps . . . 479

1799. J. F. L. Deschamps — Observations et Reflexions sur un Anevi'isme

ATai de la partie superieure de I'Artere femorale . . . 481

Part I. Symptoms, Pathology, And Causes

SELECTIONS ON ANEURISM.

PART I.

SYMPTOMS, PATHOLOGY, AND CAUSES.

GALEN.

When an artery is opened, tlie disease tliat occurs is called Second an aneurism. It happens in consequence of the skin in the . "^'•"'^' neighbourhood of a wounded artery cicatrizing, whilst an ulcer remains in the vessel, which neither becomes agglutinated nor cicatrized, nor filled up with flesh. Diseases of this description are known by their pulsating, and by their disappearing entirely when pressed upon ; the contents of the tumour, which we have elsewhere shown to be a thin and bright blood mixed with much subtile spirit, warmer than that contained in the veins, passing back into the artery. If an aneurism be wounded, the blood is spouted out with so much violence that it can scarcely be arrested. In oedema the part yields to the finger when pressed upon, forming a pit; but there is no pulsation in that disease, and its colour is pale. (Edema likewise is much more widely diffused than an aneurism, unless when any grumous blood is formed in the latter, giving rise to sphacelus.

An aneurism is a dilatation or relaxation of a venous vessel, or a dispersion of the spirituous matter under the flesh, where, it diffuses and distributes itself by jerks (per dissultationem.)2

' Claudii Galeni Opera omnia, torn, viii, fol., Venet. ap. Juntas, 1609. Vol. v, p. 84, De Tumoribus praeter Naturam, cap. 11, De Aneurysmate et Sydratione.

^ Op. cit. vol. i, p. 48. Ascriptae Finitiones Medicae Isagoge. See also Method. Medendi, cap. 5, and De Ciirandi Ratione per Sanguinis Missionem.

AETIUS— FERNELIUS.

AETIUS,

ON DILATATION OF THE VESSELS.

Sixth A dilatation of tlie vessels^ which the Greeks call an aneu- Century. j-ism^ may occur in any part of the body, but is most frequently met with in the throat, where it gives rise to a tumour that goes by the name of bronchocele. It very commonly happens to women during parturition, on account of the forcible detention of the spirits. But it may occur in the head, in the situation of the arteries, and also in any other part of the body ; as when unskilful surgeons, in opening a vein at the bend of the arm, puncture the artery that lies beneath. But a dilatation of the vessels may occur in any situation in which the blood and spirits flow out of the arteries ; or if the mouths of these be opened or burst ; the blood and spirits being then gradually poured forth, collect under the skin. The signs of an aneurism are a tumour, which may be large or small, without discoloration of the skin or pain, soft to the touch, having a loose spongy feel, and yielding in such a way to the pressure of the Angers that it almost disappears, but returning again on the fingers being removed, which is very evident in those aneurisms that have arisen without a wound ; but when it has been preceded by a wound of the artery, and the skin then uniting, a dilatation of the vessels has occurred, the tumour is not equally soft : for the blood being in larger quantity than the spirits, coagulates, and thus distends the tumour. And these are the signs of an aneurism.

FERNELIUS.2

1542. An aneurism is the dilatation of an artery full of spirituous ' • ' blood. It sometimes occurs externally, as in the hands and

* Joan. Fernelii de Morbis universalibus et particularibus ; 8vo, Lugduni Batavorum, 1645.

GORR^US. 5

feet, or about tlie throat and chest; diflfering in this respect 1549. from a varix, that it is large, swollen, and has often an annoying ' — ^ — ' pulsation. On the tumour being pressed upon, the matter contained within it disappears. It also sometimes occurs in the internal arteries, especially in the chest, or about the spleen and mesentery, where a violent throbbing is frequently observable. It is scarcely credible that some imagine that in these affections the vein or artery is ruptured or opened ; for if the blood had escaped from the vein or artery, it would soon putrefy, and give rise to a tumour of a different kind.

GORR^US.i

An aneurism is a tumour, soft to the touch, yielding to the 1564. pressure of the fingers, and occasioned by blood or spirits poured " ' ' out from an artery or vein. The blood may be efiused in two ways : from an internal cause, the vessel being opened by anastomosis ; and from an external one, the vessel being ruptured, whilst the skin remains sound. It occurs in the throat (where it is called bronchocele), in the chest, and in the groins or limbs, either from a powerful compression or an increased movement of the spirit, in consequence of which, the vessels being distended, give way; or from the vessel being divided with the superficial skin, whether accidentally or by the unskilfulness of a surgeon in bloodletting when he punctures an artery instead of a vein. For if, before the artery is healed, or cicatrized, or filled up with flesh, the integument has united, the formation of an aneurism cannot be prevented; for the blood and spirit being gradually poured forth, collect under the skin, and give rise sometimes to a large, at other times to a small tumour, according to the size of the part in which it happens, but of the same colour as the rest of the skin, and without pain. It is soft and spongy, yielding to the fingers, by the pressure of which it may be made to disappear when it has arisen without a wound. But when it is the consequence of a wound, the skin having afterwards united, it is not equally soft, as more blood than spirit is efiused

' Joanni Gorrsei, Opera Medica; Paris, 1622, fol. Defin. Medic, p. 56.

6 par6.

1564. in it ; which, becoming grumons, makes the tumour less yielding ' — " — ' to the fingers; but if this species of the disease were to be pressed back into the vessels, it would do so without any of the noise that is occasioned by that which arises from anastomosis of the artery, in which there is more spirit than blood. : and by this difference the causes of the two species of aneurism may be known. There is another difference; for that which arises from anastomosis is larger and deeper, whereas that which is occasioned by a wound is rounder and not so deeply situated. Aneurisms can in general only be cured mth great difficulty, and there is no remedy for those that occur in the throat and head; for if they be opened, the blood and spirits escape, and the patient is left dead in the surgeon^s hands. It is called aneurism from ava and evpvvr\v, and not from v^v^ov and a privative, as some have erroneously supposed, translating it by the Latin enervatio.

PARE.i

1582. An aneurism is a soft, compressible tumour, occasioned by the ' " ' blood and spirits being effused under the flesh, in consequence of the dilatation or the relaxation of an artery; so that the author of the ' Definitions^ has seemed to suppose that an aneurism might be occasioned by the dilatation of any venous vessel. Galen says that when an artery is opened by anastomosis, the disease called aneurism is occasioned. It may also be occasioned by the wound of an artery, the superjacent skin closing and cicatrizing, whilst the wound in the vessel remains without being agglutinated, blocked up, or closed by flesh ; especially if an artery be opened instead of a vein during the operation of phlebotomy. Aneurisms may thus be occasioned by anastomosis, diapedesis, rupture, erosion, and wound. They may occur in any part of the body, but principally in the throats of women who have difficult labours ; for these hold their breath forcibly, so that the artery dilates and bursts, when the blood and the spirit escape little by little and collect under the skin. The signs of an aneurism are a large or small pulsating tumour

' Les ffiuvres d'Ambroise Pare; fol. Lyon. 1641. Liv. vii, chap. 34, p. 184.

PAR6. 7

of the natural colour of tlie skin, soft to the touchy and yielding 1582. on pressure in such a way that, if it be small, it disappears en- ' — ^ — ' tirely in consequence of the blood and spirit entering into the body of the artery; and then, on removing the fingers, will instantly reappear as before. When pressure is applied to some, a noise or blowing sound is perceived; this is also sometimes the case without the necessity of applying pressures, in consequence of the impetuosity with which the spirit passes in and out of the small opening in the artery. But no noise is heard in those aneurisms that are occasioned by an extensive rupture of the artery, for this hissing is the result of a small and narrow opening.

The reason why some aneurisms become large, with a bony circumference is, that the arterial blood becoming heated and boiling, causes the coats of the vessel first to dilate and enlarge, and then to give way ; and taking from the neighbouring parts matters similar to themselves, in order to reunite, thus occasion a large or a small tumour, according to the capacity of the part. Then little by little the circumference of the tumour dries and hardens, like a vessel, becoming cartilaginous, and then osseous by a material and efficient cause, as stones are formed in the kidneys and bladder ; for the earthy matter of the blood being dried and thickened by the unusual heat, adheres to the coats of the artery and of the parts that it occupies, thus becoming hard and bony ; and this, by a great foresight of Nature (the handmaiden of the Almighty), constitutes a rampart or strong barrier, lest the hot and boiling blood full of spirit should escape and pass out of the coats of the aneurismal or dilated artery. It may, however, be said that this hardness is owing to the cold and repercussing applications constantly made to such tumours, which may harden and thicken them, as it is easy to gather from what Galen says in the last chapter of the fourth book ' De Prsesagitione ex Pulsibus.' Besides, in very large aneurisms, there is frequently no pulsation ; and on pressing upon them, the blood cannot be forced back into the artery, both because it is in too large quantity, and because it concretes into a thrombus, and afterwards putrefies, as it is no longer kept up by the natural heat of the heart, from which great pain ensues, then gangrene and mortification of the part, and, lastly, death.

GUILLEMEAU.

GUILLEMEAU.i

ON ANEUEISM, AND THE MEANS OF TYING AND CUTTING IT.

1594. The tumotir called aneiLrism is usually considered to be a ' ' dilatation of the artery, which can only apply to small aneurismsj as it is impossible that the artery can really be dilated and enlarged to the size of the large aneurisms that are often met with. Following, therefore, the opinion of the ancients, we will say that an aneurism is occasioned when the blood and spirits pass out of the vessels, in consequence of their orifices being opened, which is said to be by anastomosis ; or when the coats of the artery are divided or ruptured, either from a wound or any other cause ; which is seen when a surgeon, wishing to open a vein at the bend of the arm, wounds the artery which is below, or sometimes above the vein ; and the skin covering it cicatrizing, the wound in the artery remains, in consequence of the continued movement of the vessel, without being glued together, or blocked up or filled with flesh ; and as it cannot be compressed or ligatured so tightly as at the temple, the blood and spirits escape little by Httle and accumulate under the skin, and give rise to the aneurismal tumour. People are sometimes mistaken about this ; for being of opinion that some slimy or pituitous matter is contained within, they make an opening into the tumour, in consequence of which the patient quickly dies from the great effusion of blood and spirits that takes place, without it being possible to arrest them.

The signs by which this disease may be known and distinguished from others are a pulsating tumour of the natural colour of the skin, which, whilst it is of small or moderate size, is soft to the touch and yields to the pressure of the fingers, so as almost entirely to disappear, the blood and spirits being driven back into the artery, and on account of their passing forcibly through a small opening, they occasion a noise. The fingers being then removed, the tumour returns immediately, and the blood and spirits re-entering by a small opening, give rise to a

' Les (Emi-es rle Chiiurgie de Jacques Giullemeau; Paris, 1612; fol. p. 698.

SENNERTUS. 9

hissing noise^ which usually happens when the aneurism is oc- 1594. casioned by anastomosis, and not by a wound ; because, the ' — ' — ' orifice being open, the spirit being the most subtile, escapes before the blood, and then the tumour is almost entirely spirituous ; but if the artery has given way, much blood escapes, and then the tumour becomes more liquid than spirituous, and, becoming harder, at last coagulates, and causes a distension of the part.

SENNERTUS.^

[After examining the doctrines of the older writers on the 1628. pathology of this disease, Sennertus proceeds thus :] ' ' '

For if an aneurism be occasioned by an effusion of

arterial blood under the skin, the blood ought certainly to be diffused far and wide and all around, and should discolour the skin, as we see happen in contusions, and in venesections that are unskilfully performed, when either the vein is pierced through or else when the wound is not properly closed; for then the blood is frequently effused under the skin as far as the hand, staining the skin of a red, green, or yellowish colour ; which a wounded artery ought certainly to do to a still greater extent, as the arterial blood is thinner and flows with more violence ; but which, nevertheless, does not happen in aneurisms in which the tumour is contained within its own limits and in a kind of cyst ; nor is the skin discoloured. And likewise, if an aneurism were occasioned by an effusion of blood under the skin, it would, being in an unusual situation, putrefy, as happens in ecchymosis. We must, therefore, endeavour to explain the formation of this tumour in some other way. The author of the ^ Libri Definit. Medic.^ defines an aneurism to be the relaxation of an artery. Fornelius^ also, in his ' Pathologia,^ (lib. vii, c. 3,) says that an aneurism is the dilatation of an artery which is filled with spirituous blood. But neither of these writers explain the mode of its formation. And it is not to be supposed that an aneu-

' Danielis Seiinerti Opera omnia; Lugduni, 1650; fol. lib. v, part 1, cap. 42, p. 306.

2 Vide p. 4.

10 SENNERTUS.

1628, T^ism. is occasioned by a dilatation of both coats of an artery^ ' — » — ' but probably of one only : for arteries possess a double coat ; an external one, wbich is thin, fine, and soft, having many straight fibres, but few oblique, and no transverse ones ; and an internal one, which is thick, dense, and hard, having transverse, but no straight or oblique fibres. And therefore if the internal hard membrane be either ruptured, in consequence of over-stretching, or be opened by a wound, it will not, on account of its hardness, coalesce readily ; but as the external one is softer, it readily coalesces ; and because it is softer, and has neither oblique nor transverse fibres, it will be distended by the blood and vital spirits which are urgently seeking to escape ; and thus this kind of tumour is formed, in which the impetus of the blood and of the vital spirit can actually be seen. Nor is the objection that has been raised by Platerus of any moment, namely, that if the skin alone which covers the tumour be cut, the blood which lies directly under it will immediately burst forth, and frequently in such quantity that it can scarcely in any way be arrested, but that the patient may suddenly die, having lost nearly the whole of his blood. If we admit that an aneurism is occasioned by the dilatation of both coats of the artery, this objection will have some weight. But if it be occasioned by the dilatation of the external coat alone, the inner one being opened either by rupture or by dilatation, we cannot conceive that the whole of the blood can be contained immediately under the skin, but the external tunic, being excessively distended, may adhere so closely to the integument, which is also in a state of tension, that it becomes almost impossible to divide the one without the other.

Thus the proximate cause of an aneurism is an opening in the internal tunic and a dilatation of the external one. This is more frequently occasioned during bloodletting, when unskilful surgeons mistake the artery for the vein, or puncture it with the vein. When this happens, the external tunic being soft, and resembhng the coats of the veins, unites readily ; but the internal one, being harder, remains open ; whence the blood and vital spiiit, attempting to escape through the aperture, distend the external coat, and thus generate this kind of tumour. The same may happen, if, from a violent impulse of the arterial blood, or from the operation of external violence and too great

FABRICIUS— WISEMAN. 11

a distension of the artery^ the internal coat be ruptured^ the 1628. external one, which is better fitted to be stretched, remaining ' — ' — ' sound and uninjured.

FABUICIUS (HiLDANus).i

The external tunic then resembles the coats of the veins, and, 1633. like them, readily unites after being wounded, and prevents the ' ' ' escape of the arterial blood in the same way that the veins do that of the venous blood in varices ; in accomplishing which, that common membrane which Galen has described as surrounding the arteries in particular situations contributes not a little. Therefore, whatever kind of aneurism may follow a wound, either none of the coats, or, at most, the internal one only, is opened, the external one always uniting.

OF AN ANEURISMA.

An aneurisma, according to my description, is an ecchymosis, 1676. and indeed the highest species of it. But since authors have " ' ' given another account of that tumour, and have allowed it a peculiar chapter, I have done so too, the rather because the nature of the vessel through which the effusion is made doth require a different mode of cure.

Description. It is a tumour, soft, white, and yielding to the touch, but riseth again upon the removal of your finger, and is for the most part accompanied with pulsation of the artery.

Opinion of the ancients. It is raised, according to the opinion of authors, by dilatations or relaxations of the artery : they supposing the blood to have burst its passage through the first

' Gulielmi Fabricii Hildani Opera. Francofurti, 1646. fol. cent. 3, obs. 44. 2 Several CMrurgical Treatises by Robert Wiseman, Serjeant-Chyrurgeon to King Charles the Second. 2d ed. London, 1692. fol.

1676. coat, and dilated the second, thereby raising the tumour. And ' — ' ' this some of them have delivered to us so positively, as if they had, in opening them, found the exterior coat so dilated. This I myself was taught, and some while believed ; but not having been able by my practice to discover one aneurisma made by dilatation or relaxation of the outward coat, I am apt to believe that there is no such thing, but that it takes its rise from the blood bursting quite through the artery into the interstices of the muscles, where it raiseth a tumour suitable to the cavity it findeth, growing bigger or less, of this or that shape, as the muscles give way. But this tumour consists of blood extravasated, the artery lying undilated the while. I do therefore suspect the possibility of an aneurisma by the dilatation of the outward or softer coat of the artery, because it seems improbable that a force big enough to burst the inward coat, which is so tough and firm, should leave the exterior (being softer and weaker) whole, and go out so leisurely into it as to give it time for dilatation. Those which I have met with did all come from downright eruption through both the coats ; and those that come from external punctures must of necessity begin with a breach of the external coats first, it being next the lancet or other weapon that made the division. Sennertus would have it heal again, though contrary to my experience, who have always found it open as well as the internal; and indeed reason must tell us that the constant eruptions of blood out of the artery in every pulse, must needs keep it open ; nay, the blood keeps not within the bounds of any one membrane, but I have seen it extravasated through all the interstices of the muscles of the whole arm.