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which Mr. Holt refrained from interfering, (THE LANCET,March 1,1851, p. 237.) The patient died a few weeks ago,and we beg to subjoin the appearance of the parts involved.The particulars -were noted by Dr. Shearman, house-surgeonto the hospital.

General cerebral structures healthy; but beneath thearachnoid on the left hemisphere, at the vertex, there is anfusion of yellowish-white gelatinous matter, partly pus andpartly exudation matter; substance ’of brain healthy, excepta small portion of the size of an almond on the lateral aspectof the middle lobe, which was of a slate-grey colour, and firmon section. Over the lateral and upper surface of thecerebrum, a large quantity of pus was effused; it extendedfrom the vertex to the front of the anterior lobe, up to theroof of the orbit. The anterior lobe on the part correspondingto the roof of the affected orbit, contains a cavity whichdisplays on its surface no evidence of effusion to circumscribeit; the walls are irregular, and of a slate-grey and purplecolour. The fluid in it is grumous, dirty-grey, and not fillingits cavity. No connexion appears to exist between the puson surface of brain and that in cavity; the substance of thebrain around the cavity is softened and purplish in colour;rest of brain healthy.The whole of the upper jaw surrounding the antrum of left

or diseased side is broken up from necrosis, and the partcorresponding to the antrum more or less made up of purulentmatter and necrosed pieces of bone. The orbit contained theusual quantity of fat; the periosteum thickened, white, dense,and almost creaking under the knife; the thickness is chieflyin the posterior part, around the optic nerve; and this seemsto be the cause of the protrusion of the eyeball; the opticnerve and globe natural. The other portions of the body were Iin a normal state, and no trace of tubercular or malignantdisease found anywhere. Under the microscope, the periosteumof the orbit was found to consist of stroma and fluid part,-chiefly the former; the fibres are in bands, and closely crossedwith one another, and also considerably interweaved; theyare wavy, and rendered transparent by acetic acid. In thefluid parts were caudate cells, with well-marked nuclei; alsocells containing several nuclei; the envelope is very fine andtransparent; size, larger than a pus globule. There are othermuch larger cells, whose walls are exceedingly fine, andthese in their turn containing nuclei.

CHARING-CROSS HOSPITAL.Aneurism of the Femoral Artery in the Groin; Spontaneous

Occlusion; Gangrene of the Leg; Death; Autopsy.(Under the care of Mr. AVERY.)

SPONTANEOUS cure of aneurism has at all times been a veryinteresting, and hitherto not quite explained, surgical fact; wehave, therefore, no doubt that a case bearing upon this subjectwill be perused with a certain amount of benefit. Nor is it

very common that an opportunity should be afforded of exa-mining the parts soon after such a natural recovery has takenplace; this, however, was the case in the instance which wehave to put upon record.Authors have generally admitted various ways in which

aneurisms may cease to pulsate, and become solid withoutsurgical interference. 1. Pressure on the cardiac side of the.sac, either by the aneurism itself, or a tumour of a differentnature. 2. Occlusion of the aperture of communication bycoagulation. 3. Inflammation and gangrene of the cyst.4. The aneurism becoming diffuse. 5. Obliteration of theartery on the distal aspect. These are the different modesenumerated by Professor Miller, in his "Principles of Surgery;"to these we would add-7. Certain circumstances which musthave some influence in spontaneous cure-viz., an increased,plasticity of the blood, and a less active circulation from what-ever cause.

Mr. Porter states, in his work on Aneurism, that the casesof natural recovery which he has had an opportunity of seeing,’occurred by means which are surrounded with great obscurity.,Still it might be inferred that such cures must, to a certainextent, have been the result of one of the above-mentionedchanges. We find three such cases mentioned by Mr. Porter.In the first, the aneurism had caused the absorption of thesternum, and seemed ready to burst; the pulsation, however,without any appreciable cause, ceased, and the patient reco-vered. The second refers to a subclavian aneurism, whichpulsated strongly. Several consultations were held upon the

,-propriety of tying the arteria. innominata, but whilst the’ope.: ,qtiou was being -delayedy-the tum6ur’lost its pulsations, the

clots became consolidated, and the disease disappeared. Thethird case is one in which Mr. Porter attempted to paSS iV 11906-ture around the innominata for subclavian anetirism; thelnno-minata artery was in too diseased a condition, and could notbe tied; but the patient soon afterwards recovered withoutthe aid of surgery. It is very probable that in these cases thesac became solid by tho occlusion of the artery On the cardi&cside.

Unfortunately r Jntaneous cure is very rare, and surgeonshave for the most part to trust to deligation of the artery orpressure. In the case before us, as will be seen by the sequel,the pulsations of the sac ceased spontaneously, but other ioir-cumstances contributed to the fatal termination. We havemuch pleasure in continuing our series of aneurism cases, andfrom notes taken by the house-surgeon Mr. Lingham, wegather the following details.John Buzz, aged seventy-four, was admitted Jan. ’7, 1851,

under the care of Mr. Avery, with aneurism of the femoralartery. He stated that his habits had been temperate, andthat thirty years of his life had been spent as sailor in themerchant-service, during which period he was exposed tomany hardships. Two years since the patient contractedgonorrhoea, when a small swelling made its appearance’inthe groin; he consulted a surgeon, who gave him medicineswhich nearly, not altogether, removed the tumour. - Thelatter, however, made its appearance again in a very shorttime, and had been increasing up to admission. Patient didnot suffer much inconvenience from the swelling until aboutthree months prior to his entering the hospital, when, aftermoving some furniture (in which effort he fancies he exertedhimself too much.) the tumour rapidly increased, and a pulsa-tion was now for the first time noticed in the swelling.On examination, a large pulsating tumour-was found on the

upper part of the right thigh; it occupied the position of thefemoral artery, and extended from about three inches belowPoupart’s ligament into, and apparently entirely filling, theright iliac fossa. A pulsation synchronous with that of theheart was perceptible in every part of the tumour, an a

distinct bruit de souffiet was yielded on auscultation. Thewhole limb was swollen, cedematous, and painful, the skin pale,and the temperature below that of the corresponding leg.The femoral artery on the sound side was found small involume, its impulse feeble, and giving to the finger the sensa-tion of a peculiar sharpness. The pulsation of the radialartery was found devoid of power; these symptoms leavingbut little doubt but that the arterial system was extensivelydiseased. The patient could not assume the recumbent

posture, as the pain in the groin was thereby considerablyincreased, and he was obliged to be constantly sitting up inbed. No rest could be obtained at night, on account of thepain and the sitting posture, tongue moist and slightlyfurred.Mr. Avery ordered wine and a nutritious diet; the limb to

be bandaged from the toes upward, and five grains of soap-pill at night. On the next day it was found that the patienthad passed a restless night; the tumour has diminished insize, and pulsation had totaUy ceased in every part of it; thelimb was less swollen, and its temperature had become lowerthan it was on the previous day. The impulse of the femoralartery on the left side was now found less abrupt, and im-proved in volume. On the third day after admission, thepatient was able to lie down; he had some sleep at night; thepain was less severe, but the temperature up to the knee verylow. The leg began to present a mottled appearance,and the tumour had resumed neither pulsation nor bruit.The patient appeared weaker, but felt comparatively free frompain. Tongue cleaner; pulse seventy, feeble, but Tegular.On the fourth day, the pain was very severe in both limbs,

the lower portion of the right leg becoming colder and of adeeper mottled appearance; the left leg was at the same timeof the ordinary temperature, though the impulse of its femoralartery had again become feeble. The aneurismal tumourremained stationary. Warmth was now applied to theaffected limb by means of cotton wool. Mortification made,however, rapid strides, for on the fifth day it had appeared onthe inner side of the leg. The pulse now fell to sixty, andthe tongue became dry.The sphacelus had on the ’eighth ’day extended in evety

direction round the limb up to the knee, in which region aneffort at the formation of a line of demarcation was perceived;the pulse became small and feeble, and the tongue brown; thepatient did not suffer any pain,’ but"was becoming drowsy.The tumour presented no reaewed pulsations, and was di-’ttiinisbilÌg1in síze. ’ .on the tenth- day therl-- was considerable

516

prostration of strength; the sphacelus travelled higher; theemanations from the limb were of a very foetid character; thepulse feeble, the tongue dry, and the patient very heavy.These symptoms went on steadily increasing up to the four-teenth day, when the patient expired. The sudden cessationof the pulsations in the tumour, and the subsequent phe-nomena, gave the post-mortem examination a peculiarinterest.The lungs were completely filled with tubercles in the upper

portion, and a cacoplastic, yellow exudation had consolidatedthe inferior third of the right lung. The valves of the heartwere tolerably healthy; in the arch of the aorta and the re-maining portions of this vessel steatomatous and calcareousdeposits had caused a complete degeneration of the coats.The vessels connected with the aneurismal tumour werecarefully removed; and on a dissection being made, it wasfound that the aneurismal dilatation of the femoral arterybegan just below the branching off of the epigastric, the out-line of the sac being lost a little below the origin of the pro-

funda, where the aneurismal walls were very undefined. Thecavity was soft, filled with coagula; it would have admitted alarge orange, lay in a somewhat crescentic shape just overthe hip-joint, and communicated with the artery by whatoriginally had been a rent in the vessels. The profundaartery was quite obliterated by the pressure of the sac withwhich it communicated, the aperture being, however, stoppedup by a clot of blood. A few soft coagula were found in thefemoral artery above and below the sac, which latter waslined with soft fibrinous layers. Below the sac the samevessel was completely filled with firm fibrinous layers, throughthe centre of which ran a minute canal. The aorta and ex-ternal iliac were much diseased, hard, and puckered. Both ’,the femoral vein and artery run in front of the sac. Theopening of communication between the artery on the cardiac Iside and the aneurismal cavity was about two inches and a Ihalf in circumference, and it seemed very likely that thevessel just above it, as well as the vein, had been obliteratedby the pressure of the tumour itself extending upwardsbehind the vessels. The vein had the appearance of a thickcord, and was obliterated in front of the artery; this venouscanal was filled with coagulum half-way down the thigh. Aportion of the sac extended upwards into the iliac fossa, abovethe epigastric artery; and in the walls of this sac an openingwas observed, by which blood had escaped, and filled up thespace along the external iliac artery up to the right kidney.Towards the trochanter minor, and underneath the artery,there was a sort of offshoot from the sac, about the size of asmall apple, which was filled with firm fibrinous layers.In the history of this case there are two features worthy of

arresting the attention for a few moments-first, the lengthof time the tumour existed without pulsating; and secondly,the occurrence of gonorrheea in connexion with that tumour.Though the growth of aneurlsmal dilatation is slow, the pul-sations generally appear as soon as the swelling has attained asufficient size to attract attention. It is not improbable thatthe fact of the artery lying in front of the sac had some influ-ence on the tardy manner in which the pulsations becameapparent, and the effort made by the patient in moving apiece of furniture had perhaps caused a sudden displacementand increase of size, which gave an impulse to the tumour.Whether the swelling which sprung up sirnultaneously withthe gonorrhoea, was merely an irritated gland or an aneurismaltumour, cannot with complete certainty be determined, butthe likelihood is that the sac was already formed. This cir-cumstance will serve as a renewed caution that we should notproceed to plunge the lancet into a swelling without someattention to all the symptoms; for it is extremely probablethat the knife in this instance would have laid open ananeurismal sac instead of an abscess; the mistake being themore pardonable as no pulsation was as yet noticeable in thetumour. ’

The aneurism, as happens in old age, had probably had itsorigin in calcareous deposit and ulceration of the inner coat,the two latter having given way and been lacerated, firstslightly and then suddenly when the effort was made. As to thespontaneous occlusion, it may be accounted for in two ways-first, as stated above, the aperture of communication betweenthe artery and the sac on the cardiac side may have beenoccluded by a pressure of the tumour upwards, or the aneu-rism, becoming suddenly diffuse, and the blood accumulatingaround the external iliac artery, may have exercised on thatvessel a steady though not a powerful compression, and thusdetermined the obliteration of the artery; or the sac situatedbetween the pectineal line and Poupart’s ligament, and at the

back of the artery, may have sufficiently compressed thevessels as to render them impervious. Mr. Avery inclines tothe first of these opinions. Or these three causes may besupposed to have been acting either at the same time orshortly after one another. ’

When we consider the patient’s age, his debilitated condi-tion, and the peculiar state in which a limb is thrown by theexistence of an aneurism, we shall not be surprised to findthat the sudden obliteration of the artery (or at least com-paratively sudden) was followed by gangrene of the limb.From the steps taken by Nature herself in this case, we aretaught a useful lesson; they show, if we do not err, that a,

gradual diminution of force in the current of the blood ispreferable for obtaining coagulation and consolidation withinthe sac, than a sudden obliteration of the artery by ligature.It is true that the collateral circulation, by the mere existenceof the aneurism, is already very active, but though in certainindividuals that collateral circulation will at once carry asufficiency of blood immediately after the tying of the artery,it is clear that a little more time given for due preparationby gradually retarding the flow of blood by the main trunk,has more chance of success. These precautions (which aretaken when pressure is preferred to the ligature) are certainlyof some importance when we remember the low tone of thevital power in the limb, generally concomitant with the pro-gress of an aneurism.The complete sphacelus which overtook the limb was pro-

bably not unconnected with the peculiar state of the vein;pressure on venous trunks, or lymphatics, always producesmore or less oedema of the limb, diminution of temperature,and sluggish circulation. It is plain that in a case of thisdescription the surgeon has the grief of finding himselfpowerless, the age of the patient putting every operativeinterference out of the question. In a young and healthier-subject, the spontaneous cure would perhaps not have beenfollowed by gangrene, and even then amputation might havebeen performed. Where, however, spontaneous cure doesnot occur, the deligation of the external iliac artery mightbe tried in preference to Brasdor’s method of tying on the-distal side of the sac. (See Lacoste’s and Deschamp’s casesin Mr. Erichsen’s work on Aneurism, Sydenham Society.)As to the risks of haemorrhage after the ligature, we should

state, that in the case of popliteal aneurism under the care ofMr. Avery, which we published on February 8, 1851, p. 151,arterial haemorrhage took place seven weeks after the opera-tion, and five after the removal of the ligature. The loss ofblood was not, then, merely venous, as we had at first beenled to believe and to state.

Medical Societies.

MEDICAL SOCIETY OF LONDON.

SATURDAY, MAY 3, 1851.—DR. MURPHY, PRESIDENT.

MR. LATTY related the following case ofANEURISM OF THE AORTA.

A military officer, aged forty-one, after twenty years’ service m aIndia, returned to England in October last, having, during theprevious year, had repeated attacks of spleen, and been reducedto a state of great debility. On coming under his (Mr. Latty’s)care, in the beginning of February, he was in the following con-dition :-He was jaundiced, his lips bloodless ; he had lost flesh,and complained of great debility ; he had lost his voice, beingable to speak in a whisper only ; he had a hoarse, croupy cough,with scanty expectoration, which was glairy, more or less rustyor streaked with blood, and intermixed with sputa, having all theappearance of pus. When he slept through the night, he alwaysexpectorated, in the morning, one or two sputa of pure blood ofa dark colour, which had evidently oozed out during the night.His pulse was quick and feeble, but quite regular ; tongue foul,appetite bad, and urine scanty, very high coloured, and depositinga copious pink sediment. He had no fever. The right lungexhibited signs of being in a healthy condition. The left sideof the chest afforded, upon percussion, a very clear sound as faras the nipple, below which there was a remarkable dulness. Thevesicular murmur was very distinct in the upper part also; butall over the lower region, where the dulness existed, it wasscarcely audible, and was accompanied by a slight crepitant rate.The heart’s impulse was feeble, its action regular, and it emittedno abnormal sound. He had no difficulty in his breathing, either