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13 In an appendix the author gave the details of M. P. Broca’s I unpublished case of ligature of the subclavian artery for inno- minate aneurism, and also a table of the various cases of distal ligature for aneurism of the root of the neck which have been recorded. Mr. HoLMES said that he was glad to have the opportunity of bearing his testimony to the very gratifying success ob- tained in this case, which he thought Mr. Heath had accu- rately described as unique in the annals of surgery. He wished to defend the accuracy of the views in his article on aneurism in the " System of Surgery" from the imputations which Mr. Heath appeared to cast upon them. In fact, however, Mr. ! Heath, while saying that he "was somewhat in the dark" as to the proposals made for operation in these cases of supposed innominate aneurism, had himself, in his subsequent remarks, completely vindicated the accuracy of the statement in the "System of Surgery." The operations proposed were really as there stated. First, the simultaneous ligature of the com- mon carotid and first part of the subclavian, as necessitated by a logical following of the proposal known by Brasdor’s name, and as shown by Mr. Heath to have been practised in Rossi’s operation. This operation Mr. Holmes had spoken of as too dangerous to be justifiable, and Rossi’s case so far bore out that view. Secondly, the ligature of the carotid alone, which does not seem to hold out sufficient hope of success to justify the risk to which it exposes the patient; and thirdly, the ligature of the carotid and third part of the subelanian. Before Mr. Heath’s case this double ligature had only been practised at a considerable interval of time between the two operations, and Mr. Fearn’s was the only case in which success was claimed ; but his account was obscurely worded, and led Mr. Holmes to doubt the reality of the cure. Mr. Fearn’s preparation now before the Society showed, however, that as far as the disease in the innominate artery went it had been arrested, and probably soundly cured, and the pressure upon the trachea and threatened bursting into that tube obviated, so that the life of the patient was saved for the time. But the preparation also showed, as it seemed to him, that the aorta partook largely in the disease, and that, therefore, though life had for the time been saved, the disease could not be said in strictness to be cured. So in Mr. Heath’s case also. His account of the consultations prior to operation showed how great a doubt there was as to whether the aorta was or was not the seat of disease in this woman, and his perfectly I accurate and frank description of her present condition I showed also that the disease is far indeed from being cured, ’’ though its progress towards the trachea and towards the nervous cords forming the plexus had been arrested. But it is well known that these tubular aneurisms or aneurismal dilatations involving the aorta, innominate, and perhaps also subclavian arteries, will go on sometimes for an indefinite period without material alteration, and that the sacciform. dilatations or buds projecting out from them (like that in Mr. Fearn’s case) will sometimes, and perhaps not very infrequently, undergo spontaneous cure. Instances of these events were quoted from the recent practice of St. George’s Hospital. Considering, therefore, the great difficulty of diagnosis, the risk of finding the arteries diseased where exposed for opera- tion, the great likelihood of serious disease in the aorta or even the heart also, and the possibility of spontaneous cure, or cure by appropriate regimen, it seems prudent not to under- take these operations without the gravest consideration, and in circumstances which can but rarely present themselves. Perhaps the best indication for operation would be the relative amount of pressure on the trachea compared with that of the general symptoms. That is, when the patient is otherwise in moderately good health, but suffers much from dyspuaea, and appears likely to die soon from rupture of the aneurism in this direction, the question of arresting it by ligature of the arteries of the right side might be considered, but in any case it must be regarded rather as palliative than as curative. Mr. Holmes concluded by congratulating Mr. Heath on the success of an operation of such difficulty and magnitude, and which really appeared to have saved, or at least prolonged, the patient’s life. Mr. SAVORY referred to a remark in the report of the case which was to the effect that the left radial pulse was 102 and the right 96. He could not understand how, the heart being the prime cause of the circulation, the pulse-rate could be different on the two sides. He asked if the observation of the two pulses had been made at the same time. Mr. BARWELL thought the heart was not the sole cause of the pulse, and alluded to a case in which he had found the pulse-rate different on the two sides. Referring to Mr. Heath’s patient, he said that, as the arm had been paralysed, the aneurism must have passed as low as the pectoralis minor. Dr. PAvY thought that the cause of death in Mr. Fearn’s patient’s case might fairly be called an accidental one. If tilaments of the sympathetic or the vertebral artery be in- jured experimentally in animals, pleurisy is certainly pro- duced, and the extension of an aneurism would, by pressure on these filaments, produce a like result in man. Mr. HEATH, after thanking Mr. Holmes for the very hand- some way in which he had spoken of his case and the treat- ment pursued, remarked that Mr. Wardrop had only treated one case of innominate aneurism by the distal ligature, the other two cases being diagnosed quite correctly from the first as aneurisms of the lower part of the carotid. Only one of these latter caqes, however, was usually included in the list of operations, because in the other the carotid was found still pervious after death. He had not entered into details of other cases of innominate aneurism in his paper for fear of making it too lengthy ; but there was no question that, in all the cases at least in which two vessels had been tied, the diagnosis had been correctly established. Mr. Heath quite allowed that cases of innominate aneurism might go on for months under careful treatment, but it unfortunately happened that in most cases the disease made rapid progress and burst into the trachea or elsewhere. He alluded to the progress of Dr. Davies’ case and to two specimens which he had ex- hibited at the Pathological Society, in one of which the aneurism burst into the trachea, and in the other into the posterior triangle of the neck. With regard to the question of the pressure of the blood upon the sac after a distal liga- ture, Mr. Heath believed it to be impossible to give a decided answer. In the majority of cases the tumour immediately diminished (and notablv so in Wardron’s cases): but occa- sionally it increased. He was content to quote Broca’s own words, which are :-" I confess that I know no theory capable of explaining why Brasdor’s operation has the immediate effect of sometimes increasing and sometimes diminishing the size of the aneurism." With regard to the inequality of the pulses, Mr. Heath said he had no explanation to offer, but believed it to have been the fact, and the same difference was noticed when the pulse on the right side became perceptible after the operation. Mr. Fearn’s case hardly illustrated Dr. Pavy’s theory of pleurisy, which was no doubt a correct one, for the pleurisy in that case resulted from a direct injury to the ribs. Mr. SOLLY adverted to the age of the patient and to the traumatic origin of the aneurism-the patient had fallen out of a window. This would be a guide to the propriety of operations in future cases of aneurism. PATHOLOGICAL SOCIETY OF LONDON. TUESDAY, JAN. 1ST, 1867. ANNUAL REPORT. THE session of the Pathological Society (1865-66) has been marked by the steady advance in prosperity and usefulness which the condition of the Society’s affairs enabled the Council to pre- dict in presenting their last report. It was stated in that report that the number of annual subscriptions which had been received in the past year (303) was the largest which the Society had ever yet attained. In the present annual account, however, the receipt of 314 annual subscriptions is acknowledged, as well as two composition fees from resident members. The number of fees by admissions has also risen from 27 to 35. Thus it is seen that the number of the Society’s members con- tinues steadily on the increase. Nor will it be denied by those who have taken part in the session which has just terminated, that the activity and exer- tions of the working members of the Society in the prosecution of the object for which it was founded, is in proportion to its growth in numbers and reputation. The large expenditure which the Council have sanctioned on the seventeenth annual volume is, they hope, justified by the production of a volume not only much larger than its predecessors, but containing also a corresponding proportion of matter of permanent value and interest. It is perhaps a subject of regret that the expenses of a volume which, like this, shall be worthy of the reputation of the Pathological Society, should so nearly exhaust all the disposable funds. The Council have on this account taken into renewed consideration the possibility of obtaining a place of meeting without the great expense to which they are put for
