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speak of its claspers by which it embraces the elm ; andwould not the elm speak of its destruction by the ivy ?Would not the pretty dodder speak lovingly of the gorse,which it nevertheless so often chokes. I think the philo-sophy of the whole matter is found in "Hamlet" when thePrince says to the King := ‘ We fat all creatures else to fatus, and we fat ourselves for maggots. Your fat king andyour lean beggar is but variable service, two dishes to onetable. Alas! alas ! a man may fish with the worm thathath eat of a king, and eat of the fish that hath fed of thatworm !-What dost thou mean by this ? Nothing, but toshow you how a king may go a progress through the gutsof a beggar." In the case of parasites, it is clear that wehave no inherent power to get rid of them, and all we canattempt to do is to destroy them by violence. If there beany truth, therefore, in the germ theory of contagious dis-eases, the treatment of them is clear-war to the knife.The analogy would not be so close if it were true that theweakly and the sick first became a prey to epidemic disease.This has often been stated by writers on social science,when conformable to their views ; but facts are antagonisticto them. I have always taught the opposite, and can nowspeak with confidence, since Dr. Walshe, in a lecture lately Ipublished, has expressed the same opinion. Many years ago,when reporting cases of fever, I said that I had never foundany organic disease in those who had died of it, for it wasnot until typhus had broken out in the hospital, and aftermany years’ experience, that I had an opportunity of seeingsuch a thing as a diseased heart in a person dead of fever.I think all members will bear me out in saying that it isamongst the youthful and vigorous that small-pox, scarla-tina, &c., grow and prevail. From their own germ point ofview these diseases delight in the young and healthy; and,in the case of artificial poisons, or those introduced into thesystem by accident, I see no effort of nature to get rid ofthem. The kidney, like every other organ, has its own

peculiar function, and takes cognisance of certain materialsin the blood and eliminates them; but it often seems tohave no power to eradicate them from the system, for, inthe case of lead-poisoning, the blood may throw them downin every tissue of the body, and there leave them.Whilst on the subject of elimination, and the supposed

efforts of nature to get rid of deleterious matters from thesystem, it might naturally be conjectured that, with therejection of this doctrine, I should discard all such ideas asare conveyed in the terms, 11 conservative processes," andthe " vis medicatrix naturæ." The supposition is right, andI would more fully have dwelt on the subject, had not Dr.Bristowe so admirably treated it in the Croonian lectureslately delivered at the Royal College of Physicians. He hasput it very clearly before us, how certain physiological lawsexist which we can watch like other laws in nature, and seehow they atways act in certain definite methods; furtherthan this we have no right to go. We have no right toselect a particular instance of a natural process, and declarethat a conservative action’ is in operation, any more thanchoose another case and call the action destructive. Theforces of nature go blindly on, heedless of results, andcannot be spoken of as if they were half-intelligent powerswith benevolent or baneful objects in view. Such notionswould show that we had not reached the true scientificmethod, but, according to Comte, were still in the meta-physical stage of thought, when external agencies weresupposed to be ruling the world. If we once admit theminto our nomenclature we are led into countless contra-dictions. If, instead of regarding the hypertrophy of theventricle, in the case of obstruction of the bloodvessels, asa result of a simple physiological law, we speak of it as aconservative process, we are immediately reminded of thewrongfulness of the expression, when we see this same con-servative process causing the rupture of a vessel in thebrain, and killing the proprietor; or if we choose to callthe blocking up of the bloodvessels as they pass througha cavity in the lung conservative, how are we to name thesame process when it tends to the mortification of an organ,and perhaps the death of the patient? These laws arenatural laws, and often not even strictly physiological; forwhere is the difference between the case of enlargement ofthe superficial veins when the vena cava is obstructed, andthat of dirty water finding its way by the gutters when themain sewer is choked. If a conservative power presides inthe one case, does it not in the other ? I may be allowed

to say that I do not take up this subject as the question ofthe hour, but am giving you the result of my maturedthoughts, and such as I have always taught. I have alwaysregarded such terms as " conservative," " elimination ofdisease," 11 vis medicatrix," as purely metaphysical, andhaving no place in the vocabulary of medicine. This lastterm I discarded from my earliest student days, for I wellremember when a surgical teacher used the expression withreference to a case of fractured skull, and when, notwith-standing that curative nature was to step in and mend it,the patient was seen on the post-mortem table a few daysafterwards with inflammation of the brain, I remarked, interms which were considered almost sacrilegious, that theman would have lived with a crack in his skull if nature’svis medicatrix had not stepped in and killed him. I amconvinced that when we occupy our minds with meta-

physical entities, and talk of conservative powers of nature,vital principles, and such like vague terms, we are hinder-ing scientific discovery, by implying that there are agenciesat work behind the phenomena which we witness. I confessI don’t know the intentions of nature, and whether, when aman is purged in cholera, nature is endeavouring to curehim or to kill him. The doctor says the former, the socialstatician says the latter. I remember, too, we used to betold that not only disease itself, but even an accident, mightcontain within itself the elements of repair; for example,a thorn which sticks in the skin would set up an inflamma-tion and abscess, and thus be discharged. The very sourceof mischief contained the cure. A very striking and ridi-culous,rebuff to this doctrine occurred some years ago atmy hospital, in the case of a young man who, having hadtoo much to drink, fell off a plank whilst crossing to hisship, and was nigh being. drowned. On his recovery he waslectured on the serious consequences of spirit-drinking,whereat he replied that, on the contrary, he bad been in-formed that it was nothing but the brandy in his stomachwhich had restored him to life.

(To be co-noludett.)

THE

ADDRESS IN SURGERY.Delivered before the Annual Meeting of the British Medical

Association, at Birmingham, in August, 1872.

BY OLIVER PEMBERTON,SURGYON TO THE GENERAL HOSPITAL, AND PROFESSOR OF SURGERY IN

QUEEN’S COLLEGE, BIRMINGHAM ; FOREIGN CORRESPONDINGMEMBER OF THE SOCIETY OF SURGERY OF PARIS.

IT has been customary to leave to individual selectionthe subject of this annual address. In the exercise of thisunfettered discretion, some of my predecessors have devotedthemselves to the consideration of a particular subject onwhich they were entitled-either from the circumstance oforiginal research, or the advantage of practical knowledge-to speak with authority ; whilst others have directed theirattention to reviewing the progress of surgery, with all itsbearings on the science and art of their time. It may bethat those who followed the latter course placed themselvesmore in harmony with the original plan of this undertaking;but it must not be forgotten that during the number ofyears that have elapsed since this Association was foundedthe entire scope and character of medical literature has

been changed. In these days the scientific discoveries ofEurope, Asia, and America are, as it were, on our verytables, and within speedy reach of us all; surely it wouldseem then but a repetition of an old story to arrange them inorder before you. One of the happiest events, however, con-nected with these meetings provides an escape from anydifficulty in the selection, from any sameness in the cha-racter of the discourse. They are held, in turn, in England,Scotland, and Ireland. The great cities of these kingdomsare so many centres of surgical study, having featuresmarked and distinctive, created no less by local than by

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personal circumstances. For I take it that it will be con-ceded that whilst the great principles are wellnigh everywherethe same, no art differs by its exercise so widely, whether inforce, completeness, or success, as ours does, in varyinghands, or when practised in places removed by distancefrom each other. Hence whoever happens to be designatedto fulfil this most honourable task may be expected to pos-sess some special experiences which his opportunities haveafforded him in the place of assemblage-some illustrationsof vexed questions in surgical treatment that may arouseinterest in an audience even as critical and accomplished asthat I have before me at this moment. In this hope, andwith a full knowledge of how illustrious are the names thathave preceded me in accomplishing this task, I ask yourindulgent consideration whilst I endeavour to justify theconfidence reposed in me by the Council of this Associationand by my professional brethren, as I submit to your judg-ment the fruits of personal observation connected with oneor more of the chief maladies that demand the skill of thesurgeon.To solicit your attention to some moot points connected

with the treatment of aneurism, is sufficiently appropriatein itself, if we only consider the increasing interest thatat present surrounds it, and the impetus that must be givento its study by the exhaustive nature of the lectures nowin course of delivery before the College, by Prof. Holmes;but I cannot forget that we are assembled in Birmingham,where Freer and Hodgson lived and wrote- illustriouspair ! well fitted to be teacher and pupil. I cannot forgetthat George Freer* was the first to tie successfully the ex-ternal iliac artery, and that Joseph Hodgson† paved theway to a clearer perception of the pathology of arteriesand veins than had existed since the days of Hunter. Soit is an appropriate tribute to their labours, that here, inthis place, I should have the subject of aneurism foremostin my mind.

Professor Lister’s improvement in the Hunterian opera-tion, by which the permanent closure of the artery at thespot tied can be ensured, without dividing the coats of thevessel, at once effects a complete change in some of themost important conclusions that for long years have guidedus in our treatment of aneurism. One of the greatestdangers attending the Hunterian operation has hithertobeen considered to be the application of the ligature imme-diately beyond any considerable branch of an artery. This

impression has deterred surgeons from applying a ligatureto that portion of the artery which otherwise would haveseemed to them best adapted for the purpose. That an

abiding coagulum will form under certain circumstancesin the vicinity of almost any number of branches on theproximal side of a ligature, I am perfectly satisfied; butthe attainment of this success in many cases depends on afact which it is almost impossible for the surgeon to esti-mate beforehand-that is, the facility with which the bloodwill coagulate or deposit its fibrin in any particular instance.In the case I am about to relate, the existence of thistendency, in a much greater degree than usual, was themain cause of the success of the operation.

In June, 1870, I saw F-, aged sixty ; strumous fromchildhood, and highly intellectual. There was an aneurism,three months old, of the left superficial femoral, about fiveinches below Poupart’s ligament. There were marked in-dications of general arterial disease, and, during the pasttwelve months, of semi-paralytic seizures, evidently due totemporary hindrance to the cerebral circulation. Pressurefailed and was abandoned at the end of three months. Ithen advised ligature, the aneurism rapidly increasing. OnOctober 12th, the aneurism having "leaked" the previousday, in the presence and with the sanction of Sir JamesPaget, I tied the common femoral with a hempen ligature.Fearing, from the diseased state of his arteries, the worstresults, as the ligature might be thrown off, the wound wasleft completely open, being simply covered for protection.In forty days the ligature came away, and the patient dieda week afterwards, from causes wholly removed from theaneurism. There was no haemorrhage, but gangrene maybe said to have commenced in one toe. When I came todissect the arteries, I found the circumflex ilii, epigastric,and the profunda femoris given off together, that is at

opposite points of a line drawn round the main trunk, a* 4th October, 1806.

t A Treatise on the Diseases of Arteries and Veins. London, 1815.

little above Poupart’s ligament, the point of ligature beingfive-eighths of an inch below these vessels, the part ofartery intervening being firmly plugged. The profundawas pervious for some distance, and then plugged. Therewere plugs of former date in the right and left carotids andin the left axillary arteries. The aneurismal sac was filledby broken-down clot and fluid blood, and would have sup-purated.Now, I cannot consider this case as any contribution to

the surgery of the common femoral, though I hoped andexpected it would be so, for I think harrlly any doubt canbe entertained but that the patient would have died fromsecondary haemorrhage on the separation of the ligature,had it not been for the unusual tendency of the blood tocoagulate, for nothing could well be closer than those threevessels were to its site. At the same time I think, withPorter and Macnamara,* that the exclusion of the commonfemoral, on account of the assumed liability to secondaryhaemorrhage and gangrene that follows its ligation, is notfounded on any solid basis. It was selected in this in-stance in preference to the external iliac, and I should soselect it again, of course on the presumption that I wasgoing to place my ligature in the vicinity only of suchbranches as the epigastric and circumflex ilii, in the pre-sence of which I feel satisfied that an adequate coagulummay under ordinarily favourable circumstances be reason-ably expected to form. It is rather here then I draw yourparticular attention to this feature of coagulation; for Iask myself this question: if I had tied the artery, compli-cated as its irregularity was in this instance, with a hempenligature, and there had not existed this tendency, would ithave held ? a Assuredly not. This same tendency to coagu-lation, as manifested in the collateral vessels, whilst itpreserved the patient’s life, would, I may observe, havesubsequently caused his death by gangrene. Further, itappears to me that in proportion as the coats of the arteriesdeviate from their natural state, and as the general vitalconditions are lowered, so is this tendency increased.

Surgically speaking, then, this very circumstance of dis-eased arteries and tendency to blood coagulation, in somecases, establishes a reason why the surgeon should not re-frain from operating where the diseased condition of the coatsof the arteries alone would lead him to abstain from inter-ference. And it is clearly of the utmost importance to in-crease this tendency to the coagulation of the blood as muchas possible, after all operations for aneurism, by good diet,and by the absence of all depressing remedial agents.Apart from this question of coagulation, I feel warranted

in expressing my conviction that too much stress has beenlaid on the disturbing influence of a large branch or

branches taking origin close to the part of the vessel tied.If, however, we are to believe the teaching of Prof. Lister,†it will be of little moment in the future whether a plugform on either the proximal or distal side of the ligature atall, so long as the "prepared catgut" ensures permanentclosure of the vessel at the spot tied, without severance ofthe coats, and consequently without liability to secondaryhæmorrhage. From what I have seen since this case cameunder my notice, I am glad, before such a meeting, to beable to express my unbounded admiration of and confidencein the use of the animal ligature as placed before us byProfessor Lister. If the so-called " antiseptic system" haseffected no more for surgery than to give us the means ofeffectually closing an artery without cutting it through andwithout suppuration, it has in doing this placed the crown-ing glory on the treatment of aneurism, for which it haswaited since the time of Hunter. For forty days I watchedpatiently for the detachment of this ligature with an openwound to escape deep-seated suppuration. I watchedtwenty-one days in a case last May, in which I tied theexternal iliac for aneurism at Poupart’s ligament; andthough the case did perfectly well, the suppuration aboutthe track of the hempen cord gave me the greatest anxiety.Last August, Mr. Lund,‡ at Manchester, tied the sameartery with a catgut ligature. No pus was secreted ; thewound healed on the eighth day !

Professor Lister remarks that ligature of the innominatemust yet prove, with these means at command, " a very safeprocedure." Yes; but always, I presume, provided that the* On Ligature of Common Femoral. Brit. Med. Journ., ii. 1867, p. 285.

t Observations ou Ligature of Arteries. Edinburgh, 1869.t THE LANCET, Aug. 6th, 1871.

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coats of the artery are healthy where the ligature is applied;and on this we await further evidence; given this, and Ifeel inclined to echo the assurance.

I shall now endeavour to show that the principles oftreatment in the methods of flexion, compression of the sacand manipulation, are one and the same.The method of flexion can only be applicable to certain

arteries. All that it is needful to do is to keep the limb-flexed, not continuously, but to such an extent as to alterthe relations between the orifices of ingress and egress,and the fibrinous laminse of the sac. Some of these laminsebecome, as it were, dislocated, and protrude more or lessinto the stream when a fresh deposit of fibrin occurs, andso the cure is gradually, effected. The exercise of pressureon the artery above the angle of flexion appears to meuseless. What we want is a stream of blood flowing intothe aneurism ; that it should be more or less retarded there,and that there should be present something in the natureof a foreign body; for example, the fibrinous laminse, onwhich blood would coagulate and deposit its fibrin. Thisretardation of the blood in the sac can be effected by agentle compression of the artery on the distal side of theaneurism; as I strongly hold that what we want in thesecases is a deposition of fibrin rather than a coagulation ofblood. For surely the slow deposition, layer after layer, ofsolid fibrin in the sac, until the filling-in is complete, is asurer guarantee against subsequent mishaps, than if it wereclosed by a mass of suddenly coagulated blood. I placebefore you the case of K-, a Lascar, aged twenty-two,who came under my care on May 10th, 1859, having ananeurism of the left popliteal artery of four months’ dura-tion. Flexion was maintained for seventy-two hours, withthe result of the aneurism ceasing to pulsate, and becomingsolid in eleven. Compression during the first forty-eighthours, of moderate character, was also made by Weiss’s in-strument on the artery in Scarpa’s space. I believe thatthis was the first instance on record in which the combina-tion of compression and flexion was made use of; and thecase was published very fully at the time in THE LANCET.*But I feel satisfied now, in reviewing it, that pressurebelow the sac would have proved more advantageous thanabove.

If one wanted convincing of the very slight meanswhereby important curative changes may be brought aboutin aneurismal sacs, I have but to ask a consideration ofthe facts connected with the following cure, in thirty-ninehours, of a popliteal aneurism. M , twenty-eight, aporter, came under my care on the 17th January, 1871, withan aneurism of the right popliteal artery five months old.On the 22nd I had shown the patient how I proposed totreat him-by flexion-at the same time bending his leg,and arresting the circulation through the sac. It is verylikely that the patient, in the afternoon, subsequent to myvisit, imitated my proceeding, as he seemed very muchstruck by what I had done. Be this, however, as it may,I only bent the limb once, and fingered the sac lightly, andtold him to keep quiet. At 2 A.M. on the 23rd he wasseized with sudden aching, shooting, gnawing pain in theneighbourhood of the aneurism, extending down the calf ofthe leg as far as the ankle, and upwards as far as the crestof the ilium. The pain continued very intense for somehours, during which he had no sleep. He had severe nausea,but no vomiting, and was chilly. The pulsation in theaneurism seemed unchanged, but he remained poorly allthe day.-24th : Slept until 3 A.M., when he awoke andfound pulsation had ceased in the aneurism. The limb wascold below the knee, and cedematous, and though the painof yesterday was better it was not gone. On examiningthe aneurism it felt hard and was free from pulsation. Hewas subsequently discharged cured.

I am inclined to think that coagulation commenced hereafter the first flexion-that the deposit of coagulum, aftera few hours, increased rapidly, as indicated by pain which’culminated in intensity as the sac was solidified. There

may have been a clot detached which plugged up eitherthe proximal or the distal orifice-if so, it took place at thefinal exacerbation of pain, when pulsation ceased-for Icertainly judged the contents, when I bent the limb, to befluid. The verification of the intense pain that occurs, when

the blood current is forced suddenly into narrow collaterals,* Vol. ii., 1859, p. 232.

or at the supreme moment when the contents of the sacare solidified, was here very conspicuous.To ask, for a few minutes, the judgment of a skilled

assembly, such as this, on the probability of applyingpressure with success to the actual sac of an aneurism,would appear to be returning to the pre-Hunterian period;and yet had the theory by which aneurisms are cured nowbeen fully comprehended then, I can have little doubt butthat the necessary deposition of fibrin would have beenbrought about, in many instances, that otherwise so sig-nally failed.

I entertain the opinion that compression of the sac oughtto be used more frequently than it is now. The principleof this proceeding is exactly the same as flexion; we wantsimply to alter the relations of the laminated fibrin to thecavity of the aneurism, so as to bring about a further de-position of fibrin on the projecting surfaces of any of thedisplaced laminæ. The pressure need not be continuous.It should be very gentle. It need not even be distributed

uniformly. But it must ever be borne in mind, that if itbe carried to such an extent as to empty the sac and topress one wall against the other, then a cure cannot occur.The very conditions under which a cure is possible are hereignored. Blood must pass through the sac. It must notpass through too rapidly; and I now think that this wouldbe facilitated by gentle pressure being made on the arterybelow the aneurism.In March, 1857, I visited D-, aged sixty-seven, an

active sportsman and farmer. He had an aneurism, amonth old, of the right external iliac artery, just abovePoupart’s ligament. It was somewhat fusiform in shape,measuring three inches in length, by one and a half inbreadth. There was no bruit. I failed to arrest the circu-lation through the aneurism by making pressure on theartery above, but I found I could greatly limit the currentby making pressure on the sac itself. The question beingraised of an operation, I advised, that as a ligature couldhardly be applied to a sound artery other than in thecourse of the common iliac, and bearing in mind the vicinityof the bifurcation, no operation should now be performed,but that Dr. Carte’s compressor, under careful manage-ment, should be applied to the sac itself. Accordingly,under my directions, two senior students* remained withthe patient. The treatment extended over a period of sixweeks. During the first fortnight little good was effected;then for eight consecutive days pressure was applied, onan average of seven and a half hours per day. The pres-sure effectually retarded the circulation-nothing more-and was never applied for more than three or four hours ata time. Consequently, the patient was not wearied, andhad undisturbed nights. There was now a complete in-terval of nine days, during which no pressure was applied,the aneurism being firmer and with less pulsation, and hewas allowed to move about in his room. Then followednine days of treatment, averaging six hours and a halfper day. From this time the aneurism ceased to pulsate,and the patient gradually resumed his ordinary avocations.He is yet living, in his eighty-third year, active and well.In December last,t the remains of the aneurism were re-presented by an indurated enlargement, about the size of achesnut.

I venture to think that even Dr. Macnamara will giveme credit for having studied O’Bryen Bellingham‡ to somepurpose, who, happily for my patient, published his obser-vations in the January of this very year. Reduce the forceand volume of the blood-current by any carefully con-sidered measures, and we follow out the reasoning of Brasdorand Wardrop in the distal ligature; a reasoning which isrendering amenable to treatment internal aneurisms hithertobeyond surgery ; a reasoning that has the authority ofnature’s own proceedings to recommend it, from the factthat it is more or less identical with the mode in which theso-called spontaneous cures are brought about. I own this

case-unique as ic is in this situation-has always been inmy mind, on the discovery of any fresh instance of aneurism.It serves to confirm the soundness of the remark, that inproportion as the true method of curing aneurisms has beenfully understood-that is, the gradual lessening of theblood-current to final and complete coagulation in the sac-

* The late Mr. Dennis Moore, of Walsall, and Dr. Neal, of Birmingham.t Letter from Mr. J;;arlam, of Abbotts Bromley.t Observations on Aueurism. London. 1847.

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so have the means whereby this has been brought aboutbecome simpler and more safe.The occurrence of these cases led me to the attentive

consideration of the facts, as they are at present beforeus, connected with the purposed displacement of thecontents of the sac of an aneurism, in the hope of pluggingup either outlet; and the case of M- happened when asubclavian aneurism* was under my notice in another ward,about the treatment of which I was-to say the least of it-previously undecided. It seemed to me so impossible tolimit the degree of force, short of extreme hazard, in themethod originated by our distinguished confrère, Sir WilliamFergusson ;† and I was not reassured by perusing the caseshe has recorded, or those of Mr. Pollock.‡

I cannot but regard the treatment by manipulation to bebased on exactly similar principles to those on which themethods I have just alluded to are founded. No forciblepressure to detach fibrinous laminæ, in my judgment, oughtto be used; as the result would be the almost certain sepa-ration of small portions of the clots, which would be carriedinto the circulation, and would eventually plug the smallervessels, causing symptoms according to the functions of theparts which the plugged vessels supply. For I must own Ihave not been able to see how these clots could be locatedat either outlet to be fixed by arrangement, as it were, ata spot where it is simply impossible to be assured that theycould effect a lodgment. All that is necessary is that theaneurism should be gently manipulated, so that the laminaeof fibrin in its interior should occupy a different position tothat which they had previously held with reference to thetwo orifices of the sac ; and in order that the blood shouldnot be allowed to pass out of the sac too freely, if I have anopportunity, I shall endeavour to compress the distal arteryin accordance with the principles I have been advocating.B-, aged thirty-two, admitted into hospital Oct. 20th,

1870, a former Life-guardsman, with aneurism of threemonths’ duration in the second and third parts of the rightsubclavian ; it was as large as a hen’s egg, and was accom-panied by bruit and by dilatation of the axillary. Hestayed a month, during which time iodide of potassium wasfreely given ; and then, frightened at the idea of an ope-ration, suddenly left. On Jan. 20th, 1871, he was admittedagain ; the aneurism seemed firmer, giving me the impres-sion that fibrin had been deposited. From Feb. 10th to 14ththe sac was manipulated night and morning for a fewminutes; the proceeding was one of the utmost gentlenessand regularity, and consisted in making pressure with thethumb and finger so as to slightly approximate its fibrinouswalls, and, whilst thus limiting the circulation, probably ren-dering the clot surface somewhat irregular and promotingthe tendency to deposit already commenced. On the llththe pulsation was much weaker, and on the 14th it ceased

altogether. There was no brachial or radial pulse belowthe aneurism; and he complained of pain extending down-wards from the aneurism to the iliac region; this wasconstant, severe, and of a numbing character. Tkere wasno constitutional disturbance. During the following daysthe collateral circulation about the clavicle and shoulderdeveloped itself ; and especially noticeable was a largetransversalis colli crossing over the aneurismal sac. OnApril 17th he left for the sanatorium, the sac being smalland hard. Since this time he has pursued his business asa hawker, travelling all over England. I examined him,and so did my colleagues, as recently as the 19th of June,sixteen months after the cure of the aneurism, and I notedthe following facts : "A little induration marks the site ofthe aneurism ; the axillary artery and upper part of thebrachial can be felt, cord-like, as far as the insertion of thecoraco-brachialis-here pulsation begins, and can be felt

feebly in the radial at the wrist. He is himself excessivelythin, but well and hearty."The absence in this case of any symptoms of paralysis

during the four days in which the sac was manipulatedjustifies the inference that no clot at least passed into thecerebral circulation, and I entertain myself the convictionthat the cure was brought about by a steady process oflamination, rather than by the detachment of a clot, happyenough to fit iuto either orifice of the aneurism.

* Pollock records three successful cases of direct compression to sub-clavian auenrisms.-St. George’s Hospital Reports, vol. xvi., p. 63.t Medico-Chirurgical Transactions, vol. xl., 1857.j: Op. cit., p. 45.

I have now to call your attention to what I believe to bea not uncommon result of the cure of aneurism, after it hasbeen effected for some time; I mean the formation of vari-cose aneurism or aneurismal varix. I shall first relate twocases.

In 1844, my late colleague, Mr. Amphlett, tied the super-ficial femoral for an aneurism of the artery as it enters.Hunter’s canal. The patient was forty-one, and a soldier.There was nothing unusual at the operation, and the liga-ture was thrown off on the nineteenth day. Ten days sub-sequently there was arterial hæmorrhage from the seat ofligature. This recurred again in ten days, and a third timein fourteen. Pressure on the arch was used, and thepatient recovered. He remained well for upwards of threeyears, when a tumour formed at the seat of operation, whichwas evidently an arterio-venous aneurism. With thiscoming under the care of my colleague, Mr. Baker (ourPresident), he died from a drunken pleurisy, just five yearsfrom the date of the operation. I was fortunate in beingable to dissect his vessels. The femoral artery had formedan aneurism at the seat of the operation as large as a hen’segg, and the femoral vein communicated with the artery bya large opening. The former aneurism was cured, and theartery between it and the seat of ligature was impervious.M , aged fifty, a soldier, syphilitic and intemperate,

became the subject of an aneurism of the upper part of theright posterior tibial artery. Pressure was made over theartery on the pubic arch for three weeks; on it, below, fornine months. The aneurism was cured. Ten months after-wards an arterio-venous communication formed at the chiefseat of pressure, and the patient died in about a year andeight months subsequently. I had the opportunity of

minutely examining his body, and I came to the conclusionthat pressure on the pubes induced varix in the femoralvein, at the situation of the saphenous opening ; that thissubsequently sustaining pressure enlarged and became ad-herent to the artery, and, finally, by a succession of changes,.readily comprehended between a diseased artery and a dis-eased vein, adherent to each other, ended in establishing ananeurismal varix.At the time when I published this case, which was done

at considerable length in the Transactions of the Medico-Chirurgical Society for the year 1861, I attributed theresults merely to the injurious effects of long-continuedinstrumental pressure, producing morbid changes aroundand between the contiguous vein and artery; and I wasinclined to quarrel with Bellingham’s* remark, ,That nomorbid change of any kind takes place in the artery orvein at the site of instrumental compression." Subsequentreflection, however, and an attentive study of the prepara-tions, have led me to seek a different explanation. Thus,in consequence of the diseased conditions and diminishedelasticity of the arterial walls, which almost constantlyexist in all arteries above the seat of an aneurism, the ve-locity of the blood movement is considerably retarded. Itis evident that this retardation must be materially increasedby the obstruction at the seat of ligature, or the seat oflong-continued instrumental compression. The immediate

consequence of this retarded velocity is an increase inlateral pressure. This dilates the diseased coats of theartery into an aneurism, which-by the usual processes ofpressure-absorption and disintegration opens into an ad-joining vein. Sometimes, as in the second case I have-adduced, the opening is effected directly into the veinwithout the previous formation of an aneurism-and thevein subsequently becomes varicose by the passage of ar-terial blood into it.

It is now with regret that I must leave this subject andpass on to another.

(To be concluded.)

* Medico-Chirurgical Transactions, p. 12.

M. LABOULBENE, of Paris, has been enabled by meansof an a.spiring pump, to investigate the character of the liquidcontained in the knee of a patient suffering from blennor-rhagic arthritis. The liqnid was withdrawn in MMMO, andtherefore quite pure and undisturbed. It presented adeep yellow tint, and contained numerous purulent whiteglobules. It was twice inoculated in the eye of a rabbitwithout result.

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