known to the public, for his opportunities of making a public appearance have been few: but I have long and intimately known him, perhaps, to a certain extent, I may say, that I have directed his attention to the peculiar pursuits. I have the utmost confidence in him; and should the unexpected event occur of an interruption to my proceedings, on the part of health, a sacrifice which, among others, I have had to make in the public cause he is so conversant with my ideas, and so well acquainted with my manuscripts and other materials, that I shall be consoled by finding my place so ably occupied. Rely upon it, however, that I shall not delegate any thing which I may undertake to perform, except from the direst necessity; and the undertaking, as regards both Mr. A. and myself, is the following.

It is proposed to deliver the lectures three times a week, on Monday, Wednesday, and Friday. The Monday and the Friday lectures will be reserved for the general details of the subject, as laid down in the prospectus which has been placed in your hands; and these I purpose, with the help of Providence, to deliver personally. After a few introductory and general instructions, my colleague will enter upon the subject of TOXICOLOGY, or death by poisoning. These lectures and demonstrations we design shall be given upon the Wednesdays, pari passu with the general course, by which time will be saved, impatience for details in some measure arrested, and progress effectively made. With this introduction of my friend, I shall take leave of a subject which is to me painful only, because I can hardly allude to Mr. Anderson without speaking of myself.

It is rather a hazardous affair for a person of another occupation to speak upon matters of law, though much of what is so stiled, is in point of fact nothing more than the display of intellectual acumen. There is no lack of talent or of information-perhaps, even of knowledge of the world among medical men; but my respected brethren have hung back from an ill-founded dread of publicity. Lawyers, on the other hand, are accustomed to sharpen their wits, and, not unfrequently, polish them against those of one another-or if they can find a grind-stone in the shape of a witness, they are not loath to press hard; and rub fast; but there is a circumstance to which I have, upon former occasions, alluded; to which I may allude hereafter-and to which I shall advert now. Witnesses of all descriptions go into courts, not knowing the real nature of their situation. It is enough for the present, to exemplify by the case of ourselves, for the subject of medical evidence will receive, in due time and place, a copious share of attention. We are never harrassed by captious questions; and it is very common to hear all the witnesses ordered out of court (before the examination begins) except the medical. The real and advantageous use of

this FACT, which I beg that intended pupils will not forget, shall be noticed upon a future occasion. I shall merely say now, that the practice is a sufficient refutation of a doctrine which has been laid down by certain writers on forensic medicine-namely, that medical men intending to give evidence, ought not to confer together upon matters of professional knowledge and opinion. It is some years since this heresy was broached; and I fear it has been the cause of much embarrassment to many practical medical jurists. The authorities allow us to hear all the evidence, with the very intent that we shall form a valid opinion, and, if possible, a unanimous one.

St. Bartholomew's Hospital,

SURGICAL LECTURES,

Delivered

By WILLIAM LAWRENCE, ESQ. F.R.S. February 6th, 1832.

ANEURISM.

GENTLEMEN,

I HAVE already spoken of some of the varieties of aneurism; this evening I shall confine myself to those modifications of it, which I have not noticed before.

There have been different divisions of aneurisms; the ancients divided them into internal and external, the former being those situated within cavities, as the thorax, abdomen, and pelvis, and affecting the large vessels, as the aorta and iliacs, whilst the external ones, ar those situated in the extremities. Latterly, there has been a different division of them, into true and false; true aneurism is said to exist, when there is dilatation of the coats of an artery; false, when there has been a rupture, or ulceration, or giving way, of the coats of an artery, and a cyst has been formed of the surrounding parts. This division is of no importance in the treatment of the disease, it is merely useful in a pathological or historical point of view; it will make no difference in the treatment, whether it is a true or false aneurism, whether it is one of dilatation or rupture. The old opinion was, that aneurism was invariably produced by dilatation of the coats of the artery; this is a very uncommon occurrence, it is most frequently caused by ulceration or rupture of the coats of the vessel. Scarpa has been at considerable pains to prove, that all aneurisms belong to the class denominated false aneurisms; he says the disease is always produced by a thinning and giving way of the parietes of the artery. This is not the most common opinion of their origin;

there is, in the first instance, a partial giving way of the coats of the vessel, and it becomes distended, as it progresses; ulceration or absorption coming on, converts what was originally a true aneurism into a false one: those we operate on are generally false aneurisms.. We see, therefore, Scarpa's views are not exactly correct; in the first instance, it is a true aneurism, then it becomes false. There is another description, termed the mixed aneurism, in which there is dilatation of the vessel, and at a certain point rupture has taken place, and there is a cavity or cyst formed external to the artery. You here observe a specimen of the mixed kind-it is an aneurism of the arch of the aorta, part is contained within, part without the chest; in one part there is dilatation of the artery, and here in front there has been rupture of a very small portion of the tube; there has been absorption of the ribs by its pressure, and the cyst is formed of the surrounding parts. True aneurism seldom occurs; when it does, it is generally situated in the aorta, more especially at its arch; it now and then happens in the arteria innominata. In the majority of cases the part giving way is of a very small extent; in the preparation before you it is not more than an inch, although the disease is very considerable-this is its ordinary appearance. A false aneurism is rather a tumour formed on the outside of an artery than existing in the artery itself; here is a preparation illustrating this point-there is a large tumour formed by condensation of the surrounding parts external to the vessel, and the communication between it and the tumour is to a very small extent. A true aneurism could not take place to so large a size, the walls of the vessel would not yield to so great a degree. You will understand the difference between the three kinds of aneurism; that in the true aneurism, there is dilatation of the coats of the artery, and that this disease occurs most frequently at the arch of the aorta; that in the case of false aneurism, there is a sac formed by the neighbouring parts external to the artery, but maintaining a communication with it, and lastly there is the mixed kind.

Aneurisms occurring in Scarpa's way may happen in advanced life; at that period an alteration frequently takes place in the coats of some of the arteries-they become thickened, and of a yellowish appearance, a deposition of an atheromatous, steatomatous kind takes place; they very easily crack, and spaces are in this way formed, allowing the exudation of blood from the artery. The opportunities of examining these diseases during their early stages are not very frequent; they do not terminate fatally until they have atttained a considerable size, and it is only by accident, or by persons affected with them dying of some other complaint, that we have the means of examining their condition in the early periods of their growth. The internal and

middle coats of the artery become absorbed or ulcerated; the external, which is cellular in its texture, and very lax and distensible, yields to the pressure of the current of blood flowing in the vessel, and forms a projecting tumour, or a false aneurism as it is termed. False aneurisms are either circumscribed or diffused; the original small circumscribed tumour gives way by ulceration, and the blood is effused into the surrounding parts among muscles, tendons, vessels, and nerves; the tumour increases to an indefinite size, according to the nature of the part, and pulsation ceases, thus forming diffused false aneurism. If the brachial artery is wounded in the operation of bleeding, and if pressure is made to stop the hæmorrhage, a small swelling takes place over the injured part, which increases slowly, a sac is formed by condensation of the surrounding parts, and a circumscribed false aneurism is the result. Wounds of arteries, if the external opening is small, cause a general swelling and tumefaction of the limb in which they occur; these have been described as diffused false aneurisms, but in truth they are no aneurisms at all. An aneurism is at first circumscribed; rupture takes place afterwards; the symptoms, after having burst, are-the patient himself describes his having had a feeling as though something had given way or burst in the part; there is swelling and tumefaction of the extremity, and pulsation ceases; these then are the symptoms of diffusion. The sac in circumscribed false aneurism is formed partly by distension of the external or cellular coat, and partly by condensation of the parts and organs immediately connected with it. When the ascending or thoracic aorta is the seat of the disease, the trachea, pulmonary artery, and other important parts in the neighbourhood of the heart contribute to the formation of the sac; when lower down, the vertebral column and the viscera of the abdomen are engaged, and thus we see that any parts may be involved in the sac, so as to increase it to an indefinite size; there is a preparation in which the disease existed in the thoracic aorta, the ribs have been absorbed, and the parts externally contribute to form the sac.

At first the tumour consists only of the sac, which contains fluid blood; it is soft and yielding, and if pressure is made on it in this stage, the swelling disappears, but returns when the pressure is removed: by degrees the blood being moved out of the influence of the circulation, coagulates first at that part of the tumour most distant from the artery, at that part where it is least under the power of the circulation; or rather, the blood deposits there its fibrine, the other constituents of the blood being removed. The fibrine is deposited in successive layers; these have a white, yellow, or brown appearance, are tough and fibrous, adhering firmly to the surface of the sac, and to each other, and occupying more or less of the abscess. Here you have a fine example of

this laminated deposition occurring in an aneurism of the arch of the aorta; you see how it is deposited, stratum upon stratum. Besides these layers, in examinations made after death, the centre is frequently found occupied by a recent coagulum of blood; now if it were to become filled in this manner during life, it would undergo a spontaneous cure. In recent cases, after death, the cavity of the tumour is generally found filled with a larger or smaller quantity of blood.

The causes of aneurisms are very obscure, wounds often give rise to them, as often happens in the brachial artery; strains are another frequent cause; likewise great effort or exertion of the limb-hence the frequent occurrence of popliteal aneurism from long continued exercise and powerful exertion of the leg; by these means the coats of the artery become weakened, and give way, producing the disease: but in very many cases we are not enabled to trace them back to any local cause, they seem to arise spontaneously, or from a constitutional or internal cause; as I before observed, they occur more frequently at or after the middle period of life, in persons whose arteries have taken on a diseased action. They happen more frequently in men than women; this may in some measure be accounted for by the difference in their habits and occupations. cording to an estimate made by Mr. Hodgson, I think out of sixty-three cases, fifty-six were male, and seven female, shewing a very great disproportion.

Ac

The most important symptoms of aneurism are a swelling occurring immediately over, and connected with an arterial trunk; it is of an indolent character, very slow in its progress, without heat, inflammation, or redness. It has a remarkable pulsation, beating very strongly; its pulsations synchronous, with those of the left ventricle. In the early stage it is soft, and yields to pressure, before any laminæ of coagula or fibrine are deposited; after there is a large deposition, it becomes hard and firm. Any other tumour occurring in the tract of a large artery might be mistaken for an aneurism; in order to satisfy yourselves on this point, grasp the tumour firmly in both hands; if it is an aneurism it will pulsate equally on all sides. The tumour itself is never painful, but, from its situation, it may produce pain, by pressure on the nerves; and as these generally accompany the arteries in their course, there is frequently considerable pain or numbness. Sometimes the nerves are exceedingly numerous, as, for example, the axilliary artery is, in a measure, surrounded by the axilliary plexus of nerves; when aneurism occurs in such situations, there is great pain, both at the origin and during the progress of the disease. I have known patients complain of very considerable pain in parts supplied by nerves, which are seated in the neighbourhood of an aneurism; these pains have often been mistaken, and treated for rheumatism, until the progress of the

complaint has shewn the true nature of the case. I recollect having seen a good example of the effects produced by the pressure of an aneurism upon the nerves, in the examination of a patient who had died with an aneurism in the axilla; they were pushed forward from their situation, flattened, and drawn out like a piece of tape. As the veins and absorbents accompany the arteries in the same manner as the nerves, the functions of these vessels will likewise be impeded by the pressure of the tumour; the return of blood to the heart will be obstructed, producing general oedema of the extremity; this we see exemplified when an aneurism occurs in the ham-motion is from the same cause impeded. Pulsation is a symptom not always to be relied upon; sometimes aneurisms do not pulsate, and, on the other hand, other tumours have pulsation communicated to them from a neighbouring artery. As the disease increases, the deposition of laminated fibrine goes on, and by its accumulation pulsation is precluded; but when I have not been able to discover pulsation by the hand, in several cases, I have distinguished it by applying the ear; a noise resembling the blowing of a pair of bellows is communicated, it is named by the French, who have been at considerable pains in these matters, the "bruit de soufflet" -it is a sort of puff. Therefore, in the case of a tumour presenting itself, where aneurism is liable to occur, if you cannot distinguish pulsation by the hand, apply the ear; some persons recommend the stethoscope; this cannot answer the purpose better than the ear, indeed, in my opinion, it is not so true. There was, some time ago, a patient in the hospital with a tumour, which was supposed to be aneurism of the external iliac. No pulsation whatever could be distinguished by the touch; I then endeavoured to ascertain whether I could discover it by the ear. At first the sensation was very obscure, but, still entertaining the same opinion of the complaint, I made an examination, by the latter mode, a short time afterwards, and it was then very obvious. It now and then happens that an aneurismal tumour will pulsate at one time, and not at another; the reason of this is, that the communication between the artery and the tumour becomes obstructed by a coagulum; this, from a sudden impetus of the circulation, is removed, and then pulsation returns. There was a patient in the hospital with a tumour beneath the crural arch. It was evident, from his own statement, that in the first instance there had been pulsation, but it had then ceased; this case underwent a spontaneous cure. A gentleman from the country applied to me with a tumour in the iliac region; from the age of the person, the situation of the tumour, the cedematous state of the limb and the previous history of the case, I was perfectly convinced as to the nature of the disease, although pulsation at that time was not discoverable by means. I

performed the operation, and the patient was cured; thus you see you may meet with aneurism in which there is no pulsation.

Tumours not aneurismal may pulsate, so that it requires some discrimination properly to appreciate the disease; in order to avoid a mistake of the case, you must investigate minutely the previous history of the complaint; endeavour to raise the tumour from the artery; the pulsation is either altogether gone or weakened, it has a different kind of feel, and if you grasp the tumour in both your hands it has a solid firm feel, whilst an aneurism is soft, and transmits a pulsation in all directions; by a careful examination there are very few cases on which you will not be enabled to decide with certainty. An aneurism at its commencement is not very large, it does not make any material progress in a short time, it goes on gradually increasing, and advances towards the surface of the body, causing absorption of the intervening parts; when it has arrived at the surface it frequently bursts, and if it is from a large artery the hæmorrhage is generally fatal; this case is in some measure different with internal aneurisms, they burst before they get to the surface, they do not attain beyond a certain size, which commonly varies from that of a nut to walnut when the descending aorta is the seat of the complaint, it bursts into the cavity of the chest beneath the pleura; those of the ascending aorta, or its arch, into the trachea, œsophagus, or pulmonary artery. When an aneurism in the limbs gives way, it changes its character, and from circumscribed it becomes diffused, as when aneurism of the femoral artery bursts, the blood is effused into the surrounding parts on the internal surface of the thigh, and there is great tumefaction and distention of it. In some cases the progress of the complaint leads to a spontaneous cure, by the deposition of the laminated coagula, so as to fill up the cavity, and form a hard tumour, which pressing upon the upper end of the artery; causes its complete obliteration; sometimes inflammation of the whole sac has taken place, which has been known to lead to its complete obliteration, and to cure the complaint; but these instances of spontaneous cure are very rare; we are not justified, therefore, in trusting our patients to such an uncertain chance of recovery; we must always have recourse to the operation where it is practicable In internal aneurisms surgical aid is altogether out of the question; all that we can do in these cases, is to direct our observations to whatever will moderate the disease; this to be done by paying attention to the state of the circulation, to posture, to maintain the patient in a state of weakness; to accomplish this we must keep him in a state of rest, in the horizontal posture, have recourse to bleeding, low diet, put him on the starving system, and administer opening medicines. I have met with a case of aneurism of the aorta in which these mears were used with very considerable benefit, the tumour was very much diminished in size,

and the difficulty of breathing removed, shewing that it was much relieved; but my experience does not enable me to say that they are capable of cure by this method. Probably I have not carried the starvation far enough, the persons generally admitted into our hospital are of the lowest order, they do not like to be deprived of their sources of pleasure, which for the most part consist in eating and drinking; they do not much relish being bled, purged, and starved; after they have been put on this system a short time, they complain of being weak, and want to get at the mutton chops, porter, and good living, and would like to try other means. Some persons may possess other means of recommending their patients to practise the starving plan with a good grace; for, in a work well known on this subject, Mr. Hodgson's, we find several cases recorded to have been completely cured. In external aneurisms we have no proof of this plan having been adopted, since we have a certain mode of cure by operation. Pressure is a mode that has been tried, its effects are very different in general; on account of large arteries being accompanied by a corresponding nerve, it is very painful, and not at all available. The only certain mode of cure consists in performing the operation before mentioned, of placing a ligature on the artery between the heart and tumour; it may be taken up in any situation where it is most accessible; for popliteal aneurism we tie the femoral in the upper part of its extent, and the operation is quite as successful as though we applied the ligature just above the tumour. After the operation has been performed, pulsation continues in the tumour at first, the sac afterwards becoming filled with coagulum, is obliterated by absorption. It is said, that tying the aorta cuts off the circulation of blood in the tumour; this statement is not correct, the flow of blood is not cut off, but its force and quantity are diminished by its winding through the collateral branches. In a patient who had undergone the operation for popliteal aneurism, the pulsation returned after he had been dismissed some time: our object is to diminish the quantity and force of the blood, and to produce contraction of the tumour by counteracting the power of the artery supplying it. The sac diminishes, and the vessel contracts and becomes as firm as a cord in two situations, above the ligature as high up as the most collateral branch, and beneath the tumour as far down as the next large branch. The powers of the collateral circulation prove that the operation may be performed upon any vessel that is accessible, the arteria innominata, the common iliacs, and the common carotids have been tied, and the circulation was adequately performed; there is no question, therefore, about the propriety of the operation when it can be performed; ordinary injection of the vessels proves the same thing.

There has been a proposal made by Mr. Wardrop, to tie the vessel beyond the tumour,

when the aneurism is situated near the trunk of the body; this may be done where you can place the ligature between the tumour and the next collateral branch, but the body of experience goes against the general adoption of this operation; the only vessel on which it can be performed with success is the carotid, in its first situation, at the lower part of the neck, where there are no collateral branches given off; the anastamosing branches of the upper extremity keep up the circulation; but this theory is most applicable to the subclavian, axillary, iliac, or femoral; the only guide for us is experience, and experience is against the operation; it will not do to admit reasoning à priori, as it is called, in matters of this kind. At present I shall defer describing the operation to you until I come to operations on the arteries.

Medical Society of London,

Monday, January, 30, 1832, DR. BURNE, President, in the chair.

Exfoliation of the Internal Ear.

MR. LINNAGAIR stated the following case-In the month of April, 1830, I was first called to see the patient, an infant, eight months old, whom I found labouring under symptoms of phrenitis, accompanied with considerable excitement of the vascular system; this affection was treated in the usual manner by depletion, purgatives, and evaporating lotions, and the child shortly recovered its health. In about a month or six weeks after this attack, a purulent discharge was observed to flow from the left ear, the child at the time being in apparent good health; no notice was taken of this circumstance, nor was I informed of it, until after the expiration of three or four weeks, when the mother observing the side of the face, and neighbouring parts looking red, sent for me: I found the discharge to be copious, and of a healthy purulent character, but possessing acrid properties, from which the parts whereever it touched, became excoriated; there was no apparent pain, heat, or swelling about the ear, but rather an

unusual appearance of the left side of the face; which seemed larger than the other the eye also seemed larger than its fellow, the ciliary margins of the eyelids were inflamed, and there appeared increased vascularity of the conjunctiva; I was informed when the child slept, this eye was not closed. The patient was in good health, ate, drank, and slept well, and was beginning to walk. Leeches and blisters were applied from time to time behind the ears, and a slightly stimulating lotion was injected into the auditory passage, and the parts were directed to be kept clean. Notwithstanding the use of these means, the symptoms continued much the same, with the exception of the discharge, which increased, but lost its acrid properties, or rather the excoriation, which existed at the time I first saw the child, was no longer observable, in consequence, I suppose, of the discharge being removed more frequently. The left side of the face at length became perfectly paralysed; when the child either laughed or cried, the muscles of the right side of the face were preternaturally drawn up, whereas those of the left side were unmoved; the left eye also continued apparently larger than the right, and was incapable of being closed; during this time, the small bones of the ear were discharged through the external mea

tus.

In consequence of the family going into the country, I lost sight of the child for two or three months, and when called upon again to see it, which was in October last, I found the patient suffering from irritative fever, and disordered digestive organs; I learnt from the mother, that the child had had very good health up to this time, and that the discharge still continued from the ear, accompanied with a most offensive odour: upon examination, I found the meatus filled with fungous flesh, and the cartilage of the ear was pushed out from the side of the head; the child cried when the finger was applied to the posterior part of the organ; there