21 If the quantity of Infusum Scoparii were deducted from the Quantity of Urine we should have only 1995 C. C. passed daily. AN ACCOUNT OF THE POST-MORTEM EXAMINA TION OF A CASE OF ANEURISM OF THE ABDO- IN the year 1864 I communicated to the Medico-Chirurgical Society of London (Transactions, 1864), an account of a case of aneurism of the abdominal aorta, for the cure of which I had employed compression of the artery by the rapid method immediately above the tumour. The patient was a man, aged 26, whose occupation as a paviour had compelled him to use a large wooden rammer for driving paving stones into the ground. Between the abdominal aneurism and the free borders of the left ribs there was space enough to permit one blade of a tourniquet to press down on the spine, and on tightening the tourniquet I found that, by a nice adaptation, the pulsation in the aneurism could be completely commanded. The patient was put under chloroform on April 16th and pressure applied for two hours, and a second time on April 19th and the pressure and insensibility were kept up for about five hours. On the next day no pulsation was felt in the aneurism which was hard, resistant, and lessened in size. Neither was pulsation to be felt in the aorta below the tumour, in the iliacs, or in the femoral arteries. On the 23rd pulsation became distinct in the small arteries in the abdominal wall. On the 26th the patient walked about a quarter of a mile. On the 7th July, 1864, the patient obtained work as a 'fitter.' The lower limbs were plump but flabby, the rest of the body well nourished. The tumour was scarcely to be felt, and the aorta, iliacs, and femoral arteries, were quite pulseless. The patient continued to enjoy good health until the commencement of the year 1870, having during the intervening six years followed a variety of laborious occupations, and having also on several occasions undergone no small amount of privation through the prevailing scarcity of work. During this period the aneurismal swelling gradually disappeared, the termi nation of the aorta could be very easily distinguished by its thud against the hand when applied about three inches above the umbilicus, and its course below the thudding point remained absolutely pulseless. By far the most notable change during this period was the appearance of numerous large pulsating vessels on the front and sides of the abdominal parieties; one on either side of the rectus muscle on the site of the epigastric arteries equalled the femoral artery in size, while those on the upper part and lateral aspects of the abdomen varied from the size of the brachial artery to that of the ulnar. The course of these vessels was, for the most part, extremely tortuous and difficult to trace. About the commencement of the year 1870 the patient was compelled to resume his old occupation as a paviour, and the strenuous efforts required of him once more brought on violent pain in the epigastrium, which was speedily followed by other symptoms of an aneurism in that region. This latter disease, when fully developed, was found to lie so close to the diaphragm that pressing the aorta above it was out of the question. The aorta below this new aneurism was very carefully examined and found to be perfectly free from pulsation, in fact it was evident that the aorta above the occluded point had given way and become dilated into an aneurism. The usual symptoms of aneurism of the aorta near the cæliac axis were terminated by the sudden death of the patient on June 1st, 1870. The post-mortem examination was conducted by Dr Maclachlan and Mr Davidson, assisted by Mr Johnson, in the presence of Mr Russell, one of the surgeons to the Newcastle Infirmary, and several other gentlemen. To all these gentlemen I am much indebted for the assistance they afforded, but more especially to Dr Maclachlan, who carefully dissected the aneurism after its removal from the body. On removing the skin from the front of the abdomen a numerous array of tortuous blood-vessels was found ramifying in every direction; the tortuous branches of neighbouring trunks were seen to anastomose directly with each other, and the terminations of the trunks themselves were observed to be continuous with each other. The deep epigastric artery (as large as the axillary) ran up along the outer border of the rectus muscle, giving off lateral branches; other branches of the epigastric passed outwards and anastomosed with the lower intercostal arteries, these latter being much enlarged and tortuous. One lateral branch of the epigastric given off from its inner side penetrated the umbilicus, and running along the free border of the suspensory ligament of the liver, entered the longitudinal fissure of that organ and anastomosed with a branch of the hepatic artery. The superficial epigastric artery, enlarged and very tortuous, entered a plexus of vessels formed by it and branches of the lower intercostal arteries. The superficial circumflex iliac followed the same course and joined in an anastomosis with the lower intercostals. After opening the abdomen the superior mesenteric artery, as large as the aorta, was apparent, and the colica media branch enormously enlarged gave off branches of a very large size, which joined the anastomosis of similarly enlarged vessels given off from the colica sinistra branch of the inferior mesenteric. All these anastomosing vessels were as large as crow-quills, even at their points of union with each other. The state of the inferior mesenteric artery was most peculiar, for while giving off these large branches the trunk of the vessel was dwindled to the size of the radial artery, and its coats were thin and flaccid. This wasted state of the vessel was easily accounted for by finding that the vessel entered that part of the aorta which had been occupied by the first aneurism, and which was now a mere fibrous mass. It was evident, therefore, that a very free current had been sent through this anastomosis of the colica media and sinistra, but it must be further noticed that the sigmoid and superior hæmorrhoidal branches of the inferior mesenteric were also very much enlarged, and their branches entered very freely into their network of anastomosis lying on the left of the aorta and between it and the descending colon. The rest of the visceral branches of the aorta were in their natural state, but a very large and free union was found on the surface of the iliacus and quadratus muscles, between branches of the last lumbar and ilio-lumbar artery (which in this instance was given off from the common iliac). This anastomosis was also joined by the circumflex ilii and by branches of the upper lumbar arteries, these latter much enlarged. The circumflexus ilii divided into two branches at the crest of the ilium (one as large as the radial, the other as large as the ulnar); the upper joined the anastomosis of the ilio-lumbar and lower lumbars, the other joined the large terminal branches of the upper lumbar arteries. Thus, it will be seen-1st, That outside the abdomen the circulation was carried on between the internal mammary and deep epigastrics; the hepatic artery and a branch of the epigastric; the intercostals and deep epigastric; the intercostals and superficial epigastric; the lower intercostals and the superficialcircumflex iliac. Within the abdomen the circulation was carried on between the colica media and the colica sinistra branch of the inferior mesenteric, with its sigmoid and hæmorrhoidal branches; the upper lumbar arteries and the ilio-lumbar; the lower lumbar arteries and the circumflexus ilii. No anastomoses were found between the visceral and parietal branches of the aorta, except between a branch of the epigastric and the hepatic. In this respect the case differed very materially from the condition met with by Dr Chiene in a case of aneurism of the aorta, where the cœliac axis, superior and inferior mesenteric arteries, were obstructed at their origin, a description of which will be found in the 3rd volume of this Journal, p. 65. As regards the state of the aorta itself, it was observed to be largely dilated up to the new aneurism, which had become "diffuse" before death, and rendered any careful dissection impossible, as the whole of the precincts of the aorta were completely occupied by large coagula and masses of semi-coagulated blood. The aorta below this was completely occluded, and its walls in an atrophied condition. The importance of the case is greatly enhanced by the postmortem evidence of its reality which has been now obtained. Until this was procured I hesitated to press its claims on the notice of the profession, lest there should have been any error of diagnosis. Now that all fear on that account is removed I would claim for the case great importance, because it involves in itself not one but several facts new to anatomy, physiology, and practical medicine. It establishes, |