she could not expel; it continued about half an hour when she became more tranquil.

Saturday, Nov. 2.-Mr. Owen, who had sat up with her, reported that she had slept six hours during the night, but was now and then disturbed by her cough. The pulsation in the tumor has not returned; that in the brain has ceased, and there is no appearance of diminution of nervous energy in any part of the body.

Sunday, Nov. 3.-Last night as she had some pain in her head, leeches were applied. To-day the pain in her head is gone; her cough is less troublesome; her stools and urine are natural; pulse 96.

Monday, Nov. 4.-Slept six hours last night; her spirits are good; pulse 100.

Tuesday, Nov. 5.-In the afternoon, I found her, as may be supposed contrary to my orders, sitting before the fire with three other persons, drinking tea which she swallowed with great difficulty; she had no pain in her head; her pulse 96, and the only circumstance of which she complains, is that her cough is troublesome.

Wednesday, Nov. 6.-In a violent fit of coughing last night, a slight discharge of venous blood took place from the wound. Mr. Hopkie, of Ratcliff-Highway, was called to her; but the bleeding ceased with the cough, and a piece of lint was laid lightly on the wound; in the afternoon her cough was less troublesome; her pulse only 92.

Thursday, Nov. 7.-My colleague, Mr. Forster, accompanied me to see her and to make a drawing of the tumor, which he thought was reduced one-third. She slept eight hours last night; her pulse 94.

Friday, Nov. 8.-Evening; I was sent for by Mr. Owen and Mr. Roberts, who alternately sat up with her, on account of their observing, that her left arm and leg were paralytic. I found them benumbed, and she moved them with great difficulty; but as her pulse was weak, and she laboured under considerable constitutional irritation, I thought the powers of these parts would be restored as her health improved. She had passed a very restless night, complaining that her bones were sore, and that her teeth felt as if softened. Her head is free from pain.

Saturday, Nov. 9.-Her cough is less troublesome; her pulse is 90; her spirits good; she talks with cheerfulness, and moves her arm with more facility than yesterday. She slept eight hours last night; she said she must have something to eat, but upon attempting to swallow solids she was incapable of doing so. She has no pain either in the head or tumor, but says, when she coughs she feels a pricking pain in the wound.

Sunday, Nov. 10.—I did not see her.

Monday, Nov. 11.—She had passed a good night; her left arm she now moves with more facility, but I thought with not quite so much ease as the other. She is in good spirits, and has some appetite, but cannot swallow solids. Her chief sustenance is arrow root, to which, as she had been very much accustomed to take spirits, a little wine is added. Her cough is sometimes very violent; her pulse is only 84; the ligatures are projecting further from the wound, than at any time since the ope

ration.

Tuesday, Nov. 12.-My colleague, Mr. Lucas, accompanied me to see the woman, this day. We found her in good spirits, and the pulse only 82; her cough less troublesome, and she was able to sit up and use her arm with so much facility that it required that the attention should be particularly directed to the part, to discover any difference in the powers of the

two arms.

When the dressings were removed, the ligatures were drawn from the wound, including the intervening portion of artery. The edges of the wound were then brought together by adhesive plaster.

Wednesday, Nov. 13.-Her cough is less troublesome; she swallows liquids with more ease. The only complaint she makes is of a pain in the back, of which she was relieved by a dose of magnesia vitriolata.

Thursday, Nov. 14.—She slept eight hours last night, and her state is in every respect improved; she swallows with less difficulty; the tumor is reducing in size, and is entirely unattended with pain. As I now considered her out of danger, I did not visit her on Friday or Saturday; but Mr. Jones, one of my house-pupils, visited her and found the wound nearly closed.

Sunday, Nov. 17.-I was much disappointed to find her fabouring under a high degree of constitutional irritation; the tumor was also increased and very sore upon pressure; the wound was as large as immediately after the operation, and discharged a sanious serum; she complained of a great difficulty in swallowing, and of a most distressing cough after the fits of which she hooped violently; her pulse 96; and her left arm again weaker than the other.

Monday, Nov. 18.-She had passed a restless night; complains of pain in her head, and the size of the tumor has increased; there is great soreness upon the neck, when it is pressed; the pulse is quick, and the tongue is furred.

Tuesday, Nov. 19.-Her pulse is very quick; she had no sleep last night, although she took forty drops of tincture of opium; the tumor is still more increased, and the skin over it of a brownish red colour.

Tuesday, Nov. 20.-She had slept three hours last night; her pulse is 108, and small; she is unable to swallow even her saliva, which constantly dribbles from her mouth, and every attempt at deglutition, produces a violent cough.

Evening. Her pulse 120; she is in a profuse sweat; and still unable to swallow.

Thursday, Nov. 21.-She died.

DISSECTION.

The aneurismal sac was found inflamed, and around the clot of blood which it contained, there was a considerable quantity of pus.

The inflammation extended on the outside of the sac along the par vagum, nearly to the basis of the skull.

The glottis was almost closed, and the internal surface of the trachea was inflamed, coagulating lymph adhering to its mucous membrane.

The sudden increase which the parts had undergone from inflammation, added to the size of the tumor previous to the operation, had occasioned so much pressure upon the pharynx, that it would not easily admit a bougie of the size of a goose quill.

The nerves, as may be seen, sustained no injury, the ligature having passed between the recurrent and the artery on the one hand, and the par vagum on the other.

The cause of her death then, was the inflammation of the aneurismal sac and the parts adjacent, by which the size of the tumor became increased so as to press on the pharynx and prevent deglutition, and upon the larynx, so as to excite violent fits of coughing, and ultimately impede respiration.

A similar event, however, may be in future prevented, by performing the operation when the tumor is small, and pressure has not been made by it upon important parts, or if it is of considerable size, as in this case, by opening the tumor and discharging the coagulum, as soon as inflammation appears.

As I could not obtain permission to open the head, the cause of the paralysis remains unknown. It did not immediately succeed the operation, but was observed first on the eighth day after it. It came on whilst she laboured under great constitutional irritation, lessened as it decreased, and returned when the irritation became greater; but as it appeared that the irritation which she suffered was owing to the operation being too long deferred, it will not prevent my performing it in any case in which the disease is somewhat less advanced.

It appears that no objection can be made to this operation on account of any unusual danger of bleeding at the time the ligatures separate, since, although they were discharged from the wound on the twelfth day, and they were certainly separated from the artery on the eleventh, the ulcerated extremity of the vessel had been closed by the adhesive process and by a clot of blood which adhered strongly to its coats. Hence we may conclude, therefore, that the carotid artery may be, in this respect, as safely tied as any other artery in the body.

January 29, 1806.

Second case of Carotid Aneurism.

BY ASTLEY COOPER, ESQ. F. R. S. SURGEON TO GUY'S HOSPITAL.

From the Medical and Chirurgical Transactions.

IN the year 1806, I had the honour of presenting to this Society an account of an operation for carotid aneurism, which terminated unsuccessfully.

I then took the liberty of observing, that I thought that the result of that case ought to have no influence in preventing a similar operation under more favourable circumstances, as the death of the patient was attributable to the advanced stage of the disease at the time of the operation. The aneurismal tumor had become so large, as to press upon the air tube and occasion cough, difficulty of breathing, and even effusion of coagulable lymph upon its internal surface; and it had also compressed the pharynx, in a degree to prevent even the passage of fluids into the stomach.

I had no apprehension of the functions of the brain sustaining any permanent injury from a ligature on the carotid artery, having the evidence of Dr. Baillie to prove, that one carotid had been entirely obstructed, and the diameter of the other considerably lessened in the same person, without any apparent ill effects. I have also given a drawing in my former paper, of the left carotid artery being obstructed by the pressure of an aneurism of the aorta; and we have the analogy of animals to show, that both carotids may be tied without any visible effect upon the functions of the nervous system. I had many years made the experiment of tying these vessels in the dog, and immediately as it was concluded the animal was placed upon the ground, and showed no diminution of voluntary powers. It exhibited the same fears and affections as before, and betrayed no greater loss of appetite, or disposition to sleep than an animal usually does who has been the subject of an experiment which gives some pain, but does not injure the vital functions. A preparation made from this dog has been long preserved in the collection at St. Thomas's Hospital; and the parts have been injected to show the principal vessels which carry on the circulation, which are the two thyroideal arteries, and two

ago