47

sympathy, poetical temperament; they can work early in themorning; they are not easily fatigued by intellectual exertion;they engage energetically in the ambitious pursuits of life. A

young gentleman, full of ardour, working day and night onsome animating object of study, was told he ought to rest. He

replied he did not need rest; that he never had the headache,and was never tired. He was told he ought to be tired bysuch exertions, and that not to be fatigued by them wasmorbid. He disregarded the admonition. Shortly afterwardshe had haemoptysis. Other indications of mischief in the lungsappeared. In a few months he died of consumption.

It is my impression that there is often all interchangeablerelation between insanity and phthisis. I have known earlysymptoms of consumption subside, the friends of the patient I

disregarding medical admonition, and imagining the physicianto have made an incorrect diagnosis. Some eccentricity ofmind has appeared. As the chest seemed to recover, the brainbecame obviously affected, and the patient has become an

inmate of a lunatic asylum.I am convinced that there are many individuals of the con-

sumptive diathesis in whom external circumstances alone de-termine which organ shall be most involved in the morbid con-dition. A person thus constituted, under the influence of a

depressing life and confined air, will become consumptive:impelled by the stimulus of inordinate ambition, overworkedin any one direction of intellectual exertion, he will becomeinsane. Under favourable circumstances of prosperous, well-regulated activity, he may attain the consolidation of maturelife, and escape either catastrophe.But the blood itself, when minutely examined, may perhaps

exhibit evidence of accelerated action. If any of us were torun for a few minutes, and then, pricking his finger, submitthe blood to examination under the microscope, the discs,instead of retaining for a quarter of an hour or more theirproper outline, would probably, in a few minutes, assume astrawberry form, or become stelliform, serrated, or corrugated.A similar change is often rapidly apparent in the blood of thephthisical, especially in the cases which are proceeding badly.My observations have not been sufficiently repeated on thissubject to authorize my offering the statement positively, orpresuming to assert that the rapidity with which this pheno-menon presents itself may fairly be regarded as of moment inthe way of diagnosis; but irrespective of this suggestion, con-siderable evidence has been afforded that, in the consumptiveconstitution, there is a change of material and a change ofaction; and indications have been presented of a course ofinquiry, which promises to be most fertile in elucidating thenature of the changes associated with the consumptive organiza-tion. With so many active minds engaged in the investigation,we may hope for speedy accessions to our knowledge; butthere is much to learn. We know something of the gnate2,ialsof our frame-not much of the conditions by which they areregulated. The text of my former lecture-" Maxime in

minimis"-requires to be illustrated by a clearer light. Themost minute in form is regulated by laws sublime, but unknown.We can recognise the shape of living organisms, but as yet wecannot explain the forces by which they are determined.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noseendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

GUY’S HOSPITAL.

POPLITEAL ANEURISM TREATED BY COMPRESSION OF THE

FEMORAL ARTERY.

(Under the care of Mr. HILTON.)OUR readers perhaps remember that their attention was called

a short time ago to a case of popliteal aneurism, treated by Mr.Hilton at Guy’s Hospital, which was remarkable for the lengthof time during which the patient bore compression. In the re-

port just mentioned, we alluded to another case of the kindwhich proved very successful, and we this day redeem the pro-mise of giving a few details of this latter instance of the appli-cation of pressure.

This mode of relieving patients affected with aneurism of thelimbs has now obtained a firm footing in our hospitals, and wemay say that, with an exception here and there, the ligatureis never resorted to at once, the surgeon generally trying com-pression first, and using the deligation of the main trunk as alast resource. At the moment we are writing, Mr. Cock istreating a case of this kind by pressure at this hospital; andthere is another one at King’s College, under the care of Mr.Fergusson, where the same means are being used. We trustthat these cases may turn out favourably, and shall endeavoureventually to give an account of them. The details of the fol-lowing one were obtained from the notes of Mr. John Ince, oneof Mr. Hilton’s dressers.William D-, aged thirty-seven years, was admitted July

20th, 1853, under the care of Mr. Hilton, complaining of apulsating tumour behind the knee.The patient’s occupation is that of a warehouseman, in which

capacity he is obliged to be upon his legs the greater part ofthe day, during which time he has to run up and down stairs,and from one room to another. About six weeks before ad-mission, after walking to the City one morning, he felt muchpain in the left knee, but after resting a little this unpleasantfeeling went off. The pain, however, returned each time thepatient took exercise, and he begun to suspect that he hadrheumatism. Being one day in more pain than usual, he wasinduced to put his hand behind his knee, and to his surpriseand alarm he found a swelling about half the size of an egg, inwhich he felt a throbbing, The pain was increased by walking,but there was none when at rest. The man does not mentionany strain or blow on the part, but he was in the habit ofputting his child upon his knees, and then hanging his own feetover the back of a chair; in this manner the structures in the pop-liteal space must have been habitually more or less compressed.symptoms own arlmissiol1.-A tumour is felt in the left pop-

liteal space; it is as large as a good-sized egg, soft, equal, andsmooth, and pulsates forcibly; the pulsations subside on makingpressure on the femoral artery, and the integuments are in anatural condition. A bruit, synchronous with the pulse, maybe heard by a stethoscopic examination over the swelling.No signs of disease about the larger arteries; impulse of theheart feeble; pulse 60, soft, and compressible.Mr. Hilton, being desirous of trying the treatment by pres-

sure, had, on July 21st, the clamp put on the femoral arteryabout the junction of its superior and middle thirds. As thepressure was rather firm, the patient complained of some pain,with a tingling and benumbing sensation down the leg, andthe uneasiness was so great that the clamp was removed at teno’clock, P.M. Mr. Hilton prescribed digitalis, and did not wishany restriction to be put upon the patient’s diet, any furtherthan that he was to confine himself to as small a quantity offluids as he possibly could, beer, wine, and spirits being ex-cluded.

Second day, July 22nd.-To-day Mr. Hilton procured aweight of eight or ten pounds. It was of a cylindrical shape, re-sembling the weight of a clock, being rather rounded at thelower part, and covered all over with wash-leather. From the

upper part projected a piece of iron, about two inches long;and two or three very thick rings were also provided, that theymight be put upon the projecting iron rod, and so made to in-crease the weight of the whole instrument if found necessary.The clamp was now again applied on the same spot as on the

preceding evening, the pressure being made very firmly. Theobject of the iron cylinder above described was to act as a sub-stitute for the clamp, as the patient could bear the amount ofpressure, which was necessary to control the course of theblood, but for a short period, (about an hour.) Instructionswere given to the man, who is very intelligent, as regards themanagement of the apparatus, the nature and object of thetreatment being fully explained to him. He was admonishedthat when the pain frum the pressure of the clamp became in-tolerable, he was to place the cylinder over the artery in thegroin, and hold it there firmly and steadily; then he mightloosen the screw of the clamp, and take off the pressure fromthat part of the vessel over which it was placed; and after thepain had subsided, and he had grown tired of holding thecylinder, he was again to screw up the clamp as before, andthus keep up the pressure continually by alternating the use ofthe two instruments.

Third day.-The patient did not sleep much last night fromthe pain, and partly from the novelty of the position. Pressure

48

had been kept up the greater part of the preceding day, and hadproduced, as before, tingling, numbness, pricking and burning ;the limb is also somewhat swollen, especially about the knee;the temperature is very little reduced, as the lower part of theleg is invested in a flannel stocking. It being rather tiring forthe man to hold the cylinder, a cradle has been put over theleg, and the weight fastened to it by means of a piece of tape;in this way it is fixed over the artery, and can be constantlypressing over it. Go on with the mixture.Fourth day.-The tumour is certainly somewhat firmer, but

it is found difficult to keep a constantly-applied degree ofpressure sufficient to control the flow of blood through the sac.The patient appears to have a very small femur, but the softparts and adipose tissue are very abundant, the thigh being thusvery flabby ; hence the necessity of a great degree of pressure,such as the patient can with difficulty endure, even for a shortperiod; otherwise the clamp shifts, and but very slight effectis produced. The parts subjected to compression are to besprinkled with oxide of zinc, and the patient is to continuethe mixture.

Seventh day.-The pressure has been continued more or lesssince the 22nd; the general health continues good; the mansimply complains of feeling stiff and tired from lying so long.He has not exceeded a pint of fluid a day since he came in,but has had a full allowance of mutton and vegetables. The

pressure renders the skin very tender, red, painful, and

vesicated ; when these phenomena occur, the instruments areshifted, and the skin soon recovers. As regards the tumour,it is decidedly firmer to the touch, and not so large, althoughthe improvement cannot be called great; there is no pain inthe sac, and the integuments around it are healthy. Go-on with the medicine.

Fifteenth day.-The cure seems to be greatly impeded bythe peculiar characters of the thigh, as, owing to a small femurand flabby soft parts, (as stated above,) there is not sufficientresistance to the pressure made, unless it is exercised to suchan extent as to be intolerable. It was suggested that the legshould be swung in a cradle as a fractured limb, so that

greater resistance might perhaps be obtained. This was tried,but failed; it was found better to let the leg lie on the bed, theknee bent, and the toes everted.

Eighteenth day.-Bowels open by medicine. The clampwas taken away, that the posterior pad might be made larger,and thus encompass the back part of the thigh; but thecylinder was to be kept constantly pressing in the groin.

Twenty-first day.-The clamp has been returned, but theinteguments of the thigh are in a very unsound condition, thewhole space over which the pressure of the clamp has beenmade being quite raw. Vesications had formed, they hadbroken, and left the part quite denuded; the clamp cannottherefore be borne at present. The cylinder remains con-tinually applied during the day, but whilst the patient is asleep,it probably gets shifted off the artery. The tumour is, however,becoming much firmer, and the pulsations, although still strong,have decidedly diminished. Omit the medicine.

Twenty-ninth day. -The soreness of the thigh still continues,although the skin is better; there has been, the last two nights,an occasional acute pain at the left ankle, (just between theinternal malleolus and the tuberosity of the calcaneum,) lastingfor two or three minutes; the tumour is still more diminishedin size and increased in firmness; the pulsating force hasabated.

Thirty-second day.-This morning the pulsations haveentirely ceased, the condition of the tumour being as follows :-Quite firm, resisting, free from pain on manipulation, no heator redness round or near it, and of the size of a greengage i

plum; an artery of considerable calibre, crossing the middleof the sac, may be felt pulsating. The posterior tibial arterycannot be made out at the ankle, the temperature of theaffected limb is not perceptibly lower than that of theother, and there is no oedema, though the leg looks a littleelongated.The only pressure that has been made on the artery since

the twenty-fourth day, was by means of the cylinder, the sore-ness of the thigh forbidding the application of the clamp. Thesame amount of pressure is still to be continued, and thepatient is to keep his bed for a few days longer.The pressure was continued, during waking hours, up to the

forty-second day, the man improving considerably in generalhealth, and his delight being great at seeing the consolidationof the tumour, which is now the size of a walnut.On the forty-second day, (Aug. 31st, 1853,) the leg was well

bandaged with a flannel roller, over which an ordinary cottonone was placed, and the patient allowed to move about on

crutches, the limb swung on a broad piece of list fastenedround the neck.

Forty-eighth day.-*.Since the last report the patient has beenwalking about on crutches, occasionally bearing his weight onthe affected leg; this has given him no inconvenience. To-day he leaves the hospital, the leg being still bandaged.

Reviews and Notices of Books.

Anatomical and Physiological Observations. By JOHN STRU-THERS, M.D., Fellow of the Royal College of Surgeons ofEdinburgh, Lecturer on Anatomy. Part I. Edinburgh.1854.

THIS work consists chiefly of reprints of various papers bythe author which have appeared in medical journals, to whichnotes are now appended.Now-a-days we rarely see works of this kind, from the well-

known fact that original memoirs rarely ever pay the authorthe price of publication; the saleable medical works beingchiefly compilations, manuals, &c. Neither, we believe, dosuch works, except with a taking title, procure for theirauthors emolument in the shape of practice; while the pro-fessorships, and such like posts, which can hold out a bait forthe scientific cultivation of the science of medicine, are so few,that we often wonder at the spirit of our professional brethren,which leads to the production of even so many admirable and.truly scientific monographs. Doubtless "Fame is the spur thatthe clear spirit doth raise." The work before us contains severaltruly admirable memoirs, written without pretension and withgreat perspicuity. As it is impossible to notice them in detail,we shall select the inquiry into the " Mode of Action of LocalBloodletting in Affections of the Internal Viscera."

In applying leeches nigh to an affected part, or in cupping, theobject of course is to afford relief, by derivation, to the diseasedpart, and the general idea seems to be that the bleeding in thiscase is a local and not a general one. He then proceeds toinquire how far, in most cases, this idea is well founded, pre-mising,-" 1. That the relief in local bloodletting is throughthe bloodvessels or vascular system, and not through nervousagency; and,-2. That as blood can come from one part tanother only by bloodvessels, there can be no more specialrelief by local bloodletting, unless the bloodvessels of the onecommunicate or anastomose with the bloodvessels of the other."There is a wide difference between the local bleedings prac-

tised by surgeons to relieve local affections, and those practisedby physicians to remove internal disease. The connexionbetween the vessels from which the blood is drawn and thoseof the affected part is clear in the former case; in the latter itis not; and the object Dr. Struthers has in view is to investi-gate how far, in a case, say of inflammation of the bowels, theeffect of leeches applied to the abdomen is due to local or

general depletion. He shows, we think very satisfactorily,from the mode in which the abdominal organs are suppliedwith blood, that they can only be depleted through the generalcirculation, and that local depletion cannot affect the internalabdominal organs more than it would affect the hands or feet.In the chest the only contents that we could expect, fromanatomical grounds, to affect from local bleeding would be thepleurae, and these only to a slight extent. The case is differentwith the head. The direct communications by the parietaland mastoid foramina afford means of operating directly uponthe circulation in the brain by local bleeding; and by leechingthe scalp, " especially behind the ear, the sinuses of the dura.mater and veins of the brain may be relieved, and that asdirectly, though not so rapidly, as by the method of openingthe external jugular vein at the root of the neck." "

Agreeing, however, as we do with Dr. Struthers in his viewsdrawn from anatomy, we cannot entirely acquiesce in the firstproposition which he lays down-viz., that the relief in localblood-letting is through the bloodvessels, entirely, and not in