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not lose its vitality it is probably essential that this compen-sating circulation be quickly established. On Oct. 16th, 1872,my colleague, Mr. J. M’Carthy, ligatured the right commoncarotid and the third part of the subclavian arteries foraneurism at the root of the neck. During the operation

sphygmographic tracings of the left radial pulse were takenby Mr. W. Lang (my now excellent house-surgeon). As

each artery was ligatured, tension increased in the leftradial, so that the pressure had to be altered. Ophthal-moseopic observations were made daily. Twenty-four hoursafter the operation the right disc was much paler than theleft, the veins being distended and varicose. Seventy-twohours after the operation the arteries of the right disc weredistinctly visible, and the veins much less varicose. Ther-mometric observations were taken in both palms. The dif-ference, at first three degrees, gradually diminished, and onthe eighth day the temperature in both hands was equal.The man died on the fifteenth day of haemorrhage from theproximal side of the subclavian ligature.

I ligatured the femoral artery of a young man (Case 11)for wound an hour or two after it had been received. Hehad lost a very greal deal of blood. No complaint was evermade about the state of the limb, neither were there anyindications that its circulation had been interfered with.Still a gangrenous state of the wound supervened, and thepatient died typhoid.

I chanced to be present when a friend accidentallywounded the femoral artery in opening a psoas abscess ina child. The vessel was at once secured by a double liga-ture, and the case recovered as though nothing unusualhad transpired.Without this dilatation the vis a tergo might be expected

to force the blood-current against the sac and the liga-ture, in order to overcome the resistance offered by thelatter, and so to tend to a more rapid growth of the tumour.I must however add, that the late Mr. Guthrie did notaccept the above as the explanation of the curative powerof the distal operation, but referred it to an inflamma-tion, which, spreading from the ligature, involved boththe artery and sac, and ultimately led to obliteration.But, inasmuch as inflammation of sac, suppuration, andsloughing occasionally follow other methods of treatinganeurism, and, indeed, no treatment at all, and since thereare numerous examples of the distal operation on recordwhere no such mishaps occurred, it will be scarcely just,with our present knowledge, to regard diffuse inflammationas a necessary sequence to it. As a warm advocate of thedistal operation for carotid aneurism, Mr. Wardrop proposedto extend it to aneurism of the innominate artery. Heargued that, since pulsation often persisted for a shorter orlonger time in an aneurism which bad been subjected to theHunterian operation (ligature of the artery on the cardiacside, and at a distance from the seat, of disease), it wastherefore not essential to success that circulation throughthe sac should cease absolutely. He divided the mass ofthe blood passing through the innominate artery by three;giving one-third to the carotid, another to the subclavianbeyond the scaleni, and the last to its branches; and sug-gested that an obstruction of the carotid and of the sub-clavian in its third part would necessarily cut off two-thirdsof the blood formerly traversing the innominate. By thusdiminishing the supply of blood, he thought to lead to co-agulation in the sac. Possibly, if his reasoning werecorrect, the result would be as he hoped, but, unfortunately,he forgets, what he laid so much stress and importanceupon when discussing this operation in connexion withcarotid aneurism-the immediate and rapid enlargementof those vessels upon which the circulation must in futuredepend. Doubtless the left subclavian and the left carotidwill share with the branches of the ligatured subclavianthe necessary distribution of blood, but not to the extent ofrestricting to the latter vessels the quantity which theyoriginally transmitted; they also will enlarge, and, as Mr.Holmes has pointed out, sufficiently to maintain a channelthrough the aneurism (as in Mr. Fearn’s case), but not toattract so much blood that a practical cure, in the shape ofa deposit of fibrine on the walls of the tumour, cannot takeplace. He had also stated that the obliteration of one orthe other of the two main branches coming off from an in-nominate aneurism is a very common post-mortem pheno-menon, and says, " I think there are sufficient specimens athand to show that it is usually accompanied by obliteration

of the portion of the tumour which is in connexion with theobliterated vessel." This latter remark is equally appli-cable to aortic aneurism.* In a given case of aneurism atthe root of the neck, the surgeon will not omit to endeavourto determine whether or not one or other artery is or doesbecome obstructed spontaneously, as such would be a first andgrand step towards a cure of the disease, and the operativeindications would be clear; as in Dr. Herbert Davies’s caseof innominate and subclavian aneurism.+ "In the abovecase nature had done half of the distal operation, and by farthe more difficult half, and as the dissection proves, to ourchagrin, nothing would have been easier than to have putthe remaining fluid contents of the sac in a state ofcomplete stagnation. The subclavian and its brancheswere already occluded, and a ligature upon the still perviouscommon carotid was alone requisite."

INTERESTING CASE OF

CATALEPSY FOLLOWED BY EPILEPSYIN A MILITARY OFFICER.

BY SURGEON-MAJOR CHAPPLE,ROYAL ARTILLERY.

I RECEIVED a message one morning, requesting me to seeCaptain J. B-, who, it was stated, was very ill. CaptainJ. B-’s house adjoined mine. I was there at once, andwalked direct into the drawing-room. To my surprise Ifound my supposed sick friend sitting at a writing-table,holding open before him an official letter, as I thoughtreading it. I wished him 11 Good morning." Receiving noreply, I said, " I was told you were ill ; what’s the matter ?"Still no answer. I was puzzled to account for his silence.We were not only on good terms, but intimate. I mentionthese particulars to show how perfectly natural positionand appearance were-indeed, so natural, that his wife,after addressing him several times and failing to get areply or a look, went out of the room in tears. Not knowingwhat to think of such strange conduct, she sent for me.This was all the information his wife could give.Returning to the drawing-room and standing opposite

Captain J. B-, no doubt was left in my mind that hewas fixed in catalepsy. He was in uniform, forage-cap on,just as he returned off duty. He subsequently told methat he saw some troops off by train in the morning, anddrove himself home in a dog-cart. The last thing he re-membered was pulling up under his own porch: all thatfollowed was blank.A bundle of letters lay before him ; his right hand rested

on the table; he held the top of an official letter by theright and bottom of the letter by the left hand. His facewas cold and pale, but not paler than usual. When in thebest health he never had a trace of colour in his face. Pulseslow and weak. I had him removed to his bedroom. Hewas carried in the same position in which he sat, his armsfixed as if still holding a letter before him. His legs beingstraightened, he was placed on the bed sitting quite up-right. Clothes being loosened, his body was slowly bentbackwards towards the pillow, remaining poised at themost obtuse angles without the least muscular tremor-posi-tions, in health, impossible to be maintained without muchmuscular exertion. Soon after his head rested on thepillow, sounds to me new and startling were audible. I can

only describe the nature of the sounds by assuming that toa body of new leather at first gentle traction, gradually in-creased to violent tension, was applied to all the extremities.The expression of the face remained perfectly natural, notthe least movement in any part of the body, whilst thesounds of creaking and straining became so intense that Ithought the bones must eventuallv break if the soundsheard arose from muscular contraction.

It is difficult to conceive muscular sounds conveying anidea of strong action, and which could easily be heard a longdistance from the bed, emitted from a body placid and still

’ * Dr. Cockle : Med. Soc. Pruceeds., vol. i., p. 5.t Lond. Hosp. Reps., 1864, vol. i., p. 1.

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as death. In a moment all was changed. An epileptic fit,with the usual rapidity of its seizure, set in; the fit wassevere, but presented no uncommon features. Iregretnowthat I did not ascertain if there was any muscular tremorbefore the epileptic convulsions set in. Though Captain J.B-- lay on the bed, his clothes were not removed. Icould not, therefore, see if there was any muscular action,but I could have felt. I had plenty of time to ascertain bythe hand if there was tremor, the sounds I have describedprior to the epileptic attack lasting fully fifteen seconds.A few days after the above-mentioned occurrence, Capt.

J. B- came to consult me. In the middle of our con-versation he stood up, looked intently towards the door whichwas open behind my back, repeated questions in mono-syllables, "Who?" "What?" "Yes"; at the same timeleaning his body a little forward, though his feet nevermoved. Thinking there was some one at the door I turnedround, but there was no person there. I looked at myfriend. He drew a deep breath and said,,’ I felt ratherqueer just now." He had had the petit mal. A consulta-tion for epilepsy interrupted by the patient getting a fit,not at once recognised by his medical adviser, may appearstrange, but it is still more strange that voice, gesture, andexpression of face should remain unchanged by epilepsy inits mildest form. Of course this was not usual; indeed,quite exceptional. Most frequently during very transitoryfits of unconsciousness the mouth was drawn and expressionof face altered. I subsequently saw Captain J. B-- at-tacked by the petit mal under a variety of circumstances-on horseback (whip or sword or reins would fall out of hishands, but he never fell off), at table, &c., each fit present-ing some novel feature.

T,reatment.-Bromide of iron was first tried, without theleast benefit. Then twenty-grain doses of bromide ofpotassium, increased to forty grains, three times a day, weregiven with great benefit. Smaller doses than forty grainshad not much effect, but under the daily use of two drachmsof the bromide of potassium, the petit mal, instead of re-curring three or four times a day, had intervals of sixweeks, and this improvement took place under circumstances(to which I will afterwards allude) most adverse to a cure.Unfortunately the bromide of potassium produced such apustular eruption over the face as to leave only a choice ofevils. Of the two evils, Captain J. B- preferred riskingepileptic seizures to the certain and patent disfigurementof the remedies. He stopped the bromide, and was as badas ever.

Frequency of a short dry cough indicated frequency ofepileptic seizures. Captain J. B- described a feeling ofweight about the epigastrium, and tried by coughing toremove it. Blisters were applied to the epigastrium, andkept open, but they were not of the least use. Captain J.B-, under advice, frequently resumed the bromide, alwayswith the most satisfactory results, but a continuance of themedicine seemed to be necessary to permanent benefit.General health was at the same time attended to. The

danger of riding was pointed out to him; he quite dis-regarded it.Remarks.-To what may the origin of the disease be

attributed in this case ? There was no hereditary taint.Parents, seven brothers and sisters, were alive and healthy.Captain J. B-, aged thirty (fits first began when he wasabout twenty-five years of age), was married, had alwaysbeen steady and abstemious, never received an injury towhich one could point as a likely cause. Though verypallid and of poor physique, he was never ill. Highly in-telligent, and capable of long-continued mental application.Had, as a staff officer, a good deal of office work ; few couldequal his quickness, decision, and retentive memory in allmatters connected with his duty. He had an infirmity Ihave never seen equalled in any one-infirmity of temper.When he hated he hated heartily and implacably. In himtransitions from calmness to violent anger occurred withelectrical rapidity. A disagreeable word or look, the mentionof a hated name, was enough. There was no limit to the

frequency of his fits of anger, and unfortunately his temperwas not as rapidly regained as it was lost. The strongestnervous system could not hold out against such constantand violent paroxysms of anger. To this cause I attributethe origin of epilepsy in Captain J. B--. Every accessionof anger in Captain J. B- was a shock ; there was norising of passion, it seized on him without a moment for

preparation. I pointed out the uselessness of medicinewithout moral restraint. He promised to keep watch overhimself. In early life, if he had been taught to do so, hemight have curbed, and eventually conquered, his temper;but the habit of years became his nature. When I sawhim he was as powerless to check a paroxysm of anger ashe was to control an epileptic fit.Though the petit mal occurred sometimes three and four

times a day, and four or five consecutive days seldom passedwithout an attack, the grand mal did not occur three timesin a year.How long would the cataleptic state have lasted if not

interfered with ? Did the recumbent position, by disturb-ing cerebral circulation, end the cataleptic fit, and bringon the epileptic fit (recumbent position bringing more bloodto the brain, contrary to ansemia of the brain theory) ?and whence originated that strange sound heard beforecatalepsy had passed away and epilepsy had begun ?-arequestions I do not feel competent to answer.Kirkee.

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ON THE

DIAGNOSIS OF FATTY DEGENERATION OFTHE HEART IN ADVANCED LIFE.

WITH CASES.

BY LEONARD H. J. HAYNE, M.D.,STAFF-SURGEON, ROYAL NAVY.

SOME years since, whilst serving as assistant-surgeon ofGreenwich Hospital, when that noble institution was anasylum for our aged seamen and marines, amongst other dis-eases of old age I had the opportunity of seeing a numberof fatal cases of fatty degeneration of the heart.These cases were generally rapidly fatal, and were seldom

much benefited by remedies. Stomach derangements, ac-companied sometimes by constipation, but more generallyby diarrhoea, were prominent symptoms in this fatal malady;frequent vomiting occurred in nearly every case which cameunder my notice, and seemed to me to be a sign almost patho-gnomonic of this disease, as will be seen from a glance atthe following cases.

In one case, as general paralysis supervened, the vomitingand gastric irritation subsided, and never again returned.Enfeebled power of the heart and gastric irritation, withfrequent vomiting, I consider are the most reliable sym-ptoms of fatty degeneration of the heart; and we mayalways suspect fatty disease of the heart when these sym-ptoms occur together in advanced life, associated, as theyare sure to be, with more or less irregularity of the heart’saction.

It is, I believe, pretty generally thought that the detectionof this fatal malady in the living body cannot be made withconfidence. "Slowness and feebleness of the pulse havebeen by some thought diagnostic" (vide Dr. J. H. Bennett’sPractice of Medicine," p. 585, third edition).The arcus senilis, so far as my memory serves me,

was so common amongst the aged pensioners who wereadmitted into the infirmary of Greenwich Hospital, that itwas of considerably less value than might have been ex-pected as a guide to diagnosis of fatty degeneration of theheart.

I do not know of the existence of any statistics bearingupon the point, but I think it is probable that fatty dege-neration of the heart is far more common during the de-clining years of those who have passed the greater portionof their lives at sea than it is amongst aged persons whohave always lived on shore. The very nature of a sea-life,the diet, the vicissitudes of climate, &c., may perhapsaccount for this.CASE 1. - J. S-, seaman, aged seventy-five, was

under treatment in the infirmary of Greenwich Hospitalfrom Oct. 8th, 1854, to June 9th, 1855, for palpitation anddyspepsia, attended with frequent vomiting and epigastricpain, when he was discharged, much benefited by treat-ment. He remained tolerably well for nearly three years,but, in April, 1858, he again became an inmate of the in-firmary, suffering on this occasion from paraplegia. He