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the high temperature of the season. Instead of the regularhot winds from the N. W., the wind during the month of Mayhad been very constantly N.E., and the tatties* were conse-quently of little service. The thermometer at the end of Mayaveraged 105° in the shade, and from the unfavourable direc-tion and nature of the wind for working the tatties the heat inbarracks could be but little diminished. On the 1st of Junethe wind was still N. E. and light, with the thermometer at104°. The sensation of heat was intense. On the morning ofthe 2nd, the day of the outbreak of the epidemic, the windcame round to the N.W., and was strong and scorching. Thethermometer in a covered passage facing N.E. showed a tem-perature of 108° at two r. M.

(To be concluded.)

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.

POPLITEAL ANEURISM CURED BY COMPRESSION, PULSATIONCEASING IN FORTY-TWO HOURS.

(Under the care of Mr. HILTON.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliornm proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Korb. lib. 14. Procemium.

THE subject of aneurism, situated in various parts of thebody, has been most fully illustrated in our " Mirror" for someyears past. It is one so full of interest that it always commandsattention, from the necessarily serious nature of the affectionitself. On the present occasion, we avail ourselves of the

opportunity to place upon record two examples of poplitealaneurism, in which the treatment by compression was most re-markably and at the same time speedily successful. We must

observe, however, that, as a general rule, compression is in-variably tried in our hospitals, and not until it fails, or thatthe instruments cannot be borne, is the ligature resorted to.If it does fail sometimes, we think it may depend upon a wantof the scrupulous attention to many of the minor circumstancesassociated with it, which, although in themselves apparentlytrivial, yet become of importance when taken as a whole.These should of course be rigidly carried out by the surgeon,and success in the majority of instances will crown his efforts,as in the illustrations we place before our readers to-day.We will refer back to what has appeared on popliteal

aneurism in some of our previous "Mirrors." In our

"Mirror" of November, 1853, (THE LANCET, vol. ii. 1853,p. 475,) we collected together the references to the cases whichhad already been reported as successfully treated by com-pression. These were under Mr. Ward’s and Mr. Critchett’scare, at the London Hospital, (THE LANCET. voL ii. 1851,p. 83, and vol. ii. 1852, p. 325;) Mr. Cock, at Guy’s Hospital,(vol. i. 1853, p. 31;) one under Mr. Poland and Mr. Hilton, atGuy’s, (i,bicl., p. 11. ) At the same time, we referred to otherswherein the artery had been tied after compression had beengiven up. Mr. Cock’s case was cured by compression in twoweeks, and Mr. Poland’s after the lapse of nearly eight months.We also recorded at that time (vol. ii. 1853, p. 476-8, 497 aud498) five cases, under Mr. Hewett, Mr. Erichsen, Mr. Lloyd,and Nlr. Stanley, four of them cured by compression, one ofthe four (Mr. Stanley’s) in the short period of four days. Sincethen have appeared in our " Mirror," amongst others, a caseunder Mr. Simon, at St. Thomas’s Hospital, treated by liga-ture, (vol. i. 1854, p. 514;) one of femoral and popliteal aneurismtogether, treated by ligature, under Mr. Solly, at the samehospital, (ibid., p. 534;) one by compression, cured in seven

* Mats made of kus-kus grass, fitted into a window or doorway, and con-ually kept wet.

weeks, under Mr. Hilton, at Guy’s, (vol. ii. 1854, p. 47;) twocases treated in the Newcastle Infirmary, by Mr. Heath,(vol. i. 1855, p. 95,) one was cured by compression in threeweeks; a case of Mr. Cock’s, at Guy’s, the ligature used aftercompression had failed, (ibid., p. 211;) another case of Mr.Cock’s, the patient suddenly dying without treatment, (vol. ii.1855, p. 5;) and a man under Mr. Adams and Mr. Ward, atthe London Hospital, cured by compression within, a month,(ibid., p. 198.) More recently, two cases under Mr. Fergusson,at King’s College Hospital, in one of which compression wassuccessful in about ten weeks, (vol. i. 1856, p. 153 and 431;) a,

case cured by compression within thirteen days, at the SouthStaffordshire Hospital, (vol. ii. 1856, p. 201;) a remarkableinstance of double popliteal aneurism, treated by compressionfirst, and ligature of both femorals after, under Mr. Bowman’scare, at King’s College Hospital, with a fatal result, (vol. i.1857, p. 451, 578, and 603.)In all those instances which were treated by compression,

the period at which pulsation ceased and the sac had becomesolid varied, the intervals in some extending over a period ofmany months, whilst in others but a few days.In the first of the two cases which we record to-day, pulsa-tion entirely ceased in forty-two hours, on discontinuing thepressure, but Mr. Hilton ordered it to be continued a shorttime longer, although the tumour was perfectly solid, and ac-cordingly it was kept on until the fifth day, when it was re-moved altogether, and the man left the hospital cured on thefourteenth day from its first application.

In the second case, under Mr. Erichsen, at University CollegeHospital, pulsation ceased in three days and a half, but thecompression was kept up till the ninth day, when the tumourwas found quite solid. The patient left the hospital curedalso on the fourteenth day from the commencement of thisform of treatment. It is a somewhat remarkable coincidencethat these two cases should have been discharged cured in afortnight. The ages of both patients were favourable for treat-ment, thirty-nine and thirty-three years. They form exceed-ingly valuable illustrations of the treatment of aneurism bycompression, a method for which modern surgery is so muchindebted to such eminent men of the Dublin school as Hutton,Bellingham, Tuffnell, Carte, and others, whose names will everbe honourably associated with aneurism.For the notes of the following case we are indebted to the

kindness of Mr. John Stafford Benson, one of the clinical clerksof the hospital.Wm. W-, aged thirty-nine, bailiff, residing at Dulwich,,

was admitted, under the care of Mr. Hilton, July 22nd, 1858. Hishabits are temperate, and, with the exception of having hadsyphilis twenty years ago, he has never suffered from ill-health.

Pr-evious history. -About four months ago he first felt aslight pain on the inner side of the left knee, which, he says,entirely ceased in dry, but returned in damp, weather, in-

creasing in severity at each attack. Thinking it was merelyrheumatism, or the effect of too much exercise, he paid noattention to it. About two months ago he observed a smallswelling in the popliteal space of the left knee, which he noticed-to pulsate. Not thinking it of any consequence, he merelyapplied flannel around the knee. The pulsation and pain in-creasing, together with the size of the tumour, he applied toDr. Ray, of Dulwich, (about a week before his admission into,the hospital,) who ordered a cold lotion temporarily for a fewdays, then took him to Mr. Hilton. This gentleman advisedhim to come into the hospital. He returned home, however,where he remained for three days, and kept pressure appliedover the femoral artery by means of a clamp and of a weight,applied alternately in two different situations, to relieve thepain and irritation which would be caused by too long-continuedpressure on one spot.

Present condition, on admission.-He is a muscular, well-built man, of middle stature and healthy aspect. Complainsof nothing but stiffness, accompanied with slight pain in theleft knee. There is a pulsating tumour, about the size of alarge hen’s-egg, in the popliteal space of the left knee, thepulsation of which is synchronous with that of the radialartery; no pain is experienced in it, the pain being altogetherfelt in the above-mentioned place. His health does not appearto suffer in any way; his appetite is good, and pulse 86. Wasordered to take as little fluid as possible, and a little ice tomoisten his mouth.23rd.-He cannot sleep on account of the pain, and was

: therefore ordered half a grain of opium powder every four. hours. Pressure on the femoral artery was commenced at half-. past four P.M. to-day, by means of the ctamp and a weight of

about twenty pounds applied alternately, the former at the

201

apex of Scarpa’s triangle and the latter a little above, so as tocompress the artery just after its passage over the os pubis,some person being constantly at the bedside to see that they were properly attended to.24th.-Four P.M.: The pressure of the clamp applied yester-

day could not be borne for more than ten or fifteen minutes ata time, but a second was placed about midway between theformer and the weight, being about the centre of Scarpa’s tri-angle, which remained on for two hours; and by thus multi-plying the points of pressure no further inconvenience wasexperienced from this cause.25th.-Slept comfortably for some hours last night. At

eleven o’clock A.M. (forty-two hours after the pressure wasfirst applied) the pulsation was found, on discontinuing thepressure, to have entirely ceased.26th.-Mr. Hilton advised the pressure to be continued for

a short time, although no pulsation could be detected on itsremoval. The tumour was found to be perfectly solid, andconsiderably reduced in size.28th.-Very slight pressure has been continued for the last

thirty-six hours, and is now completely removed. The tumouris quite solid, and three small arteries can be distinctly felt topulsate in passing over its surface.30th. -Doing well.August 5th. -Mr. Hilton ordered a splint to be applied to

the leg, to prevent movement of the knee-joint for a shorttime; and the man left on the 6th, perfectly cured.During the whole time that pressure was continued, the

heat of the leg affected was greater than that of the right.

UNIVERSITY COLLEGE HOSPITAL.

POPLITEAL ANEURISM CURED BY COMPRESSION, PULSATIONCEASING IN THREE DAYS AND A HALF.

(Under the care of Mr. ERICHSEN.)WE are indebted for the notes of the following case to Mr.

John Castaneda, the dresser of the patient :-George W-----, aged thirty-three. Has always enjoyed good

health; father and mother both dead; the mother died of

apoplexy, and the father of some renal affection. The lastfourteen years his occupation has been that of wax-fitter toher Majesty, which has entailed a good deal of standing.During the last six months the patient has been troubled witha pain of a somewhat dull, aching character in and about theregion of the right knee-joint. It was considered by him asbeing of a rheumatic character, and he took no further noticeof it at the time. About a fortnight since his attention wasattracted to the existence of a tumour in the right ham. This

tumour was the seat of a throbbing pain, which gradually in-creased in intensity.On the 14th July the patient was admitted an in-patient of

this hospital. Mr. Erichsen on examination found a tumourabout the size of a goose’s egg in the popliteal space, over thesituation of the artery. This swelling was somewhat moreprominent on the outer than on the inner side. On manipula-tion, a distinct pulsation, synchronous with the heart’s action,could be felt, which was arrested by the pressure of the fingeron the femoral artery, and immediately returned on the re-moval of the pressure. There was also a distinct bruit. Allthe usual symptoms of popliteal aneurism were manifest.-At three P.M. the limb was bandaged from the toes to abouttwo inches above the knee. The thigh was shaved and dustedwith flour. Two tourniquets were then applied, one to thegroin, and the other was placed over the thigh a little above eits middle, about six inches below Poupart’s ligament. The

upper tourniquet was then screwed up so as to compress thefemoral artery as it crosses the pubes, when the instrumentwas seen rising and falling at each pulsation. The patient ex-perienced no pain.

Pressure was then kept up till eight o’clock, when the lowertourniquet was tightened and the upper one unscrewed. Deep-seated pain was now experienced by the patient at the seat ofcompression, and referred by him to the bone. A sensation oftingling and glowing was also felt at the seat of compression,and in two or three hours after the application of the tourni-quet a peculiar tingling sensation, scarcely amounting to pain,as if, to use the patient’s own words, " the blood were crawling

--

up close to the skin." was felt over the knee. The foot waswas rather numb. The temperature was slightly lower thanthat of the opposite leg.-At twelve r.M. the upper tourniquetwas reapplied, and the lower one loosened. The patient feltmuch easier as soon as the pressure of the lower tourniquetwas removed.

l5th.-Compression was maintained till six A.M. The lowertourniquet was then screwed up. The same sensations werenow experienced by the patient as on the former application ofthis tourniquet. A distinct pulsation could be seen and feltover the situation of the "arteria anastomotica magna" duringthe whole time, which in the opposite limb was not percep-tible. The patient passed a sleepless night.l7th.-At eleven P.M., the lower tourniquet was still applied.18th.-At one A.M., the upper compression was re-applied a

little higher up than before, over the situation of the externaliliac. A sensation of fullness in the popliteal space was expe-rienced by the patient. This sensation came on at intervals,and lasted the whole night. The lower tourniquet was screwedup at half-past four A.M.; it was placed a little lower down, asthe patient complained of great irritability of skin. Hestated that it seemed to him as if the blood pressed against acertain point in the popliteal space which it experienced adifficulty in traversing, and then at length, after overcomingthe obstacle, ease was experienced. This occurred at irregularintervals, and lasted about two or three minutes each time, butit was only experienced when the lower tourniquet was applied.Pressure was kept up till half-seven A.M. by the lower tourni-quet. The application of the lower tourniquet was much morepainful than that of the upper one. The posterior part of theleg over the course of the posterior tibial artery, and also theouter side of the leg from the external malleolus to two inchesabove the knee-joint, were extremely painful. The patientcomplained of shooting pains from the foot to the under partof the knee, sometimes extending up the thigh to the tuberosityof the ischium. Once he complained of a darting pain fromthe foot of the affected limb to the groin of the opposite side.No pulsation was perceptible over the seat of the aneurism.He spoke of a trickling sensation from a little behind the innerside of the knee, and extending as far as the situation wherethe seat of fullness was complained of. This was occasional,and immediately supervened on the least movement on thepart of the patient. He passed a very restless night. Theshooting pains prevented him sleeping till morning.20th.-Patient very restless. The tourniquets were kept on

between an hour and a half and two hours alternately. Greatirritability and numbness of limb existed. The difference in

temperature between the limb affected below the seat of com-pression and the sound limb was extremely marked; the

patient complained of the cold, and requested to have the footcovered with cotton wool. The pain was more intense, deepseated, and continuous; less frequently shooting. The thighabove the bandage was hot. The feeling of fullness about theknee was much talked of by the patient. The seats of thetourniquets were changed, the upper one being moved lowerdown, and placed about three inches and a half below Ponpart’sligament; and the lower one was moved up till it was broughtinto close proximity with the upper one. The leg was consi-derably swollen, the knee felt tight and numb, but there wasno pain in the latter situation except when the lower tourni-quet was pressed against the bone, and the pain was of a drag-ing character.

21st.—At one A.M., on unscrewing the instruments, all pulsation was found to have ceased in the tumour. The in-struments were, however, screwed up again. The patient com-plaiued of pain in the aneurism and down the outside of theleg. He had not passed so bad a night since his admissioninto the hospital.-Two P.M.: At the visit, Mr. Erichsen foundthe tumour solid and without pulsation. Pain was still com-

plained of. The instruments were reapplied as a measure ofprecaution, and ordered to be kept on for forty-eight hourslonger.

23rd. -Instruments taken off. Tumour solid and pulseless.Pain in leg on the outer side. Pulsation in the femoral arterycan be felt down to below the middle of the thigh; no pulsationin either tibials. Foot somewhat colder than the other, butmovement and sensibility in the toes perfect. -No artery canbe traced over the patella or anterior part of the thigh, butone about the size of the temporal can be felt pulsating alongthe outer side of the popliteal space. A slight compressionwas kept up by a bandage, and the patient directed to remain

in bed.24th.—Going on favourably.i 28th.-Discharged, cured.