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tom in albuminous nephritis. 2. That these troubles constitute a new species of amaurosis, which may be called albuminuric. 3. That the albuminuric amaurosis cannot be attributed to the deterioration of the strength. 4. That it very often announces the disease as an initial sign, before the innovation of the pathognomonic accidents. 5. That it appears and disappears, and then returns without exactly following the phases of the albuminous deposit in the urine or of the ædema. 6. That it should cad us to consider albuminous nephritis as an alteration of the ganglionic system.
Mr. Hart remarks that Dr. Roberts, in his recent work, attributes the " hæmorrhagic blindness" of retinitis albuminurica, which he speaks of as in no sense uræmic to the hypertrophy of the left ventricle, which so commonly accompanies a contracting kidney and the increased tension in the arterial system consequent thereto. But that this explanation, while it assists to understand the frequency of the extravasation from rupture of small retinal vessels, would be incomplete unless we recalled also to mind the considerable fatty degeneration of the retinal connective tissue and the sclerosis of the nerve-fibres. The deposit of fat was frequently locally anterior to the appearance of ecchymoses. The value of ophthalmoscopic examination in all cases, whether of amblyopia or retinitis albuminurica, was thus apparent, both in reference to the negative information which it afforded in the one case, and the positive data supplied in the other. Intermittent amaurosis associated with albuminuria pointed, he said, to a train of causes very different to those connected with the incomplete persistent blindness due to fatty substitution and inflammatory destruction of the nerve fibres of the retina. It was to be observed how much more complete the loss of vision was for the time where, as in the amblyopic state noted, the cause was central, than where, in the true albuminuric retinitis, the loss of vision was due to peripheral disorganisation. A considerable amount of retinal disease was compatible with the retention of considerable power of sight; and thus, as in other forms of disorganisa. tion of the retina, especially pigmentary retinitis, the patient did not discover the serious affection of the eyes until the disease had extended very far. Hence, if the use of the ophthalmoscope were deferred until urgent symptoms appeared, the examination was apt to be put off till the chances of doing good were materially diminished, It was the more important to remember this because it was precisely in the case of peripheral disease that the ophthalmoscope afforded the most extended and most useful information, and enabled the surgeon or physician carefully to intervenc, if in time and in suitable cases.
LIGATURE OF THE SUBCLAVIAN ARTERY FOR ANEURISM OF THE
By EDGCOMBE VENNING. Esq., M.R.C.S., Assistant-Surgeon to the First Life
Guards, and late House-Surgeon to St. George's Hospital, Trooper J. C---presented himself at the regimental hospital on the 31st of August, 1864, complaining of considerable pain about the right wrist and shoulder-joint. He stated that eight months previously, in going down some steep stone stairs in barracks, he fell backwards, with his right arm extended, and directed outwards and backwards. The wrist was very painful for some time after, and though a good deal swollen, he co tinued to do his dnty. Only nine days prior to admission did he notice any swelling about the shoulder-joint.
On admission he complained of considerable pain about the lower third of the right forearm, at which situation on the radial side there was an i rregular swelling This appeared like the remains of an old fracture badly united, and was the result, I believe, of a fracture of the radius caused by the accident, the bone being kept in tolerable position by the ulna, which had not been injured. On examining the shoulder-joint I found a pulsating tumour, about the size of a hen's egg, situated over the course of the axillary artery. The pulsation was very strong, and the bruit in the tumour exceedingly loud, both of which ceased when pressure was made on the subclavian artery. The ulna and radial pulses vere much diminished in force in comparison with the opposite limb. Finding from the patient's account that the tumour had increased rapidly, I requested Mr. Cutler and Mr. Pollock to see the case with me, and they were both of opinion that deligation of the subclavian artery in its third portion should be performed at once. In accordance with this opinion, having the assistance of both Mr. Cutler and Mr. Pollock, (chloroform having been administered by Mr. Freeman,) I proceeding to perform the operation, and without much difficulty succeeded in tying the artery. The external jugular vein, being in the way, was tied above and below, and cut through, and all small bleeding vessels were ligatured. On the ligature around the subclavian artery being tightened, all pulsation in the tumour ceased. The edges of the wound were brought together with silver sutures and strapping, and the limb was enveloped in cotton wool. When the effects of the chloroform had passed away, I ordered him a liberal diet, and a full dose of opium at bedtime. The following morning I found he had had several hours of refreshing sleep. The pulse was 88 in the minute; the skin was cool, and the tongue clean and moist. The tem perature of the affected limb was normal, and the only thing he complained of was a pricking pain throughout the extremity. From this date al
went on well; pulsation was felt in the brachial artery on the seventh day after the operation, and on the ninth it was felt quite strong in the radial and ulna at the wrist ; but two days after, it ceased in the brachial and radial and ulna, and has never been felt since. No bad symptoms accompanied the cessation of pulsation. No pain was experienced in the aneurismal sac, and on the eleventh day the ligature around the subclavian artery came away. Twenty-four days after the operation the patient left the hospital, the wound having almost entirely healed, and he in good health. The reason for his quitting the hospital so soon was, that small-pox had broken out in the regiment, and I was unwilling to run the risk of his becoming a victim to the malady, as there were several cases in hospital. He left London on a month's furlough for Nuneaton, where on his arrival, as he felt somewhat weak, he placed himself under the care of Mr. Nason. I heard no more of him until the end of October, when I received a letter from Mr. Nason, in which he related to me that he had been sent for to see ny patient in consequence of severe hæmorrhage having come on from that portion of the wound made at the operation, which had not healed when he left London. I immediately went to see him, and met Mr. Nason in consultation. Bleeding (although all proper means had been adopted to arrest it) was still going on. A large abscess had formed beneath the clavicle, accompanied by enormous ædema of the right upper extremity, and mortification had commenced in the little finger. The question now arose as to where the hæmorrhage came from. We came to the conclusion that it was the result of a large sloughing cavity formed by the ab. scess. I therefore put my finger into the wound, and broke down all the old adhesions, so as to allow the escape of a considerable quantity of foul pus and blood. No return of bleeding occurred subsequent to this, but unfortunately pyæmia set in, followed by a series of abscesses, one of which was situated in the elbow-joint, and for a considerable period he hung between life and death, under Mr. Nason's care; but by the untiring care and attention of that gentleman the patient rallied, and so far recovered as to be able to rejoin his regiment, though with an anchylosed elbow-joint, and considerable loss of power in the hand. This latter he is rapidly recovering, and the forearm is at a right angle with the arm ; so that there is every hope of his ultimately having a very useful limb.
EXCISION OF THE TONGUE. Dr. George Buchanan, Surgeon to the Glasgow Royal Infirmary, has successfully excised one lateral half of the tongue, following "the bold and ingenious proposal of Mr. Syme to divide the lower jaw at the symphysis.” (See Edinburgh Medical Journal, November 1865.)
MR. FERGUSSON'S CASE OF REMOVAL OF THE SCAPULA.
We have already in a previous "Mirror" (THE LANCET, August 26th, 1855) recorded particulars of Mr. Fergusson's patient. She is a young woman, from whom in January last the lower two-thirds of the scapula were removed. In February she left the hospital with the wound healed and the arm freely movable. She came to show herself from time to time, until on one occasion Mr. Ferguson found a swelling under the pectoral muscle, a spot very distant from the seat of operation. The swelling rapidly increased ; some adema showed itself in the arm, indicating pressure upon the veins. This, however, after a time disappeared. With the growth of the tumour, which was exceedingly rapid, the girl's health Legan to fail. Hoping against hope, Mr. Fergusson delayed operative-interference until it became evident that life would be sacrificed unless the disease was removed. The tumour was now so extensive that nothing short of the operation performed would have been sufficient to remove it. Accordingly on the 11th instant Mr. Fergusson proceeded to operate in the following manner :
The patient having been placed under chloroform, a grooved needle was thrust into the upper part of the tumour a little below the clavicle, at a point where it seemed just possible, from an obscure sense of fluctuation, that fluid was present. There was, however, none. A small incis sion was then made over and along the clavicle about an inch and a half external to the sterno-clavicular joint, through which the bone was divided by the saw and cutting pliers. The object of this, as Mr. Fergusson afterwards explained, was to allow free movement of the shoulder during the ensuing steps of the operation, without causing any strain upon the sterno-clavicular joint. By this step, too, implying the preservation of the inner end of the clavicle, the sterno-mastoid muscle was reserved entire. An assistant (Mr. Wood) then trust his thumb through this wound and compressed the subclavian artery upon the first rib. Next, the incision was continued along the clavicle, at first outwards, then backwards over the acromion, and lastly downwards and forwards, so as to terminate in the inner and upper part of the arm below the axilla. From the point where this incision, leaving the clavicle, tended backwards, another was made passing down in front of the shoulder-joint, and meeting the first at an acute angle. By these means two semilunar flaps were formed, one before and the other behind, and the skin of the axilla was preserved. The tumour having been exposed by dissecting the flaps from its surface, the muscular structures which attached it to the trunk were divided. There still remained to be accomplished the section of the subclavian ves
sels and the accompanying nerves, and this was the most delicate part of the operation. Behind the clavicle the tumour was less distinct than at any other parts, spreading vaguely amongst the tissues, and rendering it doubtful at first how far it might extend amonyst the muscles of the neck. A careful dissection succeeded in completely isolating it. The mass was then drawn forwards, and the subclavian artery was compressed. In order to obviate the chance of slipping, a strong forceps, such as is used for removing sequestra, had been prepared by having its teeth covered with wash-leather. The blades of this were pushed from behind forwards so as to enclose the subclavian vessels, and another instrument of the like kind was pushed from before backwards with a similar object. Thanks to these, which admirably answered their purpose, there was no difficulty in retaining and ligaturing the artery, and the operation was completed by finally dividing the remaining tissues, chiefly nerves and vessels, out. side of these blades, with the loss of scarcely a tablespoonful of blood. For precaution's sake, ligatures were applied to two or three other vessels, but they were scarcely needed. The flaps were then brought together, sutures applied, and the patient removed.
We have embodied in our description of this case some of the points which were mentioned by Mr. Fergusson after the operation. He remarked, in addition, that formidable as the operation appeared, it was more simple in its nature than that for excision of the scapula performed some months ago in the hospital. Doubtless there was much risk in the removal of so large a portion of the body, but the extent of tissues divided was not so great as in amputation at the hip-joint. It was remarkable, too, how successful operations about the upper extremity generally proved. The operation was performed in order to save the girl's life, which was serious. ly threatened by the progress of the disease. From the nature of the growth it was unfortunately only too probable that it would recur, but surgery could not hold itself responsible for such an accident. It would have been noticed that the girl appeared pale, and became faint during the operation. He was inclined to attribute this to the effect of mental influence during the last few days. She had suffered much distress owing to neglect on the part of her parents. The loss of blood had been exceedingly small, and this result was owing, he was glad to acknowledge, to the admirable assistance which had been rendered during the operation. Mr. Fergusson then referred to previous operations for the removal of the upper extremity, scapula, and clavicle; and added that this was the first occasion on which he had performed this operation, and he believed that it was also the first time it had been done in London. He