1849.] Surgery. 499 effect of irritation, or an actnal extension or translation of malignant disease. How, then, can any thinking man regard it as an important indication for or against an operation. " Happily, hospital surgeons are becoming at length practically alive to the fallacy of this distinction; and it is one of the most pleasing features of the im¬ proved condition of modern surgery, that the treatment of morbid growths by extirpation, is now the exception, and not, as formerly, the

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... le." 34. Aneurism of the Axillary Artery, Ligature of the Subclavian.-F.LeGros Clare, Esq., relates, in the London Medical Gazette, July 13, 1849, a case of axillary aneurism in a man 47 years of age, admitted into St. Thomas' Hospital in Feb. 1849. The tumour, when the patient was admitted into the hospital, was about the size of a small orange, and was situated beneath the great pec¬ toral muscle, and close to the left clavicle. It possessed all the characteristic signs of a true aneurismal dilatation of the axillary artery in the first division of its course. It pulsated forcibly, but the throb could be entirely controlled, at the same time that the swelling was sensibly diminished in size, by pressure on the subclavian artery above the clavicle. The thrill was both audible, and perceptible to the touch. When recumbent, the aneurismal sac could also be felt in the axilla. The clavicle was raised in correspondence with the size of the tumour. Pulse 60 (he had been placed under the influence of digitalis before coming to town); heart's action quiet and healthy; no evidence of any other organic disease; and all the important functions of the body were per¬ formed naturally and regularly. He was put on a low diet for a few days, pre¬ paratory to my placing a ligature on the subclavian artery. Operation, Feb. 10th.-The patient reclined on a table, being well supported by pillows, but so as to allow the left shoulder (that of the affected side) to fall. A vertical incision was first made, to the extent of an inch and a half, along the posterior border of the sterno-mastoid muscle. The integuments over the clavicle being then drawn down, a second incision was carried freely outwards, from the lower extremity of the first, as far ns the anterior border of the tra¬ pezius. By this the clavicle was freely bared, and a small artery and vein which bled freely required ligatures. When the skin had been allowed to re¬ sume its natural position, I divided the dense fascia immediately above and be¬ hind the clavicle, and conducted the remainder of the operation with the handle of the scalpel, which had been sharpened for the purpose. At this stage of tho manipulation, although no undue force was employed, and the cutting instru¬ ment had been thrown aside, a vein of considerable size (probably the supra¬ scapular, near to its termination) gave way, and poured out blood in profusion. A ligature was the only resource, and was therefore applied, at my request, by my colleague Mr. Solly, to whose prompt and able assistance I was much in¬ debted throughout the operation. The border of the scalenus muscle was then sought for and found (nearly parallel, perhaps a little external to that of tho sterno-mastoid); and the artery was at once felt pulsating upon the first rib. An attempt was first made to pass the aneurism needle from below upwards be¬ tween the vein and artery; but as this was not readily effected, the direction was changed, and the needle was introduced between the lowest brachial nerve and the artery, and brought out between the latter and the vein. A strong and stout ligature of silk (of the size of small whip-cord) was carried round the artery with the needle, and readily tightened. Pulsation in the sac and artery immediately ceased, and the former became flaccid. The patient complained of loss of power and numbness of the limb, but expressed himself as relieved of the pain he had before suffered, and which arose, no doubt, from pressure on the axillary nerves. Vespere.-Perfectly comfortable; perspires freely; pulse 72, without any¬ thing of excitement in it; no headache, nor pain in the arm; the limb which is enveloped in flannel, is quite warm. He passed a quiet night, sleeping at intervals; on the following morning, the pulse had risen, but he continued to perspire abundantly; later in the day there was more febrile excitement, the pulse reaching 96, and being rather jerking; his diet was of course limited to slops; and towards evening the excitement