layers of firm and laminated clot, and in addition there was a considerable amount of soft and recent clot in its cavity. The two openings in the sac were now separately secured, after the manner shown in the sketch. By means of the aneurism needle catgut ligatures, prepared with chromic acid, were applied, and when the tourniquet was removed there was no bleeding from the vessel. The external wound was now stitched and a drainage tube introduced. Irrigation with a solution of corrosive sublimate (1 in 2000) was employed during the operation, and the wound was dressed with corrosive sublimate wool. His progress was perfect. Before the 10th of September the drainage tube was removed; upon the 27th of September the wound was healed, except at one small spot, the site of the drainage tube, and the patient sat up in an arm-chair. Three days after this he was allowed to walk a little in the ward with crutches, an elastic bandage being applied round the limb as a support. Upon the 15th of October he was discharged cured. On the 3rd of November, Dr Hern, in a note to me in regard to another patient, writes:-" Norris is quite well, and at work."

My reasons for deciding upon the "old" operation in this case

were

(1.) The unhealthy condition of the general arterial system. (2.) The large size of the aneurism, and its rapid growth. (3.) The cedema of the leg, and feeble condition of its circulation.

The case was quite unsuitable for pressure, and it belonged to that class of cases already referred to, in which ligature of the femoral artery is acknowledged to be not only uncertain as regards the cure of the aneurism, but to be attended with a considerable risk of gangrene of the limb, secondary hæmorrhage at the seat of ligature, a risk not now so great as formerly, or inflammation and suppuration of the sac.

It may be said, and has been said, that if the arterial system. is unhealthy it is most likely that the artery in the region of the aneurism will be especially affected and unsuitable for ligature; but Mr Syme proved the fallacy of this in connexion with his brilliant operations after the old method; and having myself performed many operations of a similar kind, I can confirm his opinion, for I have never seen secondary hæmorrhage occur when the old operation has been carefully performed with antiseptic precautions.

In favour of the "old" operation in my case, was the certain. and speedy cure and obliteration of the sac provided all went well; the immediate removal of the large tumour, which was pressing upon the veins, and probably also upon the arteries, and interfering with the proper circulation of the limb,-so that in this way two of the principal risks, gangrene of the limb and suppuration of the sac, were in great part done away with; and,

lastly, that if any of the risks already mentioned had followed my proceeding, and amputation been necessitated, an amputation could have been performed lower down in the thigh than in the case of ligature of the femoral artery, and therefore with less risk to the patient. But I have additional experience to support my opinion. In the British Medical Journal for 17th April 1880, I published the notes of a case of popliteal aneurism treated successfully by the same proceeding. This case was that of a man, æt. 36, who, seven years before he came under my care, had his femoral artery ligatured in Australia, after pressure and flexion had failed to cure the aneurism. The ligature of the artery was successful, and the disease apparently remained cured until a few weeks before he consulted me, when pulsation had returned, and the tumour steadily increased in size. In this case I laid open the sac, and secured the popliteal artery at the point of its communication with the sac. This patient was perfectly well in six weeks, and remains well. In some remarks upon this case I then wrote:-" The case is an additional proof that the popliteal artery may be successfully ligatured;" and again, "I have hopes that the successful result of this case may in the future cause it (the "old" operation) to be practised with more encouragement in some of those cases which have hitherto been treated by amputation." Further, I have proved that both popliteal artery and vein may be successfully ligatured; for in the Lancet for 24th April 1875, I reported a case of arterio-venous aneurism of the popliteal artery, the result of a wound, involving the artery and vein, in which I laid open the sac and secured both popliteal artery and vein at their points of communication with the sac. This patient was completely cured in five weeks. These are the only cases of popliteal aneurism in which I have performed the "old" operation, and therefore I have no unsuccessful cases as yet to record. From my experience of these three cases, and from my experience in other varieties of aneurism, I feel justified in expressing the opinion, that the "old" operation is to be preferred to ligature of the femoral artery in Scarpa's triangle in the following conditions of popliteal aneurism :

(1.) In cases of large aneurism filling up the space, and interfering by pressure with the venous and other circulation of the limb below, or causing serious nerve pressure.

(2.) In rapidly growing aneurisms, which have attained some size.

(3.) In ruptured and diffused aneurisms.

(4.) In aneurisms which have involved the knee-joint by

pressure.

(5.) In aneurisms attacked with inflammation and suppura

tion.

(6.) In aneurisms which the ligature of the femoral artery and compression have failed to cure.

(7.) In arterio-venous and other aneurisms of traumatic origin.

(8.) In cases of general arterial disease, provided surgical interference is considered necessary or advisable.

In such of these conditions, which are of an acute nature, there must be no delay in performing the operation; and I need scarcely add, that should symptoms of gangrene already be present in any case, amputation is the rule.

III. CASE OF AMPUTATION AT HIP-JOINT, IN WHICH RE-INJECTION OF BLOOD WAS PERFORMED, AND RAPID RECOVERY TOOK PLACE.

By A. G. MILLER, M.D., F.R.C.S. Ed., Surgeon to the Royal Infirmary, and Lecturer on Surgery, Edinburgh.

(Read before the Medico-Chirurgical Society of Edinburgh, 6th January 1886.) G. T., æt. 18. Admitted 5th December to Ward XVI., Royal Infirmary, with strumous disease of both hips, left knee and left elbow, and a large abscess connected with the left hip. He was very weak and anæmic.

History. -Had rheumatic fever eighteen months ago, also erysipelas. Was under Dr Duncan's care in Royal Infirmary nine months ago for disease of right hip.

Present Condition.-Right hip improving, but extension still necessary. Left knee and elbow affected with synovial degeneration. Left hip extensively diseased, a large abscess communicating with the joint.

The abscess was freely opened and drained on the 8th December, which gave some relief. But as the patient still suffered great pain, and there seemed no prospect of ultimate recovery, or even much improvement, amputation of the left leg at the hip-joint was suggested. This was agreed to by the parents and the lad himself, the risk from the operation having been fully explained.

Amputation was performed on the 18th December as follows (Dr Duncan having kindly undertaken the important part of collecting the blood that might flow during the operation and reinjecting it):

An elastic bandage having been applied from the toes to the middle of the thigh, and a powerful elastic tourniquet at the groin, a rapid circular cut was made right down to the bone in the upper third of the thigh and the femur sawn through. A gush of blood took place, estimated at about four ounces, which was all caught by Dr Duncan in a vessel containing a solution of phosphate of soda. The femoral artery and some smaller vessels were then tied, and the tourniquet removed. After this a few more vessels required ligaturing, and a few ounces of blood escaped, which, however, Dr Duncan managed to collect and injected along with the previous quantity into the deep femoral vein. By an

EDINBURGH MED. JOURN., VOL. XXXI.-NO. VIII.

4 Y

incision on the outer side of the thigh the head of the femur was then dissected out. This part of the operation was accompanied by more bleeding than usual (five or six vessels requiring ligaturing) on account of the great vascularity consequent on the extensive amount of disease. The wound was thoroughly washed out with corrosive sublimate lotion, dusted with iodoform, brought together with four button sutures, and a few superficial ones, and the stump wrapped up in sublimated wool. After the operation the patient suffered from no shock whatever, nor had he any depression of temperature. For the first few days he was flushed, and had a fuller pulse than before the operation, but he had no rise of temperature. He has made an uninterruptedly good recovery, and is now (nearly three weeks after the operation) able to sit up in bed. The wound has always been dressed under protection of the spray, and is now quite healed as regards the deeper parts, there being only a superficial granulating surface along the line of the incisions.

The highest temperature recorded was 100.3. There was slight hæmaturia for two days. The day after the operation the number of his corpuscles was four and a half millions.

The case is one of special interest, as illustrating the advantage of Dr Duncan's method of blood injection which he described at a recent meeting of this Society.

The patient being in a very weak and anæmic condition before the operation, and the hæmorrhage during the operation having been greater than usual owing to the great vascularity of the parts from the extensive disease, it is very unlikely that he would have survived the shock of the operation had the greater part of the blood not been reinjected.

Dr Duncan, who watched the hæmorrhage, and measured the blood collected, and reinjected, calculates that the patient had an ultimate gain of blood after the operation. He estimates it thus:

There was pressed back into the general circulation by the elastic bandage, say 3v.; reinjected of blood measured, 3xj.; lost in sponges and sawdust, say iij.; lost from destruction of corpuscles, say 3j.; net gain of blood, say 3j. But to this must be added lymph from leg, say 3v.; solution, ziv. And also a diminished demand on the general circulation on account of the leg having been removed.

IV. SUBJECTIVE SYMPTOMS IN EYE DISEASES.1 By GEORGE A. BERRY, Ophthalmic Surgeon, Royal Infirmary, Edinburgh.

III. DIPLOPIA-POLYOPIA.

WHEN double vision is complained of, we have, in the first place, to determine, by covering first one eye and then the other, 1 Continued from p. 622.

whether in either case it is still present, or whether it always disappears when one eye alone is used. We have therefore to distinguish between binocular and monocular diplopia.

Binocular Diplopia.-In order that there should, under any circumstances, be binocular diplopia, it is necessary that the following three conditions should be complied with:-1. That there should be a fair amount of vision in both eyes; 2. That no circumstance should have led to a more than physiological suppression by the mind of the image falling on either eye; and 3. That both the visual axes should not be directed simultaneously on the object which engages the attention. (There is a curious possible though rare exception to this third condition, which will afterwards be referred to.) Thus there may be no diplopia complained of, even though there be wide divergence of the visual axes, owing to the suppression of the image of the one eye from more or less monocular blindness, or more frequently from habit. This is the most common condition in ordinary cases of concomitant squint. In such cases the suppression of the image of the one eye, when the other is used for fixation, is sometimes so complete that under no circumstances can it be made apparent; in other cases, by holding a red glass or a prism with the angle directed upwards or downwards in front of the fixing eye, the faulty image of the other is at once seen, showing that the suppression is only affected for normal conditions of similarity in the optical images, as well as for a retinal area only, on which, under ordinary circumstances, the images corresponding to those occupying the centre of the retina of the fixing eye are received. Again, an individual may complain of diplopia even although the visual axes are capable of crossing, and actually do cross on the same object. This is the case when other objects than the one fixed engage the attention, and is, in fact, physiological in so far as all objects not directly looked at are seen double. When, however, this kind of double vision is complained of, it is owing to an abnormal degree of attention being directed to objects other than those fixed. Usually there is a suppression of one of the images of other objects than the one on which the visual axes are directed, a suppression which is often so complete as to render it difficult for many people to become conscious of this physiological diplopia. Which eye is the one whose images are suppressed in any particular case may be determined by a very simple experiment. By asking any one, while keeping both eyes open, to hold up their finger in a line with some distant object, and then close first the one and then the other eye, they will find that the finger exactly covers the object as seen by one eye, while it deviates to one side when looked at by the other. This shows that only the image of the eye in a line with which and the distant object the finger has been placed is observed, that of the other being more or less completely suppressed. The cases of diplopia now referred to are due to the opposite condition, viz., to a too