the urine, are clearly, in this case, not to be referred to the secretion and deposition of oily matter in the tubuli uriniferi. It affords, on the contrary, an instance of what may probably be considered the effects of chronic adhesive inflammation of the venous plexus and tubuli uriniferi, causing partial obliteration of the former, and contraction and obliteration of the latter, or their infarction with solid albuminous matter. The latter phenomenon is one so frequently met with in various affections-such as scarlatina, jaundice, and active congestion or inflammation of the kidney from exposure to cold, &c.—that it might, perhaps, be readily admitted as a frequent cause of degeneration of the gland, and which I believe it is. The adhesive capillary phlebitis, which I presume to have been the principal cause of the contraction and destruction of the glandular tissue, is so closely analogous to what occurs in other organs, especially the liver, and which ultimately produces in them cicatriform contraction and induration, that the probable identity of the affection in all these cases may fairly be assumed." P. 274.

Mr. Busk attributes the obliteration of the capillary venous plexus to the formation in those vessels of fibrous clots, such as are met with in certain circumstances in nearly every part of the venous system. The examination of a great many kidneys affected with granular degeneration, as occurring in the active class of men who come under observation in the Seaman's Hospital, has led him to conclude that adhesive inflammation of the tubuli uriniferi and venous plexus of the kidney, is, among that class, by far the most frequent cause of chronic albuminuria, and what is termed granular degeneration of the kidney. And he thinks that "the presence of oil in the tubuli uriniferi, though undoubtedly of frequent occurrence, has no direct or necessary influence in the production of albuminuria, for the reason that such an undue secretion of oil by the kidney may exist to a very great extent, without any albumen being present in the urine, as may be observed in certain cases of jaundice for instance; and on the other hand, because albuminuria may exist, and all the phenomena of suppressed secretion of urea be produced, without any oil being discernible in the tubuli uriniferi."

Mr. Busk is also inclined to believe that the deposition of oil in, or in other words, its secretion by, the kidney, is, in most cases, concomitant with some affection of the liver, by which, the special function of that gland being impeded, the kidney acts, as it were, vicariously, and eliminates some of the carbonaceous matter which should have been eliminated by the liver in the form of oil, &c. That the kidney, in case of jaundice, assumes this vicarious action, is sufficiently obvious, and that the bile is actually secreted in the epithelial cells of the tubuli uriniferi, may also be distinctly seen. In other cases, however, the cause of the kidney secreting oil may be traced, perhaps, to pulmonary disease, and in these cases also it is to be looked upon as a vicarious action.

This is a case of considerable interest. Had the patient possessed two kidneys instead of a single one, his life would in all probability have been longer preserved, and the important functions of these organs would have continued to be performed sufficiently for the purposes of life to a later period even if both kidneys had become implicated in disease. It will be noticed that our author's views of Bright's disease differs materially from those of Dr. Johnson, in so far as Mr. Busk considers adhesive inflammation of the tubuli uriniferi and venous plexuses of the kidneys as a

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common cause of the affection, independently of any fatty deposit. The presence of albumen in the urine may, however, be due, as supposed by Dr. Johnson, to a mechanical cause, the fibrinous matter producing a similar effect on the circulation of the gland to that attributed to the fatty deposit. Mr. Busk's observations, however, do not imply that a structural change in the kidney and albuminous urine may not arise from the deposition of oily matter in the tubuli uriniferi, but that the latter is not the invariable, or the most frequent, cause of Bright's disease. The class to which this case belongs, we presume to be that which Dr. Johnson has announced his intention of showing to be essentially distinct from Bright's disease.

III. ON THE INTIMATE STRUCTURE OF THE HUMAN KIDNEY, AND ON THE CHANGES WHICH ITS SEVERAL COMPONENT PARTS UNDERGO IN BRIGHT'S DISEASE. By Joseph Toynbee, F.R.S. &c.

Mr. Toynbee informs us, in a note at the commencement of this paper, that he has for three years, in conjunction with Dr. Bright, been conducting investigations into the intimate structure of the kidney, but that various circumstances arose to prevent the issue of a work which had been designed to comprise the results of their joint labours. We know not what these circumstances were, but we suspect that, in most points of importance in respect to the minute structure of the kidney, they were anticipated by Mr. Bowman, in his admirable paper which appeared in the Philosophical Transactions for 1842. Mr. Toynbee states that he is now indebted to the kind liberality of Dr. Bright for the opportunity of using the drawings and engravings taken from the preparations at his expense, and generously adds, that nearly everything of value which may be contained in the observations which follow is to be attributed to the assistance of Dr. Bright, and that it is not without some diffidence that he (Mr. T.) ventures to prefix his name to the present communication.

The publication of the fruits of these investigations, whether confirmatory or opposed to the views of Mr. Bowman, cannot fail to prove of interest to the profession, and the descriptive part, in conjunction with the beautiful engravings, form a valuable contribution to the Society's Transactions. We fear that we cannot convey to our readers in an abridged form and without the illustrations a clear view of the minute anatomical structure of the kidney, an account of which forms the bulk of this paper. Those who are interested in the subject will no doubt consult the volume itself, and we must be content with noticing one or two points in which the writer differs from Mr. Bowman. The latter anatomist asserts that the corpora Malpighiana cannot be injected from the tubes. Mr. Toynbee has many specimens in which these bodies have been so injected, and he adduces the authority of Dr. Gerlach, of Mayence, in confirmation of his statement. This anatomist has also succeeded in injecting the tubuli uriniferi from the ureter and the Malpighian capsules at the same time. Mr. Toynbee is also at variance with Mr. Bowman in agreeing with those anatomists who state that the tubuli uriniferi terminate in a plexiform manner by communicating with each other, which Mr. B. denies, and believes

NEW SERIES, NO. IX.-V.

to be founded on deceptive appearances. Mr. Bowman describes the tubuli as having an expanded origin, the expansion being composed of the basement membrane of the tube and enclosing in it the wounded tufts of capillary vessels usually designated the corpora Malpighiana. Several modern anatomists have doubted the accuracy of this view, and Mr. Toynbee is also opposed to it. He states that the capsule of the corpus Malpighianum, instead of being, as supposed, an expansion of the tubuli, is a distinct globular investment, enveloping both the tubuli and the tuft of vessels. This globular investment is neither continuous with the tubuli, nor with the blood-vessels, but is expanded over them. Into one part of the capsule the artery enters, while the other receives the tubuli. The artery divides and subdivides, so as to form a globular mass of capillaries in the interior of the capsule from which the efferent vessel emerges. The tubuli, after penetrating the capsule, becomes tortuous, and twists into a coil, and after being in contact with the ramifications of the corpus, it emerges from the capsule. There are some minor points of difference in respect to anatomical detail to which, if our space permitted, we should be induced to allude. We can only add, in concluding our notice of this part of the paper, that Mr. Toynbee's observations, being the result of careful research and much labour, and tending to correct some erroneous views, are well deserving of record, but we are of opinion that they do not contribute materially to our present knowledge of the minute structure of the kidney.

Mr. Toynbee, after remarking" there appears to be no doubt that the true cause of this disease is the circulation of the blood of the organ, of an unnaturally large quantity of carbonized and azotized elements," and that it has been proved that the ultimate effect of this supercarbonized state of the blood is the deposition, in the kidney, of adipose matter, plainly gives in his adhesion generally to the views of Dr. Johnson, whose paper appears to Mr. Toynbee to be the only account which exhibits the disease in its true relations. He differs, however, from Dr. J. in one important point, viz. in believing that a state of congestion precedes any structural alteration in the kidney, so far agreeing with Dr. G. Robinson, Mr. Busk, and others. Our author remarks:

:

"Now, considering that in this disease the blood is highly charged with carbonized principles, and, consequently, that in its circulation through the kidney, that organ must be called upon to throw off a larger quantity of carbonaceous matter than the natural secretion would contain, an amount of irritation will be excited which must be followed by nervous depression and ultimate congestion of the entire organ. This general view, combined with the results of my investigations into the early stages of the disease, induces me to agree with Dr. Bright and others, that the congestive condition of the blood-vessels of the organ does precede, and that necessarily, the deposition of fat, the enlargement of the organ itself, or of its uriniferous tubes, or of any other of its vessels.

"The cause of the presence of albumen in the urine is acknowledged to be an obstructed condition of the blood-vessels of the organ. Dr. Johnson considers the obstruction to arise from a deposition of fat in the tubuli uriniferi; but there can be no doubt that albuminous urine often exists without any such deposition." P. 320.

Mr. Toynbee divides Bright's disease into three stages, each of which is founded on certain pathological conditions of the organ; but antecedent to

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the development of any of these changes, he believes that the organ is for some time in a state of congestion. In the first stage, "the kidney is enlarged, and innumerable black points are visible, which are the corpora Malpighiana dilated, and their vessels distended with blood, seen through the capsule. The white spots, which derive their appearance from the collection of fatty matter, begin to be perceptible.

"The peculiar features of this stage consist of an enlargement of the arteries entering the corpora Malpighiana; the dilatation of the vessels of the tuft, the capillaries and the veins; an increase in the size of the capsule of the corpus and of the tubuli, and a large addition to the quantity of the parenchyma of the organ." The artery and the corpus is twice or thrice its natural size, which is the case also in the Malpighian tuft and the capillary vessels which spring from the tuft. The capillaries and veins are greatly enlarged, giving to the surface of the organ the resemblance of network. This is the commencement of the stellated condition which is so marked a characteristic of the next stage of the complaint. The tubuli are also much increased in their dimensions; but the fat which is found in them is soft and white.

In the second stage, the organ is very greatly increased in size, its surface is smooth, and presents numerous white spots; the capsule is but slightly adherent to the surface and the tissue of the organ is flabby. The structural changes exhibited during this stage are the following.

"The artery of the corpus Malpighianum becomes so greatly enlarged, that frequently it equals the dimensions of the tube itself, and is eight or ten times its natural size. It is tortuous and dilated, and sometimes, previous to entering the capsule of the corpus, presents analogous swellings to those of varicose veins. The primary branches of it, in forming the tuft, are also distended to ten or fifteen times their natural size, and are not unfrequently discovered external to the capsule of the corpus, as though thrust out by some external force. The vessels forming the tuft are likewise enormously enlarged, and very often the minutest branches are fully as large as the main artery of the corpus in a healthy state. "Occasionally the tuft is broken up, and instead of forming a compact mass, exhibits its individual branches separated from each other. At other times the branches of the tuft are actually larger than the primitive artery of the corpus." P. 321.

Mr. Toynbee is surprised at Mr. Bowman's statement that he has never seen, in any one instance, a clearly dilated condition of the Malpighian tuft of vessels, which is attributed to the peculiar injection used by that anatomist. An enlargement of the renal arteries and dilatation of their branches are also observable in this stage of the disorder. The capsule too is greatly increased in size.

"The tubuli differ considerably from their healthy condition, being enlarged to two or three times their natural size, and aggregated together in masses, so as to lie in contact with each other, and form definite, roundish bodies: they are also extremely convoluted with numerous dilatations; frequently they are varicose. At other times they present distinct aneurismal sacs, which bulge out from one part of the wall of the tube, to which they are attached by a small neck or pedicle. Occasionally, some of the vessels of a convolution are smaller than the others, and their size nearly natural. The tubuli in the masses are so closely packed, that the blood-vessels are evidently compressed, and rendered incapable of admitting an injection. At times a tube, even at some distance from the corpus, becomes very convoluted, and knotted into a mass." P. 322-3.

Q

In cases where the kidney is much enlarged, the parenchymatous cells will be found not merely increased in size, but adipose depositions will be visible throughout them.

In the third stage of the disease" the kidneys are smaller than their natural size; hard, white granules are prominent on their surface, which is more or less lobulated; the capsule is adherent; vesicles of large size are frequently every where interspersed; and numbers of smaller ones stud the whole surface. On making a section, the organ is found to be deprived of blood; the cortical part contracted, the blood-vessels large, and their walls thick."

The arteries are in a more contracted condition than that described in the second stage; and the Malpighian tuft is so often changed from its natural state, that the greater part of its vessels are not capable of being injected. The capsule of the corpus has assumed a more contracted appearance. "The tubuli are larger than in the preceding stage, and are gathered into rounded masses, which form the granules on the surface of the organ. The latter are of a white hue, and are most commonly fully distended with fatty depositions; though not unfrequently they appear like dark spots: the tubuli in that case being full of blood. A rounded appearance is generally characteristic of the granules, in each of which the component tubule forms innumerable convolutions." The tubuli are filled with oily cells, granular matter particles of various size, and blood globules. The parenchyma is hard, and is composed of elongated stellated cells, from the angles of which fine threads proceed, and communicate with each other. There is nothing said on the subject of treatment. Mr. Toynbee agrees with Dr. Johnson in recommending hygienic measures in order to prevent the development of the disease.

We must confess that this paper has disappointed us, especially as great pains have confessedly been bestowed on the subject of which it treats. There is less of novelty and interest in the pathological part even than in the anatomical, and no conclusions of a practical character are deduced from the author's researches.

IV. HISTORY OF A CASE OF Ligature of the LEFT SUBCLAVIAN ARTERY BETWEEN THE SCALENI MUSCLES, ATTENDED WITH SOME PECULIAR CIRCUMSTANCES. By J. C. Warren, M.D, Professor of Anatomy and Surgery in Boston, U. S. A., Honorary Fellow of the Royal Medical and Chirurgical Society, &c.

Dr. Warren remarks that the history of an operation for the ligature of the subclavian artery would seem scarcely worthy the attention of the Society. This operation has been done many times in various parts of the world, and the annals of this distinguished body contains no less than twelve cases. The case which he has the honor to lay before them possesses peculiarities, and will, he hopes, afford some practical inferences.

James Avery, aged about 30, on the evening of Dec. 23rd, 1843, while in a state of intoxication, slipped on the ice, fell, and struck his left shoulder against the curb-stone of the side walk. Surgical aid was called, and violent efforts were made to reduce the dislocation, but in what man