eased bone, and the unhealthy suppuration around. Hence my first object was to try and secure the vessel directly at the bleeding point. But, on examining the exposed surface, which the extensive incision in the leg readily admitted of, there was no jet of blood or other indication to guide me, while the altered condition of the structures in the wound, the matting together of some parts, and the sloughy condition of others, caused me to desist, as I felt that, under such circumstances, without some direct indication of bleeding, a tedious dissection would be required to reach the vessel, with no certainty of reaching it at the open point; and, after all, my surmise as to its being the fibular artery, might be wrong. Again, if an opening in the vessel were found, its coats might be so unhealthy as not to hold a ligature above and below the opening. The subsequent dissection of the limb proved the difficulties of direct ligature to be even greater than I had anticipated. The portion of the vessel where the opening existed, was surrounded by an encysted abscess, and had only bled indirectly into the wound; hence the reason that no jet could be observed on removing the pressure on the femoral, when examining the wound. The arterial tunics, where they were isolated, were so soft and sloughy, that they would not have held a ligature for a few hours, if at all; whilst immediately beyond the isolation, the whole track of the vessel was so incorporated with adherent lymph, as even to defy its separation to any extent, by careful dissection, when removed from the limb. What probability, then, would there have been of treating the vessel by direct ligature?

As to the method of indirectly controlling the bleeding, by weakening the general circulation through the limb, by ligature of the superficial femoral, no one can be more impressed than myself with its uncertainty, as compared with direct ligature, owing to the free anastomoses in the thigh, and around the knee, above the bleeding point. But when, for the reasons above stated, the latter could not be adopted, I considered it right to give the patient that chance, rather than amputate, as I had seen it succeed in cases of a similar character. I had likewise, by somewhat similar means, successfully arrested hemorrhage from ulceration of the brachial from sloughing, after a severe burn, by tying the third portion of the axillary artery, as recorded in this Journal for February 1848. It is true that in that instance I, at the same time, applied ligatures above and below the wound of the brachial; but these ligatures separated by ulceration on the 5th day; so that except for the ligature of the axillary artery controlling the circulation, bleeding would have recurred. Hence I felt warranted in trying it in this case; and, indeed, there was little room for hesitation, for the patient was so sunk from the recent bleeding, as to put immediate amputation out of the question; and as oozing was still going on, and direct pressure had failed, something required to be done.

There can be no doubt, I think, as to the generally admitted pro

priety of giving preference to direct ligature above and below the opening, in all cases of wounded arteries, as a great general rule, and it is one which can scarcely be too much insisted on; but at the same time, we must keep in mind that there are exceptions to this, as to all other general rules, and that much must depend upon the state of the vessel opened. If its coats are diseased and sloughy, if their vitality and that of the surrounding parts be impaired, as after extensive unhealthy suppuration or severe burns, then direct ligature, if trusted to alone, without controlling the force of the circulation by ligature on a healthy point of the vessel higher up, must often prove abortive, and repeated hemorrhage from rapid ulceration of the deligated part of the artery be the result. In fact, everything depends upon the state of the arterial tissue in the neighbourhood of the lesion, and the probable destructive power of the agency producing it. I have instanced burns by fire; on the other hand, ulceration from caustics generally leaves the parts, whence the slough has separated, healthy, and curiously enough, the very patient, whose case I have just narrated, nearly lost his life on a previous occasion from ulceration of the radial, caused by nitrate of silver applied to a bite. On that occasion I also saw him, but, knowing the limited action of the caustic, I exposed and tied the radial above and below the ulcerated point with success. But it would have been a very different matter in the sloughy condition of the fibular in the present instance, even if there had been any indication to guide me to the bleeding point. In the present case, the ligature of the femoral did effectually prevent all hemorrhage for a time; it allowed the patient time to rally; and when, on the circulation being fully established, the bleeding recurred, it was both less active and less in amount, and had the patient been even tolerably strong, I doubt not but that moderate and regulated pressure might have ultimately succeeded in arresting further hemorrhage. But, debilitated as he was by the previous exhausting disease and the repeated bleeding, and peculiarly depressed by the fear of hemorrhage from a remembrance of the risk he formerly ran, I felt that even a very trifling loss of blood might prove fatal, and the danger to life seemed so great, as to forbid any further attempts to save the limb.

CASE III.-Disease of Bones of Tarsus; Amputation at Ankle Joint; Recovery. M. Rigali, ætat 25, when a boy, had suffered from disease of the os calcis ; portions of diseased bone were removed at that time, the wound healed and continued well until the present attack. About five weeks prior to my seeing him, he felt pains in the foot which soon became very acute; the foot became inflamed and swollen, and he was treated for erysipelas, but without relief. I saw him for the first time on the 9th of February 1852. The foot was swollen, tense, and of an erysipelatous appearance; he was suffering from irritative fever, pulse 120, dry furred tongue, great general depression and exhaustion from want of sleep. The local pain was most severe over the region of the heel, but extended generally over the foot. From the history of his case, I felt satisfied that the symptoms depended on disease of the bones, and this

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opinion was confirmed on introducing a probe into an opening at the old cicatrix on the heel, when I felt the bone bare for a considerable extent. On grasping the anterior part of the foot and moving it laterally, the tarsal bones were distinctly felt grating on each other. As there was much tension and inflammation over the dorsum of the foot, I made two longitudinal incisions, which gave vent to unhealthy purulent matter, and the probe introduced into these incisions at once passed down into the diseased bones. I ordered him an opiate draught, and directed the foot to be dressed with lint dipped in warm water, and covered with gutta percha membrane. Next day the pain, swelling, and redness of the foot were diminished, and there had been a considerable discharge of fœtid pus. I directed the foot to be enveloped in a large poultice at night, the warm water dressing to be continued during the day, and directed him to have an opiate at bedtime to procure sleep, and also to arrest diarrhoea, which had commenced. The tension and inflammation gradually yielded to this treatment; but profuse foetid discharge continued, with great pain on the slightest movement of the foot or leg, and the irritative fever subsided into hectic, with loss of appetite and profuse perspiration, alternating with diarrhoea. The use of quinine and sulphuric acid, with wine and beeftea, was had recourse to, in order to support his strength till the erysipelatous form of inflammation, which had involved the leg, was sufficiently subdued to allow me to remove the foot. Having obtained his consent to the operation, I amputated the foot at the ankle-joint, on the 18th February. Owing to the previous inflamed state of the parts, a very considerable number of vessels required ligature. The stump was covered with lint dipped in cold water, and an opiate given. He complained a good deal of smarting pain in the part, but slept better after the operation than he had done for some weeks. There was no tendency to erysipelas attacking the stump, which healed very well. His general health improved steadily, though at first slowly, and at the end of two months he was able to walk about on the stump. He has since continued in excellent health, and is able to walk considerable distances without difficulty. Dissection of the Foot.-On examination the whole of the tarsus was found more or less affected with caries, whilst the os calcis presented extensive necrosis of its outer fibrous lamella, as did also some of the other bones. The part of the os calcis from which portions had been removed when the patient was a boy, seemed firmly healed by deposition of new bone, and that part did not seem affected by the more recent disease.

CASE IV.-Necrosis of Head of Tibia; Secondary Affection of Knee-Joint ; Amputation; Accidental Attack of Scarlatina; Death.

On the 20th October 1852, I was requested by Mr Falconer, surgeon, Loanhead, to visit J. B., residing at Lasswade, on account of disease of the left kneejoint. On seeing him with Mr Falconer, I found the knee much swollen; over the upper part of the tibia the skin was discoloured, and an opening surrounded by unhealthy granulations led into a cavity in the head of the bone, the walls of which felt rough, and the probe detected some loose portions of dead cancellated texture. There was considerable boggy swelling and redness over the knee-joint; but the principal swelling was evidently caused by great effusion into the cavity of the joint, the patella moving on the surface of the deep swelling. Some years prior to my seeing him, he had had an operation performed for removal of a sequestrum from the head of the tibia, and after its removal continued well for a considerable period, but from time to time he suffered from severe pains in the head of the tibia; the cicatrix opened up, discharged matter, and then a temporary relief occurred. Of late, however, the pain had been very severe. About three months before I saw him, swelling and pain began in the knee-joint, attended with febrile irritation and loss of sleep; and for some weeks before my visit, his health had been rapidly sinking from hectic. His pulse was 130 and weak, besides the swelling of the knee, the affected limb was oedematous, and he suffered intense pain on

pressure or movement of the knee. His extreme weakness and the oedematous state of the limb gave me an unfavourable opinion of the case; but as both he and his friends were anxious he should have the chance of relief afforded by removal of the limb, I amputated it at the middle of the thigh, by double flap, on the 25th October. During the operation a large escape of serum from the cellular tissue took place, but he lost little blood. He was directed to have forty drops of morphia, when the effects of the chloroform should have passed off. I saw him on the third day after the operation, and dressed the stump, removing some of the stitches, and applying adhesive straps to support the flaps. His pulse was still quick, about 120, but he stated that he had slept well. His bowels had been opened, and he passed water freely of natural appearance, and not coagulable by heat. His tongue was furred and rather glazed on the edges and tip. I was informed that one of his children had taken scarlet fever (then very prevalent) on the evening of the operation, but that the child had been kept away from him in a different room. On the next day I heard from Mr Falconer, that B. had had a slight shivering and complained of sore throat, and that towards the following morning the eruption of scarlatina appeared over his body, accompanied with increased sore throat, very rapid pulse, and delirium, and he gradually sank and died on the sixth day after the operation.

Dissection of the Amputated Limb.-On examining the joint I could not by pressure on the knee succeed in causing the contained fluid to pass out by the opening over the head of the tibia. On opening the joint it was found filled with turbid glairy fluid mixed with pus; the cartilages had suffered but little, there was great injection of the synovial membrane, with patches of recent lymph, and considerable gelatinous deposition near the lateral ligaments on each side. On opening the cavity in the head of the tibia, it was found to contain a portion of dead cancellated texture lying loose; the walls of the cavity were of a pale brown colour, and at some points covered by a lardaceous looking substance. On carefully passing a probe upwards, it was found to pass into the knee-joint through an ulcerated orifice with round thick edges, but overlapped internally by a fold of the synovial membrane, which had acted as a valve, preventing fluid from passing out of the joint when pressure was made on the knee.

CASE V.-Caries of Os Calcis; Previous Operation for removal of Diseased Bone; Amputation at Ankle-Joint; Recovery.

In May last, I was requested by Dr Thomson of Dalkeith to visit Mr L., who was suffering from disease of the os calcis. I was told that for some time previously he had been under surgical treatment, and that an operation had been performed with the view of removing the diseased portion of the bone, but that the wound had never healed. The pain had become intense, scarcely alleviated by large opiates, to which he had recourse and his general health was evidently sinking under the continued irritation. On examining the foot, I found the soft parts about the heel and ankle swollen, discoloured, and excessively painful on pressure. Deep-seated fluctuation was felt on the plantar aspect of the os calcis, on the posterior and outer side of the heel there was the citatrix of a crucial incision still partially open, and discharging thin fetid pus. On introducing a probe into the sinus, it passed readily round the os calcis, which felt rough and bare, and at one point it penetrated the substance of the bone itself. The general health of the patient had suffered greatly, both from the irritation of the disease, and also from his excessive use of laudanum. His pulse was 140, and weak; he was greatly emaciated; whilst his appetite and digestive powers were much impaired. stated his age to be fifty, but appeared to be considerably older.

He

On taking all the circumstances of the case into consideration-that the previous operation for the removal of the diseased portion of bone had proved abortive, that in all probability the greater part of the os calcis was involved in

the disease, together with his age, debilitated constitution, and the risks of further partial operations, I proposed amputation at the ankle joint. He willingly consented to this, and I performed the operation on the third of May. The existence of the cicatrix of the former operation appeared rather unfavourable to the ordinary plan of operating; but any difficulty from that cause seemed more than counterbalanced by its advantages over other methods. I therefore operated as usual, and experienced little or no difficulty from the adhesions in separating the flap from the os calcis. The stump progressed favourably, but erysipelas appeared on the seventh day on the anterior part of the leg, and required incisions to be made to relieve the tension, and evacuate purulent matter. A considerable portion of the tendon of the tibialis anticus sloughed, and when this separated, the tendency to erysipelas disappeared, and the case went on favourably. The opiates were gradually withdrawn by diminishing the doses, and this was soon followed by a marked improvement, as regarded his appetite and general health. The discharge continued for some time from the orifice of the old cicatrix.

The stump is now solid and well formed, and can bear considerable pressure, though the patient complains of the weight of the artificial limb.

Dissection of the Amputated Foot.-On examination, the disease was found to be confined to the os calcis, with the exception of a slight ulceration of the cartilages of the corresponding surface of the os cuboides. On looking at the os calcis, its posterior and external surface was nodulated and rough, from the development of new osseous matter. Immediately below the insertion of the

tendo achillis, a circular black portion was observed, and on making a longitudinal section of the bone, this was found to be a circumscribed sequestrum of the cancellated texture; whilst at the anterior part of the bone was a carious cavity, containing portions of partially dead cancellated texture, as shown in the accompanying woodcut.

The pale brown colour and general appearance of the ulcerated surface in contact with the sequestrum, indicated its weak vitality and carious character, whilst at some points the cancellated texture had become dense and hard.

Remarks. These three cases afford examples of certain peculiarities attendant on necrosis, occurring in the cancellated texture of the short or heads of the long bones, which renders that condition in it less amenable to treatment by removal of the sequestrum, than similar disease occurring in the shafts of bones. At first sight, this appears contrary to what we might expect, for whilst the looser texture of the cancellated structure would seem less likely to suffer from the pressure of abnormal congestion or exudation than the denser structure of the shaft, its larger amount of vascular supply