portion of the anterior border of the malleolus of the tibia. On the 25th of June the patient was permitted to rise for the first time, the leg and foot being supported upon a stool. His recovery went on without interruption. The discharge and the swelling of the foot diminished, and the wounds gradually healed.

On the 27th July, 109 days after the accident, the man was discharged from hospital in excellent general health. The original wound had contracted to the size of a sixpenny piece. On the inner side was a granulating surface, an inch and a half long, by half an inch wide. The discharge was very slight. The foot and ankle were still swollen, and the former is firmly anchylosed to the leg. The patient can bear some weight upon his foot, but is compelled to use crutches.

I have extracted from a detailed account in my report book the most important particulars of the case. On two occasions the poor fellow was on the brink of death from the serious effects of the injury, but he finally and completely recovered, and will for the remainder of his life enjoy the use and benefit of the foot which has been so happily preserved.

Three matters of practical moment are suggested by the consideration of the history just narrated. First, would it have been practicable or proper to have reduced the astragalus. Secondly, should the head of the bone have been removed as well as the body, a practice recommended by some, and thirdly would it have been more for the patient's advantage to have removed the foot in the first instance at the ankle joint, or performed amputation even higher up, a course still advocated by several distinguished surgeons, amongst others by Chassaignac, Guersant, Tufnell, and by Begin who says:-"J'ai vu plus d'un malheureux à qui des jambes avaient été ainsi conservées, regretter la liberté de mouvement, la sureté et la facilité de la marche, dont jouissaient ses camarades, porteurs de jambes de bois."

These are points upon which experience alone can decide. With regard to the first, the amount of force exerted by the powerful muscles of the leg in drawing the foot against tibia would have rendered the reduction of the astragalus difficult, if not impracticable, and necrosis must inevitably have followed, in consequence of the fracture at the neck having separated the portion where the nutrient vessels mainly enter, and the bone being also displaced almost entirely from its other connexions.

This case, so far as it goes, establishes the propriety of leaving

the head of the bone undisturbed. A surgeon who thought that to the dangers of compound dislocation, those of compound fracture were likewise added by fracture of the neck of the astragalus failed, on one occasion, in his attempt to remove the head of the bone in a case of dislocation of its body outwards, and the patient subsequently died. To do so, in fact, is as unnecessary as it is difficult.

The third question, that of the relative merit of primary amputation and of extirpation of the astragalus, may be considered in connexion with the result in Hamilton's case. I saw my patient in the March of the current year, eleven months after the accident, in the following condition. The wounds were long since quite healed, the swelling in the limb had subsided, and there was neither pain nor uneasiness in it. The joint was quite anchylosed, but there was already some compensating movement in the medio-tarsal articulations. The most important fact however is that Hamilton can go about without the assistance of a stick, with comfort to himself, and with only a slight halt. He is daily gaining fresh power. The limb on measurement appears shortened one inch, but the man does not find it necessary even to wear a high heeled shoe. The second figure on Plate III. represents the foot in its present condition and also the portions of bone that were removed from it. Plate IV. copied, as well as the preceding figure, from a photograph, serves to give an idea of Hamilton's general appearance and age, and demonstrates how little appreciable deformity remains, and how little the functions of the foot have been impaired by one of the severest injuries which could have befallen it. I do not think a result such as this has been attained at too great a cost, although as was said by Hildanus of his case published in 1608-which is, I believe, the first upon record of extirpation of the astragalus for compound injury-" Curatio difficilis fuit dolorosa atque longâ."

It is a saying oft quoted, but none the less true, that it is better to live with three limbs than to die with four. In other words the safety of human life should be paramount to every collateral consideration. It has, however, I think been established by Broca in his exhaustive papers on dislocations of the astragalus, and his views are endorsed by Malgaigne and others, that primary excision of the astragalus for dislocation of the bone is less dangerous than primary amputation performed for a similar injury, while secondary excision of the bone is hardly dangerous at all. Broca has collected 86 cases in which the astragalus was excised. In 59, immediate removal of the bone was had recourse to, with a fatal result in 17 instances.