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12th.-Yesterday, an enema acted copiously; to-day, thebowels were naturally moved; pulse 100 ; wound very healthy.

I need not continue the record any further. She rapidly im-proved, and on the fourteenth day the wound had healed, andshe was readv to leave her bed.Remarks. -This was, I think, a case upon which the most

sanguine surgeon would have pronounced an unfavourableprognosis; and taking into consideration that the strangulationhad existed four days-that she was a weakly woman, debili-tated by previous illness-that the entrapped intestine wascongested to lividity and incipient gangrene-and that the

peritoneal membrane had begun to sympathize with the gut,-I believe most justly so. But, the. operation over, all morbidprocesses ceased, and the vis medicat1.ix naturce fully provedthe wisdom of our attempt. That the pulse never rose above112, that no sloughing worthy of mention followed, that theimprisoned bowel so soon recovered its natural function, andthat the constitutional symptoms after the operation were soinsignificant, are all, in my opinion, facts worthy of note, andfull of encouragement for the future. I am convinced that

long-attempted taxis, where strangulation is not recent, is asuseless as it is perilous, and that if it succeeds once, it failstwenty times. I feel sure, too, in these days, a generous dietand due administration of stimulants after an operation oftenward off extensive suppuration and vital depression; or, failingthat, enable the patient to survive them.

Gresford Cottas’e, 1859.

EXTENSIVE CARIES OF THE OS CALCISCURED BY OPERATION.

BY WILLIAM STILLMAN, M.D., Southam.

MR. S-, aged twenty-eight, looking pale and cachectic,came under my care some time ago. He was then sufferingfrom cough and night-sweats. Upon examination, I found theupper portion of the left lung in the first stage of tuberculardisease. Under a course of treatment, with tonics and cod-Ever oil, he much improved, and almost lost his cough. Be-

coming moderately stout and healthy-looking, my attendancethen ceased until five months ago, when I was again summonedin consequence of the patient having met with an accident, bywhich his left ankle was sprained and the heel bruised. The

redness and swelling of the ankle subsided under treatment;but the outer side of the heel continued much inflamed, and therewas deep-seated pain upon pressure. Leeches were appliedwithout benefit, and after three weeks had elapsed from thetime of the accident I detected fluid, which I evacuated ; thefluid was thin and unhealthy-looking. In a short time it againformed, and discharged itself by means of two sinuses ; a probepassed through either of these openings readily detected dis-eased bone. As the patient was again suffering from cough andexpectoration, with night-sweats, I placed him under consti-tutional treatment, giving him quinine and cod-liver oil, withiodide of iron. His sweats and expectoration left him ; a slightcough in the morning only remained ; but the local disease wasevidently extending, and, fearing that other bones of the footwould become implicated unless the disease was removed, I de-termined to operate without delay, and did so on July 12th,1858. I made a crucial incision on the outer side of the oscalcis below the malleolus externus and slightly behind it, andremoved with the gouge nearly the whole of the cancellatedportion of the bone, the disease being so extensive as to neces-sitate this. There was very little blood lost. In consequenceof the thoracic disease I did not use chloroform.

Since the operation the foot has gone on well under simplewater dressing, and upon examination on August 9th, I foundthe wound quite healed, and the foot free from either swellingor pain. The patient has continued to take the oil, and willdo so for some time. The lung disease is arrested, and maywith care on the part of the patient continue so for years.The case most certainly points out the necessity for not de-

ferring operative measures in caries after the disease has oncebecome confirmed and shows a tendency to extend; for I haveno hesitation in saying that, had I not removed the diseasewhen I did, the neighbouring bones would have become carious,and there would most likely have been an end to any conser-vative measure, besides the probability that the sufferer wouldhave died from the exhaustion and constitutional irritation

produced. As it is, he has a healthy foot, and, should he bespared, the cavity will again become filled by bone. Of courseit will be some time before the heel is strong enough to bearany weight.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

WESTMINSTER HOSPITAL.

COMPOUND COMMINUTED FRACTURE OF THE LEG, FOL-LOWED BY GANGRENE.

AMPUTATION AT THE KNEE-JOINT BY RECTANGULAR FLAPS;FATAL RESULT.

(Under the care of Mr. HOLTHOUSE.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliornm proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Procemium.

WELL-DIRECTED conservative efforts will do much to saveboth life and limb in the great majority of severe injuries.In the following casa, however, wherein there was not onlyhaemorrhage from a torn artery, but also the formation of largebullæ a few hours after the accident, we think an earlier resortto amputation would have held out a better chance for the life ofthe patient, whose occupation was of a well-known unhealthycharacter-namely, that of a brewer’s drayman. Mortificationcommenced at an early period, and produced a fatal result,from exhaustion, two days after the operation, and thirteendays from the receipt of the injury.There is a young man at the present time in the Royal Free

Hospital, under Mr. T. Wakley’s care, who sustained a com-pound fracture not unlike that in Mr. Holthouse’s patient. Itwas determined to resort to amputation, but as no bloodvesselwas wounded, and the patient’s age and constitutional powerswere favourable, the limb was put up in a Macintyre’s splint,and a recovery has ensued, with an excellent limb. We hopeshortly to record this very interesting case.For the following notes we are indebted to Mr. Ponsonby

Kelly Adair, house-surgeon to the hospital :-Henry H--, aged sixty, was admitted into Henry Hoare

ward on the 14th of December, 1858, with a compound fractureof the left leg. He is a brewer’s drayman, and whilst at workfell down into a cellar. When brought to the hospital aboutfour P.M., it was found that both the tibia and fibula of theleft leg were broken, and that the fracture of the tibia wasboth compound and comminuted, two of the pieces protrudingthrough an opening in the skin, just over the upper part of thelower third of the leg. These were removed, and the wound

covered with a piece of lint soaked in blood so as completelyto exclude the air. There was at this time but little hæmor-rhage, which was venous. The limb was placed in position ona Macintyre’s splint, well padded, and an evaporating lotionapplied to the injured part. The man had a most unhealthylook, and fears were expressed as to the ultimate issue of thecase. During the evening, in spite of the closure of the wound,a small stream of blood tlowed from it at intervals, and largebullas formed about the seat of the fracture.During the two or three succeeding days, the bleeding occa-

sionally recurred, and the leg swelled very much. Above thewound there was a sense of fluctuation, as though blood orsome other fluid were under the muscles. There was also agood deal of oedematous pitting on pressure, and when a groovedneedle was introduced pretty deeply on the outer side of theleg, a few inches above the wound, where the fluctuation wasfelt, a small quantity of blood and thin serum oozed out. Verylarge bullse, filled with blood and serum, formed about thewound, and also behind it, and bursting, left the whole of theleg at the seat of the injury raw.

Dec. 21st.-The bowels have been moved for the first time

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since his admission. The night before last, he was in a verylow state: the surface was quite cold, and he seemed to begetting rapidly worse; but he revived on the administration ofbrandy, half an ounce of which was ordered to be given everytwo hours. This morning, the whole of the surface of the legabout the seat of the injury has a sloughing aspect; large bullascontinue to form, and the swelling of the whole leg increases.There is still occasional oozing of dark blood from the wound;sometimes a large quantity escapes, and the leg requires to beremoved from the splint daily to be cleaned. A suspicion hasbeen raised that there is a wound of the anterior tibial artery,but no pulsation can be felt in the swollen limb, nor has therebeen any escape of arterial blood. The foot is quite warm,and there is evidently no deficiency in its supply of blood.22nd. -The appearance of the limb is much worse; a quan-

tity of blood and unhealthy pus escapes from the wound; theswelling of the limb is increasing, and the skin looks quitegangrenous ; the dorsum of the foot also is much inflamed, butdoes not look at all gangrenous; pulse 96, not wanting inpower; tongue very dry, and brown. For several nights hehas wandered a good deal, but not much during the day-time.Mr. Holthouse was of opinion that the best and almost onlychance of life for the patient was to remove the leg; but Mr.Holt and Mr. Brooke, whom he consulted, advised that thiscourse should be delayed a few days at least, and recommendedthat a free incision should be made from the wound upwards.Accordingly, this was done on a director, and the skinfound to be in a sloughy condition through its whole thick-ness, and separated from the subjacent fascia. The tissuesbeneath did not appear to be seriously implicated. No collec-tion of blood was found. The wound was stuffed with lint, anda chlorine lotion applied. The odour from the limb was veryfeetid. The patient continued to take half an ounce of brandyevery two hours, and two pints of porter during the day.23rd.-The dressings were removed this morning, when the

whole wound presented a very sloughy appearance; otherwisethe limb did not seem in a worse condition, the free openinghaving relieved the tension of the skin; a quantity of un-healthy pus was discharged. A poultice was applied to thewound. -.--’:- 24th.-The man seems more exhausted to-day, his pulse is

feeble, and he is frequently light-headed. The wound looksvery unhealthy, and Mr. Holthouse does not think it possiblefor the patient to survive the exhaustion which must accom-pany such an extensive injury to both the soft parts and bone;he therefore intends to remove the leg by amputation throughthe knee-joint. Accordingly, at two P.M., he cut a long ante-rior flap, leaving the patella in it, and a short posterior one,which terminated just opposite the middle of the posterior sur-face of the articulation; and having secured the poplitealartery, which was the only vessel requiring a ligature, hebrought the edges of the flaps together by silver sutures. The

flaps were the rectangular ones of Mr. Teale. The small quan-tity of blood which escaped from the popliteal artery was verydark-so much so, that had it not been for the manner inwhich it escaped, it would have been taken for venous blood.25th.-He has been in a very exhausted condition ever since

the operation, and has not yet recovered it. He has had hic-

cough at intervals during,the night. Pulse 120, feeble.26th.-About midnight (last night) he seemed to be sinking

so fast that the amount of brandy was increased, and he hadit as often as he could take it, with beef-tea, &c., and it wascontinued during the rest of the night. To this treatment hispulse answered well; and this morning he is better than hehas been for several days.-Noon : These favourable symp-toms have only been temporary, for he has suddenly becomeso much worse that he cannot swallow. The heat is leaving hisextremities.-Eight P.M.: He has just died, not having ralliedsince he became so suddenly worse about midday.Examination of the amputated limb.-Pus and blood were

found beneath the integuments in the neighbourhood of thefracture; the skin and areolar tissue were in a sloughy state;the same condition prevailed beneath a considerable portion ofthe skin on the dorsum of the foot. Blood also was found tohave been extravasated in small quantities between the muscles.The tendon of the extensor proprius pollicis was nearly tornthrough in the neighbourhood of the fracture; the tendons ofthe other muscles were perfect, but some of the muscularfibres- of the extensor communis digitorum were lacerated.The anterior tibial artery was traced to the seat of the injuryboth from below and from above, its continuity being inter-rupted either by sloughing or laceration, or both, to the extentof two or three inches.-Back of the leg: Coagulated bloodwas found in considerable quantity between the skin and

muscles, and between the muscles themselves, and in theirstructure. It was found in largest quantity between the deepfascia of the muscles, and extended quite up to the poplitealridge. The posterior tibial artery was sound. The fracture ofthe tibia was very oblique, and two inches of the upper partwere deprived of periosteum, and must have inevitably perished.

ST. MARYLEBONE INFIRMARY.

STRICTURE IN THE SIGMOID FLEXURE; CONSTIPATION FORFORTY-ONE DAYS, RELIEVED BY OPENING THE COLONBEHIND THE PERITONEUM ; DEATH FROM PERFORATIONABOVE THE SEAT OF STRICTURE.

(Under the care of Mr. HENRY THOMPSON.)

H. P-, aged thirty-nine; admitted into the InfirmaryMarch 9th, 1859. She was soon transferred from the medical,to the surgical ward, under Mr. Thompson’s care.

Previous history.-She is the mother of nine children, and isnow about five months pregnant. Has generally enjoyed goodhealth. Says that her habit has usually been rather consti-pated. She is quite certain that she has passed no motionfrom the bowels since Monday, Jan. 31st (thirty-nine daysago). Two or three days previously, she was lifting an un-usually heavy weight, and " felt something give way in herstomach." During the five or six weeks which have elapsedsince that time, she has had much purgative treatment (crotonoil, &c.), which has been repeated, and without success.

Present state.-Although unwieldy, she contrives to walkabout the ward, and her countenance is not anxious. Whenlying down, she does not raise the knees. The abdomen isenormously distended, and it is tense and tympanitic every-where except the region of the left colon, from the stomach tothe iliac fossa-there it is dull on percussion. Marks of thecoils of small intestine are well seen on the surface, and aroundthem can be traced the colon, much distended. There is gene-ral slight tenderness, considerable only on deep palpation inthe left lumbar region. Much gurgling is heard. Pain con-stant, but not severe, except at times; relieved by change ofposture : it is greatest in the left iliac region. The finger in-troduced per rectum can be passed only with difficulty, fromthe enormous distension of parts within the abdomen. The

gut is wide from flattening. A flexible tube can be passedonly six or seven inches. Injection of a pint of fluid returns.immediately, evidently not passing beyond the rectum. The-bladder is very low in the vagina; the catheter passes perpen-dicularly into the bladder from displacement of that viscus bypressure. The urine is scanty and high-coloured. The fcetus-is felt in utero; the womb itself is moveable. She vomitssome dark-brown matter, with an unpleasant but not fsecaj;odour, about every hour or hour and a half. The stomach.retains fluids about half an hour. The tongue is white, andcoated ; pulse 130, weak. Ordered-half a grain of opiumevery six hours; brandy and strong beef-tea.March 12th. -Vomiting diminished; has slept much better;

has retained fluids. No alteration in physical signs.13th.-Morning: Rather weaker; pulse 140; some vomiting

occurred early this morning, but has since ceased.—Evening.:No alteration. Mr. Thompson decided not to delay longer toopen the left colon. The woman lying on her right side, hemade an incision through the integuments in the left lumbarregion, two fingers’ breadth above the crest of the ilium behind.its middle, midway between it and the last rib, commencingabout six inches from the vertebral spines, and directed back-wards to within about two inches and a half of them. He then.carefully dissected through the fascia and muscles in this course,dividing a portion of the quadratus lumborum in the deeperpart of the dissection, where the colon appeared crossing thecentre of the wound. Drawing it well up, he attached it bythree stitches to the integument, and then opened it with thebistoury sufficiently to admit the forefinger. Pascal matterissued immediately in abundance. She took nourishment and,stimulants in the course of the night.14th.-Nine A.M.: About ten pints of semi-fluid faeces have

passed during the last twelve hours. She is weak, but expressesherself as feeling much relieved. Has taken three eggs beatenup with brandy during the morning; pulse 136; no vomitingsince the operation.-Evening: Tongue dry; pulse 148. Fluidfasces pass in great quantity, as if the purgatives taken before-operation were acting. She is evidently weakened by thisover-action.

15th.-Nine A.M.-: Miscarriage occurred during the night;foetus and membranes expelled entire. She is very weak; no.