to set up fœtid discharge and poison the wound or the patient; and so it does if proper care be not taken. But if the strangulated part of the pedicle which projects beyond the clamp be well saturated with perchloride of iron, as you saw me use it just now, the slough is tanned; it becomes as hard and dry as a piece of leather, and there is an end to that objection. It is said to cause suppuration about the wound; but this again, I have seen quite as frequently, in proportion, after the ligature or cautery. I never saw more profuse suppuration of the stitches than in one case where I divided the pedicle with the écraseur, and closed the wound with platinum wire sutures. Then, after the wound is closed, it is said to lead to a re-opening each month, and an escape of some menstrual fluid. And this is true in some-perhaps in nearly a third-of the cases. But if the patient be prepared for it, it is not of the slightest consequence. The Fallopian tube contracts completely after a few months, and there is no further escape. The fact that it does escape sometimes is to my mind an argument in favour of the clamp; for if menstrual fluid can escape through the partially close Fallopian tube fixed in the cicatrised wound, so it may escape if the tube be left within the peritoneal cavity, and the result may be a fatal hæmatocele. I have known this to occur in cases where the ligature was used and cut off short; and I believe it to be one of the strongest objections to this method, or any intraperitoneal method of dealing with the pedicle. As to any fancied impediment to the increase of the uterus in pregnancy, and to its contraction during labour, from the adhesion of the tube cicatrix, I can only say that nine of my patients have had children after ovariotomy-two of them two children—and there was no such complaint in any one case. One real objection to the clamp is that it may possibly pull on intestine, or a tense pedicle may strangulate intestine (and I have seen one such case). But this objection is of little weight if the use of the clamp be restricted to cases where the pedicle is so long that there is not much drag on the clamp. In such cases, I repeat, I desire no better method. But where we have a broad, thick, short pedicle, or a broad connection between uterus and cyst rather than a distinct pedicle, we want something better than the clamp. And we have the choice between wire or needle pressure, the ligature, the écraseur, and the combination of crushing and cauterisation, to which I have before alluded as an improvement due to Mr. Clay, for which he has certainly not received due credit.

I say nothing about acupressure or the wire compress, because I have never tried them. Sir James Simpson was successful in one case, and the plan is certainly worthy of trial.

The ligature of the pedicle can always be effected by transfixing it, and tying in two or more portions, before the cyst is cut away. Or a clamp may first be applied, the cyst cut away, and the pedicle then transfixed and tied below the clamp. But, if this be done, the clamp must be loosened before the ligatures are tightened, or the compressed tissues are so held that the knot cannot be tied so tight that it will not slip off as soon as the clamp is removed. If it be desired only to tie the vessels, it may be done by feeling the arteries, and carrying a ligature round them through the pedicle before the cyst is cut away; or after the application of a clamp and removal of the cyst, holding the pedicle carefully with forceps as the clamp is loosened, and tying any vessel which bleeds. The great objection to this plan is, that there is often much loose cellular tissue, rich in small veins, which go on oozing after all the larger vessels have been tied. Whichever may be the plan preferred, the important question arises, Shall the ends of the ligatures be cut off, and the wound closed? or shall they be left hanging out through a part of the wound, purposely left open for their passage, and that of the slough they embrace when it separates? Dr. Clay, of Manchester, still advocates this latter practice. I have tried it, and with success in about a fifth of the cases only; and I shall not willingly adopt it again. in its favour, it may be said, that it is a method applicable in all cases; that it secures an outlet for serum from the peritoneal cavity; and that, after the separation of the ligature and slough, no foreign body is left within the patient. But it seems to me better to have a choice of methods, and adopt each in its appropriate case, than to strive after one method applicable to all cases. I think the ligature-threads act as a sort of seton in the peritoneal cavity, set up inflammation, and excite the formation of the serum for which they are said to provide the outlet. Then, if the patient recover (and I have very great doubt whether very many subjected to this plan do really recover), there is a great liability to ventral hernia. The cicatrix remains weak at the spot where the ligatures passed out, and it yields before the pressure outwards of the viscera. I have seen this in nearly every case where I followed this plan; but I do not remember more than two cases where it followed the clamp. Therefore, if we use one or more ligatures, I am inclined to cut off the ends short, and close up the wound completely. Wire has been used for this purpose; but it seems an irrational practice. Silk, if pure, is an animal substance; and experiment proves that it may be absorbed. Wire cannot be absorbed, and must be more or less of a mechanical irritant. I tried wire on one side and silk on the other side of a sheep on which Professor Gamgee operated for me at the Albert Veterinary College, and

the superiority of the silk was manifest. But what we have to look to is the effect on the tissues strangulated, rather than the material by which the strangulation is effected. If anything like what goes on outside the body when the clamp is used, or inside when the wound is left open for ligatures, were to go on when the wound is closed, it is difficult to understand how any patient could possibly survive the process. She would almost infallibly be poisoned by absorption of the fœtid products

the decomposing stump. But a very different series of changes must go on when the wound is closed and access of air is shut off. At any rate, experience proves that patients do survive the process; and post mortem examination has shown that ligature and pedicle have been coated by a sort of capsule of lymph. In my own hands, this practice has been much less successful than the clamp; and, even when patients have recovered, some of them have long remained in a state of semi-invalidism, very different from the robust health which is the rule after successful clamp-cases. This plan is that always followed by Dr. Tyler Smith. It was originated in 1821, by Dr. Nathan Smith, of Baltimore, who used leather ligatures. Dr. Rogers, of New York, in 1830, also cut off his ligatures "close to the knot, and left them to absorption." If I used the ligature, I feel disposed to cut off the ends whenever the patient is in pretty good condition, and sthenic peritonitis with effusion of lymph may be expected; but if low diffuse peritonitis and effusion of serum may be feared, then I suspect it would be better to leave the ends of the ligatures, and secure a drain through the wound for the serum. But we should still search for a better method than the ligature.

The écraseur I used once, and successfully. But I have not ventured on it again; for, if it should prove untrustworthy, and internal bleeding occur in any case, one's self-reproach would be very painful.

The cautery alone would almost certainly fail to stop such large vessels are as frequently met with in a pedicle. So might the écraseur alone, or the crushing which precedes division by the écraseur. But the combination of crushing and the cautery is certainly efficacious in a considerable proportion of cases. Mr. Clay, of Birmingham, as I said just now, introduced the practice, and carried it out by his " adhesive clamp" and hot irons. I wrote to him at the time, that, if it answered for adhesions and omentum, it ought to answer for the pedicle. And I might have tried it; but my first trial on a piece of omentum was unsuccessful, and I did not repeat it. But latterly Mr. Baker Brown has published so many cases in which he has successfully secured the pedicle on Mr. Clay's principe of combining pressure with the cautery, that I have tried it in five

cases.

Three of the patients recovered, and two died. In three, the

cautery was alone sufficient to stop all bleeding. Two of these patients. recovered, and one died. In two others, on opening the clamp, consid erable vessels bled, and ligatures had to be applied. One of them recovered, and the other died. I shew you here Mr. Clay's "clam," and the instrument as modified by Mr. Brown. It will be for further experience to determine whether, in cases of short pedicle, the ligature with the ends cut off short, or the écraseur, or the combination of crushing and cauterisation, is the more successful practice. For a long pedicle, I still prefer the clamp. It has been used before you in two cases, and you will hear the result. I feel very hopeful that it will be favourable in both cases; for Dr. Waters, as well as the surgeons, Messrs. Brittain and Weaver, to whom you are indebted for the opportunity of witnessing this operation, still new in many of our hospitals, have done everything in their power to insure success-have placed separate rooms at the disposal of the house-surgeon, Mr. Karkeek, who will add his earnest and hearty endeavours in a good cause; and, with such pure air to assist us as we sadly want in smoky London, and which comes here direct from the Welsh hills which you see from the windows, I trust the attempt to save the lives of the two women will prove creditable to surgery.—British Medical Journal.

THREE CASES OF COMPOUND DISLOCATION OF THE ASTRAGALUS, WITH REMOVAL OF THE BONES.

By T. T. GRIFFITH, Esq., Wrexham.

The chief interest and value of the following cases, is that they illustrate and confirm the clear practical rules laid down by Mr. Turner, in his valuable monograph on "Dislocations of the Astragalus" published in the eleventh volume of the Transactions of our Association. The rules of practice there recommended are logical deductions from a thorough consideration of the subject in its anatomical, physiological, and pathological relations, and have received the sanction of the principal surgical authorities which have subsequently treated of this branch of local injuries; and I consider myself most fortunate in having read Mr. Turner's paper before meeting with a case of serious accident to the astragalus.

One important fact is that in compound complete dislocations of the bone, reduction may be considered impracticable from the almost immediate contraction of the muscles acting upon the os calcis and foot generally, bringing the tibia, fibula, and calcaneum into more or less

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close and firm contact, leaving no space for restoring the astragalus to its wedge-like position within the joint. Then follows, as a conclusion, the necessity for removing the bone at once, to prevent the constitutional disturbances so likely to arise from its presence as a foreign body, detached more or less from its vascular and vital connexions, and liable to a long process of caries and suppuration.

I. Case of Complete and Compound Dislocation of the Astragalus forwards and outwards: Removal of the Bone: Death from Tetanus. David Roberts, aged about 40, of spare habit and of nervous temperament, suddenly leaped from a horse which started. He alighted on his feet, stood for a moment, and then fell. On visiting him, I found the astragalus of the right foot completely dislocated forwards and partially outwards through an extensive wound reaching across the instep; it remained attached to the ankle only by a few ligamentous bands. Upon dividing these the bone was at once removed. There was neither fracture nor displacement of the tibia or fibula. It was at once apparent that reduction of the astragalus would have been impracticable, and here I felt the great value of the rules laid down by Mr. Turner, deduced from sound physiological and pathological principles, as to the treatment such cases required. On examining the astragalus, I found that a small portion had been broken from the posterior and inner angle, and doubtless restrained in the joint by ligamentous union. The same circumstance occurred in another case; but there the fracture was through its posterior and outer angle. In both cases I deemed it best to allow the broken off portion to remain, hoping that its connection with living parts might secure a continuance of its own vitality. The wound was closed, and the limb laid on its outer side on a leg splint with a foot-piece. As far as the foot and wound were concerned, all went on favourably, and the general constitution was less disturbed than might have been expected, but on the fifth day symptoms of tetanus appeared and continued rapidly to increase till they ended in the patient's death. I think we may fairly exempt the mere removal of the astragalus from participation in causing the tetanus, but rather refer this untoward event to the laceration and contusion of the soft parts, and more particularly of those fibro-ligamentous structures through which the bone had been so violently forced.

II. Case of Compound Dislocation of Ankle-joint, with Complete Fracture of the Neck of the Astragalus, and Extension of the Bone. On August 14th, 1854, I was sent for to Wynnstay by Mr. Richard Roberts to see a patient, who had received a serious injury to his right foot. Edward Redington, aged 20, in perfect health, a helper in the stables,