746 bone, and hammered cautiously with a mallet in an inward 1 direction till felt to be in the softer central part of the bone, when it was withdrawn and driven in towards the anterior surface of the bone in the same plane, then towards the posterior surface. On withdrawing the chisel and pressing the limb outwards with the line of incision fixed as the fulcrum, the hard bone on the inner side was easily snapped and the limb could be bent inwards and rotated apart from the upper fragment; it

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... uld not, however, be drawn down away from it, nor could it be bent much outwards. This appeared to be due partly to the firm contraction of the muscles and tissues on the inner side of the leg and partly .to the locking on the upper fragment. A wedge-shaped piece of bone was therefore sawn off this, and a probepointed curved bistoury, passed into the wound round the anterior and then round the posterior surface of the bone, was made to cut through the fibrous tissues around it as far as was deemed safe without endangering the large vessels. Considerable traction being then made on the foot, the position of the limb judged by its inner aspect was found to be greatly improved, while the traction was maintained, though the upper fragment still remained in its previous position and its lower end could not be forced inwards, owing apparently to the contraction of the glutei. No spray was used during the operation, but the wound was constantly washed out with a 1 in 1000 perchloride of mercury solution, and after the operation about I three drachms of a saturated solution of iodoform in ether was syringed into it; the wound was dressed with lint soaked in carbolic oil and the limb put up in a Maclntyre splint. The following day the morning temperature was 98 2°, evening 100°, after which it never rose above normal during his stay in the hospital. The day after the operation the limb was taken out of the Maclntyre splint and an extension apparatus fastened to it, ten pounds weight being used, and the foot of the bed raised four inches, the heel being one inch off the bed, and the calf steadied by sandbags. The wound was syringed daily with iodoform dissolved in ether and dressed with carbolised lint; there was very little discharge from it, and it healed in three or four weeks. On Jan. lltb, elastic traction was commenced on the upper fragment by a broad piece of adhesive plaster fastened round the thigh just above the wound, both ends of it being carried under the left thigh and attached to a stout indiarubber tourniquet fastened to the left side of the bed, and attached when stretched so as to get considerable elastic extension inwards and slightly backwards on the lower end of the upper fragment. On Jan. 19th the foot extension weight was increased to 131b., 2 or 31b. of which were probably taken off the limb by the support of the sandbags ; the foot of the bed was further raised to eight inches. On Feb. 14th the sandbag supports were discontinued, so as to get the entire weight for extension. On March 25th the limb was examined with gentle movements. There appeared to be no adhesions in the hip-joint. Union had taken place between the chiselled ends of the bone, the limb moving as a whole up to the hip-joint. The adhesions were firm throughout the knee-joint, with thickening around it. There was a considerable amount of hard callus at the seat of fracture, and the limb appeared nearly straight, the femur operated upon being straighter than the other one. Extension and lateral traction were continued as before. April 25th : On examination, the right leg was found to be only from an inch and a half to two inches shorter than the left leg, and quite straight ; the bony thickening about the seat of operation had diminished, and the femur felt quite sound and firm. The patient could move the right leg off the bed nearly as well as the left. The extension apparatus was discontinued. On May 1st the patient was anaesthetised with the object of breaking down the adhesions about the knee-joint and restoring its mobility ; but, on partially ilexinar the knee, the patella still remained fixed on the condyles of the femur, and a depression formed below its lower border, with rapid effusion in the neighbourhood below the patella. It was found impossible to move the patella from its adhesions to the femur directly, and further force only increased the rupture of its ligamentous union to the tibia. The patient was therefore put to bed and evaporating lotions applied. Within a fortnight the swelling had subsided, and he could lift the foot off the bed with comparative ease. For the next two or three weeks he got about on crutches, after which he was allowed out, using two sticks, the limb being rather less than two inches shorter than the other. He was discharged on June 10th. His report the following November was that he could walk comfortably several miles without a stick though he generally uses one. The lameness seen in his gait is not very noticeable considering the shortening. , aged thirty-five years, a master plumber, of robust frame, good family history, and of a healthy constitution, active and temperate habits, came under my care on Feb. 1st, 1889, suffering from laryngeal catarrh, attended by the ordinary symptoms. No especial fever or disturbance of the general system beyond increased huskiness of the voice and tickling of the fauces, supposed to have been brought on by cold whilst working overnight in a ship's hold. I ordered him to bed, and attended him until the 24th. On the 18th, however, he complained of haemorrhoids. I did not examine for them, but simply ordered hot fomentations and a dose of castor oil, presuming that they were due to costive bowel and his lying up. On inquiry the following day they were better, and I heard nothing more of them during my attendance. On March 4th, however, he came to my consulting room, and informed me that he had taken another bad turn with the piles" three days whilst at the closet felt something pricking at the back body, and, putting his hand down, drew from it a piece of stick." This was an inch and a half in length, with a sharp point, and most resembled a spike from a hawthorn tree.