No. 1864.

MAY 21, 1859.

ROYAL COLLEGE OF PHYSICIANS.

Troonian Lectures,ON

INTESTINAL OBSTRUCTION.Delivered at the Royal College of Physicians.

BY WILLIAM BRINTON, M.D.,FELLOW OF THE ABOVE COLLEGE; PHYSICIAN TO THE ROYAL FREE HOSPITAL;

LECTURER ON PHYSIOLOGY IN ST. THOMAS’S HOSPITAL; HONORARYFELLOW OF KING’S COLLEGE, LONDON, ETC.

LECTURE II. -(Concluded.)THE CHIEF VARIETIES OF INTESTINAL OBSTRUCTION.

Rernaining varieties ; share of obstruction in them. Obstructionof small and large intestine contl’asted. Two (Jl’OUPS of ob-structions chiefly affecting these segments. First group, :structions chiefly affecting these segments. First yroMp .’

bands; diverticula ; vermiform appendices ; rents in mesen-ter; gall-stones. Second group : strictures; twistings ofbowel.

IN passing on to consider the remaining varieties of intestinalobstruction, it may be premised that while, in the precedinglesion, the share taken by obstruction is, in the main, subor-dinate to that of inflammation, obstruction now becomes para-mount ; so much so, that the whole features of the maladyseem chiefly dictated by (1) the locality, and (2) the nature, ofthe obstacle. And the practical importance of the first of thesetwo modifying causes is enhanced by the fact, that there is aclose clinical connexion between them both. The several

varieties of obstruction under discussion, though they have noessential relation to either of the two divisions of the intestine,do really affect them with so very disproportionate a frequency,that, as we shall see, strictures and twistings obstruct chieflythe large intestine; bands and peritoneal lesions, the smallintestine. Nor is the practical value of this connexion, as arule, at all incompatible with the scientific value attaching toits exceptions ; which, for example, not only teach us, on theone hand, how the symptoms of obstruction are modified bystrictures of the canal, apart from their situation, or by bandsof adhesion, apart from the segment of intestine they maychance to strangulate; but conversely, how the mere situationof the obstacle, independently of its situation, influences thewhole course of the malady.An analysis of this kind shows that obstruction of the small

intestine is characterized by the following peculiarities.Pain is more early and severe; and, until distension brings

the affected bowel against the abdominal wall, is less distinct inits reference. The first of these circumstances is probablyto be referred to the more abnormal character of distension inthis part of the canal, the scanty contents and rapid transit ofwhich are contrasted with the more voluminous and solid con-tents of the large intestine, and with their slower progressthrough its cavity.The umbilical seat of the pain caused by lesions of the small

intestine is, I suspect, connected with the homologies (orrather with the development) of this segment of the canal.Vomiting is also more early, severe, and frequent: characterswhich are ascribable, partly to the same law of distension,much more to the pathology of this act itself; which, as Ihave endeavoured to show elsewhere,* occurs in lesions of thevarious parts of the alimentary canal with a facility varying(caeteris pa1’ibus) with the closeness of their alliance to thestomach, the central organ of this expulsive process. Fseoal

vomiting is also a much more prominent symptom. For, asstated in the preceding Lecture, the rapidity of its access isinversely as the length of intestine intervening between the

- - - - - .

* Diseases of the Stomach, p. 63.

obstruction and the stomach. While the peculiar arrangementof the ileo-caeoal valve postpones this symptom to such a periodof an obstruction in the colon, as is even later than the lengthand width of the additional segment of bowel to be traversedby the reflected contents woald suggest. And it must not be

forgotten, that in any wide clinical observations on obstructionin these two parts of the intestinal canal, the frequency withwhich this symptom ;s present, must follow the same rule asits speediness. For whatever defers faecal vomiting in mostcases, will, in many, prevent it altogether; by allowing thelater access of the symptom to be anticipated by the death ofthe patient. A similar uncertainty seems to be traceable iiithat curious intermittence (or even cessation) of this symptomwhich has been sometimes seen in fatal obstructions of thelarge intestine.The quantity of the urine is another symptom on which

great stress has been laid as a means of diagnosis. The rule(generally attributed to Dr. Barlow) propounded respecting itstates, that the nearer an obstruction is to the stomach, thesmaller is the amount of urine passed by the patient. And theexplanation of this rule refers it to that diminution of intes-tinal surface for the absorption of fluid ingesta which the ob-struction brings about. Even while questioning the accuracyof both the rule and the explanation, I cannot but regard it asan interesting example of valuable clinical observation, stop-ping short at a half truth, but pointing to a whole one. Thatit has little direct value, numerous examples might be adducedto prove:-cbstructions near the end of the large intestine, withscarcely any urine passed during many days; obstructions highup in the small intestine, with the urine tolerably copious;and, lastly, obstructions in which the urine, at first suppressed,gradually attained a considerable amount as the disease ad-vanced, or, conversely, was only suppressed towards the veryclose of the case. And as regards the above explanation, Ishould substitute for it, on grounds strictly pathological, atleast three or four contingent causes ; among which suppressedor restricted absorption by the bowel would find but a verysubordinate place. That it has no share whatever in causingsuch a diminution of urine would be a hardy assertion. Butcontrasting the copious vomiting seen in some of these caseswith the moderate ingestion of fluid often accompanying it,and with the enormous quantity of liquid further found dis-tending the bowel after death, it does seem to me, that theeffusion of such vast quantities of liquid from the affected tubeconstitutes by far the most obvious and simple cause for adiminished secretion of urine, especially when viewed by thelight derivable from the analogous diminution seen in Bright’sdisease and Asiatic cholera-in which we may often notice thesame mucous surface acting vicariously to the kidney, on theone hand; and depriving it, by a similar process of effusionand expulsion, of the watery materials which conditionate itsfunction, on the other.

Hence, without denying that the obstructed intestine maybe seriously damaged, as regards its absorptive function, I con-tent myself with asserting, that all proof of an extreme degreeof such injury fails us. And while I believe that the amountof vomiting is the truest symptomatic correlative of the dimi-nution of urine, I should not be disposed to lay too much stresson even this connexion, close as an analysis of cases shows it tobe. For though it roughly measures the amount of intestinaleffusion, as well as the proximity of the obstruction to thestomach (the organ of its exit), and would account for more ofthe urinary variations observed than any other explanation, it,too, affords no single or satisfactory rule. On the contrary, itwould seem that violence of the general fever, or of the local in-namma.tion, the pain of micturition, when the bladder is in-volved in peritonitis, and (I would almost add) mere collapse;-can all, by turns or in combination, greatly diminish thequantityt of urine passed during intestinal obstruction.To that general contrast in the rapidity and severity of the

disease in the two portions of the intestine which is suggestedby the above details, we may add some signs specially belong-ing to obstruction of the large intestine. Flatulence, in theshupe of violent borborygmi, and extreme tympanitic distensionof the bowel, unattended with any expulsion of gases per anum;and tenesmus; are phenomena belonging too strictly to thephysiology of this segment of the digestive canal to demandany further explanation here. The mere anatomy of the largeintestine-that is to say, its size and situation-often affords afurther means of distinction ; especially when the information

Thus, in obstruction of the small intestine, all other symptoms may beanticipated and prevented by collapse, destroying life in a few hours.

asI Some of these would, of course, rather be instances of concentration asregards its essential constituents.

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thus suggested is compared with that obtained by a careful ex-ploration of the bowel per anum with the finger, a bougie, ora full enema. The size and situation of the tumour formed bythe distended intestine is, however, often equivocal. Forwhatever its original seat, it gradually usurps a large portionof the cavity of the belly; and, even if small intestine, uitimately acquires a diameter easily suggesting that of the colon. *Indeed, as regards its locality, there is a further source ofambiguity. To say nothing of obstructions originally occupy-ing the cxcum, the structure and arrangements of this part oftencause it to bear the brunt (as shown, not only by its dispropor-tionate distension, but even by its inflammation and rupture)of an obstruction in some distant part: for example, in thesigmoid flexure. While we shall find that the right iliac region,which is thus a common seat of special pain, tenderness, andswelling, in obstructions of the large intestine, is also by farthe most common locality for the same prominent symptoms inthose varieties of obstruction which chiefly affect the smallintestine,! as well as in the more frequent kinds of intus-susception already noticed.

In the promiscuous collection of necropsies I have made, theremaining varieties of obstruction may be arranged in twogroups, which refer chiefly to the small and large intestine re-spectively, and have to each other proportions nearly as 3 to 2.In the larger group, which includes obstructions produced bybands, adhesions, diverticula., gall-stones, and lesions of themesentery or other peritoneal structures, the small intestine isthe seat of the obstacle in nearly 95 (94’53) cases per cent. Inthe smaller group, formed by strictures or tumours, and twist-ings of the bowel and mesentery, the large intestine attains aconverse (but less prominent) disproportion of nearly 90 (87.36)per cent.The bands and adhesion, together amounting to 42} per cent.

of the larger group, are only distinguished from each other bythe length of that new deposit of which, in its various grada-tions between lymph and fibrous tissue, they are constituted.More than 80 (81’13) per cent., however, possess the extensionentitling them to the former name. The contingencies of ute-rine activity seem to render them somewhat more common inthe female (as 15 to 13); a circumstance perhaps connectedwith a slight difference in the age at which they conditionateobstruction (35 to 37: average for both sexes, 36 years.)

FiG. 16.

Loop of intestine strangulated by a band fixed at both endsw lUebel1tery.

i, intestine, of which the mesentery, m 7r, gives origin toc c, the strangulating band.

a, distended intestine above,b, contracted intestine below, the double strang-lation cor-responding to c c.

Their attachment is generally (75 per cent.) to mesentery oromentum (as 4 to 1 )-(as in a, b, Fig. 17): often (18 per cent.) byboth extremities (Fig. 16): oftener (34 per cent.) by one end to Ithe free margin (or some other part) of the bowel (as in a, Fig. 17). ).Rarely (1 case in 5) are they fixed to the large intestine: andit is still more (thrice as) infrequent for them to unite two Ipoints of bowel, t In about 32 per cent. of the female cases, I

they adhere by one end to some part of the internal organs ofgeneration. The small intestine is the seat of the obstruction ’,they cause in about 93 per cent. General or local peritonitis,and the diseases to which these inflammations are incident(such as typhoid fever, dysentery, &c.), often figure in the pre-vious history of the patient; but seem (as the details of the

* The healthy colon, though, not the distended one.t This uncertainty would be greatly guarded against by recollecting, that

such iliac symptoms occur in different stages of the obstruction of these twosegments.i The epiploic a-’nencas’es are rarelv (1 ;n 16) their origin.

lesion independently suggest) to account for only the minorityof cases.The formation of these bands from soft inflammatory lymph

is evidently by a process, in which a pasty mass is sometimeselongated gradually by the mere movement of one or both ofthe two viscera or surfaces it unites ; sometimes continuallydrawn out by such a gentle traction on its fixed extremity,while it is as constantly lengthened by new deposit at the otheror inflamed end. Offering no essential distinction from thesimilar processes witnessed in the serous covering of thestomach,* liver, heart, and lung, the wider range of the intes-tines in their containing cavity, as well as the greater com-plexity and independence of the movements of their varioussegments, sometimes bring about curious results (as in Fig. 17;)which are, however, easily explained by the above statement.

FIG. 17.

Loop of intestine twisted so as to be strangulated by twobands of adventitious tissue. (From a preparation in theMuseum of St. Thomas’s Hospital.)

o, omentum, giving origin to two bands ; passing, a, tothe free margin; b, to the mesentery, m, of a loop ofintestine, i.

Of these bands, a only completes the noose; b strangu-lates the bowel in two places, c and d, the first mostseriously. The bowel appears to have dropped intothe noose from above.

In another sub-variety of this group, the obstruction is formedby the cord-like tube of a dive2-ticuluq)t ilei, or by the verrniforrnappendix, and constitutes about 28 per cent. of the group; theabnormal and the normal tube having, however, the relativefrequency of 2 to 1.The anatomy of the dit’el.ticulu7n, as a relic of faetal develop-

ment, has been so well treated of by Meekel and Struthers,that I need not dwell upon it here. Originally a process of theumbilical vesicle, it forms a tube, leaving the ileum a littleabove the caecum at an acute angle, and passing to a variabledistance towards the navel, which it sometimes joins. Theobstruction it causes seems limited to the small intestine. Andit is, in nearly 80 per cent., an adhesion of some part of thetube (usually its free extremity) that completes the strangulatingnoose: the adhesion attaching it to the following parts in dimi-nishing order of frequency-the abdominal wall, the mesentery,the small intestine, the navel, the omentum, and the largeintestine, tThe obstruction caused by the vermiform appendix suggests

somewhat analogous rules. Strangulating the large intestine, inspite of its proximity, not oftener than once in 14 such cases;and always adherent (usually at its tip) to form the noose;its attachment, oftenest to the mesentery, declines throughsmall intestine, large intestine, and ovary, to the omentum,and the abdominal wall generally. Proximity and relativemovement are the causal relations here suggested. Ageseems almost to correspond for both; their youth (about 22years) suggesting (however vaguely for the lefoions of the vermi.form appendix) some developmental origin. Sex seems onlyto differ in the case of the diverticula; the obstructions pro-duced by which appear (like intus-susceptions) to be from twiceto thrice as frequent in the male as in the female.Apart from these facts, there is little in the pathology of the

four preceding kinds of obstruction calling for notice. The

vague and casual suggestions of peritonitis, or of previousobstruction, sometimes afforded by their history, have scarcelyany practical bearing on their diagnosis during life. The painwhich ushers in their obstructive results is equally uncertain;and seems not only to be, on the whole, but moderate in in-tensity ; but where severe, to be quite as often referable todistension of the bowel, as to hypersemia or inflammation, suchas cause the characteristic pain of the bowel when impacted,either by intus-susception in its own coats, or by protrusion

* Compare "Diseases of Stomach," p. 162, et pa8im.t Compare Aleckel, Anat. Path., vo].i.,p.555; Struthers’ Anat. Obscrv.;

also Author’s article, " Intestine," Cycloptedia of Anatomy, Supp., p. 4,04.

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through a hole be mesentery. In this respect they seemakin to ordinary strangulated hernia. The duration of the

malady is on an average about six days: an estimate which willapply to the other varieties of this group of obstructions, withscarcely any alteration. The rarity of any spontaneous resto-ration of transit appears at a glance when we consider thecircumstances necessary to effect it: the exactness of coaptationand of gangrene necessary to a fistulous communication betweenthe segments of bowel above and below the obstruction, on theone hand; or the hazards which attend the formation of an ab-normal intervening cavity, on the other.The obstructions caused by the compression of a fold of pe7i

toneum constitute about 2 L per cent. of this group. Of this 21,ruptures of the mesentery form about 15 or 16, or three-fourths;the average age being 34i years, and the sex at least two malesto one female ;-a fact doubtless connected with the violentexertion to which most of them are immediately traceable.The intense pain and haemorrhage which often attend the acci-dent, and usher in the symptoms of obstruction, are equallyexplicable. The other peritoneal causes are too various andinfrequent to repay notice : obstructions from protrusion ofbowel through a hole in the ragged omentum (23 per cent.), ),through a persistent urachus, through the suspensory ligamentof the liver, through the muscular coats of the bladder, andthrough the meso-colon, are alike occasional.

Obstructions by gall-stones form about 8 per cent. of thisgroup. Their average age is 57 ; their sex, four females toone male. So far as I know, the stone always enters thebowel by direct ulceration, through the coats of the apposedgall-bladder and duodenum, and not down the cystic duct;a fact sufficiently explained by the large size such a stone mustpossess, in order to become impacted in the intestine at all.It is often the only gall-stone present; indeed, is often a com-plete cast (oval or pear-shaped) of the gall-bladder itself; or isthe severed half or third of such a cast. These details are

practically important, since they suggest (what, indeed, expe-rience confirms) that, while we may always expect, in the pre-vious history of such cases, evidence of the hypochondriacinflammation and ulceration by which the stone enters the duo-denum, we must not expect to find equally constant evidenceof the ordinary paroxysms of pain and jaundice which attendthe passage of gall-stones down the duct. In some of thesecases, indeed, the enormous gall-stone which causes the ob-struction seems to be the first, as well as the last, the unfor-tunate patient is ever troubled with. Once free in the duo-denum (which, by the way, has been fatally strictured by thechronic inflammation thus set up, long after the stone has leftthe body), it passes down the small intestine, in its course to-wards extrusion from the bowels. Rarely, it becomes saccu-lated in the intestinal walls, and remain thus for years with-out affecting the intestinal calibre. In a majority of cases, itis in the jejunum or upper part of the small intestine thatthese stones become impacted; but about one in every five seemsto be stopped by the constriction of the ileo-cascal valve. Howmany of them safely traverse the whole canal it is impossibleto conjecture; but we are entitled to suppose that the success-ful fugitives are at least half as numerous as those arrested;which latter, by the way, rarely exceed 2½ inches in theirlongest diameter.

I have never seen a case exactly of this kind; but venture tohope that the information thus briefly put together will renderit henceforth easy to distinguish them from all other obstruc-tions. Taken in conjunction with the duration and intensityof their premonitory symptoms; their great pain; their inces-sant and severe vomiting; the frequent and intermittent attackswhich sometimes seem to indicate their being obstructed hereand there in their slow passage down the small intestine; andthe rapidity with which the last attack sometimes ends indeath; they constitute a form of obstruction which, both fromits proximity to the stomach, and its other circumstances, ex-hibits features, to say the least, unusually suggestive of a cor-rect diagnosis of its cause. While, pathologically, they havegreat interest from the fact, that the diameter of the obstruct-ing gall-stone, as contrasted with that of the intestine aboveit, seems to indicate either some active muscular contractionat the obstructed part, or some dilatation above such as requiresfurther elucidation. *

* It is probable that the distension produced by the obstruction is oftenincreased by the cadaveric chang’es of the intestine and its contents. (Com-pare the author, "On Ulcer of the Stomach," p. 213.) But even allowing forthis increased distension in the necropsy, I should be disposed to regard theobstruction as attributable, in part, to active contraction; to which, however,considering its provocation and its object, I should hesitate to apply the termflF spasm."

The strictures and twistings which form the second group,affect the large intestine in proportions of 92 and 76 per cent.respectively; on an average of both, 87’. per cent.The strictures are about 73 per cent. of the whole group.

But I have found it impossible to exclude from this class sometumours probably of malignant nature and of external origin;and can only conjecture that this excess would be compensatedby the cases in which twisting is produced bv a tumour droppingover the bowel or its mesentery. As regards the sex of thesecases of stricture, the males are to the females as 3 to 2; andtheir average ages, 43 and 46! respectively, afford a mean forboth sexes of 44 years.The frequency with which stricture causes fatal obstruction

in the several parts of the large intestine is as follows. Of 100such cases, 4 are in the cæcum; 10 in the ascending colon; 11in the transverse colon; 14 in the descending colon ; 30 in thesigmoid flexure; 30 in therectum. In an estimate of the patho-logical liability of these different parts, it is well to bear in mindthat while the shortness of the cseoum renders the above numbertoo small, the greater length of the sigmoid flexure renders itunduly large; so that, for equal surfaces of intestine, there is amuch more uniform increase in the liability of the bowel tothis lesion as it approaches the anus. But a more practicalview may be summed up by the statement, that to bisect thetransverse colon in the median line of the body would dividethe large intestine into two segments, of which the left one isvisited by this form of obstruction four times as frequently asthe right.As regards its symptoms, two points only need be added to

what has already been said respecting obstruction of the largeintestine generally. One is that, in a majority of cases, thereis a history of increasing (sometimes intermitting) constipation,gradually deepening into downright obstruction during themany months (or even years) which precede the last attack.Sometimes, indeed, the patient’s life has already been placedin imminent jeopardy by foregoing obstruction. Sometimesdiarrhoea, or haemorrhage are the chief premonitory symptoms;especially where the stricture is caused by a cancerous excre-scence. The other is the duration of the malady, which (evenincluding several cases where the operation for relief of thedistended bowel seems to have been deferred to a period whenit probably hastened death) shows an average of 23 days ofcomplete obstruction prior to this event. The aid to diagnosissometimes afforded by a digital or instrumental examinationper anum, or by the shape and size of the faeces, requires nospecial notice.The twistings of the bowel, which, as frequent causes of ob-

struction, were first set in their proper light by the researchesof Rokitansky, seem scarcely to be influenced by sex, either asregards their number, or the age at which they occur. If any-thing, they are a trifle more common in the male (13 to 10).In both sexes indifferently, the average age is a high one (54years); a feature in which this variety of obstruction is curiouslycontrasted with all the preceding. In nearly one-half of thesecases, the sigmoid flexure is the seat of the lesion. The trans-verse colon, however, seems less subject to it than the ascend-ing colon or ileum, and scarcely more so (really less?) than thecaecum. In respect to their causes, these twistings seem todiffer materially in different cases: tumours, abnormal laxityof meso-colon, and (still more frequently) hernial displacementsof other parts of the canal, are the circumstances oftenest foundin connexion with them; and, taken in conjunction with thegreat age of their subjects, go far to suggest a failure of peri-stalsis as forming at least a frequent immediate cause of theiroccurrence. Their symptoms may be usefully contrasted withthose of obstruction from stricture. The diminished durationof the process (for example) which is reduced from 23 to about9 days, exactly corresponds with the absence of those longand marked premonitory symptoms which, in many cases, notonly precede obstruction by stricture, but are associated with.an effort of Nature to ward off this fatal event. Indeed, sometraces of a similar contrast may be seen in these twistingsthemselves; those due to abnormal laxity of the sigmoid meso-colon being not only associated with a longer duration, andmore gradual approach, of the obstructed state, but often show-ing a degree of chronic hypertrophy and dilatation such as con-cnrs with these symptomatic characters. In most cases, how-ever, the twistings are distinguishable from the strictures, notonly by the absence of this tendency to the chronic character,but by an amount and rapidity of inflammation, which stillmore specifically accounts for the difference, and even permitssome of the marked characters imparted to the symptoms ofobstruction by its situation in the large intestine, to be obscuredby the circumstances which thus regulate the nature and the

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rapidity of its access. For instance, the obstruction of thetwisted colon often destroys life more quickly than that of thestrictured ileum; which, again, both as to its premonitorysymptoms, and its hypertrophied state, offers a close and in-structive parallel with the strictured colon.

Here, then, I end this brief survey of the chief varieties ofobstruction from a diagnostic point of view-a survey fromwhich I have reluctantly excluded many curious details, as wellas all citation of the numerous interesting cases which aboundin the records of the obstructed state. I can only hope, thatthe conclusions I have offered, based as they are on a careful

analysis of a large proportion of the facts which have hithertoaccumulated towards the study of this important group of

maladies, will help to justify the proposition which seems tome independently deducible from the narrower (but deeper) in-

formation furnished by my own personal experience-namely,that even in the earliest stage of an intestinal obstruction, wemay, in most instances, recognise both its situation, and thegroup of obstructions to which it belongs.

Some of the chief statistical facts of the preceding Lectur&1are conveniently summed up by the following Table :-

INTESTINAL OBSTRUCTIONS (EXCLUDING HERNIA).

Frequency, 1 in 280 deaths (from 12,000 promiscuous necropsies).Varieties, relative frequency per cent. (from 600 necropsies of obstruction).

ERRATUM.-From p. 479, line 24, in the preceding number, omit the words "cæcum and colon."

ON AMPUTATION AT THE WRIST-JOINT.

WITH ILLUSTRATIVE CASES.

BY NATHANIEL WARD, ESQ., F.R.C.S.,ASSISTANT-SURGEON TO THE LONDON HOSPITAL.

THE rarity of this operation renders valuable any evidence asto the best method of performing it, and its consequent results.The following communication can, therefore, hardly be withoutinterest to the surgical inquirer :-CASE 1. -A sugar labourer, aged twenty-five, was admitted

into the London Hospital with a severe injury to the hand.He had a short time previously been heedlessly passing a loafof sugar forward to the cutting machine, an instrument revolv-ing like a wheel, and connected with the steam-engine of theestablishment in which he was working, and set with knivesor rather broad cutting-pieces of iron passing from the centreto the circumference of the instrument, and with their edgesturned outwards. The right hand was drawn in with the mat-ting that protected it, and was chopped up. In consequence ofthe cleanness of the cuts, the patient lost a considerable quan-tity of blood prior to admission. When he came in, the onlypart of the hand that was left was the first row of carpal bones,and a bare fragment of the os magnum at the back part. The

pisiform bone, by-the-bye, was separated from its connexionwith the cuneiform, and lay in contact with the soft parts thatremained about the wrist-joint. The disarticulation betweenthe two rows of bones was so clean, that one might almost havethought that the scalpel had been at work, and could be ex-plained only by the dragging and cutting manner in which theinjury had been effected.

I disarticulated the scaphoid, lunar, and cuneiform bones

from their connexions with the radius and lower surface of theinter-articular fibro-cartilage, and managed to obtain a notvery bad flap from the remnant of the palm, and which wasbrought up over the radius and fibro-cartilage, and connectedby suture to a short dorsal flap. Strips of wet linen were ap-plied.The man remained under treatment nine or ten weeks, and

was then made an out-patient. The constitutional treatment

immediately after the operation consisted in the use of generousdiet, with from twenty to thirty ounces of wine daily, and quinineand iron. Hospital gangrene was rife at the time of the opera-tion, and three weeks at least elapsed before the wound put ona healthy granulating aspect, occasional bleedings during thisperiod having taken place. The threatened gangrene, how-

ever, was checked by the daily application of nitrate of silverand water-dressing, and the limb being kept perfectly quieton an angular splint. Five or six abscesses formed betweenthe flexor tendons of the former, and when he left the hospitala small sinus, resulting from one of them, remained. A goodstump resulted.

, This patient called on me six months after the operation.The stump was perfectly firm and painless, and the rotatorymovement of the radius on the ulna ranged from fifteen totwenty degrees.CASE 2.-A lad, aged twelve, robust, and in excellent health,

was admitted with the hand so lacerated and fractured as to

put aside all hope of saving it. He had been assisting a manto turn the handle of a large wheel which communicated witha smaller wheel by a flat strap passing over the circumferenceof either. The boy was resting for a short time, when hethoughtlessly placed his hand between the strap andIthe small

I wheel, and thus sustained the injury. Although the injurywas very extensive, there remained sufficient of the soft parts