surgeons who dreaded chloroform least, and gave it even in dressing surgical wounds, were more unsuccessful than those who dreaded it most. Professor Nathan R. Smith, of Baltimore, has written an article that expresses my views of these agents. In an article on the "Toxical Effects of Chloral," in the January number of the London Lancet, he says:

"Chloroform, we know, when inspired, exerts its influence upon both brain and heart. In the numerous cases in which it has caused death by inspiration this result has been produced by its interrupting the circulation. Secondly, it appears, when given in small doses and continuously for some time, to induce a form of toxæmia similar to that caused by the continued administration of ergot. If chloroform, developed in the blood from chloral, is productive of such disastrous effects, primary and secondary, can the direct inspiration of chloroform be as innocuous as it is thought to be? The profession are sufficiently aware of the fatal primary effects of chloroform in numerous instances. It has undoubtedly caused death in many cases in which it has been given with every caution in regard to quantity and mode of administration-in cases, too, where there existed no malady of the brain or heart to forbid its use. In some cases it has been administered fatally in which it had been previously breathed with good result. But I would more especially call the attention of the profession to the chronic poisoning of the blood which I believe results from its free and repeated use. I have administered chloroform perhaps as often as any other surgeon in America, both in hospital and private practice, commencing its use from the time of its discovery and its first application as an anæsthetic. Indeed I have been constrained to use it in many cases in which my judgment was adverse to its employment, for such is the overweening confidence in its effects that many patients refuse operations except under its influence. But the more I have used chloroform the less has my confidence become in its innocuousness. When I compare the results of my operations performed before anæsthetics were employed with those performed during the last twenty-two years by the aid of chloroform, I am satisfied that unpleasant secondary results were less frequent during the first period than they have been under the use of that agent. I allude to secondary hemorrhage, pyemia, erysipelas, and hospital gangrene. Whoever will take the trouble to look over the medical journals and retrospects of the last ten years will discover that pyemia or septicæmia occupies far more space in the surgical records than it did before anæsthetics were so generally employed. When chloroform is administered during the period of an hour or more, as it frequently is, it undoubtedly enters copiously into the circulation, not only powerfully impressing the brain and heart, but modifying the constitution of the blood and the function of the capillaries."

We all understand that in the constitution of bleeders we are to suspect some dyscrasia. In severe hemorrhages that occur independ

ently of local trouble, we are careful to look after the urinary secretion, and to examine searchingly for albuminuria. Indeed in all cases of troublesome post partum hemorrhage, when the bleeding recurs repeatedly after the expulsion of the placenta, we will find albuminous urine, or at least such is my experience. We who live in yellow fever cities and malarial districts know how often hemorrhage from mucous membranes are produced by the poisons that develop these fevers. Indeed every educated physician appreciates how prone febrific poisons are to beget a hemorrhagic tendency. This reasoning clearly foreshadows the opinion that in all the three cases of secondary hemorrhage, blood poison was the immediate cause. In both Rupert's and Askew's cases, I believe chloral had something to do with it. The poisoned condition of Bleck's system was fully evinced by the sooty regurgitations from the stomach, and the free black vomit. I am convinced that the calomel saved his life, and I would do violence to my feelings were I to suppress my indebtedness to Dr. Stone of New Orleans for his valuable hints in regard to the use of calomel in such cases. This case beautifully illustrates how a poisoned condition of the blood, from other causes than yellow fever, may produce black vomit. The pyæmic condition of his blood favoring hemorrhage furnished the bleeding through the tissues of the stomach when the mucous membrane was denuded of its epithelium, caused by the vomiting. It poured out guttatim and was acted upon by the gastric juices, precisely as we have it in yellow fever. Indeed, these septic poisons that we have in surgical cases may produce hemorrhages precisely as we see them in broken down constitutions of the system from other causes, whether scrofulous, scorbutic, or febrific. My friend and colleague, Dr. Owen related several years ago, to our local society, the history of a patient of his that had thrown up black vomit from the bite of a rattlesnake, thus showing how this hemorrhagic tendency is begotten by septic agents. After the second amputation in Rupert's case I secured the femoral artery with silver wire, cut off both ends short, and managed the case as has been described. The wire has never given him any trouble.

One of the interesting points in Mr. Askew's case was the pathological changes that had taken place in the diseased bone. My experience tells me that this condition of eburnation that I have so often seen following gunshot wounds, described by the name of sclerosis of bone, does not occupy that prominence in surgical works that its frequency merits. Of course, we all comprehend that the inflammatory process may develop the same changes in the osseous tissues that we see in the soft parts, but these changes are for the most part passed over under one general head, "caries." By caries we of course comprehend molecular wasting of bone, without designating the structural changes that precede the molecular separation. This is sometimes attended by softening and sometimes by hardening. Now the change should be well appreciated by a surgeon, in

many instances before determining the course of practice he will pursue. Sclerosis is indeed a more formidable disease than softening, and, when it has taken place, usually the vitality of the part is so lowered that it cannot resist carious encroachments.

During and since the war, I have operated a great many times for diseased bone, resulting from gunshot wounds, and in many instances the results have been foiled by caries setting up in the sclerosed bone after the removal of all necrosed bone, even when no rough or carious spots could be detected remaining. The shock and the disturbed condition of the circulation in osseous structures from gunshot wounds seem to invite sclerosis ossium. While on this subject, I might mention a case I saw a number of years ago. Dr. Parker, of Starkville, Miss., invited me to see a patient of hisa young widow, of about 23 years of age. Three years previously, whilst standing in front of a buggy, the horse attached to it started off, and caused the forewheel to pass over the front part of one of her feet. She gave it but little care, the vehicle being a light buggy without a top and not paining her scarcely at all until more than two weeks afterwards. Then a dull, heavy aching attacked the metatarsal bone of the great toe. This gradually increased, and from that time she suffered atrociously; she looked careworn and wasted, had become exceedingly nervous, and could not bear any one to walk over the floor without causing her more or less torture. An examination revealed nothing, except tenderness. The meustrual function was somewhat deranged, and it occurred to me that it might be hysterical neuralgia. Weighing the case well, I determined to make an incision down upon the tender bone and examine its condition. I found the periosteum not much thickened, but loosely attached, the substance of the bone completely softened. Now, this was no more caries than fatty degeneration is ulceration. But it was fatty degeneration, just as we see in soft parts when inflamed. I need not tell you that I removed the great toe with its metatarsal bone and cured the poor woman of her suffering. Hence, I insist that sclerosis and softening are equally the precursors of caries; and I desire, by the detail of these cases, to impress you with the frequency of sclerosis after gunshot wounds, and that it explains why the removal of all detached spicula so often fails to arrest discharges caused by bones diseased from wounds inflicted by firearms. Amputation arm at shoulder joint- railroad injury- recovery. During Christmas week I was called to see Wm. Leach, at the City Hospital, who had a few hours previously fallen from the top of a freight car, being a brakesman on a freight train, and the wheels of several of the cars had passed over his right arm. Upon making a careful examination I found it crushed as high as the tuberosities, the soft parts badly mutilated, and bleeding from every opening through the skin. No pulsation could be felt in the axilla. The hemorrhage being arterial and profuse, I felt sure that the axillary artery was ruptured. The fourth, fifth, and sixth ribs of the same

side were broken, and the pectoral muscles were severely contused and distended with blood and air; the right lung was emphysematous, showing that it also participated in the injury. Without awaiting any reaction, I determined to remove the arm at the shoulder joint articulation, by the most expeditious method. This I did with the assistance of a number of medical students, by transfixing the deltoid with a long amputating knife, and making a posterior flap; then sweeping around the head of the humerus, disarticulating it, and making the anterior flap, we found as predicted, the artery ruptured. In his collapsed condition, but little chloroform was required to produce insensibility. His reäction was slow, yet in forty-eight hours was fully established. The emphysema of the lung and chest slowly disappeared. His recovery was protracted by a large abscess that formed under the pectoral muscles.

Amputation Arm at shoulder joint-recovery.-Patient Master Pierrard, aged fourteen years-gun shot injury of the right arm, fracturing the humerus as high up as the surgical neck. The arm was removed by Larrey's method at the shoulder joint.

Mr. Gauldon-railroad injury-amputation of arm, upper third, flap operation. Assisted by Dr. Wm. H. Ross, and patient afterwards treated by him; made a good recovery.

James Simes--amputation of leg--railroad injury, causing fracture of the right leg through the ankle joint, both malleoli fractured, and the tibia passed through the soft parts, presenting itself on the inner side of the leg, pushing the extensor tendons in front, and flexors behind. The internal malleolus was detached entirely. The patient was at Citronelle, thirty miles from the city. Amputation of the leg in the lower third was performed; circular method. Patient promptly recovered.

Mary Andres, Creole, aged 55 years; syphilitic caries of tibia. Amputation of the leg--recovery. There was a fatty degeneration of all the tissues, arteries not excepted. The posterior tibial artery gave way under the ligature, owing to its softened condition, making it necessary to use acupressure to control the hemorrhage. The flaps were not brought together, but left open for several days, until all the slough came away, and granulations covered every part. They were then firmly strapped up, and union by the moddling process obtained.

Mr. Spencer, Mobile and Ohio Railroad, at Sisters' Infirmary, May 15th, railroad injury of the foot. Pirigoff's amputation performed. Death from gangreen four days after the operation.

Negro man, at City Hospital, aged 43 years, syphilitic caries of tarsal bones. Pirigoff's amputation performed. Death.

Negro man, at City Hospital, severe burn of both feet; double amputation at the point of election, below the knee; performed simultaneously, Dr. A. P. Hall operating on one leg and Dr. Gil

more on the other. The patient had epileptic convulsions, and died of secondary hemorrhage.

William Asberry, colored, at City Hospital, thirty-five years of age, railroad injury of the foot. Two weeks after the injury, Lisfranc's operation through the tarso-metatarsal articulation was performed. The flaps were left open and dressed with carbolized oil. After granulations could be seen covering them, they were brought together by strips of adhesive plaster. Made a good recovery.

All the foregoing cases have been treated upon a general plan. When I saw there was no prospect of obtaining immediate union to any considerable extent, the practice has been to keep the flaps open until healthy granulations studded every part of the raw surface, and oakum saturated with carbolized water was closely applied to them to keep the secretions absorbed. When fever existed the dressing was changed every few hours. The flaps always were carefully supported by bandages and adhesive straps. As soon as healthy granulations appeared everywhere, all the smaller ligatures were pulled off, and the parts approximated by supporting straps of adhesive plaster with a properly applied bandage. One of the greatest elements of success in the management of surgical wounds being to inflict as little pain as possible. I have in no instance employed sutures in the cases treated as above described. I believe it would be well also in these cases to use the metallic ligature on the main vessel, cutting the ends short and allowing them to become embedded as reported in Rupert's case.

RESECTIONS.

Resection of hip joint.--During the earlier part of the spring, Mr. Blanton, of Pickens county, in this State, placed his son under my care for caries of the hip joint, of two years duration. I found him pale and anæmic. The leg and thigh of the diseased side very much swollen, and at several points on the inner and outer side of the thigh there existed a number of fistules that poured out in large quantity creamy pus. This discharge had lasted so long, without evidence of improvement, and the patient being only about twenty years of age, and free from disease in every other respect, with his digestion and circulation as good as it could be under the circumstances, I resolved to try re-section of the joint. The operation was done after the usual method, by a linear incision just external to the greater trochanter. The head of the bone was found lying loose in the acetabulum. The neck had disappeared under the destructive action of the disease. I removed the head and sawed off the trochanter to prevent its prominence interfering with the healing of the wound. The patient was rendered entirely comfortable by the operation. All hectic disappeared, the appetite improved; the muddy hue of the skin, and the anxious expression of the countenance