the proper treatment to be adopted: whether amputation must be resorted to at once; what should be its site if it be determined upon; or whether the operation may be delayed until the advance ceases, and a line of demarcation between the living and dead tissues is established. Some part of the decision on these points must always depend on the state of a patient's constitution. In a man with a strong and healthy frame, without much general excitement, the operation may be delayed, in the expectation that a line of demarcation will be naturally established; in one with a weakly frame, and with indications of commencing septic infection, amputation at the lower third of the thigh without delay will probably be the right course to pursue. If a limiting line be formed, the amputation may be usually performed with advantage in the healthy structures adjoining it. But the subject is one which always demands serious consideration. Connected with it are many special questions of practical importance which can only be thoroughly discussed in a systematic treatise on injuries of blood-vessels or on the subject of amputation.

Treatment of secondary hæmorrhage after gunshot injuries. -The many different circumstances which have been elsewhere enumerated as the occasional causes of this complication, sufficiently point to the different principles on which its treatment must be based in different cases.

The treatment of hæmorrhage occurring during an early period after a wound, and attributable either to local disturbance or fresh injury of a wounded vessel, or to increased arterial excitement, differs in no respect from the treatment of primary hæmorrhage. A knowledge of the sources of local injury sufficiently indicates what would have acted as means of prevention; but when a recurrence of bleeding has been thus accidentally set up, it must be controlled and arrested in the same way as if it were a first occurrence. Hæmorrhage produced by the effects of reaction on the circulation, or by cardiac excitement, must also be treated on the same principles as the arrest of primary bleeding, according to the nature, size, and situation of the vessels involved. This treatment has already been considered when describing that of primary hæmorrhage.

Secondary hæmorrhage, the result of a morbid process leading to ulceration or sloughing of the vascular coats, necessitates considerations over and above those which have to be given to hæmorrhage occurring at earlier periods. The state of the vessel itself, as well as of the surrounding structures, has become changed. Still the general rule is the same as in primary bleeding-viz., to place a ligature or ligatures at the part of the vessel from which the bleeding is taking place, instead of tying the vessel elsewhere at a distance from the wound. The same reasons hold good for this proceeding in secondary as in primary bleeding-viz., the

greater assurance given to the surgeon that the right vessel is ligatured, and the security afforded against a return of the bleeding, especially from the distal opening, through the influx from collateral branches. The operation is rendered more difficult on account of the generally infiltrated condition and altered aspect of the structures involved in the wound. Especial care has also to be taken not to ligature the bleeding vessel roughly, on account of its diminished elasticity and power of resistance. The unhealthy and more yielding condition of its outer tunic-the result of the morbid action to which the vessel has been subjected, and probably in part also to the effect of septic suppuration in the tissues surrounding it has to be particularly taken into account in applying a ligature to it. The ligatures will have to be applied at a little distance from the bleeding aperture, in order to secure sufficiently sound and reliable parts of the vessel for their application. Some surgeons have objected to ligatures being placed near the bleeding part of the vessel in such cases, from a conviction that they will inevitably fail to accomplish their intended purpose in the altered condition of the vessels; but experience has proved that antiseptic ligatures, carefully applied, will sometimes retain their hold, both on vessels in suppurating wounds, and even in sloughing wounds; and, moreover, when the constitutional state and other circumstances are favourable, will lead to the obliteration of the tied vessel, as in other cases, and to permanent arrest of the bleeding. An attempt, therefore, should always be made, at any rate in the first instance, to secure the bleeding vessel in the wound itself, and to apply ligatures both above and below the opening whence the escape of blood is taking place, before resorting to other measures.

It can only be in rare and exceptional instances that the employment of styptics can be of permanent avail in such cases of secondary hæmorrhage; and, therefore, in all cases where the character of the hæmorrhage points to a vessel of considerable size as being the source of the flow, their employment had better be avoided. Their action on the tissues tends to lessen their vitality, and thus to place the parts in a condition favourable for the extension of the morbid action which has originated the existing mischief. The application of continued pressure by a tourniquet is also objectionable in cases of secondary hæmorrhage of ulcerative or sloughing origin. Pressure will generally have to be applied in the first instance when the bleeding occurs, but its prolongation should be avoided as far as practicable. Digital pressure, applied to the main trunk until more efficient surgical steps can be taken, is the least hurtful; but the sooner the bleeding vessel is fully exposed to view, and the orifices, if possible, secured by ligature, the better. When once secondary hæmorrhage has occurred to any considerable extent, and the evidence

sufficiently points to the bleeding having come from a vessel of important size-even though the flow may have spontaneously ceased or have been stopped by remedies of a temporary kind in the absence of the surgeon-the wound should be opened up as soon as practicable, and the bleeding vessel secured. The hæmorrhage may otherwise recur in the night, or at some other time when surgical help is not at hand, and a fatal result speedily ensue. If there is sufficient evidence to show that the bleeding has not proceeded from a large vessel, and if it have stopped by the time of the arrival of the surgeon, delay is allowable, for the arrest in such a case may prove to be permanent under proper care and treatment; but under opposite conditions delay is not justifiable.

Secondary hæmorrhage, the result of constitutional causes, such as scorbutic deterioration, peculiar states of the blood, in which its red particles are deficient, and its power of coagulation and plasticity lessened, is the most difficult of all kinds of bleeding to control. If the original wound be deep and of a severe character, secondary hæmorrhage occurring from large vessels can rarely under such circumstances be treated with permanent success by ordinary expedients. The artery itself is probably in an unsound condition, its coats softened or abnormally thin, and even though a ligature may stop the bleeding for a time, it soon makes its way through the vessel and becomes detached. The debilitated state of the patient's constitution having prevented the healthy protective action which might have taken place under other circumstances, the bleeding then recurs, and the patient's life is in greater hazard than ever. Under such circumstances it becomes an anxious question for a surgeon to decide whether the safety of the patient will not be best ensured by immediate amputation of the injured extremity. The extent and gravity of the wound, the state of the limb, the degree to which the constitutional powers of the patient are reduced, and the opportunities of watching the patient and of giving him due care and attention-hygienic and dietetic conditions being included in this last point-must all be considered in each particular instance before a decision can be come to on the proper treatment to be pursued. Similar difficulties occur when considering the most judicious treatment for secondary hæmorrhage proceeding from wounds in limbs, the large veins of which have become obstructed by thrombosis; as well as for that occurring in stumps after amputation. As a general rule the hæmorrhage is more under control in the stumps, because the whole face of the wound can be thoroughly exposed to view; but even in these cases, when the circulation of the limb is obstructed above, or when, from the unhealthy state of the patient, the stump shows a disposition to slough, or the arteries become opened by extension of ulcerative action to them, the attempts made to arrest the hæmorrhage will sometimes prove fruitless. The ques

tion of re-amputation then arises, or of ligature of the principal artery of the limb with a view to giving time for the patient's health to improve and the stump to get into a more healthy state. Mr. Guthrie has advised that in such a case the shortest distance from the stump at which compression of the artery commands the bleeding should be carefully noted, and that at this spot a ligature should be applied, provided it be not within the sphere of the morbid process in the stump. If this plan prove unsuccessful, then recourse must be had to re-amputation.33

Treatment of hospital gangrene in gunshot wounds.-The treatment of hospital gangrene as practised by different military surgeons has varied very much according as they have considered the disease to be chiefly local or constitutional in its origin. Some have accordingly placed their chief reliance on topical, others on internal remedies. The most judicious treatment seems to have been when the two were combined. It is undoubtedly a form of disease in which local applications for the purpose of destroying the morbid action in the wound appear to be urgently indicated. It is usually so intense in character, and so rapidly destructive, that there is not time for arresting it by constitutional treatment only.

The first step to be taken by the surgeon must be to remove the infected patients from the sphere of those influences by which the occurrence of the disease has been favoured, if it have not been communicated by them. This must be done no less in the interest of the patients themselves, than to prevent the extension of the disease to other wounded men under treatment. As soon as a wound presents the appearances characteristic of hospital gangrene, the patient should be removed to another building and isolated. The isolation should be as complete as possible. Not only should the infected patients be segregated, but the surgeon in immediate charge and attendants should be debarred from attendance on other wounded patients. After dressing a patient suffering from hospital gangrene, the hands should be carefully disinfected. None of the utensils used by men suffering from the disease should be employed for other patients. In short, isolation should be not merely applied to the infected patients, but it should be extended, within the utmost limits practicable, to all persons in direct communication with them, and to all articles used by them.

At the same time, if possible, it will be better for the wounded men under treatment to have the advantage of a change of atmosphere. With this view they should be removed from any ward in which the hospital gangrene has appeared, and either be placed in tents or huts, or taken to a fresh building in which free ventilation can be secured. This is especially necessary if the walls and floors of the hospital in which the gangrene has appeared are of an absorbent nature. If this change cannot be made, the

unaffected patients who must remain in the wards where the disease has shown itself should be separated as widely as possible from each other, so as to give them the most copious aëration, and to prevent concentration of wound effluvia to the utmost available extent,

The most rigid attention to cleanliness; to the prevention of transmission of infectious particles from patient to patient by the hands of surgeons or dressers, or by means of articles employed in cleaning wounds, such as tow, water, &c. (the use of sponges should never be permitted); to freedom of ventilation; to the immediate destruction by fire of all foul dressings; to the removal of rubbish, stagnant water, and all objectionable matters in the precincts of the hospital building, should be insisted upon. The efficiency of the drainage, and all other hygienic matters, should be strictly attended to.

All dressings employed should be strictly antiseptic; the perchloride of mercury, carbolic acid, and iodoform being probably the most reliable bases of them. If, however, these applications do not appear to arrest the progress of the morbid action, other means must be resorted to.

A very large variety of substances, escharotic, stimulant, and sedative, have been employed as local remedies in hospital gangrene after ordinary applications have failed. Among British surgeons the undiluted mineral acids, especially the nitric acid and the liquor arsenicalis, have been the two remedies most employed. When one of the strong mineral acids is used, an anaesthetic should be administered, the parts surrounding the gangrenous tissues protected by a thick layer of ointment, the sore freed from sloughs and moisture as much as possible by means of pads of tow, and the acid applied steadily to the surface until it presents the appearance of a tough fibrinous mass; until, in short, the qualities of its substance are completely destroyed. Lint wetted with perchloride of mercury or carbolic acid lotion should then be laid over the sore. The acid may be applied by means of a piece of lint rolled round the end of a glass rod. Another plan of using the nitric acid has been to cause it to destroy a circle of skin and subcutaneous areolar tissue around the diseased part, so as to isolate it from the sound structures. When the yellow coriaceous slough becomes detached, it will probably carry with it the gangrenous surface of the sore, and the wound may then granulate healthily. This does not appear to be so reliable a mode as the former one. The pain resulting from the application of the acid does not usually last long.

It is equally necessary to give attention to cleansing the surface of the gangrenous parts before applying the liquor arsenicalis to them. When they are cleansed, lint soaked in the arsenical solution, diluted with an equal part of water, is applied, and is to be renewed at intervals of half-an-hour. Mr. Blackadder, who