which appeared to adhere more firmly, and was of rather a more gelatinous consistence.

What relation these two fungi bore to each other, I cannot say; but I have long considered the first, as being nothing else than firm coagulum, and the second, a real fungus growing out of a diseased sac. The case of Richard Finney, in Mr. Hey's collection, strongly favours this conjecture, for here we see the coagulum destroyed by the seton; but the second fungus, that arose from what we conceive to be the diseased state of the sac, could not be destroyed by the same means.

There is another circumstance peculiar to this affection, and which renders it somewhat analogous to arterial aneurism. Whenever this tumour lies contiguous to a bone, it will incontestably destroy it; but this destructive principle I suspect, is more active in venous, than arterial aneurism. In the case of Ann Hartley, about an inch and a half of the fibula was destroyed, and an osseous substance, mixed with coagulum, either lying in the vacuity or very near it. In one of Mr. Else's cases, also, a part of the bone was wanting. I mentioned the circumstance of part of the fibula being dissolved, in Hartley's case, to Mr Hey, after the limb was examined (for she was not this gentleman's patient) and by not availing himself of this hint, he subsequently lost the opportunity of inspecting the state of the bones in two cases. His words 66 are, a few years ago I amputated the arm of a middle-aged man below the elbow, - who had a tumour exactly similar to the last described; but the state of the bone was not examined, nor did I examine it in the case of Mr Ward, having seen no affection of the bone from it at that time." Hence, if the contents of this tumour be capable of making such ravages among the bones, we cease to wonder at the morbid appearance, in the soft contiguous parts, and at the sac being incapable of sending forth good granulations.

If the above theory be admitted, it follows that the primary state of fungus hæmatodes is venous aneurism, and which may be divided into two stages, for practical purposes. The first is, that which consists of fluid blood entirely, and where the sac is in a sound state. Here a simple division of the tumour, and se curing the vessel will probably be sufficient, as was practised in the case already described. The second stage is, where the contents of the tumour consist of coagulum. Here the sac may be conceived to be in a morbid state, and capable of throwing forth a fungus, which properly constitutes the disease designated by the term above-mentioned.

Wherefore, if this tumour containing fluid, as well as coagulated blood, be venous aneurism, as there is reason to

believe,

believe, it is obvious that what are denominated the two stages of the same complaint, constitute two distinct diseases. This is exemplified in case 1st of Mr. Hey's collection, where we see all the coagulum removed, and only a smail part of the sac remaining, from which grew the substance, which ought to be considered only as a fungus. One particular relating to the case of William Priestley, I had forgot to mention in its proper place, and which was the quantity of blood which he lost during the operation, and which was greater than what usually occurs in similar cases of amputation, and the consequent sicknes that ensued. It must be remembered here, that the limb was amputated above the knee, and the disease was in the calf of the leg.

The following case will prove the inefficiency of two tournequets, for suppressing hæmorrhage, from the end of the stump, in amputating one of the lower extremities, for an affection. different from the fungus hæmatodes.

On the 12th of May last (1810), I was requested to be present at the amputation of the leg of a man, of the name of John Beaumont, aged 34 years, of a very cachochymic and reduced habit of body. The operation was in consequence of a white-swelling of the knee, of some years standing, and which was of a very large size. He had employed a variety of means, both internally and externally, and particularly blisters, which were continued for several months successively, and renewed, or repeated, as often as the part cicatrized. The patient was in an emaciated state, had a quick low pulse, at 106, a slightly furred tongue, and night sweats, but without symptoms of any other local, or general affection.

After securing the tournequet effectually on the upper part of the thigh, I was much struck at the quantity of dark-coloured, or venous-like blood, that followed the division of the integuments, and which continued to increase, as the operator prosecuted his incision through the muscles. The hæmorrhage, by the time the muscles were divided down to the bone, was so profuse, that it was judged necessary to apply a second tournequet to the middle of the thigh, and which, together with the first, though tight, did not seem to have any effect in checking the effusion of blood; for whilst the bone was sawing through, a considerable quantity still continued to flow uniformly from both the superior, and inferior portions of the divided limb. There was no apparent bleeding from the crural, or any other arteries of the thigh. As soon as the bone was sawed through, the hæmorrhage considerably abated, and before half the interval transpired, that was spent in taking up three or four small arteries,

arteries, it was reduced to little more than a general oozing, from the end of the stump. In about fifteen or twenty seconds, as nearly as I can estimate, after the crural artery was tied, a large stream issued forth, from the mouth of the great vein, which was soon stopped, but whether, by a farther tightening of the tournequet, or what is more probable, from the pressure I made with my finger, on one side of the mouth of the vessel, so as to afford the operator, room for securing it with an armed needle, I cannot say. All the smaller arteries, previously to their being tied, on slackening the tournequets, threw out arterial blood, of quite a different colour from the hæmorrhage already mentioned, and which was as often suppressed, as the tournequet was again tightened, exactly as we see in amputations in general. After all the arteries were taken up, and the circulation set at liberty, the stump did not seem disposed to bleed any more than what is customary in such cases, notwithstanding the application of a moderate artificial heat for some time, to the end of the stump, in order to relax the mouths of the divided vessels. The muscles appeared darker coloured than usual, and that part of the thigh, which was operated upon, seemed to me not quite so small as might have been expected, from the emaciated state of the body, and the size of the swelling. The cutaneous veins of the knee were enlarged, but no more than we frequently see, in affections of this nature. The knee, on examination, displayed those morbid appearances, which we usually meet with, in scrophulous swellings of the joints; and the ancle joint, also exhibited signs of a beginning state of a similar disease; and the whole leg, especially the lower part of it, was somewhat swelled and oedematous.

The man was sick after the operation, yet for the first two days went on tolerably well, though his pulse evidently portended debility, as they had not acquired any force, as is usually the case at this period; but at the beginning of the fourth day, he was seized with vomiting, and constipation of the bowels, which yielded not to any means that were prescribed. His pulse were nearly at the same number they were, previous to the operation, but evidently was sinking. He complained of pain, both in the epigastric, and hypochondriac regions, and the fluid that he vomited, had a greenish, and a somewhat yellowish cast, and was sweet to the taste of the patient; but as his disorder advanced, it assumed a bloody appearance. He had but little thirst, yet his tongue continued rather more furred, than before the operation, and his stump looked well. On the fifth day, however, his pulse sunk, and were at 112: his countenance became more ghastly, respiration short, and somewhat an helose, his eyes glistened, delirium and cold clammy sweats suc

ceeded

ceeded, and death, the sixth day after the operation, closed the

scene.

Here the integuments and muscles, on their division, displayed the same dark colour as the consequent flow of blood; and the greatest current of the hemorrhage was at the precise juncture of dividing the muscles, and which seemed to abate insensibly till the limb was amputated, without the influence of any means, that were employed for stopping it. The stump,

after the hæmorrhage ceased, had rather a fresher and more oxegenized aspect.

In Priestley's and Hartley's cases, who both lost an unusual quantity of blood, especially the latter, the same phænomena were observable, as to the colour of this fluid, and the hæmorrhage, which burst forth occasionally from Campinet's tumour, before the first amputation, displayed a similar cast.

Of the quantity of blood, lost in this case of amputation, I can form no correct idea. I think it could be no less than from thirty to forty ounces, and which greatly diminished the force of the pulse, at the time of the operation; and though they acquired some small re-accession of strength, in consequence of the symptomatic fever, for the first two or three days, yet, as soon as this subsided, the real state of the system unfolded itself, and the patient sunk more from extreme debility, than from any other cause. any

I do not know of any case of amputation on record, for a similar affection, attended with such phænomena as the above; for though Mr. Hey mentions his having seen the circumstance of two tournequets being insufficient to stop the circulation in the artery, more than once, he only alludes to the cases of Campinet and Hartley, both of which were of the fungus hæmatodes. The most obvious way here, in my opinion, of accounting for this extraordinary phoenomenon, is on the principle of local plethora, as above mentioned, or by supposing the veins of the limb surcharged with blood stagnating from a languid circulation, or from some other cause; for the hæmorrhage seemed to flow from the under, as well as the upper part of the limb, when divided; and this circumstance will account for a good part of the blood, that was lost; for as soon as the limb was amputated, the hæmorrhage from the stump could be more clearly ascertained, and which was very considerably lessened, as before stated.

The pressure on the thigh was very great; for on the first appearance of an increased effusion of blood, the first tournequet was further tightened, insomuch, as to give considerable pain; the second also was screwed to a similar degree.

This case, by being different from those of the fungus hæmatodes affords apparently other data, for accounting for the singular hæmorrhage, that attended it; and which has never before been found to occur in amputation, that I know of, except in Mr. Hey's cases, from the supposed morbid state of the capillaries; but here there can be no ground for suspecting any defect in these vessels. On the contrary, this case militates strongly against Mr. Hey's theory. For to say that the efflux of blood was occasioned from a disease in the capillary arteries, is to assert a solecism, in the face of facts and probability; for the blood, that flowed from the divided parts, seemed not only general, but venous and dark-coloured; and the part operated upon, had no appearance of disease externally; and internally, every part of the limb, bore a similar aspect. Of all the phænomena attendant on this case, none perhaps is more difficult to account for, than the large stream of blood, that burst out from the mouth of the crural vein. If we admit the principle of local plethora, as above mentioned, we then may conceive this vessel, surcharged with blood, especially after the tournequet was tightened, partly from the smaller veins emptying themselves into it, and which this supply would every moment more and more distend, till at length the valves became ruptured, or gave way, and consequently the regurgitating blood would rush out, with considerable force, as was actually the case, from the enlarged or distended state of the vein.

The above remarks on fungus hæmatodes, comprize nearly the substance of my private communication to Mr. Hey, on this complaint, and had I not met with two such cases, as are above detailed, the observations accompanying them would never have met the public eye. Wherever I have differed from this gentleman in opinion, as to either theory, or matter of fact, I have in the one instance assigned my reasons, such as they are; and as to facts, I have described them, as they appeared at least to me, with a proper and high respect for Mr. Hey's abilities, and a becoming diffidence of my own. In this gentleman's polite and friendly answer to my remarks, he rightly observed, that some of his cases could not be dependent on the cause which I had assigned, and particularly mentioned the case of Mrs. Storr; but in reply, I must beg leave to say, that I endeavoured to prove no more than that several of his cases were similar to those of Mr. Else, which he demonstrated by experiment to be venous aneurism; therefore, the obvious inference must be such, as I have already deduced.

Huddersfield, July 10, 1810.

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