ing these, it has been the fashion to compare it with amputation; but we must also compare it with an expectant treatment and conservation of the limb. Disadvantages.-The shock of the operation is very severe, and it is followed by severe surgical fever. After amputation for disease in the child, there is usually but little shock or fever; the child often sleeps soundly a few hours after the operation, and mends steadily from that time. The shock and suppurative fever after excision are, however, not often fatal. Arrest of growth in the limb after the operation. This is rather common; it is due to the removal of the whole of the epiphysis and part of the shaft of the bones. In the femur, the epiphysial line comes very close to the edge of the cartilage, and consequently, the risk of removing the epiphysis is great. In some cases this can be avoided by merely slicing off the cartilage, and leaving a rounded or truncated end to the bone; but often owing to the extent of the disease, a horizontal cut is absolutely necessary. In the tibia, the space between the articular surface and the line of junction of the epiphysis is greater, and, consequently, there is a better chance of being able to save part of the latter. Of course, the younger the patient the greater would be the relative shortening from this cause. The risk of soft union between the bones and of bad apposition.—The tibia has always a great tendency to fall back, so that only the anterior part of the cut surface is in apposition with the femur, and the partial union thus formed is not strong enough to support the weight of the body; or, if the cicatrix be stronger, it may yield gradually to the weight of the trunk, and the limb may bow outwards, giving it a shortened and awkward appearance. These deformities may be corrected by splints if treated at once, and, unless the shortening and bending be excessive, the limb is still better than a wooden one. A shortening of six inches, compared with the sound limb, is no great hindrance to walking; the pelvis drops on that side, and this obliquity, with a high boot, readily compensates for the shortening. These, then, are minor disadvantages; the real obstacles to the operation are its severity, the tedious convalescence which follows, and the liability to recurrence of the disease. It is very difficult to judge of the comparative mortality after excision of the knee; statistics especially are very fallacious. It is not sufficient to compare the total mortality after excision with the total mortality after amputation. Even the most enthusiastic surgeons limit their practice of excision to young patients and to favourable cases, while amputation is performed at all ages, and often under desperate circumstances. Excision, again, is never done for cases of acute injury; in military surgery it has been exceedingly fatal. To arrive at any satisfactory result, we must compare similar cases in considerable number; and this is not an easy matter. I believe myself that the mortality after excision is about double that of amputation. I should say, too, that the period of convalescence is about four times as long after excision as it is after amputation. This estimate is, if anything, rather below the mark. The risk of recurrence of the disease is not great when the wound heals rapidly; but, if convalescence be prolonged, a renewal of the caries often results. And when this does happen, do not be in too great a hurry to amputate; treat it as you would caries in the continuity of a bone; there is now no joint to complicate the treatment. Scrape out the diseased bone or apply caustics; if this do not answer, you can excise again; though this, of course, increases the shortening. The coleur de rose doctrines which have been advanced by some surgeons have certainly produced very mischievous results. Excision is not an operation which can be employed indiscriminately; it must be reserved for cases of favourable age, and in which the disease is not too acute or too extensive. When it is thus reserved for suitable cases, the result is infinitely superior to that of amputation. The advantages, indeed, are more marked the earlier the age of the patient. Amongst the lower orders, amputation of a leg almost ruins a child's prospects for life; few will have anything to say to him, and the greater part of his life is passed at the cripples' home in the workhouse. But after excision he is fit for a sedentary or even for a moderately active life. I have known patients who could easily walk ten and fifteen miles a day after excision; and a German surgeon has recorded the case of a man who was able to follow successfully the ardous profession of a chamois-hunter after this operation. After middle life, the advantages are doubtful. The result of the operation is not generally so good, and an adult can seldom afford the long period necessary for convalescence. The complete use of the limb, after excision of the knee, is not fully acquired for some years. On the other hand, the number of cases which are available for excision, even in the child, are limited by the fact that many of them are curable without any operation, if you can only give them time. In private practice, amongst well-to-do people, where the parents will readily nurse a child for three or four years, you may cure cases of abscess in the kneejoint, or even of chronic disease of the bones, by means of simple expectant treatment, and may even get a tolerably useful joint. In hospital practice this plan of treatment is impracticable, and then it is that, by excision, you can hasten and facilitate the process of cure without materially altering the nature of the result. On the whole, then, whilst I fully recognize the advantages of excision, I am strongly in favour of the close restriction of the operation to a limited class of cases. So far, we have been dealing with the operation in the abstract. We have now to consider, more particularly, the principles which should guide us in the selection of cases, the best mode of perform ing the operation, and the necessary aftertreatment. Age. The patient must be under forty or forty-five. The elbow or shoulder may be successfully excised at a much greater age; but, after middle life, excisions in the lower extremity are exceedingly fatal. In the case of very young children, free incisions into the joint and expectant treatment are so successful, 1 that formal excision is seldom necessary; the risk of getting an excessively shortened limb is also very great. This is not absolute contra-indication, since excision may be, and has been, practised successfully in early infancy; but the most favourable age for the excision of the knee may be said to be between five or six and twenty. The operation may, however, be performed, with fair hope of success, when the other circumstances are favourable, as late as thirty or even beyond. Constitutional state.-There must be no visceral disease. The lungs must be examined for signs of phthisis, and the urine for evidence of the albuminoid kidney, which often accompanies chronic disease of the bones; nor should examination of the liver be neglected. There must be no acute surgical fever, and no marked depression of the general health; no great wasting or confirmed hectic. Local state.-a. The bones must not be too extensively softened. Unless you can remove all the softened bone, you will be almost sure to get soft union or no union at all. In excision of the elbow, and even of the hip, this objection does. not hold good—you do not want to get firm osseous union, as you do in the knee. In many cases, it is quite impossible to diagnose the actual state of the bones before the operation; you must, therefore, always be prepared to change your excision into an amputation, and must always previously obtain the consent of the patient or of his friends to this course if necessary. One of the most favourable classes of cases for excision are those of so-called "strumous" disease of the synovial membrane, though the patient often shows no sign whatever of the strumous diathesis. It is characterized by pulpy degeneration and thickening of the synovial membrane, and by the frequent presence of small abscesses in the thickness of this pulpy mass, which may, or may not, have burst into the joint; the bones are scarcely affected at all. The operation also is exceedingly simple in these cases; you need not be particular about removing all the thickened synovial membrane, and have only to remove a thin slice of bone and | The Operation itself is tolerably simple. cartilage from the articular surfaces. Then there are the cases where a superficial necrosis of some part of the articular surface has taken place, and a sequestrum has formed. In some of the other joints you may just remove this sequestrum, and trust to rest, etc., but in the knee this procedure is followed by such severe shock and profuse suppuration that it is better to excise at once. b. The disease must not be of too long standing, and the limb must not be too much atrophied. In children especially, if the disease have lasted for any considerable time, there is great risk that it may have extended beyond the epiphyses, and that the operation would consequently be followed by arrest of growth in the limb. Some surgeons, as Mr. Butcher, still adhere to the H-shaped incision; this, however, is rarely required-only when a joint is ankylosed in an awkward position, or when you wish to expose the bones very freely. Others make a large anterior flap, inclosing the patella; the only advantage of this is that you can at once amputate, if necessary, without removing much of the femur; the objections are, that there is a large hollow left after the removal of the patella, and that the wound is larger, and, consequently, the shock is increased and convalescence retarded. Langenbeck, I believe, operates, or used to operate, on a totally different plan, and with a different object in view. He makes a longitudinal incision down each side of the joint, divides the lateral and c. The soft parts must not be too ex- crucial ligaments, and turns the articular tensively undermined. d. The disease must not be in an acute stage. I have seen excision successfully performed for acute abscess in the kneejoint, but, as a rule, the operation under these circumstances should be discountenanced. This rule also does not hold good in the case of other joints, especially of the elbow, where excision may be safely recommended in the acute stage of abscess. It will thus be seen that the most favourable cases of disease of the knee-joint are those which are selected for excision, whilst the more unfavourable are left for amputation, and that this, therefore, tends to increase the mortality after amputation. Some have argued that the tendency is to some extent neutralized by the fact that, since the introduction of chloroform, amputation has been performed in many favourable cases of old deformity, etc., which would formerly have declined the operation. This may be true, but, on the other hand, a far larger number of favourable cases are saved by the conservative surgery of the present day, which would formerly have undergone the operation; so that I do not doubt that, on the whole, amputation for disease is now practised in a class of cases less favourable for recovery than was formerly the case. When the pa surfaces out through one of the wounds. He leaves the patella and its ligament entire; his object being to get a movable joint, while we look for firm ankylosis. I have no experience of Langenbeck's treatment, but, from my own experience, should always advise the removal of the patella, or, at all events, of the whole of its cartilaginous surface. tella is left, it often becomes the seat of the recurrence of the diseaase, and, if the bones are to be firmly united and soldered together, there is no advantage to balance this risk. You will see, by the examination of such cases several years after recovery, that the quadriceps extensor cruris becomes atrophied, and the function of the patella entirely abolished.' I think, then, that the best plan is to make a single straight incision from the back of one condyle to the back of the other, cutting across the ligamentum patellæ, and completely dividing both lateral ligaments. After turning up and removing the patella, the limb is well flexed the back of the condyles cleaned, and the lower part of the femur sawn off nearly perpendicular to the axis of the bone; the head of the tibia is then cleaned and sawn across horizontally. The danger to the 1 See an illustration in Holmes's System of Surgery, vol. v. page 708. Second edition. popliteal is not great, unless it be bound | year ago there was published in the Brit. down to the back of the bones-glued to them, as it were, by inflammatory products; nor is there any motive for sawing the femur from behind forwards, as has been recommended. Be very careful to tie all bleeding points. I always use the carbolized catgut ligatures, and cut off both ends quite short; the knots do not interfere in the least with rapid union. I find this much more satisfactory than torsion, especially for small vessels. Put up the limb at once, before the patient recovers from the chloroform. There are several different forms of apparatus. The limb should be perfectly straight, and the splint should be carefully adapted to it. The plaster of Paris splint is very good; the best form is that of Dr. Patrick Watson, a description of which is inserted in the System of Surgery. The objection is that, if the limb become inflamed and swells, you have at once to take it all down; and if, as sometimes happens, the limb shrinks, the splint allows too much motion. The same objection applies in some degree to Mr. Butcher's apparatus; this consists of a sort of trough, formed by three flat wooden splints, open in front. In this hospital we usually use a McIntyre's splint, cut away at the sides opposite the joint. Wooden side splints are applied to this, and a well moulded leather splint is fitted over the front of the thigh. Whatever apparatus you use, do not disturb the limb oftener than you are absolutely obliged; perfect rest is the great point of the after-treatment. If you can avoid any changes for four or five weeks, so much the better; by that time there will probably be a sufficient amount of union between the bones to dispense with all special apparatus for the future. Do not allow the patient to use the limb too soon, and watch him for some little time after he begins to move about on it, so that you may at once check and correct any tendency to bending or bowing at the seat of union.-Brit. Med. Journ., Oct. 12, 1872. HOSPITAL NOTES AND GLEANINGS. Med. Journ. the results of the experience "As regards the treatment of sick headache," says Dr. Wilks, "I have until late years been able to do little more than recommend to my patients the avoidance of all those circumstances which they know from experience would induce an attack. I allude, of course, to nervous headache, for I believe that this is almost the only form for which we are consulted; a tem Treatment of Sick Headache.-About a porary disturbance of the head arising from various causes, requiring no medicine, or but a casual dose. During the last three or four years I have been able, with others in my profession, to do something more positive than preach hygienic principles to my patients, having in our possession three remedies which have been doing eminent service in this terrible complaint. In the first place, there is the bromide of potassium, which is so valuable a medicine in many cases of sick headache that it can scarcely be superseded by a better remedy. The patient, who is very often a gentleman, comes home with a splitting headache, fatigued and worried after a hard day's work; he takes fifteen or twenty grains of bromide of potassium, presently goes off to sleep in his easy chair, and wakes in an hour well. I have known this occur in so many instances, that I cannot hesitate in my belief as to the efficacy of this medicine. It is one which I always first employ, having seen such eminent advantages follow its use. I have known many patients declare, that the bromide was the first medicine they had taken in their lives which had had the slightest effect in relieving their headache. to our notice as a remedy for sick headache, and here, again, we have a very valuable addition to our Pharmacopoeia. In many instances, especially those of ladies, I have had the most positive assurance given to me of the power of this drug in arresting headache, so that not the slightest doubt can be entertained of its immense value. A dose is usually taken when the headache is approaching; and if this is not quickly successful in arresting it, a second powder is swallowed; after an hour or so, if the remedy is to be useful, the headache has disappeared. I know of several cases in which the greatest enthusiasm is expressed by patients as to its merits. At the same time, I am constantly hearing of cases where it has failed. I am now trying it in smaller doses by daily administration. "I feel certain that these three drugsbromide of potassium, cannabis Indica, and guarana-constitute a most important addition to our nervine medicines, and that in them we have remedies against a terrible complaint which, a few years ago, constituted the opprobrium of medicine. I might say that I know of cases where galvanism has very speedily cured a pain in the head; and I can call to mind the case of a lady, where the application of the bisulphide of carbon invariably relieved the most severe headaches."-Brit. Med. Journ., Dec. 21, 1872. "About two years ago, I commenced to use the cannabis Indica, and I have no hesitation in saying that in this drug we possess a most valuable remedy against headache. I have never given it in large doses with the object of counteracting the pain by producing an immediate effect, Ruptured Jejunum; Absence at First of but have employed it in doses of a few Serious Symptoms.-John R———, aged 32, drops three times a day, and continued brewer's man, was admitted into the Lonfor some weeks. In several cases where don Hospital, under the care of Mr. Rivmy patients were subject to constant head-ington, February 19, 1872. Patient was ache, great benefit was experienced, seve- walking across a plank laid over a brewral of them having written to say that er's vat, when he missed his footing, and they had got rid of their trouble, or it had fell a distance of sixteen feet. When he been less frequent. I consider it superior came to the hospital he was examined by to all other remedies in this respect that, the house-surgeon, who was unable to deif efficacious at all, it preserves the pa- tect any sign of a serious injury, and, tient from his malady; whereas other consequently, gave him an out-patient's medicines do little more than arrest the ticket. Later in the day he returned, attacks when they have commenced. I complaining of pain in the chest, and also have not given cannabis in the manner at the lower part of the belly. He was recommended by Dr. Williams (of Hay- admitted as a case of contused chest. The ward's Heath), in the form of a dose of patient was a very stout man, with much the extract daily. fat on his body, and it was therefore dif “Thirdly, guarana has been introduced ficult to examine satisfactorily his ribs |