exhaustion of the nerve centers, making reaction impossible. And this seems in accordance with a sound analogy. What is reflex paraplegia but central exhaustion from peripheral irritation, the persistent transmission of impressions by afferent nerves to the spinal ganglia until their power of responding is gone, for a time at least, and motion ceases in the muscles dependent on them. A dislocated womb, a stone in the bladder, ascarides in the rectum, etc., now and then cause loss of power over the lower extremities.

But such agents are mere trifles when compared with the bruised, torn and pulpified nerves of a whole limb, aggravated with every move by the rough fragments, and sharp serrations of broken bone. By removing this the patient exchanges a hopeless, mischievous mass for the smooth cut surfaces and neatly adjusted flaps of a "stump," made comfortable and protected by every possible mechanical contrivance. He can surely bear up under the operation-as well as the presence of the crushed and comminuted limb. The procedure of removal cannot depress in the same space of time more than the contact of the injured, mutilated nerves of the part, and then you have reduced the irritation to a minimum, and the reaction comes on once and for all. On the other hand, you wait, and supposing his vital forces and power of resistance to be sufficient, "reaction" follows the "shock" and is "well established." You now amputate, and the "shock" of the operation succeeds to the "shock" of the injury. In the midst of the excitement and commotion of her first rally from the terrible stroke, and while contemplating the ruins with dismay, and mustering her forces to clear away the rubbish and repair the injury, the system thus all unprepared receives the second blow, and must now recover from two shocks instead of one. You can partly understand how the stunned and half-conscious centers should be little affected when not in a condition to receive and respond to impressions? From such considerations to fortify our experience we concluded that it was best to amputate the little fellow's legs soon after his admission. It was the suggestion of my friend, Dr. Dean, in which I fully concurred; and the result has justified the practice. A double amputation is a severe ordeal at the best, and yet no case, even the most favorable, could proceed more satisfactorily and beautifully. In the other boy's case we followed the same rule with the right leg, but deeming it possible to save the other, yielded to the entreat

ies of his parents, and made the attempt with the great advantage antiseptics give us. But it was only a few days when its condition unmistakably declared that it was hurt past recovery. Then we amputated, and although his age and strength seemed in his favor in the beginning he has not done nearly so well. The first stump is progressing fairly, but the last operation has been followed by sloughing of one of the flaps, while his general condition has been anything but good for several days. The inference is obvious; for while I shall always, by precept and example, try to impress you with the fact that you should never amputate when it can be avoided, you see in this case an illustration of the value of early and prompt action.

Now, let me again call your attention to the patient whose right lower limb we amputated through the thigh. This was for disease. He had an abscess of the upper end of the tibia, then destructive arthritis, with the leg and lower part of the thigh ploughed up by suppurating tracks. He had been treated in another hospital for abscess of the leg, and not until he came here was it discovered that the joint was involved. Every effort was made to save the extremity, and when we found this hopeless, prepared to excise the knee-joint, although he is much on the shady side of forty. Before beginning the operation he was warned that when the parts were exposed by the preliminary dissection their condition might necessitate amputation. The apprehension was realized, and much against his inclination it. was cut off as near the joint as possible, in order to retain good coverings and sound bone for the stump. I pointed this out at the time, spoke of the greatness of conservative surgery (why we had been baffled in it in this case), and then some of the methods by which amputation is performed. And here I will repeat that had it been discovered at first (before he came here) that the abscess of the leg and persistent suppuration following it was symptomatic of the abscess of the upper end of the tibia, his limb might have been saved; and I say this, not in a spirit of criticism, but that you may profit by this fact in the clinical history of the case. Never rest satisfied when dealing with an obstinate suppuration like this has been, until you get to the root of the matter, until you discover the starting point, the first cause, the primary inflammation nest from which it springs, and is, probably, still kept going. Make free incisions and be free with finger and probe (when practicable).

The propriety of amputation being concluded, you have these aims to preserve the longest leverage consistent with a good covering for the stump. This is the test of the method of operation as to the ultimate result. The last is to provide for thorough drainage, and thus prevent destructive inflammation and blood-poisoning-incidental wound disease. Decided by such considerations we must give the preference to the anterior flap over the others mentioned, and all which you have now seen executed. We cannot always choose, however. Now and then the soft parts are so irregularly torn and bruised that we are glad to get a covering from any direction. Such cases test our ingenuity and resource. Remove all badly injured tissue but no more, always providing for drainage. Preserve a good covering for the stump, but not at the expense of drainage. In operations for the removal of disease there is generally more latitude for choice. When thus favored, make a good covering for the bone, of integument, so shaped that the scar will be upon the side of the limb, instead of in the end of the stump; that it will not be adherent to the bone, but move freely over it; that it will not act as a receptacle, a bag to catch discharges (pus, etc.), but covering and protecting the wound from atmospheric contact, at the same time permit the constant, thorough escape of all fluids. For such an operation we are principally indebted to such men as Carden, Teele and Lane, but as to detail, mainly Carden. The last named gentleman formed "a rounded anterior flap of integument only, without any posterior flaps, and retracting the soft parts somewhat from the bone before dividing it with the saw, thus forming a flat-faced stump with a bonnet of integument to fall over it."

Notwithstanding the admirable results obtained by this gentleman, both in safety to life and the amount of pressure that can be borne by a stump so formed, which he gave to the world about the year 1856, and which has been often corroborated by others since; and, notwithstanding its obvious simplicity and excellence, I must advocate it before you to-day. The only serious objection is the liability of so much integument as the anterior flap inclines to slough from insufficient vascular supply. This may be obviated by making the anterior flap about as long as two-thirds of the diameter of the limb, including all the fascia and a little muscle, if there is any at the point, and a posterior flap of integument about one-third the length of the anterior. This 'general plan is the best for any portion of the lower ex

tremity. In both the leg and thigh, so direct your incisions as to provide for the contraction of the long stout muscles of the "calf" and posterior portion of the thigh that all the tension upon the anterior flap covering is prevented. See to it that no pressure upon the stump is made by the dressings, that the circulation is left free and uninterrupted, and surrounded with sufficient warmth. Such precautions obviate the sole objection to this method of amputation. It is not denied that the final result gives the patient a far better stump than the others. Being covered by the natural integument, the scar, upon its posterior aspect, thus eventually becomes, by pressure and friction, thick, brawny and hard, like the palm of the hand and sole of the foot of the laborer-capable of enduring, without pain, the pressure of an artificial limb fitting to the end of the stump, and enabling the patient, finally, to walk without other aid than a cane. Some of them even dispense with this.

During the present course I shall be able to illustrate this to you with more than one patient, even in amputations of the thigh. The scar in the end of the stump and generally adherent to the bone in both the circular and ordinary flap methods, generally makes an artificial limb a most imperfect substitute, worn with difficulty, atended with pain and followed by disease which may require a second amputation. The same general principle may be applied to the upper extremities. Another merit which this method possesses over all others is the facility afforded for antiseptic treatment, upon which the life of the patient, as well as a good stump, may depend. Of the value of antiseptic methods I will speak presently.

We will now give our patient ether and amputate his leg just above the junction of the middle and lower thirds by the method just described. (The patient being completely anæsthetized the amputation was made upon the plan above mentioned. He reacted well. The operation was made in the "carbolic spray," and the stump dressed antiseptically, drainage tubes being left between the flaps.)

[TO BE CONTINUED.]

Original Contributions.

ARTICLE II.

THE HYSTERICAL SIMULATION OF ORGANIC NERVOUS DISEASE. By ALLAN MCLANE HAMILTON, M. D., of New York, Visiting Physician to the Hospital for Epileptics and Paralytics, the Randall's Island Idiot Asylums, etc., New York City.

The connection between certain forms of hysteria and organic nervous diseases of well-established character is beginning to receive the attention it deserves, and the impetus given to this branch of study, especially by Charcot 1 and other French observers, is indicative of its importance. It was this writer who first traced the probable relationship of hysterical contractures and disease of the lateral columns of the spinal cord, and his valuable autopsy established the existence of primary sym metrical sclerosis in a case of this kind. Seguin and myself have observed hysterical symptoms in certain forms of hemiplegia, while the existence of exaggerated emotional states with cerebral tumor have been fully recognized 2. In cerebral syphilis I have on two occasions found quite pronounced hysterical attacks, which recurred after slight excitations. It is not of these manifestations that I propose at present to speak, for when the diagnosis of organic disease is made, the appearance of hysterical symptoms may only be regarded as interesting clinieal features, and rarely affect diagnosis; but when I say that it is possible for organic disease to begin with hysteria, or for hysterical symptoms to counterfeit the true evidences of organic nervous disease so closely as to almost defy detection, I think I do not speak of improbabilities.

During the past three or four years I have occasionally encountered examples of this class which were puzzling in the extreme, and I am convinced that the unwary practitioner may be sometimes easily led into the commission of a blunder. Cases of

1, Gaz. Hebdomidaire, 1865, No. 7.

2. Brain, April, 1878.