thetics as employed in the large hospitals of Great Britain, has recently determined to use ether exclusively.'

The English have always shown great care in their administration of an anesthetic, and to a visitor it is interesting to notice in their hospitals the great variety of ingeniously constructed instruments which they employ for this purpose. The ether inhaler, devised by Dr. Allis and exhibited by him to this Society, at the annual meeting in Pottsville, June, 1875, has attracted attention in England, and among others has been commended by Dr. Martin Oxley.'

The manner in which morphia, atropia, and nitrous oxide gas modify the anaesthetic effects of chloroform and ether has recently been studied. In 1863, Prof. von Nussbaum pointed out that chloroform anæsthesia could be maintained during several hours by means of the hypodermic injection of morphia. And Prof. Claude Bernard found, while experimenting upon a dog, that by the hypodermic injection of morphia the anesthesia would return after the effects of chloroform previously administered had almost disappeared. He also found, that, if the morphia be injected before the chloroform is administered, a smaller quantity of chloroform will be required, and that insensibility will be more profound. The conclusions which may fairly be drawn from the experience of those who have employed this combination in surgical operations are, that the anesthesia can be more rapidly induced, that it is of longer duration with a smaller quantity of the anesthetic, and, on the other hand, that there is a danger in some cases of impairment of the respiration.

Sir Henry Thompson' earnestly recommends Mr. Clover's plan of administering nitrous oxide gas for thirty seconds and then ether. He has found the process to be rapid and usually without subsequent sickness. Formerly, in the operation of lithotripsy, he employed no anesthetic, now he prefers this combination. In England it is easier to make use of such agents involving special apparatus than in this country, because it is the sole business of certain persons to administer the anesthetic, and to provide the apparatus.

1 Medical Responsibility in the Choice of Anesthetics, with a Table of the Anæsthetic employed, its Mode of Administration and Results in nearly Fifty Large Hospitals in the United Kingdom, by H. Macnaughton Jones, M.D., M.Ch., etc. etc. London and Dublin, 1876.

2 Lancet, Dec. 18, 1875.

On the Modification of the Anaesthetic Process by Hypodermic Injection of Narcotics, by J. C. Reeve, M.D. Amer. Journ. of Med. Sci., April, 1876. Administration of Anesthetics, J. T. Clover, Esq. Brit. Med. Journ., Jan. 1, 1876.

Lancet, Jan. 8, 1876.

The conservative surgery of limbs has continued to make good progress. The publication within the last month of Dr. Culbertson's Prize Essay on Excision of the Larger Joints of the Extremities, by the American Medical Association, marks an era in the literature of the subject. In it he has collected, tabulated, and collated 596 cases of excision of the hip, 745 of the knee, 326 of the ankle, 984 of the shoulder, 1075 of the elbow, and 182 of the wrist, making 3908 in all. The work proves his right to the motto he had chosen Labor omnia vincit." My own experience of the good results to be obtained by the excision of joints, especially when done because of disease, leads me to believe that these operations will continue to receive more and more favor at the hands of the profession.

2

Subcutaneous Osteotomy.-In 1870 Mr. William Adams, of London, divided the neck of the femur subcutaneously on account of anchylosis of the hip-joint. Since then he has collected twenty-two cases; in these the operation was successful in twenty, there was one death from pyæmia and one from chronic suppuration. His instruments, which I show you, are exceedingly simple. They are a narrow knife like that used in tenotomy, but longer and stronger, and a long narrow saw with a pistol-shaped handle.

The neck of the femur is often greatly absorbed in cases of hipdisease resulting in anchylosis, and cannot, therefore, be readily divided. In other cases the deformity is chiefly the result of contraction of the psoas muscle, and a division of the neck of the femur will not relieve the deformity. In such cases Mr. Gant has modified the operation. He uses the same instruments, but divides the femur below the lesser trochanter. Mr. Maunder also divides the femur below the lesser trochanter, but instead of a saw, uses a chisel and mallet. He also has met with good success; but the employment of a chisel and mallet exposes the wound in a greater degree to the air, and thus takes away from its subcutaneous character and safety.

Generally, after the operation, the bones unite and remain firm in a position which removes the deformity; but useful motion has been obtained by Mr. Jessop, of Leeds, Mr. Lind, of Manchester, and Dr. Sands, of New York.

1 Address on Resection of Joints before Congress of German Surgeons, by Prof. Hueter of Griefswald, and discussion by Prof. Gurlt and Prof. von Langenbeck. Medical Examiner, April 19 and 26, 1877.

2 Paper read before International Medical Congress, Philadelphia, Sept. 1876. Paper read before Royal Medical and Chirurgical Society, Oct. 10, 1876. Lancet, Oct. 14, 1876; Amer. Journ. Med. Sci., Jan. 1877.

3 Medical Times and Gazette, June 17, 1876.

1000

990

The operation is also applicable to cases of deformities of bones from other causes, such as badly united fractures, and promises to take the place of the operations proposed by Dr. J. Rhea Barton, and Dr. Lewis Sayre, and also of the operation of perforating the bone subcutaneously, and then fracturing it as suggested and practised by Dr. Brainard, of Chicago, and repeated by Drs. Peace, Pancoast, Gross, and others.

After subcutaneous osteotomy there is hardly any more constitutional disturbance than after subcutaneous tenotomy. The accompanying wood-cut shows the pulse and temperature of a case recently

980

operated upon by me. At the Children's Hospital the femur has been divided subcutaneously by Dr. John Ashhurst, Jr., and myself several times, without any serious symptoms, and with good results.

Neurotomy.-Great progress has been made of late in the study of affections of the nerves. This is in a large measure due to the experiments, clinical observations, and writings of Dr. BrownSéquard and Dr. S. Weir Mitchell. The advantages to be gained in certain cases by nerve-section are becoming more understood, and the causes of failures better appreciated. An ordinary section, and even the removal of a large portion of a nerve, is generally followed by the reunion of the nerve not only by fibrous tissue, but even by the nerve substance, owing to its regeneration as shown by Dr, Bertolet1 in some cases submitted to him by Dr. Mitchell, and by myself.

On November 8th, 1876, M. Notta' reported to the Surgical Society

1 Neurotomy. By S. Weir Mitchell, M.D., of Philadelphia. With an Examination of the Regenerated Nerves and Notes upon Neural Repair, by R. M. Bertolet, M.D., Pathologist to the Philadelphia Hospital. American Journal of Medical Science, April, 1876.

2 London Medical Record, Dec. 15, 1876.

of Paris, a case of excision of the median nerve, on account of a neuroma. In order to secure the union of the nerve, he applied a suture to it and drew its ends together. In the light of the examinations made by Dr. Bertolet, this would appear to be unnecessary. It also added to the complications of the operation the dangers of a punctured wound of the nerve, and the irritation and inflammation arising from traction and the presence of a suture in the nervesubstance.

Dr. Richet has attempted to explain the reason of the continuation or quick return of sensibility in the fingers after the section of only one of the main nerve trunks of the arm. He has called it "collateral innervation," and has pointed out that the median, radial, and ulnar anastomose amongst themselves to form loops from which come off the filaments which end in the touch-corpuscles.' In my own cases of neurotomy the area of sensibility lost by nerve section has been so small and so quickly recovered from, that I was led, some years ago, to suggest in a case of division of the radial that the return of sensibility was due to the median and ulnar by anastomosis. I have also become convinced that it is advisable in all cases of neuralgia, when possible, to make the section of the nerve at a point after it has pierced the deep fascia and become superficial. By this precaution all the benefit hoped for can be obtained without any loss whatever of the power of motion in any part of the limb. No motor filaments are divided, because none pass through the deep fascia. Those fibres which pass through the fascia are only those which go to the skin, and are concerned merely with sensation. The operation on these small nerves requires a good anatomical knowledge and surgical care and skill in order to find them. The preser

vation of the movements of a limb, and especially those of the fingers, is worthy of any effort. I have thus operated with success upon the radial, internal saphenous, and digital nerves, and in no case has any impairment of the power of movement resulted. If the main trunk containing both motor and sentient filaments had been divided, all motion would have been lost.

Reflex Epilepsy.-Very closely connected with the last subject is that of reflex epilepsy. This form of epilepsy has been very carefully studied by Dr. Brown-Séquard, and many new facts in connection with it pointed out by him. I have myself had two cases, both of which I have been able to relieve by operation. In one the epileptic attacks followed, and were due to a contused wound of the eyebrow. The convulsions were not severe, and could for a time

1 British Medical Journal, April 1, 1876.

be controlled by the use of bromide of potassium; but they were permanently relieved by excision of the scar. The other was a very bad case, in which all medicines failed, but the operation was followed by the most brilliant results. A child had been struck on the side of the head by a piece of brick. The contused wound readily healed, but epilepsy quickly followed. The child had been under the most skilful care of Dr. O. P. Rex and Dr. H. C. Wood in consultation. The most powerful medicinal agents had been employed without success. The child had scores of convulsions every day, and these were accompanied by epileptical mania, in which the violence became so great as to threaten serious danger to his own life, and to the lives of those waiting upon him. I was sent for, as it had become evident that drugs could not relieve him, and that the only hope would be in operative interference. My friends were disposed to think that the skull and membranes of the brain had been injured, and that the operation of trephining would be necessary. Upon examination, however, I could find no depression of the skull. The scar in the scalp was movable and very sensitive. Pressure upon it was soon followed by an epileptic attack with mania. The conclusion, therefore, seemed to me clear that it was a case of reflex epilepsy, and that the simple removal of the scar would benefit the patient. With the consent of my colleagues, I therefore merely excised the scar, and brought the edges of the wound together. They united by first intention. The convulsions at once diminished greatly in number and in violence. The mania soon disappeared. The convulsions occurred at longer and longer intervals, and now, as I learn from his father, he has had none for several months.

Of late years the most remarkable triumphs of surgery have been those in which operations have been performed upon the abdominal viscera. After making full allowance for the tendency to report successful cases only, there is strong evidence that the abdominal section may be done with greater success than was formerly supposed, and that important viscera may be removed without serious disturbance to life. These operations when undertaken to save life, which would otherwise be lost, are not only justifiable, but are imperatively demanded; but, when performed where life is not in danger, are only to be condemned.

Abdominal Section in Cases of Extra-Uterine Fotation.-In this operation there has been great difference of opinion in regard to the management of the placenta. Some operators have preferred to remove it, others have allowed it to remain. If removed, there is