7had occurred. Out of doors he would have had, he said, per-haps a dozen in that time, for during the last twelvemonth his ’,fits had averaged three or four a week. Dr. Gull remarked Iupon the frequent, nay, almost constant influence of novelty in

controlling the attacks in what he called " essential epilepsy."By this term he meant that -form in which pathological condi-tions to account for the disease are wanting, or at least are notto be discovered. New doctors, new medicines, changed cir-cumstances, always " cure" this form of the disease for a time,and it is in this fact that we are forced to recognise the re-markable success which attends the treatment of epilepsy byendless different methods,

CLINICAL RECORDS AND OBSERVATIONS.

THE SEQUEL IN SOME CASES OF EXCISIONOF JOINTS.

PERHAPS the most interesting point connected with a sur-gical operation is the condition of the patient some years afteIits performance. It is exactly this point, however, which,owing to a variety of circumstances, is least often recorded.We are glad, therefore, to have the opportunity of noting thecondition, at a very recent date, of some patients who under-went excision some years since.In the year 1859, Mr. Thomas Bryant, of Guy’s Hospital,

excised the head of the right humerus from a man, agedtwenty-three, on account of a chronic disease of the articula-tion of some months’ standing. He adopted the single verticalincision through the deltoid muscle. The case did well. Afew weeks since the patient came under observation, and itwas learnt that he was then, and had been for several years,engaged as a coachman, driving a pair of horses. The arm wasabout an inch and a half shortened, but little or no differencewas presented by the two shoulders. The man said that hecould use the right arm quite as well as the left; indeed thathe could lift a heavier weight with it. He could readily raiseit to, but not above, the horizontal line. Mr. Bryant is dis-posed to think that the line of incision employed has somethingto do with the successful result. By the plan adopted thedeltoid muscle is preserved, its fibres being separated ratherthan divided.

In August, 18Gl, Mr. Bryant excised the head of the femurfor extensive disease of that bone and disorganization of thehip-joint, in a boy aged flve years. The case was fully re-ported in THE LANCET of July 12th, 18G2. The boy recovered,and has been seen at frequent intervals since. He has nowa very useful limb. He can walk and run with facility, andstand upon the affected limb without inconvenience. The legcan be raised as high as its fellow, and rotated with perfectease. The limb is nearly two inches shortened, but with ahigh-heeled boot the deformity is little noticed.A carter, sixty-two years old, came under Mr. Bryant’s care

in August, 1859, with disease of the right elbow-joint followingan injury. There was great enlargement and pulpiness aboutthe articulation, with numerous fistulous openings, throughwhich exposed bone could be detected by a probe. Movementof the joint caused crepitation and great pain. The patientrefusing to have the joint excised, the arm was iixed upon asplint at an appropriate angle, and constitutional treatmentadopted. For three years he persisted in this treatment, butwithout improvement, and eventually in May, 1862, consentedto excision, which was performed. The patient was verytroublesome after the operation, refusing to wear a splint, andin other respects disobeying instructions. Nevertheless, a

steady convalescence followed, the wounds healing, and thesoft parts recovering their natural condition. In six monthsmovement was complete, and he returned to his occupation.When seen recently, it was found that he had been engaged athis work without feeling any inconvenience. He could wieldhis whip with skill, and it was difficult (looking at the arm) tobelieve that excision of the joint had been performed.A man, in whom Mr. Timothy Hohnes, of St. Oeog-rjr’.9 Hos-

pital, excised the shoulder-joint for extensive disease of thearticulation about two years ago, is now employed as a gate-keeper at Kensington Museum. He has a wonderfully usefularm, being able to do almost anything with it. There is somemotion at the seat of the joint, but Mr. Holmes thinks that inthis and similar cases the essential power of mobility is derivedfrom increased freedom in the movement of the scapula uponthe back.

THE TREATMENT OF OPHTHALMIA.

The treatment of gonorrhceal ophthalmia and of purulentophthalmia of infants has undergone considerable change oflate years. In place of the heroic treatment of former days-leeches by the dozen, low diet, tartarized antimony, &c.,-wefrequently see only the mildest forms of treatment pursued,and apparently with greater success. At St. Mary’s HospitalMr. Ernest Hart has cases of both varieties now under treat-ment, which have been brought through severe attacks success-fully by the persevering use solely of weak alum lotions and ofthe spray douche, with the local application of the dilutednitrate-of-silver stick to the mucous lining of the lids. Thealum lotion is of the strength of three grains to the ounce ; it isto be used every half hour at first, and then every hour andtwo hours. In the case of a child the head of the patient is tobe fixed between the knees,-and the eyelids then drawn apart,and the discharge washed away first with lukewarm water,linen rags being used. The nitrate-of-silver sticks are dilutedwith nitrate of potash, as recommended, we believe, by DeGraefe ; this localizes the action of the caustic, and limits it tothe parts touched. In order to prevent the excess of actionfrom superfluous caustic, Mr. Hart uses milk with a camel-hairbrush immediately after applying the nitrate of silver. On theContinent it is usual to employ a solution of common salt, butthis is in itself irritating, Mr. Hart learnt to use the milkfrom a suggestion of Dr. Horace Dobell, who applies it tothe throat, and as a bland fluid it has many advantages oversalt water, in the treatment of the eye more especially. Thenitrate of silver usually needs to be applied every second day.This treatment Mr. Hart describes as very successful, and pre-ferable to more heroic methods. The spray douche may beobtained by the use of the double tubes sold by perfumers forshowering scented fluids. Many such have been devised. A

particularly convenient form has been arranged by Dr. AndrewClark. õ:’ Those patients who cannot afford the few shillingsmust be content with ordinary cold douches applied every halfhour for five or ten minutes in succession, a wet rag being applied in the interval.

IODINE IN THE TREATMENT OF UTERINELEUCORRHŒA.

The treatment of leucorrhoea is a constant subject of diffi-culty and vexation to the medical practitioner. Although theuse of various astringents will often effect improvement, yetthis is seldom lasting, and the recurrence of the symptoms isa continual source of annoyance. We have lately observed aplan which is being pursued by Dr. Murray at the GreatNorthern Hospital, and which promises to be a very usefuladdition to our means of treatment in this very troublesomecondition. Dr. Murray first ascertains, by means of the specu-lum, that the discharge proceeds from within the uterus. Hethen introduces a small short-haired brush (much like thatused for washing phials) by a screw-like motion, so that thethick phlegm-like layer on the uterine wall is swept off withevery turn of the brush. When this reaches the fundus hesteadily withdraws it, charged as it is with the mucous de-posit. Its place is then taken by a gum-elastic catheter withseveral apertures, through which is injected a lotion consistingof one part of the compound tincture of iodine to two parts ofwater. The uterine wall is thoroughly washed with this.The muscular contraction which follows this injection is re-

markable, the tube being tightly grasped, so that its reintro-duction at the time is extremely ditficult. Dr. Murray hasreason, after an experience of many cases treated by this plan,to feel highly satisfied with its success.

TREATMENT OF MALIGNANT AND RECURRENTTUMOURS OF THE ORBIT.

During the last few weeks we have had under notice a some-what novel treatment for the more complete eradication ofthese obstinate and distressing affections ; and, as far as weare able at present to form an opinion, the results seem mostpromising. The treatment appears to be applicable, not onlyto the malignant growths within the orbit, but also to thoseforms of recurrent fibroid tumour which spring from the peri-osteum of the orbital bones, and recur almost as rapidly asthey are excised.The first case was under the care of Mr. De Morgan, the

second under Mr. Hulke, both of the Middlesex Hospital, andSold 1,,- Divey and Son; Xew Bond-street.. ’

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the third under Mr. Geo. Lawson, of the Royal London Oph-thalmic Hospital, Moorfields.The treatment consists in rapidly excising the whole of the

growth from within the orbit, removing, as far as practicable,all the tissues within the bony cavity as far back as the opticforamen, and then freely applying the chloride of zinc pastespread on strips of lint to the bottom and sides of the orbit, soas to effectually destroy any germ of the disease which mayhave escaped the knife. In two of the cases, the actual cau-tery was used to the periosteum lining the orbital walls pre-vious to the application of the chloride of zinc, as there stillremained small adherent particles of the disease, which it wasdifficult to get away with the knife. No untoward symptomsfollowed in either of the three cases ; the pain was not moresevere than after an ordinary cutting operation; and each ofthe patients made a rapid recovery. In the first case, morethan twelve months have elapsed’ since the disease was re-moved ; in the second, more than six months ; and in neitherhave any recurrent symptoms appeared. The last case is stillunder treatment, the operation having been performed onlyabout three weeks ago. Each of these three patients mighthave been fairly considered most unfavourable for any surgicaltreatment, as in two the disease had been twice removed andhad returned, and in the third the tumour had attained a sizewhich it seemed almost rash to attempt to meddle with. Weshall at some future period take an opportunity of reportingthese cases in detail, when more time has elapsed to justify apositive conclusion as to the beneficial results of this mode ofdealing with these terrible affections.

SUBACUTE SYNOVITIS AND CONTRACTED JOINTS.

Mr. W. Adams has been employing for some time past atthe Great Northern Hospital a mode of treatment for effusioninto joints which he finds very satisfactory. In subacutesynovitis, especially of the knee-joint, where there is muchfluid, a large blister is applied to the skin, and when this hasrisen, the cuticle is cut away completely, leaving a raw surface,which is then dressed with strong mercurial ointment. Thedressing is continued so long as the blistered surface remainsunhealed. Occasionally healing takes place very rapidly. Insuch cases a dressing of equal parts of mercurial and of savnointment is applied in order to keep the blister open. Noconstitutional disturbance or salivation, Mr. Adams tells us,results from this treatment ; but he finds the fluid in a jointabsorbed with unusual rapidity. The best cases for the em-

ployment of this method are those where, after an attack ofacute synovitis, although all inflammatory symptoms havesubsided, the amount of effusion shows no tendency to diminish.In very chronic cases with much thickening, he considersScott’s dressing more useful. As regards the propriety of em-ploying forcible extension in the contraction which so oftenfollows synovitis, Mr. Adams considers that where this condi-tion ensues upon traumatic or rheumatic affection of the joint,the process is allowable, and may often be employed withgreat advantage. His plan is to give chloroform, and apply afair amount of force, not in jerks, but steadily. When thejoint is felt to yield, even ever so little, the limb is immediately placed upon a splint, provided with power of extensionby screws, which are turned daily. In contraction from stru-mous disease of joints, he objects even to this amount of vio.lence, having frequently seen grave mischief lighted up by thismeans. When, however, a joint has been very long quiet, ancbony anchylosis has taken place, the strumous taint meanwhilEalmost disappearing, the objection ceases’to apply with th(!?a,me force, and very careful extension is often found useful.

FRACTURE OF THE SPINE: ATTEMPTEDTREPHINING.

A case in which the spine was successfully trephined, for afracture in its lower part, was recently submitted by Dr.Gordon to the Medical and Chirurgical Society (see THELANCET of Dec. 16th, 1865). This is, we believe, the first inwhich success has followed the operation. The subject hasexcited some considerable attention of late years; and it willbe remembered that Dr. Brown-Sequard expressed. himself infavour of the performance of the operation.A young man was brought into St. Bartholomew’s Hospital

in November last, who had been engaged in a brawl. His ad-

versary had lifted him by the hips, and flung him backwards,so that he fell upon the back of his head. It was noticed thata convulsion of his limbs took place immediately on his fall.When admitted a few minutes afterwards, there was complete

palsy of motion and sensation of all the extremities, and ofthe trunk below the fourth rib. There was no unconscious-ness, and the man ate, drank, and slept well from the Satur-day night till the following Monday morning. A gutta-percha

splint was fixed to the back of his neck. On Monday, symp-toms of impending asphyxia showed themselves; he becameblue, and his pulse was very slow. As the, man was evi-dently in a hopeless condition, Mr. Alfred Willett de-cidecl upon exploring the cervical vertebral region, with theview of removing any portion of fractured bone which mightappear to be pressing upon the cord. He accordingly made alongitudinal cut along the back of the neck, taking the spinousprocesses as his guide. On reaching the spine, the theca spi-nalis was found exposed between the fourth and fifth cervicalvertebrae; it was lying, as it were, at the bottom of a gapcaused by rupture of the ligaments between the vertebralarches. There was very profuse bleeding during the operation.Whilst it was being performed, the man suddenly appeareddying; but on pulling the head bacliwards, so as to reduce thedislocation, he revived. Presently, however, he became worse,and died before any removal of bone could be effected.

In this case the upper part of the column was, as usuallyhappens, dislocated forwards. On examining the cervicalregion after death, it was found that the intervertebral sub-stance between the fourth and fifth cervical vertebras was tornaway, carrying with it small portions of bone from each ver-tebra. Above the seat of fracture a considerable quantity ofblood was extravasated upon the cord under the arachnoid.

FRAGMENTARY NOTES ON THERAPEUTICS.

The large numbers of out-patients that flock for assistanceto our metropolitan hospitals give opportunity for useful expe-rience in the value of certain methods of treatment, whichmay be noted occasionally with advantage. There arc

symptoms met with in old persons which are often the pre-cursors of apoplexy, and which remind one of those that fre-quently portend insanity, such as dizziness in the head, confu-sion of ideas, and general embarrassment of the mental faculties.Dr. Headland, in treating such cases in the out-patient depart-ment of the Charing-cross Hospital, finds that half-drachmdoses of the solution of bichloride of mercury (L.P.), if giventhree times a day for three or four weeks, have a useful influ-ence in removing these sensations.* In the chronic bronchitisof the old, where there is great dyspncea, accompanied by adry state of tubes, he finds the tincture of stramonium, givenin doses of ten minims, combined with other expectorants, veryuseful. In cases of excessive secretion, he finds no objectionto the use of opium in half-drachm doses of the compoundtincture of camphor. On the contrary, great relief results fromthe exhibition of this drug. In tænia, the result of his expe-rience is that the oil of turpentine, combined with castor oil,three drachms of each, is a better remedy than the oil of malefern. The castor oil prevents those unpleasant head symptomswhich are apt to arise if the turpentine is given alone. Tur-

pentine he also finds very valuable in epilepsy. He gives iteither in half-drachm doses three times a day, or in a singledose of three drachms at occasional intervals, combined withan equal quantity of castor oil. The results of treatment of

lepra and psoriasis, with five-minim doses of the liquor arseni-calis three times daily, and the external use of the liquidpitch ointment, he finds very satisfactory indeed. The arseniccan be continued for months without any deleterious effects.If such should arise, Dr. Headland suspends this medicine, andgives bicarbonate of potash for a short time, when the symp-toms of poisoning-rash, irritation of the bowels, &c.—subside.In chorea, he has used nothing which has a better effect thaniron. In chlorosis with suppressed menses, he finds the oldGriffiths’ mixture the best treatment, combined with half-ounce doses of the compound decoction of aloes in the morning.

* We are at a loss to know the reason for the omission from the BritishPharmacopoeia, of this valuable method of administering small doses of mer-cury.

TREATMENT OF EPILEPSY.—Dr. Schreyer, of Ham-burg, enforces a very spare diet, gives every day a warm bathof half an hour, when a pail of cold water is poured on thenape of the neck and the back from a height of from four tosix feet. This is followed by sharp frictions. Internally a salinepurgative for some days ; afterwards, twice a day, two grains ofextract of belladonna, which dose may gradually be increasedto six. Out of sixteen epileptics thus treated only three hadrelapses ; and those who have undergone the treatment de

! novo perfectly recovered.