view healthy osseous structure. I sawed off the olecranon and coronoid processes of the ulna, and the head of the radius in the same manner. With a strong pair of scissors I then pared away any thickened structures about the joint, and having tied three small vessels, I immediately washed out the wound by pouring into it cold water from a height, and introduced four points of silver wire suture to approximate the flaps, dressing the wound with strips of lint wet with spirit lotion. I gently flexed the forearm to a right angle, and placed the limb, carefully bandaged, on a well-padded rectangular wire splint. The patient was forthwith put to bed, and got an opiate.

The daily record of the case does not present any peculiarity. Passive motion was commenced about sixteen days after the operation, and increased gradually so as to ensure the formation of a false joint. The girl now possesses great command over the motions of the forearm and hand; she can supinate and pronate, flex and extend, the forearm, and can use her fingers sewing.

On examination of the portions of bone which had been removed, it was found that the cartilage had disappeared from part of the trochlear surface of the humerus, and had been replaced by fungous granulations, the greater sigmoid cavity having been almost filled up with a gelatinous fleshy mass; the coronoid and olecranon processes were denuded of periosteum and covered with spiculated bony projections; the head of the radius, at its articulation with the humerus, was diseased, the radio-ulnar joint alone remaining sound.

Plate II. gives a faithful representation of the different portions exsected. Two inches and a half of bone were removed. The primary incision which I adopted in the present case, as well as that in which the excision was performed for compound fracture, was one which gave ample room for the exposure of the articulating ends of the bones about to be removed. Different operators of eminence, however, recommend various preparatory incisions; as, for example, the H-shaped incision-Moreau, Fergusson, and Syme. The single vertical is recommended by Park, Chassaignac, and Langenbeck; the crucial by Park, Fergusson; the semi-lunar by Gross. All these methods have their respective advocates. Syme, to whom much is due for bringing this operation to perfection, in his Observations in Clinical Surgery, speaks highly of the H-shaped. He says:-" This incision I still regard as the most convenient for the purpose, since it not only affords free access to the joint, but also allows the transverse part of the wound to heal

by the first intention, and thus prevent the obstacle to mobility which would result from the process of granulation, followed by cicatrization at this part." The form of cut adopted in this case will, I feel confident, be found amply sufficient and convenient. The advantages of this operation as a conservative measure require in the present day no advocacy, excision of the elbow-joint having been firmly established among the safe and beneficial operations. Whether performed for joint disease, compound fracture, or inconvenient anchylosis, it has been found that the proportion of deaths is very small, amounting to about 22.15 per cent., while amputation through the humerus yields 334 per cent. of deaths. Another encouraging circumstance is that this operation is most successful in young patients, among which class it is likely to be more frequently performed from the prevalence of joint disease in early life. The drawing, Plate III., gives a very good representation of the present condition of the limb, which is in every respect a most useful one.

3.-Excision of a Large-sized Epulis, Springing from the LowerJaw; Recovery.

Cecilia O., aged twenty-nine years, and married, was admitted into the Meath Hospital, under my care, July 16th, 1866, suffering from a large epulis. This woman was in a very weakly condition, having been confined only three weeks previously; and prior to that event, her circumstances being very straitened, she was ill clad and badly nourished. On admission she presented the following symptoms:Her left lower jaw appeared at first sight greatly swollen, as if from a severe gum-boil. The examination of her mouth, however, displayed a large tumour, occupying the position of the teeth on that side of the inferior maxilla from the second incisor to the last but one molar. Its measurements, taken with a callipers, were one inch and a-half in its transverse diameter, and one inch six-eighths in its antero-posterior diameter. It pushed the tongue towards the right side. Its colour was that of the surrounding gum structure, and its surface was slightly lobulated, giving it a somewhat hour-glass shape. To the touch it felt firm and elastic, like healthy gum tissue. Its upper surface was ulcerated from pressure of the teeth of the upper jaw indenting the growth. The patient was unable to close the teeth in front, a space of half an inch existing between the upper and lower incisors. She suffered pain when she tried to masticate.

The only teeth visible on that side were the

incisors and the last molar. The others had (with the exception of the first molar) been thrust out by the tumour, which had apparently sprang from the socket of this tooth after its extraction two years previously. She did not feel any pain until the ulceration of its surface commenced, nor had the tumour bled before it ulcerated. Although wretchedly emaciated and looking feeble, there was no malignancy in her aspect, so that the absence of glandular contamination, coupled with the length of time it had taken to grow, made me decide on its removal. Any operative interference, however, in her debilitated condition was not to be thought of, so I determined to bring up her health by generous diet and rest.

On the 10th of August, her strength having very much improved, I proceeded to excise the tumour in the manner following:-I had her placed on a low table, with her head and shoulders slightly raised, and had chloroform administered. And here I may remark that although some surgeons have a great objection to the use of this agent when operating on the mouth, still my colleagues and I frequently give it in such cases, and never fear an unpleasant result, provided that any flow of blood is rapidly sponged up as the necessary incisions are proceeded with. The second incisor was drawn, and one of my colleagues having inserted a strong copper spatula, bent to an abrupt curve at its end, into the mouth, he forcibly dragged the cheek outwards and backwards. This manœuvre gave me a good deal of room, but not sufficient to allow me to work with a saw behind the tumour without splitting the cheek. The tongue having been well depressed, I cut downwards through the mucous membrane inside and outside the jaw, behind the mass, to about the extent of half an inch from the alveolar process. I then, with a strong nippers, the blades of which I placed in the incisions, cut through the bone to the same depth from the surface of the adveolar process. I now carried similar incisions through the mucous membrane in front of the epulis, and cut, with a small saw, to the same depth in the jaw bone as I had done behind with the nippers. Having now isolated the swelling before and posteriorly, I made incisions connecting these on the outside and inside through the lining membrane. Then with the saw I partially cut through the body of the inferior maxilla beneath the epulis, and completed its entire removal by means of a strong cross-cutting nippers. There was very free hemorrhage from the inferior dental artery, but I carefully plugged the space with lint, over which I placed a thick compress, and tightly bandaged the lower-jaw to the upper. This arrested all

bleeding. At the same time sufficient space was permitted between the front teeth to allow of the patient getting fluids with a spoon. She was then removed to bed, and an opiate administered. On examination the tumour appeared to be a simple epulis. The section of the bone was sound, and the growth had arisen from the sockets of the teeth, and overlapped externally and internally. The above case may be considered interesting, showing, as it does, the feasibility of extirpating a large tumour from the lower maxilla without the infliction of any wound on the face. The epulis itself afforded a larger example of this disease than is usually met with. This poor woman made a good recovery, and left the hospital on the 31st August in excellent health.

ART. XIII-Contributions to Operative Surgery. By HENRY GRAY CROLY, F.R.C.S.I.; Licentiate of the King and Queen's College of Physicians; Surgeon to the City of Dublin Hospital; Lecturer on Clinical Surgery; Senior Demonstrator of Surgical and Descriptive Anatomy in the School of Surgery of the Royal College of Surgeons.

FOUR cases of Amputation by long and short rectangular flaps (Teale's method), illustrated by practical observations advocating this mode of operation, viz:

I. AMPUTATION OF THE LOWER THIRD OF THE LEFT THIGH; RECOVERY.

II. AMPUTATION OF THE ARM; RECOVERY.

III. AMPUTATION OF THE ARM; RECOVERY.

IV. AMPUTATION OF THE LOWER THIRD OF THE LEFT THIGH;

RECOVERY.

When the surgeon is called upon to amputate a limb the first question which naturally suggests itself to his mind is, by which of the several methods shall I perform the operation? And although the subject is one which, from the earliest history of our noble art, has received a large share of attention from surgical writers, there is, perhaps, none on which surgeons, even in the present day, are more undecided. We find some preferring the old circular method