into the follicles. It is a discutient, and as a consequence the epidermis is soon raised and gradually thrown off, during which period of exfoliation there is practically no remedy in contact with the scalp. This explanation applies to all remedies that act in this manner-for example, to carbolic acid. The constant application of the parasiticide, that the same may enter and penetrate the follicles, I believe to be the desideratum in the treatment. To this end oils and ointments are preferable. Before leaving iodine, reference may also be made to a formula, consisting of iodine, 388; carbolic acid, 3j; and glycerin, 3j, which acted as a discutient, raising the epidermis in large masses, but, like the other preparations, was not found efficacious.

For some of the cases the oleate of copper was ordered in the form of an ointment of petrolatum, one and two drachms to the ounce. After a fair trial it was abandoned without having exerted apparently any beneficial influence upon the disease. It neither irritated the scalp nor in any degree allayed the symptoms. It seemed to possess, as far as could be noted, no curative merits.

The mercurials were at one period fully prescribed, chiefly in combination with sulphur and carbolic acid. Some of the preparations, however, were employed alone, such as ointment of the nitrate of mercury and oleate of mercury. This latter was given a faithful trial in from 10 to 30 per cent. strength-the results, however, not meeting expectations. Some of the other salts of mercury, as the red and yellow oxides, white precipitate and calomel, were also tried, but nothing favorable can be said of them as parasiticides. Calomel, however, was found of value in subduing inflammatory action, from whatsoever causes due. With the ointment of the oxide of zinc, a half-drachm to the ounce, it was found serviceable when active parasiticides would not be tolerated. Corrosive sublimate, so useful in the localized and early stages of ringworm, was not prescribed, for the reason that, owing to the disseminated character of the disease and the large extent of surface invaded in almost all the cases, it was not deemed a safe remedy.

Croton oil, in sluggish cases, proved especially useful in provoking acute, purulent, inflammatory action. After this had been well established, the milder parasiticides, as the sulphur ointments and lotions, were advantageously prescribed. The oil was usually applied with olive oil, one part to three parts, which strength proved to be safe and efficacious. This would generally produce pustulation after one or two applications at intervals of twelve or twenty-four hours. In spite of care in the mode of application, only a thin layer being put on, the action sometimes would spread beyond the line intended. In one instance only was pain complained of. After free follicular pustulation had been established, in from two to four days, an ointment composed of equal parts of petrolatum and oxide of zinc ointment, or a mild

sulphur or calomel ointment, was applied to control the suppuration. In two or three cases only was kerion set up, and it seems remarkable that this form of inflammation should not have occurred oftener in the whole series of cases. In no instance did it occur spontaneously as a symptom of the disease, but resulting from the action of the oil, it was noted that the disease was benefited, as was to be expected. As stated, however, this pathological condition was difficult to produce, much as its presence might be desired. No unfavorable results followed the use of the oil, although in one or two cases destruction of the follicles in some localities seemed imminent; but I believe even in these cases the hairs eventually grew out again. On several occasions the oil was applied in the form of a moulded wax stick, but the desired action could not always be obtained, and the method was abandoned for the diluted oil and the brush. Cantharidal blistering fluid was now and then used, but possessed no special virtues. Cantharidal collodion was tried as a vehicle for such remedies as chrysarobin, but this mode of application cannot be commended. It may be referred to in passing that notwithstanding the extensive and severe cutaneous irritation and artificial inflammation started and kept up by the remedies, prolonged in some instances in more or less severe degree for months, no case of eczema was developed. In no instance did this disease, from whatsoever cause produced, complicate the ringworm. The observation is one of interest, bearing upon the etiology of eczema as concerns its local origin.

I come now to speak of two well-known parasiticides, from both of which good results were obtained, namely, sulphur and chrysarobin. They are, of course, different in their action on the skin, one being comparatively mild, the other a powerful remedy. They were often advantageously prescribed to supplement each other, especially the weaker after the stronger.

Sulphur may be first considered. It was used mainly in the form of ointment, varying in strength from one to three drachms to the ounce. As a weak ointment it was found to be especially serviceable after the stronger remedies, and more particularly in clearing up scurfiness. This condition, scurfiness, was a common and embarrassing symptom-its precise nature, whether parasitic or not, being at times difficult to determine. In most cases it proved to be simple or non-parasitic, but it was nevertheless a persistent and troublesome condition. As has just been pointed out, it yielded more readily to weak sulphur ointment than to any other remedy used. In the strength of two or three drachms to the ounce, it was valuable in those cases where, for certain reasons, a safe remedy was demanded. It proved an efficient, mild parasiticide. As has been already referred to in the earlier part of this paper, it was also prescribed in various combinations, as with soap, and with tar ointment, and carbolic acid, but it was thought to be more useful employed alone.

The most active and potent parasiticide employed, however, was chrysarobin. At one time or another it was in use upon the greater number of the patients, and as it can be spoken of in terms of praise, a short account of it may be given, especially as my experience with it has been different in certain particulars from that of some other observers. It was prescribed in twenty-nine cases. In seven, more or less irritation of the scalp occurred, while in twenty-two there was none. By irritation is meant sufficient local disturbance to demand the temporary suspension of the drug. The strength varied from fifteen grains to two drachms to the ounce of ointment-the weaker ointment, however, having been seldom employed. The strength in common use was one drachm to the ounce. Some of the patients, it is unnecessary

to state, tolerated a much stronger ointment than others; thus, in one case nine applications of a two drachm to the ounce ointment were made without causing swelling or inflammation of either the scalp or face. In another instance ten applications of the same ointment gave rise to no inflammation of the eyes. Several cases were recorded in which the eyes escaped even though other parts of the face were slightly inflamed and stained. In one instance only did oedema of the whole face occur, and this after the fifth day. In one patient an ointment of one drachm to the ounce was applied to the whole scalp without giving rise to undue inflammation. These cases are alluded to for the purpose of showing how well borne was the drug in most cases. There was no reason to doubt that it was of good quality. Unpleasant burning sensations and heat were noted in only a few instances. On one occasion pain in the head was complained of, although the scalp did not look painful or even sore, while in some cases the whole scalp became apparently inflamed without giving rise to either heat or pain. In some cases, too, the forehead and sides of the face were stained without involving the eyes. In only one case did the glands of the neck become markedly engorged. The inflammation of the scalp passed off in the form of desquamation of a peculiar character, consisting of large, papery masses of scale. When the ointment used was strong, the scale would come away in large and thick patches. From my experience with the drug in these cases-which, be it remembered, were all chronic and had long been subjected to strong remedies of one kind or another-there would seem to be not much danger from its employment if applied under the supervision of the physician, and if due care be exercised in avoiding the face, in making the applications sparingly, and in gradually increasing the strength. It is a remedy always to be handled with caution. It is remarkable that so little excessive cutaneous disturbance and so few complications were noted. It proved the most valuable parasiticide in the list. In the form of ointment it possessed power to penetrate the follicles and to destroy the life of the fungus, and in this latter power

lies its great worth. It may be mentioned that in no instance was chrysarobin used in combination with other remedies; therefore, such results as were obtained may be attributed directly to it.

In conclusion, I would say that it should invariably be applied in the smallest possible quantity and be well rubbed in with a bit of cloth or a mop. Used with caution, the staining of the skin of both patient and nurse may be reduced to a minimum.

In the class of cases of ringworm under consideration, all treatment, at best is slow, but I have no hesitation in giving the preference to chrysarobin. It is the most potent remedy at our command, and the observations and experience here recorded demonstrate that it is not only a valuable but a comparatively safe remedy, and that with due precaution and care it may be applied to the scalp, under the supervision of the physician.

TEN CONSECUTIVE CASES OF EXCISION OF THE KNEE-JOINT, WITH THEIR DEDUCTIONS.

BY JOSEPH D. BRYANT, M.D.,

OF NEW YORK.

IN presenting these cases, I shall draw from my own individual experience rather than from the literature of the subject and from theoretical suggestions. This course is made especially proper, not only by the short time now at one's disposal, but also by the fact that results are more entertaining and instructive than are unestablished theories. In March, 1885, my first paper on excision of this joint was presented to the Orthopaedic Society of New York, now the Orthopaedic Section of the Academy of Medicine of that city. In that paper two cases, each successful, were presented for examination, namely, Nos. 1 and 2 of the appended series of cases. The belief was then expressed that excision of the knee-joint was admissible for the following conditions:

"1. It should be done when remote or unsound ankylosis appears to be the only result that can be reasonably expected.

"2. It should be done when mechanical and remedial measures, faithfully applied, have failed to afford any permanent relief.

"3. It should be done for vicious ankylosis, or for deformities that cannot be overcome under anesthesia combined with tenotomy or extension.

"4. It should be done as a substitute for the expectant plan of treatment, when the unfavorable surroundings of the patient, or the slow course of the disease, make hopeless or even doubtful a recovery with sound ankylosis."

I will not recapitulate now the course of reasoning that led up to these conclusions, since the conclusions themselves are not altogether new, nor are they surrounded by any uncertainty of diction. Each case as it appears in the appended tables is of itself quite suggestive of its history and of the final treatment which it represents.

Subsequent to this time (1887) a second series of four cases was presented before the Orthopaedic Section of the Academy of Medicine. One of these cases (third of the appended series) died of Bright's disease on the thirteenth day after the operation of excision. As the result of this unfortunate termination, the propriety of the adoption of the following measures in connection with chronic diseases of the large joints or of bones was emphasized by the writer:

"1. A constant and close scrutiny should be made of the functions of the kidneys in all cases of chronic diseases of large joints or of bones, with the view of detecting the first manifestations of the consequent complications of the kidneys in these diseases.

"2. The advisability of operation in severe cases before kidney disease may be manifest; provided all other well-recognized measures of treatment have been given a reasonable trial without substantial benefit.

"3. The advisability of operation at once, when kidney disease is found to exist as a presumptive consequent complication, to limit if possible the further involvement of the kidneys from these causes.

"4. The use of chloroform instead of ether, in operations with kidney involvement.

"5. A careful scrutiny of all the nooks and crevices of the joint, and of the surrounding tissues, that all diseased products may be removed to prevent the infection of the fresh surfaces."

The employment of chloroform instead of ether in operations complicated with kidney involvement is not a settled question by any means; although, in my judgment, the conservative thinkers and workers are strongly predilected to its use in these cases. At all events, without desiring to classify myself at all in this connection, I am accustomed to use and to advise the use of chloroform in such cases.

The care necessary for the careful removal of all diseased products is too obvious to be entitled to the dignity of a mere mention, except that by so doing the attention of the operator is called to the wisdom of exercising close scrutiny, that none such may escape his attention.

Another of this number (fourth of the appended series) presented the question of the advisability of operation for the relief of long-continued and very troublesome rheumatism of the joint, attended with much pain and ankylosis, together with great demoralization of the patient. This patient was told that she would, no doubt, ultimately recover with a stiffened and insecure knee, subject probably thereafter to periodic attacks of pain and tenderness. To this prediction she replied: "If I am to have a stiffened leg anyway, why not have it at once, and avoid