passing of the stitches, of which there are two kinds, can not only be accomplished easily but efficiently.

For example, in the removal of a large adenoid sarcoma of the mamma, which many of you saw me undertake recently, there was a considerable gap to fill up, and the method I adopted of

A. The Button of Ogilvie Will.-The wire is passed through the aperture in the centre, hooked round the pillar of one end and carried onwards to that of the other.

B. The Button of Lister.-The wire is passed through the hole in the middle, twisted round one of the everted sides and then round the other.

C. The Button of Macewen.-A double thread of wire or gut is passed through the two small openings in the centre. If the former is used, the ends are secured by twisting the one round the other in the usual way with this material, and with the latter a reef-knot (aa) on the one side and a slip-knot (bb) on the other complete the arrangement, as shown in the following figure. With this button the amount of pressure which it is thought desirable to apply can be regulated with the greatest evenness and nicety, and there is no tilting of the sides.

Will's Buttons are made of silver, and consequently are expensive. Lister's are of lead. Macewen's are made of block tin. They possess more pliancy and adaptability to the shape of the parts in their neighbourhood than either of the others. To prevent friction protective plaster should be placed between them and the skin, and in this case there is no liability to the throwing down of a black deposit as usually happens with lead.

bringing the raw edges together was as follows:-Two button sutures of thick gut were passed first of all, aa, bb, Fig. 3, so as to approximate the bases of the flaps. Several deep stitches of the same material placed at regular intervals followed, which took a good grasp of the tissues, and are termed the stitches of relaxation; and finally, between these were inserted a number of threads of fine gut, termed the stitches of coaptation. The strain on the parts was in this way relieved, the edges were closely and evenly approximated, and union by first intention took place along the whole line of incision.

In the figure below an excellent illustration is given of the best method of bringing together the raw edges in the amputation of a mamma, and as performed in the way just narrated. The letters aa represent the button sutures (catgut), tied by means of a reef-knot, and the letters bb show the same threads secured at their other end with a slip-knot. At c are seen the decalcified drainage tubes threaded with horse-hair, and retained in their places by means of catgut stitches. Four stitches of thick catgut (stitches of relaxation) are placed at

regular intervals along the line of incision, and between these are inserted a number of threads of fine gut (stitches of coaptation).

The scar which followed this wound was thus reduced to a minimum, and in a short time, unless closely looked into, would probably pass unobserved.

The gauze dressing, with which you are all familiar, is a great improvement on that of lint. It thoroughly protects the part it covers from all external influence, it does not require so frequent changing, and it has much more absorbent power

three very important points to be borne in mind as regards the wellbeing and speedy recovery of the patient.

The operation of osteotomy, devised and most successfully carried out by my friend, Dr. Macewen, for the relief of certain deformities of the lower limbs, is a great advance made in surgery, and to have attempted such a thing a few years ago would have been considered nothing short of madness. The statistics* of this eminent surgeon, however, prove that in his hands it is a safe procedure, resulting in benefit to the patient, both as regards appearance and powers of locomotion. The operation mainly consists in the division of bone, and in order to accomplish this either sawing or cutting must be resorted to. The latter is the more preferable, as well as the easier, method of effecting this, as in sawing there is not only laceration of the soft tissues, but a considerable amount of bony debris must be left in the wound, which is apt to lead to suppuration. On the other hand, when using the chisel in the proper way, the bone is divided without much difficulty, and beyond the first incision which, if properly performed, ought to be a clean cut, there can be little or no injury done to the soft parts.

Excepting cases of osseous anchylosis, osteotomies are performed mainly for the relief of three kinds of deformities-knock knees, bow legs, and anterior tibial curves. In the first class the femur is divided on its internal aspect, at a point opposite, and corresponding to, one inch above the external condyle. In the second the tibia, and if need be the fibula, are osteotomised in one or more places, but in the case of children it is not always necessary to accomplish the latter proceeding, as after section of the tibia the fibula will frequently yield to pressure, a green stick fracture being produced. Where there are prominent anterior tibial curves, the best way is to remove a wedge of bone, after which straightening of the limb will be found comparatively easy. The tibia is much harder and denser than the femur, and requires a good deal of force to sever it. When rickets is present this characteristic is especially well marked. In all osteotomies it is highly desirable at the first to get the chisel well into the bone with a few vigorous strokes of the mallet. In this way not only is division rendered easier, but there is much less chance of the instrument getting out of the groove, and in consequence excoriating the periosteum or otherwise injuring contiguous structures.

*Osteotomy, with an inquiry into the Etiology aud Pathology of Knock Knee, Bow Leg, and other Osseous Deformities of the Lower Limbs. By William Macewen, M.D. Page 161, chapter xxi.

In the treatment of the various kinds of talipes, the cutting of the offending tendons, coupled with the after wearing of steel boots or other mechanical appliances, is the only curative measure followed by many surgeons. The division of the tendons no doubt aids in the rectifying of the mal-position, but unless the foot can be subsequently kept in its proper place tenotomy is of little use, and the old habit speedily regains the ascendency. Theoretically, the wearing of steel boots may appear easy and efficacious, but practically they often give rise to much discomfort, and as the pressure which they exercise is confined to a somewhat limited area, abrasion, and if neglected, even sloughing may take place in consequence. The application of splints is frequently unsatisfactory, as the constant movements of the child soon render the whole apparatus loose, and consequently ineffectual for accomplishing the object we have in view.

The introduction of paraffin has, however, been turned to good account here, and many cases of club foot can be cured without division of the tendons by the wearing of a boot of this material for a sufficient length of time. I have frequently practised the method recommended by Macewen, and with excellent results. It may be described as follows:-The patient having been put under the influence of chloroform, a gauze bandage is wound round the limb, after which a sheet of the ordinary coarse wadding of the requisite size, previously soaked in liquid paraffin, is moulded over it. The foot is now forced into as favourable a position as possible, and kept so until the process of solidifying has taken place, which may be hastened by the action of cold water. The boot can be worn for six weeks, when it may be taken off, and at the end of this period, if the foot should still tend to revert to something of its old habit, the paraffin can be re-applied.

It may be fairly claimed for paraffin, in the treatment of talipes, that while thoroughly effectual, it is easy of manipulation, and almost always well borne by the patient. After being applied to the limb it is not liable to subsequent displacement, so that the foot, when once securely fixed, cannot resile to its original position. Movement on the part of the child does not matter, and as the pressure which the boot exercises is equally diffused, it seldom happens that any injury is done to the skin. I have invariably found that age is a most important factor as regards the after result, and the younger the child the more hopeful is the prognosis. When patients are allowed to walk before being operated on, a partial cure is in many instances only to be

looked for, and much time and pains are demanded in securing even this.

In obstinate cases of talipes varus, the removal of a wedge from the astragalus and os calcis is frequently followed by improvement, and it is not difficult to see that the gap which is so produced must permit of the foot being everted into a more favourable position than it could otherwise оссиру.

A totally different method of dealing with abscesses is now carried out as compared with the practice of even recent

years.

Formerly, after incising the cavity and pressing out the contents, the case, with the exception of frequent syringing, was almost entirely left to nature, while recovery in most instances was tedious. At the present time, and with antiseptic precautions, a much more vigorous line of treatment is adopted, and we have no hesitation in removing the pyogenic membrane en masse, interference with which older surgeons looked on with disfavour. In order to accomplish this we make use of Volkmann's spoon, and if the whole of the inflammatory products contained in the cavity are scraped out, two healthy surfaces are left apposed to each other, and which speedily becoming covered with granulations soon coalesce. During the process of healing the less the parts are disturbed the better, and syringing the cavity irritates the tissues composing its walls, and leads to increased discharge while the progress of cicatrization is interfered with, and as a natural consequence recovery, instead of being accelerated, is considerably retarded.

The spoons of Volkmann are extremely useful instruments, and will be found invaluable for the removal of diseased granulation tissue, and similar purposes. They are made of different lengths, and the head of the spoon can be procured in either a round or oval form.

The transplantation of bone* is now an accomplished fact, the greater part of a humerus having been replaced by Dr. Macewen during the last year or two. Many of you may remember of having seen the case alluded to in Ward 22, in which the most of the shaft of the bone had become necrosed, and it was thought that amputation was the only course left. Before proceeding to that extremity, however, Dr. Macewen thought it would be as well to try if living bone could not possibly be transplanted from one subject to another, and taking advantage of the wedges removed in tibial curves he * Proceedings of Royal Society, No. 213. 1881.