you from all operations of mere convenience, and from all measures of what may be called decorative surgery in phthisical people; but it should not always dissuade you from operations that will cure diseases from which they suffer much, and by which their lives are wasted, as they are by fistula and diseases of bones and joints.

In these and the like cases, the main question is, whether the local disease-say, a diseased joint-is weighing on the patient so heavily, or aggravating his phthisis and shortening his life so much, as to justify an operation attended with more than the average risk of life and health. Of course, the weight of each local disease must be separately judged; but in reference to the risks of operations, cases of phthisis must be divided into two classes which, by comparison, may be called acute and chronic, or progressive and suspended, phthisis.

In all cases of acute or progressive phthisis great risk is incurred by almost every operation. The risks of the excitement of many days of feverish disturbance, and of loss of food, and of pain, and all such consequences of operations, are much above the average; to say nothing of the special chances of exciting some pneumonia. I cannot doubt that I have seen patients whose acute phthisis has become more acute, and others in whom the early stages of phthisis were accelerated, by the consequences of operations. Therefore I should follow the rule of never performing any considerable operation, if I could help it, on any person whose phthisis is in quick progress. Small things may be done on them for the relief of great distress or pain; but larger things had better be left undone, even if they should never be done at all.

The case is very different with chronic and suspended phthisis. In these it is often advisable to incur the somewhat increased risk of even a large operation, in order to free the patient from the distress and wasting of a considerable local disease such as that of a joint; and I should be disposed to say that it is always advisable to cure, if you can, a small disease such as fistula. I say if you can, for you will often be disappointed. In the tuberculous, as in the strumous, your wounds will remain for weeks unhealed and, perhaps, be unsoundly healed. at last. Still, as to the mere question of operating, I have seen so many advantages accrue to patients with chronic phthisis from the removal of limbs with jointdisease that I am disposed to speak strongly as to the general propriety of whatever operations they may reasonably require. For instance, I still sometimes see a man about the hospital from whom I remember that, at least fourteen years ago, Mr. Stanley removed the left lower limb above the knee for disease of the knee-joint. He was the subject of chronic phthisis at the time of the operation; and the question was carefully discussed whether amputation should be performed on him. It was decided on; and though he has been phthisical ever since, and always very poor, yet he is still well enough to pursue some quiet occupation. I can hardly think he would have been doing so at this time, if he had had to bear at once the burdens of both tubercular lungs and a painful knee-joint.

There is a risk, common to the progressive phthisis and the suspended alike, that by long-continued confinement to one atmosphere, such as must happen after the excision of a

joint, you may put the patient into that state of quiet gradual impairment of health which is so terribly favourable to the progress of tubercular disease. Among all these risks you must make the best choice you can. And there is one point in relation to them about which it will be well to speak. Patients with long-standing strumous disease often look phthisical, whether they have tubercular disease or not. And, occasionally, you find one with cough and rapid breathing, and many other symptoms so like those of phthisis, that nothing but the most exact stethoscopic examination can persuade you that the lungs are in their structures sound; yet all these symptoms may be removed by the removal of the diseased part. Some years ago, I had a young lady for a patient with strumous disease of the knee-joint, of six or seven years' duration; and for many weeks she had had irritable cough at night, quick pulse, and rapid breathing, and all the signs which on a superficial examination might have led to the belief that she had phthisis. Yet no tubercular disease of the lungs could be detected, and I removed her limb above the knee. Up to the night before the operation she had been restless with coughing. After the operation it was doubtful whether she ever coughed again.1

1 The question of operating for fistula in phthisical patients is fully discussed in Curling, Diseases of the Rectum, 1863, p. 102; H. Smith, Holmes's System of Surgery, 2nd Ed., Vol. iv. p. 832; Allingham, Diseases of the Rectum, 1871, p. 39; Erichsen, Science and Art of Surgery, Ed. 5, Vol. ii. p. 515. The general conclusion from their statements is similar to that of the lecture.

LECTURE III.

CERTAIN diseases of the kidneys increase the risks of operations more, I think, than do the equally chronic diseases of any other internal organ. And the chief of these diseases are, first, those which are associated with the constant existence of albumen, or with the frequent or constant presence of pus, in the urine. In the first group, those of which we commonly speak as cases of albuminuria, the risks of erysipelas and of pyæmia seem to reach their climax. Not that I know this from having frequently operated on patients thus diseased. We are too cautious for this; and, as you know, no patient with any chronic ailment goes from my wards into the operating-theatre without a previous examination of the urine. But you may learn it from the frequency with which accidents, such as scalp-wounds, compound fractures, and the like prove fatal in those who are subjects of albuminuria. All the dangers of which you are taught in medical lectures as to the tendency of albuminuria to generate pericarditis, pleurisy, and other internal inflammations, are proved emphatically when the patient's general health is disturbed by the consequences of injury, whether accidental or by design. I do not know by how many times the risks of a given operation are increased in any patient who has albuminuria, but I do know that you

will find it a safe rule never to perform any operation without an acquaintance with the manner in which the patient's kidneys discharge their function; and never to perform one, except under something like compulsion, on a patient whose urine is constantly albuminous. I do not say that you should never operate on such a patient, for the exigencies of the local disease may justify you, as they may justify you in operating in the advanced phthisis; but be clear that you operate against heavy odds; for even if the patient do not die with erysipelas, or pyæmia, or some other form of diseased blood, he will be apt to linger with a wound half-healed, till at last he dies of his renal disease just as if you had done nothing.

You saw a patient of mine, in whom we were certain of the existence of advanced granular disease of the kidneys, with albuminous urine, die last year. A poor woman who, ten years before, had one limb amputated below the knee for chronic ulcer of the leg, came with the remaining limb so badly ulcerated, and so hindering her poor means of living, that she begged me to remove this leg too. She had recovered from one amputation, and had such comfort in consequence of it that she begged me to give her the possible advantages of another, at whatever risk. After many vain attempts to improve or palliate her condition, I removed the limb; and then you saw how, week after week, the stump remained unhealed, and how, though she was relieved of pain, and remained hopeful to the last, she became more and more feeble and oedematous, and died, just as she would have died if she had retained her limb-in greater comfort indeed, but not a day later.