this exception had been always healthy, until eighteen months previous to his entrance to the hospital, when, in St. Louis, Mo., he received an injury which caused a compound comminuted fracture and dislocation of the left ankle-joint. He was treated for five months in a hospital in St. Louis, and, at the end of that time, was able to walk around with a cane. On account of an outward deviation of the foot, however, walking was painful, and could be endured for only a very short time. In June an abscess formed around the internal malleolus, which was opened on admission, and some pus evacuated. No denuded bone could be felt through the wound. He left the hospital at his own request, August 10, the wound not yet being healed, but returned September 1, suffering with increased swelling and pain, and was placed under my care.

Examination.-Patient is unable to walk on account of pain in the region of the left ankle-joint, at which point is found a Pott's fracture healed in a bad position, with outward deviation of the foot. The internal malleolus is very prominent, considerably enlarged, and covered on its inner surface with a layer of adherent cicatricial tissue. Above and exterior to the external malleolus is an irregularly shaped ulcer, about three-quarters of an inch in diameter, with quite abrupt edges and an uneven floor, covered with grayish-red discolored granulations, and secreting a large amount of thin, grayish pus. The surrounding skin is dark-red, swollen, and tender.

FIG. I.

The deformity of the foot (shown in Fig. 1) is the real cause of his inability to walk, as the line of gravity of the limb falls internal to the foot, or, in other words, the foot is in a position of dislocation outside of the line of gravity; that is, the line of gravity of the foot forms an angle with the line of

gravity of the limb, which opens outwards, and in which the apex of the angle corresponds to the base of the internal malleolus, the seat of the old Potts' fracture.

To remedy this deformity-after careful investigation upon the cadaver, as to the best method of performing osteotomy in such cases-I devised the following operation:

September 12.-I operated, assisted by Dr. Sawyers, and in the presence of Drs. Gunn, Isham, Jacobson, and Lee. The patient was anesthetized with ether. A transverse semilunar incision was made over the inner surface of the inferior extremity of the tibia, two inches above the apex of the internal malleolus, through the skin and subcutaneous tissue, being careful not to open the sheaths of the tendons of the anterior and posterior tibialis muscles. A transverse incision was then made through the periosteum, and a short longitudinal incision on either end of this. The two flaps of periosteum were separated from the bone with a gouge, and a base three-quarters of an inch in width was marked out with a saw, for a wedge-shaped piece of bone, which was cut out by means of hammer and chisel, the point of the wedge being at the external border of the tibia. The attempt was now made to reduce the deformity by taking the foot in the right hand and bending it over the knee. While reducing this deformity, the fibula fractured at about an inch below the cut through the tibia, and the upper fragment of the external malleolus broke out through the ulcer described above, thus making a compound complicated fracture which extended into the ankle-joint. The external malleolus was the seat of a diffuse osteoporotic osteitis, and consequently the osseous tissue at this point was very fragile. The remaining part of the diseased malleolus was now removed, the cut surfaces of the tibia approximated and secured by strong silver wire sutures, a drainage-tube inserted, the wound closed by sutures, and Lister dressing applied.

The leg was then placed in an apparatus devised for the purpose, which consisted of a padded leather band around the upper part of the calf, which contained a heavy steel bar, that came down on the external side of the foot, bearing a foot-piece, which. was inverted and kept in place by a strap on the inner aspect of the leg. The steel bar, when passing over the external malleolus, was bent out so as to permit the application of Lister dressings around the ankle-joint without removing the apparatus. The band was secured around the leg by leather straps and buckles, and the foot fixed to the footpiece by roller bandages. The whole apparatus was suspended in a Hodgen's anterior splint.

13th.-A little hæmorrhage occurred during the night, with some pain.

14th.-Wound dressed; no suppuration. 16th.-Wound dressed; very little suppuration, but considerable pain. Applied ice-bag over the dressing.

October 8.-For the last two weeks he has had no pain. The wounds, both over the tibia and fibula, are granulating somewhat luxuriously. Touched with nitrate of silver.

18th.-Wound dressed. Foot seems to be turned

FIG. 2.

In uncomplicated cases, in which the patient's health is good, and the osseous tissue at the seat of the operation normal, the time for the healing of the cut surfaces of the bones and the osteotomy wound will not greatly exceed the usual limited number of weeks required for the recovery from a common, subcutaneous Pott's fracture. This I intend to show by the following case:

CASE II.-Outward deviation of left foot, subsequent to Pott's fracture-Operation four months later -Aseptic course without suppuration - Eight days later, drainage-tubes removed-Perfect osseous union in four weeks-Complete recovery. (Fenger, Chicago, 1880.)

John B., Irish, aged thirty-eight, a painter, was admitted to Cook County Hospital, July 14, 1880. He had previously had good health. On April 15, he was seated beside a tree, eating dinner, and got up suddenly; in so doing, he put his left foot into his dinner-pail; his right foot slipped, throwing his weight on the left foot, which turned outward and upward, causing him much pain. A physician was called, who pronounced the injury a fracture. At this time the foot was turned outward and upward until it was nearly at right angles with the leg. It was placed in loose dressings for a week, after which a starch-bandage was applied, which was continued for four weeks. The patient remained in bed for more than four weeks, and was then allowed to be up on crutches, but was not yet able to bear his weight on the foot. Consequently, four and onehalf months after the receipt of the injury, the patient entered Cook County Hospital, and was placed in my care.

On admission, the patient was unable to walk without the aid of a cane. He could not bear weight

on the foot without intense pain. The same de- | formity existed which has already been illustrated in Case I.; that is, the foot was in a position of outward subluxation; the line of gravity of the limb, instead of being continuous with the line of gravity of the foot, formed with the latter an angle of from thirty to thirty-five degrees, the apex of the angle being at the base of the internal malleolus.

August 13.-The patient having been anæsthetized with ether, I proceeded to perform osteotomy, following the same plan devised in Case I., namely, a transverse incision was made across the lower extremity of the internal surface of the tibia, about one and three-quarter inch above the apex of the internal malleolus. The skin, subcutaneous tissue, and periosteum were divided; the periosteal incision being in the shape of an H, having an elongated cross-bar. The two narrow flaps of periosteum were now loosened from the bone. A narrow retractor was inserted between the periosteum and the bone, so as to avoid opening the sheath of the tendons of the tibialis anticus and posticus. Two parallel transverse incisions were made through the periosteum of the lower end of the tibia, distant about four lines from each other. With hammer and chisel, a wedge-shaped piece of bone was cut out through the whole thickness of the bone, the apex of the wedge being the cortical substance of the external surface of the tibia. The fibula was perforated by means of a drill, in different directions, but on the same horizontal plane. I now grasped the foot with my right hand, pressed my knee against the internal surface of the tibia, from which the wedge of bone had been cut out, and made powerful traction until the bones fractured. This restored the foot to its normal position, in which the cut surfaces of the tibia were in apposition. This position was maintained by means of sutures of heavy silver wire through the bone. A small drainage-tube was now inserted, the wound in the skin united, Lister dressing applied, the leg placed in Dr. Verity's modification of my original apparatus for the dressing and suspension of the foot in the aftertreatment of supra-malleolar osteotomy, and the patient placed in a tent, in the grounds of the hospital.

15th.-Pulse, 90; temperature, 99.5°. Wound dressed. No redness, swelling, nor suppuration. 16th.-Pulse, 93; temperature, 99.4°. tient suffers some pain in the wound. This was controlled by morphia.

The pa

21st. The wound is now superficial. It was dressed; very little discharge. The drainage-tube was removed.

September 1.-The silver sutures were removed, and the foot placed in a fracture-box filled with oakum.

11th.-Firm union of the bony surfaces. The foot was taken out of the fracture-box and placed in a blanket splint. The wound is still superficially granulating.

October 2.-The dressing was removed, and the wound found to be healed. A plaster cast was applied, and the patient allowed to be up on crutches.

11th. The patient wears the plaster cast contin

ually, is gaining strength rapidly, and is now commencing to bear weight on the foot.

18th. The patient was discharged from the hospital at his own request.

During the whole course of the after-treatment, the patient's temperature never exceeded 100°. In January, 1881, I received a letter from the patient, who was then in Wisconsin, asking advice in regard to a cough. In the letter he stated that he was then able to bear his weight on the foot and walk around, without any trace of his former complaints.

(To be continued.)

THE USE OF ANHYDROUS SULPHATE OF ZINC
AS A CAUSTIC IN CANCEROUS ULCERS.
BY WM. C. DABNEY, M.D.,

OF CHARLOTTESVILLE, VIRGINIA.

On the 1st of March, 1880, I was consulted by a lady, sixty-seven years old, for a "lump" in her breast, which, she said, had only appeared five weeks before. The lump was about as large as a pullet's egg, and quite hard. The skin over it was puckered, and the nipple retracted. It was not adherent to the tissues beneath it. There was an enlarged gland in the axilla, which suggested a longer period of growth for the tumor, but the patient and her daughter were very positive that it had only been perceptible for five weeks.

In view of the rapid growth and the presence of an enlarged gland, and the further fact that the patient's father had died with cancer of the face, I hesitated to operate, and asked Dr. I. L. Cabell, of the University of Virginia, to see the patient with me. He advised that the whole breast and enlarged gland be removed, and in case of recurrence that anhydrous sulphate of zinc should be employed as a caustic. The general health of the lady was quite good.

On the 4th of March I excised the whole breast and the superjacent skin, and allowed the wound to heal by granulation. The axillary gland was also removed, and one of the branches of the brachial plexus which it surrounded was carefully dissected out. In spite of the care exercised, however, the nerve-trunk was necessarily somewhat contused, and when the patient aroused from the effects of the chloroform she complained of considerable aching and pain in her arm. This lasted for two or three days, and then passed off in great measure.

About six weeks afterwards, when the breast had nearly healed over, the fingers commenced to swell at the joints, and to present a glossy appearance. She complained also of pain in the finger- and elbowjoints, especially on motion.

The wound in the breast was entirely healed in six weeks; but, one week after, it reopened, and in three days' time an ulcer was present as large as a silver half-dollar. The anhydrous sulphate of zinc was applied in the form of powder, and after the slough came away a healthy granulating sore remained, which healed in a few weeks; but, in a very few days, an ulcer again made its appearance, to which the zinc was applied as before. The ulcer each time was very painful, but the pain disappeared

soon after the application of the caustic, and did not recur till the cancerous ulcer formed again. The application of the caustic gave comparatively little pain. My patient lived at a distance, and in the country, so I lost sight of her for some time. On November 1, 1881, I received a letter from her daughter, in which she says: "Zinc has been applied eleven times, burnt alum twice" (the latter was an idea of the daughter's). "I applied alum on the 29th day of December last, which formed a scab which stayed on eleven weeks, to the day. When the alum was applied the second time the scab only

remained on two weeks. I then used zinc as before. Pain is generally relieved when the caustic is applied, till a short time before we have to use it again. Her hand is not swollen now, and she doesn't suffer with her arm as much as she did, but she has no use of her fingers."

On the 21st of February last, nearly two years after the cancer was removed, I saw the patient again. A cancerous mass, the size of a pigeon's egg, had made its appearance just above the cicatrix in the breast, and she had a very troublesome cough

and considerable shortness of breath. The caustic

had been applied in all sixteen times, and had always given relief from pain for some weeks. Her arm was in the condition her daughter had described, and she told me that when the caustic was applied it caused acute pain for some hours in the arm and hand; very little in the breast.

new.

The use of sulphate of zinc as a caustic is not It was a favorite remedy with Sir J. Y. Simpson, and is highly extolled by Dr. Stephen Smith, who speaks of it as the most useful caustic known for open surfaces.

Sir James Simpson (quoted by Dr. Smith) thus summarizes its advantages as a caustic: (1) It acts powerfully; (2) It acts rapidly; (3) It is very simple and manageable; (4) It is easy of application; (5) It does not tend to deliquesce or spread; (6) It is perfectly safe; (7) It is efficacious. On the latter point he speaks with some hesitation, but says he has seen very remarkable results from its use. If I may judge from my limited experience he might have added: (8) It causes much less pain than most of the agents of this class.

The case which I have reported is not calculated to make one an enthusiast on the subject of sulphate of zinc as a remedy for cancer, but I am satisfied that it has prolonged my patient's life and saved her much suffering, and I think the case worthy of record, in order to draw attention to a remedy which deserves a higher place than is generally accorded to it in works on surgery.

HOSPITAL NOTES.

PRESBYTERIAN HOSPITAL, PHILADELPHIA. (Service of THOMAS B. REED, M.D.) INJURIES OF THE SKULL.

(Reported by J. P. CROZER GRIFFITH, M.D., Resident Surgeon.) Two very interesting cases of injuries of the head have recently been successfully treated at the Presbyterian Hospital.

Compound Comminuted Fracture of the Mastoid Bone. J. McM., brakeman, aged twenty-three, was brought to While on the top of a freight-car, he had been struck, the hospital early on the morning of November 3, 1881.

of blood, which had saturated his clothing, and spread it is supposed, by a bridge, and had lost a great amount over the roof of the car. At the time of admission he was suffering from severe shock, and from concussion of the brain. Examination revealed a large gash completely through the left auricle, and extending backwards and horizontally over the position of the mastoid process. The tendon of the sterno-cleido-mastoid muscle was torn asunder, the auditory canal laid open and communicating with the rest of the wound, and the mastoid process broken into several pieces, the largest of which had been driven deeply inward towards the bottom of the wound.

Cerebral irritation soon developed, and the patient became so unruly that ether was administered, and the wound in the auricle closed by sutures, that in the neck being left open.

Liquid diet and ice to the head were ordered. All through the 3d and 4th days of November the patient lay in a totally unconscious condition, incapable of being roused, and with eyes shut, and snoring respiration. By the 5th it was possible to awake him, and his respiration was natural; and by the 8th of the suffering from very severe headache, entire loss of apmonth he was perfectly conscious and rational, but petite, and complete left-sided facial palsy.

A dangerous typhoid condition, lasting some time, now developed. This, however, yielded to treatment, and by the 1st of December he was able to leave his bed, although continuous and exceedingly severe headache still persisted. He constantly inclined his head of the left side was, of course, unable to sustain it. His to the right, and supported it by his hand, as the muscle temperature up to this time, and through his whole recovery, was but slightly elevated, reaching 100° but

once.

Meanwhile the wound, which measured about two and a half inches in length, and one inch in breadth, and which extended inwardly fully two inches, had been suppurating freely, and filling up by granulations. The auditory canal opened directly into it, and no tympanic membrane could be discovered; and the patient was unable to hear a watch even when applied to the auricle.

Several small pieces of bone were at different times removed, yet the large fragment at the bottom of the wound was still firmly held by granulations. An aural examination, made early in December by Dr. Burnett, the aurist of the hospital, showed that hearing was still preserved, but that the fragment of bone was obstructing the passage of sound through the auditory canal. Subsequently, this piece, measuring about three-eighths of an inch in length, and one-quarter of an inch in breadth and thickness, was removed, and from that time the patient's headaches, which had been gradually becoming less severe, very markedly diminished both in number and degree.

A partition wall now commenced forming in the wound, partially shutting off an auditory canal, but leaving so narrow an opening internally that the condition of the tympanic membrane could not be seen. It was evident, however, that a perforation existed, since air could be forced from the nose through the wound. On January 2, 1882, he was discharged from the hospital. He was seen again about the middle of February. His health during the interim had been excellent, and there had been no headache. The wound had healed almost entirely, and the new auditory canal was almost completely formed; but its internal opening had become exceedingly small, and it was utterly impossible to see the tympanic membrane. He could not, at

this time, hear a watch even when pressed against the auricle, although he stated that during the preceding month he had been able to hear it at a few inches' distance. The sterno-cleido-mastoid had reunited with the skull, and he was able to hold his head erect. The facial palsy was as marked as at first.

Probable Fracture at the Base of the Skull.-J. A. S., aged twenty-four, fell from a locomotive, not in motion, a distance of five feet, striking his head over the left parietal bone. He walked to the hospital, though experiencing much faintness, nausea, and vomiting upon the way. There had been considerable hæmorrhage from the nose and left ear. He reached the hospital early on the morning of December 31, 1881. The bleeding from the nose had ceased, but that from the ear still slightly continued. He complained of being a little cold and sick, and appeared to be laboring under great torpor and confusion of mind. He was put to bed, and dry cold to the head, low diet, and a purge ordered. Vomiting, sometimes of the blood which had been swallowed, was frequent during the day, and the patient lay perfectly quiet, and with eyes shut, except when a question, spoken in a loud voice, would secure a response of few words. His condition continued just the same for several days; great mental torpor, respiration quiet, pulse about 50, and, on one occasion, only 47 beats in the minute, temperature ranging from 99° to 100°, discharge from the ear more and more watery, and finally, almost colorless and very profuse, wetting the dressing of absorbent cotton and soaking completely through the pillow beneath. Unfortunately, no chemical examination was made of the fluid, and no means taken to collect and measure it; but certainly, in all, there were not less than one and a half pints discharged, a quantity far too great to be produced by exuded serum. Probably the amount was even greater than the estimate given. Under the microscope nothing was revealed but a clear, colorless fluid, containing a very few blood corpuscles floating in the field of view. The presence of blood disks is easily understood from the fact that hæmorrhage had at first taken place in the auditory canal. Upon the 3d of January he was somewhat better, now lying with eyes open, but still perfectly quiet, and never speaking unless addressed. The pulse was now about 60 beats in the minute. dition from this time steadily improved. By the 6th of the month the discharge from the ear had almost ceased, the pulse ranged from 65 to 70 in the minute, and the mental torpor was less; but he suffered from severe headache. On January 11 he was permitted to leave his bed. Headache was still very severe, and usually situated over the right temple. He still seemed stupid, appeared to think slowly, and when addressed roused himself as though from sleep. In the left ear he was markedly deaf, and could hear a watch only at a distance of two and a half inches. Examination showed that both membrana tympani were whiter than normal, while that of the left ear exhibited at one point a reddish spot, probably a cicatrix. The patient stated that he had been slightly deaf previous to his injury, but that it had never caused him any inconvenience, as at the present. On January 15 he was discharged, cured. His headaches were at this time very slight, and his pulse was, pretty constantly, 84 beats in the minute.

His con

Remarks. This case is especially interesting in that it is almost certainly one of fracture of the base of the skull, and that so complete a recovery followed. Certainly the patient showed two of the prominent symptoms of this injury, viz., profuse watery discharge from the ear, and a very slow pulse.

MEDICAL PROGRESS.

INTESTINAL DIGESTION.-Dr. ROBERT MEADE SMITH, the Demonstrator of Physiology in the University of Pennsylvania, has been engaged for some time past in the study of intestinal digestion. Our entire ignorance of any positive knowledge of the composition of the secretion of the small intestine, and of its action on the different food-stuffs, depends upon the failure of all attempts as yet to secure a pure secretion, free from pancreatic or biliary juice, and yet keep the intestine in its normal condition. The method of Thiry, the best process yet described, of resecting a loop of intestine, one end of which is closed, and the other fastened to the opening in the abdominal walls, while the continuity of the intestine is restored by again uniting the divided canal, has entirely failed to give any reliable results; for, although the isolated loop still has its circulation maintained, the necessary removal of the mucous membrane of the part experimented on from contact with the other intestinal juices and contents of the intestine, and its consequently enforced functional inactivity, renders it impossible to regard its secretions as at all representing a normal intestinal juice. The method which Dr. Smith has found to give the most reliable results, is to establish a fistula in the duodenum, about six inches below the pancreatic duct, using a tube similar to the ordinary Bernard gastric canula, the inner plate of which is rolled on itself, so as to form a section of a tube, and thus adapt itself to the curved anterior walls of the intestine; the stitches which fasten the tube in the gut also serve to unite the canal to the abdominal walls and to close the wound in the latter. Dogs subjected to this operation usually do well, and in from two to three weeks are entirely recovered from the effects of the operation. When it is desired to collect the intestinal secretion, the animal is allowed to fast for thirty-six hours, so as to remove all debris of food from the intestine, and a thin rubber bulb, with a narrow tube, is then passed in through the tube into the intestinal canal, and carried just below the opening of the pancreatic duct. The bulb is then slowly distended with warm water, and the intestine thus entirely occluded, and all fluids prevented from passing from above downwards. Another similar bulb is then passed down the intestine for about twelve inches, and distended, and the portion of the intestine between the two, communicating with the canula, washed out with distilled water. The dog is then supported by straps around his body, which only restrain him when he attempts to move, and the secretion which flows from the tube is caught in a funnel and collected. In this manner, from twenty to forty cubic centimetres of intestinal juice, absolutely free from pancreatic juice and bile, as shown by the chlorine and Gmelin's tests, can be collected in an hour, while by Thiry's method only a few drops are to be obtained.

Dr. Smith finds that intestinal juice thus collected has an invariably alkaline reaction, with a specific gravity of 1018, is pale yellow in color, and filters with difficulty. Analysis shows that in one hundred parts of the filtered juice there are:

Water, Albumen, Ferments, Mucin,

Chlorides of Sodium, Magnesium, and Potassium, Sulphates and Carbonates of Sodium and Potassium, Carbonate of Calcium,

98.860001

.547560

⚫592410

99.999971

Two ferments have been isolated, one converting starch into sugar, and the other changing cane-sugar into grape-sugar.