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axilla. It was slightly movable at its base, but firmly adherent to the integument over the more prominent upper portions of the tumor. Although the early history did not point to a carcinoma, the appearances indicated that this was the nature of the growth. An operation was not advised, but the probable results were carefully stated if the growth were allowed to take its course, on the one hand; and if removed, on the other; and the final decision left with the patient. She returned on the above date, requesting the operation.

Sept. 19th. Patient was etherized, and the growth found to be very extensive, extending beneath the latissimus dorsi and muscles between the scapula and the humerus, as well as involving both pectoral muscles. It was thought that the patient and her family did not realize the extent and gravity of the operation, which was deferred in order to consult further with them about it.

Sept. 26th. The patient was etherized, and the growth excised, only after the most careful dissection, however, necessitating the removal of the larger portion of the pectoral muscles, a portion of the latissimus dorsi, and all the tissues down to the chest walls. The upper portion of the tumor was in relationship with the great vessels of the axilla, and its separation from them, although they were carefully excluded and not injured, caused such extreme shock, that collapse was feared before the operation could be completed. Her pulse reached 160 on the table, and repeated hypodermics of brandy were necessary. She recovered from the ether well, but her pulse continued high150 to 160; and her temperature that evening was 95°. Brandy diluted was given occasionally by the mouth until evening, when she slowly began to rally, and before morning her temperature went up to normal, and her pulse gradually declined.

Sept. 27th. Evening temperature, 100°; pulse, 100. From this on she made good progress, pulse falling to 80, and temperature normal. The wound healed throughout, except a small place as big as a split pea, which had not healed when she was discharged, Oct. 21st..

Microscopical examination showed the growth to be a carcinoma. (See foot-note, p. 19.)

AMPUTATIONS.

There were eight amputations during the quarter, six of which were capital ones. In those of the thigh, that of the forearm, and the first one of the leg, the combined flap and circular method was used. In the last two of the leg the method was adapted to the special needs of the case. In all, serviceable

stumps were obtained. Bone drainage tubes were used, and answered the purpose to perfection. One of those of the thigh was a case of Dr. W. S. Smith's, and was operated upon by him, with most happy results.

CASE I. Mr.

nosis, senile gangrene.

; age, 70. Admitted July 22nd. Diag

Ten weeks ago he had an attack of erysipelas in the left foot, which had been similarly affected several times before, and he had always treated it himself with iodine and poultices. This time, under the same treatment, it grew worse, the disease beginning in the second toe, and gradually extending to the others. He had been addicted to the moderate use of alcoholic liquors, and lately had taken considerable opium in the form of laudanum, from sixty to seventy drops a day. The pain had been very severe, and his general health was much reduced. The toes were quite mummified, although there was still movement at the metatarso-phalangeal articulations. The line of demarcation was well defined across the middle of the metatarsus, and above that the tissues were healthy. The sloughing extended further up on the dorsal than on the plantar surface. Examination at all accessible points showed that there was a general calcification of all the arteries; the radial artery was a rigid noncompressible tube.

July 25th. Patient was etherized. Amputation had been previously advised through the tarsus, but it was deemed wiser to remove above the ankle. The foot was amputated at the junction of the lower and middle thirds of the leg, by the combined flap and circular method. The arteries presented a most peculiar and interesting appearance, the muscles retracting from them leaving them projecting from the surface of the wound, hard and rigid, like twigs; when forceps were applied to an artery and compressed, it crushed with a sound audible twelve or fifteen feet away. The hemorrhage, however, was slight and easily controlled. The periosteum was drawn over the ends of the bone and sutured, the muscles were brought together by a continuous catgut suture, and the stump so dressed that there could be no pressure upon its end. During the operation the pulse was very weak.

The dressings were changed on the 27th, and the wound was looking well. On the third day there was much œdema of the stump, with ecchymosis of the margins of the flaps, and, altogether, it did not promise favorably. It was carefully dressed so that there could be no pressure, either upon the stump or upon the leg immediately above. There was much less pain, and the patient was comfortable. On the fifth day the wound began

to discharge pus, and by August 9th the stump was gangre

nous.

August 10th. The patient was etherized, and the leg was again amputated at the junction of the middle and upper thirds. Long lateral flaps of both skin and muscle were made down to the bone, the periosteum was divided and reflected for about an inch, and the bones were squarely sawn off, the fibula about one-half inch shorter than the tibia. The skin and muscle flaps were thus made so that they could be opposed naturally, and without the slightest traction at any point. The vessels were found in a condition similar to that of the preceding operation. The periosteum was sutured over the ends of the bone with fine catgut. The flaps were brought together and held in position. by three or four silk-worm sutures passed transversely, from side to side, through both flaps and secured at either extremity by large lead plates and bullets. A drainage tube was brought out at the posterior angle of the wound, the edges of which were brought together by interrupted silk-worm sutures, introduced one-half inch from the margin of the flaps, and so carefully tied as not to cause strangulation and yet hold the flaps in apposition. As few as possible were used.

Although he slept but little, there was much less pain following this operation. At infrequent intervals he had one-half gr. morph. sulph. hypodermically, late in the evening. On the third

day the stump was dressed and was looking well. On the fifth day, part of the transverse sutures were removed, and the wound was satisfactory. It was dressed daily after this, and syringed with peroxide of hydrogen.

Soon he began to complain much of the right foot, the circulation in the toes of which was very much impared, and it was seen that this was about to follow the course of the left one. By August 16th, gangrene was well defined in the second toe, and rapidly extending to the others. The pain was continuous and excessive, appetite poor, and sleep most unsatisfactory, so that it was felt that the success of the previous operation was much endangered by the results incident to the condition of the right foot. The pain extended into the thigh, and was particuiarly severe about the knee.

August 29th. The stump of the left leg was looking well, and, although there was some suppuration at one or two marginal stitch wounds, there was no appearance of gangrene. It was decided to remove the right foot as giving the patient. the best chance for life, and, under ether, the leg was removed at the middle, in the manner of the preceding operations. The arteries were found as before. Although the hemorrhage was light and easily controlled, the patient was very weak and well

nigh in a state of collapse, the temperature sinking to 95°. Hypodermic injections of brandy were given twice.

August 30th. There had been good reaction, temperature normal; considerable pain; gr. morph. sulph. hypodermically. On the following day the pain was still severe. The stump

was dressed and looking well. After that the pain became an insignificant feature of the case.

Sept. 4th. The temperature again went down to 95°, and he again had hypodermic injections of brandy. Conium 3x was given and continued.

Sept. 6th. The left stump was thoroughly healed, and had lost much of its sensibility. In the following days he had much. pain in the right leg, which did not present a satisfactory appearance, and there was an increasing discharge of bloody pus

He also complained of sharp, catchy pains in the cardiac region. The flaps were undermined, were unhealthy in appearance, and were discharging a great deal, but still were not gangrenous. He was now given, twice a day, an egg-nog with four teaspoonfuls of brandy, which he duly appreciated.

Sept. 11th. The stump was looking much better- healthy in fact, the discharge was less, the appetite improved, and he really began to gain in general health. Since that time he has continuously improved. The left stump was entirely and soundly healed; the right one was almost healed and in a healthy condition.

CASE II. Mr. ; age, 32. Admitted July 18th. Diagnosis, osteo-malacia. He is Irish, unmarried, a weaver by occupation. Case represented as "exostosis of tibia."

About ten years ago the tibia was injured by a blow from a piece of iron. This was followed by a thickening of the tibia throughout its middle third, which was very painful and compelled him to give up his work. When at rest the pain was lessened, but upon resumption of work or use of limb the pain. returned. Two years after the injury was received, the leg was operated upon, and the front of the tibia for about two-thirds its length was removed. He was confined to the hospital for six months, and it was eighteen months before he was able to resume work. For about four years after the leg healed it gave him little or no trouble. Then it again became sensitive and painful, and compelled periodical resting to enable him to continue his work. The tibia thickened in all its diameters throughout the middle two-thirds and was constantly painful. When admitted to the Hospital the leg was swollen, smooth, shiny, and reddened, very exquisitely sensitive to the touch, especially anteriorly; the tibia was broadened and the front of

it had lost all semblance to normal shape. It appeared like a sub-acute periostitis of long continued duration. The scar of the former operation was noticeable.

The patient was put to bed and the leg frequently bathed and wrapped in compresses as hot as could be borne. After two weeks, although the leg looked better and was much less painful, it was not materially improved, and so it was decided to operate, with a view to removing the diseased bone, if possible. Aug. 1st. Under ether, an incision was made over the tibia, when the skin and the periosteum were found so inseparably blended into one membrane that they could not be differentiated. The periosteum readily separated from the bone. With the trephine, several openings were made deeply into the bone, which consisted of a very hard shell externally, containing within a yellowish mass of much softer consistency. The anterior and lateral walls were cut away for about eight inches of its length, and nothing at all approaching the appearance of normal bone being found, the operation was discontinued for the purpose of advising further with the patient. The cavity was packed with iodoform gauze, and dressed aseptically. The dressings were removed the next day, because of the oozing of so much serum and blood, and the cavity syringed with peroxide of hydrogen. Pain not mitigated by the operation.

Aug. 5th. The consent of the patient having been obtained, the leg was amputated three inches above the knee by the combined lateral flap and circular method. After sawing the femur, examination showed a condition similar to that existing in the tibia, as having begun. The centre of the bone was yellow, soft, and very oily. The periosteum was sutured over the end of the bone, the muscles drawn together with catgut, and a continuous suture applied to the surface wound. Two silk-worm sutures were passed transversely through the flaps and muscles, and fixed on either side by lead plates and bullets. Drainage. Dressed aseptically.

On the third day the dressings were changed. There had been considerable oozing of blood and serum, but the wound was progressing finely. On the next day the tube was shortened one half, and on the following day, five days after the operation, it was removed entirely. After this the stump was dressed daily. The flaps united at once, with the exception of a small fistulous opening posteriorly, through which there was some discharge of blood and serum admixed with liquid fat. He made a good recovery with a useful stump, well shaped for the application of an artificial leg.

This case is particularly interesting, because representing a condition which is rare. Eichhorst says: "Osteo-malacia is a

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