benefit; the pain diminished very much, and the fœtid odor of the discharge disappeared, but the wound did not heal, nor the discharge cease, nor the general health improve. After being under Dr. Gott's care, for two and a half months, she returned to her home in Iowa, and eschewing the profession, betook herself to patent remedies of many different kinds, some of which she swallowed and others she applied externally with the result which might have been foreseen, viz: that the old condition of of the foot gradually returned, and her general health became seriously impaired. A traveling agent of the so-called Surgical Institute of Indianapolis, persuaded the patient to resort to that miraculous (1) establishment for advice and treatment, and thither she went early in November, and was promised a cure by excision of the diseased bone (the os calcis). Mrs. H. and her husband who accompanied her, having at last learned to recognize quacks and impostors, promptly declined the services proffered by the gentlemen of the institute, and were advised to come here.

On examination, the following state of the case was discovered: Patient very thin, sallow and cadaverous looking, with the characteristic symptoms of hectic fever. The dorsum of the foot was swollen over the whole of the tarsal region, and to the touch gave the peculiar sensation of gelatinous degeneration of the synovial membranes.

On the outside of the heel there was an indolent ulcer two inches in length, from which there issued a copious discharge of extremely fœtid pus. The surrounding tissues were cartilaginous and unyielding.

The patient was unable to place the slightest weight on the foot and for many months had gone either upon crutches or her knees, and she complained of almost constant pain in the anklejoint and through the posterior part of the foot.

The probe passed at once into a rough irregular cavity in the os calcis. The patient declared herself willing to submit to anything that held out a fair prospect of permanent relief, and was strongly opposed to further partial or palliative treatment.

Syme's ankle-joint amputation was unhesitatingly recommend

ed and was at once agreed to by the patient, and on the 23d of November, with the assistance of my colleague, Prof. Frothingham, I performed the operation in the usual way. An unusual amount of difficulty was met with in dissecting the heel-flap, owing to the rough and scooped-out condition of the os calcis, and owing to the unnatural condition of the soft tissues, the result of the long standing disease. The utmost care was taken to avoid injury to the internal calcaneal and other arterial branches distributed to the heel, and that these precautions were successful, was agreeably demonstrated, on the removal of Esmarch's bandage, after the completion of the operation, for arterial blood was at once seen to ooze from the very lowest extremity of the long flap.

On sawing off the articular surfaces from the tibia and fibula, a dark, grumous fluid was seen to ooze from the cancellated tissue, a phenomenon which excited some unpleasant apprehensions of future trouble from that quarter. These apprehensions, however, were destined to prove groundless.

The flaps were brought together with silk sutures and supported by a pad of lint and a bandage, and in short, this, with a tepid water bath morning and evening, and the additional support of an adhesive strap, constituted the whole after treatment. Any serious oozing or suppuration which occurred within the stump was already thoroughly provided for by the opening in the posterior part of the flap formed by the old ulcer. Had this opening not pre-existed, an artificial one would have been made.

In a week from the date of operation all the ligatures and sutures had been removed, the discharge had lost its fœtid penetrating odor and became quite laudable and comparatively small in quantity.

The patient's general condition also improved very rapidly, so that on the 23d of December, just one month from the day of operation, she was able to leave for her home in the far West, with her health quite restored, her painful and disgusting local affection entirely removed, the wound of the operation healed, and a stump on which, even at that early date, she was able

almost to bear one-half the weight of the body. The difference in the length of her two limbs was not over one inch.

On submitting the amputated foot to careful examination, the os calcis, the synovial membrane of all the tarsal articulations was thickened and gelatinous, and the cartilages of most of the joints more or less ulcerated.

In looking back over the history of this case, we have no hesitation in saying, that, treatment at the proper time, by plaster of Paris cast, either alone, or combined with the actual cautery, would in all probability have led to a very much earlier and more satisfactory result.

For the notes of this case I am indebted to my student, Mr. W. R. Birdsall.

MEDULLARY SARCOMA-DEATH-POST MORTEM. Reported to the Wayne County Medical Society, by THEODORE F. KERR, M. D., Detroit, Mich.

On the 11th of December, 1875, Dr. James F. Encke, of this city, requested me to see a patient of his of whom he gave the following history:

Mr. C. was a Scotchman, forty-eight years old, and a painter by trade. He had always enjoyed good health until about six months ago, when he was attacked with vomiting one day after he had been engaged in boiling some "paint skins." Since then his health had been poor though he had always worked when he had work to do. During the latter part of the summer he had an attack of what he called bloody dysentery, but no physician attended him at that time. Subsequently, at times, there was severe constipation and likewise colicky pains, though these were not related as cause and effect in his mind. Several weeks before the date given above, he had called on Dr. Encke, who treated him for lead poisoning, the symptoms of which were plainly exhibited in the dark line along the edge of the gums. A cyanotic condition of the nails and fingers, the constipation and pain, not severe, in the region of the umbilicus were ascribed to the same cause. The bowels were first acted upon by strong

cathartics, of which large doses were required, and iodide of potassium was given. Under this treatment he rapidly improved, so that within ten days the discoloration of the gums had entirely disappeared and the patient felt better. Three weeks before I saw him the patient took to his bed complaining of some pain in the bowels, a general weakness and debility, but chiefly of exudations of gas from the stomach and vomiting of bilious matters. For these symptoms tonics and anti-dyspeptic remedies were prescribed, but without satisfactory results. Sometime during the last week in November, the patient first called the attention of his physician to the condition of his abdomen, which was then for the first time examined, and a large tumor discovered. The patient was restless and opium was prescribed, one grain every three hours, which he had taken ever since. Within the last ten days there had been several discharges from the bowels, which the doctor had not seen, but from the description thought they were mostly blood. He had ordered the last one kept, which we could see this morning.

On reaching the house we were shown a chamber vessel about half filled with a thick, semi-fluid, bloody discharge, of an extremely offensive smell. This had been discharged from the bowels since seven A. M., in two motions. A physical examination of the patient showed the veins on the surface of the abdomen largely distended, indicating some marked obstruction to the portal circulation. The abdomen was also distended in the umbilical region, the enlargement reaching into the right lumbar region and below into the hypogastric. By the hand the full, rounded border of the tumor could be distinctly outlined on the upper and right sides, but it gradually became ill-defined and seemed to lie deeper in the abdomen on the left and lower sides. It was of quite firm feel, almost solid, and seemed to be adherent to the anterior wall of the abdomen. Percussion gave a deep tympanitic note. The examination caused no pain of any note. The opinion was expressed that the growth was a malignant one, probably of the medullary or encephaloid type; that ulceration had taken place and that a fatal hæmorrhage was liable to take

place at any moment. Dr. Encke fully concurred in these views.

The prognosis was verified by the death of the patient on the evening of the 14th of December, immediately after a copious discharge of blood from the rectum, and the post-mortem examination, which was made sixteen hours afterward. On cutting through the abdominal wall the tumor was reached directly and found adherent over a space about as large as the back of the hand. The whole of the small intestine and the colon presented the black color of partial decomposition. The stomach and rectum were normal in appearance. The mesentery was wholly infiltrated with the new growth so as entirely to displace the original tissue and was much enlarged. The mass was much decomposed and was inseparably connected to a loop of the small intestine about a foot and a half in length into which it had opened by extensive ulceration, forming a cavity that would hold a pint. Along the spinal column was a considerable section which had not suffered degenerative change, and on cutting into this it presented the gross appearances of the true medullary cancer. The entire mass when removed and cleaned weighed five pounds. Around the left common iliac artery just at its point of bifurcation, lay another tumor about the size of a turkey's egg. This was encapsuled but suppuration had taken place and the scrotum was half full of pus, the inguinal ring being much enlarged in consequence of an old hernia. The mucous membrane of the bladder was considerably thickened; the kidneys were quite small. The liver and spleen were rather pale in color and the spleen was quite small in size. No evidences of cancerous deposit were found in either.

Dr. Leonard made microscopic examination of sections from the two tumours and reported that they presented the characteristic type of the true medullary cancer-simple cell-structure without intercellular substance, the cells containing two or more nucleoli and granular matter.

We are

It is interesting to note the presence of both the infiltrated and encysted varieties in the abdomen of the same patient. not aware that this is of frequent occurrence.