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atrices are not uncommon, nor is it of very rare occurrence to observe in persons of advanced age indolent ulcers upon the site of scars existing since infancy. Not infrequently we encounter well-marked papillary epithelial cancers which have taken the place of the original scar and subsequent ulcer. They are, according to Paget, most frequently seen on the lower extremities and connected with scars repeatedly injured. From the superficial tissues the neoplasm invades the deeper structures, the periosteum and the bones, and may endanger life by exhausting hemorrhages and by systemic infection.

CASE I. The specimen which I have the pleasure of exhibiting to you was taken from a patient in whom there occurred a degeneration of a scar into an ulcer and finally into a wellmarked epithelioma.

Anamnesis.-H. B., a farmer from the northeastern part of the state, æt. 51, with no hereditary or acquired constitutional vice, sustained a compound, comminuted fracture of the left leg, thirty-three years ago, in the lower third, for which he was treated by the late Dr. Joseph McDowell. In the course of the reparative process several necrotic pieces of bone were removed. The leg was somewhat deformed, but to all intents and purposes a useful one, and only occasionally gave him trouble, when, on account of some injury to the scar, which indicated the site of the original injury, an ulcer would form over it. Simple remedies and rest usually healed these ulcers. About two years ago he struck his leg, at the place where the scar and subsequent ulcers had been. There was free hemorrhage at the time and afterwards an ulcer formed which gradually grew larger and which bled quite freely.

Status presens.-February 9, 1885. The patient is highly anemic from excessive hemorrhages. The neoplasm encircles the entire leg and extends upwardly to the middle of the leg and downwardly to the ankle-joint and bleeds very freely on removing the dressings or on touching it with a probe or the finger. Its surface exhibits shreds of necrotic tissue and several openings through which the probe touches roughened bone. The anklejoint is anchylosed. No enlarged glands. The diagnosis of epithelioma was subsequently confirmed by the microscope.

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The leg was amputated February 17, at the junction of the upper and middle third; the wound healed partly by first intention and partly by granulation. His general condition began to improve at once, and he was allowed to return to his home March 29, 1885.

The site of fracture is easily discerned; there is angling and lateral union of the tibia and fibula; part of the anterior surface of the tibia is destroyed and both bones are covered with osteophytes.1

The frightful deformities which are sometimes produced by the contraction of extensive cicatrices after burns, come under our notice both for cosmetic purposes and also for the restoration to usefulness of the part involved in the cicatrix.

CASE II.-The photographs to which I desire to direct your attention are those of C. L., æt. 43, who, according to the history kindly furnished me by my friend Dr. Dean, was admitted into the City Hospital about nineteen months prior to his coming under my observation, August 19, 1884. More than one-third of the surface of the trunk and the lateral aspect of the thigh were involved in the burn. Cicatrization aided by skin grafting took place slowly but surely, and when the patient left the City Hospital, nineteen months after admission, the entire burnt surface, except a few ulcerating patches, was covered by a very

1. Since writing the above Vol. II of the Transactions of the American Surgical Association has come into my possession, in which Dr. T. F. Prewitt, of St. Louis, records two cases of malignant degeneration of ulcers of the leg. Vide Transactions, etc., p. 491.

pliable cicatrix. Unfortunately the arm was fastened to the side for two-thirds of this length, as shown in the picture marked

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B, and was therefore useless to him. He sought relief for this condition.

Owing to a very exhausting diarrhea from which he had suffered during his illness, his general condition required attention, before the arm was freed from its attachment to the trunk by a free division of the cicatrix and the subjacent tissues. Extension was employed from the very beginning, and so soon as the large wound surfaces began to granulate they were freely covered with grafts to facilitate and accelerate their cicatrization and also to prevent as much as possible the contraction of the new cicatrix, for it is a well-known fact that cicatrices formed from grafts have little tendency to contract and do contract less than the ordinary cicatrix.

March 31, 1885, the patient was dismissed presenting the ap

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pearance shown in the photograph marked C, and having very good use of his arm.

DISCUSSION.

DR. PREWITT said that degeneration of cicatrices into epithelioma was not uncommon. Malignant growths are not in the beginning constitutional. Had reported a similar case. Had seen carcinomatous degeneration follow irritation of that character. Had seen the case the doctor reported. The result was most satisfactory.

DR. HALLEY stated that the reason that infection was not so apt to follow in cancer of cicatrices, was probably owing to there being no lymphatics or lymph spaces in a cicatrix. Therefore infection could not take place until ulceration had extended beyond the border of the cicatrix. DR. GRIFFITH agreed with Dr. Prewitt. Had amputated four breasts without any return of the disease.

DR. FRYER.-Some two years ago had removed a large epithelioma from the lower eyelid, filled up the wound with a large detached skin graft, healed perfectly; very slight deformity; to date no return of the disease.

DR. JACKSON had also removed several cancers; which did not return. DR. GEIGER indorsed Dr. Halley; believed that there was a difference between the two forms of epithelioma. Reported a case of wound of the leg from a shell, followed by an epithelioma. Removed the mass; Returned. Had operated several times on the case. Believed that although he did not cure the case, he prolonged the patient's life. Epithelioma in cicatrices less malignant.

DR. MUDD.-Cancer in cicatrices is not the rule, and then the scars are always large and old. The cancer was always at the site of irritation. If there is infection there must be lymphatics at some point. He thought that the removal of an epithelioma was a curative process.

REPORT ON ORTHOPEDIC SURGERY.

BY A. J. STEELE, M. D., St. Louis.

I

HAD been hoping that some one of the other members of the committee on the progress of orthopedics, appointed to which you honored us, would have offered a report ere this, but waiting in vain, and not wishing the subject to go wholly by default, I herewith present a few hastily thrown together thoughts.

CLUB-FOOT.

In the young infant the treatment is most advantageously carried out by bringing the foot into good position with the employment of strong manual force, and there retaining it by the application of a plaster of Paris bandage, extending to above the knee, otherwise it may slip off, for the infants foot is dumpy—without character. A thin piece of board or shingle, cut larger than the sole of the foot, and of correct shape, should be fastened to the sole by the early turns of the bandage. The board may then be used as a lever by which to hold the foot in improved position while the gypsum bandage is being further applied. A thin piece of hoop-iron or strip of tin may be incorporated into the bandage, being bent around the instep of the foot and extending up the outside of the leg. This greatly fortifies the plaster. The foot, thus held until the plaster hardens, remains in good position, the shortened ligaments and tendons stretching, and the lengthened ones shortening. A snug fitting stocking or flannel bandage should encircle the parts previous to the application of the plaster bandage. In ten or fourteen days the appliance should be cut open and removed, and the foot forced into still more improved position, the parts stretched and moulded, and the splint reapplied, or better, a new put on. And thus the bandage may be renewed from time to time as is found necessary. Later on a retentive shoe should be worn, and still later, a walking shoe.

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