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, a 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 after-treatment of supramalleolar osteotomy, and the patient placed in a tent in the grounds of the hospital.

August 15th: Pulse, 90; temperature, 99.5° F. Wound dressed. No redness, swelling, or suppuration.

August 16th: Pulse, 93; temperature, 99.4° F. The patient suffers some pain in the wound. This was controlled by morphin.

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

September 1st: The silver sutures were removed, and the foot placed in a fracturebox filled with oakum.

September 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 2d: 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.

October 11th: The patient wears the plaster cast continually, is gaining strength rapidly, and is now commencing to bear weight on the foot.

October 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° F.

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 about without any trace of his former complaints.

CASE III.-Outward deviation of right foot, of ten years' standing, from Pott's fracture. Operation. Five weeks later dressings removed. Seven weeks later can bear weight on foot. Complete recovery. (Verity, 1881.)

William B. W., a groceryman, fifty-three years of age, was admitted to Cook County Hospital January 19, 1881, suffering from suppuration of the metatarsophalangeal articulation of the great toe of the right foot, caused by frost-bite.

The patient has for many years been addicted to the excessive use of liquor. During the past year he has taken from 10 to 20 drinks daily. He has had syphilis. Ten years ago, while in Colorado, he sustained a Pott's fracture, which in default of proper care healed up in a bad position.

On admission the patient was found to be well nourished. The right foot was turned outward at an angle of about 30 degrees.

February 20th: After the usual course of treatment preparatory to an operation for the restoration of the contour of the limb, the patient was anesthetized with ether, and after the application of Esmarch's bandage Dr. Verity, the house surgeon, performed the operation. A longitudinal incision was made, beginning 3 inches above the internal malleolus, and extending to its extreme point. The soft parts were widely separated by retractors. A transverse incision was made through the periosteum, 111⁄2 inches above

the lower extremity of the tibia. Two longitudinal incisions, perpendicular to the first incision, were then made through the periosteum, making altogether an H-shaped incision. The periosteum was now carefully retracted, laying bare a portion of bone about 14 inches long and 1⁄2 inch in breadth. A base having first been marked out, a wedge-shaped piece of bone was cut out from the tibia with a hammer and chisel, the base of the wedge being inward, and the apex pointing outward at an angle equal to and compensating the angle of deformity. The cut ends of the tibia were now approximated and united by a heavy silver suture, the fibula having first been bored through in order to facilitate its fracture. A drainage-tube was inserted, the wound closed by aseptic silk sutures, and a Lister dressing applied. Verity's modification of my osteotomy splint was now applied over a plaster-of-Paris cast, embracing the upper two-thirds of the leg and lower two-thirds of the thigh, the leg being flexed upon the thigh at an angle of about 45 degrees, in order to give greater leverage and prevent rotation of the foot, and the leg suspended.

The wound was dressed every two or three days and healed kindly. The temperature reached 101° F. on only one occasion.

March 28th: Dressing removed. The patient can move around with the aid of crutch and cane.

April 10th: He can bear considerable weight on the foot.

April 20th: He is able to walk with a cane and has done some light work in the ward. May 2d: At his own request the patient was discharged from the hospital cured.

This supramalleolar osteotomy is not any more or any less dangerous than osteotomy in any other location, and it is in the power of the operating surgeon to reduce the danger to a trifling minimum by means of strict antisepsis.

As regards the method of operating, we shall make the following remarks, based upon careful observations upon the cadaver, made by me prior to the performance of my first operation:

It is essential not to open the ankle-joint, that is, to have no communication whatever from the cut osseous surfaces, or even from the incision through the soft parts to the joint, for the following reasons: First, suppuration may take place when there is an osteitis in the bones operated upon in spite of all antiseptic precautions; and, second, thorough drainage of the ankle-joint is so difficult that suppuration in this location cannot be combated with as great ease as in the knee-joint.

The operation has been so minutely described in the report of Case I that recapitulation will be unnecessary. We shall, therefore, mention certain points only in regard to the operation.

The cutaneous incision we shall recommend to be longitudinal, 22 to 3 inches in length, in the middle of the medial surface of the lower extremity of the tibia (as was done in Dr. Verity's case). The transverse incision through the periosteum should be 2 inches above the apex of the internal malleolus. The 2 incisions in the periosteum perpendicular to that last mentioned should be from 3/4 inch to 1 inch long. Care should be taken not to open the sheaths of the tendons of the tibialis anticus and posticus.

It is needless to state that the size of the base of the wedge of bone to be cut out depends on the degree of the deformity, but from the cases operated upon we think that from 10 to 15 mm. will include the

average width. It is advisable to define the base of the wedge by two transverse cuts through the cortical substance by means of a small saw, so as to avoid unnecessary splintering of the cortical substance by the chisel. In cutting out the wedge care should be taken at the anterior and posterior cortical surfaces to avoid opening the sheaths of the tendons with the chisel.

It would be impossible to perform this part of the operation with perfect exactness, if we could not, by means of Esmarch's bandage, make the operation bloodless, but with the bandage and a good light this part of the operation can now be done with exactness, the sheaths of the tendons having first been retracted.

A common carpenter's chisel is preferable to the so-called surgical chisel, because the extremity of the latter forms the apex of an isosceles triangle, while the extremity of the former forms the apex of a right

3

Fig. 33.-Apparatus for immobilization.

angled triangle. The carpenter's chisel is the only one which permits the cutting out of a wedge of bone of the exact shape and size required.

The point of the wedge will be the cortical substance of the lateral surface of the epiphysis. This need not be divided, but should be simply fractured, as no osseous substance here needs to be removed.

The drilling of the fibula-at a point corresponding to the incision through the tibia, and which we wish to fracture may be done through so small a cutaneous opening as to permit the passage of the drill only, and not to require drainage.

It requires a moderate degree of force, after the bones have been cut, to restore the foot to its normal position. If there is too much resistance, it is evident that either the chiseling of the tibia or drilling of the fibula has not been sufficiently thorough, and, consequently, must be completed.

It is advisable to unite the cut surfaces of the tibia by a suture of heavy wire, because here, as in any other fracture, perfect immobility facilitates osseous union.

The main difficulty in the after-treatment is to keep the parts absolutely immobile, and, at the same time, permit the application of the necessarily voluminous antiseptic dressing. This was accomplished by the apparatus shown in Fig. 33, as devised by Dr. Verity and used in his case.

This consists of a broad leather band (1), secured around the upper part of the calf of the leg, outside of a plaster-of-Paris cast (2), extending from the middle of the thigh to the middle of the calf. The plaster cast prevents excess of pressure from tightening the leather band. A steel bar (3) extends down the posterior side of the leg, and has attached to it a movable foot-piece (4), which may be fixed in any desired position by means of screws (5). The foot is attached to the foot-piece by a plaster-of-Paris bandage (6). This apparatus allows, as will be readily seen, ample room for the antiseptic dressing (7), which can be changed without the least movement of the leg, which is suspended from a wooden frame. The adduction of the foot is further secured by a cord (8) from the inner side of the extremity of the foot-piece to the inner side of the leather band.

The cases above mentioned have demonstrated that supramalleolar osteotomy is a justifiable procedure: first, because it perfectly restores the proper function of the foot, and, second, because the inconveniences or dangers subsequent to the properly managed operation do not constitute an insurmountable barrier against the advantages obtainable.

It is to be hoped, however, that the indications for the operation will be more and more rarely met with, as deformity is avoidable by proper management of Pott's fractures. Not less than four cases of this deformity have applied for aid at Cook County Hospital within the last three years. (Dr. Gunn performed the operation in the fourth case.) It seems natural to conclude that such cases are, as yet, not so very uncommon. If this is the case, the operation may prove to be of some practical value, which will entitle it to a trial by the profession.

SIX CASES OF ANEURISM *

WITH E. W. LEE, M.D.

As the title indicates, this paper is simply a casuistic report, which we desire to lay before the Society. The number of cases is so small, and their nature so different, that the subject of aneurisms in general cannot be considered here.

We do not need to state that while the general term, aneurism, is perfectly correct anatomically, it is altogether too general when location, symptomatology, therapeutics, and cure are taken into consideration. The necessity of individualization in this respect has been mentioned in only very few of even the more elaborate hand-books of surgery. Attention must be given to this important point in future. This individualization can be accomplished only by a large number of casuistic reports, and to this end our paper of tonight is intended as a small contribution. To counterbalance the necessary dryness of the bare casuistic reports, we have added some remarks intended to point out some of the practical points of unusual interest to which our attention has been directed in some of the cases.

CASE I.-Traumatic Popliteal Aneurism. (Fenger, 1881.)—Synopsis.—Traumatic left popliteal aneurism from revolver bullet, wound passing through the artery. No external hemorrhage. Ligation of the popliteal artery in loco. Gangrene. Amputation at upper third of thigh. Death.

J. M., a laborer, thirty-five years of age, was brought to Cook County Hospital July 5, 1881, and placed under Dr. Fenger's care. On admission he gave the following history: July 4th, while walking across State Street, he felt a sudden pain in the left popliteal region; simultaneously he heard the report of a revolver which had been fired from a group of boys on the sidewalk. He was able to walk home, but pain and a feeling of tension in the popliteal space soon rendered walking difficult and compelled him to lie down. A small wound could be seen at the lower extremity of the outer hamstring tendon, from which, however, there was only very slight hemorrhage. The pain and swelling increased during the night, and the next morning, as he was unable to walk, he was brought to the hospital.

Examination revealed a revolver bullet wound an inch above the head of the fibula, close to the tendon of the biceps. Severe pain in the leg, which is slightly flexed at the knee, and the slightest movement of which is painful. The capsule contains no fluid, and there is no swelling on the anterior side of the limb, but the popliteal space is swollen, tense, and tender. The swelling extends downward through the upper third of the calf, and upward through the lower third of the posterior side of the thigh.

The hand applied over the popliteal space feels distinct pulsation, and the stethoscope

* 'Gaillard's Med. Jour., 1882, vol. xxxv, p. 1. Read before the Chicago Biological Society, February 1, 1882.