present, which is relieved by traction, so we shall now add the jurymast. (Fig. 8.) The plaster jacket is first wet, and a few turns of fresh plaster-of-Paris bandage are applied. The jury-mast is placed in the exact median line of the body, and in such a position that the cross-bar is directly over the middle of the head. (Fig. 9.) Sometimes the jury-mast comes from the instrument-maker's with the transverse strips of tin passing entirely across the upright pieces. The portions of tin embraced between these two uprights at the bottom of the jurymast should be clipped out, otherwise, if there is a very prominent knuckle on the spine, the tin strip is likely to exert injurious pressure on it.

Some orthopaedic surgeons prefer a rigid chin-piece to the head-sling of the jury-mast; but the patients, after trying both, always prefer the jury-mast, notwithstanding its less elegant appearance, because of the greater elasticity and comfort.

CASE V.-Here is a boy who has had disease in the lower lumbar region for a long time, and who had practically no treatment until I saw him about eight months ago. He is now wearing a plaster-of-Paris jacket; the deformity is not marked, and the boy will in time recover completely. You notice that his jacket is pressed in close to the crests of the ilium. This "waisting-in" of the jacket is very carefully done while the jacket is still moist. This is a detail of treatment which is especially important when applying plaster jackets to young children.

CHRONIC ULCERS OF THE LEG.

CLINICAL LECTURE DELIVERED AT ADDENBROOKE'S HOSPITAL, CAMBRIDGE.

BY SIR GEOrge murrAY HUMPHRYS, F.R.S., M.D., LL.D., Sc.D., F.R.C.S.E.,

Professor of Surgery in the University of Cambridge, and Surgeon to Addenbrooke's Hospital.

GENTLEMEN,-Chronic ulcers, that is to say, simple chronic ulcers, are peculiar, or nearly so, to the lower half of the leg, more particularly the inner and fore part of the leg, and the adjacent region of, or behind, the malleoli. In other words, a simple ulcer rarely holds its ground in any other part of the body. If, therefore, you see an ulcer of such standing and of such characters as to be rightly called simple chronic ulcer in any other part of the body, except, of course, a bedsore, you may infer, indeed may be almost sure, that there is something special in its nature, that it is syphilitic, cancerous, or tubercular, or is maintained by some peculiar persistent local source of irritation. We often find an ulcer at the side of the great toe nail, but it is maintained by pressure and chafing upon the bare jagged edge of the nail, and is quickly cured by removal of the nail. Ulcers, or fissures as they are called, within the margin of the anus persist because they are, time after time, torn open by the passage of fæces through the sphinctered part; and they heal when the sphincter is divided, stretched, or otherwise impaired. From a nearly similar cause a crack or ulcer at the edge of the middle of the lower lip is often a source of continued annoyance; but it is cured by collodion, or some application which prevents the tearing apart of its edges by the action of the orbicularis muscle. An ulcer in the damaged skin under the thick, hard cuticle of a corn will remain for a long time, and may perforate the tissues down to the bone or joint, especially if there be any atrophic, neural, or senile condition of the part. If, however, irrespective of these causes, we find an ulcer or ulcers upon the toes or in the clefts behind them, about the anus or the lip, we suspect syphilis, unless the base and edge be hard from cancerous infiltration or the surround

ings dotted with tuberculous points. The ordinary simple ulcer rarely is met with in these parts. Let us then consider how it comes about that ulcers so often affix themselves and hold their ground on the lower part of the leg while other regions of the body are so free from them.

VARIX CONSIDERED AS A CAUSE.

Varix is one of the causes, perhaps the most frequent one, though I think its influence in this respect is somewhat overestimated. The internal saphenous vein has a longer subcutaneous, that is, comparatively unsupported, course than any other vein in the body, and it bears the weight of a long column of blood; and the frequency with which its coats yield under the pressure exerted shows that it is scarcely equal to its requirements. A varicose state of the vein does not interfere directly with the circulation in the skin, or with the nutrition of the skin, for the blood-current through the small vessels of a part is but little, commonly not at all, affected by the increased calibre or varicose condition of the vein leading from it. The blood-stream in the dilated vein itself is slowed, but not so that in the tributary vessels, any more than the stream through a pipe or system of pipes is affected by the bulging of the tubes at one or more parts. An illustration in point is furnished by the testicle, which does not seem to suffer in size or structure or activity in consequence of varicocele, even though the dilatation of the spermatic veins be very considerable. The way in which a varicose vein acts injuriously upon the skin is, first, by throwing the covering skin into prominence, and so subjecting it to friction, which may induce irritation or inflammation, and often leads to pigmentation, or other degenerative changes, and perhaps may induce ulceration of the skin. Secondly, these changes are further promoted by the pressure of the dilated vein causing atrophy and absorption of the subcutaneous tissue, including the blood-vessels, and so interference with the bloodsupply to the skin. Thirdly, the stretched vein-walls and the immediately investing tissue are liable to inflame; and the inflammation with extravasation or proliferation, or both, of cells spreads around, causing œedema and induration of the subcutaneous tissue, and probably inflammation. Not infrequently has the dilated soft fluctuating vein, thus circumstanced with its tender surroundings and red covering of skin, been mistaken for an abscess and opened, much to the discomfiture of operator and patient, when blood only was seen to issue instead of pus. Fourthly, the slowed blood-stream in the stretched, and more or less altered, epithelial lining of the dilated vein often leads to the formation of blood-clots, which are commonly attended with inflammation

of the vein and its surroundings, extending to and involving the skin. The blood-clots may, and usually do, become removed, and the channel in the vein may become restored, but the effects on the skin may nevertheless remain. By one or more of these various causes, rather than by any immediate effect on the circulation, inflammation of the skin, with its consequences, more particularly eczema and ulceration, may be, and often is, induced and maintained by a varicose condition of the subcutaneous veins.1

It is worthy of notice, however, that these ill effects, beyond some pigmentation of the skin, rarely take place at or above the knee, even although the vein in the thigh may be considerably more dilated and tortuous than in the leg; nor do they attend upon varix in other parts of the body, except about the anus, where the conditions are peculiar. We must, therefore, search for some other conditions which render the skin and subcutaneous connective tissue of the lower part of the leg so liable to derangement.

OTHER CAUSES.

One of these conditions is, I think, to be traced to the fact that for the purpose (much nullified by the unphysiological construction of our supra-pedal garments) of facilitating progress, especially in running, and to permit the other foot to sweep by without contact, the human leg at, and more especially just above, the ankle is reduced to the smallest possible dimensions, the result of which is that a greater weight is borne upon a given transverse sectional area than in any other region of the body; and this renders the part, as we know, very liable to fractures and to rickety flexures, as well as to affections of the periosteum and other soft parts. In short, all the tissues are placed at a considerable disadvantage by this reduction in size. The muscles are heaped up behind into the calf, and in front into the bulging tibialis anticus and extensors of the toes, whereas below they, as well as the peronei, are reduced to tendons ensheathed in dense fascia. This arrangement, while it gives comeliness to the leg and ankle and contributes to the freedom of the step, has, like many other peculiarities of the human

1 I must, however, not leave the valves out of account. In the natural condition the valves prevent a return current, and facilitate the onward flow by causing external pressure to operate in the right direction, and by counteracting the impulses of the blood-pressure from above during abdominal straining and various movements of the limbs. When in varix, owing to the dilatation of the vein-walls, the valves are rendered inefficient, there is nothing to resist the reflux of blood, which may act prejudicially upon the tributary veins and cause dilatation of them. Even then, however, it does not seem very detrimental to the capillary circulation.

form, its pathological disadvantages. The tissues, compressed within narrow limits, and somewhat tight or stretched, suffer in vascularity. In by-gone years, when it fell to me to inject bodies for dissection, I was struck by the tardiness with which the colored fluid thrown into the aorta permeated this region. Moreover, the skin lying upon the surface of the bone and the fasciæ, and separated from them only by a comparatively thin layer of connective tissue, is very liable to suffer severely from slight injuries. We all know how easily a broken shin is caused, and how much trouble it often gives. These features, then, in the anatomy of the part-the smallness of the circumference or weight-bearing area, and the consequent compactness and relatively low vascularity of the several tissues, bone, tendons, fascia, connective tissue, and skin, with their well-known liability to injury-are, I believe, the causes which, in addition to the disturbances attendant upon varix, lead to the formation of ulcers of the leg, and to their continuance when formed.

CAUSES WHICH RETARD HEALING.

The shape of an ulcer which is least favorable to healing is the circular, because in it the skin-forming margin bears the least proportion to the surface to be healed; and, cæteris paribus, the more the ulcer deviates from the circular shape, and the more irregular is its margin, the quicker will the healing be. Again, the more adherent and the more compact are the surroundings, the slower and more difficult will the healing of an ulcer prove. An ulcer with soft swollen circumference, and with perhaps a thick, white, overhanging edge of cuticle, will commonly, under moderate carefully-applied pressure by adhesive plaster or other means, soon acquire a level edge, and a delicate red film of cuticle will be seen shooting from the edge over the granulations. This proceeds more slowly as it approaches the centre of the ulcer, where the greatest difficulty in healing is encountered, owing to this part being farthest from the growing or healing base. When, however, the surrounding infiltrating media have hardened, rendering the skin thin, smooth, shiny, and tightly bound to the subjacent bone or fascia, the reparative work is, under the best of circumstances, very slow and, for the most part, inefficient. Even if such an ulcer can be induced to heal, it commonly soon breaks out again, and is as bad as ever, or worse.

CUTICLE-GRAFTING.

I believe good results in such cases as those last named can be obtained in one way only,—namely, by the Thiersch method of grafting,