caustics. The thought has occurred, and has been even expressed, that it is an unkindness to prolong life in circumstances so dreadful as those of an advanced case of Rodent Cancer.

It is, however, unnecessary to adopt so gloomy a view of these cases. The knife and caustic may be so combined that the Surgeon shall extirpate the disease in a very advanced stage, protecting the patient absolutely from pain and shock by the use of chloroform and the subcutaneous injection of morphia, and supplying by a suitable mask the shrunken gap which is left after the cicatrisation of the wound. I first found how far such an operation can be carried in the case of Mary H., in which I removed all the margin and contents of the right orbit, with the bridge of the nose, and laid a paste of the chloride of zinc upon the freshly cut surface, which still presented fragments of the disease in the exposed portions of the bones. Before the patient awoke from the effects of the chloroform, I injected morphia beneath the skin, and under its influence she remained asleep for six hours, and awoke free from pain. In five weeks the inodorous slough came away, the wound healed, and the patient lived three years in comfort, wearing a vulcanite mask, which was skilfully moulded and painted to represent the defective features. Another patient, who was under the care of Mr. De Morgan, after as extensive an opera

tion, completely recovered, and afterwards not unfrequently enjoyed a day's shooting.

Such an operation demands a very careful study of the whole of the boundaries of the disease. In a region naturally so complicated as the face, the morbid growth extends in many directions, each one of which requires attention, since a fragment overlooked in the operation is sure to continue to grow, and to reappear in or near the scar.

The advantage of this method of treating Rodent Cancer appears to consist in the completeness of the caustic action of the chloride of zinc. There is no ex

penditure of it upon the dense margin of the disease, but it acts directly upon the soft textures which are exposed by the incisions. These apparently healthy but really morbid parts are readily permeable by the caustic, and they can be destroyed to any depth which may be deemed requisite. From a fear of augmenting the already great deformity, it is likely that a sufficient quantity of the zinc may not be applied, and, indeed, it is possible to lay on too much. As a matter of fact, however, there is little need to withhold it, except in certain situations, since, notwithstanding the loss of substance due to both knife and caustic, the subsequent contraction of the scar reduces the chasm in the features to a less size than it had before the operation.

The parts requiring particular caution in this use

of the caustic are those near the eye and the brain, the nostrils and mouth. It would be easy to destroy the eye by a reckless application of it, or by so placing the head of the patient in bed that some of the caustic should trickle over the globe. Caution is necessary in this respect, both in having a paste so concentrated as not of itself to run, and in securing it from passing into the nostrils and throat if the moisture of the wound should render the caustic too liquid. The effect upon the brain and its superficial appendages requires a more exact notice.

In almost all the cases in which the chloride of zinc has been applied to the cranium, or to a diseased surface of the dura mater, an epileptiform fit has ensued. This has usually taken place within one or two days of the operation, but it is sometimes later. The ordinary convulsion is slight, the unconsciousness endures from three to ten minutes; after a little sleep the patient regains his usual health, and has no repetition of the attack. Sometimes there has been no fit after the operation, especially when the portion of the skull-cap, though destroyed in its entire thickness by the caustic, has been small. In one case no fit occurred till six days after the operation, and it was afterwards repeated without any certain connection with the state of the wound. On one occasion, in the practice of Mr. De Morgan, after the application of zinc to that part of the ulcerating surface which

lay next over the brain and pulsated, the cerebral symptoms in the night following the operation were extremely threatening. The consciousness of the patient did not return immediately upon the subsidence of the first fit, but he passed into a state of coma and deep exhaustion, alternating with regularly recurring fits, from which he did not rally until after eight or nine hours. He then awoke and took food, but two days elapsed before he quite regained his usual manner and mental vigour.

It is clear, from the state of the brain near the wound or scar in those who have subsequently died, that the fits are not necessarily due to any injurious action of the caustic upon that organ itself. There is sometimes a clear arachnoid space beneath the dura mater, and the membranes and the brain are in the same healthy state near the region to which caustic was applied as they are elsewhere. This was clearly the fact in the case of Luke H., who had no fit till the sloughs were separating, six days after the application of the caustic. His brain was quite healthy, and the zinc was found to have not completely penetrated the roof of his orbit. Upon the dura mater itself the effect is the same, whether the zinc be applied upon its exposed surface or first reach that membrane after penetrating the bone. In either case the epileptiform fits occur within a few hours of the application of the caustic. But from the case just

mentioned and from others which are subjoined, it appears clear that fits also occur when only a superficial layer of the cranium is necrosed. They are then, however, sometimes postponed until the exfoliation of the thin sequestrum begins. Fits came on in Luke H. on so slight an occasion as the puncture of his oedematous eyelid. It is clear, therefore, that irritation of a more superficial structure than the dura mater is sufficient to produce them. They remind us of cases in which fits are induced by touching the skin at the extremities of particular nerves; and though formidable in appearance, they imply no serious affection of the brain.

It is remarkable that the result of this irritation should be so slight and so transitory as it almost invariably is. When originating in a disease of the bone, irritation is sometimes much more injurious than this, and it may even be fatal. I insert among the cases in the Appendix, an example of death from such disease, and also an instance in which the application of zinc to an exposed bit of healthy skull preceded fatal cerebral abscess. That it does not lead to this issue when the chloride of zinc is itself the cause of the fits, is probably due to the complete quiescence of the healthy parts adjoining those into which the zinc has infiltered. So soon as that infiltration is over, there is no longer any irritation, but usually a moderate vascularity, and a quiet detachment of the part which has been deprived of its vitality.