mal. The patient leaves for home this week. She retains her feces except when very fluid, a condition which will doubtless still further improve as cicatrization advances.

A rectal cancer being present and excision not possible, how can relief be obtained? Pain and obstruction of the bowels are the symptoms demanding attention. Until the growth becomes large, pain is complained of principally during defecation, the patient, as in anal fissure, avoiding a movement for as long a time as possible, and then passing hard masses of fecal matter with intense suffering. It is of primary importance to secure, therefore, a soft evacuation daily, although the patient may be taking opium. When the rectum is freely open injections cleanse without discomfort, but as the lumen of the tube diminishes I have not found large injections of water so valuable as I could wish, although if hard masses impact they are necessary. Attempts to keep the passage open by bougies are of more than questionable utility; great pain, which often persists, attends their use, while the passage is irritated, bleeds, and closes all the same. Iodoform suppositories often alleviate the condition of the sufferer, but they should not be used continuously; their employment should be suspended for several days at a time.

The chief agent for relief is, of necessity, opium in quantity proportionate to the pain experienced. Linear rectotomy of the sphincter and rectum back to the coccyx and lower sacrum has given, in my hands, relief second only to that afforded by large doses of opium. It is an operation of unquestionable merit in cases attended by much. irritability and spasm of the lower bowel. Spooning the cancer with the curette I have not yet tried. Sooner or later, in almost every case of rectal cancer, either from the great pain attending the passage of alvine discharges through the inflamed and ulcerated bowel, or in consequence of obstruction more or less complete, it becomes necessary to consider the advisability of opening the gut above the seat of trouble. Such a measure can, of course, be suggested only for the purpose of giving rest to diseased structures by diverting the bowel contents, and thus marked alleviation of suffering may be, and is, obtained. I have had occasion to do colotomy three times, and in similar cases shall recommend the operation. To two of the patients, death came from the disease some time subsequent to the colotomy; the third still lives, the operation having been done somewhat more than a month ago. The discomfort attending the lumbar anus is far more than compensated for by the comparative quiet afforded the

rectum. A pad of oakum and snugly fitting bandage suffice to retain discharges as well as, if not better than, any other dressing. Most of the objections to the operation come from those who have no practical knowledge of its advantages.

The details of colotomy are so clearly laid down in the text-books as to leave little to be desired, the only point perhaps worth recalling to mind being the relation between the colon and kidney. When the colon is distended it is easily found, but when empty it may not present in the lumbar wound. It is then to be sought for, and will be found resting upon the anterior surface of the lower end of the kidney, and as this latter viscus can be easily felt in the sub-peritoneal fat, it may be considered as perhaps the most reliable guide to the gut. Of the three colotomies referred to two are reported in the Am. Jour. Med. Sci., Oct. 1877, the third is as follows:

J. P- aged 60, suffered from rectal discomfort, so he applied to a pile doctor. This worthy, after a sufficient amount of manipulation, obtaining of fees, etc., stated that the piles were cured, but that there was an ulcer of the bowel which a specialist in piles should not treat. J. P―― therefore consulted his family physician, with whom I saw the patient. There existed an epithelioma, probably three inches in diameter, in the anterior wall of the rectum, adherent to subjacent parts. The finger could not quite reach the superior limit of disease. Excision was contraindicated and palliative measures adopted. Six months later the rectum was almost entirely closed, so colotomy was offered, accepted and done on March 9th, 1882; no complications occurred, the wound healed well and rapidly, and the patient has his evacuations from the loin.

OSTEO SARCOMA OF THE FEMUR-AMPUTATION AT

HIP JOINT-RECOVERY.*

BY L. MCLANE TIFFANY, M. D.

Professor of Surgery, Univ. of Maryland.

George K, white, male, aged twenty years, applied for treatment November, 1881. Eighteen months previously he noticed a lump in the outer aspect of the left thigh, midway between hip and knee, which slowly increased without pain. During the past two months nocturnal pain has been marked, although increase in size has not been more rapid than usual. There is no history of syphilis. The father of George K- died of cancer of the eye, which recurred after extirpation.

Patient is a strong, fair man, of muddy complexion, very muscular. The middle third of left thigh is occupied by a firm, elastic, oval, smooth swelling, about six by nine inches in size, firmly adherent to femur. No glandular enlargements in groin or elsewhere. Locomotion painful, and patient uses crutches.

Mercurial inunction was used and kal. iod. given to amount of gr. 30 daily. Under this treatment the pains disappeared and crutches were laid aside; four days later, however, the left femur broke at the site of the tumor.

Amputation at hip joint was done November 14th, in the University Hospital, lateral flaps being formed by transfixion. Hemorrhage was controlled by Prof. Michael, who grasped the flaps as cut. The flaps were brought together lightly, leaving a free opening at the lower angle. Oakum and carbolized oil constituted the dressing.

On the 21st day the patient had a smart attack of pleurisy, lasting five days, and sending his temperature up to 103°. On the 30th day he felt very well and ate largely of ice cream and oysters, injudiciously supplied by relatives. The result was an attack of acute indigestion lasting twenty-four hours, his temperature reaching 104°, the highest point touched during convalescence.

On the 41st day he was practically well, leaving for home.

Examination of the amputated limb showed a firm, fusiform, white growth, involving nearly one-third of the length of the femur. The compact tissue of the shaft, outer aspect, was wanting for a space of six inches; the tumor extended in the medullary canal as high as the lesser trochanter. The bone gave way about the middle of the growth. The microscopic structure of the tumor was that of a small-celled sarcoma.

* The patient was exhibited before the Association.

CONTRIBUTION TO THE STUDY OF FRACTURES OF

THE INFERIOR EXTREMITY OF THE RADIUS.

BY GEORGE HALSTED BOYLAND, A. M., M. D., ETC.

Mr. President and Gentlemen of the Faculty:

The diagnosis of lesions of the inferior third of the fore-arm is, in general, a comparatively easy affair; but the difficulties that may arise in some instances, as to determining the exact nature of a given injury to this member, were never so forcibly presented to my mind as by the following two cases, to a brief consideration of which your attention is invited. On the 18th day of December last I was called upon to attend a well-developed, healthy man, twentyfour years of age, residing in the eastern section of the city, who, returning home late in the evening, had slipped upon a patch of ice on the pavement and fallen upon the palm of his hand. He complained when first seen of lively pain in the wrist, being unable to execute certain movements. Upon examination of the injured part a special deformity was observable, consisting of an abnormal rounded projection, with corresponding depression, about the size of a pigeon's egg, on the dorsal surface; on the palmar surface was likewise a protuberance abnormal, somewhat angular and irregular, corresponding to the dorsal depression. The appearance of the wrist is very fairly reproduced by the back of a fork, and has been so designated "dos de fourchette" by Velpeau. Had my patient sustained a severe sprain, a luxation, or a fracture? Accepting that the last might be the case, I cut splints from a cigar-box, made an effort at reduction, applied a roller bandage and put the arm in a sling for the night-reserving my diagnosis. Next morning much the same conditions prevailed. A closer examination, however, revealed two important lateral points: there was an abnormal protuberance more or less marked of the styloid apophysis of the ulna on the inner side; on the outer side, a corresponding disappearance more or less complete of the styloid apophysis of the radius. Furthermore, this apophysis did not occupy its customary level; it was situated on a line with that of the ulna.

In a case of this kind reported by Monsieur Duplay, in his clinic, the radial apophysis had gone up above the ulnar; whereas we all know that in the normal state the summit of the styloid apophysis of the radius descends a little below the summit of the corresponding apophysis of the ulna. Independent of these different symptoms, the hand as a whole deviated to the radial border of the fore-arm; it was easy to verify this by the line which represents the axis of the fore-arm instead of continuing as it does in the normal state with the axis of the hand, falling within this. My diagnosis was now fixed-as fracture of the inferior extremity of the radius; nevertheless, there was no abnormal mobility such as we see in fractures of the radius higher up, and no crepitation; for pathological anatomical reasons that will be cursorily touched upon these classic symptoms are almost always absent in fractures of this nature. With these signs could it have been a question of a different injury? The existence of the general deformation of the wrist and of the abnormal protuberances on the palmar and dorsal surfaces might lead to the belief that an articular displacement was present. Formerly that error was almost always committed. However, the diagnosis between fracture and luxation ought to be quite easy. In the first place, luxation of the wrist is a pathological rarity; besides, the characters of the two lesions are very different. In luxation the abnormal prominences are regular, representing the well-known articular surfaces. In fracture, on the other hand, they are irregular and angular, not resembling in any particular the displaced articular surfaces. Finally, in luxation, the styloid apophyses preserve their normal relation. In my first case, the prominences being irregular and well enough marked, the differential diagnosis from simple sprain was not difficult; but in certain cases of these fractures the deformation is hardly perceptible, and then they might be confounded with simple sprain; it is true that such a mistake would not be fraught with danger to the patient, but even in that case it seems to me that the diagnosis is almost always possible. Again, the seat of pain differs in the two cases. In sprain the pain is usually localized along the interarticular line; in fracture a little above it. In fracture we can more often determine an abnormal special mobility comparable to a stem of wood incompletely broken; thus the stem may be bent at the point of rupture, yield to one side, but there is no total displacement. It is the same in certain fractures unaccompanied by deformation, the edges of the bone, like those of the wood, fitting into each other by fine denticulations. The point of fracture is situated a few lines above the