wrist and fingers, as well as the stiffness of the fingers, will probably be at once greatly relieved.

It is curious that these two cases should come to the clinic for operation within a few months of each other. It shows how common is improper treatment of these fractures. I frequently have to reset imperfectly set, or refracture improperly united, fractures in this locality.

[Note. The patient returned at subsequent clinics and recovered the good use of her fingers and wrist with but moderate deformity. She stated that the discomfort after refracture was much less than before the operation. The result naturally was not quite as satisfactory as it would have been if the fracture had been properly reduced in the early treatment of the case.]

The ignorance of the true pathology of this fracture was formerly so great that many ridiculous splints were devised for its treatment. Many were constructed on the theory that the extensor muscles of the thumb were a cause of the deformity, and not a few were employed that failed to recognize the curvature of the palmar surface of the lower portion of the radius.

After reduction, the ordinary fracture of the inferior extremity of the radius rarely requires such rigid support as a splint, because the transverse fracture gives a broad rough surface of contact, and the extensor tendons running over the dorsal surface of the bone act as tense straps to hold down the lower fragment.

If there is much comminution, or if the patient is a careless man or a romping boy, it is at times wise to use, as an extra precaution, a short and narrow dorsal splint upon the back of the wrist. It may be made of a piece of cigar-box, a strip of metal, or two or three whalebones such as are used in ladies' dress-waists. It should extend only from the middle of the metacarpal bones to the junction of the middle and lower thirds of the forearm, being therefore about six inches long. Its width need not be over one inch. It should be held in place by adhesive plaster or a bandage encircling the limb.

This dressing should not be employed longer than ten days or two weeks at the outside, during all of which time the patient ought to be encouraged to use his fingers as freely as pain and swelling will permit. In the great majority of cases this dressing is unnecessary, and a simple roller bandage or a wristlet made of two or three superimposed strips of rubber adhesive plaster is all that is needed.

This simple method of treating the fracture gives the patient the necessary freedom in moving his fingers from the instant the fracture

is set, does not prevent his wearing a sleeve, allows inspection of the parts, is inconspicuous, light, clean, and efficient.

The dressing employed may usually be discarded in ten days or two weeks in ordinary cases, and in three or four weeks in comminuted fractures. Long retention of the appliances is unnecessary and even deleterious when splints are employed, because of the greater tendency to stiffness thereby induced.

In properly-treated cases of ordinary severity, perfect use of wrist and fingers is obtained within a few weeks after the injury. Patients can often write a little, and use the hand for dressing themselves, within two weeks. This facility varies with the amount of comminution and inflammation. Persons of gouty and rheumatic tendencies are probably more liable to stiffness of fingers and wrist than others. Fractures in other regions present the same complication in such individuals. Much of the rigidity of wrist and fingers attributed to rheumatic and gouty causes, or to the senility of the patient, I believe to be due to imperfect reduction of the fragments and to unscientific and unwise treatment. I have not recognized the stiffness and rigidity after this fracture in the aged which some authors mention with emphasis. I expect the same early and perfect freedom of motion in these as in the young, except in so far as the aged are more liable to rheumatism and gout.

MACEWEN'S OPERATION FOR RACHITIC DEFORMITY OF THE FEMUR; INFLAMED HEM

ORRHOIDS.

CLINICAL LECTURE DELIVERED AT THE BUFFALO GENERAL HOSPITAL.

BY ROSWELL PARK, A.M., M.D.,

Professor of Surgery in the University of Buffalo.

GENTLEMEN,-This case is that of a young child with rachitic deformity of the lower limbs. On inspection you will notice that there is very much more deviation of the axis of the leg from that of the femur than there should be. The tibia appears to be perfectly formed; the trouble is that the inner condyle of the femur is on a lower level than is natural. We cannot raise the condyle without splitting it off and performing an operation that is unwarranted on account of its severity, but we can bend the femur, or, at any rate, break it, and thus atone for the position of the condyle. An operation below the knee would be a mistake in such a case as this. When the knees are directed forward and brought together, we find that there is marked knockknee and anterior curvature of the femur.

If one had sufficient room to grasp it, the bone could hardly resist the force which I apply; but, on account of the small size of the bones of the child, I will use the osteoclast. I now apply considerable force with the osteoclast. After the removal of the osteoclast, I find that nothing has been accomplished. I think, therefore, that I shall do less harm to break the bone by means of the chisel. There is a prevalent opinion that a child's bones break very easily, but in more than one instance I have exerted all my strength on such a case and have failed to break the bone.

The point for the insertion of the chisel in this operation is just above the tubercle of the adductor magnus, which is slightly above the internal condyle of the femur. After carefully washing and disinfecting the leg, a small incision is made just above the tubercle for the insertion of the great adductor, high enough to avoid the femoral artery and its accompanying structures. The wound is relatively larger in a small child than in an adult. After introducing the chisel,

the wound is closed temporarily with antiseptic gauze wound about the handle of the chisel, the bone is cut into sufficiently to allow it to be broken with the hand, and then a light gauze dressing is wrapped about the thigh. I will repeat the operation on the other leg.

I now dress the wounds with iodoform gauze, and bichloride gauze over that, held on by a gauze roller bandage. A cotton-wadding roller is applied to the leg and thigh, beginning at the foot, and over this a starch bandage.

Professor Macewen, of Aberdeen, Scotland, has done this operation nearly a thousand times without a death. Those figures will give you an idea of the amount of rachitic disease in Scotland. Do not imagine that the operation is finished with putting on this bandage, for a great deal remains in seeing that the position of the leg is correct while the plaster-of-Paris bandage, which we will now apply, hardens. If we do not correct the deformity now it will not be corrected at all. It is better to over-correct the deformity slightly than not to correct it sufficiently. In the left foot the child has a slight tendency to talipes equino-varus, and in applying the plaster-of-Paris bandage I will overcome that deformity also.

You have seen that I have made two wounds here, and have sealed them hermetically without thought of drainage. You remember a little colored infant from whom I removed the astragalus for an aggravated case of club-foot. That was quite a severe operation of the removal of bone and opening into a joint-cavity, but we observed perfect asepsis throughout the operation, and the wound was closed without drainage, and it healed perfectly in two weeks. This present operation is certainly much less severe nevertheless, if I had not absolute confidence in our aseptic precautions, I should not think of so closing any wound without drainage.

My next case is one of considerable pathological importance, and one which would probably give you considerable trouble. I have not yet seen the case, but, taking the statement of others as to his condition, I am having him anesthetized, and I shall present him to you in a few minutes. It is a case of inflamed piles. Let us consider the nature of acutely-inflamed hemorrhoids. A number of hemorrhoidal protuberances which come down frequently, or which remain down, constitute a bad enough state of affairs, but when to this is added the element of acute inflammation there is positive danger. Our patient was sent here late in the afternoon yesterday, and the main thing then was to give him relief. He was given a quarter of a grain of morphine and a suppository of opium, belladonna, and ergot.

VOL. I. Ser. 4.-14

Hemorrhoidal tumors, composed as they are of a series of enlarged veins, being really nothing but originally varicose veins covered by mucous membrane, are just as liable to inflame as venous structures enlarged into varices anywhere else. I have told you that inflammation of veins is always a very serious thing, though it is not necessarily fatal. The exposed veins and the hemorrhoidal tumors are covered ordinarily only by mucous membrane, which, however, by constant contact with the clothing and the air, if the piles are always exposed, becomes thickened and tough, and sometimes loses its characteristic appearance, while the exposed veins bleed frequently, as is well known to the laity. They are easily ruptured and are subject to inflammatory irritation. When once inflamed, the trouble may remain in the group of varicose veins, or it may spread to two or three veins with which they are connected. While the external hemorrhoidal veins are virtually subcutaneous veins, and connect with the veins of the skin, the middle and superior hemorrhoidal plexuses connect with the veins of the portal system. An inflamed pile may degenerate and suppurate, forming a septic focus; septic thrombi may then form in the veins, become dislodged by defecation or by some motion on the part of the patient, and may be carried, as thrombi always are, along the course of the venous circulation, and taken, not to the right side of the heart, but to the liver, where they will set up just the same trouble as thrombi from the systemic veins would set up in the lungs, that is, a series of minute abscesses. Thus, not infrequently, men have died of abscess of the liver consequent upon trouble which began in hemorrhoidal tumors. That is one objection to the method of treating hemorrhoids by injection with carbolic acid, a procedure which is largely practised by a number of quacks who travel about the country, advertising to cure piles without pain. That is a euphemism, because they do inflict some pain, although it is a minimum. They usually keep their method secret ; they get the patient to expose the part, and then they draw a hypodermic syringe and make an injection without letting the patient see what they are doing. Usually there is not a great deal of pain, and a cure is effected, though sometimes death follows from abscess of the liver and septicemia or pyæmia resulting.

An inflamed vein, under any circumstances, is to be dealt with with great caution. To treat an acutely-inflamed pile as one would treat an uninflamed pile would be the height of rashness. I do not mean to say that the result would be always fatal, but that there would always be danger of such a result. One must adopt the mildest form of treatment and subdue the inflammation unless there is some element of the