the epiphyseal cartilage; it has never given any pain, nor discomfort, but its position on the inner side of the right leg makes it very inconvenient to him when walking. The diagnosis of this growth is of special interest from a differential standpoint. The various growths from which it must be distinguished are, osteoma, chondroma, fibroma, and sarcoma. It is not an osteoma in the ordinary sense of the word; although it is of bony consistency. Osteoma is a true neoplasm, may develop anywhere along the length of the bone, and would not have the pediculated appearance, which we can in a measure distinguish here. A chondroma would start from cartilage, and would therefore be nearer the joint than this growth is.

tre of these growths consists of an excessively cancellated bone structure. Useless to say that this growth is benign, and the complete recovery of the patient requires only chiseling away the growth as near the femur as possible. The operation consists in making a free incision over the growth through the skin, and directly through the quadratus femoris muscle over the femur. The muscle is drawn down completely on each side. The growth is found covered with a thick fibrous membrane, which we recognize as hypertrophied periosteum; this is also incised and drawn down on each side; the growth presents a hard mulberry like shiny surface, and is found attached to the femur by bone, which on using the hammer and chisel shows an ivory like A sarcoma would have been of more hardness. The attachment is of bone; and rapid development, and would not present on its removal is found to be two inches the hardness found here; nor would there long and one inch wide. The large amount be freedom from pain; a fibroma would not of periosteum that covers the tumor is now be as hard as this growth, nor as fixed, but resected to the level of the femur. The it would be movable. The location of this cavity is packed with iodoform gauze; the bony mass over the epiphyseal cartilage, wound is closed by deep stitches, incorpothe fact that it developed during adoles- rating the muscular tissue. On microcence, that it grew constantly, without giv-scopical examination of the growth, the ing pain, but only mechanical discomfort, surface presents the peculiar mulberry-like points to the condition known as exostosis. surface, mentioned above, the rounded An exostosis is a protrusion of bony ele-bodies of which are of a mother of pearl ments from the source of development of color. The interior of the tumor presents bone at the epiphyseal cartilage, during the here and there pieces of hard ivory-like period of adolescence. The etiology of the bone, while the main portion of the intecondition is not well understood; but we rior is of spongy, cancellated consistency. do know that there is an excessive prolifera- In no way does this tumor present a dantion of bone cells at that special cartilage, gerous aspect; and nothing stands in the and that, instead of forming true bone, way of this patient making a rapid recovthey protrude to one side and accumulate ery, with a perfectly useful limb. there. It is possible that some of these young cells undergo further karyokinesis. At all events they eventually produce a bony mass, after the fashion of the formation of callous for the healing of a fracture. A miscroscopical examination of all these growths does not show a true histological bone formation, but rather a mass of bone cells, incorporating a large mass of cal-membrane. careous salts. The vascular system is very poorly developed within the mass; the cen

THE TREATMENT OF ANGEIOMA AND AN

EURYSMAL VARIX BY THE THERMOCAU-
TERY.

Both angeioma and aneurysmal varix consist essentially of dilated blood vessels. They exist mostly on the surface of the body and sometimes under the mucous

The pure angeioma consists mostly of tortuous and enlarged arterioles, while the aneurysmal varix has a fair pro

portion of veins combined with arterioles | By this method it is impossible to have a constituting the tumor. com- return of the trouble as has often been found to be the case with other methods that have been advocated. The following five cases will illustrate the efficiency of this mode of treatment.

Case I.-E. F., a little girl three years of age, was taken to the Medico-Chirurgical Hospital for treatment. She was referred to me by Professor Shoemaker. She presented an aneurysmal varix, involving onehalf of the upper lip, one-half of the nose, and fully three-fourths of the cheek on the left side. The deformity was very great, and the mother assured us that the trouble. was rapidly increasing. was rapidly increasing. The child was anesthetised with chloroform, and the narrow blade of the thermo-cautery, at almost white heat, was introduced perpendicu

Both are pressible, but the varix is more readily reducible. The etiology is far from clear. While many cases of angeioma and aneurysmal varix are congenital or are developed in early childhood, there are others developing later in life without any apparent cause. They all have a progressive tendency. Their size and appearance, together with the discomfort from pulsation which may be present, and the danger from hæmorrhage, require us to secure the safest method of procedure for eliminating their presence. The object to be attained in the treatment is the obliteration of the blood vessels constituting the tumor. This can be attained by a subcutaneous ligature, a method which consists in passing stout ligature around the base of the growth sub-larly in the tumor. The depth to which cutaneously, and ligating the mass so as the blade was introduced was guided by to cause a coagulation of blood within the my finger placed within the child's mouth. blood vessels in the tumor. This method At no time was the cautery blade allowed is painful, unsafe and exposes the wound to penetrate the mucous membrane of the to sepsis and its dangerous results. The mouth. These perforations were made over injection of chemical irritants within the the whole growth at the distance of a fourth tumor, and the resulting inflammation and of an inch, one from the other. There was coagulation of blood within the growth, no bleeding, and on waking up the child presents the same disadvantages as the liga- did not experience any pain. Two months ture. The tumor may slough, and sepsis after this treatment the child was brought may result. The complete dissection of back to us, showing complete healing of these tumors has been advised, but so great the wounds that had been made with the is the risk of hæmorrhage that this opera- cautery. There were still several soft parts tion may also be considered unsafe. in different portions of the growths. These were cauterized in the same way as at the first sitting, only five or six points, however, being judged necessary. Every two months the child was brought back, and if necessary the cautery was then applied. Altogether the child was cauterized five times. The growth at the end of the year had entirely disappeared. To-day, as you notice, the cheek seems quite normal and of the same size as the sound side, with very little deformity, in the shape of a

Of all the methods for creating inflammation and for the obliteration of the blood vessels within these growths, the one which does so in an aseptic way is the multiple introduction of the slender blade of the thermo-cautery, whereby many foci of violent inflammatory reaction result in the formation of a vast amount of cicatricial tissue. There is but very little reaction following the procedure. A certain number of perforations are made at the first sitting, and in a month, should the tumor not be obliterated, the operation may be repeated. A hard mass of fibres is eventually substituted for the former growth.

scar.

Case II.-A. L., age 2 years, was brought to us with an angeioma in the left axilliary region. The thermo-cautery was applied

ensue.

in six different places, perforating the blood vessels, and that a hæmorrhage would We therefore concluded to remove growth to such a depth and in such a direction as would not risk the wounding of the blood supply of the tumor by ligating the blood vessels or nerves of the axilliary the external carotid artery at its first porspace. Two months afterwards the child tion between the superior thyroid and linwas returned to us and it was deemed neces- gual arteries. This being done pulsation sary to apply the thermo-cautery per- disappeared from the tumor. We then inpendicularly into the softer parts three troduced the fine blade of the thermo-cautimes. This second application of the cau- tery about forty times through the tumor. tery completely effected a cure. By this We did not meet any hæmorrhage as a retime the tumor has been transformed into sult. The blood-supply evidently came from a dense cicatricial mass. the occipital and posterior auricular arterCase III.-E. R., age 32 years, devel- ies. During this process of treatment by oped an angeioma about the left labial com- the thermo-cautery no trouble was experimissure. It was about the size of an al-enced outside of a slight oozing, which may mond. In this locality it would have been take place from the punctured spots in the A little iodoform and ordinary especially difficult to resort to the ligature tumor. or the knife. The lip was anesthetized by gauze will suffice to keep these spots from means of subcutaneous injection of cocaine. suppurating. The thermo-cautery point was then introduced eight times into the tumor. In a month the growth had entirely disappeared. Case IV.-E. T., age 4 years, developed an angeioma on the tip of his tongue. It was about the size of a cherry and seemed quite sessile. The peculiar locality of the growth and its rapid increase in size made it impossible to apply a ligature to excise it with any degree of safety. The tongue was anesthetized by means of cocaine and the thermo-cautery was introduced at four different places in the tumor. One application sufficed. The angeioma disappeared entirely in six weeks, leaving a stout scar in its place.

Case V.-R. F., age 46 years, developed a pulsating angeioma back of the right ear. It grew to the size of a goose egg within five months, and spread quite rapidly later. It gave him no particular trouble except for the pulsation, which kept his mind on the parts. On pressing the external carotid artery below the angle of the lower jaw the pulsation would stop within the tumor. Owing to the large size of the blood vessels that we suspected constituted this tumor, we deemed it inadvisable to introduce the blade of the thermo-cautery directly within it, for fear that it would not obliterate the

Should the angeioma be in the mouth, any antiseptic mouth wash will suffice, such as boracic acid, five grains to one ounce of water. There seems to be no pain following the treatment. Altogether the application of the thermo-cautery in the manner above described seems to be the ideal way of dealing with a most rebellious form of hæmorrhagic hyperplasia, the treatment of which until lately was accompanied with exceeding risk to the patient.

THE RADICAL CURE OF VARICOCELE.

The series of symptoms so distressing to the patient that result from a varicocele warrants the discussion of such means as will safely and permanently remove the cause of the affliction. The distress result

ing from a varicose condition of the veins of the spermatic cord is reflected throughout the whole system. General health is impaired, obscure pains radiate throughout the muscular system, a general sense of heaviness ensues, with loss of appetite. The mind becomes more or less clouded and heavy. Patients seek the advice of the physician, who often fails to refer this obscure group of symptoms to the proper source. It has happened to me to see patients who have for years been treated for all manner

of nervous trouble, without relief. A large | quite distended with blood, and then we varicocele existed, on one side or both, at are enabled to dissect them out from the the same time. The causes of the affliction rest of the cord, being careful not to remay be varied, sometimes possibly due to move all the veins, but leaving at least one the natural anatomical arrangement of the to help carry on the return circulation. veins, whereby stasis is produced within The veins to be resected are isolated from them; and sometimes to the weakened the rest of the cord and a chromicised catdartos, whereby a relaxed scrotum ceases to gut ligature is passed around the dissected be a support to the testicle, hence the mass of veins above. mass of veins above. These are securely weight of it falls upon the veins, weaken- ligated. At the lower portion of the dising their walls. Sometimes also a chronic sected mass of veins another chromicised congestion of the parts, incident to im- catgut ligature is securely applied. The proper sexual hygiene, produces such a intervening mass of veins is now resected, distension as to finally result in the per- care being taken not to cut too near the manent varicose condition of the cord. ligature, above and below, for fear of the possible slipping of the ligature beyond the stump. The projecting ends of the ligature are then brought together, thus lifting the testicles and bringing the lower stump. in contact with the upper stump. One end of the ligature above and below is cut away, and the remaining ends of the ligature above and below are tied together, keeping the lower stump in permanent and direct apposition with the upper stump. The wound is then closed and a strand of silkworm gut is placed at the bottom of the scrotum for the purpose of drainage. The ordinary aseptic dressing is applied, held by a tightly fitting T-bandage. The patient remains in a recumbent position for three days, and on the fourth day he is allowed to walk about. The T-bandage is worn for two or three weeks, after which the patient is allowed to attend to his work. This method of procedure gives the best results. Not only is the local trouble effectually removed, but the general health of the patient is improved, and he benefits from any tonic treatment which before the operation seemed to be unattended by any beneficial effect.

For years one may suffer with varicocele without knowing that the general disturbance of the system is attributable to it. The treatment naturally divides itself into the palliative and the curative. Indeed, the palliative treatment, which consists simply of wearing a snug suspensory bandage, is only partly so. The tumefied veins, although not quite so distended because of their being so supported, still exert a certain amount of compression upon the spermatic nerves. Partial relief may be obtained by the use of the suspensory bandage, and also of astringent solutions that will tend to contract the white fibres of the dartos. But at best this plan of treatment is palliative, temporary, and incomplete. There is no permanent remedy for the evil effects of the dilated veins of the cord outside of a removal of the redundant veins. The radical procedure appeals to us as being more directly surgical and precise than the subcutaneous ligature, where the surgeon's work is performed without precision, not being able to regulate the number of veins to be ligated, according to the necessities of the case.

The method of procedure adopted by us consists in controlling the cord between the index finger and thumb of the left hand, and cutting directly upon the cord from above and downward until the cord is fully exposed. By gentle compression of the upper end of the cord the veins become

With the disappearance of the local symptoms of varicocele, and with the tonic treatment of the case, many functional disorders from which the patient might suffer will disappear. We would direct special attention to such disturbances as are more directly referable to the sexual functions,