equally divided among them. The cases occurred mostly in the youthful, but a hereditary history could be obtained in only 76 per cent of cases. The results in total resections were complete cure, 60 per cent; incomplete cure, 18 per cent; secondary amputation, 7 per cent; incomplete cure, 18 per cent; secondary amputation, 13 per cent.

A complete cure signifies in the above forms ankylosis without fistulæ. Sepsis, one; tetanus, two; tubercular meningitis, one; erysipelas, one, were causes of death. In reconsideration of the above cases, deducting deaths and return of unfavorable cases, the author makes out a good result in 85 per cent of cases operated upon by both methods. of partial and complete resection. Of sixty-one cases there resulted angular deformity in thirty-two, 52 per cent of total and 52 per cent partial resection. This is not favorable to the partial method considered in the total number

of cases. Lengthening was observed in only three cases after operation. Shortening was observed on discharge of patients in only four cases. In only one case could it be established that shortening was absent years after the operation. The ages of one to ten years were favorable to the least amount of shortening; this, though true for partial resection, is not the case in total resections, where we find the shortening greater at these years, and the partial resections were only favorable operative cases in younger individuals. (Deutsche Zeitsch. f. Chirg., XXIX, Sept. 4; Loc. Cit. Annals Surgery, Vol. XI, p. 392.)

Results in arthrectomies of the knee by Dr. Angerer (München):

Angerer has performed eighty-two arthrectomies during the last four years. in the polyclinic and children's clinic. Sixty-three of these were those of children below fourteen years of age. Angerer has concluded from the study of these cases that there is little danger in overlooking foci of disease which may cause subsequent trouble. Of the seventy cases operated upon up to August, 1889, primary union was obtained in forty-eight. Ten of these cases were marked by a return of dis

which might compromise subsequent growth. (Beilage z. Centblt. f. Chir., No. 25, 1890; Loc. Cit. Annals Surgery.)

as seen in the accompanying cut, was perfect in every sense. No shortening.

It is now almost three years since the operation, and the last report received through a medical associate emphasized the success of the operation and the usefulness of the extremity. The operation was carried out in a bloodless manner, and he was confined to my infirmary but six weeks.

CASE 2. Exsection for tubercular gonitis. No distinct history of an injury nor tubercular history could be obtained. This girl was operated upon before the class at the Louisville Medical College. The operation was carried out in the bloodless manner. Primary union throughout was obtained. The so-called "permanent dressing was used, and was removed at the end of six weeks. The patient was then allowed to go about with the aid of crutches. The accompanying photograph was

CASE 2. Exsection for tubercular gonitis.

From the foregoing it is apparent that the Germans have made a strong case in favor of exsections and arthrectomies. It must not be inferred, however, that this measure is indiscriminately resorted to without the exercise of judgment as to the time and the selection of cases for the operative

treatment.

Report of Cases. CASE I. CASE I. Dr. F., of Peoria, Ill., consulted me for the relief of a bony ankylosis resulting from an injury received during childhood. Cuneiform exsection of the knee was advised and carried out. The result,

CASE 3. Tubercular gonitis.

taken eight weeks after the operation. She was seen about six months after the operation. Result good, and the

thickening seen in photograph absent. CASE 3. Mabel. Tubercular gonitis. Operated upon two years ago before the class at the Louisville Medical College. The bloodless method was used. In this, as in the two preceding cases, no nails were used to steady the long surfaces. In their stead, deep sutures introduced into the structures surrounding the bone were used, supplemented by a "guttered" posterior splint and plaster paris dressing from the toe to the pelvis inclusive. Primary union was obtained, the dressing being removed at the end of six weeks. There was practically no shortening at the end of two years, the accompanying photograph being a recent one.

Societies.

The Louisville Surgical Society.*

Stated Meeting, January 2, 1899, the President, Turner Anderson, M. D., in the Chair.

ANGEIO-SARCOMA OF THE GROIN.

BY DR. A. M. CARTLEDGE.

Mr. R., the subject of this report, is forty-three years of age, with about this family history: His father is still living; mother died at the age of thirty

seven of what was thought to be tuberculosis of the bowel; so far as brothers and sisters are concerned, the history is negative. I saw Mr. R. for the first time last October (1898), when he consulted me in regard to a tumor in the right groin. This tumor was very large and most unpromising in its macroscopical appearance; it was an ugly color, with large veins coursing over it, and the venous enlargement out to quite a distance from the tumor was marked. The tumor was a slightly lobular, soft mass, irregular in shape, and without. fluctation, and the first glance at it would cause any surgeon to believe that it was undoubtedly malignant in charac

The patient's general health had deteriorated; he had lost twenty pounds in weight. The weight of the tumor was considerable, the center of it being about the center of Scarpa's triangle.

* Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

I did not believe any thing could be done with the growth; thought it was inoperable. I did not believe it would be possible to remove the tumor. There was considerable swelling and interference with circulation. One reason I thought the case inoperable was the angeiomatous appearance of the growth; it had a great many new vessels as well as great enlargement of pre-existing vessels that partook largely of what you would call angeioma probably of sarcomatous nature. It was an angeio-sarcoma of the groin; it was more or less fixed at its base, and I discouraged him against operation when I first saw him, telling him to come back again, and in the mean time I would think about it. He reapplied, fully realizing the serious nature of the trouble. At the time he was having a little elevation of temperature, night sweats, etc., which I think now was as much due to his condition of depression as any thing else.

The growth of the tumor had been very rapid for one and a half years; it was first noticed three years ago; it grew very little the first year and a half, but rapidly afterward. The tumor was altogether larger than my head, including the extension of the base, etc. him, with the thorough understanding I finally consented to operate upon of the great dangers to be apprehended and the extreme gravity of the case, rather hoping that he would refuse it by giving him such a gloomy prognosis. I told him I did not believe he would come off the table alive, but if he desired the operation performed I Iwould do the best I could.

On November 2, 1898, Dr. Dugan saw him with me, and with the assistance of Drs. Dugan, and Bullitt the removal of the tumor was attempted at the Norton Infirmary. I have seen few such cases, although we were prepared for the frightful complications which might come up. I worked upon the center of the tumor, while Drs. Dugan and Bullitt worked at either end. Large venous channels ran in every direction. The operation was done hastily, and a great many ligatures were put on, though we did not pretend to get any thing like an ideal removal.

We removed the tumor down to its base, of course, but left large channels running out into the surrounding tissues; the walls of these channels were thickened and seemed to be connected with the disease, as it had infiltrated in all directions. The man was bloodless and pulseless after this was done, although the operation was performed quickly. A large amount of saline solution was injected directly into the circulation, and rectal injections of the same material were also practiced, and the wound closed. A four-flap arrangement was made in removing the tumor, and this cavity was liberally packed with gauze, both for hemostatic and drainage purposes.

Much to our surprise the man reacted well, and in a few days was doing as nicely as could have been expected in a more favorable case. Dr. Dugan and myself had but one agreement when we had finished the operation, viz: that we had made a great mistake; that we had operated upon an inoperable case, and that it was simply the result of the saline solution that we were able to get the man to bed alive. We thought the only lesson to be drawn from the case was that we had operated upon an inoperable case.

About this time Dr. Bullitt began the use of protonuclein, special, packing this powder into the crevices, covering all the raw surfaces underneath the flaps at each dressing. The man improved rapidly. There was never very much suppuration about the wound.

What I want to call attention to to-night is the marvelous improvement that has taken place; and while the case is not complete, and it is probably too early to make a report, it seems to me that we are justified, in watching the course of the base of this neoplasm from day to day, in believing the man will recover. The infiltration of new vessels in the base of the tumor is constantly diminishing, until to-day we have nothing much but cicatricial tissue. The few places which remain open would probably have healed, but we have kept them open in order to get the protonuclein powder down to the base of the growth.

The man has gained considerably in weight; he looks like a different man; his appetite is good, he walks about, and is free from pain. I report the case because this is so contrary to what I had expected the growth to do. In my experience in removing inoperable growths, it has been my observation that they spring up at once, especially where they are not completely removed. There is no question but this growth was not ideally removed down to the base and into the infected blood-vessels, yet it has grown gradually smaller until there is practically none of the neoplasm left.

An interesting question is what effect the protonuclein powder had upon the remains of the sarcoma. Microscopic examination shows the growth to be a small round-cell sarcoma. I am free to say, although it may appear dogmatic, that if all the miscroscopists in the world had said the growth was not malignant, I would have still claimed, from its clinical appearances, that it was malignant.

To be thoroughly appreciated the case should have been seen before the operation.

DISCUSSION.

Dr. James B. Bullitt: The tumor was very soft, and I think Dr. Dugan will remember that there were several fingers, so to speak, reaching deep down into the thigh alongside the large vessels, and no attempt was made to remove these projections. Unquestionably quite large masses of the growth were left. On the third day the gauze packing was removed; there was very little hemorrhage, and protonuclein, special, was packed into the wound, and this was done every day or every other day up to the time the man left the hospital, since which time protonuclein has been applied once or twice a week. At the same time he took large doses of protonuclein internally-twenty-seven grains a day. Whether or not the protonuclein has had any effect in the case of course is a moot question. I take it the Fellows of this Society remember a patient Dr. Chenoweth presented to the Society about a year ago. The man apparently

had a malignant growth in the sacral region which was imperfectly removed, and the case was then treated in the way Dr. Cartledge has outlined, packing the wound with protonuclein, which was also given internally. The man had gotten entirely well, and the conclusion was reached that the growth was probably not malignant. The tumor had unfortunately been lost, so that no microscopical examination was made. The results in that case suggested to me to try protonuclein in this case, which was readily agreed to, as the case seemed hopeless. It was thought that the man would die inside of two weeks.

Dr. W. O. Roberts: Was there sloughing at any time?

Dr. James B. Bullitt: There was continuous sloughing. The protonuclein seemed to have the property of breaking down the sarcomatous material. The sloughing masses had a modified odor of decomposition, and there has been more or less odor to the discharge up to the present time.

I

Dr. W. C. Dugan: I simply desire to confirm what Dr. Cartledge has said in regard to the serious nature of this case and the difficulties attending the operation. I have witnessed a good many bloody operations, but this was the worst that I have ever seen. The base of the tumor was simply made up of large blood-vessels, and, as Dr. Bullitt has said, between these vessels were pits filled with sarcomatous tissue. had no idea that the man would recover from the effects of the operation. He looked like a dead man when he came off the operating-table. I think the saline solution saved his life. As to an ultimate cure, that was at the time deemed to be an impossibility. Dr. Dr. Cartledge and myself decided that the lesson to be drawn was that it was an inoperable case, and that we would not operate upon another case of a similar character.

I remember the case referred to by Dr. Bullitt, presented before the Society by Dr. Chenoweth, and at that time questioned the diagnosis. I did not believe it was a sarcoma, because the result was a cure. The reporter stated that he did not remove all the tissue,

and afterward used protonuclein. I was satisfied that the neoplasm was not malignant.

In the case reported to-night there is no question about the diagnosis; the macroscopical and microscopical evidence places it beyond any doubt.

Dr. H. H. Grant: I have in a number of instances tried protonuclein both internally and externally, and have also used the injections of the socalled Coley's fluid, always with disappointment. At the same time I have constantly borne in mind that a good many cases reported, by Coley especially, and in other hands in a few instances, have turned out very favorably from treatment both by injection of the toxin and with local application of protonuclein and its administration internally; and it has led me to believe that there must be different forms or different influences of some kind prevailing in these forms of sarcoma which do not appear in microscopical examination, and although it does not appear there is any possible way by which any particular case can be determined as one susceptible of this special form of treatment, it certainly has been successful in a few instances in some hands, though in the great majority of cases has failed. This is a peculiar case presented by Dr. Cartledge in which the influence of protonuclein has produced a wonderful effect, although the time has not yet come when we may say this patient is out of danger, or when it is even probable that he will not have a recurrence; but I do believe that the wonderful improvement shown by the administration of protonuclein proves that this is a peculiar form of sarcoma which is susceptible to this particular treatment.

Recently I have had under my care a man upon whom I did an amputation at the hip-joint over a year ago, who lived just a year after the operation. I tried protonuclein internally and also used injections faithfully of the fluid as prepared by Coley, which I received directly from his hands. I could discover no benefit, or at least no visible effect upon the tumor. Although this tumor recurred within six weeks after the operation, the man lived a year,