In spite of an early and accurate diagnosis, radical surgery, for evident reasons, is attended in this locality by even more unsatisfactory results than in other parts of the head or body.

In this case of malinant disease, as in many others like it, the onset was insidious, and its real characters were masked for months, until finally, without special cause or warning, its activity was centered in one locality. Here its real characters were soon disclosed, and from this time on it was marked by an almost incredibly rapid course, an exuberant growth and malignancy. That later it will be followed by metastatic deposits in adjacent parts or in remote organs of the body is certain.

The orbit is not infrequently the first and only locality in which the most characteristic expression of this form of malignant disease shows itself, by a slow or rapid growth of a tumor attended by exophthalmos, ulceration and sphacelation of the cornea from exposure, etc.; other foci, which can be assumed are present elsewhere, remain latent for a much longer period, or they manifest only a low grade of activity. In such cases the orbital lesion is only the most conspicuous local expression of a simultaneous general infection. It may also start, and this is even more frequent, as a primary growth and general infection through metastasis result subsequently, or an intra ocular sarcoma may burst the confines of the globe and infiltrate the tissues of the orbit and become an extra-ocular or orbital neoplasm. If this has once come about, a rapid course and vicious malignancy are the invariable attendants, followed by a speedy fatal termination.

So far as my experience with the malignant varieties of sarcoma of this locality is concerned, it has been uniformly unfavorable, and this was the case in spite of prompt and radical surgical treatment resorted to during the early stage of the disease. Only in one case in which the neoplasm, a small round-celled sarcoma, which probably had a delicate capsule, was surgery successful in saving the life of a little girl aged four years.

In reporting this case, another sad example of the hopelessness of this malignant variety of sarcoma of subperiosteal origin, I wish to emphasize the uselessness of even the most radical surgery.

It is a question whether such cases should, when once the diagnosis is conclusively established, receive other surgical treatment than that which would afford relief from suffering, such as the removal of the prominent or dislocated eyeball, or an exploratory operation to determine the location and real character of the growth. Certain it is, and I fear this will also be confirmed by the future progress of this case, that radical surgery is invariably resented, and is followed only by renewed activity in the site or vicinity of the tumor.

The patient, a little girl aged nine, bright and intelligent, and presenting every physical indication of good health, was brought to me about eight days ago.

Her parents had noticed that for several months she had been languid and appeared depressed. About ten days ago prominence of the left eye was first noticed, and the child complained, at times only, of a feeling of fulness in the left side of the head, and occasional double vision. There was no pain, no vomiting or constitutional disturbance; in fact, nothing except the general physical and mental depression already mentioned.

The protrusion of the eye rapidly increased, and eight days after it was first noticed the child was brought to me for examination. The exophthalmos at this time was pronounced. The globe was dislocated downwards and forwards. The pupil was moderately dilated, there was no neuritis optica, and vision was 0.5.

The movements of the globe were, owing to the protrusion of the eye, restricted, but only upwards was this very pronounced. No tumor could be discovered.

An exploratory operation was at once proposed and consented to by the parents

The outer commissure was divided and the external rectus detached at its

Operation three hours later. Gut was also in sac and almost gangrenous. Superficial epigastric vein was injured with needle. He is making a rapid recovery.

Convinced that the prognosis must necessarily be hopeless, as a measure of beneficent expediency, and to avert unnecessary suffering, the prominent eyeball and the neoplasm were removed with no other hope than that the inexorable future progress would be less agonizing to the patient, her parents, and her physicians.

The child rallied, and for several days appeared brighter and more active. The interesting features of this case are the rapid course of the neoplasm, the steadily increasing and excessive degree of exophthalmos, the absence of a distinct cachectic appearance, and freedom from implication of the adjacent lymphatics. The possibility that a cyst or other pathological changes might be responsible for the almost incredibly rapid exophthalmos led me to advise an exploratory operation.

Unfortunately, it revealed that the case was hopeless, and that surgery, except to relieve suffering was useless and contra-indicated.

Specimens and Case Report.

DR. MERRILL RICKETTS: Case of carcinoma of the rectum. Excision eight months ago. Three weeks ago an inguinal colotomy was made, with the result as shown.

Specimen 1.-Appendix removed from a man, forty years old, four days ago. Contained pus. A son of this man, aged eight, was operated upon by me twenty-three days before the father. Both are recovering rapidly.

Specimen 2.-Mass of omentum removed in a case of incarcerated left omental hernia one week ago.

Specimen 3.-Omentum found adherent in right hernial sac, of same patient. The double herniotomy having been made one week ago, rings closed with kangaroo tendon. Recovery rapid.

Specimen 4.-Omentum found in left

Specimen 5.-Ends of humerus, radius and ulna. Excision last Saturday, woman, aged twenty years, for ankylosis as result of fracture of radius and olecranon, with dislocation of radius.

A Case of Spontaneous Intestinal

Anastomosis.

DR. W. D. PORTER: On the 24th of January, 1897, I was called to a colored man, aged seventy, who was suffering from strangulated inguinal hernia.

The hernia, as shown by later developments, was of the oblique variety. The tumor was spherical, tense, and the size of a small cocoanut. Taxis lasting a few minutes was rewarded by apparently complete reduction. The patient stated that he had had several such experiences, always as the result of neglecting to wear his truss, and at such times had succeeded in reducing the hernia without assistance.

Three days later I was again called, and found the patient with a temperature of 100.5°, vomiting frequently, and complaining of severe pain in the inguinal region. On examining this region I found, to my surprise, that there was not a tense spherical tumor, but instead a comparatively small one, which was dense and unyielding and of cylindrical outline. This mass was exquisitely tender. I was puzzled at the condition, but felt that an exploratory incision was demanded, and decided to do it that evening by lamplight. I was assisted by Drs. C. E. Caldwell and W. D. Berry. A free incision was made and the hernial sac, which was greatly thickened, laid open. This disclosed a cylindrical mass occupying the inguinal canal and the upper portion of the scrotum. This was about three inches in length and more than an inch in diameter at the distal extremity, dimin ishing in size towards the internal ring.

The surface of the mass and the interior of the sac presented the appearance of acute inflammation. But there

were also conditions that could not be explained by a recent inflammation.

The mass had remarkable solidity, suggesting old inflammatory exudates, and there was a considerable adhesion between the sac and the mass at its distal extremity. On manipulation beads of pus oozed from the mass at several points.

The finger, carried along the outer side of the mass, readily entered the abdominal cavity at the internal ring. This furnished an explanation of the large hernia which I found and reduced on my first visit.

Evidently a portion of intestine had slipped through this opening, forming an additional hernial mass, much larger than the one which was permanently incarcerated.

In order to determine the attachment of the mass the incision was extended through the abdominal wall a short distance, disclosing a seemingly inexplicable condition. The mass was apparently attached to the side of a small intestine, but did not encroach on the lumen of the gut. Dr. Caldwell suggested that a loop of small intestine might have been incarcerated in such a manner as to cause, first, an agglutination, and later an anastomosis between the portions of gut which would necessarily be brought into contact within the abdominal cavity opposite the internal ring. Incredible as this would seem, it is, as we found later, the only possible explanation.

The mass was ligated near the intestine and removed. The stump, after careful cleansing, was dropped into the abdominal cavity, and the wound closed with silkworm-gut. The patient made The patient made an uneventful but slow recovery, as a portion of the wound did not unite by first intention.

The specimen, which I present, is clearly a knuckle of intestine, as the lumen can be followed entirely around, though at one end it is almost obliterated.

The previous history of the case is fragmentary and unsatisfactory. Briefly stated it is as follows:

His rupture is of ten years' duration. Two years ago there was apparently a

condition of strangulation, and he was taken into an infirmary in Virginia, where he was then living, for the purpose of an operation. He, however, refused to permit the operation, and was very ill for five or six days. His description of this illness is limited to the brief statement that he suffered great pain and vomited at short intervals. Finally these symptoms diminished and after several months he was dismissed.

He has had no further trouble from the hernia until the present attack. In the attack two years ago there was doubtless a localized peritonitis, which extended to the portions of the gut on either side of the loop. Lymph was thrown out freely, and the sides of the gut near the knuckle were glued together. Then, as a result of the strangulation and peritonitis, assisted possibly by pressure of a fecal mass, there was sloughing. A lateral anastomosis was established, making the loop imprisoned in the canal no longer necessary to the intestinal current.

DISCUSSION.

DR. G. B. ORR: The specimen exhibited by Dr. Porter is quite interesting; it is so changed by having been in alcohol that it is difficult to say just what it is, but it resembles part of an old thickened sac at this time.

In reference to one of the specimens exhibited by Dr. Ricketts the gangrenous omental plug-the one that he says resulted from the wrong application of a truss-is also interesting. There is no doubt of the ignorance of the man who applied it; but trusses are sometimes applied by men (improperly) who are of recognized ability. This recalls to my mind one such case, that happened in my first years of practice. It was as follows: One afternoon I was called in a great hurry to a child, aged about three years; the child was in a spasm, and the family doctor (a very distinguished man, aged at that time sixty years) was absent from his office, and I Iwas asked to render service until he could be gotten (which I was glad to do). I told the mother to prepare a warm bath as quickly as possible, and began to remove the clothing from the