228 plied. But the pain continued unabated, and on April 10th was so intense as to call for active treatment. A consultation was held, and two of my colleagues who were in the hospital agreed in the diagnosis, and in the urgent necessity for operation. Half an hour later, after an Esmarch's bandage had been applied, I made a free incision into the tumour, turned out a large quantity of blood-clot and soft tumour substance, and found, contrary to what had been expected, that the bone was nowhere

more »

... bare. The sac which contained the tumour was everywhere perfectly smooth-walled, except where the solid tumour was lightly adherent to it, and lay deep down between the muscles and around the radius, over which the periosteum lay smooth and closely adherent. Had the tumour been subperiosteal I should at once have amputated, but the immunity of the bone from disease and the smoothness of the cavity in which the tumour was enclosed tempted me, in spite of the malignant aspect of the new growth, to scoop it out and try to save the limb. One of my colleagues was decidedly of the same opinion. Every visible and tangible particle of the growth was therefore carefully removed, the cavity was sponged out with a solution of chloride of zinc (forty grains to the ounce), a drainagetube introduced, and the operation concluded. The patient made a good recovery and returned to his work with a perfectly useful limb. In October he was again admitted into the hospital for the removal of a recurrent growth, which had been springing up during the past few weeks in the deep tissues on the ulnar side of the scar. The enlarged axillary gland had entirely subsided. The growth was removed by Mr. Smith, who dissected it out from amidst the muscles. It was not so clearly deiined as on the first occasion. The patient again recovered speedily, and was able to resume his work, the movements of the limb being unimpaired. On May 16th, 1883, Mr. Smith removed a second recurrence, much smaller than the first and seated in the fascia covering the superficial flexors. The deeper parts were not affected, and even the surface of the muscle was not invaded. The operation was therefore trivial, and the patient quickly recovered. A microscopical examination of the tumours showed that they were chiefly spindle-celled, but contained also numerous bodies like elongated nuclei, and round cells. The disease was, therefore, a spindle-celled or mix-celled sarcoma. It is, of course, too early yet to claim success for the conservative treatment which was adopted in this case. But thus far the result appears to justify the attempt, I might almost call it the experiment, to save the limb. The appearance of the first tumour was that of a medullary cancer which had been bled into, and the situation of the disease made it almost certain that it was a roundor spindle-celled sarcoma. I have already said that if it had been subperiosteal I should at once have amputated. It may be asked why an attempt was made instead to scoop the tumour out. To this the reply is that the information we possess regarding the malignancy of subperiosteal sarcomas is sufficient not only to justify but to call for amputation; that, on the other hand, our knowledge of the properties of parosteal sarcomas is very slender, but there ia some reason to believe that they are not so malignant as the subperioe:.! tumours. We have been too much in the habit of regarding all spindle-ceiieu ss.rccms.?, or all round-celled sarcomas, no matter what part they affect, as equally malignant and requiring similar treatment. I have endeavoured to show2 that this is not the case, and that the malignancy of sarcomas of the same kind depends very largely on their situation. The malignancy of subperiosteal round, and spindle-celled sarcomas of the radius and ulna is much ]es than that of subperiosteal round, and spindlecelled sarcomas of the humerus. The malignancy of central sarcomas of the radius and ulna is much less than that of subperiosteal sarcomas of the radius and ulna ; the former may be safely treated by excision or scooping out, the latter require early amputation. From many facts of the same kind it is quite clear that the application of general rules to the treatment of malignant disease of all parts of the body is of very little use, and that it is absolutely necessary that the mal'gnant diseases of every part should be studied separately. The comparative malignancy of parosteal tumours is still unknown, and the treatment is therefore experimental. I can shortly recall one or two instances which tend 10 prove that they are less malignaut than subperiosteul tumours of the same parts of the body. 2 Sarcoma and Carcinoma, 1332. Introduction, &c. A woman, aged fifty-five years, suffered amputation for a parosteal sarcoma of the ulna, which had projected through the skin and appeared as a very malignant mass on the inner aspect of the forearm. She died from causes connected with the amputation; and the post-mortem examination showed that the lymphatic glands and viscera were quite free from secondary disease. Yet the tumour had existed more than two years, and was an excellent example of spindle-celled sarcoma. At a recent meeting of the Pathological Society,3 Mr. George Lawson exhibited a tumour which appeared to have grown from the outer surface of the periosteum of the lower jaw. This tumour was a sarcoma composed chiefly of spindle cells, and was the eleventh recurrence, ten previous tumours having been removed during a period of many years, the first by Sir William Fergusson, the last by Mr. Lawson. The few cases of subperiosteal sarcoma of the lower jaw I have been able to collect have run a very different course from this. Of two cases of spindle-celled sarcoma, of which the result was known, one patient died at the end of twentyeight weeks, the other within a year. The parosteal tumour of the bones of the forearm may be compared with the cases of subperiosteal tumours of the forearm in the tables in my book on Sarcoma and Carcinoma (page 68). To the cases there tabulated I can add another, which has just been treated in the hospital by Mr. Smith. The patient was a woman, aged twenty-seven, who had noticed a swelling in the forearm only about six months, but had felt pain for a much longer period. She appeared generally a healthy person and presented no signs of constitutional disturbance. About the middle of the right forearm, and presenting chiefly on the outer side, was a fusiform tumour about five inches long, firm and smooth. The skin was not affected and the glands were normal. On July 20th the tumour was cut into, and removed by cutting and scooping. Three inches of the radius, where it was bare of periosteum and rough, were also removed. The growth, like the recurrent tumour in the first case, infiltrated the muscles. It bore all the general characters of a soft cancer without cysts and without capsule. It corn-isted largely of fibrous tissue, in the meshes of which were numerous round and oval cells, and I regarded it as a fibrifying sarcoma. The wound healed well and the patient left the hospital. But, three months later, in October, she returned with considerable recurrence in the parts above the scar, extending so high towards the elbow as to render amputation through the arm necessary. The contrast between the infiltration and rapid and extensive recurrence in this case and the circumscribed character and more kindly course in the first case, is the more striking when it is noted that the tumour in this case was much the firmer and more highly organised. Of the diagnosis between parosteal and subperiosteal tumours, I can only say that it appears impossible until the tumour has been freely opened, but may then be easily made by feeling with the fingers whether the bone is closely covered with periosteum, or whether the latter is raised and the bone at any part rough and bare.