AFTER operation for empyema, a cover of oiled silk or gutta-percha over the gauze dressing serves to prevent admission of air into the pleural cavity, while it will not interfere with the escape of air already in the chest. Indeed, a flap of rubber may be laid over the wound and fastened, with a little chloroform above. This allows pus to escape from beneath it and excludes the admission of air.Amer. Jour. of Surg.

SOME OBSERVATIONS ON PROSTATECTOMY. -L. Bolton Bangs considers the following factors in deciding whether or not to advise prostatectomy: the general condition of the patient, his social condition and environment, his temperament and his accessibility to judicious medical advice and assistance; whether or not catheter life is likely to fail, and, if it has failed, in what degree; and, finally, what measure of relief is to be gained if, after the operation, some imperfection should remain which is insignificant in comparison with the prior condition. The writer then gives the histories of a number of patients which show how often significant symptoms are unappreciated or overlooked. He speaks of certain cases in which small prostates have been removed when there were few or no signs of obstruction. In these cases it was not recognized that chronic interstitial cystitis had reduced the capacity of the bladder so that frequent urination had become a necessity. Each case must be studied by itself. The final outcome of the operation cannot be foretold definitely, but when the indications are clear it can be wisely advised on account of the great relief and comfort which result.-Med. Record.

AMERICAN MEDICAL EDITORS' ASSOCIATION. -The thirty-seventh annual meeting of the society was held in Boston on June 4, under the presidency of Henry Waldo Coe, M. D., of Portland, Oregon. In its many years of existence this was the most satisfactory session ever held, not only in point of attendance, but the character of papers presented as well as the many applications received for membership. This association numbers over one hundred and forty-five members, representing ninety-two of the leading medical journals in America. Interesting and timely papers were read by Drs. Frank P. Foster, Harold N Moyer, W. C.Abbott, Walter M. Brickner, James Evelyn Pilcher, Kenneth Millican, J. J. Taylor, William J. Robinson, T. D. Crothers, John

now

Punton and Charles Wood Fassett. The officers elected for 1906-07 were as follows: President, James Evelyn Pilcher; first vicepresident, Frank P. Foster; second vice-president, Charles F. Taylor; secretary

and

treasurer, Joseph MacDonald, Jr., New York. The annual banquet held at the University Club was, as usual, the social event of the week. About seventy-five covers were laid.

THE FEEDING OF INFANTS DURING THE HOT WEATHER.-I. L. Polozker states that almost invariably infantile troubles are due to improper feeding. Mother's milk should always be examined by the physician from time to time while she is nursing the infant, according to Holt's simple method. The ideal wet nurse exists only in the imagination, in this country. Laboratory milk, properly prescribed, is one of the most valuable resources of the physician. Infants cannot all be fed alike. Even those of the same age and weight cannot always be fed on the same formula. It is the digestive capacity of the child which should be the governing factor. In speaking of the preventive measures in the treatment of summer diarrhea, the writer advocates a laboratory milk or a good clean milk. The mother ought to be educated in the care of the child when diarrhea occurs. As soon as this condition appears a teaspoonful of castor oil should be given to the patient, but no food. Whiskey in water and rice or barley water are also indicated. Only half the quantity of milk that the child can take in health should be fed to it. The mothers should be taught the importance of various hygienic measures, and should be instructed in the value of fresh air, water excursions, clothing for the children, bathing, and the proper care of the napkins.-Med. Rec.

PHYSICIANS AND PROPRIETARY REMEDIES. -G. B. Kuykendall, Pomeroy, Wash. (Jour. A. M. A.), condemns physicians who permit their names to be used by manufacturers of proprietary drugs, and believes that the profession generally has allowed the drug vendors to do their thinking for them altogether too much. It is not the rank and file that is altogether to blame, he says, there are many so-called medical journals that devote their advertising columns and even their pages to the interests of nostrum makers. While the manufactureres have done much to advance "elegant pharmacy," they have so manipulated many useful drugs that their elegance far outruns their usefulness. Some, too, of the houses we have been considering as reliable, have been guilty of slips into unethical practices, and he gives several rather pointed. instances of this. He pleads for independent study in our prescribing and less dependence on the proprietary medicine makers.

DR. STERN has used formic acid with benefit in cancer, and thinks it has certainly delayed the fatal issue in a number of inoperable cases.

SOCIETY PROCEEDINGS

ST. LOUIS MEDICAL SOCIETY.

Regular meeting held June 16, 1906. The president, Dr. Geo. Homan, in the chair. SYMPOSIUM ON CANCEROUS AND

TUBERCULAR SKIN DISEASE.

THE SURGICAL TREATMENT OF EPITHELIOMA.

Dr. M. B. Clopton said that surgical interference in new growths is not difficult in the early stages. Opposed to this view stand two factions: First, the "medical-cancer-fatalists" who first decry malignant diagnosis and then by sceptical allusions make the patient of the same mind; second, the group which fears the knife and are willing to undergo anything to avoid operation. The first lesson to be learned about this condition is that the earliest removal of sufficient epitheliomatous tissue insures perfect cure. A second lesson which has been learned is that in cases apparently hopeless by a combination of wide excision of the epitheliomatous growth with the application of the X-rays. years can be added to the patient's otherwise short lease of life.

.

Rodent ulcer and true squamous epithelioma are the two classes of epitheliomata. Rodent ulcers are seen on the wings of the nose and on the borders of the mouth. Tissue from these regions cannot well be spared in operating by excision. If rodent ulcer is taken immediately after diagnosis, painless excision with cocaine anesthesia is practically scarless. A limited application of X-rays after this gives perfect cures.

The application of X-rays requires a technique that only a few operators are successful enough to acquire. In unskilful hands, the ray may exert an opposite function and stimulate the malignant cells. In excising round the ulcer, the operation should go at least one-half inch into tissue to insure perfect results. Inasmuch as rodent ulcer is not carried to the glands, the operation resolves itself into a plastic operation. In the larger growths there is a certain element of danger and in some cases the cause of death has been erysipelas, pyemia and meningitis. These Causes ought to be eliminated and the mortality reduced. The reasons for bad results are the usage of caustics and infrequent use of the X-ray. Patients who are not cured are benefited, and there is always a marvelous relief of pain.

It is no longer correct to use the old threeyear limit of the disease, but the five-year limit is used now. With this five-year limit

of cure, there is a higher percentage of cure than there was before the days of the X-rays.

True epithelioma which attacks the lips is almost as slow as rodent ulcer, or it may take on the picture of an acute infection and patient will die within a few months. The submiliary glands become involved in this conMost dition, and it is best to remove them. cases adapt themselves to a V-shaped incision through which the lymph glands of the neck can be removed. Lip cancers should be excised and then the rays applied. The glands should always be removed. In lip cancer the mortality is less than 1% with percentage of cures of 56% of all cases. This is better than is given by operative interference in any other locality. The condition is hopeless and operation useless if the bone is involved.

What has been said of epithelioma of the lip is true of cancer elsewhere. These growths may take on a rapid growth at any time, and may be transferred to the lymphatic channels in the vicinity. It is a question whether the operator should go after the lymphatic channels in all cases. In the early stages, excision is the correct procedure in any part of the body. If there is a suspicion that there is a growth at the bottom of the wound, the wound should be left open and the rays applied to the bottom.

The two points which Dr. Clopton wished to impress were: First, that early interference is especially recommended; secondly, that no case is so hopeless that we may not expect some relief to the part upon which we wish to use the ray.

X-RAY TREATMENT OF EPITHELIOMA.

Dr. H. P. Wells discussed the X-ray treatment of epithelioma. He said that he wanted to offer one case which would speak eloquently of this treatment. He said that he agreed with the preceding speaker who said that the best results depend upon the technique of the operator. Many have turned their backs upon the ray, because they failed to get results from their technique. Without disparagement of a predecessor in office at the Skin and Cancer Hospital, he wished to state that he had taken a few cases some weeks ago on taking charge of this department and had obtained gratifying results where no improvement had been taking place previously under X-ray treatment. It occurred to him that he was justified in some bad cases of cancer of the skin in burning them severely. He did so. Instead of eight or ten inch tube distance, he placed the tube two or three inches from the lesion, with a soft light and with exposures of from fifteen to twenty minutes. The ultimate effect was satisfactory, as shown

by the one case which the doctor presented later.

Dr. Wells stated that radio-therapy is a thing which must be left to the specialist who is giving all, or most of his time to this kind of work. He showed photographs of the man's face to illustrate the bad condition before treatment and the man was present in person to give evidence of the results obtained. There was one point the doctor wished to touch upon, and that was the Leed of having some means of measuring the dosage of the rays. There have been several radiometers devised for the purpose of quantitatively analyzing the rays, but so far there has been no effective instrument for measuring dosage. There seems to be in the little instrument used at the Boston Hospital a new means of getting over this drawback. It consists of interposing a piece of radium and a qualitative measure is obtained by interposing a piece of aluminum in the path of the ray, in this way telling the degree of effect upon the skin.

PRESENTATION OF CASES OF SKIN CANCER TREATED BY X-RAYS.

Dr. W.H. Mook presented a number of interesting cases. The first case presented was a patient of 66 years, family history negative. Present trouble began five years ago with a lesion on the nose, the entire surface of the nose and cheeks being gradually affected. There was ulceration and pustulation of the entire nose and cheeks when he entered the Skin and Cancer Hospital, also a lesion.on the side of the neck. Over the left temple was a small ulcerated tumor. There was a keratotic condition of the skin of the hands, known as "sailor's skin," with pigmentation and an atropic condition. This patient was treated for 12 months without results. Six weeks ago Dr. Wells increased the dosage of the rays with beneficial effects.

The next case presented was a lupus condition. The patient was thirty years of age. After an attack of erysipelas, this lupus condition extended all over the face. Mucosa shows tubercles. There is a lymphatic edema, illustrating a rare form of lupus. Histo

logical examination shows small tubercles deep in the cutis, composed of round cells and giant cells. Tuberculosis of the skin is comparatively rare in St. Louis as compared to other cities. The mistake is often made of diagnosing lupus when it is really true epithelioma. The patient shows some improvement under X-ray treatment.

Case 4, next presented, female of 19 years of age; ten years ago she suffered a severe burn of the thigh. The left posterior side refused to heal. When patient entered the hos

pital, two-thirds of the posterior surface of the left thigh was affected, presenting the picture of a fungating carcinoma. The edges of the wound were elevated. Inguinal glands were enlarged. X-ray treatment was given with improvement. The patient is suffering from pulmonary tuberculosis also, but in spite of this, she continues to improve in weight.

PRESENTATION OF CASE OF CARCINOMA AND LUPUS.

Dr. Joseph Grindon presented a case of carcinoma and lupus. He said that lupus tissue has a special tendency to develop carcinomatous changes. The lupus element in his case was the most striking. He wanted to say something first about lupus. This case presented two remarkable points: First, is that the patient is an American of American parentage on both sides, and American lupus is comparatively rare. Lupus is comparatively rare and the few cases which the speaker said he had seen have been in persons of European parentage, mostly Austrian. Another point that is interesting is that although the tuberculosis of the skin in this case is well marked, the patient's general health is excellent. The trouble is purely local. third point of interest is the length of time, 57 years, which the disease has lasted. There is a characteristic appearance of the nose, the disappearance of all the cartilaginous tissue therefrom.

A

Dr. Grindon then showed a picture of the case, showing the lupus tissue undergoing carcinomatous change. There developed at one time during the treatment of this case a burn from the rays upon the right cheek, burn of the second degree. It yielded without trouble to treatment, yet precisely at that point there developed the carcinomatous change. Whether it was caused by the burn or whether it was merely a coincidence, the speaker did not know.

Dr. Grindon called attention to the fact that the face of this patient was simply one cicatrix. The lupus is entirely healed, but there are few places which are "lupoid." There existed in this case a troublesome nasal catarrh which was lupus in character, and that is now entirely well. The X-rays was used to treat the carcinoma on the cheek without result. Dr. Morfit excised the growth and it returned. A second operation was performed. Ectropion followed. After the lupus was cured, operation for the relief of the ectropion can be safely performed.

Dr. Grindon then showed some pictures of cases treated by him. He said that he had treated superficial growths with success and deep growths with uniform failure.

RADIOGRAPHS OF INTERESTING CASES.

He

Dr. A. V. L. Brokaw showed a great number of radiographs of interesting cases. said that all the pictures which he showed were of the "snap-shot" variety, that is, taken immediately when the case presented itself in his surgical practice for the purpose of assisting in diagnosis and pointing to the proper treatment of the cases. He showed a picture of a vesical calculus, pictures of bullets in the body, fractures and dislocations of all kinds and variations. He showed one picture of a Murphy button in situ, and also one picture of a "lost drainage" tube. A number of other pictures were shown, illustrating the usefulness to the practical surgeon of X-ray pictures.

DISCUSSION.

Dr. H. P. Wells said that he wanted to

qualify the remarks he had made in treating bad cases by severe burning with the rays. He hardly recommended the method he had used in his cases to the private practitioner, because the reaction was so severe, because the patient might leave him at the time when he was getting the erysipelatous condition. He said that he could afford to produce this condition at the hospital where he was enabled to handle the material in any way he judged fit and right. He said the reaction produced by the severe treatment resembles erysipelas. Sometimes the edema is very severe, but it subsides readily. He said that he had never seen any improvement during the radiation, but the improvement occurs. while the patients are resting after radiation has been stopped.

Dr. J. J. Miller said that the radiographs shown by Dr. Brokaw recalled a case which he saw during the Civil War, in 1864.

One of the patients at the Libby prison asked him to open a "boil" on his chin. He opened it and a minie ball was found in it. The point of entrance for this ball was at the point of the shoulder. Unfortunately, he said, the society would have to take his word for the occurrence, as he was unable to get a radiograph at that time! (1864).

A NEW MICHIGAN STATE MEDICAL SOCIETY. At a meeting of physicians and surgeons of Grand Rapids, on June 11, a committee was appointed to formulate a plan of action looking toward the organization of a new and independent State Medical society. The new organization will be independent of the American Medical Association. The committee is composed of Drs. Perry Schurtz, J. B. Griswold, J. Kirkland, Charles E. Hooker and Henry Hulst.

MEDICAL SOCIETY OF THE NEW YORK POLYLCINIC MEDICAL SCHOOL AND HOSPITAL.

Stated meeting held April 2, 1906. The President, Dr. J. J. MacPhee, in the chair.

INTESTINAL DEPRESSOR.

This instrument was presented by Dr. J. E. Fuld, who devised it for the purpose of depressing the intestines to prevent them from extruding into the abdominal wound and interfering with the operator. Gauze pads are usually inserted to overcome this difficulty. The instrument has proved of value in pushing aside not only the intestines, but the other abdominal contents as well, thus affording the operator a full view of the area to be inspected.

The instrument is of polished steel, and tongue depressor, being eight inches long, shaped something like the ordinary glass one and one half inches wide at one end and three-fourths of an inch wide at the other.

TUBERCULOSIS OF THE CARPUS.

This patient was presented by Dr. V. C. Pedersen. She was a young woman who had suffered from tuberculosis of the wrist for many years. Several years ago a palmar operation was performed in a small town up the State, but there are no evidences that tuberculosis ever existed in the hand. Two years ago the wrist was operated on, a median incision being made, and a year ago two lateral incisions were made. The wrist is now free from pain, and except for the ankylosis of the joints which followed the first operawrist. tion, there is no difficulty in using the

In dealing with tuberculosis of the wrist, the speaker said that an operator often forgets the divercitulum of synovial tissue which passes upward between the radius and the ulna. At the last operation performed upon this patient, it was at this point that the first foci of tuberculosis was found. The largest synovial pouch passes forward between the surfaces of the metacarpal bones, and here was found the second foci. Both foci were removed and the patient recovered. matter of precaution, she is wearing a metal splint while performing her household duties. The ankylosis of the fingers is the result of the operation performed four years ago, and nothing seems to correct it.

GUMMA OF THE FRONTAL BONE.

As a

Dr. Pedersen also presented this patient. He first saw the man last summer, eight weeks after he had received a violent blow on the head. At that time there was a tumor,

It

which was supposed to be an adenoma, partly chanchroidal, partly syphilitic. travelled down under the skin, down into the fatty tissue, eating out large masses of the tissue, and finally was stopped by bromidia water. Soon after the lesion on the head broke and took on the characteristics of a specific lesion and was dressed surgically. There seemed to be a fissure in the skull, which had been previously treated, and exfoliation of the bone took place. There was no temperature except that which would naturally accompany anemia. At one time the lesion was thought to be tubercular, but recovery under specific treatment seemed to confirm the diagnosis of gumma with profound anemia.

The next patient, also presented by Dr. Pedersen, came to the House of Relief two weeks previously, having been discharged from one of the city hospitals. The nails and the tissue surrounding them showed evidence of great destruction on the left foot, and there was a great deal of pus. The interesting question as whether to apply blue ointment or a wet dressing. The patient's conditions of life made it impossible for him to obtain any benefit from a wet dressing, so blue ointment was used, with beneficial results. The foot presented an appearance very similar to nephritis, but the other foot is not at all swollen.

VARICOSE VEINS.

Dr. Alexander Lyle presented a patient, 48 years of age, who had had scarlet fever and whooping cough as a child, and typhoid fever when 28 years of age. He was a heavy smoker and beer drinker. Present trouble dates back twenty years to swelling of the ankles. The veins of the right leg ulcerated several years ago, and a diagnosis of varicose veins was made. The ulcers are very large in both legs, but cause the patient no discomfort. The speaker concluded that at the time of the typhoid a thrombus had formed in the injured vena cava, and the superficial veins and taken up the circulation. No abdominal tumor can be located, and the

colic at intervals of from two to five weeks, passing clots but no stone. During the past two months he had suffered severe intermittent pain during the night, beginning with the hypochondrium and extending over to the mid line; also intermittent pain referred to the knees, more marked on the right side. The urine of late has been free from albumin and never showed any crystals.

The patient's strength gradually diminished, and he lost about 45 pounds in weight. No tumor could be felt seven months ago, but during the past three months a mass gradually increasing in size has occupied the right hypochondrium. Patient would not permit cystoscopy.

He was admitted to the Polyclinic Hospital February 15th, demanding operation for the relief of intolerable pain, although he had refused all previous suggestions of surgical interference.

His lungs, on physical examination, were found to be normal; heart sounds soft, no murmur; radials moderately thickened. The abdomen was relaxed and the upper limit of liver dulness diminished one intercostal space. The right hypochondrium showed a tumor ovoid below, descending on deep inspiration to a position opposite the umbilicus. pressure it took the position occupied by the normal kidney. Blood examination showed a white count of 8,000, hemoglobin, 100%.

On

A right nephrectomy was done on February 20th. The operation was difficult, as the kidney was about three times the normal size, covered with a network of veins, and adherent on all sides. Wound was closed, except The time of for cigarette drains at angles. operation was one and one-half hours, and the patient rallied fairly well; but the following two days there was almost total suppression of urine, only two ounces being secreted. secreted about the same amount and characThereafter his condition improved, and he ter of urine as before the operation; but at the end of a week he began to fail, and died on the eighth day. Autopsy was refused, and thus the opportunity of discovering if metastases had occurred was lost.

A cursory review of the reported cases of

vis.

NEPHRECTOMY.

Dr. F. C. Yeoman reported this case. The patient, aged 56, had been a heavy consumer of alcohol. About seven months previous to operation he was siezed with a severe pain in the right groin, shooting downward to the groin and corona glandis, and the next passed blood clots in his urine, but never passed any gravel to his knowledge. During the next three months he had attacks resembling renal

tive conclusions: Metastases is the rule, especially to the liver, lungs and bones. These tumors have a tendency to spread and involve veins, but not lymphatics. The renal brim is usually involved, and sometimes the cava, but does not obstruct sufficiently to cause edema of the extremities. In a few cases the growth long remains local and can be sucessfully removed. Clinically, the symptom that may be of diagnostic value is bleeding and its results. Tumor and pain are