Treatment begun August 12 and has continued to date, with a rest from October 11 to November 4, on account of dermatitis and some blistering. Patient's general condition somewhat improved, but cannot state what changes have taken place in larynx. Will ask Dr. Dabney to speak of this.

CASE XVI. Referred by Dr. J. M. Holloway. E. J. H., white, male, age 25. Psoriasis, on elbows, knees, and hands. Treatment limited to back of hands. Began treatment September 6; by September 26 spots of psoriasis on both hands apparently well, only one small spot remaining. Treatment now directed to other portions of hand with marked improvement.

CASE XVII. Beiore treatment. Ulcer 24x234 inches, involving outer edge of upper and lower lid.

CASE XVII. G. G., age 67, white; no history of cancer in family. September 9, has ulcer 2x2 inches in right temporal region, almost round, with hard, everted edges. Photograph shown; right eye inflamed; both upper and lower lid involved on outer portion. Began as wart nine years ago. Condition typical of epithelioma. Section taken, but not yet examined; had been treated with caus

tic for past year. Patient seen by Dr. Dabney.

Treatment begun September 9; continued to date. Present condition, ulcer more healthy in appearance, reduced to 1x1 inches in size, and healing now very rapidly. Treatment caused some inflammation of cornea and sensitiveness to light, but patient assumed all responsibility of damage to eye, as the question was one of saving life even at the expense of loss of one eye. Eye is now improved and less sensitive.

CASE XVIII. Mr. E., September 10, white, age 55. Trouble began two years ago as wart on inner surface of foreskin; phimosis. Circumcision done and growth found to be tightly adherent to glans penis. Section made but no report of examination. Patient X-ray treatment since October 1; wound healed except where growth was separated from glans; this was slow to heal at first, but now markedly improving. No deductions can be drawn from this case as yet.

on

CASE XIX. J. W.B., male, age 30; referred by Dr. W. O. Roberts. First noticed pain in supraclavicular region in November, 1901. Glands of neck, left side, began to enlarge in March, 1902. Had a bad tooth, which was removed, but swelling continued. Extensive removal of glands done by Dr. Roberts in June, 1902. Trouble rapidly returned. Blood examined in June; hemoglobin 85 %, red cells 4,500,000, white cells 9,000. Patient's condition on September 23, large mass of glands left side of neck, extending from behind ear down along sterno-cleido muscle. Separate bunches of glands along anterior border of trapezius and between this line and sterno-cleido-mastoid. Measurement of neck on level with thyroid cartilage 40.5 cm. (16 inches), temperature 100°, pulse 100.

Treatment begun September 23 and continued to October 7, when it was stopped on account of dermatitis and blistering. This patient was very susceptible to the ray and more blistering occurred than was intended, but now it

is all healed with the exception of a small area the size of a 25-cent piece, and this is rapidly healing.

Treatment resumed on October 22. The swelling has been greatly reduced, measurement now 36 cm. (141 inches), which is considerable when we consider that this reduction is all from one side. Patient during rest developed enlarged gland under chin, which is now being actively treated. The patient's general condition has not markedly improved, still showing daily rise of temperature.

The following ten cases have been under treatment so short a time that no definite conclusions can be drawn from them. They are added simply to make this a complete report of the work done prior to October 15th.

Case re

CASE XX. Photo shown. ferred by Dr. Yoe. Female, white, age 47. First noticed small lump between nipple and armpit about six years ago. now has area of induration 2 inches, involving left nipple, with some small glands in left axilla. Neoplasm moveable over muscle, but firmly attached to skin. Some ulceration in neighborhood of nipple, with considerable scabbing. Patient complains of great pain, stating that she often walks the floor at night. Treatment began September 23 and continued more or less regularly to November 1, when it was stopped on account of dermatitis. Much relief from pain after first week's treatment. At present states that pain has entirely disappeared, and sleeps all night without disturbance. Present condition: Tumor somewhat softened, less induration, apparently considerable improvement.

CASE XXI. Mrs. A. Referred by Dr. Turner Anderson. White, age 63. First noticed slight scabbing about nipple in June, 1901. At same time suffered with aching "like toothache," which has continued steadily ever since. Occasionally has shooting pains. Has slight retraction of nipple, with some induration, and slight excoriation. No apparent enlargement of glands in ax

illa, but tenderness on pressure along the lymphatic line from nipple to axilla. Began treatment September 24. Has had treatment on an average of every other day since, with considerable relief to pain. No marked change otherwise.

CASE XXII. Referred by Dr. Gilbert. L. A., mulatto, age about 40. Tumor in right breast, right lower quadrant, about size of a hen's egg. Complained of considerable pain and shooting pains into axilla. Began treatment on October 1; treatment every other day. Present condition: Pain entirely gone, but no marked change in tumor that can be noticed.

CASE XXIII. Mr. W., white, age about 70; referred by Dr. Ray. Had suspicious wart about inch in diameter and raised of an inch above surface of skin of face, near right ala of nose. Followed a slight cut with a razor one year ago. Condition typical of incipient epithelioma. Began treatment October 5, with almost daily treatment since. Present condition, growth entirely disappeared, with an area of dermatitis at site of growth and about it for a half-inch. After evidence of dermatitis disappears, all traces of tumor will probably be gone.

CASE XXIV. Mr. M., medical student. Has a very painful fibro-neuroma on stump of right leg, which has followed amputation. Patient suffering with great pain, and the X-rays tried simply to see what effect it would have on this condition. Considerable relief to pain after a few days following each daily treatment, but return of great pain after a week's time which the Xray seemed to have no effect upon.

CASE XXV. Mr. O., age 48; brewer by trade. Condition when first seen, October 9: Ulcer on right cheek, half an inch wide, one inch long, surounded by considerable scar tissue. Clear fluid escaping from ulcer with movement of jaws, due to salivary fistula. This case had been under active caustic treatment for the past six months. Considerable doubt in writer's mind as to malignancy in this case, as from statement of pa

tient it apparently began as a sycosis. Has been in the hands of quacks. Was put under X-ray treatment more for the stimulating effect than for any other reason. The fistula was operated upon and patient still under treatment. Cannot yet tell what result will be. Ulcer healing and cicatrizing, but not yet entirely healed.

CASE XXVI. Mr. T., age 73; marked psoriasis over almost the entire scalp. Trouble of many years' standing. Patient treated from October 14 to 23, when he left the city. No improvement in the writer's opinion, although the patient seemed to think there

was.

CASE XXVII. M. H., age 23, white, female. Has a bilateral goitre of five years' standing, which has gradually increased in size and causes quite considerable pain. Began treatment October 12, and after one month's treatment, averaging about every other day, cannot see any change in the size of the goitre, and patient says no relief to pain. Am now pushing treatment a little more actively, and expect to get up dermatitis in the next week, and possibly may be able to give a better

report.

CASE XXVIII. Referred by Dr. Ap Morgan Vance. Mrs. B., white, age 45. Rapidly growing tumor appeared in the left breast in June, 1902. Removed by Dr. Vance. Thought to be a sarcoma. October 15, there is a large hard mass over region of right breast, no definite outline. Scar breaking down and discharging a foul-smelling, ichorous pus. Arm swollen and very painful. Began treatment October 15, almost daily. Present condition: Pain in tumor greatly relieved, but still complaining considerably of arm. Mass somewhat softer and probably disappearing to a slight degree.

CASE XXIX. Photo shown. Referred by Dr. W.O. Roberts. E.G., age 58, white, male. Rapidly growing ulcer, which has destroyed two-thirds of mouth and an area on left cheek one inch wide, an

inch and a half long. Also marked involvement of mucous surfaces of both jaws. Began treatment October 16 and continued only until October 31, when patient got into the hands of quacks. Could see no improvement during this length of time.

A few remarks in conclusion: Don't consider the X-ray a "'cure all," for it isn't.

Don't use the X-ray to the exclusion of other surgical methods, as often better results could be obtained by using it in connection with them.

Don't wait until recurrences have occurred in the cases in which the knife has been used, but submit all amenable cases immediately to treatment.

Don't try all other methods in the external cancer cases and then send the case for X-ray treatment. The X-ray promises more than any other form of treatment in the majority of external epitheliomata, in lupus, and in all recurrences after amputation of the breast.

Society Proceedings.

THE LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.

Stated Meeting, October 17, 1902, The President, B. A. Allen, M.D., in the Chair.

CARCINOMA OF THE PENIS.

DR. LOUIS FRANK: I wish to report a case of carcinoma of the penis, removed from a man 39 years of age. It begån over a year ago, and I saw him first about two months ago. There was first a little abrasion of the prepuce, which would heal apparently only, however, to recur. The history was a syphilitic one, and he had been treated twelve or fifteen years before. Simple treatment resulted in no improvement at all, and he was referred to Dr. Butler for treatment with the X-rays. During Dr. Butler's absence, he came to me, and I advised amputation, to which he would not then agree. At the first operation,

I split the prepuce, which was adherent, and dissecting it away excised the carcinomatous tissue. Then with the actual cautery I burned it all very thoroughly, and within a week again began treatment with the X-rays. He

had a very large suppurating gland, but I did not think it was carcinomatous. He did not improve under the X-ray treatment, and a second operation was advised. The penis was amputated, and he was again put under the X-ray treatment. It is as yet too early to tell the result. A point of interest in this case is that his wife died six years ago with cancer of the uterus. There is no history of cancer in his family and no tubercular history.

DISCUSSION.

DR. T. L. BUTLER: The case reported by Dr. Frank I saw for the first time in June, and then it was in an ugly condition. He had an epithelioma on the end of the penis, involving the glands and prepuce. It looked like the original growth had infected the prepuce, and he had two distinct epitheliomata. I believe that this is not an uncommon condition; I have seen it several times. I advised that the epitheliomata be removed and he be put under X-ray treatment. He did not agree to the removal, but consented to the treatment with the X-ray. He had a few treatments and then went to Dr. Frank, who removed the growth. He came back and was put under very active X-ray treatment. There was some improvement in the ulceration for possibly one-fourth of the surface, but the rest of it did not improve to any extent. He was under treatment during my absence. I consulted with Dr. Frank, and we decided to do an amputation of the penis and treat the stump and enlarged glands of groin with the X-ray. He has been under treatment now about two weeks. I saw him this afternoon and he has still a great deal of induration of the glands. One gland is fixed to the surrounding structures and is as large as a guinea egg. There is also a linear mass

about as wide as my index finger extending up the groin. I cannot see any effects of the X-ray treatment after two weeks, but I do not believe he has been under it long enough to come to any conclusion. We have produced no dermatitis as yet, and hope to see better results in the case in a short time.

DR. W. O. ROBERTS: I have done quite a number of amputations of the penis, and I think it is very important to remove the glands on both sides. I had one case in which the tumor was small and on the prepuce. This was removed, and later on the man died, I think with malignant disease of some of the abdominal organs, the mesentery, perhaps. There was no recurrence on the penis. I have in mind one case of amputation in my own practice, and one that was done by Drs. Yandell and Bloom. Both of these men are still living, after more than five years from date of operation.

TWO CASES OF NEPHRECTOMY.

DR. H. HORACE GRANT: These specimens represent two kidneys, one larger than the other, which are not, however, from the same individual. One was removed about five weeks ago; the other about three. The first was from a man 28 years of age, who had complained of more or less trouble with his bladder for two years. When I saw him his urine was quite offensive and there was a large amount of pus in it. I could make out no evidence of kidney disease at that time, but the suffering was so great that I did a perineal section. The symptoms did not entirely clear up. Later, believing the symptoms were due to disease of the kidney, I did a nephrotomy. A large amount. of pus was found in the kidney proper, which was believed to be due to tubercular disease. The sinus continued to discharge and five weeks ago I did a nephrectomy in the lumbar region. This kidney was very large indeed; it dipped down into the pelvis. The incision had to be prolonged across the abdomen and the peritoneal cavity

opened. The peritoneal wound was closed at once. We washed out carefully and the patient recovered without any shock, and within a week's time was able to sit up and after eight or ten days to be wheeled about. He was greatly improved and has gone home, and is in every way relieved, but there is still some discharge. It is possibly due to the heavy silk. The pedicle was almost inaccessible and its ligature quite difficult. After we had cut the tumor away we were obliged to reapply ligatures to the stump.

This other specimen was removed three weeks ago from a man 63 years of age. He had presented no symptoms of disease of the kidney. A distinct tumor was made out, very hard, and I suspected a sarcoma. Dr. McMurtry exmined this case also. An incision was made over the tumor, along the border of the rectus. We found a fluctuating tumor, which I believed to be a cyst, and was preparing to evacuate it, but when the fatty capsule had been separated from the surface of the kidney there was a free discharge of pus, perhaps about a pint and a half. The operation was exceedingly easy; we washed out the cavity and made a drain of rubber tubing through the loin. A sinus still persists in the loin, but there is almost no discharge. His recovery was without temperature or shock, notwithstanding his age and the amount of

pus. He has had no bad symptoms whatever, and is now able to sit up at the end of three weeks.

These two operations, both exposing the peritoneal cavity and both making complete recovery, have removed my hesitation about attacking the kidney by the abdominal route. The cause of the infection in case second was doubtless infecture by germs of suppuration, either from the ureter or else circulating in the blood. The symptoms were of short duration, four or five weeks altogether.

DISCUSSION.

DR. L. S. MCMURTRY: These are

cases of great interest, and I am sorry Dr. Grant did not write them up in detail. The second case had in its history one thing which Dr. Grant neglected to mention: In the early part of his history the patient had fever, and was laid up with evidence of acute infection. It was an infection of the pelvis of the kidney, which terminated in pus, and it was that which made a suggestion of its being a pyonephrosis. The operation was easy, as the man was thin, and it was very gratifying to find it was not a sarcoma.

DR. W. O. ROBERTS: Dr. Grant is to be congratulated on the results in these two cases. I have had some experience in the removal of large kidneys, and I find that the easiest way to get at these tumors is to make a transverse incision, beginning just below the ribs, and extending to outer border of rectus muscle, push back the peritoneum in front of the tumor and you get at them much easier than through the incision made by Dr. Grant..

DR. LOUIS FRANK: Just a word as to the method of removing the kidney. I believe the best way is not by the transperitoneal operation. Of course there are possible exceptions, but I mean as a rule. The fact that these cases did not infect the peritoneum should not make us feel there is no danger in this method. The danger of doing damage transperitoneally is certainly greater. The danger of infection is far greater. I believe the method advocated by Kelly is better-making the incision along the direction of the fibres of the external oblique muscle. You can do all the surgery about the kidney by this method that is necessary. The incision is far better, and in some of these cases, especially those of tubercular kidney and ureter or where there may be a stone in the ureter or kidney, this will be the only manner in which the disease can be removed. I believe this is the preferable way of operative procedure. If the incision is made large and free, it is surprising with what ease the organ may be manipulated.