search of the literature, to have been practically abandoned except by Coley himself. In some rare forms of sarcoma it is reported by a number of observers to have caused retrograde changes, but no law of control has been established. In a recent article Coley again urges the claims of his fluid as a remedial agent and reports some remarkable cases.

Oophorectomy has caused the retrogression and disappearance of a number of mammary tumors, always, however, ultimately followed by death from the disease.

Caustics and pastes may cure some cases of superficial growths, but with pain and with longer time, as a rule, than is necessary with the operative treatment.

Surgical treatment has, largely by process of elimination, been established on a firmer basis than ever before. It is the sheetanchor in our work to-day, and, as a rule, the only bridge across which safety lies. This may be epitomized under the following heads:

(1) Removal of inflammatory conditions, cicatrices and benign tumors before they have undergone any malignancy, thus paradoxically curing the cancer before it exists.

(2) Removal of cancer when present, with a margin of health tissue, and the extirpation of lymphatic vessels and lymphatic nodes in close relation to the disease.

(3) Free exicision, even running risks, if necessary, in order to accomplish complete eradication of the disease.

(4) In so-called "inoperable" cases, where the disease cannot be entirely eradicated, removal of as much as possible, shutting off the blood supply to that which cannot be removed, so that the growth may be slower, is certainly a rational procedure. In inoperable cases of cancer of the uterus good results have been reported from Chrobak's clinic by cauterizing with fuming nitric acid or with Paquelin cautery, after removal with a sharp spoon of as much as possible of the diseased tissue.

(5) In those cases which are truly inoperable, where the entire cancer cannot be removed, or even a portion of it, in many cases great comfort may be afforded by cutting nerves and relieving secondary conditions which cause so much suffering.-Medical Record.

Extracts trom Home and Foreign Journals.

SURGICAL

CONSERVATIVE SURGERY,

OR THE USE OF EXTERNAL APPLICATIONS IN CASES OF
DOUBTFUL PROCEDURE.

BY F. W. HANDER, M.D., BEAUMONT, TEXAS.

Without any comment on the conservatism with which a surgeon should use the knife in doubtful surgical cases as regards time, symptoms and condition of patient, I shall give you several cases which have been under my own observation:

Mrs. H., age 24, married, had suffered pain in both ovaries, especially the right, shortly before, during and for a short time. after menstruation, from the beginning of her menstrual life at the age of 14. This pain gradually increased in severity and time of duration until it had become almost constant and unbearable.

After being advised by several excellent physicians to undergo operative procedure for diagnostic as well as curative purposes, she consented. When the abdomen was opened both ovaries were found to be cystic, the cysts being more numerous in the right. The appendix was normal and healthy and gave no evidence of having been in a pathological condition at any previous time. Both ovaries were removed as a curative and preventative measure.

The patient made an uneventful recovery from the operation, but for three years after, when she again sought medical advice, the pain continued as before, with the addition of slight swelling and tension in the right hypochondriac region. The patient passed through the artificial menapouse with very little inconvenience or nervous disturbance.

Case 2.-Man, married, age about 27, suffering from acute attack of appendicitis, as diagnosed by the attending physician, two consulting physicians concurring. Constitutional symptoms

present and anatomical appearances, such as tension, redness, swelling and pain at McBurney's point, pronounced. Operation advised, to which patient and wife objected.

In both the above cases Antiphlogistine was repeatedly applied, with the most marked benefit. In case one, although the woman had suffered three years after the operation, through the influence of Antiphlogistine, the pain and tension were modified, leaving only a small, soft elevation in the region of the appendix. Pain returned only at long intervals and with diminishing severity, and there is every indication now, after one year's treatment along this line, of permanent relief.

In case two the same treatment was carried out. Tension, redness, swelling and pain diminished with the first application of Antiphlogistine, and disappeared after ten days. With some constitutional treatment the patient entirely recovered in this time. In this case there has been no recurrence of the attack in three years.

I had another case in which two wire nails were driven through the palm by a falling timber. This was followed by pain and swelling after a few hours (no bleeding), the swelling extending up the forearm.

Another case was one of a deep infected wound following paronychia. This wound was opened to the bone and free drainage established, but it gradually grew worse, involving the whole hand. Amputation of the finger or hand was advised, to which the patient objected, saying he would die first.

In both these cases the local application of phenol and Antiphlogistine gave relief and finally cure. In the latter case I cleansed the wound with hydrogen peroxide and applied silver nitrate to the exhuberent granulations.

Multiples of these minor cases could be given, where the knife seemingly was indicated, but which rapidly yielded to local applications along the above lines.

I also had an interesting case in a boy 12 years of age, who suffered from osteo-myelitis of the femur of several years' standing. The discharge was constant through a fistular opening, and the case showed no evidence of improvement, although at sev

eral operations all diseased bone and some healthy bone had been removed. An Antiphlogistine dressing was persistently applied, with the result that several large particles of bone sloughed off, after which the opening rapidly closed. No further pathological process has been observed in this case in ten years, although an enlarged joint and some ankylosis remain as sequelæ.

The above was read before the semi-annual convention of the South Texas Medical Association, June 26, 1906, at Houston, Texas.

GOITRE EXTIRPATION.

Kocher's report of the completion of his third thousand goitre extirpations and his summary of results in this series is of more than passing interest to the profession.

This series began in November, 1900, and terminated in August, 1905. It includes cases of malignant disease, of acute inflammation, of Basedow's disease, and of ordinary goitre, and is attended with a mortality of .7 per cent. There were 36 malignant cases, with 3 deaths; 8 cases of strumitis, none of which died; 52 cases of Basedow's disease with one death, due to secondary bleeding, for the relief of which the wound was re-opened, the second operation being followed by tachycardia and heart failure.

In 1904 operations for ordinary goitre there were three deaths, all of them complicated cases. One of these deaths was due to secondary bleeding, in a case of congenital thyreopriva. Because of the pressure upon the trachea the thyroid required removal. Such patients are peculiarly likely to bleed. The second patient died of pneumonia after complete healing of the neck wound. In addition to bronchitis this patient had myocarditis and dilatation of the heart and atrophy of both kidneys. The third fatality occurred in a patient who from infancy suffered from double sided paralysis of the recurrent laryngeal and a high grade of myocarditis.

His experience leads Kocher to conclude that goitre operation is free from danger, providing the heart is sound, even when the

tumor is placed deeply, has reached huge size, and is found in old people. In the thousand cases there was not one instance of infection sufficiently severe to threaten the life of the patient. Of 293 benign goitres treated in the private hospital there were seven instances of local infection, though the average stay of the patient in the hospital was but ten days.

The simplest form of cleanliness is employed. The surgeon and his patient are washed with hot water and soap, then with 75 per cent. alcohol. No antiseptic solution is brought near the open wound. Silk is used as the ligature material. It is disinfected by boiling in sublimate solution. Minute care is taken of hemostasis, and drainage is also employed. In twenty-four hours the drainage-tube is removed.

Crippling of the heart is regarded as the most ominous accompanying organic disease. Patients contemplating operation should be subject to the most careful and searching examination in regard to the efficiency of the heart; also, blood-pressure should be studied. When the patient can bear pain general anesthesia is omitted, not only because of its depressant effect upon blood-pressure, but because in its use an important guide in regard to the recurrent laryngeal is lost.

Kocher, while strongly advising pre-operative treatment of cases characterized by arhythmia, dilatation, low tension, and deficient blood-pressure, urges against postponing operation so long that what he calls the "goitre heart" is developed, and particularly does he caution against too prolonged and vigorous use of iodine preparations and thyroid. He calls attention to the fact that dyspnea is generally recognized as an indication for immediate operation, but that this is no more dangerous than the heart condition which results from this dyspnea and the misuse of iodides. He holds that the heart condition in Basedow's disease is the one of greatest moment, and that if this can be prevented from developing the prognosis is extremely good. Early operation is the best means of preserving the heart.

The last conception which should exist in the surgeon's mind. is that operation should be the final resort in exophthalmic goitre; rather it should be the means of treatment first to be considered.