erly shod after recovery from operation. The most common and most potent reasons for failure are the first two.

If insufficient bone is removed the deformity cannot be corrected although all the other precautions are observed. If bone is removed from both metatarsal and phalangeal surfaces a stiff joint will surely result.

The most potent obstacle to reduction of deformity that is most frequently overlooked is the shortened tendon of the extensor proprius hallucis.

With the idea of trying to avoid all these causes of failure, I devised the following technique, and have followed it exactly in every case, I do not know how many, during the past five years, without having one dissatisfied patient.

TECHNIQUE.

The foot is elevated and a constrictor put around the ankle. The operation can be done much more rapidly if the field is not filled with blood. A crescentshaped incision two inches long is made just below the edge of the callus which covers the enlarged head of the metatarsus. I found after several experiments that this incision gave freer access to the joint at exactly the spot the bone is to be removed than any other, and the resulting scar, if any, is just between the points where the upper and sole of the shoe make pressure.

The capsule is incised in the same direction and to the same extent as the skin incision, and the capsule and periosteum are pulled away from the bone a little at the point where they meet.

With a pair of narrow, long-jawed bone scissors about three-quarters of the articular surface of the head of the metatarsus is removed, at such an angle as to include all of the enlarged inner tuberosity.

I do not remove all of the head of the bone for three reasons:

1. It is not necessary. The deformity can be perfectly corrected without.

2. It does not shorten inner border of the foot, and thus make it look unnatural.

3. Motion will be more free if some of the articular surface is left.

After the bone has been removed the toe is pulled strongly inward, and the tendon of the extensor proprius hallucis, which is thus brought up into prominence on its external border, is divided subcutaneously at the level of the joint.

Then it will be found that with very little pressure the toe can be made straight.

Here a small gauze sponge wrung out of hot antiseptic solution is crowded into the cavity and the constrictor removed. While the toe is held in its corrected position a mattress suture of strong iodine catgut is carried from the lower angle up to the upper angle, returned through the upper angle and brought out at the lower angle. The gauze packing is removed and the suture tied, thus approximating the upper and lower angles of the capsule incision, and if the bone has been properly removed and the tendon divided, when that suture is tied the toe will remain straight. The skin wound is then closed with horsehair or catgut, and a thin gauze dressing put on.

Over the dressing I put a piece of piano felt with a hole in it, like a bunion plaster, and a cigar box splint a trifle longer than the foot and a trifle wider than the toe is fastened to the inner border of the foot with adhesive plaster.

The splint is then covered with a bandage, starting at the ankle, and the splint is fastened firmly to the foot and the toe fastened firmly to the splint.

If the patient is going out from my observation I cover the whole dressing with a narrow plaster of paris bandage. Unless there is some indication for doing so I do not disturb the dressing for two or three weeks, but I allow the patient to step upon the foot as soon as he can comfortably. When the dressing is removed I put on a lighter one, still keeping the toe fastened to a splint.

It is not safe to remove all restraint from the toe for at least six weeks.

Now about shoes. The patient must never again be allowed to wear tapertoed shoes, but a straight-lasted shoe, with a broad ball must be insisted upon even with women in the height of fashion. Otherwise the fibrous tissue with which the injured joint has been repaired will stretch and the deformity recur. If you cannot dictate the shoes, don't do the operation.

DISCUSSION.

DR. H. R. ALLEN, Indianapolis, Ind.: I have been much interested in Dr. Porter's paper, and what he has said can be relied on. There is not one step he has mentioned in connection with this procedure that is not absolutely perfect, from a mechanical standpoint, from start to finish. It is very essential to encourage motion

of the toe in these cases. The most I can say about Dr. Porter's work is that he has simply given us a perfect demonstration of a really simple procedure, which will relieve the most distressing case of bunion, and I desire to congratulate him on it.

DR. PORTER (closing the discussion): The great advantage of this simple procedure is its rapidity. The whole operation can be done in ten minutes, and it seems unnecessary, in the light of the good results which I have had from this simple procedure, to resort to others.

Society Reports.

OBSTETRICAL SOCIETY OF

PHILADELPHIA.

Meeting of May 7, 1908.

THE PRESIDENT, JOHN M. BALDY, M.D.,
IN THE CHAIR.

Hemorrhage in Pregnancy Contrasted with Ruptured Uterine Pregnancy.

re

DR. GEORGE ERETY SHOEMAKER reported the cases of two private patients, under treatment at the same time, which presented similar symptoms from widely different causes, quiring different treatment. Both patients were pregnant, both had sudden severe pain in the right abdomen, perspiration, vomiting, decided shock, sudden pallor and reduced hemoglobin. Both had distention; one from gas and obstipation in early ruptured extrauterine pregnancy with intraperitoneal hemorrhage; the other from sudden concealed hemorrhage high in the uterus, distending the organ from the size of six to that of eight months' pregnancy. There was no external hemorrhage. The child was dead. Delivery was accomplished by dilating bags, etc., first the child, then firm clots, then placenta. There was no fresh bleeding. The cause was said to be acute nephritis with retinal hemorrhage and retinitis. The ruptured extrauterine pregnancy was treated by abdominal section. Recovery took place in both cases.

DISCUSSION.

DR. FREDERICK HURST MAIER: In doubtful diagnosis of extrauterine gestation an excellent method, before proceeding to abdominal incision, is to open the cul-de-sac to determine if there is free blood in the abdominal cavity. This frequently saves the woman an unnecessary abdominal section. I remember one case some years ago at the Jefferson Hospital in which this procedure undoubtedly saved the woman's life. She was from the slums and was brought in in a practically moribund condition. There was a mass on the right side, and the question arose whether the woman was suffering from retained secundines with chronic inflammatory mass, or whether there was ruptured extrauterine gestation. Incision

a

into the cul-de-sac showed the mass to be a chronic inflammatory one. The uterus was packed and the woman made a good recovery. Had she been subjected to section she undoubtedly would have died.

DR. JOHN B. SHOBER: I was much interested in Dr. Shoemaker's case of concealed intrauterine pregnancy, though personally I have never seen such a case. An interesting case which came under my notice not long ago was that of a woman, about thirty-six years of age, who had been married thirteen years and was sterile. She had suffered for many years with dysmenorrhea. She had had an obstinate leucorrhea and an endometritis, also a retroverted uterus in the third degree. When the abdomen was opened there was found to be a chronic appendicitis. The appendix was removed. There was, in addition, a small fibroid nodule on the anterior wall of the uterus which was removed. The uterus was stitched forward by hysterectomy. The tube was found to be very attenuated. The woman made an uneventful recovery and reported after her next menstrual period great relief. About six months later she reported that she was suffering intense pain on the left side. Examination revealed a mass upon this side. The uterus was in proper position following the hysterectomy. Upon opening the abdomen it was found that the mass on the left side was an extrauterine pregnancy of six or eight weeks. A fibroid nodule at the left cornu was present which had developed since the previous operation. As the right tube was suspicious and the woman was anxious to have everything possible removed, the ovaries and tubes were taken away. The nodule which had developed contained a degenerated blood sac. It was obvious that in the presence of the attenuated tubes and the fibroid at the cornu the ovum could not find its way into the uterus, and she consequently developed an extrauterine pregnancy.

DR. SHOEMAKER (closing): I have seldom seen smaller or thinner tubes than those in the woman with extrauterine pregnancy. They must, however, have been originally healthy tubes, for she had had five children and a number of miscarriages.

Value of Acetone in the Treatment of Inoperable Carcinoma of the Uterus.

DR. MAIER, in a paper upon this subject, states that despite the fact that the great majority of women who come to the gynecologist suffering from cancer of the uterus are inoperable, but little progress has been made to improve the condition of these unfortunate individuals. He describes Gellhorn's treatment, and reports a number of cases with excellent results. He claims that it is the most practical method yet instituted, as it exercises a most effective cauterizing action. It does not burn the healthy structures. It can be applied every second or third day without narcosis, and after the preliminary curettement, the treatment can be carried out by the practicing physician.

DISCUSSION.

DR. JOHN M. FISHER: I understand that Dr. Maier reported a case which he was treating at

the Jefferson Hospital last August. The case was one that could be diagnosed by the odor that attended her entrance to the clinic. Upon examination we at once made a diagnosis of carcir oma and decided that the case was inoperable. Dr. Hirst suggested that the acetone treatment be tried. Immediately after curettement and the first application of the acetone there was cessation of the bleeding and the horrible stench. There has been a gradual shrinkage of the carcinomatous growth with disappearance of ulceration, the parts now presenting the appearance of a high application of the cervix. The improvement has been marked, locally and constitutionally. The success attendant upon Dr. Maier's cases at the Jefferson Hospital led me to have it tried in a number of cases at the Philadelphia Hospital. It was reported to me that the odor in all of them was at once checked. It certainly appeals to me as being a very great advance in the treatment of inoperable carcinoma, especially in those cases attended with discharge.

DR. SHOBER: Any method of treatment which will accomplish what has been claimed for this method by Drs. Maier and Fisher should be welcomed by the medical profession. I have for many years been deeply interested in inoperable carcinoma of the uterus. I was the first in Philadelphia to apply the X-ray treatment in these cases, and, as Dr. Maier has well said, this treatment has proved almost useless. The results obtained in the relief of hemorrhage in the X-ray treatment, when used after the technique of the gynecologist, encouraged me to try to do something with radium, having been fortunate to secure very excellent specimens of radium some years ago. I have observed that if the patient is allowed to retain a capsule containing radium of a powerful denomination there is accomplished exactly what has been accomplished by the acetone method. In a patient now having this treatment the odor seems to have been completely controlled, there is little hemorrhage or discharge, and the general condition improves. It does not cure the trouble and does not seem to reach in its effect further than a certain distance from where it is placed. I have never seen a burn from the use of radium in this way, and it is one more method which we can look forward to being able to use more generally when radium becomes less expensive and the technique improved.

us.

DR. JOSEPH PRICE: I have not had experience in this line. It is interesting to know that our profession is eager to relieve this class of patients whose presence always distresses Sims' lecturing to John Holmes' anatomical class was really the beginning of the cautery treatment which is practiced so commonly today throughout the world. If the new remedy will do more than the curette and cautery have done, we cannot help but welcome it. We do know that the curette and cautery remove the diseases and involved structures and put the patient and family in a comfortable atmosphere and stop the exhaustion from hemorrhage and discharge. The distressing conditions are relieved and the woman is enabled to take charge of her home, and her life is prolonged for two years or even longer. Some of our patients live as long as three or four years after a very free use of the curette and cautery cooking to sound structures. We find that the parts shrink

to little funnel-shaped scars and we sometimes think there must be an error in diagnosis. So it pleases me to find that this celebrated old scientific body continues along some of the old lines. In a recent number of the Journal of the American Medical Association, Wright quoted freely from the transactions of this organization. I rarely go to a meeting that I do not hear some reference to your contributions.

DR. MAIER (closing): I was very much interested in the remarks of Dr. Shober concerning the use of radium; but, unfortunately, that, too, is impracticable. I agree with Dr. Price that we really have made very little advance since the time of Sims in the treatment of this class of cases. Thermocauterization is more effective than any other method we know of at present. Unfortunately, however, we cannot thermocauterize very frequently, as it cannot be done without narcosis, and there are very few patients who will submit to periodical treatments of this kind. The claims for the acetone treatment are that first of all it has effective cauterizing power; and, second, that it does not destroy the healthy tissue; third, that it can be applied at short intervals and without subjecting the patient to narcosis. It would be impossible to say, from the short time it has been used, that it is going to prove as effective as some of the other methods. The object of this paper is to incite others to try it. The treatment can easily be carried out by the general practitioner. Even if it does nothing more than relieve the distressing local conditions and make life more endurable for the patients and their friends we shall have accomplished much.

Hypernephromata-Specimens.

DR. L. J. HAMMOND presented the subject of hypernephromata, and showed an unusually large tumor which illustrated the great size which a growth of this kind could attain. It was removed from a woman forty-four years of age, who previous to two years ago, had been in perfect health after the removal of a fibroid tumor of the uterus twenty-two years before, or when she was twenty-three years of age. The existence of the growth had been known for two years and it was not until its great size, causing such distressing pressure symptoms, coupled with a continuous reflex hacking cough, that she sought medical aid. During this period she had lost in weight more than forty pounds, showing marked emaciation accompanied with dyspnea. Both the thoracic and abdominal cavities with the exception of the right kidney seemed normal. The immense tumorous distention could be shifted throughout the entire right side of the abdomen. The leucocytes numbered from five to six thousand. There was no expectoration, though there was continuous cough. Malignancy of the kidney was diagnosed, and on August 14, 1907, under ether anesthesia, an ileo-costal incision, extending obliquely forward five inches in length, was made and the kidney was with some difficulty removed, owing to the extensive adhesions

of its capsule to the peritoneum anteriorly. The difficulty in its removal was also greatly added to by reason of the imbedding of the cystic end of the ureter in a dense mass of adhesions which was a product of the hysterectomy performed twenty-two years before. The definite stenosis of the ureter would seem to have been a factor in causing the development of the neoplasm through its interference with the normal drainage from the kidney and in blocking the circulation. The ureter was one and one-quarter inches in circumference, clay colored, giving to the sense of touch a feeling not unlike that of a clay pipe stem. The mass was the size of a double fist, unequally enlarged, pale in color, and when in place was completely covered by the kidney capsule; in the removal some parts of this were torn and as a result the growth protruded as a spongy, friable and in some places necrotic mass, having a somewhat papillomatous or cauliflower appearance. The growth springs from the antero-lateral aspect of the kidney nearer its convex border than the hilus. Microscopically the normal kidney is shown to be separated from the tumor by dense fibrous bands, from which at not frequent intervals less heavy trabeculæ extend into the new growth; this causes the neighboring kidney structure to become condensed and the tubular epithelium and glomeruli are atrophied, and there is a marked interstitial fibrous overgrowth, the tumor itself showing fine capillary lace work and the capillary endothelium in places being well preserved. The tumor cells are polygonal in shape and in some areas arranged indiscriminately about the capillaries, the t'ssues in this area being more or less condensed and the capillaries intricately interlacing. In other ones they are not so numerous, and are separated from the condensed portion by a more pronounced fibrous tissue band, the capillaries having a more definite direction, though still interlacing, and upon these the cells are columnar and arranged in somewhat tubular fashion. Large areas of necrosis are present, heavier portions of the stroma showing slightly hyalin degeneration.

This malignancy of the kidney has been studied and reported by Grawitz, Klebs, Gatti, Luborsch, Busse, Kelley and others. They are usually found after middle life (thirty-seven to sixty), more often in men, with but a single recorded instance in childhood. It is rapidly growing and the majority of them show a tendency to metastasis to the liver, lungs, brain and bones; the metastasis taking place by way of the blood streams and renal veins, they may attain great size, destroying the greater part of the renal tissue and are encapsulated. They have been looked upon as carcinomata.

DR. B. F. BAER: When I saw the title of this paper I concluded to ask the privilege of presenting the following case of hypernephroma which had some bearing upon the subject: Mrs. M. E. H., aged forty-nine years, consulted me in January, 1906. She was pale and emaciated. She had suffered from attacks of pain in the right hypochondriac region, associated with sick headaches of an unusually severe character. The attacks had been growing more frequent and severe, and on several occasions had been associated with jaundice.

Examination revealed a tumor in the right upper quadrant, which was decided to be a dislocated kidney much enlarged. In view of some suspicious signs of pulmonary tuberculosis, it was thought the kidney might be tuberculous. The urine was, however, free from tubercle bacilli and showed nothing abnormal save a transitory albuminuria. The urine obtained by catheterization of the left ureter proved to be normal, and the left kidney otherwise seemed to be normal.

In February, 1906, the right kidney was delivered through an incision in the loin. Situated in the upper pole was a well circumscribed and encapsulated tumor of the size of a mandarin. The kidney itself, or what remained of it, was studded with small cysts, had a granular surface, and was increased in consistence. The pedicle was ligated and the mass removed. A smooth recovery followed. At once the pain disappeared and the sick headaches were cured. The tumor macroscopically has all the characters of a hypernephroma; and on microscopic examination, presented a typical picture of this interesting growth. The pathological examinations were made by Dr. David Ri sman, who managed the medical part of the case.

DISCUSSION.

DR. J. M. BALDY: There is a peculiar difference of opinion among surgeons regarding this neoplasm of the kidney. Dr. A. O. J. Kelly regards it as exceedingly common. Yet upon inquiry I find that surgeons generally have seen comparatively few of them.

DR. EDWARD A. SCHUMANN: I think it has been brought out in the question of the histogenesis of these tumors that they are perhaps an embryonal form of sarcoma. This, I believe, was Sanger's opinion.

DR. HAMMOND (closing): Dr. Baldy's statement accords entirely with the results of my inquiry among surgeons regarding the infrequency of this growth. I was unable to find but two instances of the condition, save in the Philadelphia Hospital, where two cases were found post-mortem. While in Europe a few years ago a single case of hypernephroma was shown us and from what was then said of its rarity I assume that it was the only case up to that date they had met with in St. George's Hospital. The case referred to in the paper had been in several hospitals before it was sent

to the gynecologist, and the condition was believed to be some intra-abdominal growth, having been diagnosed by several surgeons as tubercular peritonitis. The abdominal viscera was thoroughly studded with growths, also the necessary glands and omentum, while the growth in the kidney itself was quite small. I understand that there is to be later a complete report of the case.

Drainage of the Pelvic Cavity.

GENERAL DISCUSSION.

DR. PRICE: It is exceedingly kind and generous of your chairman to invite me to open the discussion of this subject. I think it would have been better if he had opened up the question and given us a chance of discussing a subject upon which we are so fond of talking. I thank him of the privilege of discussing the subject in the presence of this old scientific body. I do not think I could have more pleasure in going into a scientific organization at any other point of the globe than here. I have a great deal of pleasure in thinking of just what this body has contributed to the world scientifically. I can remember that at one time our transactions were published in some fifteen or twenty journals, and it was quite common for other good societies to make reference to the work our society was doing.

The subject of drainage is a large and old one practiced by Hippocrates and Galen. In short, they used caustics, charring holes in cavities favoring drainage. Those were really aseptic methods of drainage, more aseptic probably than some of our modern practices of incisions through healthy lymph spaces in the midst of filth and infectious material, favoring infection. This society and other American societies have contributed generously to the invaluable papers and discussions upon this subject. While Martin, of Berlin, opposed drainage, he commonly practiced perforation of the vaginal vault and drained with gauze. It is interestin~ that while he was doing incisions for suppurative forms of tubular and ovarian disease in Berlin, and doing vaginal drainage with a mortality of twelve in seventy-two or fourteen in seventy-seven, we were doing in this city precisely the same operations, but draining from above with a glass tube, and a nil mortality. Many of the gentlemen present, at least Dr. Baldy and I were then doing abdominal sections in alleys and courts, garrets and stables throughout the slum districts, with anything else but favorable environments, and with a nil mortality, and all having abdominal drainage. Martin was one of the most scientific operators I have ever known. work was rapid, clean, and strictly aseptic. It is curious, but early in the history of vaginal incisions the mortality was high. Until the work of Seguin, Jacobsohn and Pryor was published no one did vaginal operations with low mortality. We know that Pryor's methods were about perfect. No one but Pryor could remove all pathology and drain those surfaces so completely. I believe he even practices the removal of the appendix by the vaginal route. A good many American operators, after he published his works, questioned his statistics. did not, because I knew that Pryor was doing his vaginal work from below just about as thoroughly and completely as we were doing it from above and established a perfect drainage. But

His

I

are

he did more. We were foolishly in the puerperal case removing from above about all the pathology we found and our patients either died of pneumonia or went on and died of infections. Pryor simply established drainages, controlled the sepsis or lymphangitis and saved his cases. The solution of his low mortality was that he did less extirpation and more drainage than we. Mundy and his valuable contribution lists the great surgeons in gynecology who practiced drainage and those who were opposed to drainage-Goodell and Tait and others. He was in error in so listing Tait. He, Tait, did occasionally use drainage, and if he had practiced it in more cases his mortality would have been lower. His pupils about all strongly advocated and practiced drainage, and were abundantly rewarded by fine results. At present our methods so nearly perfect that I doubt whether there is a single operator in the world who has not tried to avoid drainage. Carteledge, who wrote a splendid paper on the subject, wrote, "When in doubt, drain." Keith wrote, "After all, where would we be without drainage?" In Italy the first one hundred cases of ovariotomy died. Nothing could have been more unfortunate than the study and practice of ovariotomy, abdominal surgery, without varied surgical experience. The clinical experience, prolonged hospital apprenticeship, rotating in his hospital residency from women's medical to women's surgical, men's medical to men's surgical and the specialties, gained in this citv, is given in only a few cities of the world. Here the young surgeon enters upon pelvic work with about a nil mortality. I think the answer to the inquiry of "How shall we avoid drainage?" would be to have early operations, early diagnosis and prompt operation, no cold storage, no delay for blood counts. If the operation is done the first hour, the first day, drainage is not necessary. Primary closures are pleasing.

Along the line of gangrenous and perforative forms of appendicitis we have made great progress. I remember the time when if a man reported a case of recovery from general infectious suppurative peritonitis he was thought to be a liar, and commonly lived under that appellation. Even at present we have a few surgeons who tell us they never save a general suppurative peritonitis. I am familiar with the good work of the surgeons of this country, and I have known a number of young surgeons of this city to open dirty peritoneal cavities, establish drainage and obtain recoveries. I have recently opened five cases, two of my own and three of some one's else, of acute obstruction and reversed peristalsis. I found obstruction about the ileum, and the small bowel distended with fluid. By puncture and operative drainage of the small bowel, large bowel absorption was avoided.

While discussing the importance of drainage, and comparing the results of men who have the reputation of draining too much, let me call your attention to what occurs here and elsewhere. Several patients have recently died because of the adoption in some of the hospitals of the modern practice of waiting for the subsidence of acute symptoms. Now, while the good surgeons of this city were waitin~ for those acute and alarming symptoms of neritonitis to subside, five patients went into my own house at midnight, and the order had been