pulled to liberate it. By a plan which I hit upon in experimenting, only one thread has to be pulled in order to liberate the knot, therefore I think it is better and there is less danger of disturbing the surfaces which have been ligated. The time has not yet arrived. for removing the ligature, so I am unable to say how nicely it will work.

The kidney, as you will observe, is filled with abscess cavities. I take it the ideal surgery in this case would have been to isolate the ureter and vessels and ligate them separately, but the man did so badly under the anesthetic that I hurried through with the operation by making a single ligature of the entire mass.

DISCUSSION.

Dr. W. C. Dugan: It has been my experience that preliminary nephrotomy usually results in a call for a nephrectomy later, and while this is true, it is no reflection upon the former operation, because the patient's condition is usually such that the major operation of nephrectomy would not be advisable. In the majority of cases of abscess of the kidney we should first do an operation for drainage, and when the patient has been built up, then do at second operation-a nephrectomy. My experience has been, with one exception, that the nephrotomy wound never completely heals. I operated upon a young lady for a large abscess where I tapped the pelvis and drew off the pus, then incised the kidney and allowed it to drain. She was brought to me in a profound typhoid state, so that we were apprehensive of a fatal termination fatal termination under the anesthetic. The kidney was opened and irrigated and drainage established, and the wound promptly healed; she became perfectly well, and has since become a happy mother. This is the only case not demanding the removal of the kidney after the nephrotomy.

Dr. A. M. Vance: I think I had the honor of starting a discussion upon removal of the ligature in operations upon the kidney. Perhaps a much simpler and better way might be to use a forceps constructed especially for the purpose. A snare might be used constructed in such way as to be under

perfect control of the operator. We always drain in these cases with a rubber tube, and a snare might be used upon the same principle as it is in the nose. A snare would perhaps be more surgical, more accurate, and more easily removed.

Dr. James B. Bullitt: In this case I used a forceps which seemed to be well adapted for the purpose. It is a forceps with a blade at right angles to the handle. I thought some time ago, while Dr. Chenoweth was experimenting as to the best means of taking care of the pedicle and getting rid of the ligature in these cases, that it would be quite feasible to use a forceps, and believe that one might be devised for the purpose. It would have to be one which would turn over at right angles to the long axis of the forceps, and then incorporated in the dressing so as to be out of the way of the patient. The opening in lumbar nephrectomy is so far back that the patient would be inconvenienced by any kind of an instrument which projected out of the wound. I believe by softening the parts with peroxide of hydrogen that the ligature. used in this case can be removed without making undue traction upon the pedicle.

The essay of the evening was read by W. C. Dugan, M. D., "Treatment of Injuries of the Skull, etc." (See page 242.)

DISCUSSION.

Dr. A. M. Vance: I have always been very much interested in the subject of injuries about the skull, and in the last few months have seen two patients where perfectly patent fractures of the skull were overlooked by the attending physician, so patent that the introduction of the finger into the scalp wound would certainly have revealed fracture. One was a girl sixteen years of age, who was run over by an electric light wagon and knocked down. She sustained a scalp wound from the base of the skull to the left occipital protuberance, which healed after granulating, and I was sent by an insurance company with Dr. Cartledge as an expert to determine how much

injury she received. It had been only three months since the injury, and she was having epileptiform seizures, and it was perfectly patent by an examination through the scalp that she had a fracture not only in the outer but the inner table, because pressure was so great that it could not help affecting the inner table. When we made our report the insurance company did not want our testimony, and I understand that the jury gave her five thousand dollars damages.

I recently saw an old lady who fell down a cellar three years ago and had a similar fracture, and she was then suffering from epileptiform and maniacal seizures. Fracture of the skull in each case was overlooked by the physician who was called. These cases could have been relieved just as one I saw the other day at the St. Mary's Hospital, a little boy who had been hit on the head with a brick, which produced a fracture of the base of the skull so extensive that a distinct ridge could be felt. He was in bed only two days after elevation of the fragment, and the other two cases I have mentioned might have been relieved as easily at the time of the accident.

There is another class of cases in which good often follows trephining, that is cases of epilepsy resulting from blows upon the head that seem even after years upon exploration to have received no fracture, still they have paralysis, epilepsy, mania, etc., and I believe that we have heretofore looked too unfavorably on this class of traumatic cases of epilepsy and other nervous phenomena. My experience has been that more can be done for them than our teaching heretofore has led us to believe.

I want to emphasize what Dr. Dugan says about the use of the mallet and chisel in these cases. I have for a long time used the chisel, and it is wonderful with what rapidity and precision any amount of bone can be removed.

In

fact, the trephine ought to be discarded except when you want to do a plastic replacement. The chisel is the best instrument, and I do not believe any harm comes from its use. It was formerly thought the concussion by the mallet would do harm, but by holding

the chisel at the proper angle and using a sharp instrument, it is surprising how easily and quickly one can pass through even an adult skull. By way of illustration I show you several pieces of skull that I have removed by this means.

I believe all these old traumatic cases ought to have the benefit of an operation, and oftentimes a small operative procedure will do much good. I have several cases which have been markedly improved by opening the skull. One boy was an imbecile; he is now able to earn his living. Another man, Mr. F., whom you will probably remember as having been exhibited before the Medico-Chirurgical Society upon two occasions, was perfectly relieved after having been in coma for over four weeks. Another man was relieved by a button being taken from his skull; he had sustained a blow on the head twelve years ago; he was unconscious for three days, had been paralyzed for twelve months, and epileptic for twelve years. Such cases might be multiplied.

Dr. J. G. Sherrill: There are a few points which should be emphasized : In the cases of fracture of the skull that I have seen, localized pain on pressure has been the most prominent symptom. I believe this to be true in all instances where the patient is not unconscious. If the patient is unconscious, then the supposition that fracture has occurred is more than probable. Another symptom is fullness about the head which is felt by the patient. These two symptoms should lead us to suspect that fracture has occurred.

In regard to late cases of epilepsy that occur after injuries to the skull; the question comes up, however, do we ever have such cases without fracture? In one case I trephined, removing a piece of bone over what I thought I had localized as the point of injury for epilepsy eleven years after the injury occurred; the point was located by the localizing symptoms, the way in which the spasms were initiated, etc. After removing the piece of bone I found no evidence of a fracture or injury to the brain. The question is, can we have a fracture of the skull without any involvement of the dura? It may be possible, but I doubt it. It is perfectly

possible for nature to repair a certain amount of damage to the bony structure, perhaps leaving no trace of the injury; but we will always find more or less adhesion of the subjacent structures, which produces the epilepsy. I have such a case in mind, where trephining was following by some benefit; convulsions returned, but they were not so frequent as before the operation. No injury about the head is of so little importance as to be disregarded, and in cases where there is any doubt we ought to make an exploration, because simple incision of the scalp is not dangerous; and if we find no fracture of the outer table, but symptoms point to a fracture of the inner table, we ought to trephine, because the mortality following the operation is comparatively slight and the prognosis without operative measures extremely grave.

Dr. Jas. B. Bullitt: The fact, as shown by Dr. Dugan, that these apparently desperate cases may be completely relieved in a comparatively short time after receipt of injuries to the skull, ought to encourage anyone who does general surgery to attempt to emulate the example he has set.

Dr. Vance has been singularly fortunate in the cases he has mentioned. He has attained results superior to those which have been attained by most surgeons who have operated in similar cases at similarly long intervals after receipt of injuries. While it is recommended by most of the best authorities on such subjects that operations be undertaken in the hope that something may be done for these unfortunate patients, and with the knowledge that occasionally some relief is accorded, it is still a well-accepted fact that where the epileptic habit, so to speak, has been acquired for several years, that only a small percentage of cases are positively and permanently benefited. Nearly all are benefited for a shorter or longer space of timeusually shorter --but permanent benefit in most cases is slight. Dr. Dugan's remarks emphasize the fact that these cases should be operated upon early.

There is another class of cases, hardly coming under the head of those discussed in the paper, cases in which

injuries have been sustained without fracture of the skull. These cases are more difficult to handle. I remember one boy who received a severe blow on the head just behind the ear. There was no external injury and not a great deal of swelling, but the boy developed in a few hours a condition of coma. The bone was exposed and no fracture found, but the bone was distinctly reddened; evidently a little hemorrhage had occurred into it; the skull was trephined by Dr. Chenoweth and a large extra-dural blood-clot removed. The boy made an uninterrupted recovery. I take it this case is one which in after years might have developed exactly the train of symptoms mentioned by Dr. Vance. I have had the pleasure of seeing him operate upon two of the cases referred to, and must say it seems remarkable to me the amount of good that has been done, and it puzzles me to know exactly what the mechanics are which accomplished the result. A bone flap was raised, the brain was exposed, and in one or two cases some little dissection was done for the purpose of determining whether a cyst or clot was present, but in none of the cases was such a condition found. The brain in one case presented simply an edematous appearance; it looked as though it were filled with serum, and there was quite an escape of fluid as the bone flap was raised. While this discharge continued for some time, I still can not understand how the good result was accomplished. Where a bone flap is taken up, you certainly produce some irritation, while on the other hand you relieve a certain

amount.

Concerning the method of invasion, the chisel is a most admiral weapon. I noticed, however, a few months ago a report by some operator who had been making experiments upon animals, in which he mentioned one case where hemorrhage in a dog had been produced by blows from a mallet. That this occurs frequently in the human being I do not believe. A great deal of skill is required in holding the chisel and so directing the blow that little force is expended upon the head itself. Recently I have noted a method which seemed to me a most admirable one,

especially where large areas of bone are to be taken out for the purpose of exploration, and where it is desirable to replace the bone. In taking out large areas of bone you expose the head to the liability of future injuries, from which it would be well, if possible, to protect it. This method is by the use of the Gigli wire saw.

Dr. W. C. Dugan : I desire to emphasize what has been said about the use of the mallet and chisel. I do not know when I have used the trephine. Like Dr. Vance, I think the chisel is perfectly safe in the hands of any one who has a knowledge of mechanics. Of course, if you hold the chisel at an angle of forty-five degrees, or more than that, you must necessarily do great injury to the brain. Where you hold it at an angle of ten or fifteen degrees the skull receives the force of the blow and the brain is undisturbed. With this instrument you can cut where you desire within a hair's breadth.

Dr. Vance's experience in neglected cases has been more favorable than mine. I have operated in a number of cases of traumatic epilepsy of long standing, and my results are not very encouraging. Still, I operate where there is any sign of trauma, upon the hypothesis that a condition might exist as mentioned by Dr. Bullitt-a subdural hemorrhage without a fracture of the skull. In speaking of these hemorrhages without fracture: Not long ago I saw an old lady in the City Hospital who was having epileptic seizures one after another. We first tried to persuade ourselves that it was hysterioepilepsy, but finally decided it was not, and thought she had either a hemorrhage or a fracture. We exposed the skull at a point corresponding to the motor area and found no fracture; not satisfied with that, we went down to the dura with the chisel and exposed quite a large area of the dura and found no clot; we then separated the dura with. a periosteum retractor and found a large hemorrhage occupying a point just anterior to the motor area of the left side of the body. She had no more trouble, and made an uninterrupted recovery.

In speaking of neglected cases, I saw only a few days ago an old lady who had

fallen from a street car; she was picked up, and was conscious for a short time, then developed unconsciousness and remained in that condition until she died. The physician in the case contended that it was a case of "concussion," notwithstanding the fact that she had complete paralysis of one side of the body and incontinence of urine and feces.

J. G. SHERRILL, M. D., Secretary.

Resolutions of Respect to the Memory of Dr. W. E. Fowlkes, Adopted by the Physicians of Owensboro.

WHEREAS, The great Ruler of the Universe has, in his infinite wisdom, removed from our profession our fellowlaborer, Dr. W. E. Fowlkes; and,

WHEREAS, The relation he held with the profession makes it fitting that we record our appreciation of him; therefore,

Resolved, That the wisdom and ability which he exercised by counsel and service will be held in grateful remembrance;

Resolved, That the sudden removal of such a man from the community. leaves a vacancy that will be deeply realized by all members of the profession and its friends, and will prove a grievous loss to the city and the public;

Resolved, That with deep sympathy with the family, afflicted relatives and friends of the deceased, we express an earnest hope that even so great a bereavement may be overruled for their highest good; and be it further

Resolved, That a copy of these resolutions be conveyed to the family, and that they also be put upon the records of this society.

C. H. TODD,

W. E. IRVIN,

D. M. GRIFFITH,

Committee.

Mississippi Valley Medical Association at Nashville.

There was much about this meeting to declare its success. The program was complete, and a large proportion of the essayists were on hand. For three days the attendance by distinguished foreigners was unusual, and the scientific value of the contributions and the discussions will appear in the published proceedings. The prompt and efficient ruling of the President aided in the disposal of the papers so as to get through with the program almost as indicated. The accommodations were most agreeable and the entertainment elaborate. To the energetic and genial Chairman of the Arrangement Committee is due praise for the manner in which the members were cared for. However, the co-operation and support of the local profession in the halls of the society were missing in some degree, and indeed the profession from surrounding towns was little in evidence. Though the registration was something above one hundred, it was made up largely by visitors from a distance.

The success of a medical society depends not only on the quality but also on the number of its members, and when this number of necessity varies at each session, the point of assembling must be chosen with careful judgment.

Three features chiefly control the prosperity of such meetings. The convenience and accessibility of the location to the largest number is by far the most important. The local attractions of the point is second, and last, but of great value, the welcome of the local profession. This last is not alone the good cheer and hospitability of entertainment, but a participation in the meeting, an audience to the invited essayists, a multiplying of membership. The home and the field of the Mississippi Valley Medical Association is between the cities of that valley, of which Nashville is one, and to swerve too far out of it in search of attractive meeting points is to endanger its loss of identity and thus the security of its usefulness. The next session in Chicago will find the essentials of a successful meeting. We hope to hear early of the inauguration of plans looking to such success.

Doctor A. M. Owen.

In the recent death of Doctor A. M. Owen, of Evansville, Ind., the medical profession of this country has sustained a serious loss. He was one of a trio that organized the great and successful meeting of the Pan-American Congress, at Washington, a few years ago, and it is a lamentable fact that both the president of that Congress, Doctor Wm. Pepper, and the treasurer, Doctor Owen, are now dead. Possessed of a personality that few men have, Doctor Owen at once made friends with all classes. A great surgeon, he was rewarded with a large practice; a skilled physician, he had a loving clientele. What is found in but few physicians, he had fully developed, viz: a business knowledge which enabled him to amass a fortune. He was a man liked by all men, beloved by his patients, and re