and probably to a certain extent the course of the disease was modified by the injections. The internal administration of protonuclein was persevered in for a considerable time, and the injections for a period of two months, although Coley maintains that if improvement does not take place in two or three weeks, it is not to be expected. It does seem to me that from reports of the few successful cases, chiefly it appears in the hands of Coley himself, that there must be some special form of sarcoma, which we can not determine by microscopical examination, which is susceptible to the local treatment of injection, and perhaps sonie other form which is susceptible to protonuclein, the two of course being entirely different methods of treatment. But in the great majority of cases it appears that the injection method is unsatisfactory and nearly always fails. That it occasionally succeeds there can be no question, and the only explanation seems to me is that although the microscope reveals no difference, yet there must be a special form of sarcoma in which this treatment will succeed.

Dr. W. O. Roberts: The result thus far in this case justifies the operation. I think there is no question but there will be a recurrence. I can not believe that there is much in protonuclein. In reference to the toxin: I have used this on a number of occasions, and have never seen any change take place for the better in but one case. That was the case of a physician in Shelbyville, Kentucky, whom you all know. I removed from his groin a sarcoma; the specimen being lost, no microscopical examination was made. Three or four months after he had entirely recovered from the effects of the operation he returned with a mass in the groin quite as large as the original one-about the size of an orange. It was then fixed. There was not only a mass in the groin, but there was also a mass in the lower portion of the abdomen of that side. The latter appeared to be much larger than the mass in the groin. It so happened that the day he was here to see me Dr. Coley was in Louisville on a visit. I had him see the case;

he considered it an inoperable tumor, and suggested that the toxin be tried. He at that time claimed that the toxin had little or no effect on small roundcell sarcoma, but it was in the spindlecell sarcomata that he met with such success. I advised the patient to go to New York and be under Dr. Coley's immediate observation, which he did. He returned to Louisville after having been in New York for a month or six weeks, during which time Coley had given him injections regularly. Upon his return I examined him, and there was little or no change in the size of the tumor in the groin, but the mass in the abdomen had entirely disappeared. He went home, and the treatment was carried on (toxin injections) by his son, who is a doctor, and after being home a few weeks he had to give up business, and in six weeks after he reached home I was sent for and found him with the mass in the groin very much enlarged, looking as though it was going to break, as they frequently do. It was very vascular; the mass in the lower part of the abdomen had returned, although the toxin treatment was continued. I have used the toxin in a great number of cases, and all of them have gone on from bad to worse. year ago I removed a tumor from the forearm, just above the wrist joint, of a gentleman. I had seen the patient once or twice several months before. It appeared to be a tumor in the skin. A month before I removed it another one appeared on the back of his hand, about the size of an almond. A short time before the operation there had been applied over the forearm a mercurial mull plaster which had produced considerable irritation of the skin extending some distance from the edge of the tumor. We waited until the inflammation had about subsided, but there was still some discolorization and thickening of the skin. The tumor was distinctly circumscribed. In the operation the skin and cellular tissue for some distance from the tumor were removed with the growth. The skin that had been blistered and irritated by the plaster mull was very vascular, and the gentlemen present all thought that very likely this was infiltration

A

from the sarcomatous growth. These wounds healed perfectly, but later on the one in the forearm broke open again, and I felt satisfied there was a recurrence. I advised him to have the arm removed, but he wanted further counsel, and concluded he would go to New York and consult Coley. I gave him a letter to Coley and also to Bull. He went on there, and they cut out a section of the granulation tissue and had it examined under the microscope by two prominent microscopists of New York. Both of them reported that there was no sign of sarcomatous tissue in the specimen examined. One of them said that the microscopic appearance was that which was frequently found in but not characteristic of syphilis. I knew the man had never had syphilis, because if he had he would have so stated to me. Still they advised, notwithstanding the fact that he gave no history of syphilis, that he be placed on iodide of potassium and mercurial inunctions. This was three months after the operation that I performed upon him. In July I was not pleased with the condition of the skin, and sent him to New York again. Coley said he did not think it amounted to any thing; that it was probably the result of irritation produced by the mercurial blister; a mercurial eczema he called it. He said he thought it would be advisable, however, to put the man on preventive doses of toxin. He kept him there two weeks giving him this treatment; he had but little reaction from its use, his temperature never going above 101° F. He came back here. Coley advised that the treatment be continued for a month. This was done, and last August I sent him back again.

Coley then took out some of the skin where the eruption was, and an examination showed it to be sarcoma of the small round-cell variety, like the original growth, the examination of which was made by Dr. H. A. Cottell. The patient came back, and I amputated his arm at the junction of the middle with the lower third of the humerus. I also went into the axilla and cleaned it out, but found no enlargement of the glands there.

Notwithstanding the fact that we did a perfectly aseptic operation, suppuration took place in the stump, and I was inclined to believe that this suppuration was the result of hypodermic injections of toxin which had been used around the site of the operation. The wound finally healed. This man has had a painful stump ever since. Nothing can be seen to account for the pain, and every care was taken in the operation not to include any nerves in the ligatures. I did not continue the toxin treatment.

Some six weeks ago there appeared just above the ankle of the leg on the same side a red spot, then two more on the same leg a little further up. These spots when I first saw them were about the size of a silver half-dollar. They have continued to increase, and are now double the size when first seen. I am afraid these are recurrences in the skin.

Coley speaks of this as a rather unusual case of sarcoma of the skin. It is the only case of the kind that I have

seen.

Dr. A. M. Cartledge: I have seen several cases of sarcomatosis, and my observation has been that generally the skin is the point involved. We are all familiar with the frequent and wide dissemination of pigmented sarcoma of the skin, and even the non-pigmented. I have seen one marked case of this kind where recurrences took place in the skin, the original growth being in the bone. The first one was just above Poupart's ligament, which appeared shortly after the original operation. Subsequently there appeared similar growths in the skin of the entire body, until finally the patient was in a condition of universal sarcomatosis. I have also seen another case where the lesion was in the skin, beginning just above the ear, and there never was a growth anywhere except in the skin. I recall having seen several cases of pigmented sarcoma where there appeared hundreds of black spots in the skin, the patients finally dying from exhaus

and was treated for this disease. There was a thickening of the skin extending all over the body, the man finally dying from exhaustion. The disease also involved the mucous membranes, the soft palate, etc. A patient came to the city hospital during my service there last year with sarcoma involving the skin, first noticed on the inner part of the thigh. Finally he had perhaps two hundred of these thickened patches in different parts of the body. The original growth was pigmented, the others

were not.

Dr. W. O. Roberts: The skin covering the spots I have mentioned does not present a tumor, but simply red spots.

NEW OPERATING-TABLE.

BY JAMES B. BULLITT, M. D.

I have here a model of an operatingtable which I desire to present. It presents some new features which I would like to submit to your critical judgment. Most of the operating-tables, as you are aware, which are provided with means for producing the Trendelenburg posture, have this disadvantage: if the table is high, when the patient is thrown into the Trendelenburg posture the patient is out of reach, and for this reason a great many of the tables are made very low, thirty inches or less; then when the patient is thrown into the Trendelenburg posture he is at about the right height for convenient operating. The tables for ordinary operations, where the patient is lying out flat or for operations upon the breast or any part of the body except the abdomen, are about thirty-six inches in height, a height which permits the surgeon to stand with his back straight. Such a table is entirely too high for the Trendelenburg posture. I have seen a number of operators attempt to overcome this trouble by having a bench or stool on which they stood to operate in the Trendelenburg posture.

Baldwin, of Columbus, has designed a table which has the feature which you will see in the model before you; that is to say, the table is pivoted in the middle, so that the whole plane of the table is changed when the Trende

lenburg posture is desired, the head of the table going down as the foot goes up. In the model before you the Trendelenburg posture is easily produced by releasing a spring at the front part of the table.

This can be done by the anesthetist by putting the foot on the trigger, and then by placing one hand on the handlebar the table is readily lowered or raised. The weight of the patient is balanced at about its center, so that the strength of the little finger suffices to effect the change in position. soon as the foot is removed from the trigger the spring snaps back into one of these catches, permitting any degree of elevation to be maintained. It will be observed that this movement of the whole plane of the table, the head going down and the foot going up, keeps the field of operation always on the same level. Consequently a table conveniently high for all purposes can be employed, say thirty-six or thirtyseven inches high. This is a most important consideration.

This table further differs from the Baldwin table in that the movable extension, by means of which the table is lengthened from fifty to seventy-two inches, is fixed to the frame of the table instead of to the table top. This arrangement permits a very much more stable mechanism, and one which is also very much more conveniently and rapidly manipulated. It will be observed that this extension is at the foot end of the table instead of at the head end, as in most operating-tables. This constitutes a great convenience and advantage. During the course of an operation begun with the patient in the horizontal position, it is frequently found necessary to place the patient in the Trendelenburg posture. In the ordinary type of table the patient has first to be pulled down on the table and then elevated into the Trendelenburg posture. This requires at least two assistants, and produces always some confusion. With this table the patient is already in proper position, and the change is effected by simply pressing the trigger with the foot and depressing the head of the table by means of one hand on the handle-bar.

DISCUSSION.

Dr. J. M. Ray: I think the fifth leg ought to have a broader foundation, otherwise it seems to me the table might be easily overturned.

Dr. J. M. Mathews: There is no surgeon who has not been impressed with the great danger of wheeling a patient from an adjoining room, for instance, then lifting him-say a man or woman weighing two hundred or two hundred and twenty-five pounds to another table for operation. I have often thought if some one would get up a table like this, for instance, with wheels by which it could be carried into the operating-room, say in your infirmary, ampitheater of the college or in a private hospital, so there would be no necessity of changing the patient from one table to another-in other words, making your operating-table the one upon which you wheel the patient into the room-it would be of decided advantage. Time and again I think my patients have been endangered by this violent attempt to lift them from one table to another. I could never understand why this was necessary.

Dr. J. G. Sherrill: I have only one suggestion to make in reference to the Trendelenburg posture: I see in his model that Dr. Bullitt has provided no means for fastening the patient so he will not slip downward when this posture is assumed. I would advise that he put a strap on either side of the table at its extremity, an arrangement by which he could tie his patient to that part of the table and thus prevent slipping.

Dr. Jas. B. Bullitt: Rollers might

be attached to this table as well as to any other table used for surgical purposes. The weight of the patient is born by the center of the table, therefore there is no more danger of this table being overturned on account of the fifth leg than would obtain in the case of any other surgical table.

GALL-STONES.

BY DR. W. O. ROBERTS.

On December 8, 1898, I operated upon a patient sent me by Dr. Stevens, of Mayfield, Ky. The patient was thirty

five years of age and apparently in good condition. He had been the subject for three years past of violent and frequent pains in the gall-bladder region. He had never been jaundiced in the least, and never had any symptoms of gall-stones except pain. I had his urine examined and found no bile, and in an examination of the region of the gall-bladder was unable to make out any tumor, his abdominal wall being rather thick. I felt satisfied, however, from the location of the pain that the trouble resulted from biliary calculi; that every now and then when the pain would come on there would be obstruction of the cystic duct. Such was the opinion of Dr. Stevens. I told him I suspected that to be the condition of things, though I was not certain, and advised that an operation be performed. He consented to this, and I did the operation, as stated, on the 8th of last month.

Cutting down to the gall-bladder, I found it to be not much larger than my thumb; it was filled with stones; there was very little bile in the gall-bladder. On the second day after the operation bile began to flow through the opening.

I mention the case because of the absence of tumor and the absence of jaundice, the diagnosis being based upon the localized pain. The man has made a good recovery.

DISCUSSION.

I

Dr. W. C. Dugan: The absence of jaundice in these cases I have not found to be the exception but the rule, especially where there is no tumor. had a case recently very much like the one Dr. Roberts has reported. A lady was sent to me by a doctor in Harrodsburg, Kentucky, with the history of great pain, at no time jaundice, but with typical hepatic colic minus jaundice. At no time did she have a tumor in the region of the gall-bladder. The diagnosis was made, as Dr. Roberts has stated, upon the location, character, and persistency of the pain. By pressing deep down upon the liver she would give signs of pain. Operation was advised, and as in his case I found a small gall-bladder filled with stones

masoned in and very hard. They were removed, and as I think should be done in all these cases, the gall-bladder was stitch to the abdominal parietes. No bile was discharged through the opening for a week; then there was a gush of bile which continued until she went home three weeks after the operation, and it has continued more or less ever since. It has given me some little anxiety as to what the outcome of the case is going to be. Why this flow of bile should commence a week after the operation and continue for such a great length of time I am unable to say, unless some fragment of stone was left, getting down into the common duct and obstructing the flow from the hepatic into the common duct, and drainage has caused absorption of the inspissated bile that might have been in the cystic duct, and in this way bile is made to flow out through the wound.

The trouble in Dr. Roberts' case seems to have been entirely in the gall-bladder, which was not true in the case I have reported. This is the second or third case that I have operated upon with this history.

Dr. A. M. Cartledge: There is no doubt that a great number of cases treated as violent indigestion are cases of calculous trouble in the gall-bladder with occlusion, giving rise to pain without jaundice, passing off in a few days, either as I formerly thought by the stones shifting back from the cystic duct into the gall-bladder, allowing the bile to flow freely, or what probably now appears more rational, a subsidence of the catarrhal thickening of the cystic duct.

Of

In regard to the diagnosis of these cases, usually it is not difficult. course when a tumor is present we are placed at a great advantage, but as far back as 1896 I advocated that we ought not to rely upon the presence of a tumor in cases of gall-bladder trouble. It seems almost impossible to get the question of jaundice disassociated from gall-stones in the professional mind. They look upon jaundice as being necessary to establish the diagnosis of gall-stones, and it seems impossible to correct this impression. It is not advisable to wait for a tumor, although

undoubtedly it should be sought for. With a history of recurring pain in this region, a history that pain is sometimes relieved in a few hours, I always ask these women, for such cases occur principally in women, "Do you ever feel a lump when you have this pain?" Frequently they will say yes, although we may be unable to feel it at the time. I have operated upon a number of cases where there was no tumor, no jaundice, and felt sure of the diagnosis of calculous trouble in the gall-bladder from the symptoms. In some of them I had a guide in the fact that the attending physician had found a tumor during a paroxysm of pain; when the cystic duct was occluded the gall-bladder became distended and the tumor became manifest; after the paroxysm of pain was over the tumor subsided. In many of the cases there was no history of a tumor.

One of my first gall-bladder cases operated upon was a woman who had been treated for four and a half months in bed for dyspepsia of the chronic type. During this time she had been kept upon a milk diet. I made an exploratory incision in the median line to determine the nature of her trouble. The gall-bladder contained seventy calculi. I believed that these stones would get down into the duct and probably one pass now and then, which gave rise to the paroxysms of pain from which she suffered. There was never any history of jaundice. She was entirely cured by the operation. We should not wait for a tumor to make its appearance, nor should we wait for the development of jaundice, but operation is indicated where the symptoms are pain recurring at intervals with a more or less constant tenderness in the region of the gall-bladder itself. I think this represents the advanced idea of gall-bladder surgery. The longer I continue in practice the less faith I have in indigestion that gives rise to violent acute pain in an area of three or four inches in diameter in the right side of the abdomen, the so-called colic.

Dr. W. O. Roberts: I agree with Drs. Cartledge and Dugan that we must not depend upon jaundice in