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REPORTS ON PROGRESS way much should be done in a preventive Comprising the Regular Contributions of the Fortnightly De.

way. The etiology of carcinoma, is still as partment Staff.

unknown today, as it has ever been. The

possible parasitic origin of carcinoma is not SURGERY.

tenable aocording to Senn. He has inocu

lated bimself with caroinoma witb the same JOHN MCHALE DEAN, M. D.

negative results that many have had previ

ously. Autoinoculation has shown negative The Surgical Treatment of Cancer of the results as well. It is essentially a local disStomach.-Wm. J. Mayo (Jour. A. M. A.) ease of embryonio or postnatal epithelial grapbically describes the treatment of cancer causation. Heredity influence has been of stomach. The author begins his article found in statistics to the extent of 12 to 33% with truthful and bold statement that no au. till predisposition or aptitude for carcinoma thentic case of cancer of the stomach was ever may be transmitted from generation to gen. cured by medicine. Would that this state. eration as well as congenital deformities and ment will open the eyes of the practitioners physionomies have. It is most prevalent in to tbis conclusive fact, and oonvince them the aged, although the author has seen carcin. that cancer of the stomach is no medioal dis- oma of the breast in a girl of 21 years and ease, but a strictly surgical one. The results rectal caroinoma in a girl of 17 years. The of the author's cases show a low mortality reviewer has seen a case of carcinoma of the of 5%. When we understand that cancer of stomach in a girl of 23 years. Carcinomas stomach means inevitable death, why not grow more rapidly in the young than in the give tbe unfortunate patient a chance for life old. When it occurs in the youth the case by opreation? The article is illustrated by more malignant than when it occurs in the artistic, clear drawings that are so instruoting aged. Racial and social influences seem to that the valuable text is well understood. play some important role in its oocurrence. The patient operated on is given one-sixth of The yellow and black races as well as the a grain of morphia hypodermically one-half North American Indians seem little or not hour before the other anesthesia is begun. all affected with caroinoma. Habits, customs An incision is made in the median line be- aud manner of living predispose the more tween the urbilious and ensiform cartilage civilized nations to it. Strenuous life, worry small at first for exploratory purposes. If and discontent often proedispose some to it. the case on account of extensive involvement Climate and topography bave their peculiari. is found inoperable the incision is closed, ties about its prevalence. Rare in the ex. if not the incision is enlarged and the opera. treme North and South; rare in Central tion of resection begun. The stomach is Africa, South Sea islands, and Central Amer. diawn downwards and lesser curvature im. ioa, and almost unknown in New Guinea; mobilized, while the liver by an assistant is most frequent in temperate zones of Asia elevated. The coronary artery at suitable Europe and America. Alluvial soil favors point is doubly ligated, as well as the gastro. it, chalky or lime soils exercise an opposite epiploio dextra, gastroduodenal arteries. The influence. The reviewer offers a query at gastrobepatic and gastrocolic omentum is li. this junoture that probably these localities gated and incised. Clamps are applied to wbere it is not prevalent it is not seen or rocthe duodenuin and stomach, and the portion ognized. If it is uncommon among the igis removed. The gastric stump is closed with norant races could it not be possible that it through and through catgut using the C, H. has been less recognized and studied thera? Mayo stitch while the outer coat is sutured Meat diet some claim as favoring its developwith linen. The duodenal stump is either ment, but the author states it is very rare in closed and on independent gastrojejunostony the Arctics where the native live exclusively performed, or if long enough is anastomosed on a meat diet. The author offers a possible with the stomach according to Kocber meth. explanation for its rurity here on account of od. Saline solution, according to the Mur. iodin contained in the food obtained from phy method, is used per rectum, and one to the sea animals. Habits of life is thought to one-balf ounce of hot water allowed by stom. predispose to it as we often blame the clayach every hour after the sixteenth.

pipe for sublabial carcinoma, yet in Turkey,

Palestine, Algeria and Morocco, where to. A Plea for the International Study of Car- bacco is extensively used by the natives carcinoma.-Nicholas Senn (Jour. A. M. A.) in cinoma of the lip or mouth is of rare occur. a paper read before the International Medi. rence. cal Congress at Lisbon makes a plea for the That constant irritation produced by to. international study of carcinoma. He avers banco to the mucous membrane of mouth that while much has been done in a curative and tongue may predispose to is plausible. Trauma evidently plays an important part, Additional Observations on the Use of the and so important that it is often overlooked. Roentgen Rays in Dermatology.-Stelwagon Still trauma favors more the develoument of (Jour. Cut. Dis., March, 1906) gives an in. sarcoma than carcinoma. Often as the au. teresting and instructive résumé of his broad thor states the trauma merely calls the pby. experience with the X-ray, during the last sician's attention to its presence. Prolonged three years, in the article referred to. His con. irritation from ocoupations, babits, malposi. clusions are, 1st, that a coil is more convenient tions, diseases of teeth and displaced organs and less liable to get out of order than a form some factors in its development. statio machine, but is more dangerous in the Chronic inflammations or ulcerations have hands of the inexperienced, “or the experibeen repeatedly shown to antidate its occur. enced either." 2d. That the vacuum of the rence. This has been so often demonstrated tube should rarely exceed at the most, that in regard to ulcer of the stomach developing equivalent to a three-inch spark, and between malignancy or of an ovarian tumor becom. one and two is best. 3d. He advises changing carcinomatous. Warts, "verruca senilis" ing the vacuum during a treatment, that is, have been shown to be the starting point of he begins an exposure at a vacuum equal to epitheliomas. Soar tissue and benign tumors about a one or two inch spark, and then dis. also favor its development. The author con. connects the regulator, and allows the vacuum cludes with a strong plea for the study of to slowly rise during the exposure. He bethe cause of cancer. He urges the various lieves that the disease, in its varying depth, international scientists to work unitedly in can be better influenced in this manner. this direction, and to wander from the labor. This applies more especially in the treatment atory to study the etiology as well as the of epithelioma, and in other growtbs of some pbases of the disease from the facts he has depth or thickness. 4th. In the majority enunciated in his paper.

of cases, no improvement occurs until X-ray dermatitis (erythema, etc). has been exuited. Excepting epithelioma and similar diseases,

however, it should not be purposely allowed DERMATOLOGY.

to go beyond tbe slightest possible erythema. ROBERT H. DAVIS, M. D.

(By following this procedure, he occasionally

causes a second degree burn, but finds the A Note on the Treatment of Simple Warts discomfort and disfigurement only tempor. by Internal Remedies.-Hall (British Jour ary as a rule). Exceptionally, atrophic nal of Dermatology, March, 1906) reports an changes, such as thinning and wrinkling of interesting case of multiple warts oured by the skin, atrophic lines, and spots follow active daily purgation extending over two careful, and even Dioderate use of the ray. montbs and a half. This treatment has been This he has observed in a few cases of acne brought forward before, some ascribing its treated, and in only one was it at all marked, virtues to epsodi salts alone, but, in this case, and, in that case, the changes are slowly besulphate of magnesium failed to properly coming less marked. These changes did not move the bowels, and had no effect on the develop until several months after the last warts. Aloin and nux vom., in pill form, cycle of exposures. 5th. As to time of exgave the necessary relief, and the warts dis posure, and distance of the tube, he recomappeared in two months and a balf. They mends, in tbe first several seances, except in had been present for some years, and were the case of epithelioma and other malignant very numerous, 367 being on one band and dermatoses, a distance of ten inches from the wrist only. (J. B. Cooper, in British Med. tube, and an exposure of three minutes. In Jour., August 26, 1905, reports cures of mul. epithelioma the duration of first exposures tiple warts by lime water taken internally. can be five minutes. In the milder dermaHe made the observation accidentally, on toses, six to eight inches in point of distance, himself, while taking lime water for some and ten minutes exposure should rarely be digestive disturbance for a period of ten days. exceeded, and these limits cautiously reached. At the end of two weeks, a wart on his thumb, In malignant dermatoses the limits can be that had not yielded to local treatment, had more extreme, and much more boldly ap. entirely disappeared. He tested other cases proached, “the tube in obstinate cases almost with marked success. The time taken for the touching the surface, and the duration extotal disappearance of the wart varies from tended to fifteen or twenty minutes or four days to six weeks. He advised the use of longer." (It is almost needless to say that the remedy in wineglassful doses with a little such treatments as these last should be given milk added to be taken after the mid-day only by a skilled operator, that the patient meal.- Per Review in Jour. Cutan. Diseases, should be under constant observation, and Feb., 1906.)

that the cases are desperate that require suoh heroic measures. -Ed.) In changing from following, there was considerable disagree. ope tube to another, in the same case, dura. ment over the statement that in acne an tion should be lessened, and distance length. erythema must be produced in order to acened for the first two or three exposures, as complish a good result. The majority were different tubes may have different degrees of against the production of an erythema. action. 6th. The usual measures for proteot. Duhring had experienced alarming results in ing the patient, and operator should be taken one case of psoriasis, when, without warning, 7th. As regards special diseases (a) epitheli. a violent reaction, with suppuration extend. oma. "The best of all treatment is, first ing down to the subcutaneous oonnective tisenucleation, either by excisión, curette, or Montgomery and Bronson bad had excellent cauterization, as may seem most expedient sue, occurred in the patob under treatment. in the individual case, and the immediate, results in rosacea when the ray was used as supplementary action of the X-rays to tbe an adjunct to the usual constitutional and extent of probably five, or ten, or more, mod. local measures. erate exposures." He thinks this plan would give the most rapid results, give the least Two Cases of Multiple Tumors of the Skin chance of recurrence, and be the least expens in Negroes, Associated with Itching.-Schamsive, in the long run, to the patent. (Of berg and Hirschler (Jour. Cut. Dis., April, these conclusions there appears to be little 1906) report two unique and interesting cases doubt but most patients dread an operation, of a trouble reported in 1880 by Hardaway, and prefer the slower and less certain way.- with no oases reported since until now. The Ed.) (b) lupus vulgaris. The action bere lesions consist of nodules, varying in size is sometimes brilliant, but always slow, and from a pea to a small finger nail. They are cannot be predicted in a given case. (c) situated mostly on the extensor surfaces of Lupus erythematosus. Here it is only occa- the arms, on the dorsal surfaces of the hands sionally satisfactory. (d) Acne. Although and fingers, on the back and the extensor relapses after its use are less common than surfaces of the legs. The soles of the feet with other methods, bis conclusions are that were free in each case, and the palms in one, its use in acne should be extremely cau. the other exbibiting a single nodule on the tious, and that it is probably best reserved thenar eminence. The nodules were for the obstinate and extensive cases. The sharply circumscribed, and showed no best and quiokest results are attainable only tendency to a coalescence. The skin between after the production of a mild erythema, and the lesions was normal in their cases, in the danger of subsequent atrophic changes, Hardaway's, there were thickened, pigmented as already mentioned, should be borne in plaques in the intervening skin. Hardaway's mind. Suob changes may not oocur for case showed also lesions on the palms and several months after exposures bave been dis soles. The nodules are not painful or contined. It is not improbable, also, that a tender, and are firm to the touch, most of downy growth of bair is stimulated at times them distinctly elevated, and covered with a by the ray. So, in the obstinate cases, when somewhat horny epidermis. In each case, the the ray is employed, it should be used cau. nodules developed in the course of a few tiously, and in conjunction with the other weeks, and have never disappeared, remainknown methods of treatment. (e) Psoriasis. ing, in one instance, more than fourteen Bere it should be used only for obstinate cases years. No new ones appeared after the first and large areas. (f) Eczema, only in ob. crop, but some of the early ones grew slowly. stinate, thickened areas, and rebellious, lo. The outbreak is attended by violent itobing calized forms, as, for example, persistent which is with difficulty controlled, and has eozema, of the hands, but here it should be been continuous since the onset, being muoh employed with great caution. (g) In sy worse at sometimes, e.g., the menstrual cosis, be has bad good results, but uses the period, than at others. In Hardaway's case, ray cautiously, and in conjunction with the some of the nodules were confluent, and the ordinary methods of treatment. (h) In ker. trcuble began in the form of "blisters,” atosis of the palms, and localized hyperidro. which were followed by the development of sis be bas obtained good results as have the tumors. In all the cases, the nodules remany others. (i) In ring worm of the scalp, curred after extirpation. Pathologically the results were very favorable, but the pas. there was a dilatation of the cutaneous blood tiles of Sabouraud and Noiré, for measuring vessels; cell infiltration chiefly in sharply the dosage were unreliable. He concludes circumscribed masses; proliferation of the with the advice that in non-malignant der. fixed, connective tissue elements; and the matoses, except in extremely obstinate cases formation of new, collagenous fibres. In the ray should be used more, as an adjunot the larger tumors, there was more pronounced than as the sole remedy. In the discussion vascular dilatation, and an enormous overgrowth of the horny layer of the epidermis. sides of a patch, and then opening tbem bo There were a great number of mast cells as to put the skin on the stretch.” Some. present, but careful searob, in many sections, times, in syphilis, a red, ringed eruption revealed no plasma cells. The cause of this with a desquamating center occurs, but it is very rare disorder is ondetermined, and treat. a rare manifestation, and occurs much later ment is of little avail, the disease lasting than the roseola. Of course, as in several many years with little or no change. In the cases quoted, sypbilis and pityriasis rosea two cases reported, the itobing was confined may coexist. As to treatment, he recomto the tumors, while in Hardaway's case, it mends: The patient should be soaked daily, was general and the pigmented, thickened for half an hour, in a bath to wbich two or plaques, above mentioned, existed.

three teaspoonsful of Condy's fuid bave been

added, after wbich Pityriasis Rosea.-Montgomery (Jour.Cut. B Acidi salioylioi.............3 to 5 Dis., April, 1906) combats the common hypo

Vaseline....................100 thesis that this disease is a cutaneous mani. is applied freely to the skin. festation of a constitutional disturbance. The obief point against a constitutional cause is the "primitive patoh." This appears a considerable time before the generalized

OTOLOGY. eruption, and exactly as if it were tbe seat of

ALBERT F. KOETTER, M. D. first inoculation from which the virus afterwards spread. The primitive patoh is better The After-Treatment of the Radical Operamarked than the lesions of the subsequent tion.-(Compilation of Dr. A. Sontag in In. rush, like the lesion of inoculation in many ternationales Centralblatt fuer Ohrenheil. undoubtedly infectious diseases. Peripberal kunde). —That the after-treatment of the rad. extension with central clearing of the lesions ioal operation is fully as important, and in is also strongly suggestive of parasitism, but many cases more difficult than the operation this alone is not conclusive. The results of itself is a well known fact. To the physician, local treatment also favor the parasitio view, who, without teobnical training and large exfor, while the disease is generally of somewbat perience takes care of the after-treatment the long duration, its course can be materially results will not be flattering. The time for shortened by appropriate external measures. healing, depends on the position and the It is very rare, however, to get an evidence kind of case, varies from four weeks to several even hinting at the transmission of the dis. years. In order to have epidermization of ease from person to person. Constitutional the wound cavity take place as rapidly as disturbance previous to or during the attack, possible different forms of plastic operation on the other hand, is the exception. The and transplantation are executed, these bave differential diagnosis from seborrhea andu. been discussed in a former compilation by lata is made with difficulty: There are the Hoelscher. Since this publication several same light red rings with buff wrinkled cen. new methods of plastic and transplantation ters in both affections. Usually, however, the have been published and these I will now rapid distribution of the rosy rash is suffi- discuss. cient to differentiate the affections. It is Alt reports a modified Koerner's plastic differentiated from measles by the severe con after formation of Koerner's flap, be places, stitutional symptoms, the rash on the face from the upper posterior portion, a broad (an unusual situation for pityriasis rosea), pedunculated flap into the wound cavity to the catarrbal affection of the nose, throat and cover the whole antrum and part of the cupola bronchi, and the absence of the rings with of the cochlea. The loss of substance is sewed the bufi colored, wrinkled center in tbe up after making an incision to relieve tenlatter disease. In German measles, also, there sion. In order tbat no sinus or pocket may is an absence of the peculiar rings. The ocuur between the anterior wound margin greatest liability of error lies in its differen- and the pedunculated flap, a strip 1 mm.wide tiation from the roseola of sypbilis, and espe. excised from the cutis of the pedunculated cially if the patient has at the time a venereal flap corresponding to the anterior wound sore. “The first search should be for the margin and to this place the anterior margin “primitive patoh," and, if that cannot be is sewed. The complete epidermization found, tben a careful examination should be should occur in from seven to eight weeks. made for the small, red rings with the skin, in The same plastic was described by Berens bethe center, buff colored, and wrinkled. The fore the New York Otological Society. wrinkling, otherwise unobservable in the early Delsaux resects the posterior membranous stages, can sometimes be demonstrated by wall of the canal after a horizontal incision placing the thumb and finger on opposite in the median line he separates each flap by two new incisions whioh unite at the extreme sometimes more posterior from the insertion end of the first incision and diverge to the of the auricle. From this skin between the interior. The whole superior and posterior incision and the line of insertion he forms, wall of the membranous canal, including the after the operation, by an incision in the adjoining part of the concha are removed by line of insertion of tbe auriole, one or two Caboche, meaning thereby to simplify the thick flaps which are tam poned tightly to operation and produce a large opening, also the bone and through their bulkiness 611 avoiding the curling up of the flap in the out the cavity. The retro-auricular opening powder treatment which follows.

is allowed to close when the entire cavity Luo modifies Siebermann's Y plastio, by of the antrum is filled with a thick cushion which the crus of the Y in the concha are of solid fibrinous tissue that every cavity with placed in a posterior superior and posterior exception of the exposed tympanic cavity is inferior position in such a way that he exe- obliterated. cutes one incision directly to the back and For epidermis transplantation after the the other to the lower portion. Moreover he radical operation Politzer has for some time does not incise the posterior wall, but the been using glass tubes which terminate at posterior superior wall of the external canal. one end in a perforated bullet. For the He has never observed periohondritis follow. transplantation which should be done in six ing and the wide opening does not disfigure. to twenty days after the operation only such

According to Botey none of the prevailing cases are applicable where plastic faps have methods can with certainty prevent a narrow- healed and the retro-auricular wound has, ing of the canal, Siebermann's plastio which been closed. There must be only slight seis the safest is unsatisfactory from a cosmetic cretion and the walls must be covered with standpoint. He incises from above over the granulation. Several hours before the transwhole length of the membranous canal to plantation the cavity is cleansed with sterile the upper border of the tragus and the root water and 6% 4,02, and then filled with of the helix in the conoba. As the tragus sterile gauze. The Thiersch flaps are then completely covers the large opening, large placed on the glass bullet with the epidermis enough to allow the thumb to enter, the surface to the glass and by means of a bulb cosmetio results is a good one.

and rubber tube are blown on the intended A combined plastio has been used by eurface. The flaps are held in place by small Bruebl in fifty cases with good results. After cotton sterile pads. After four days, when executing a Pance T incision in the mem- the bandage is removed, the flaps will be branous canal wall a short Koerner flap is found healed in situ. formed by two parallel incisions in the

The primary closure of the retro-auricular cavum concha at the upper and lower end of the vertical transverse incision. This flap

wound by means of a suture is done by most

Operators if no complications exist. Heine can, if desired, be enlarged to the cavum conoha. Thus there are three flaps which

treats the wound cavity for two or tbree

weeks through the retro-aurioular opening can be made thinner by removal of epider

and then allows it to gradually close. The mis from their posterior wall, so that they

time for the first change of bandage varies fit snugly to the walls of the cavity. In

according to the after treatment and the plasthe almost constantly used primary suture,

tic. Heath leaves the first dressing one day, the short Koerner flap is seized with a thread

then changes daily. and drawn to the baok until its free margin hugs closely to the bony wall. A disfigure.

Riechel removes first bandage after three ment of the auricle is out of question.

days, and then tries trappslantation with Pagson forms a short Korener Aanag de small flaps. scrbied above, this he fixes posteriorly by Eeman, Moure, Delsaux, Lermoyez and two sutures. Then instead of a T incision Caboche allow first bandage to remain four be splits the external auditory canal posterior days, most authors remove it in from five to inferior entirely, but on the upper margin eight days. Eschweiler after fourteen days. makes only a short incision. In tbis way he Mabu favors chloroform narcosis for the first gets a very movable flap which fits smoothly dressing. How often the dressing above.

afterwards depends on condition and the A diametrically opposite view is taken by amount of secretion from the wound. Often Chevalier Jackson. This author on account times it is necessary to change every day. of an occasionally occurring perichondritis The too frequent change of dressing is depreand an ofttime remaining deformity of the cated by Krebs as the bandages after a radi. external canal opening does not touch either cal operation do not show the ideal of a prohe external canal or the concha. He makes tective treatment of a wound, and the princibe first incision one centimeter wide and ple unanimously advocated by surgeons that

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