tally substandard, accurate results could not be obtained. The eyeball was displaced outward about three-quarters of an inch, and downward about one-half of an inch. A distinct tumor could be felt deep in the orbit which appeared to communicate with a nodule about the size of a marble situated upon the brow just above the supraorbital notch.

After consulting with Doctor Canfield to exclude the accessory sinuses as a possible origin of the tumor, it was decided to remove the nodule from the brow and determine the nature of the growth. While the patient was under the anesthetic, deep palpation revealed the fact that the orbital tumor was movable.

The report from the Pathologic Laboratory on the nodule removed from the brow was fibroma, possible neurofibroma.

The diagnostic points were as follows:

(1) A nonmalignant growth, as revealed by the history and pathologic report.

(2) The displacement of the globe outward and downward indicating that the tumor was situated outside and above the muscle cone. (3) It was movable.

An osteoplastic flap was made after the method of Krönlein. A curved incision was made beginning over the temple extending along the outer margin of the orbit, dividing the periosteum, then backward along the upper edge of the zygomatic arch.

The periosteum lining the inner side of the outer wall of the orbit was retracted together with the orbital contents. The lateral wall of the orbit was cut through with a chisel in two places. Above in the suture between the great wing of the sphenoid and the malar bone and below in a horizontal plane passing outward in a line directly above the insertion of the zygomatic arch. This piece of bone with its muscle and cutaneous attachments was forced backward giving free access to the orbit. The periosteum was divided in a horizontal direction and the tumor dissected out. After removal of the tumor the periosteum was sutured with catgut, the bone and soft parts replaced and the latter sutured with silk, and dressings applied.

Union was perfect and recovery uninterrupted. The excursion of the eyeball is perfect and the vision the same as before the operation. The tumor measures thirty-five by twenty-five by nine millimeters and apparently has its origin in the frontal branch of the fifth nerve. It will be sent to the Pathologic Laboratory for examination and a detailed report will be given later.

DISCUSSION.

DOCTOR R. BISHOP CANFIELD: There is great difficulty in the diagnosis in such a condition. The first Krönlein I saw was by Krönlein himself. He found nothing but congestion. The case turned out to be polyp of the sphenoid, causing the congestion and so the ptosis. Another point to be observed, is that in almost all cases where the condition is caused by disease in the accessory sinuses. there

is an inflammatory reaction. There was no evidence of inflammation. in this case and the accessory sinuses showed no evidence of disease. DOCTOR REUBEN PETERSON: I would like to ask why there is no pain from so distinct an involvement of the supraorbital nerve.

DOCTOR SOLIS: We usually find excessive pain associated with such a growth. This is probably due to the pressure of the growth on the surrounding tissues.

DOCTOR PARKER: There is rarely or never pain in multiple fibromata. They are in fact fibromata arising from the fibrous sheath of the nerve, and not true neuromata.

NEPHRECTOMY FOR HYDRONEPHROSIS DUE TO RENAL CALCULI.

DOCTOR REUBEN PETERSON: I have an interesting specimen to present, a case of stone in the kidney, giving rise to hydronephrosis of marked size. The kidney tissue has almost disappeared, the pockets or loculi being of immense size when filled. An interesting point is that this long, peculiarly-shaped calculus blocked up the ureter completely so that there was absolutely no communication between the pelvis of the kidney and the ureter. I also call your attention to a stone lying in another pouch. This specimen was removed from a woman of forty-seven, whose previous history had been in every way normal, except that for the last ten years she had noticed in the right side, especially in the flank, occasional pains, but never to a marked degree. She had complained that when in bed there was a sense of discomfort at this point.

Two months ago she noticed a tumor just under the right ribs, which has grown rapidly since that time. I saw the patient a week ago. At that time there was a tumor which did not distend the flank to any great degree. It went beyond the median line and downward to the anterior superior spine. The circumstances were such that I could not make an examination of the ureters. The patient was extremely fleshy so that I could not determine with any degree of certainty whether the growth was cystic or solid. The intestines covered the growth, so we were dealing evidently with a retroperitoneal growth in the neighborhood of the kidney or with a cystic kidney. My diagnosis was probable cystic kidney, possibly a retroperitoneal growth in connection with the kidney.

Then came the question of the operative route. It reached so far over in the median line that it seemed to me better to get at it by the transperitoneal route. An incision was made from the edge of the ribs downward at the outer edge of the rectus. The incision through the peritoneum was made well outside. There was great difficulty in enucleating on account of the adhesions, which shows the advisability, in these large growths with adhesions, of adopting this route in preference to the extraperitoneal route. I think it would have been more difficult by the other operation. I drained posteriorly and also anteriorly, and sutured up the peritoneum.

The woman has done very well since the operation. The gallbladder was filled with calculi-there must have been twenty or more. I decided that inasmuch as the patient had never given any symptoms, we would leave them alone, as her condition at the completion of the rather long operation was none of the best.

DISCUSSION.

DOCTOR CYRENUS DARLING: I think that everyone who removes a kidney and the patient recovers, thinks that is the easiest way.

DOCTOR CHARLES B. G. DE NAN CREDE: I think when the absence of pus can be determined, the transperitoneal route is preferable. If one has to deal with a large tumor, by making a straight transverse incision, going, if necessary, past the median line, gives greater ease in reaching the pedicle. One can see what he has, and can control the hemorrhage more easily. Still, experience has shown that through the posterior route we can take out the large adherent tumors piecemeal without having much additional hemorrhage.

READING OF PAPERS.

"SOME CARDIAC ARHYTHMIAS.”

DOCTOR LAWRENCE C. GROSH, of Toledo, Ohio, read a paper on this subject. (See next issue of The Physician and Surgeon.)

ORIGINAL ABSTRACTS.

SURGERY.

FRANK BANGHART WALKER, PH. B., M. D.

PROFESSOR of surgERY AND Operative SURGERY IN THE Detroit posTGRADUATE SCHOOL OF MEDICINE; ADJUNCT PRofessor of operative SURGERY IN THE DETroit college of mediCINE.

AND

CYRENUS GARRITT DARLING, M. D.

CLINICAL PROFESSOR of SURGERY IN THE UNIVERSITY OF MICHIGAN.

EXOPHTHALMIC GOITRE.

THERE were three papers read before the Section on Surgery and Anatomy of the American Medical Association, at its last meeting, on "Exophthalmic Goitre," that clearly express (Journal of the American Medical Association, September 1, 1906) the present idea of the profession concerning this disease and the newer methods of its treatment.

The first article, by John Rogers, M. D., of New York, is on the treatment of thyroidism by a specific serum. He would discard the term exophthalmic goitre and designate the condition by the word thyroidism, modifying it by such variations as hyper, atypical, chronic toxic, acute toxic, and psychopathic or neuropathic. The symptoms which characterize each classification are carefully noted, an arrangement necessary

in order that individual cases may receive treatment indicated for the particular case. In certain cases he has employed a serum of his own with favorable results. It is obtained from the blood of animals (rabbits, dogs, and sheep) inoculated with nucleoproteids and thyroglobulin from the human thyroid gland. When injected into the patient this is supposed to have a specific effect on thyroidal epithelium. The best results are obtained where one cubic centimeter of the serum is injected every third or fourth day until from four to eight injections have been administered. Reaction is noticed by a burning sensation at the point of injection, followed in a few hours by swelling and redness, later by fever, with rapid pulse. He reports ninety cases treated; twentythree cured, fifty-two improvements, eleven failures, and four deaths.

Improvement is indicated by changes in the size and character of the thyroid. Large soft glands become smaller and harder, while a hard gland will become softer. Chronic cases past middle life, with hard glands, when not benefited by a month's treatment may consult a surgeon.

The second article, by S. P. Beebe, M. D., Ph. D., of New York, deals with the preparation of the serum mentioned in the previous paper. The first products were made from normal human thyroid glands obtained at autopsy. These contain a very small amount of nuclear material and a relatively large amount of colloid. The method of preparation is given in detail but is too extensive to be repeated here. The material thus prepared from the glands is injected into the peritoneal cavity of dogs, sheep, and Belgian hares. Rabbits are given five injections six to eight days apart and eight days after the last injection. the animal is exsanguinated.

Other preparations were made with pathologic human glands removed at operation and from these he obtained the most active serum. No marked clinical difference was found in the results whichever serum was employed, except that where the normal ceased to do good the serum prepared from pathologic glands would show marked results when employed in its stead. The degree of actvity differs according to the animal used in producing the serum.

The title of the third paper is "The Surgical Treatment of Exophthalmic Goitre," by Francis J. Shephard, M. D., of Montreal. Operative treatment, while comparatively new, is not yet conceded by all as the best means for relief though many cases of complete cure have been recorded. Operation is based on the opinion that the disease is due to increase of thyroid tissue, hyperactivity or hypersecretion. Early operation is advised when the condition is not too severe, also in cases where the enlargement is greater on one side, not excessively vascular, and where symptoms of Graves' disease have preceded by months the tumor formation.

Operation should be avoided in large vascular thyroids with definite febrile exacerbations and excessive tachycardia, with acute dilatation of

the heart, precordial distress, gastric and abdominal pain, vomiting and diarrhea, sleeplessness, perspiration, sense of suffocation, great restlessness, edema of the feet-in fact all the symtoms of toxemia due to thyroidism. Most physicians are opposed to operative measures and nearly all recent medical writers on exophthalmic goitre condemn surgical procedures as being too dangerous and not always successful.

Statistics are of little value in estimating the mortality from operations as much depends upon the case in question. General anesthesia is looked upon by some as greatly increasing the danger. Collected cases by most experienced operators give a mortality of six to eight per cent,

In discussing these papers Doctor Ochsner, of Chicago, said that there were four distinct dangers connected with anesthesia for the operation. Unless anesthetized with great care patients may be so thoroughly asleep that it will be difficult or impossible to arouse them. There is danger of producing a toxemia by violently handling the gland while the patient is asleep, as well as of injuring the recurrent laryngeal nerve. There is also danger of infecting the wound through the patient's breath. Doctor Bacon believes that the line of progress in the surgical treatment of exophthalmic goitre will lie in a more careful analysis of the cases. Doctor Dawbarn advocated the ligation of the superior and inferior thyroid arteries on both sides as a safe operation, devoid of mortality, with no resulting deformity or mutilation. They all spoke favorably of the serum although they believed it to be in the experimental stage and advised operation in selected cases where the serum failed.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.

C. G. D.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D.

FORMERLY FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

ARTIFICIAL RENAL COLIC AS A VALUABLE MEANS OF

DIAGNOSIS.

HUTCHINGS (American Journal of Obstetrics, Volume LIV, Number III) continues Kelly's observations on the production of artificial renal colic, published first in May, 1899. One hundred cases in all were studied, being selected from one hundred fifty examinations made in Kelly's clinic. These examinations were made with a view to locate the cause of various pains in the abdomen and back when they could not be explained by ordinary methods of diagnosis. Aside from pains with definite locations are those of an indefinite character located in various regions of the body and not diagnostic of any one lesion. These pains may be met with under a variety of pathologic conditions