triangle, and left them 24 hours. There was considerable inflammatory reaction with fever, abdominal pain and distention; and on the evening afterwards a tempt. of 130. A considerable quantity of morphine was given the next three days, and although his condition was at no time very alarming, there was certainly much more disturbance than had been expected. On the 15th everything had returned to about the same condition as before the insertion of the needles. During the next ten days the abdomen seemed to be growing constantly softer and the tumor to be less prominent, hence it was not punctured until the 25th. A considerable diarrhoea had followed the local peritonitis, and when, therefore, on the 25th the tumor was punctured with a large trocar, and only a very little pus obtained, owing to the constant stoppage of the canula by small plugs, it was thought that the pus of the supposed abscess had been partly inspissated by the diarrhoea, and hence also the apparent diminution in size.

On the 29th, therefore, Dr. Rogers performed laparotomy. The incision was made in the triangle formed by the needles, and at this spot firm adhesion existed between the tumor and the abdominal wall. Incision of the tumor was the occasion of a very great surprise for us all. In brief, a large medullary cancer had been opened, a portion of it having broken down so as to form a large cavity, containing perhaps a quart of grumous masses floating in a small quantity of purulent fluid. The patient died a couple of days afterward, and a post-mortem showed an enormous malignant growth, originating apparently in the left kidney, which was completely degenerated, then extending downward and inwards by a sort of isthmus until in the umbilical region it had again expanded into the tumor above described. The cavity also extended upward to the region of the kidney. One or two other nodules were found in the mesentery and there were old inflammatory processes in the immediate neighborhood of the tumor, but otherwise the find was negative. Microscopical examination showed the growth to be an alveolar carcinoma.

Remarks.-The most interesting and instructive feature of this case is the fact that a medullary cancer of the kidney could appear as a fluctuating tumor of the umbilical region and, even after aspiration, be mistaken for an abscess. For I must admit that in spite of the polymorphous cells and the momentary suspicion of some

cancerous process which they caused, I had pretty firmly settled upon the diagnosis of a localized peritoneal effusion and regarded the case as one of chronic simple peritonitis of traumatic origin. Surely the presence of a round fluctuating tumor which gave a purulent fluid on aspiration was not calculated to afford a very strong basis for the diagnosis of a cancer! It was of course a familiar fact that a medullary carcinoma frequently breaks down in spots, but the idea that this might be so extensive as to actually present all the physical signs of a pus cavity had never occurred to me.

Is there anything further to be learned from this case in addition to the above certainly unusual fact? Did anything point. strongly to cancer of the kidney? Nothing except the polymorphous cells and the possible exclusion of other conditions. As to the former, while they should properly suggest carcinoma, I do not know that one would be justified under any circumstances in diagnosticating carcinoma from individual epithelial cells. They might have originated in the pelvis of the kidney or perhaps in a fecal abscess, though certainly more irregular in outline than the usual epithelial cells in these localities.

A diagnosis by exclusion might perhaps have reached a high degree of probability had the fluctuation been thought of as a possibility in a case of renal cancer. The tumor evidently extended to the region of the left kidney. I have already described the sort of isthmus by which the umbilical expansion of the growth could be traced upward beneath the ribs in the mammary line. The presumption was therefore a strong one that the tumor had developed downward rather than upward since, aside from the indurations of a tuberculosis or cancerous peritonitis, no abnormal growth of the umbilical region is likely to develop upward toward the diaphragm. Any tumor of the left lobe of the liver could be excluded; the liver was otherwise normal, and the tumor was too far to the left. An enlarged spleen is usually suggested by etiological factors, is a more superficial tumor, being usually above and not beneath the colon, and presents a sharp edge in which the notches can often be readily detected. On the other hand any malignant growth of the spleen is an extremely rare condition. Hence the kidney would remain as the most probable origin of any growth like the one under consider

ation which appeared to proceed from the left hypochondrium.

However, with such a tumor one would be obliged to carefully consider the following conditions: simple chronic peritonitis with local suppuration.

This was my diagnosis. But it was made by exclusion and with great reserve. For it is not only an extremely rare condition, but the insignificant fever, the absence of chills, the very incomplete history of any preceding acute stage (a very important element in the diagnosis) made this hypothesis exceedingly difficult to maintain.

Tuberculous peritonitis may be attended by large and irregular abdominal tumors of varying size, produced by exudative and adhesive processes among the intestinal loops, and presenting to the touch an unmistakable resemblance to malignant growths. But there is generally an irregular continued fever, no suppuration, quite marked ascites, frequently tuberculous deposits in the lungs, and the patient is usually young and not particularly cachectic. These cases frequently maintain a remarkable degree of general nutrition even when the abdominal enlargement has existed for a long time. Tuberculosis was easily excluded in our case.

Cancerous peritonitis is usually attended by multiple tumors and ascites with marked cachexia. The absence of ascites and the more local development of the tumor would have excluded cancerous peritonitis as the original disease, even had there been no local fluctuation.

Cancer of the retroperitoneal glands is nearly always secondary. Tuberculosis of these glands is a disease almost exclusively of childhood. The large omentum may be the seat of primary cancer, forming, however, usually a transverse nodular mass which may move with inspiration, and in general presenting a very different picture from the present case. The omentum may also be the seat of a chronic inflammatory process, frequently specific, which is part of a more general chronic peritonitis, and which I mention here because of the fact that clinically such an omentum may closely simulate a malignant growth. I was once led to make this diagnosis in an individual whom I knew to be syphilitic, where I found a very prominent nodular tumor extending across the lower part of the epigastrium. I tried in vain to work out some plausible association between this

and the man's syphilis, but could think of none, and finally settled upon a malignant growth. Here again my disregard of the law of probabilities was avenged, for the post-mortem disclosed a chronic inflammatory process of the omentum, undoubtedly specific, which had transformed it into a dense, retracted nodular mass of indurated tissue.

Returning briefly to our case, and having reasonably excluded all tumors except those of the kidney, the diagnosis should not have been difficult even in the presence of fluctuation. It would be between hydronephrosis, perinephritic abscess and malignant growth. Hydronephrosis does not to my knowledge advance toward the umbilicus. The tumor is, usually at least, found more in the iliac and lumbar regions. Granting that it were large enough to invade a considerable part of the abdominal cavity, its contour would be more symmetrical; the formation of what I have described as the isthmus. of the tumor would be inexplicable.

The same would be true of perinephritis. This diagnosis was made by one gentleman who saw the case, but in my experience a large perinephritic abscess either simply bulges more or less symmetrically into the abdominal cavity, or burrows down along the quadratus muscle and points far around on the side. On the hypothesis of a perinephritic abscess I could neither explain the isthmus nor the apparent pointing at the umbilicus. On the other hand, the hypothesis of a primary cancer of the kidney which had secondarily affected the retroperitoneal glands, would at least have explained the peculiar form taken by the growth in its development.

It may be questioned whether such a post mortem discussion of a case is of any use. It will be rightly affirmed that no two cases are alike, but surely there are certain general facts in the diagnosis of abdominal tumors which bear upon every case and in so difficult a field reiteration is perhaps not wholly inexcusable. To me, my mistaken diagnoses have usually proved the most instructive.

SHEER PRESSURE WITH THE HOT SNARE.

BY DAVID H. LUDLOW, M. D.,

Assistant to the chair of Laryngology, Gross Medical College, Denver, Colorado. Although snaring with the hot wire has been more or less in vogue for a long time, the principle of using the hot snare with sheer pressure does not seem to have been recognized as feasible, or, if so, it has not received the attention it merits.

If a loop of steel wire be adjusted to the canula of a suitable electro-cautery handle and kept heated to a bright cherry color, it may, by a steady gentle pressure, be buried quite rapidly into any of the soft tissues to any reasonable depth that may be indicated. The wire burns its way bloodlessly through the tissue, and after its distal portion has reached the required depth the incision may be carried toward the operator by simply varying the direction of the pressure, the tissue to be removed being thus engaged within the loop. The removal may be completed either by a continuation of the process described or, with a tensional strain, by drawing in the loop as in the usually practiced method of snaring.

This method of using the hot snare offers a ready means of removing flat sessile growths and even depressed areas of diseased tissue, and of taking away pedunculated and lobulated tumors without. leaving a stump. The writer has found it especially satisfactory for the removal of hypertrophied lingual tonsils, which so often proves tedious when the usual means are resorted to. It is also applicable with advantage to many cases of pharyngeal adenoids, to some cases of hypertrophy of the faucial tonsils, to nearly all cases of nasal polypi, and to many other conditions which will suggest themselves to the operator. The writer has so far used this method of hot snaring only in the nose and throat, but it may possibly prove of service in other departments. It has one objection which need only be mentioned to be avoided, and that is the temptation it presents to the removal of too much tissue at one sitting, with the consequent production of objectionable secondary inflammation.

Platinum wire is too pliable for use in this way. The slightest sheer pressure will bend it, but steel wire, even though heated to a yellow, offers sufficient resistance, and may be used several times, if