Pain: All the cases complained of more or less constant itching in the early stages. Aside from the pain on urinating, it was not especially characteristic and did not cause severe suffering. There was an occasional darting pain in the region of the growth, and some slight pain in the groin, radiating down the legs. These pains were always a late symptom, appearing only after the growth had existed many months.

Urinary Symptoms: In two cases these were caused solely by the disease occluding the urethral orifice by extension. After the canal had become obstructed, the urine would always find its way through one or more usually several fistulous openings on the floor of the urethra. The entire glans was in

small stream, and at other times several. One case had incontinence from over-distention of the bladder. In other case the urinary symptoms preceded the urethral obstruction, which was not marked-in fact, this was the only case where it was possible to pass an instru. ment into the bladder. A number 14 F. sound was passed with considerable difficulty at the time of operation. This, however, was followed by considerable bleeding. The urinary difficulties in this case continually grew worse after the operation, and on cystoscopy, three months after, the bladder was found to be involved. The patient refused another operation for his relief, and died four months later from exhaustion. This case undoubtedly had a cancer of the bladder at the time his

a unilateral involvement of the inguinal glands in all cases, but whether or not this was due to cancerous or pyogenic infection I am unable to say, as no microscopic examination was made. Neither am I able to state at what time the glands became involved, as all the were seen late excepting one, which was seen very early, when cancer was not suspected. This case soon passed from my observation and was. not seen again until late, when the whole penis and part of the scrotum were involved. The prepubic glands were infected and suppurating in one case. The distribution of the lymphatics of the penis is very important when we come to consider the progno

However, I know of no way of diagnosing infection of the lymphatics and glands ante-mortem.

Lymphatics of penis: These may be divided into three groups: 1. Those of the skin proper. 2. Glans. 3. Ure

thra.

(1) Those of the skin originate around the region of the median raphe and turn around the sides to the dorsum, running backward to the angle of the penis, where they turn outward and empty into the nearest superficial inguinal gland. Those originating in the prepuce run directly backward along the side of the superficial dorsal vessels; thus, amputation of the penis by leaving a dorsal flap should be abandoned, as lymphatic tissue is included in the flap unless the lymphatics have been removed.

(2) The collecting trunks from the glans run first to the frenum and then join trunks from the urethral mucous membrane, and are then reflected backward in the coronal fold until they meet in the center. From here they form trunks which accompany the deep dorsal vessels. Arriving at the symphy

sis, they intercommunicate freely, forming some glandular nodules. Several trunks are formed from these nodules, which run out beneath the fascia of the thigh and terminate in the deep inguinal glands. Other trunks from these glandular nodules pass up through the inguinal canal behind the cord and terminate in the external retrocrural gland.

(3) Those of the urethra are not important channels of infection in early cancer of the penile portion of the penis. It is only when the bulbar urethra is primarly affected, or when disease of the penile portion is extensive

especially after blocking of the above mentioned collective trunk-that metastasis may take place. The collecting trunks that arise from the mucous membrane in front of the navicular fossa join those from the glans and terminate in the same lymphatic gland. Those originating just back of the fossa pass posteriorly with the trunks from the ejaculatory ducts, seminal vesicles and vas deferens.

The bulbar and membranous portions. of the urethra have three collecting trunks: 1. One following the external pubic artery and artery of the bulb, terminating in the intrapelvic gland. 2. Running under the symphysis and ending in the external retrocrural gland. 3. Running upward over the anterior surface of the bladder, joining a trunk from its surface, and finally terminating in the internal iliac chain.

Evidence of internal metastasis: In one case there was considerable doubt as to whether an operation was indicated. This patient was very cachectic; had marked edema of the legs, anasarca, nausea and vomiting, all of which, however, subsided after the operation. This patient was given the cancerous extract. It may have been a coincidence, but this patient certainly did gain very fast after injecting the cancer residue; before its administration the gain was very slow.

Recurrence: One case died seven months after operation from cancer of the bladder. It is very probable that this condition existed at the time of operation.

Still Living Without Recurrence: One, 11 years; one, 16 months.

Diagnosis of Cancer is only difficult in the early stages of the growth. The existence of chronic or often recurring fissure, thickened scaly patches, warty growths and vegetations, particularly in elderly men with a phymotic foreskin, and more especially if these apparently simple lesions are rebellious to ordinary treatment, may give a clue to its nature. In the late stage when syphilis is suspected, iodides and mercury will soon clear up the diagnosis, but it must be remembered that failure in any suspected case must not be determined absolutely until treatment has been tried in all its various forms and pushed to the point of tolerance on the part of the patient. Sections of the growth should be examined as early as possible and will clear up all doubt.

Prognosis: Without operation this is, of course, bad. If operated on early before there is much glandular involvement, it is generally considered that if the patient lives three years without a recurrence it is safe to consider him cured. However, recurrence has occurred after a lapse of 15 years. The same prognosis should be given here as in other parts of the body. No case should be considered cured unless proven by autopsy. It should be remembered that in young, emotional individuals whose mental stability is insecure, total amputation with emasculation may be followed by profound melancholia, but fortunately this disease is seen at a time of life where sexual matters are in abeyance.

The object of all modern operations for the removal of cancer, wherever occurring, is not only to remove the primary growth en masse, but the removal of all fat, glands, and lymphatic

vessels intervening between the primary growth and the area of probable secondary extension. Cancer practically always originates on the surface of the glans or prepuce, and more frequently in the sulcus of the corona near the frenum. Cancer of the penis extends along the dorsal lymphatic channels on either side of the dorsal vessels, and affects the superficial and deep inguinal glands of the groins. It is only late in the disease, after the corpora cavernosa and corpus spongiosum have. become involved, that the intrapelvic glands are affected through the lymphatics which pass under the pubic arch.

Operation: When the disease is confined to the distal end of the penis, the parts likely to be infected lie along the dorsum of the penis and either inguinal region, but if the bulb or membranous urethra is affected, the intapelvic gland may be involved, and complete removal of the penis is necessary. Even then, the prognosis is not so good.

The first step in the operation is the complete covering up of the cancerous

mass.

After thorough washing and drying, a piece of dry, sterile gauze is wrapped around the penis, including the cancerous tissue, and this is covered by gutta percha tissue and tied tightly behind, so that no fluid can be squeezed backward. A good, stout condom ans. wers this purpose admirably. Skin incisions are made as follows:

From opposite the internal ring, along the track of the cord, bending slightly inward to reach the middle line at the angle of the penis; from this point outward and downward across Scrapa's triangle, the skin is reflected well back; all arteries are ligatured as they are met with, and removed with the glands. There is no danger at this stage of wounding the large vessels of the thigh, which lie deeper, but as the saphenous opening is approached more care must be exercised. Here the deep fascia should be opened and the fat and

glands removed. The inguinal canal should be opened freely. The retrocrural glands will almost always be found enlarged and hard, and are easily removed. The peritoneum is pushed upward and all glands and fat removed, whether enlarged or not. The spermatic cord is ligatured high up, cut, and removed from above, downward, and the whole mass of glands, fat, and fascia, and all vessels removed from the canal. Hemorrhage having been arrested, the cut ends of Poupart's ligament are adjusted by sutures and the skin sewn into place. A similar dissection is done on the opposite side.

The patient is now placed in the perineal lithotomy position. On account of the extensive involvement of the scrotum in all these cases, two lateral incisions are made on the side of the scrotum at its junction to the perineum, leaving enough skin on each side to cover the perineum. After removing testes, these two lateral incisions are joined by a circular incision just be hind the scrotum. By blunt dissection, the corpus spongiosum is freed from its attachment to the cavernous bodies. The urethra is now freed as far back as the triangular ligament, cut across and placed to one side until the succeeding steps of the operation are completed from above. The skin flap is pushed back toward the pubis, the suspensory ligament divided, and the cavernous bodies separated from their at tachments to the ramus of the pubis until only the crura remain. Owing to the close attachment of the crura to the bones, its separation is a matter of considerable difficulty, and may be followed by a free hemorrhage which is

not easy to control, especially if the periosteal elevator is used. However, this procedure may be rendered bloodless by employing the angiotribe advised by Downes. I employed the Paquelin cautery in one case to burn through the crura close to the attachment to the bone. By this method the corpora cavernosa were readily freed from the pubis without hemorrhage, but the operation was followed by a troublesome slough. All bleeding being controlled, the detached penis, with the mass of fat and glands removed from the groin, together with the testes and scrotum, are removed en masse. The skin wound is closed with silkwormgut sutures, the urethra split in the median line for one-half inch and fastened in the lower part of the wound in the median line, about one inch in front of the rectum.

There is considerable shock after this prolonged and extensive operation, but by keeping the bleeding well under control, even old, debilitated patients are not beyond hope of a cure.

Drainage is necessary, as the free removal of so much tissue is followed by an excessive secretion of lymph that has a tendency to distend the wound.

When the patient is placed in bed his knees should be slightly flexed; otherwise the skin wound in the groins will have a tendency to bridge, whereas it is necessary to keep it in contact with the deep tissues. This may be easily done with a pillow under each knee, and the free use of dressings secured by a double spica bandage.

A soft rubber catheter may be fixed in the urethra, or regular catheterization may be carried out for a few days.

EMBARRASSING.

Little Mary: "Mother, when I die will I go to heaven?"

Mother: "I think so; you've 'most always been a good little girl." Little Mary: "And you, you go too?"

mamma,

will

Mother: "I hope so." Little Mary (fervently): "Oh, I do, too; for it would be terribly awkward to be pointed out in heaven as the little girl whose mamma was in hell!"-(Harper's Magazine, July, 1912.)

Leonard W. Bason, who wrote the section on General Surgical Prognosis, in the last large System of Surgery published says: "The disastrous effects of surgical operations upon diabetics have led some to the absolute proscription of all operation in the presence of this disease." He further says: "Nor do recorded observations throw any light as to the liability to post-operative accidents of diabetics whose diabetes comes as the concluding member of the 'biliary sequence,' as compared with those whose diabetes has had no antecedent cholelithiasis, biliary stasis, and chronic pancreatitis. Both of these points, however, merit consideration."

William J. Mayo, in an article on "Pancreatitis Resulting from Gall Stone Disease," makes the point that in 2200 operations on the gall bladder and biliary passages the pancreas was coincidently affected in 6%. In 81% of the pancreas cases the disease was due to or accompanied by gall stones. In the common and hepatic duct cases the pancreas showed disease in 18%. against 4% where the gall bladder only was involved.

Reginald H. Fitz says: "The pres ence of glycosuria should arouse the suspicion that the pancreas may be diseased."

Opie believes: "1. That in considerably more than half of all cases diabetes is the result of a destructive lesion of the pancreas. 2. Where diabetes is the result of pancreatic disease, injury to the islands of Langerhans is respon sible for the disturbance of carbohydrate metabolism, since that influence which the normal pancreas exerts upon the assimilation of sugar is a function of these structures. 3. The most com

mon lesions which injure the islands of Langerhans are chronic interstitial inflammation of the interacinar type and hyaline degeneration. 4. Other lesions of the pancreas do not exhibit a tendency to select the islands of Langerhans, but produce diabetes because they destroy the interacinar islands along with the secreting parenchyma."

Robson refers to four cases of cholelithiasis that were accompanied by glycosuria, in three of which operation was followed by disappearance of sugar from the urine.

With reports of this kind it is diffi cult to understand statements like the first one in this article, yet it is true that many medical men' do coincide with that opinion.

The presence of gall stones is an indication for operation, and if sugar is present in the urine the necessity for operation is greater than if the urine is negative to sugar.

The danger of delay in any gall stone case is sufficiently great when one considers cholecystitis, the formation of diverticula, perforation, cancer and other complications, but with the presence of sugar one is warned that another very important organ is already involved and delay may result in irreparable damage to the pancreas.

Nature does not require us to be very keen. She gives us ample time to make a diagnosis. In animal experimentation it has been shown that if one-fourth or one-fifth of the pancreas is left, carbohydrate metabolism is not materially disturbed. It seems as though one should be able to determine the presence of chronic pancreatitis before three-fourths of the gland is destroyed.

Nature has again been kind to us in that the usual pancreatitis (the inter