that there is a wrist drop with a contracture, or a foot drop with a contracture, or a pronounced foot clonus or a pronounced hand clonus. If we are dealing with a case of poliomyelitis, the chances are that the covers are too heavy and permitted to remain upon the greatly enfeebled muscle or muscles as a result of the paralysis, which favors the deformed position and interferes with the ability of the muscle to recuperate. The time to recognize is the first day of the paralysis. A foot clonus is far more easily corrected if you have a simple cradle to protect the limbs and to support the covers; and a very light splint, or some pressure (nct continuous but frequent) to support the limb, is very beneficial. As has been said by both the essayist and Dr. Orr, the disposition of the strong muscle to take away from the weakened one favors deformities and makes cripples for life. The anterior muscles of the leg cannot compete with the calf muscles in holding a foot up, if the calf muscle completely takes away or relaxes or paralyzes, as it were, in addition to the paralysis, as you would paralyze the muscle with a suspension weight. The reason the essayist and other men are dividing tendons is because of deformed joints as a result of absorption from a longcontinued deformity, or because of a failure to recognize and protect the weakened muscle from the grasp of a strong one. The residual paralysis would not be one-half as great, association with poliomyelitis, as it is, if these deformities were recognized early and placed in proper position, and the necessary applications of heat, such as water, etc., were applied to favor the development of the muscles and to keep the muscles warm, which are nearly always cold. In other words, the thing to do is to try to teach or aid the individual in doing the things that he has difficulty in doing. I want to emphasize the statement made by Dr. Orr in regard to braces. I have seen several who have suffered from poliomyelitis come in with a brace that would weigh four or five pounds. Some appliance to the foot and the leg, with an intervening piece of rubber or web, or something that would help to act as that muscle, would have been a benefit; whereas it is utterly impossible for that child with the enfeebled muscle to carry the weight without its being an absolute injury. There are far too many deformities associated with multiple neuritis. The individual has sometimes a very pronounced acute and easily diagnosed multiple neuritis, but sometimes the attack is insidious. But you see a big strong man, whose hands are painful to handle, with contractures-a useful mana business man-made a cripple for life because of the failure to recognize that this brace should be kept in a suitable position; and you find the same in the feet, for with multiple neuritis we have a bilateral foot drop or wrist drop; but it can be with a simple neuritis, if extensive enough, as well as with a multiple neuritis. Now, the time to prevent is at the time of the recognition of the disease, and it is hard to say how long it should run before the time to cease operating. Good results have been obtained in cases of deformity due to poliomyelitis and to neuritis by tenotomies and breaking up adhesions, and by massage and by fixation, letting the stronger muscle, as it were, be overcome or weakened, while the weak one has an opportunity to regain its strength. I think the paper timely and the points well drawn out, but the individual who treats the patient is responsible, and ought to be as amenable for neglect along this line, as he would be for the treatment of a fractured limb without properly coapting the parts and keeping them in position. The tendency in the major part of the cases of poliomyelitis is for the residual paralysis to be much less than the initial, and the tendency of Nature is to restore, and she would restore very much more if she was given half an opportunity by the aid of the physician into whose hands this patient comes. A. I. MCKINNON, Lincoln: I would like to ask Dr. Lord to describe briefly his treatment for flatfoot, and if it does not seem too impertinent, I would like to ask him if he can cure flat-foot? By that I mean if a patient can have a foot nearly normal, or one that he can get along with, by using an orthopedic shoe. WM. BERRY, South Omaha; I wish to rise to corroborate the essayist and to say that we are proud of the work that he and Dr. Orr are doing in our state (which of course is not the best state) in the correction of deformities. I would like to emphasize a few points that the essayist has touched upon in the early recognition of deformities and the prevention of deformities in early life. It is easy for those of us that have to do with babies and children, if we are observant, to note how early in life a baby needs correction; that is, how soon any deformity which it is born with it or develops early should be corrected, or correction attempted. In our "Better Babies" contest in Douglas county I had the pleasure to observe a great many babies and to note babies that had not been seen by the physical inspector, as Dr. Lord terms it, or medical inspector of the schools, or come to the notice of any one, and how chagrined the mother was and how badly she felt when her baby did not take the prize or had nothing in sight of second place. Yet it is natural for every mother to think her baby is the best, no matter how scrawny, weakly or imperfect it is. I found there in some of our inspections babies with small deformities (and yet, though they were minor, they would produce crippling) in various forms, humpbacks, swaybacks and pendulum abdomens, and a number of defects physically, either from improper or improperly developed beginning bony growths or muscular deformities. One thing that is coming to light in our modern-day science is to make better babies and increase eugenics, and I wish to emphasize the point: The school inspections are very paramount, and they should be forced upon the communities and we should insist upon every state passing a law that will help our physical inspection in schools and further it. I believe in the doctors doing a little more. As our late Dr. Macrae over here in Council Bluffs used to say, enter politics a little more; get busy. It is our duty to have a better family beginning, and of course in early childhood prevent these deformities which are so hard to correct. We don't like to send all of them down to Dr. Lord and Dr. Orr of our state, and I know you don't in the state of Iowa. DR. LORD (closing): I am very grateful for the full discussion which you have given this subject. I find that there are a number of things here to be discussed, and so I will hasten and take up these points seriatim. Dr. Bierring wishes to know at what time I would recommend the treatment after acute anterior poliomyelitis. I must confess that I am not an authority. I am not a pediatrist; I practically never see these cases; and I have not accumulated an experience covering that particular phase of the subject. My ideas are, however, that the child should have a proper period of rest-six weeks at least-possibly more, and that as soon as the paralysis is discovered the imperfect posture or position of paralyzed limbs should be guarded against. Heavy covers avoided, as suggested by Dr. Woodson, and such light support provided as may be necessary to prevent the position of the limbs starting deformity, which they are sure to do if they remain habitually in a bad position. Surgery is usually not indicated until there has been ample time for regeneration of muscles; usually one or two years. Dr. Orr raised a point in regard to the importance of preventing the over-stretching of muscles that are weakened by the disease but not necessarily totally paralyzed. That point was amplified by Dr. Woodson, and I thoroughly agree with him. We often find that muscles that are supposed to be entirely paralyzed have perhaps a third or a half of their fibres in good condition; and if the over-stretching is removed, the limb properly supported, and these fibers properly developed, much can be gained. That is the reason why some of the assisting operations, such as the supplemental action of silk ligaments, and arthrodesis, sometimes do so much is because they take the handicap off the weakened muscle. Dr. Woodson raised the point of the harm of As a braces-more particularly heavy braces. matter of fact, that is a thing that is out of the hands of all of us, because perhaps some osteopath recommends these cases to the instrument maker, or the parents see the advertisement of a brace-maker, and go themselves and have these things applied, and have the child continue to wear them. Those that are applied by physicians are often imperfect. We have overcome the weight objection in large measure by using a lighter materials duralamin put out by the Maxim Gun Co. There are several alloys of aluminum that answer very well, approaching the strength and stiffness of steel, and weighting only a fractional part as much. Dr. Woodson raises the point of heat. I think it is the consensus of opinion among those who observe these cases that heat is one of the most valuable agents in improving the nutrition of these partially paralyzed limbs, and the application of dry heat, by an electric heater, is one of the most practical methods now in use. When he Dr. McKinnon asked a question in regard to my method of treatment of flat-foot, and whether I can really cure it. The child's foot is normally flat. The child should be prevented from continuing his normal condition of flat-foot. begins to walk he evolves an arch, if he has a good foot. If he has a weak foot he may continue flatfooted, and at a later time when his feet are used a great deal (and this varies, of course, with the occupation) he may develop a fixed flat-foot or so called inflammatory flat-foot. A patient with inflammatory flat-foot should be treated ordinarily by over-correction in a cast for an indefinite time and finally be brought out upon some supportive device usually a splint, brace, or an arch, such as he can comfortably wear, and his balance on his foot so arranged that the weight will be thrown upon the outer rather than upon the inner border of his foot. I have found it impracticable to undertake to make casts of feet and have special steel braces made, because it makes an intolerable You must appliance for the individual to wear. educate the individual to wear a support. If you turn him loose with a thick support he discards it and you have done him no good. I ordinarily educate these patients to a point where I can get them to accept a reasonable degree of correction. I think most of us try to use an arch of ideal height and expect every patient to wear it. This cannot be done. Each patient must have an arch fitted to his individual foot. I would like to dis cuss this point further, but will have to abandon it on account of time. I think that many of these things are destined to be improved by these numerous inspections. I was flooded with over-anxious parents who had been at our baby show and were very much incensed to think that some "sprig of a doctor" had The told them that their babies had flat feet. "sprigs of doctors" were right. The feet were flat, and the children were past the ages when they should have been carrying flat feet. By a little attention and proper selection of footwear they can be brought out of that condition. Dr. Ross speaks about special forms of electricity. I really know so little about it, I can't give it an intelligent discussion. I may say this, however, that most orthopedists have put the electrical treatment in the discard. I would not say that in regard to the special forms of treatment recommended by Dr. Ross, because I don't think they have been given sufficient trial among those working along these lines, those who may have been working so long as to be prejudiced and inThis I have observed: tolerant to suggestions. that men who were holding on to their patients by the use of electricity, were observing their cases, and were in position to control and handle them, and give them the attention that they required, and consequently could deliver better results than those who were so pessimistic as to use nothing and allow their patients to drift and fall into other hands. If there is one thing more discouraging than another in the treatment of deformities, it is that these cases are so long drawn out; it is such a long story and such a discouraging proposition. The general practitioner hasn't enough resources at his command to offer sufficient encouragement to these people to get them to receive the attention which they require. They require months and years of intelligent observation, and they can't get it if nobody is treating them. I doubt not that the men who make use of electricity, either as a method of holding their patients or for the good it is thought to offer, are in closer touch with their patients, and are securing better results in the care of paralytic cases, than those who do not have this string to their bow. RELATION OF RADIUM TO SURGERY.* D. T. QUIGLEY, M. D., Omaha, Neb. Several years ago, soon after the discovery of radium it was found that it had a destructive effect on living tissue. Further experiment showed that this destructive effect was due mainly to alpha and soft beta rays that were thrown off from the metal. The early use of radium in therapeutics was for its destructive or caustic effect on surface lesions such as rodent ulcer, epitheliomata, tuberculosis of the skin, etc. With years of use and clinical study it was found that the radium owed its healing properties not so much to the weakly penetrating but caustic soft beta and alpha rays, but to the exceedingly penetrating hard beta and gamma rays which *Read before the Medical Society of the Missouri Valley, at Colfax, Ia., September 18, 1914. 5 Case of skin cancer, three years standing, cured by four hours application of 75 milligrams of radium sulphate. Case referred by Dr. Wade, Lexington, Neb. Cancer of lip from razor cut 31⁄2 years ago. Cured by six hours application of 75 milligrams radium sulphate. Case referred by Dr. Tayman, Cozad, Neb. were not nearly so irritating to normal tissue as the soft rays. This led to the working out of a scientific use of radium with screens, so that the maximum of efficiency with the minimum amount of irritation of normal tissue might be produced. It follows, therefore, that this substance is not one to be picked up and used by any physician, but is capable of little good and much harm if not used by one who has acquired skill in its use. A fresh graduate from a medical school buying a scalpel and a few forceps and venturing to do major surgical operations would be in no more unreasonable position than the inexperienced physician who presumes to use this most potent substance. In the hands of the unskilled the results as to the use of radium are unreliable and conflicting but the results from the clinics where the radium is in the hands of experts is so satisfactory as to assure radium a place as a useful addition of our therapeutic armamentarium. The effect of radium is not the same as the X-ray. It has several hundred times more penetration than the X-ray, the burns heal quickly, and with very little pain, and it has been found the best treatment for X-ray burns, X-ray eczema, and X-ray cancer is the application of radium. Mistakes have been made with radium by using too large a quantity. If an unreasonably large quantity be used and the exposure be too long the patient will be overwhelmed with broken down cells and the resulting auto-intoxication may hasten the death of the patient. Radium is a good thing used in reasonable dosage just as strychnine is a good thing used in reasonable dosage, but over-dosage of the one is just as unreasonable as over-dosage to the other. Two of the leading clinics of Europe have substituted radium for the knife in the treatment of cancer, but in most of the European clinics and in my own work it has been reserved for inoperable cases and post-operative treatment. In most inoperable cases the results of the treatment are very gratifying, and beyond any other treatment. The first thing noticed is the disappearance of pain, this often occurs on the second or third day of treatment. The next thing is the drying up and disappearance of discharges and bleeding, this occurs in from ten days to four weeks. The third effect is the shriveling up and in some cases disappearance of the tumor mass, this shrinkage goes on for months after the treatment. Radium is indicated in every case of can cer. In the operable cases as a post-operative treatment to prevent recurrence and in the inoperable cases to relieve distressing symptoms, prolong life, and as a possible cure. Schauta reports eleven clinical cures in twenty-two inoperable cases of cancer of the uterus, Wertheim six out of eighteen, other clinics in proportion. Besides a large number of inoperable cases have been brought into the operable class by the DISCUSSION. JOHN PRENTISS LORD, Omaha: I began the use of X-rays in the treatment of cancer very early -very soon after the X-ray was introduced to the profession. I will not say I was a great user of it; I did use it rather heroically in inoperable cases and in cases in which I thought its limitations were not too great. I have also been an advocate of radium treatment where it could be utilized, and have always regarded it as having a very distinct place in the treatment of malignancy and those other conditions as recited by Dr. Quigley. Therefore last year when in Europe, in going the rounds of the health resorts W. F. F.. Hastings, Neb Malignant skin condition which had existed for sixteen years. Been treated by different specialists and diagnosed by some as cancer, by others as tuberculosis of skin. The patch across the forehead had the appearance of tuberculosis, while the spots in front of each ear were undoubtedly carcinomatous. This case was treated with 125 milligrams of radium sulphate for ten days, about two hours each day. with the result that the condition is entirely healed. The case shows the difference between the action of radium and the X-ray, as several months before he came to me he had been treated without any benefit by one of the leading X-ray and skin specialists of Chicago. retrogression brought about by radium. No case of cancer or sarcoma should be considered hopeless unless radium has been tried, and in no case of cancer should radium treatment be neglected if it be possible for the patient to get the treatment. Radium should not supplant surgery in any operable case, but should be used in conjunction with surgery to get the best results. In skin cancer about the face, radium is to be preferred to the knife as hardly any scar is left, and the results are at least equal to surgery. In benign tumors the action of radium is well brought out by Kelly's recent article in the Journal A. M. A. in which he states he does not operate any more for fibroma or myoma except in the small per cent of cases where satisfactory retrogression of the tumor cannot be brought about by the use of radium. In keloid the action of radium is practically specific as it is also in lupus and tubercular glands of the neck. and hospitals I was greatly interested to see the very large use of this agent for a very wide range of conditions-more particularly its use in cancer. One would get the impression that they are radium-crazy over there, because of its very extended use. When we come to consider the generally hopeless conditions of malignancy and its treatment, we must be somewhat charitable in questioning the applicability of this agent in the treatment of cancer. They were able to show over there most astonishing results, and when such master clinicians as Doderlein of Munich and Wertheim of Vienna, and some of the others who have been masters in the operative treatment, will come across and make such extended use of this agent as they have been doing in the last two or three years, it is up to the rest of us, to use the vernacular, "to sit up and take notice." Some of us have been somewhat "radiophobic," perhaps, because of the disposition in some quarters to exploit unduly the virtues and advantages of radium. That is somewhat deplorable, but when these things come upon us in this way it is not strange that some should be over-enthusiasm. Perhaps the very over-enthusiastic of those few caused some of the rest of us to be unduly pessimistic, and perhaps unfair in the consideration of the value of this agent. I am one of those who believe that radium has its limitations, just as the intelligent users of it all recognize; but I still believe that with our present lim itations in the curative treatment of cancer it has a very distinct place. The great regret is that the supply of radium is so very limited that it cannot be utilized to more than a very limited extent. As many as ten or a dozen years ago, by the use of the X-ray, which is first cousin, perhaps, to this new force, radium, I was able to cure some cases that were most remarkable. One was a proven case of angio-sarcoma in a lad of eighteen who had an eye closed by the growth, a cheek enormously enlarged, the angles of the neck entirely obliterated and absolutely inoperable. It being so distinctly inoperable, and pursuing such a rapid course, it was estimated by me, that the most heroic X-ray treatments would be necessary in order to cut short the effect of the disease; therefore this fellow was given 105 treatments. For the most part he was treated every day, and part of the time, when we saw that we had much to gain by haste, because the disease would outrun us unless we did, this fellow had the tube (without screening in those days, because that was not understood) within two inches of the surface of this growth; and that was continued at times for as high as forty minutes—a quite unprecedented duration of exposure. That disease broke down so fast that it was necessary to incise it freely in order to allow the products of tissue destruction to drain away, to relieve the toxic condition from which the patient suffered. He showed it distinctly-a great deal of pallor and all the symptoms of marked auto-intoxication, but the treatment was continued, because it was the only thing we could do. The tumor disappeared, the fellow got well. He had a patch of necrosis on the side of his cheek and neck as large as the palm of my hand. The skin was entirely destroyed, the fatty tissue was destroyed, and the deep fascia lay exposed in his neck. It was necessary to dissect that off, because of the slow disintegrating process. It was afterwards necessary, because of this very dense indurated ulcer base, and so lacking in blood supply, that it was deemed inadvisable to attempt the Thersch grafts, and so a flap was taken from his deltoid region and sutured to his face. Eight years after-I did deltoid-he was living and well. But if with the X-ray, admittedly a much weaker agent than radium, an incurable case can be cured, I think it speaks pretty well for these radioactive agents in the treatment of cancer. A. F. TYLER, Omaha: I am glad that Dr. Lord went into detail in describing this case of sarcoma which he successfully treated with the X-ray, because it gives a good opportunity for the comparative results between the X-ray effect on sarcoma and radium effect. If this same sarcoma had been treated with radium, the skin would not even have sloughed, yet the growth would have disappeared; because the radium has a specific action on the endothelial lining of the blood-vessels. If a sarcoma is exposed to the action of radium rays, in a short time, if a section be made from that growth, you will find that the vessels of the growth have become obliterated by the thickening of their walls; so that radium produces a starvation of the sarcoma as well as a destruction of the growth. C. E. RUTH, Des Moines: I have no criticism to make of the use of radium, as I have no experience to justify it. I have had considerable experience in the use of the X-ray when they knew much less about it than they do now, and came very near having serious trouble myself from its prolonged employment; and yet I am satisfied that in massive doses the X-ray is a very valuable aid, and the fact that it is so much cheaper than the use of the radium will for a long time yet probably commend it to many. The limited amount of radium and its high cost will for a long period of time, evidently make its general use prohibitive in this country, at least, particularly with the large class of the poor who will need it most. I want to report a case that has recently been through my hands, in which we used the heat treatment. The case was one such as indicated in this photograph that has been passed around by Dr. Quigley, with the enormous mass on the side of the man's face that is stated to be an epithelioma. From the picture I would question the diagnosis. In the case that I have in mind the man came into the service of Dr. Pearson in June of last year with a sarcoma involving the lachrymal gland. The doctor entirely eviscerated the orbital cavity on that side. The man came into my service in November of last year. He then had a very large secondary sarcomatous manifestation involving nearly the whole of the parotid region. The case was also seen by Dr. Osborn, who is here, while he was on the same service later. The case passed out of our hands and did not return until March of this year. Then he had an enormous mass occupying the whole of the parotid region, almost all of the right cheek, with all of the glands in the upper portion of the neck on that side. The inflammatory extension was very great. The top of the mass over an area of over two inches, probably, was sloughing. The odor was so terrible that nobody would care to stay anywhere near the man-certainly not in the same room-on account of the stench. It was clearly folly to attempt any operative procedure. I believe that no human skill would have made it possible to remove the growth without involvement or infection of surrounding territory. I injected cocaine about the main growth and destroyed it with slow heat. I was surprised to find it rapidly cicatrizing and all the induration disappearing over a large territory on the main portion of the cheek. I made practically no attempt to deal with the mass in the upper part of the neck because of its close relation to the carotid vessels, with the exception of two glands that I could feel pretty well, which I penetrated quite deeply with the needle. The main portion destroyed by the cautery cicatrized rapidly, and when it was almost dry, so that I felt it would be possible to do a clean operation, I made an incision over the course of the carotid sheath in the lower part of the neck, opened it, isolated the common carotid and internal jugulars, passed a ligature around these vessels and then clamped them, to see if there was any circulatory disturbance; and no indication of anything of that kind taking place, we went ahead with the destruction of everything on that side of the fellow's neck practically to the pharynx, with the exception that I tried to be careful not to destroy the pneumogastric nerve. I will close by saying that we had destruction of a good deal of the superficial layer of the jaw, and an enormous slough; but that has all healed and seems entirely well. He is perfectly relieved and has had no pain since the first application of the cautery. How permanent the relief I do not know, but the experience we have had in treating these inoperative cases with the application of slow, dull-red heat justifies us in further attempts, especially in those cases in which we could not use the radium for the reasons previously mentioned. DR. QUIGLEY (closing); I have very little to say in closing, except that this question of radium and the X-ray always comes up, and there is no doubt but the X-ray is very well described by Dr. Lord when he says it is a weaker agent. It undoubtedly cures some of these cases, but I think the field of radium is very much greater than the field of the X-ray. By the way, as a means of illustrating that, I had on my arm here within the last three months a bad radium burn (showing arm). If I had had a bad X-ray burn I would have had it for |