is surmised from changes in the stools, such as diarrhea or constipation, ribboned or narrowed stools. Interference with the fecal passages may cause colic or visible peristalsis, or an area or tympanitis is seen or felt through the abdominal walls. The benign growths of the intestines are cysts, myoma, fibroma, adenoma lipoma and rarely cause symptoms until obstruction of the bowels occurs, either acute or chronic. If these growths can be palpated they are felt as smooth, movable, and painless tumor. Obstruction of the bowels occurs when the growth is occluding the lumen, or when the tumor is carried down the intestinal stream forming an intussusception, or twists or kinks of the bowel occur blocking the fecal passage.

The cysts of the mesentery and benign growths of the peritoneum and omentum are rarely diagnosed as such before operation. If a centrally located movable fluctuating tumor is crossed in front by a bowel it is a mesenteric cyst. Chylous cysts of the mesentery can hardly be diagnosed from the other fluid tumors of the mesentery, and a distinguishing point might be the discomfort after eating when absorption is taking place. The complications may be peritonitis or obstruction of the bowels. A mass firmly adherent to the surrounding organs may be due to abscess or tubercular infection. Tumors may become adherent to the intestines and form an irregular mass but the history will usually give information to eliminate septic and tubercular infections. Diverticulum of the bowels as the result of inflammation will have dense adhesions thrown around it and many of the cases have been thought to be cancer. When inflamed the symptoms are similar to appendicitis. These cases are rare. The sigmoid has given more cases than other parts of the bowels.

Malignant tumors of the bowels usually occur in the large bowels. In the Mayos' statistics the ileocecal region was the most frequent site of cancer. The rectum furnishes nearly one half of the malignant tumors of the bowels. The early symptoms of malignant disease will be those of functional diseases of the bowels. Constipation rather than diarrhea is given as the early symptom. Rectal specialists advise us to make a rectal and sigmoidoscopic examination in all cases of constipation or diarrhea. A nodule of beginning cancer has not a movable mucous membrane covering it. If ulcerated it may be some time before blood is detected in the stools. A rapid growing tumor in the central region of the abdomen may be sarcoma. If occurring in a young person the probability of the growth being a sarcoma is about certain; in adults a cancer. Cancer of the transverse colon will early have involvement of the lymph nodes about the pancreas. Cases have been reported of cancer of the ileocecal region in which it was impossible at the operation to tell without a microscopical examination whether the growth was a cancer or tuberculosis. Contrary to the ideas of the laity that cancer of the bowels is painful, a malignant growth may attain quite a growth before the pain would cause them to seek medical advice. It is the blood and the fetid discharge of the stools that arouse a suspicion of cancer. Most of the patients come to the doctor with their own diagnosis of piles. If the tumor is of the scirrhus type early stenosis may cause symptoms which make the growth recognizable by causing a dilation of the bowels above the seat of the growth and the extra efforts to propel the intestinal contents through the narrowed opening. The symptoms would be abdominal pain, vomiting, diarrhea, or constipation; the symptoms of chronic intes

tinal obstruction. Colicky pain from the exaggerated intestinal peristalsis are the suggestive signs of chronic obstruction due to cancer and stricture due to other causes.

TUMORS OF THE PELVIS

Prominent surgeons have mistaken a pregnancy for a cystic tumor. The solid tumors of the pelvis are the fibroma and sarcoma of the ovaries; fibroma and cancer of the uterus; floating kidney, extra-uterine pregnancy, lithopedeon, tumors of the cecum, sigmoid and rectum; hypertrophy and tumors of the prostate; and pelvic tuberculosis. The cystic tumors of the pelvis are the distended bladder, ovarian cysts, tubal pregnancy, pyosalpinx, parovarian cyst, dermoid cyst and pelvic exudate due to inflammation, hematocele, collection of pus and blood and pregnancy. Bi-manual examination is made with one hand on the abdomen and the finger in the vagina or rectum. An effort is first made to mark out the normal organs and if a mass is found on examination our efforts are directed to determine its consistency, origin, size and its relations to the normal anatomy. Ovarian and parovarian cysts, if their pedicle becomes twisted, have symptoms of peritonitis, appendicitis or of obstruction of the bowels. Cancer and fibroma of the uterus have a vaginal discharge of the blood as one of the symptoms. The discharge is inclined at first to be watery or serum like. Irregularities of menstruation, either the loss of too much blood at the menstrual time, or between the regular monthly periods, will suggest fibroids, or cancer if of the can

cerous age or where there is no other satisfactory explanation of the extra flow of blood. Collections of pus will give a history of fever or chills, an attack of appendicitis, labor, abortion or septic infections or a history of gonorrhea. In ectopic pregnancy the symptoms will be that of an ordinary pregnancy until abortion or menstruation is supposed to have taken place or there are sudden pains and fainting or collapse. If there be the symptoms of pregnancy, and uterine pregnancy can be ruled out, a mass felt in the Fallopian tube and inflammatory conditions can be ruled out, the case is one of extra-uterine pregnancy.

The retro-peritoneal tissues may be the seat of tumor or of suppuration. Suppurative conditions come from diseased vertebrae, sepsis in the abdomen, absorption through the mesenteric and retro-peritoneal glands. Sometimes suppuration appears primarily. The disease may be confused with hip joint and sacro-iliac disease. Retro-peritoneal hemorrhage and hematocele are rare and the symptoms will be obstruction of the bowels due to the pressure or misplacement of the mesentery. Retro-peritoneal lipoma is another rare condition and some of the cases were thought to be ascites until attempts were made to use the trocar when no fluid was found. Others of the cases were thought to be ovarian cysts. Edema of the lower extremities, dyspnea, and Death vomiting occur in this disease. occurs in from two to five years. In the beginning of this peculiar condition there are no symptoms.

The Journal of the Michigan State Medical Society

All communications relative to exchanges, books for review, manuscripts, advertising and subscriptions should be addressed to Wilfrid Haughey, A. M., M. D., Editor, 24 West Main Street, Battle Creek, Michigan. The Society does not hold itself responsible for opinions expressed in original papers, discussions or communications.

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SEPTEMBER

EDITORIAL

more care

"Look at the program and decide If you can afford to miss the papers, decide even fully whether you can afford to miss the stimulus of contact with your old time friends, with keen, enthusiastic men. Bring your wife and daughters; bring your own enthusiasm and carry back a fresh enthusiasm to your work. You may miss two days from the daily grind of practice, but your patients, in the months to come, will feel your enthusiasm, and esteem you as a man who keeps up with the profession."

DAVID INGLIS.

THE BAY CITY MEETING

Forty-Fifth Annual Meeting of the Michigan State Medical Society, Bay City,

September 28, 29

The forty-fifth annual meeting of the Michigan State Medical Society convenes this month in Bay City. A complete and interesting scientific program has been prepared, and is published in this issue of the JOURNAL.

The arrangements committee has been busily at work for several months, and no detail has been too small to receive careful attention. All the sessions of House of Delegates, Sections and General meeting will be held in the Ridotto, thus giving us a more unified meeting, and it is hoped one. free from confusion.

The time is late enough so that all will have returned from their vacations, and early enough so that we will not be hindered by the rush of our fall and winter work. The weather at Bay City should be

Bay City is easily accessible to all parts of our State, is a city of ample proportions and ample accommodations, has an enthusiastic profession and can well take care of us. A large attendance is desired and expected. The meeting at Kalamazoo last year was the largest ever held outside of Detroit-let this one set a new recordone that has never been exceeded even by Detroit. The expense of attending is small, and the confidence, zeal and enthusiasm, absorbed, imbibed and soaked in, are great.

LET US ORGANIZE

The objects of our medical organization are worthy, our work important, and we should have the active support of every reputable member of our profession in Michigan. There may be some activities of our Society which do not receive the endorsement of every member, but in this democratic country the majority rules, and the officers and representatives try to carry out the wishes of this majority. If your wishes are not followed in some particular the remedy is easy-become a more active member; take a more active part in the County Society meetings, become a delegate, or help elect your delegate to the State Society. Be among the first to pay your annual dues; be among the foremost workers for the development of your society-then you will be a power to demand and receive recognition. Your views will be heeded and sought after. The ideas and views of the most modest of our members are not intentionally ignored, but the strong active member, the recognized leader, the progressive, constructive man enforces attention to his ideas.

In these times of establishment of sects in medicine our profession should stand