dyes and the injection of toxins. Coley's treatment ilis into the system should not bring about a series of is more suited to sarcoma than carcinoma. In sar-changes in the skin.

coma of the skin early and complete removal was the DR. JOSEPH GRINDON, of St. Louis, said we should best treatment if the growth were local. When gen- expect, reasoning a priori, to see such eruptions in eral, some cases have been successfully treated by the syphilis. injection of a solution of arsenic. The injection of toxins had not proved successful in Dr. Shepherd's hands.

DR. POLLITZER, of New York, read a paper on

A CASE OF NEVUS CANCER; METASTASIS; OPERA-
TION; CURE.

DR. KLOTZ stated that he was inclined to consider it a syphilitic eruption, different from the erythema and similar affections.

ENDOTHELIOMA OF THE SKIN DEVELOPING IN THE
SCAR TISSUE OF LUPUS VULGARIS ; ANGIOSAR-
COMA OF THE SKIN.

The patient was thirty years old when a small, DR. JOHN A. FORDYCE reported the case of a slightly pigmented mole on the back, about an inch to patient, the subject for a number of years of a lupus the left of the eighth dorsal vertebra, began to ulcer- vulgaris of the forearm. A nodular growth deate. During six years of treatment the ulcer never veloped in the scar tissue which followed various ophealed, and finally began to exceed the limits of the erative procedures on the lupous tissue. The tumor original mole. It was then excised, the skin stitched was excised and proved microscopically to be an enup, and the wound healed well, producing a linear dothelioma, probably starting in the perivascular lymph scar. Six months later the skin in the neighborhood spaces surrounding the smaller vessels. From the of the scar became raised, red, glistening over an ir-size and appearance of the cells alone, as well as from regular area about two inches in diameter, and broke the general conformation of the cell collections in the down at two points, producing small ulcers. Soon connective-tissue spaces, it would be impossible to difafter the patient consulted the writer. There was ferentiate the growth in question from a small-celled then, in addition to the condition described, a small, epithelioma. The grouping of the cells about the hard, round tumor clearly below the skin, and an inch dilated blood spaces, together with the absence of and a half from the edge of the red, glistening patch. other possible points of origin, enabled a diagnosis of The patch, including the scar and a large extent of endothelioma to be made. Although epitheliomas healthy skin, was excised, the subcutaneous tumor was springing from lupous tissues have not infrequently found within the substance of the trapezius muscle, been reported, the writer believed the case in question and the latter was stripped up from its attachments to to be a unique one in which an endothelioma has been the spines of the ninth to twelfth dorsal vertebræ and found in such a connection. cut out to an extent that included the tumor. Microscopic examination showed the cutis throughout the red, glistening area to be filled with round, oval and irregular tracts of cancer cells, without connection with the surface epithelium. Examination of the tumor in the muscle showed it to be made up of large nests of cancer cells separated by dense masses of connective tissue, which had replaced the muscle fibres.

Six years have elapsed since the operation, and the patient is entirely free from any sign of a recurrence. Cases of nevus cancer are usually of such striking malignancy that the favorable result in this case, in which a metastatic deposit had already occurred, makes it worthy of record.

66

SYPHILITIC LESIONS OF THE WHEAL TYPE.

Several instances of angiosarcoma were referred to in which single tumors had been found which were identical in structure with the so-called idiopathic pigmented sarcoma of Kaposi. These growths start from the connective-tissue covering of the vessels and are histologically to be differentiated from the true endotheliomas.

TWO CASES OF RHINOSCLEROMA.

DR. C. W. ALLEN, of New York, presented with colored drawings and photographs 2 cases of rhinoscleroma, one of which had been under his observation since 1889, the other for about three months. Both are already known to literature. In the first case the portion of the growth involving the centre of the upper lip, gum and inferior portions of the nose broke DR. H. G. KLOTZ, of New York, described an un- down in a gangrenous suppuration, and within the usual eruption observed during the early period of period of a fortnight was completely thrown off, leavsecondary syphilis, and quoted similar descriptions ing the bones denuded. These subsequently became from Taylor and Langehert. The lesions resemble covered over with a reproduction of the new growth, so wheals, except for the absence of itching and other that eating, breathing, sleeping, etc., became more natusensory symptoms, and for their long duration. Nev-ral and life was prolonged after it had been despaired ertheless he believes it justifiable to accept the lesions of. In the case of the man, whose affection had exas wheals, especially as the conditions found in the isted for nineteen years at least, there was enormous wheal of urticaria by several authors would fully ac- enlargement of the external nose, dilatation of the count for the clinical features. Dr. Klotz called atten- nostrils, which were also practically occluded. For nine tion to the want of actual knowledge in regard to years a tracheotomy tube had alone made breathing angioneurosis, and mentioned a recent paper by Bril-possible, and the stenosis extended the whole length lippsoro, which attempts to establish the origin of the so-called angioneurosis from embolism.

DR. JOSEPH ZEISLER said he had never had his attention called to this distinct syphiloderm as an independent form, but he had seen a case much like that described by Dr. Klotz.

DR. JAMES NEVINS HYDE, of Chicago, saw no reason why the introduction of a poison such as syph

of the pharynx, shutting off the posterior nares by bands and masses of fibrous tissue. Despite the severity of the condition present in both cases, there had been recent improvement in the general health.

AN UNUSUAL FORM OF TUMOR OF THE SCALP.

DR. ALLEN presented a colored painting, gross specimen and microscopic preparation. The tumor,

which had been of slow growth upon the scalp of a in the lower part of the area. Over all there is a woman advanced in years, had been widely excised fine linear network of scars, soft but marked.

after the diagnosis of probable carcinoma was made. The chief clinical feature of the tumor was its extreme hardness, almost like that of ivory. This was due to a central encapsulated mass which had undergone hyaline or colloid degeneration. Sections made by Dr. Martin Ware, to whom the reporter is indebted for a description of the appearances, showed an alveolar arrangement of polyhedral cells, growing in a very atypical manner. These cells are arranged about a central canal, indicating that the growth emanates from glandular structure, either sebaceous or sweat gland. The cells do not take the hematoxilin and eosin stain well, because of the degeneration they

have undergone.

THREE CASES OF BLASTOMYCETIC INFECTION OF
THE SKIN, ONE OF THEM PRODUCING A "TUMOR "

OF THE LOWER LIP.

DR. F. H. MONTGOMERY and DR. H. T. RICKETS

reported these cases.

Dr. J. N. HYDE, of Chicago, gave

A REVIEW OF THE SUBJECT OF BLASTOMYCETIC
INFECTION OF THE SKIN, WITH Α REPORT OF
TWO NEW CASES.

Dr. James C. White, Boston; Dr. William A. Pusey, The subject of blastomycetes was discussed by Chicago; Dr. John T. Bowen, Boston; Dr. H. G. DRS. S. SHERWELL and J. C. JOHNSTON reported Dr. M. B. Hartzell, Philadelphia; Dr. Joseph Zeisler, Klotz, New York; Dr. Samuel Sherwell, Brooklyn; A CASE OF XANTHOMA TUBERCULATUM DIABETI- Chicago; Dr. John A. Fordyce, New York; Dr. CORUM, SHOWING RAPID DISAPPEARANCE OF James C. Johnston, New York; Dr. T. C. Gilchrist, LESIONS UNDER ANTIDIABETIC REGIMEN AND Baltimore; Dr. Frank Hugh Montgomery, Chicago; and Dr. James Nevins Hyde, Chicago.

TREATMENT.

As long ago as 1890 Dr. Sherwell sent one of these cases to Dr. A. R. Robinson. The patient in the present case was a woman, age forty, somewhat plethoric, apparently well nourished, who was first seen on January 8, 1900. The urine was full of sugar. The lesions were first noticed between five and six years ago, most marked on the arms, elbows, knees and nates, and are less noticeable during the summer months. Last winter the symptoms became so distressing that she could obtain no relief by night or day. It would seem that from the first she had had classic symptoms of glycosuria. The appearance was such that, roughly speaking, at the distance of the width of a room the eruption might have been taken for a case of variola at the height of the pustular and confluent stage. She was put upon antidiabetic regimen and diet, together with mild laxative alkaline treatment, and rapidly improved. The papular and tubercular masses flattened, the inflammatory halos entirely disappeared. At present there is scarcely even a pigmented spot to mark where the original lesions existed. The glycosuria is quite slight. So far only about 30 such cases have been reported.

DR. JAMES CLARK WHITE inquired whether the

blood had been examined.

DR. JAMES NEVINS HYDE said he had seen at least 2 such cases.

DR. SHERWELL, replying to Dr. White, stated that
the blood had not been examined. The lesions were
not compressible, looking almost like a pus formation
or a conical furuncle. The patient felt as if there
were crumbs in the bed.
BLASTOMYCETIC

DERMATITIS AND ITS RELATION
TO YAWS.

A CASE OF ERYTHEMA ELEVATUM DIUTINUM (?) was reported by DR. T. C. GILCHRIST, of Baltimore, who said that the case did not recall the diagnosis of lichen planus, and did not at all resemble Galloway's case of ringed eruption.

DR. J. N. HYDE said he had seen a case which was almost identical with Galloway's case. A vote of thanks was tendered to the retiring presand Dr. Francis John Shepherd, of Montreal, the ident, Dr. Henry W. Stelwagon, of Philadelphia, ducted into his office. newly-elected president of the association, was inThis was followed by adjournment.

THE OBSTETRICAL SOCIETY OF BOSTON. MEETING of February 20, 1900, the President, DR. A. WORCESTER, in the chair.

DR. F. H. DAVENPORT read a paper entitled

THE USE OF THE ANGIOTRIBE.'

DR. G. W. WASHBURN: I am rather impressed by the apparent clumsiness of the instrument, and would fear that there would be more or less dragging upon the tissues. The danger of secondary hemorrhage is not, it seems, as great as one would fear.

DR. W. L. BURRAGE: I have seen the instrument used in only one case, and was not especially impressed with it then, as it seemed clumsy and heavy. A separate assistant is needed on account of the danger of dragging upon the tissues. I have noticed that some men after using the angiotribe cauterize as well, as if suspicious of the absolute safety of the instrument, which seems to me rather a return to methods DR. ISADORE DYER, of New Orleans, read this discarded years ago. I have been fairly well satisfied paper. In many particulars the case fulfilled the with the use of animal ligatures in abdominal work, clinical characteristics of yaws. Dr. Dyer examined and would not feel inclined to use it there. Its best specimens and confirmed the diagnosis of blastomycetic field would be in vaginal hysterectomies, where vaginal dermatitis. Under the iodide treatment the improve-ligatures are apt to become infected and clamps are ment was rapid, the lesions flattened, the exudate greatly in the way. Its clumsiness seems to me rather diminished. Finally mercurial plasters were applied a disadvantage for use within the abdominal cavity. to all of the lesions, successfully reducing the granula- The feeling of lack of security of which I have spoken tions. At the present time the face shows a smooth, makes me feel rather sceptical as regards its use in glossy area, marked here and there by a fibrous tab, the future.

and with a large, branching, somewhat keloidal scar

See page 4 of the Journal.

DR. J. G. BLAKE: Theoretically vaginal hysterec-plicity of small growths which cannot be detected in tomy would seem to offer a very good field for the in- the thickened wall and may subsequently develop strument. It is a great disadvantage to obstruct the into large and dangerous ones must be borne in mind. view with many clamps, which are also very annoying More precise knowledge is needed on the subsequent to the patient afterwards, for forty-eight hours very history of those that are left behind whether their likely. If this instrument can be modified so as to growth is accelerated or retarded by enucleation of become lighter and yet retain its crushing power I some of them. should regard it as a great addition to our, armamentarium.

that I have seen disappear have been through the activity of some surgeon. Of course I have under my care, as has every man, more or less fibroids that I do not operate upon but keep under observation. These cases are quite different from cases seen as I see them at the hospital.

AMERICAN MEDICAL ASSOCIATION. FIFTY-FIRST ANNUAL MEETING, HELD AT ATLANTIC CITY, N. J., JUNE 5-8, 1900.

SECTION ON THE PRACTICE OF MEDICINE.

(Concluded from Vol, CXLII, No. 25, p. 670.)

DR. SOLOMON SOLIS-COHEN, of Philadelphia, read a paper entitled

THE RELATIVE IMPORTANCE OF VALVULAR AND
MUSCULAR LESIONS OF THE HEART.

give rise to are numerous and must not be forgotten. As regards the development of other tumors after one has been enucleated, I hardly feel that we can so lightly say another operation can then be done. Myomectomy is so serious an operation that I think we ought to lay the possibility before the patient and let her decide for herself, whether she wants to run the risk or not of a secondary operation. The question of operation would also be determined for me by my relations with the patient. If the patient were one that I could follow or was under the care of some one in whom I had confidence I might wait. It is surprising how large a tumor can be enucleated yet the uterus be but little mutilated. I am getting more and more inclined to remove small tumors and in my eyes the whole question hinges upon the comparative safety of the operation as now done. A fibroid is a pathological condition and operation in the early stages is almost always successful. The patient has the right to be relieved of possible future danger. As to building up, the method I have found best to avoid The exact site and nature of the valvular lesions loss of blood is whenever the patient is bleeding to are of less importance therapeutically and prognostipack the vagina tightly, changing the packing when- cally than the state of the cardiac muscle. Mitral steever needed. This method may be kept up for weeks nosis with great narrowing is an exception to this or months and is much more effective than any drugs.eral rule. Aconite is often used in this condition to DR. J. L. HILDRETH: In the past I have many reduce the excessive muscular effort. The symptoms times asked myself what the prognosis was to be in a and physical signs of cardiac myopathy are inconstant, given case, and now I know no better way of telling and in the early history of the case may be slight. In than I did then. I wish we could have some tangible the absence of valvular lesions, intermittence or irregprinciples to work upon, but there are none as far as I ularities of the pulse or apex beat, disturbance of rate or rhythm by slight causes, and recurrent pain referred to the pericardium in non-hysteric and nonneurasthenic subjects, are the principal local symptoms calling attention to the disease of the cardiac muscle. Tinnitus, vertigo, dyspnea, venous ectases, visceral congestion, edema and other evidences of circulatory disturbance may be slight and escape attention until sought for. There is usually impurity or weakness of the first sound of the heart, with approximation of the two sounds in quality or relative accentuation of the second sound; later embryocardia and gallop-rhythm may develop. Gout, syphilis, alcohol and tobacco, lead-poisoning, tea and coffee, sexual excesses, mental strain and physical overwork, either in serious pursuits

know.

gen

DR. G. J. ENGELMANN: I do not think it is as rare to see these tumors disappear as would seem to be the case from what has been said here to-night. The man in general practice is more apt to see such cases than the surgeon, who very likely sees the patient only when she is brought to him to be operated upon. I have five such cases vividly in mind, cases with large, easily bleeding tumors which disappeared in time. Years ago in post-mortem work I saw many cases in which unsuspected fibroids were discovered. I have also seen many cases where treatment has succeeded in keeping the patient along in good health. The question of operation all depends upon the conditions present, whether we can keep the patient under close or sports, are among the chief provocatives of disease observation or not. My feeling is to wait till symptoms develop and then operate only when other methods have failed. Rapid growth would indicate operation. I see no way to determine in a given case what the future is to bring forth. I have seen cases where puncture seemed to hasten changes for the worse. Preservation rather than removal is the spirit of modern surgery. I do not believe in the principle of early operation if that means the removal of small tumors before there are any symptoms.

of the myocardium, apart from those lesions secondary to the acute infections or consecutive to nephritis or valvular disease. Among the acute infections, influenza is a frequent cause of cardiac muscle disease. The diagnosis between neurasthenia of the heart and disease of the myocardium may be difficult. The chief importance of the subject lies in the avoidance of error in the prognosis and treatment of valvular disease, which may be overtreated or undertreated through failure to estimate properly the condition of DR. MALCOLM STORER: If symptoms are waited the muscle; in the recognition of serious lesion of the for it will often be found that operation presents many musclar structure of the heart in cases that have been difficulties. The removal of a small fibroid by enucle- supposed to be normal because of the absence of valation before there have been any inflammatory pro- vular murmurs; in the distinction between organic cesses to complicate matters is so simple an operation and muscular lesions and functional disturbance, and that to me its dangers are far less than those coming in the realization of the fact that the latter may lead from the practice of waiting for symptoms to develop. to the former. In treatment, judicious regulation of DR. RICHARDSON: I would reply to all that has been said by various members about not operating until other treatment is exhausted by quoting from my paper that if the tumor can be controlled we should not operate. I confess to a certain scepticism as to the disappearance of fibroids without operation. All

diet, rest and exercise, avoidance of exciting causes, and excesses of any kind, the good functional condition of the skin and eliminative organs are of the first importance. Warm, saline, carbonated baths, and, in some cases, gentle massage and resistance exercises carefully adapted to the individual case are of great

benefit. Nitroglycerin is the most useful single agent atheromatous changes taking place throughout the of the materia medica. Strychnine, digitalis, adonis, system, but it is more frequently present than has cactus, strophanthus and spartein have their usefulness hitherto been suspected without such pathological in individual cases. Arsenic, gold and sodium chloride manifestations being present. Do not inform a young and iron are useful tonics. Potassium iodide and mer-man between eighteen and twenty-five that he has curials sometimes have special indication. Venesec-heart disease, because you discover some hypertrophy, tion should be made promptly and sufficiently early in with no complication, the result in most instances of the case of sudden and urgent symptoms of cardiac active exercise. Never hesitate to ask a patient to refailure. turn for further examination, as the condition then may be entirely different from the original investigation. There are more snap "diagnoses " made in the realm of cardiac affections than in the study of diseases in any other portion of the body.

A CLINICAL STUDY OF MYOCARDITIS.

DR. LOUIS FAUGÈRES BISHOP, of New York City, read this paper. Valvular and arterial disease are modified appreciably by myocarditis. The myocarDR. FRANK BILLINGS, of Chicago, said that acute dium is as important as the endocardium or the peri- ulcerative endocarditis might result in sudden death. cardium in cardiac disease. Myocarditis is eminently In atypical cases it may not present the classic sympa clinical disease. Syphilitic cases are the most acute toms; emboli may or may not be present. It is diffiand often result fatally in young persons. There are cult to diagnose; but among the symptoms of importwo clinical groups of the disease: (1) Myocarditis tance are low blood pressure and anemia. Myocarditis due to infectious diseases and (2) myocarditis due to frequently is due to chronic toxemias. The disease disease of the blood-vessels. The significance of pain gives rise to nervous symptoms; gastro-intestinal sympin the left shoulder and left breast is difficult to deter-toms may arise; then dyspnea and oppression supermine, but in persons past middle life it should lead vene, the pulse changes in character and there is evione to suspect myocardial disease. The chief symptom dence of malnutrition. Myocarditis requires early of the condition is the lack of power of the heart to attention. respond to extra work. The earliest symptom is irregularity in the force and rhythm of the pulse. The tive endocarditis is very difficult to recognize. Leucodisease is very common in the negro race, probably cytosis is often very marked, and when there is no owing to the tendency of mixed races to degenerative evidence of a localized collection of pus the occurchanges. Complete physical rest is important in the rence of this phenomenon should lead to a suspicion treatment of cases of myocarditis. It may be caused of the disease. He spoke of a case in which the ulby the intemperate use of alcohol, disuse of the mus-cerative process had perforated the interventricular cular system in general, overwork, worry and infec-septum without producing a murmur. The changes tious diseases.

A PLEA FOR A MORE RATIONAL PROGNOSIS IN CAR-
DIAC AFFECTIONS,

DR. DELANCEY ROCHESTER said that acute ulcera

in myocarditis are the most serious of any heart lesions and are frequently overlooked. Of the valvular lesions, aortic insufficiency is most dangerous. The presystolic murmur is of less serious prognostic import in cases of mitral obstruction than the diastolic murmur. The condition of the general circulation is very important, since changes in the arteries of the body indicate changes in the coronary arteries. The disappearance of a murmur that has existed for a number of years is serious, because it indicates marked changes in the muscle.

by DR. J. J. MORRISSEY, of New York City. Diagnosis should not be based solely upon physical signs, but on a consideration of the cardiac efficiency, the presence of hypertrophy and of the condition of organs far removed from the thoracic cavity, whose relations, while not intimate, yet are closely affiliated with the results arising from an interference with the circulatory system, in consequence of the cardiac dis- DR. JAMES B. HERRICK, of Chicago, said that the ease. Obtain an accurate and comprehensive history present tendency was to lay more stress on the heart of the causation. Closely consider any special feat- muscle than on the valve. The time has passed when ures characterizing the case. When a heart murmur a diagnosis of a cardiac condition can be made merely is discovered, do not give a gloomy prognosis upon from the presence of a murmur. Besides making a that fact alone; consider the condition of the cardiac definite diagnosis of a valvular lesion we must go walls, the probable length of time the lesion has ex- farther and determine the condition of the muscle, beisted, the presence of dilatation or hypertrophy, or cause patients with valvular disease can live a long both combined. The occupation and temperament of time if the muscle is intact. In cases of acute articthe patient are very essential factors in the prognosis. ular rheumatism it is difficult to speak of the condiMurmurs do not invariably mean endocarditis, and a tion of the myocardium. The significance of a murprognosis based simply on the presence of a murmur mur appearing in the course of rheumatism is doubtful; would be rank injustice to the patient, and demon- it may indicate myocarditis, endocarditis, or hemic strate incapacity upon the part of the physician. A presystolic murmur does not always indicate a mitral stenosis, nor has a so-called musical apex murmur any particular significance in prognosis, indicating, as it does, the passage of a stream of blood through a small aperture in the segment of a valve. From the standpoint of longevity aortic stenosis is a favorable lesion. It is usually found in that period when a man should be at the highest point of physical capability, between thirty and fifty. It is frequently present as a part of a general decay, and then develops in consequence of

change. In the treatment of myocarditis rest is of the greatest importance. When dilatation has occurred and death is imminent, bleeding is of value.

DR. JUDSON DALAND, of Philadelphia, spoke of a case of acute ulcerative endocarditis in which there was leucocytosis and said he thought that the sign was of no great value. He spoke of a second case in which antistreptococcus serum was used, and in which alarming symptoms developed in consequence.

DR. HOWARD M. FUSSELL, of Philadelphia, spoke of the importance of other signs than murmurs in