elements, muscle cells and elastic fibres are pressed close to each other, and show by their coloration and retained shape that their injury is slight." Similar investigations by Bissell, of New York, show how complete is the hemostasis. A clot forms on the side of the clamp where the artery enters, and a second one in the central groove of the blades. If a little tissue is left next to the blade when cutting the uterus away, there is a third barrier. Microscopically he has shown that the muscular coats of the arteries are cut and retract and curl inwards, adding to the efficacy of the blood stasis. From this it will be seen that the danger of secondary hemorrhage is slight, and the reports of cases corroborate this view. My conclusion with regard to the angiotribe, therefore, is that it is a safe and efficient means of controlling hemorrhage, renders the operation easier for the operator and much more comfortable for the patient, and is distinctly an advance, and has come to stay. Clinical Department. A CASE OF MORBID FEAR. BY J. W. COURTNEY, M.D., BOSTON, From the Nervous Clinic of the Boston City Hospital. Of all the varied and widely diversified symptoms that arise in connection with that adynamic condition of the nervous system which we designate neurasthenia, none are more interesting than the morbid fears which are prone to fasten upon its victims. It is not in the least surprising that a nervously weak person should be assailed by fears- since fear is the almost inevitable outcome of weakness but the curious forms which such fears at times invest and the psychopathic effects to which they may give rise are always worthy of serious attention. An attempt has been made to give certain forms of these fears specific names, but the result of this attempt is undesirable for two reasons: (1) Because it leads us to suppose that all of these forms are intrinsically different from one another; and (2) because the designations selected are, for the most part, of the usual polysyllabic type with which the nomenclature of nervous diseases is already sadly overburdened. Exactly what to call the variety under which the case to be reported comes is somewhat puzzling. As its basis was a fear of death, it may be considered, primarily, one of "thanatophobia." In its evolution, however, its primary identity became so much encroached upon by other morbid factors that the term selected cannot be said ultimately to entirely cover the condition. At all events, call the case what we may, it was certainly the most difficult, of the kind, to treat that has ever come under my observation, and I doubt seriously my ability to give in words even the faintest idea of the horrible mental torture endured by the patient. Another brother, younger than the other, is now under my care with very marked neurasthenia, and suffers severely from numerous imperative concepts. There are three other children in the family, all of whom are of nervous temperament and of marked nosophobic tendency. The previous history of this patient contains nothing worthy of special note. Her present complaint dated back to her father's death some seven years ago. This, as I have said, occurred suddenly, and immediately afterward the patient suffered from severe nervous chills, which persisted for upwards of a month. Recovering from these, she remained in a more or less nervous condition which had no definite mental expression — up to a year ago last spring, when two other deaths occurred· one in her own family - which completely upset her. The fear of death then took complete possession of her and she began to imagine every one she knew in caskets. She also became very emotional and cried a good deal of the time. She feared death from typhoid, from lightning-stroke, from heart disease and from surgical operation. Her visualizing powers developed to a high degree and she could see herself in the agony, with the family, the nurse and the doctor standing at the bedside. To this general picture the finer details of her demise were finally added with torturing vividness, and she could see herself drawing her last breath and her eyes closing. In addition she could actually feel the death chill creep over her. Among other things in reference to her taking off she worried as to whether this should occur on a hot or cold day, a stormy or a fair one. All this time she was doing her work that of a stenographer - in a purely mechanical but satisfactory way, and insisted to me that she did not in the least foster the above ideas and fears, but that they surged through her brain at all times and under all circumstances. Her entire family were kept in a continual state of anxiety over her condition and were naturally fearful as to the ultimate results upon her mental stability. On my first examination, about a year and a half ago, her physicial condition, except for some impoverishment of the blood, was found to be good, the only physical signs being a slight hemic murmur over the pulmonic area of the heart and a trifling inequality of the pupils. The eyes had been examined by an oculist and no refractive error made out. The question of treatment presented exceptional difficulties, as may readily be imagined. The patient was already goaded to desperation by solicitous friends. and others who insisted that her sufferings were controllable and urged her to busy herself with various things which would enable her they thought to forget them. She insisted that no one could possibly form any idea of how hard and how variously she had struggled to rid herself of her morbidness, but without the slightest avail. The course of treatment I pursued was somewhat The case was that of an unmarried woman of twenty- as follows: I began by explaining to the patient in two years, American-born, of mixed Yankee and Irish some detail she was intelligent, had had a high stock. Her father was distinctly neuropathic and school education - the nature of the general nervous finally died suddenly, near sixty, of coronary sclerosis. condition upon which the mental symptoms were Her mother is alive and well, but of nervous tempera-based, and showed her how necessary I considered it ment. Her eldest brother is nervous and high-strung to direct our combined attention to the nervous system and at one time was prevented from pursuing his busi- in general, without regard primarily to such specific ness for an entire year through fear of heart disease. manifestations as the fears. To accomplish this the For a long time it was terribly discouraging for both of us. She returned at intervals, and always with the story that she was worse. In addition, she complained that her stomach had gone back on her and that she had a constant "bad feeling" extending from the left hypochondrium to the umbilicus. To account for this she expressed the fear that there were probably finger-nails in her stomach - she was an inveterate nail-biter — which she had swallowed; she had heard of a girl dying from such a cause. only drug used was iron. For the rest I insisted nodular, immovable tumor mass. Enemata gave but upon forced feeding, graduated exercises done in class little results. No radical operation was advisable. work, and moderate bicycling, which she had formerly Operation. A left inguinal colostomy was adenjoyed. vised and accepted. After opening the abdomen in the usual position it was impossible to find either the sigmoid flexure or the lower descending colon. After some trouble the splenic flexure was found and brought into the wound, and opened seven hours later. A small amount of feces escaped, and the patient was relieved for a few hours only. She died four days later. Autopsy. Nothing of importance in head. Peritoneal cavity: Small intestines and stomach greatly distended; adjacent coils bound together by an almost black, sticky, mucoid-like material. Portion I insisted that the prescribed treatment should be of intestine forming the borders of the surfaces rigidly adhered to in every particular, and within three in juxtaposition injected. No free fluid in peritomonths she gained sixteen pounds. I then began to neum. Surface of intestine pale except the lines of use suggestion without hypnosis, going, however, injection along the contiguous surfaces. In splenic through the maneuvres which are ordinarily em- flexure is an opening 5 centimetres in size, edges ployed to produce the first stage of the latter. This swollen, reddened; surrounding mucosa dark. There was done, at first, as often as three times a week. is an adjacent pedunculated' mass of fat, deep red, My only success was in substituting a different moist. Descending colon passes directly backward though no more desirable — mental condition. Every- from splenic flexure for a distance of 12 centimetres. thing began to seem strange to her. As she herself In the remainder of its course it is firmly bound said: "It seems queer to think of living; of having down to the posterior wall of the abdomen. The peldefinite work to accomplish; to hear people planning vis is filled with a dense, firm mass; the anterior porto do things at some future time." The most commonplace acts of life assumed a character hitherto undreamed of by her, and she grew so discouraged at her condition and her impotency to rid herself of her horrid incubus that she threatened on two occasions to drown herself. tion of the superior surface being formed by the wall of the bladder, which is covered with hard, irregular, grayish-white, opaque nodules 1 centimetre and more in size. A coil of small intestine is firmly bound down to this pelvic mass, and the sigmoid flexure is lost in it. Anatomical landmarks are completely obliterated in the pelvis. In the right posterior portion is a small, thin-walled cyst resembling in ap I continued my pseudohypnotic séances and set her definite tasks such as memorizing passages from prose and poetic works, which was not congenial and con-pearance a simple ovarian cyst, but no other evidence sequently required considerable mental concentration of the tubes or ovaries or of the outlines of the to do in the interim between visits. I also used uterus can be discerned. The lumen of the loop of the static breeze to the head, but merely to aid the small intestine appears constricted, although its distal suggestive measures. I never allowed her to abandon as well as its proximal end of the U-shaped figure her work for even a day at a time and was finally re- is dilated. The cecum is bound down to the pelvic warded after many relapses with what may prac-mass and the lumen of the ileum near the ileocecal tically be termed a complete cure. She now does not valve appears occluded. The intestine here is bound care to have the old fears or the queer thoughts men-down posteriorly and is apparently converted into a tioned at all. If they are spoken of, she changes large cord. Beyond this point the intestine is colcolor and turns the conversation into other channels. COLOSTOMY FOR OBSTRUCTION DUE TO MA- BY J. B. BLAKE, M.D., BOSTON. lapsed. No trace of appendix is found. It is evidently buried in the mass of fibrous tissue about the cecum. Here and there over the serosa of the intestine and mesentery are firm, granular appearing, whitish nodules, .5 centimetre to 1 centimetre in size. Only three or four of these bodies were found. Similar nodular masses bound the sigmoid flexure to the pelvic wall. Gall-bladder distended; united to hepatic flexure by fibrous bands. Diaphragm fifth interspace left side; fourth space right side. In the upper part of the anterior mediastinum the tissue is indurated and a small dense area found, which on section shows a fibrous structure beset with white opaque spots, giving it a rough, granular appearance. Metas THE abdominal viscera from a case of extensive malignant disease were recently shown at the Surgical Section. The case seemed of sufficient interest to warrant a description. The patient was an Italian woman, age fifty. She had irregular and profuse menstruation until four months before entrance. Since then flowing had ceased, but the abdomen had Anatomical diagnosis.— Cancer of bladder and vaincreased steadily in size. In bed five weeks before gina with direct extension into pelvic organs. coming to hospital. During this period her bowels tases in retroperitoneal, bronchial and mediastinal moved only six times. She entered March 26, 1900. lymph nodes. Stricture of ureters; hydronephrosis of She was poorly nourished and cachectic. No nodules right kidney; obstruction of intestine at ileocecal in breast, but some in left supraclavicular region. Ab- valve; edema of lungs; chronic fibrous peritonitis; domen considerably distended and tympanitic, except chronic fibrous pleurisy. in right iliac region. Intestinal peristalsis visible. Uterus fixed in pelvis, and an ulcerated crater replaced the os. Rectal examination showed anteriorly a hard, The case offers two points of interest: (1) The remarkable extent of the growth and the rapidity of its development; (2) an unusual complication in the comparatively simple operation of inguinal colostomy. some way influenced the appearance of the eruption. The distended small intestine bulged into the wound In attempting to classify the cases, certain characterand was returned to the abdominal cavity with diffi-istics that have not been emphasized as usual features culty. The apparent absence of descending colon was of dermatitis herpetiformis force themselves upon our very puzzling for some time and the presence of the notice. The localization of the lesions was striking, omentum at the splenic flexure made it more difficult as there was a marked tendency to grouping about to bring the intestine properly into the wound. The the mouth, chin, nose and ears, and upon the backs of operation gave no permanent relief, because the small the hands and feet. Besides this, the extensor aspects intestine was occluded at the ileocecal valve. In of the extremities were in general more prominently palliative operations, therefore, for the relief of more affected. In all the cases the trunk was affected but or less complete intestinal obstruction due to intra- slightly as compared with the other regions of the abdominal malignant growths, it is well to bear in body. The itching was not very pronounced. In the mind that the right as well as the left inguinal region present state of our knowledge of the bullous dermamay be the seat of the stricture; and it is possible toses it is wise to go slowly and imprudent to draw that in these cases a median incision and an explora- deductions from any but a large number of carefully tory operation, as a preliminary, would be advisable. reported cases. If the condition of the case demanded, an artificial anus might be made at this opening. There was no indication of the hydronephrosis before death. Reports of Societies. AMERICAN DERMATOLOGICAL ASSOCIATION. FIRST DAY. MORNING SESSION. DR. GEORGE T. JACKSON, of New York, read a paper on LOSS OF HAIR. This was a study of 300 private cases. Elaborate statistical tables were presented. His conclusions were as follows: Loss of hair is far more frequent among men than among women. Neither the unmarried nor the married state exerts any influence on the hair. Intellectual occupations and worry and strain are predisposing causes. Sixty-six per cent. of the cases begin before thirty years of age. In women general thinning of the hair is the most common form, while the receding forehead is uncommon. In men THE President, DR. HENRY W. STELWAGON, of the whole top of the head is most often affected, and Philadelphia, read the ANNUAL ADDRESS. the receding temple is common. The great predisposing cause of loss of hair is heredity. Most of the women who lose their hair show a well-marked hisOur ultimate aim, he said, is the diminution of tory on the maternal side; the men show it on the suffering and the cure of disease. It is well to re- paternal side. All disorders of the general nutrition member that this end is not attained by the clinician of the body are predisposing causes. The greatest alone, nor by the therapeutist alone, nor by the patho- exciting cause is dandruff, a term used to include logist, nor by the bacteriologist, but by these investi- seborrhea sicca, pityriasis, seborrheal eczema or dergators going hand in hand, each having an important matitis. As to treatment, the best drugs are sulphur, and necessary share in the final result. Bacteriology resorcin and the mercurials. The only stimulant especially must be persistently cultivated. At the worth mentioning is massage, and this should not be same time, the hereditary receptivity, the family vul- employed until the dandruff is checked. nerability, the environment, and the state of the The paper was generally discussed by Dr. A. general health, are factors of moment in many cases, Ravogli, Dr. Isadore Dyer, Dr. J. N. Hyde, Dr. and their removal or modification by hygienic and Joseph Zeisler, Dr. T. C. Gilchrist, Dr. Wm. A. constitutional treatment will often render the mi- Hardaway, Dr. Samuel Sherwell, Dr. Joseph Grincrobic invasion less calamitous, and be of aid in re-don, Dr. Henry W. Stelwagon, and Dr. George moving the disease. Thomas Jackson. The reader referred to the teaching of dermatology in the medical colleges, and the increased importance attached thereto and the great advances therein. He spoke of leprosy as a disease which must as yet be considered from the standpoint of prevention, and the necessity that the matter should be handled by the national authorities. DR. JOSEPH ZEISLER, of Chicago, read this paper. Othematoma consists in a rather suddenly appearing effusion of blood between the cartilage of the auricle and the perichondrium, separating this latter from the former. It is situated on the upper half of the anterior aspect of the organ, and the swelling is con siderable. The chief occurrence of othematoma after traumatism is well established. The writer carefully searched the authorities as to the possible connection of othematoma with syphilis, and the only reference he could find to it was by Bouvier, in 1889.1 Dr. Zeisler's attention was called to this possibility by the following case: Dr. X, about forty years old, had a small wart-like lesion on his right thumb, which was removed by excision and cauterization with nitric acid. Archive for Dermatology and Syphilis, vol. xx, 1890. SKIN AND MEASURES NECESSARY TO LIMIT THEIR The glands of the axilla became much enlarged. Six THE PREVALENCE OF PARASITIC DISEASES OF THE weeks after the operation on the thumb, a generalized, copious roseola made its appearance. Mercurial injections, inunctions, etc., were given. About a year later an othematoma appeared on the right auricle. Under a liberal administration of iodide of potassium the othematoma promptly disappeared, never to return again. The most natural explanation of the case is on the basis of perichondritis due to syphilis. EVENING SESSION. A CASE OF BROCQ'S ERYTHRODERMIE PITYRIASIQUE DR. J. C. WHITE, of Boston, reported this case. The patient was a healthy Irishman, with a negative family history, who about twelve years ago noticed red spots of considerable size on his lower leg which disappeared in the spring, and reappeared each autumn, invading more and more the general surface until the entire surface was almost covered. They showed themselves every year at the beginning of cold weather, remained unchanged throughout the winter, and vanished in April. They had never given rise to any subjective symptoms. On inspection his face and neck were largely occupied by bright red areas of irregularly circular outline, varying in size from onehalf inch to two inches in diameter. They were mostly smooth, not at all elevated even at the margin, and were not thicker than the normal skin. Another case was seen about the same time by Dr. Charles J. White, in a young German, age twenty-six. The two cases bore a strong resemblance to each other in the general appearances, but were far from identical, the second one covering much larger individual areas uniformly and being more scaly, as in Brocq's case. It also lacked the peculiar brownish tint of the first case. DR. WILLIAM THOMAS CORLETT, of Cleveland, read this paper. The frequency of diseases of the skin due to animal and vegetable parasites as reported by this association show that, next to eczema, epizoic dermatoses are the most prevalent of all skin affections in this country, being met with 95 times in 1,000 cases of skin disease, or 9.529%. Favus in this country is almost wholly an imported disease. The frequency as well as the severity of ringworm differs in different countries: in lowlands it thrives and is virulent. The principal sources of infection are asylums and similar institutions where children are often accepted and congregated without due regard to their contagious condition; kindergartens and schools; the poor or slum districts where children are crowded together in uncleanly tenement houses, and domestic animals, especially horses, cows, dogs and possibly poultry. The habit of using the same barber's utensils without previous cleansing for different persons should not be tolerated. The hanging of roller towels in hotels is a dangerous custom. Barber shops should be under the supervision of boards of health. Treatment of parasitic dermatoses should be prolonged until the disease is wholly eradicated, and a certificate to this effect given by the medical attendant before the person is admitted in close communion with others. DR. HENRY W. STELWAGON, Philadelphia, reported TWO CASES OF PERSISTENT EXFOLIATION OF THE LIPS. The first case was in a young woman, about eighteen. The urine showed considerable deposit of DR. PRINCE A. MORROW, of New York, read a urates. The condition was limited to the vermilion paper entitled THE PROPHYLAXIS AND CONTROL OF LEPROSY IN of the lips, neither overstepping the mucous portion of the mouth nor the cutaneous integument. The lips when free from the scale or crust formation appeared normal, at times showing scattered points of The reader referred to the growing likelihood of superficial abrasion. The first stage in the formation contagion from our recently acquired possessions in of an exfoliating film consisted of slight but scarcely the Philippines and Hawaii, and the necessity for na-perceptible thickening. In a short time, from two to tional action in order to prevent the spread of the five days, the affected parts would break up into disease. He suggested the employment of skilled ex- plaques, by a breaking through of the film, and the perts as quarantine inspectors. He deprecated the edges of the plaques would gradually become medieval conception of the horror and virulence of everted, and slowly loosen and detach themselves. the disease, which is now known to be no more con- If pulled off or forcibly detached the lips would be tagious than tuberculosis. Isolation or segregation red, slightly abraded and somewhat tender. The exundoubtedly are the most effective means known to foliative process went on unceasingly. The disease is sanitary science for the control of this and other con- still persistent but no longer under the reader's care. tagious diseases. Homes or asylums with suitable The second case was in a woman aged thirty. The hygienic surroundings should be provided by the na-patient was profoundly neurasthenic. Both lips were tional government for the care and maintenance of to a great extent involved, although the central parts lepers. Such asylums should be made comfortable were most markedly affected. There was slight and attractive and arranged with especial adaptation seborrhea capitis in both cases. The reader was into the requirements and peculiar needs of its in- clined to consider the disease as allied to eczema mates. In view of the chronicity of the disease, seborrheicum. lepers should not be condemned to close confinement in inactivity, but should be provided with interests, means of employment and recreation. As a large proportion of lepers are able to engage in some kind of industry, such institutions might be made partly or wholly self-sustaining from the proceeds of these industries. THE ETIOLOGY AND PATHOLOGY OF CUTANEOUS CANCER. DR. A. RAVOGLI, Cincinnati, who read this paper, said that from the greatest antiquity the clinical conception of cancer has been an ulcer, especially of the skin and glands, with exuberant growth of granula tions, which when removed has a tendency to relapse, cessive generations of some families, due, as is now gradually spreading and under marantic conditions believed, not to the inheritance of the disease, but to causing death. The true etiology was first given by an inherited susceptibility. The influence of age upon Billroth, who considered as carcinoma only those new the appearance of carcinoma is so very evident that it growths which result from epithelial production, to- is no longer a matter for debate; in the great majority gether with an infiltration in the connective tissues. of cases the patient with cancer is past forty years of It is quite natural that the masses of epithelial cells, age, the exceptions to this rule being in most cases crowding themselves into the midst of the connective examples of rodent ulcer. Ribbert produced numertissues, must produce an irritation which causes a pro- ous tumors in the abdomen, uterus, diaphragm and liferation of the connective-tissue corpuscles. These pleura of an animal (a rabbit) by allowing free epithecorpuscles, which have the task of providing for the lial cells to diffuse through the peritoneal cavity. Cannutrition of the connective-tissue fibres, are greatly cer possesses a considerable number of features, clinical developed in the embryonic stage. In adult life and pathological, which suggest the possibility of its they are very much smaller, but on account of some being an infection, although other explanations are not inflammatory exudation, they return to their em- absolutely precluded. We may regard it fairly well bryonic stage; increasing in their volume, their demonstrated that this neoplasm results from a pronuclei proliferate, they increase in quantity, produc- found and more or less permanent alteration of the ing hypertrophy of the connective tissues, until they mechanism of cell division. This alteration may rereach the form of papillary growths. In carcinoma sult from long-continued irritation of a mechanical or the presence of sharp epithelial cells crowding down chemical kind. The immediate causes are therefore upon the delicate structure of the connective-tissue multiple. In cases of xeroderma pigmentosum it may fibres, causes the connective-tissue corpuscles to take be assumed that some inborn defect of the skin exists. part in the proliferation, hence carcinoma is a malig- DR. F. J. SHEPHERD, of Montreal, considered nant production consisting of masses of epithelial cells imbedded in a connective-tissue structure, inflamed and infiltrated. DR. E. B. BRONSON read this paper. The import of the epithet malignant as applied to disease varies according to the circumstances under which it is employed. As most generally used the term implies a rapid, destructive course, tending to a fatal issue. It is thus used to designate certain forms or varieties of a disease of a severe and dangerous type, in contradistinction to other forms of the same disease that pursue a relatively milder or "benigner" course. Thus we have malignant and benign form of syphilis and tuberculosis. Pernicious cell growths may originate either in the epithelial structures or in the connective tissue. In the one case the resulting disease is carcinoma, in the other sarcoma. All known 66 lignant "growths pertain to one or the other of these two diseases. An epithelioma, though, in the common acceptation of the term, a skin cancer, is not necessarily a malignant growth, only potentially so. A promising field for the study of malignancy in diseases of the skin and of the conditions relating to it is found in those diseases that, beginning as an inflammation or simple perversion of growth, end in malig nant cancer. The epitheliomas that develop on old syphilitic lesions, on lupus, or from some indifferent local irritation of the skin, are common instances. DR. M. B. HARTZELL spoke on (c) THEIR TREATMENT. As a surgeon who had to treat all kinds of malignant disease, wherever situated, excision of the growth and the adjacent lymphatic channels and glands seemed the most scientific procedure in the majority of cases. He said that all now believed in the local origin of cancer, and also that whenever found it should be quickly and completely removed. The disease being local, only local treatment was curative. Constitutional treatment was of no avail. In There are two forms of local treatment, removal by knife and removal by caustics. Surgeons favor the former and dermatologists the latter. The weak point in the treatment of malignant disease of the skin by caustics is that it postponed the removal of the neighboring lymphatic tissue and glands. Dr. Shepherd held that there may be malignant disease of the glands and yet they cannot be always told, as in the axilla and submaxillary region. Even the microscope would fail to detect the disease in the glands, the cancer cells in the very early stage being so few and far between. He instanced the magnificent results of the removal of mammary cancer by modern methods of ma- very extensive operations. In Paget's disease of the nipple he advocated removal of the whole breast. cancer of the lips, scrotum, penis, vulva and whenever the skin was loose, removal by excision was advocated. Certain malignant ulcerations of the skin he admitted might be successfully treated by caustics, especially rodent ulcer and those slow-growing forms of epithelium situated in regions somewhat removed from glands, as the nose, forehead, temples, cheeks, hands and where the glands are not early affected. He had successfully employed free curetting and the after application of caustics in such cases. The best caustics were arsenic, chloride of zinc and caustic potash. Some hold that arsenic has a selective action; that is, an inflammation may be produced which will destroy cancer cells but not normal tissue. Before employing arsenic the ulceration should be curetted, or the epidermis over it should be destroyed by caustic potash. Several other methods of treatment were alluded to, such as the parenchymatous injections of alcohol, nitrate of silver, chloride of zinc, electrolysis, aniline (b) THEIR ETIOLOGY AND PATHOLOGY. Heredity, age, traumatism and long-continued slight irritations have long been considered as predisposing, in greater or less degree, to the occurrence of cancer. While heredity is no longer believed to play the important rôle formerly attributed to it, yet it is apparently well settled that cancer is apt to occur in suc |