læ just beyond it much enlarged, and the interpapillary prolongations of the rete prolonged downwards, for a considerable distance laterally, and below the tumor there was dilatation of vessels surrounded by round cells (leccocytes) thicker just about tumor, diminishing as the distance from tumor increased, going into the adipose tissue in some places; cell infiltration especially abundant about hair follicles and sweat glands, obscuring, sometimes obliterating them.

Sections parallel with longitudinal axis of tumor appeared as if made up of loosely arranged delicate fibrils, with a clear outline, running with the long axes, and formed a fine network with narrow flattened meshes lying horizontally, containing many fusiform cells, attached to the border of the mesh. These cells, everywhere numerous, are most abundant about the vessels.

The fibres in the papillary layer ran at right angles to those in the tumor, forming a narrow band of cribriform tissue. In many sections the papillæ and rete pegs were quite normal over the tumor in some parts and obliterated in others even in same section. It appeared to depend upon whether tumor was farther from or nearer to surface, whether the papillæ were normal or not.

On comparing this with what Langhaus, Warren, Jr., Neumann, Kaposi, etc., (who examined older tumors) say, we find some further changes produced. When the tumor has lasted for some time, a large number of vessels, especially in the centre, obliterated by pressure of carm. tissue and becomes fibrous bands (oblique bands of Langhaus). The cells and nuclei disappear for most part; the new fibrous tissue contracts and forms close bands which are parallel to long axis of tumor.

So far true and false (scar) keloid are identical in their anatomy; they differ, it is said, in that in true keloid the papillæ and retepegs over the tumor are intact, while in scar keloid they are obliterated. This alleged difference has been considered a proof that spontaneous keloid was a true new growth of the corium, while the false kind was on an hyperplastic cicatrix. Bahes examined a spontaneous case (Schwimmer's) and found same condition as in scar keloid. From this we must infer that Bahes examined a scar keloid, or that obliteration of papillæ, etc., had occurred by pressure of the growth. Crocker thinks this may occur and is demonstrated by his case. The cicatrix of origin was linear; rete and papillæ presumably normal on each side till keloid formed and that

evidently developed by two lobes, one on each side of cicatrix and growing upward, obliterated the papillæ in some parts and not in others.

Bahes finds this supposed reliable distinction absent in a spontaneous keloid, while it is present in Crocker's scar keloid, which would make them the same.

Division into true and false keloid is unsound on clinical and anatomical grounds: cases may be called spontaneous which are not known to originate from scars, but it is for clinical convenience, not to express pathological difference.

Both Warren and Crocker observed that the blood vessels (starting points) are affected far beyond the tumor. This accounts for recurrence after removal, to avoid which cut wide of the tumor. Spontaneous evolution does occur.-Brit. Med. Jour. Sept. 18, 1886.

COCAINE INTOXICATION.-Dr. Taylor, in a late discussion before the Richmond Medical Society, mentioned the following case to illustrate the danger from cocaine intoxication. A young physician who, while a student, had cocaine prescribed for some supposed kidney disease. The cravings of his system for more of the drug became more and more pressing. If his own knowledge warned him of his danger, he probably consoled himself with the reflection that his kidney disease was progressing, and more of the remedy was demanded. For weeks before he was seen by Dr. Taylor, he had been in Richmond on a protracted spree, and his conduct was so strange as to give rise to the suspicion that he was insane. It was then discovered that he was taking cocaine hypodermically every few hours. When a stop was put to this he was a raving madman; swore he would kill himself, and had to be watched constantly to prevent him from carrying his threat into execution. His delirium finally became so violent that a commission of lunacy sent him to an asylum, but in a few days he made his escape and returned home. His brothers then took charge of him, confined him to his room, and kept a guard over him constantly, and in that way finally broke him of the habit, to which he was a slave. For six weeks his ravings were represented as violent, and his delirium was acute and distressing.-Quar. Jour. of Inebriety, Oct., '86.

MANY good temperance people can only see inebriety from one point of view. All the relations and surroundings of the subject are not considered. The one view is considered correct beyond all doubt and question.

SOCIETY PROCEEDINGS.

ST. LOUIS OBSTETRICAL AND GYNECOLOGICAL

SOCIETY.

Stated Meeting, October 21, 1886.

VESICO-VAGINAL FISTULA-VESICAL SPASM.

Dr. Prewitt.-I will report two cases of vesico-vaginal fistula I have had recently and which are interesting from the circumstances connected with them. In one of the cases a physician in Illinois had attended the woman in labor, which had lasted for about eighteen hours when he applied the forceps and delivered her. A fistula followed, and the husband at first was disposed to think that it was the result of the use of the forceps. Some doctor had told him that this was the cause, and he was disposed to sue the attending physician for malpractice. The doctor wished me to take charge of the case and also tell the parties my view of it. The doctor said in his letter that the labor had been rather tedious, and had lasted eighteen to twenty hours when the head became engaged in the outlet of the pelvis, and he used the forceps to deliver her. I examined the patient and found a fistula at least an inch and a half in length, lying pretty well back. The cervix itself was so greatly lacerated and ragged that, had she not been a young woman and just delivered, I would have been tempted to believe that there was an epithelioma. After a few days I operated, passing the stitches from the right extremity through a portion of the lacerated tissue about the cervix, so that I had some doubt about the union being complete and told her so. She was very anxious to get back, and couldn't wait until the parts were entirely healed. Union occurred throughout the greater portion of its extent; but there was a very small opening left at the point where the stitches had passed through the lacerated tissue. I wrote to the physician that the fistula was not the result of the use of the forceps, but that he applied his forceps too late. The forceps are

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applied laterally, and could not by any possibility touch that part of the vagina. The trouble was that the forceps in this case were not used early enough. I simply wanted to bring the matter before the society, because there still seem to be some doctors who are ignorant enough to suppose that the use of the forceps could produce vesico-vaginal fistula.

Another case of considerable interest to me I operated on about two weeks ago, a woman who had been operated on five times before by three different surgeons, each time the operation proving a failure. In that case the excoriation and swelling of the labia and parts were something tremendous, the labia were as big as my two fists, and red and angry, covered with a little phosphatic deposit, which is frequently found in such cases, and the itching was agonizing. The poor woman suffered perfect torture every night. It was absolutely necessary to get the parts in better condition before any operation was attempted, and I kept her in the hospital perhaps three weeks, using the douche, administering benzoic acid and borax internally, and finally the parts improved very much and became in much better condition, so that I operated. A peculiar circumstance was that I placed in the bladder a self-retaining catheter, and within a short time there commenced such a spasm of the bladder as I never before saw. I attended her for three or four hours, and in the meantime she had been suffering perfect agony. When I was called to see her, I attempted to remove the catheter, and it required quite an effort to pull it out. The mucous membrane seemed to be forced into the little openings in the self-retaining catheter, so that it required quite an effort to draw it out. was puzzled to know what to do. I replaced the catheter, but the trouble began again as violently as ever. I introduced a small, soft catheter into the bladder, and she was able to retain it, at least with the use of rectal injections of McMunn's elixir freely administered, and I replaced the large one the next morning. The catheter got out several times, and she passed water through the urethra. I think the next day she passed water through the urethra, and several times during the week before the removal of the stitches, she did so; and she preferred it so much to the draining of the catheter that I think she was anxious to do it and not have the catheter replaced. On the eighth day I removed the stitches. I find since, on applying the speculum, that there is some leakage. She told me that she had suffered from these spasms of the bladder after the

other operations, but it did not occur to me to take any precautions against it. Probably had I profited by the experience of the others, I might have avoided this by using either a soft catheter primarily, or by the use of McMunn's elixir by the rectum or by suppositories. The soft catheter did not seem to provoke the spasm: whether she would have had it had the soft catheter been used first, I cannot say.

FIBROID TUmor.

I have here a portion of a fibroid tumor of the uterus, which is interesting chiefly from the circumstances connected with it. The patient was an unmarried woman 28 or 30 years of of age, who had been under the care of a physician of some intelligence in this city, for some months, and he was treating her for ulceration. Within the last two or three months she had placed herself under the care of a female doctor, and this female physician had continued to treat her for ulceration of the womb, and had seen her only a few days before I was called in. Another physician had been called in, and, upon making a slight examination, found a growth or tumor there, and immediately called for me to see the case with him. I had with me two écraseurs, as I hoped to be able to remove the growth with them. I found quite a large fibroid projecting into the vagina. The lower portion of it had sloughed, so that there was a most offensive odor from it. How anybody could have mistaken it for an ulcer is a most singular thing to me. It is not possible that that tumor could have protruded through the os without having been apparent. In fact it must have been very apparent even before it projected into the vagina; yet a physician had treated her locally for ulceration of the cervix, and this female physician had also treated her locally for the same condition; and had told her two or three days before before I saw the case, that the discharge was so bad she could not make a treatment. The tumor was as large as my two fists. I applied the wire écraseur and broke two wires, althoug I had quadrupled them. Then I put on a flat chain écraseur. As you all know, if you happen to get a little twist in the chain, and it is almost impossible to apply one without getting it twisted, it is apt to break. I put it on as high up as I could, and tightened it. When a considerable way through the tumor, the chain broke. If it had been a round chain instead of a flat one, this would not probably have taken place. The tumor projected so far into the vagina that I could not get up high enough inside the uterus to en