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C. That in the absence of a laparotomy one can never tell with certainty whether any intra-abdominal organ is injured.

13. A healed perforation of the uterus apparently does not interfere with the normal development and the normal termination of a subsequent pregnancy.

BLASTOMYCOSIS.

BY GEORGE W. SPENCER, M. D., PROFESSOR OF DERMATOLOGY, CLEVELAND HOMEOPATHIC MEDICAL COLLEGE.

Gilchrist, in May, 1894, and shortly afterward, Buschke, were the first to find the organism of blastomycosis in the secretion of the skin, and showed that the disease was due to the invasion of the tissues by sacehromycetic-fungi. Gilchrist, Stokes, Curtis, Hyde and Montgomery have inoculated animals and have produced the lesion from which fungi have been recovered and cultivated.

The clinical and pathologic features have been chiefly worked out by American dermatologists. The initial lesion is a split-pea-sized nodule, which after a time becomes pusular and breaks down into an ulcer. This may extend in several directions and others may form in the neighborhood. In nearly all cases there is a papillary growth, sometimes fungating. In the case here reported a cauliflower growth projected at least one-half inch above the surface of the skin.

A thin mucoid discharge, often offensive, exudes, which may temporarily be overcome by the crusting over of the lesion, but the crust is soon thrown off and a thin pus discharge can be pressed out from between the papillae. In this pus the blastomycetes can easily be found, by the addition of a little liquor potassae, as doubly contoured, refracting, budding bodies. When pus cocci are present they can be eliminated by adding a weak solution of potassium iodid to the culture medium, which kills the staphylococci, leaving a pure culture of the fungus.

The general aspect is that of a scrofuloderma with papillary growth, and lupus verrucosus. The lesion is usually multiple, as the patient innoculates himself from one place to another. It may appear on any part of the body, but must have a starting point. It may be very extensive without affecting the general health. Anthony Herzog reported a case lasting twenty years, without any general. constitutional disturbance.

Pathology:-The disease is due to the presence of blastomycetes in the skin, followed by millary abcesses in the epidermis and upper part of the corium and in these the fungus element can be found,

[graphic]

DR. SPENCER'S CASE OF RLASTOMYCOSIS.

usually in budding pairs, also singly or in groups. Secondary changes are in the epidermis, more or less destruction of horny layer with branching down growths; in the corium, papillary growths and sometimes cauliflower growths.

Diagnosis:-Hyde and Montgomery say that a diagnosis of blas

tomycetes and lupus verrucosus can only be made with certainty by the microscope and cultures. In general, lupus verrucosus is slower in evolution, more often limited to small areas, has a more distinct violet halo and more often about the lower forearm and ankle. It closely resembles so-called protozoic infection, which is a variety of blastomycetes.

Prognosis: It is fully amenable to treatment, but if allowed to go on unrecognized, great destruction and disfigurement may result. A closely allied fungus disease was described first by Wernicke of Buenos Ayres, in 1890, then by Rixford and Gilchrist and was thought by these observers, at first, to be a coccidial disease and called protozoic dermatitis, however, it was shown to be due to fungus elements very like those of blastomycetes. When internal organs are involved, all the cases, thus far reported, have proven fatal.

Case: I am indebted to Dr. A. N. Seidel, of Cleveland, for the case herein reported.

Mary C.-two and one-half years old, apparently in the best of health. The family history of the best, nationality Hungarian, environment seemingly good.

The lesion first appeared on the back of the neck as a small nodule, afterward breaking down, and ulcerated to about the size of a quarter of a dollar. This yielded to treatment, for it was healed when I first saw the case. The second lesion appeared on the right side of the chest. This followed the same course as the first lesion.

Then several nodules made their appearance upon the legs, which after ulcerating, developed the fungus-like growth which the picture shows. An offensive exudation was constantly exuded, if not allowed to dry and form crusts. These crusts were very easily removed but rapidly reformed. One peculiarity was the well defined demarkation of the cauliflower growth as shown on the left leg, where tension was exerted to separate the lesions. One of the growths was cut off with scissors, from which slides were made. This showed clearly the nature of the disease. Salicylic paste was then applied which destroyed the pus and blastomycetic element. Healing resulted. The others broke down, shortly, and were treated similarly, care being constantly taken to prevent the implantation of the disease on other parts of the body. No other nodules appeared and the case made a complete recovery.

Before deciding on the necessity for a laparotomy for some vague abdominal condition, where distention is present, empty the bladder. In many cases the acute abdominal distress will disappear.

REPORT OF A SURGICAL CASE.

BY JAS. D. PARKER, M. D., SANDUSKY, 0.

On the 22nd of January, 1909, I was called to attend Hazel S-, aet. 22 years, who gave the following history: Has had more or less stickness ever since she was ten years old. At one time it was thought that she had pulmonary tuberculosis. Never any attacks like this one however. Physical examination showed a well nourished body, menstrual periods regular, complains of pain on right side of abdomen with some tenderness over the appendix, menses due in a few days, slight vomiting. A diagnosis of probable appendicitis was made. No elevation of the pulse or temperature was found at this or any other of my visits except on the last day when the temperature was subnormal and the pulse was thready and finally lost.

Although there had been no marked constipation I gave her one grain of calomel in broken doses followed by a saline cathartic. Bryonia 3x every hour was also given. The next day the patient was much better and the bryonia continued. I did not hear form her again until the 26th, when her mother came to the office. At this time she was having some pain apparently due to her period which had made its appearance; for which she was given pulsatilla 3x. I next heard from her on the 3rd of February, when she was able to be out of bed and eating ordinary food, with no pain. At the evening meal that day she ate a large quantity of canned string beans. At 3 o'clock the next morning her father came to my office for something to relieve her pain and vomiting and told me what she had done. Ipecac 2x was prescribed and I sent her some opium belladonna suppositories to relieve the pain.

Upon visiting her the next morning she seemed as well as usual. There was no pain nor vomiting and aside from a very slight tenderness over the appendix there was apparently nothing the matter with her. In the evening her mother called me on the telephone and said that the patient had rested well all day but that the pain was returning again somewhat. The family did not think it necessary to call me even though she became worse in the night. At 8 a. m. I was called hurriedly and upon arrival found that the patient had been vomiting since midnight and examination of the vomitus proved it to be fecal in character. The face was blue and the expression drawn, body surface cold, with no perceptible pulse, although the heart was acting fairly well. She was at once removed to the hospital and the abdomen opened with the expectation of finding a perforation. The incision was therefore made over the appendix and

this organ removed. While it was badly congested and the caecum as well, it did not account for the grave condition of the patient. As the caecum and small intestine were collapsed while a portion of the small bowel higher up was distended an obstruction was known to exist. Upon tracing the bowel, about twelve inches of the small intestine was found to be buried in an exudate behind the uterus. This completely shut off its lumen at one point. The general appearance of the bowels was very dark, almost gangrenous.

The adhesions were hastily broken up with no hemorrhage and as the color came back and the collapsed portion filled with the gases the abdomen was closed after filling with normal salt solution. During the operation an assistant gave three pints of normal salt beneath the skin. Patient was removed from the table in better condition than when she went on. While she rallied for a time, later she sank and died at 9 p. m. the same day.

The questions arising in my mind are these: Upon my first visit I advised early operation. 1. Would a surgeon operating at that time for a mild appendicitis be likely to find such a pelvic condition as must have existed in this case? 2. How could a physician of ordinary ability have made a diagnosis of the true condition by the symptoms previous to the last day of her life?

In my opinion there must have been a partial obstruction for some time which did not produce serious symptoms until it became complete. The appendicitis and her indiscretion was the spark which produced the conflagration resulting in the death of the patient.

GENERAL MEDICAL CLINIC AT CLEVELAND CITY
HOSPITAL.

Nov. 19, 1909.

BY PROF. A. B. SCHNEIDER.

1. Broncho pneumonia; myocarditis; chronic parenchymatous nephritis. James, D., aet. 50, laborer; Irish.

Previous history:-Always well until three years ago when he had an attack of pneumonia, from which he recovered completely Has had at different times dislocation of left shoulder, and of right ankle.

Present illness:-Has had shortness of breath and pain in precordium for several months. Patient says pulsations under left nipple felt like blows from a trip hammer. There has been swelling of the face and feet and he could not remain long in recumbent posture.

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