glenoid fossa behind the articulation of the jaw. A tumor starting here would meet with less resistance going into the mouth, than outwards into the face."

In spite of the diversity of structure in the tumors above described, they all resemble each other in that they are heterologous growths, that is, they consist of, or contain, tissues which are not normally present in the part from which they originate. In other words, they are all undoubtedly the result of the development of embryonic inclusions, and fall properly under the head of growths known as teratomata. These inclusions are prevented from developing in early life by the pressure of surrounding structures; but when, later in life, for some reason or other, this pressure is lessened, or some unknown irritation arises, the potential power of the inclusion may be converted into a condition of active proliferation, and a teratoid tumor results.

TREATMENT OF EPITHELIOMA OTHER THAN BY THE KNIFE.

BY JOHN L. COFFIN, M. D., BOSTON, MASS.

[Read before the Mass. Surgical and Gynecological Society, Dec., 1900.]

The treatment of epithelial growths of the skin by caustic rather than by the knife has claimed the attention of the profession, more and more for the past few years, and has constantly gained in favor rather than lost. It was my privilege, fifteen years ago, to hear the method of cauterization in selected cases advocated by Dr. A. R. Robinson, of New York, and in a most able and interesting article, published in the New York Medical Record for March, 1900, after twenty years' experience, he is more firm than ever in his conviction that cauterization is in many cases the best, safest and most effectual treatment for cutaneous cancer.

Just what is the condition which confronts us in an epithe

lioma of the skin? We have an abnormal proliferation of the epithelial cells, pushing down into the subcutaneous tissue which, as the disease progresses, becomes itself invaded. The lymph-channels take up the wandering epithelial cells, carrying them to the nearest lymph glands where, becoming localized, they act as new foci for the development of the disease, and we have what is known as regional infection. For the reason that the new epithelia constituting the growth never reach maturity, they are short lived and soon undergo degeneration of one kind or another, and we have the well known and characteristic ulceration as soon as marked extension of the original focus begins. From this it follows that in any case, where ulceration to the slightest degree has taken place, there must exist a surrounding zone already invaded by the epithelial hyperplasia, a zone the extent of which it is impossible to estimate from the macroscopic appearances.

It is not within the province of this paper to discuss whether it is a blood or microbic disease, suffice it to say that Nicholas Senn, in the recent second edition of his admirable work on tumors, quotes De Morgan in these words: "I can see no analogy between new growth, whether as innocent as lipoma or as malignant as cancer, and the products of true general or blood diseases. From the first, a tumor is a living, self-dependent formation, capable of continued growth, by virtue of its own power of using nutritive material supplied to it. Nothing like this is seen in any of the blood diseases," to which Senn adds, "Until additional and more positive light is shed upon the microbic origin of a cancer, we must adhere to the theory that carcinoma is an atypical proliferation of cells from a matrix of embryonic epithelial cells of congenital or post-natal origin."

From the careful study of the pathology of a carcinomatous growth it is evident that up to a certain point, probably when the lymphatics begin to take up the hyperplastic cells, and subsequent regional affection takes place, cancer is

practically a benign growth and is susceptible of absolute cure, provided sufficient tissue is removed and no diseased cells left behind to serve as foci for new development. This result is undoubtedly accomplished by excision provided sufficient surrounding, apparently healthy tissue is sacrificed, but to determine just how much is necessary, is difficult to tell from appearances. In some cases excision sufficient to produce the desired result is productive of great mutilation, necessitating secondary plastic operations for cosmetic effects. It is in this latter class of cases especially that destruction by cauterization is applicable and gives most excellent results. Its advantages are that owing to the lessened resistance the cancer cells are destroyed much more quickly than the normal tissue, so that comparatively little normal is sacrificed, and the resulting disfigurement is reduced to a minimum. Again owing to what some believe to be a selective affinity on the part of certain drugs, especially arsenic, the cauterization extends sufficiently into surrounding tissue to destroy the diseased cells, thereby rendering return as little likely as if the whole surrounding zone was excised, or again, what is more likely, by the surrounding inflammatory action set up. On this point Robinson says, "The destruction of these outlying cells depends, in my opinion, first, upon the existence of the acute inflammatory process destroying the pathological tissue quicker than it does normal tissue, according to a general law in pathology, and especially so in this instance, as the pathological epithelia lie in the lymph spaces and can, therefore, be vigorously acted upon by the inflammatory lymph, thus changing quickly and very greatly the previous condition under which they live; second, that arsenic has a special selective antagonistic action on the epithelia in this disease, and third, that the toxins and toxalbumens from the necrosed tissue act distinctly upon the epithelia, or if the disease is a parasitic one, upon the organisms present."

Of the various substances used in this destructive cauterization, I much prefer arsenic and have, of late years, seldom

used anything else.

attention to detail.

Success, however, depends much on For small, scaly patches, with which

many cases begin, the repeated painting with Fowler's Solution, three or four times a day, until considerable inflammatory reaction is set up is sufficient. For the ulcerated cases the Marsden's Paste is by far preferable. Should there be much elevation above the surface it is best to curette the surface first, and it is imperative that any sound skin over the border of the ulcer and surrounding infiltration should either be entirely removed or thoroughly scraped or scarified. The length of time that the paste should be applied is much a matter of judgment and experience, some tissues reacting very quickly and others very slowly, so that its action must be more or less closely watched in any case. An average time is from twelve to sixteen hours. It should be applied until the whole visible portion is thoroughly necrosed. The subsequent dressing consists in simple application of some aseptic dressing, such as carbolized cosmoline, borated ung. aq. rosae or, as Robinson suggests, subiodide of bismuth, twenty grains to the ounce. After the separation of the slough, if healing is slow, I apply a ten per cent. aristol ointThe pain suffered by this plan is often severe for the last few hours, sometimes necessitating a small dose of morphine. In the last four cases I have operated upon, however, I have incorporated ten per cent. of eucaine with, so far as I could see, no injurious results and with complete absence of pain or even discomfort. But the number of cases is, as yet, too small to draw conclusions concerning all cases.

ment.

SOME THROAT SYMPTOMS OF LACHESIS.

MAURICE W. TURNER, M. D.

The throat symptoms of Lachesis may be divided into two

groups.

The first includes the characteristic symptoms, i. e., those which differentiate this remedy from others; and also some

general symptoms applicable to the part. It consists of nine more or less complete symptoms, which are as follows:

1.- Throat and neck sensitive to slightest touch or external pressure; it may cause nausea.

Everything about the throat distresses, even the weight of the bed clothes.

If in the evening on lying down anything touches the throat or larynx, it seems as though he would suffocate and the pain is much increased.

2.- Difficulty of swallowing of saliva, not food; of liquids more than solids, they escape through the nose.

With spasmodic stricture, on swallowing solids there is a struggling and the food "goes the wrong way," gagging follows.

3. Feeling of a lump in the throat; sometimes painful; suffocative sensation; must swallow often; on swallowing the lump descends but returns at once. It feels as if it could be brought up, but it will not come. May wake from sleep distressed and unhappy with this sensation of choking; must have the whole neck bare.

4.- Tendency to affect the left side either alone or to begin on the left and extend to the right.

This is the common feature, but the reverse may be true, i. e., the right side first involved with extension to the left, where it remains fixed.

This does not contra-indicate Lachesis.

5.- Recumbent posture often impossible..

6.— Aggravation after sleep; or the aggravation wakes him from sleep; i. e., sleeps into the aggravation.

This is spoken of as the morning aggravation of Lachesis when it comes on waking in the morning, more properly it is the aggravation after sleep.

Often, especially in the severer cases, the patient feels the aggravation immediately on going to sleep and it arouses him.

7.- Aggravation from hot drinks.

8.- Pain in the throat, extending to the ears; desire to