MEDICAL MEMORANDA. For Sale.-First-class surgical chair and fine improved nebulizer. Both will be sold cheap if taken at once. Address" Removed," care Medical Fortnightly, St. Louis, Mo. Authorities and our experience teaches that the most important step toward the amelioration of chronic nasal catarrh is cleanliness. A generous use of an alkaline antiseptic with spray, sufficiently stimulating to encourage the formation of new blood vessels and invigorating those that have remained. Germiletum has proven in my hands the ideal solvent and alkaline antiseptic and will effectually cure the most advanced cases of chronic nasal catarrh.-A. W. Latimer, M.D., formerly physician to the St. Louis City Hospital. My oldest son was troubled with a skin eruption on his chin aud forehead (between the eyes) which he seemed to have caught at school, it resembled a ringworm in some particulars, but was very stubborn, and hard to cure: so I sent to you for samples, believing, through past experience with resinol, that it would do the work. After the first application I could see the improvement, and inside of a week his face was clear again. It is one of the greatest remedies I know of for those nasty, inflamed, raw looking, and rapidly growing sores so often seen on school children's faces, and will cure them every time. I have prescribed it extensively in my practice for some years past, and always with success.-John Husson, M. D., 418 W. 124th street, New York City. Syrup Trifolium Compound with Cascara-An Effective Combination of an Alterative with a Laxative. The superiority of syrup trifolium compound with cascara must be apparent when its composition is noted. Each fluidounce contains the active constituents of red clover blossoms, 32 grains; lappa, 16 grains; berberis aquifolium. 16 grains; xanthoxylum, 4 grains; stillingia, 16 grains; phytolacoa root, 16 grains; cascara amarga, 16 grains; potassium iodide, 8 grains, and cascara sagrada, 40 grains. The dose is from one to two teaspoonfuls, three times a day. While it is particularly indicated in the treatment of secondary syphilis, with or without mercury, syrup trifolium compound with cascara commends itself as a general alterative. În skin diseases it evidently stimulates the action of the emunctories, adjusts the balance of waste and repair, and produces marked improvement. Many eruptive diseases are aggravated by constipation, induced by sedentary habits, and in such cases syrup trifolium compound with cascara P. D. & Co. may be regarded almost as a specific. While regulating the bowels and restoring natural peristalsis, it continues to exercise its alterative effect, which is enhanced by the elimination of waste products. In psoriasis and eczema it may be found effective when other measures produce indifferent results. In strumous cases its favorable effect may be supplemented by combinations of iodide of arsenic, bichloride of mercury, sulphide of calcium, or iron. As it is easily borne by the stomach and pleasant to the taste, it may be taken by children for a long time without giving rise to derangement of the stomach or producing nausea It also proves useful as a vehicle for calcium iodide in the acne of adolescents; iodide of mercury in specific ulceration of the fauces; and for the administratiion of large doses of iodide of potassium in tertiary syphilis. In anemia, chlorosis, amenorrhea, etc., the most favorable results are produced by alterating it with some iron preparation. A New Preparation for the treatment of septic and inflammatory conditions should hold great interest for physician and surgeon, particularly when the article has been subjected to tests and trials which have demonstrated its efficacy with such positively beneficial results as to make certain that it is entitled to a prominent place in the category of drugs which the physician considers absolutely necessary in the treatment of diseases which are most frequently met with in practice Extravagant statements concerning the action of a remedy do not establish confidence in its influence. Nevertheless, the seemingly marvelous results following the use of this new preparation have led all physicians who have tried it to express in the most positive and enthusiastic manner, their astonishment at the benefit obtained by its use. This remedy is a combination of echinacea, thuja occidentalis and baptisia. It is placed upon the market under the name of eusoma. Dr. Finley Ellingwood, of Chicago, Therapeutic Gazette, May 15, 1905, says of echinacea: "Its field covers the entire range of organic infection. Blood poisoning in all its forms is met more promptly with this remedy than with any single remedy or combination of remedies. In septicemia the promptness of its action has surprised every physician who has prescribed it If it had no other influence than that of antagonizing direct septic infection, this would be sufficient to class it as of first importance among spe cific remedies for this purpose.' While Dr. A. B. Matthews, of Elberton, Ga., in a paper presented to the Medical Association of Georgia, April, 1904, says; "Echinacea does play a part in its influence upon the character of the blood as to be well worthy of the title, a corrector of dyscrasia.' Eusoma, therefore. is a preparation which should be of use in the daily work of every physician. Full information and sample may be obtained by writing the manufacturers, The Eusoma Pharmaceutical Co., Cincinnati, O. For diarrhea due to exhaustion after fevers, Dr. Waring recommends nux vomica with opium and iron. For rachitic diarrhea, Dr. Hare recommends the administration of sodium phosphate, lime salts and common salt freely. Heroline is a compound of petroleum with hypophosphites of lime and soda and heroin hydrochlorate, recommended in chronic bronchitis. The Special Strain of pregnancy is never long well borne by the overburdened liver and kidneys. To maintain normal activity in these organs is therefore of great importance. Allouez bi-magnesia water stimulates activity and aids materially in carrying off the intensely toxic bodies secreted from the digestive disturbances peculiar to gestation. The soft light, alkaline diuretic has the advantage of continuous use without any liability of reaction. Chronic and Recurrent Coughs and Their Treatment.-Abstract of article by J. E. Alter, M D., In treating coughs we quite often encounter obstinate cases, which, no matter what combative measures may be instituted, will continue without abatement. Such cases are best classified as the chronic cough and the recurrent winter cough. Both of these classes are extremely obstinate in their course and yield reluctantly to treatment. They are usually of long duration, and, while not, in themselves directly dangerous, may become so by inducing emphysema and bronchiectasis. In the great majority of chronic and recurrent winter coughs, the basic trouble lies in a low form of inflammation of the bronchial mucous membrane; especially that of the bronchioles. In many case I have used codeia, but lately I have been having much more success with another derivative of opium, i. e., heroin. In comparing the results obtained from the use of these two drugs, I notice that heroin will not constipate the patient, nor will it have the stupefying effect characteristic of codeine. Another advantage possessed by heroin is that it is effective in young children in very small doses. I had been accustomed to prescribe heroin alone, but about a year ago my attention was called to a preparation of that drug-glyco-heroin (Smith). Upon giving it a good trial I found that it gave me better results than obtained when heroin alone was given, and much more quickly. Glyco-heroin (Smith) has one distinct advantage over plain heroin in that it can be given for a long time without ill effects, and in this class of patients in question this is indeed a most important feature. During the past year and a hnlf I have treated a number of cases and recurrent winter coughs with glyco-heroin (Smith) and have obtained uniformly good results. Example.-A. L.; salesman; aged 28. I saw this patient early in the spring of 1903. He is robust and of good habits. He consulted me concerning a constant cough which had troubled him for over a year. It was usually worse in the morning and after meals, and accompanied by expectoration of thick muco-purulent matter. Sometimes blood-stained, and especially so after a severe paroxysm. This circumstance preyed upon his mind considerably-he thought he had consumption. I learned that he had had a severe attack of acute bronchitis during the spring of 1902 and had been coughing ever since. Physical examination excluded tuberculosis. The diagnosis was chronic bronchitis, sequential to acute. The patient was immediately put on glyco-heroin (Smith) and the same hygienic measures ordered as in case 1. Here again the financial condition of the patient was given syrup of hypophosphites as a tonic. did not see him again until last October. He then reported himself absolutely free from cough. He continued taking the glyco-heroin (Smith), and during the present winter has not experienced any return of the trouble. In this case a complete cure was effected by means of quieting the cough and stopping the irritation of the mucous membrane, in this manner allowing the restorative powers of the body, aided by the tonics and good hygiene, to accomplish a cure. precluded change of climate. In addition to the glyco-heroin (Smith) the patient Example.-Miss R. M.; aged 24; teacher. This lady had been coughing ever since she was nineteen years of age. At that time she had had an attack of rheumatism with a complicating bronchitis. After the acute condition had moderated, she continued to cough, the cough being very annoying in character, spasmodic and prolonged. After each paroxysm she was left in a state of exhaustion. During the attacks she urinated involuntarily. On examination she was found to have chronic bronchitis, aggravated by an exceedingly irritable condition of the respiratory tract. The mere odor of cigar smoke was sufficient to induce a paroxysm of coughing. In treating this patient it was necessary to devote attention to the neurasthenia as well as the chronic bronchitis. She was placed on a diet and her mode of living regulated. Arsenic, strychnine and iron in pill form were given For the cough Ï ordered glyco-heroin (Smith). The improvement was marked and rapid. The gencral nervous condition became much improved, the cough grew much less severe and gradually lost its spasmodic character. At the present time its amounts to but little more than a "clearing of the throat." This case, more than any other, demonstrated the excellent properties of glyco-heroin (Smith). The quick relief afforded was surprising and no more gratifying to the patient than to me. Papers for the original department must be contributed exclusively to th's magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R EDWARDS, M. D., Chicago, Ill. Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. FERD C. VALENTINE, M. D., New York. LEADING ARTICLES BILATERAL DERMOID TUMORS OF THE OVARY.* CARL W. WAHRER, M. D. FORT MADISON, IA. THERE is as yet no satisfactory classification of dermoid tumors, few authors agreeing as to their origin, and the confusion can hardly be made clear until the nature of tumors in general is better understood. Most authorities divide them into two classes: Dermoids and teratomata. Martin classifies them as follows: 1. Simple dermoids, a sac lined with a dermal membrane. 2. Complicated dermoid, those containing heterogenous structures, as hair, teeth, bones, etc. 3. Teratomata-a sac containing formed organs, as brain, mammary gland, thyroid gland. 4. Solid Teratomata. Solid tumors containing the same structures as cystic teratomata. Some authors draw a sharp distinction between teratomata and dermoid cysts. Waldeyer and Bland Sutton believe that derinoids spring from the graffian follicle, and that the epithelial cells lining it are capa Read before the Lee County Medical Society. No. 7 ble of producing all the elements found in a dermoid cyst. Teratoma they regard as the product of a suppressed conception. Olshausen, on the contrary, holds that there is no genetic difference between the two tumors, and regards them as being due to fetal inclusion. Many of the older authors taught a somewhat similar view, namely, that these growths were a "fetus in fetu," and it was once believed that the finding of a dermoid tumor in the ovary of an unmarried woman was an evidence of unchastity. It is probable that old tubal pregnancies which had undergone lithopedian formation and be. came closely allied to the ovary, were often reported as dermoid tumors. Bland Sutton has pointed out that in women dermoid tumors have never been found growing from any abdominal viscus except the ovary. Most authors are inclined to accept Conheim's theory as peculiarly adapted to the etiology of dermoid and teratoid tumors. Conheim believed that all tumors were due to the misplacement of embryonic cells during fetal life, and a dermoid of the ovary would, therefore, be an inclusion in the ovary of epiblastic, and sometimes mesoblastic embryonal remains which had taken on increased growth at some subsequent period, usually at puberty, when the activity of the sexual organs is suddenly increased and the organs themselves undergo marked changes. Bandler gives a more extended theory, as follows: "The pro-nephros, the Wolffian body and the Wolffian duct through their position in the mesoderm and their relation to the normal development of the ovary, their position at the hilum of the ovary, and the extension of the tubules into the vascular layer and their growth through the ovary even up to the surface, and from the fact that their remnants furnish the ciliated growths of the broad ligament and form the cyst-adenomata of the ovary-are capable of carrying with them, mesodermal and ectodermal cells, up to and into the ovary and of forming mesodermal and ectodermal products and structures lined with ciliated epithelium. Cysts of the testicles lined with ciliated epithelium arise from the tubules of the Wolffian body. Therefore the mesodermal tumors, the mixed tumors, and the ectodermal tumors, originate in this same way. If ectodermal cells are misplaced to such an extent that their presence is manifested by hair, skin, teeth etc., we speak of dermoid cysts. If the misplaced cells are located in one part of the ovary, and if they grow equally and if the skin cells as in normal glands, excrete their products, a cystic dermoid must result. Since the contents found in dermoid cysts are secreted by the so-called "derm" of the cyst, they must lie when secreted between the derm' and the enveloping tissue of the organ, or, tissue in which the dermoid grows. The larger the amount of secretion, the greater the pressure on the secondary tissue. If the mass of secreted material reaches a fair amount, and if it causes a tissue growth at its periphery and compresses the enveloping organ, so that it is stretched or flattened, we then have a cystic dermoid whose wall consists of a skin or dermoid layer, and the tissue of the enveloping organ. The original group of misplaced cells is then found only as a prominence in one part of the cyst wall, and it is this part which grows gradually for years, and in which are formed the hair, sebaceous glands and other parts of the cyst contents." The greater the amount and number of the products formed by the misplaced ectodermal and mesodermal cells the larger the cyst. A dermoid cyst may occupy a part or all of an overy, and while usually unilocular, as many as five cysts have been reported in one tumor. They are usually intraperitoneal, and rarely found between the layers of the broad ligament. Both skin and mucous membrane may be present in the cyst-wall, which is usually thicker than that of an ordinary ovarian cyst. The amount of skin may vary greatly; it may completely line a large cyst, or be confined to a small daughter cyst and be entirely overlooked at the examination of the specimen. The contents of a dermoid cyst may include all or any of the following: Skin, mucous membrane, hair, teeth, nails, horns, sebaceous glands, sudoriferous glands, mammae, bone, unstriped muscle fiber, brain and nerve tissue. The hair may spring from the cyst wall in tufts or lie free in the cyst cavity, generally rolled into a ball. It may be short or long, and vary in color from blonde to black. It does not necessarily correspond in color to the hair of the patient. In old age it may become gray and be shed into the cyst cavity. The teeth may be embedded in bone formation or in the fibrous wall of the cyst. There is no limit to the number of teeth that may be found in one cyst; they may include all the varieties found in the jaw. Nails and horns project from the cyst wall and are formed of masses of squamous epithelium. Sebaceous glands and sweat glands are almost always present, and sometimes form small retention cysts. Mammae are usually in the form of a nipple attached to a lump of fatty tissue containing sebaceous glands. Cases have been reported of mammae which contained both milk and colustrum. The fluid contents of the cyst are formed of the thick oily, cheesy secretion of the sebaceous glands and degenerated epithelium. Small floculi of a cheesy or fatty material of the glands may be floating in the fluid. On exposure to the air the fluid hardens and turns deep yellow in color. After standing some time cholesterin crystals form on the surface. Some authors regard this fluid as extremely irritating to the peritoneum, and warn dominal cavity. It is difficult to see why this against allowing it to be spilled into the abshould be so, unless the fluid was infected. The possibility of tumor implantation from this source has often been discussed, but probably never occurs. I have seen a number of these cysts ruptured in being removed, but with the exception of one case, in which a pelvic abscess subsequently formed there were no complications. Owing to their poor blood supply and low vitality these tumors are especially liable to suppuration, and as a result of the adenoid elements present and the embryonal character of the cells, a large per cent undergo malignant degeneration. Dermoid tumors of the ovary are usually unilateral and occur as often on the left as on the right side. Involvement of both ovaries is not very rare. Kelly reports one case in a series of twenty-two. Martin reports four bilateral cases in 107. Mantell reports 26 double dermoids out of 191 cases, the highest per cent reported. Martin advises that when removing a dermoid of the Ovary the opposite ovary, if at all enlarged should be incised to determine the question of a double involvement. The cysts may vary in size from those no larger than a corpus luteum, to that reported by Kelly, which contained two and a half gallons of fluid. As a rule they are rarely larger than a man's head. may not, be pediculated. They may, or Dermoids are found at all ages, but usually appear in early life. They are the most common abdominal tumor in young girls before and during puberty. Their presence in the ovary apparently has no influence on conception, and only a mechanical one on preg. nancy. In the second case I report the patient, both of whose ovaries were involved had gone through nine pregnancies without mishap. There seems to be a peculiar tendency on the part of dermoid cysts to produce attacks of localized peritonitis, even the smallest cysts being often found covered with a veil of adhesions. This condition was present in both the cases I operated, and I observed the same condition in several cases during my interneship at the Presbyterian Hospital of The attacks of inflammation may Chicago. be recurrent and simulate appendicitis. There is usually in these cases extension of the inflammation to the opposite tube and ovary. Tumors have been found completely detached from their original vascular supply, depending on the adhesions between them Dermoid and other organs for nutrition. cysts are not usually diagnosed before operation. Kelly emphasizes the following points: (a) The spherical shape of the cyst giving the appearance of a mono-cyst; (b) the appearance in a young patient at the time of puberty, and (c) recurrent attacks of inflammation and a tendency to emaciation. Küstner mentions as important their tendency to float up from behind the uterus and lie directly behind the abdominal wall. Quite as often, however, they are found choking the pelvis and simulating a soft fibroid or pelvic abscess. During my service at the Presbyterian Hospital of Chicago, a woman entered the hospital to be operated on for pelvio abscess. The pus, in large quantities, was evacuated through the usual incision behind the cervix. After washing out the cavity for several days it showed a tendency to close too rapidly, and the attending surgeon dilated the opening with his fingers. In doing so he discovered and removed several teeth, a nipple and portion of mammary gland, and a quantity of hair. E. C. Dudley has reported a similar case. The cases which I report are as follows: CASE I. This patient is 20 years of age; unmarried; frail and anemic. Her illness dates from puberty. Her menses began at fourteen, and have always been quite painful. They have never become regular, sometimes missing six to eight weeks, and occasionally flowing twice in one month. She was not constipated till one year ago. In spite of her trouble her health was fair till a year ago when she had a severe attack of pelvic peritonitis. She was in bed three weeks at this time, and since then has had almost constant pain in both sides of pelvis, with bearing down pains. Four months ago had a second attack of pelvic inflammation, was sick a week this time. Since the last attack, has been very constipated, and has lost about fifteen pounds in weight. Physical examination. Heart and lungs normal; abdomen negative, rigidity of abdominal walls, and tenderness over both groins. Vaginal examination. Irregular masses felt in both sides of pelvis; they are soft and fluctuating and cannot be differentiated from the tubes or There is considerable tenderness. ovaries. On opening the abdomen, the uterus was found retroverted. On each side there was a tumor mass obscured by extensive adhesions. The tumors were about the size of goose-eggs and firmly adherent to the broad ligament and pelvic walls, and on the right side to the uterus. The adhesions were so extensive and firm that it was considered best to remove the entire mass. As the contents of the cyst had been ruptured in attempting to free them, pan-hysterectomy was performed to facilitate drainage. Examination of specimens. These consisted of uterus tubes and two tumors equal in size and about the size of goose-eggs. The walls were about the thickness of an orange peel and quite friable. They were lined with a rough, granular material, easily rubbed off with the fingers. The contents of both cysts was an oily brown fluid, which soon hardened to the consistence of soft butter. There was no evidence of hair, teeeth, etc. Microscopical examination showed the walls of the cyst to consist of a membrane resembling true skin, except for the absence of the rete-malpighi. The inner friable surface consisted of degenerated epithelium macerated by the oily contents of the cyst. In the skin walls were found sudoriferous and sebaceous glands and traces of hair follicles; according to Martin's classification, a simple dermoid cyst. CASE II. This woman is 55 years of age; married, and mother of nine children; a The patient complains of se farmer's wife. vere more or less constant pain in both sides of abdomen and in pelvis, backache, constipation and loss of strength and weight. She has always been a very hard working woman, but enjoyed good health till two years ago. Her pregnancies were uneventful and without complication. After the usual period of irregularity her menses ceased a year ago. Her pain, which began two years ago, she attributed to the menopause; it began in the left side, was only present at times and varied in severity; about a year ago began having pain in the right side also, and in the back. At this time she had considerable leucorrhea. In the last three months she has lost strength and weight steadily, and twice has been confined to her bed with sudden exacerbations of |