ment of all the complications of fibroid tumors that I have ever seen. I find that I have had four sarcomas of the uterus. In one case the microscopic report was somewhat doubtful. The tumor was so necrotic that the pathologist would not say positively whether or not it was a sarcoma; it might have been a fibroid; the opinion was that it was a sarcoma. The presumptive diagnosis was the more probable as the patient apparently died of recurrence of sarcoma in the abdomen. However, there was no post-mortem. In the other three cases there was no question as to the microscopical report. In one case the diagnosis was further confirmed because the patient died of sarcoma of the lungs. The third case disappeared. The fourth case had sarcoma of the cervix. In the other three there was sarcoma of uterus. In the case of sarcoma of the cervix there was a large necrotic mass filling the vagina. Operation under the circumstances consisted in removing the tumor which filled the vagina. In this case there was the history of a similar operation having been done for about the same condition some years before at the Woman's Hospital. I learned that the tumor removed then was also sarcoma. This woman refused to have a radical operation, and she also passed out of my knowledge. I have, therefore, certainly seen three, and probably four, cases of sarcoma of the uterus.

As to the other complications of malignant disease with fibroids I have had four cases of carcinoma of the body of the uterus complicating fibroids and seven cases of sarcoma of the cervix. The outlook from Dr. Clark's case would seem to be very good. My experience with sarcoma of the uterus has been bad. I believe the general literature gives the prognosis as bad. I once removed a sarcoma from the ovary that weighed seven pounds. That has been at least six years ago. The patient is well. With a case so well localized as Dr. Clark's it seems to me that the ultimate outlook is very good.

Dr. THEO. A. ERCK: I would like to report a case, a photograph of which I will pass around. The case was operated upon a year ago at the Gynecean Hospital for chronic pelvic inflammatory disease, and the specimen showed, in addition to other lesions, a fibroid tumor of the round ligament.

In connection with the association of sarcoma and fibroma, I have a case which presents symptoms as did this particular case. A woman, probably 60 years of age, was admitted to the Frederick Douglass Memorial Hospital several days ago. Her general condition was bad, and a good history could not be obtained. She had a profuse bloody discharge, which had been present for three weeks. I examined her

abdomen and found a tumor extending to the umbilicus, a lobulated tumor, cystic in some portions, solid in others. Vaginal examination. showed that the cervix was not involved. Introducing my finger into the vaginal canal I found a inass which I took to be a necrotic fibroid or sarcoma. To-day I removed from the uterine cavity a mass as large as a fist; it appeared to grow from the fundus. As fas as I could reach with my finger the interior of the uterine cavity was smooth. After having removed the necrotic tissues the tumor assumed an outline which

showed distinctly that the patient had fibroid nodules. There seemed to be no adhesions. Certain features distinguished it from a necrotic fibroid and I believe the microscope will prove that this is a case in which we have association of either sarcoma or carcinoma with fibroma.

Dr. GEORGE ERETY SHOEMAKER: It is a curious fact that although we have so many fibromas associated with malignant disease, the malignant disease does not involve the fibroma itself. They are generally separate. Last June I did hysterectomy for fibroma, where there was true carcinoma of the fundus involving endometrium and muscle but not the fibroma; another hysterectomy case this fall showed fibromatous interstitial masses with malignant disease of the fundus uteri involving the bowel secondarily. The nodules of fibroma were not degenerated. Dr. Clark's case illustrates the same thing: that the sarcoma is entirely independent of what fibromatous change there is in the uterine system.

Dr. J. M. FISHER: In considering these claims of the assocition of fibroma with carcinoma the question always arises whether or not a microscopic examination had been made to prove the diagnosis. I recall a case of Dr. Nassau's in which he removed the uterus and in which there was apparently a collection of fibroids in association with carcinoma. Upon microscopical section all proved to be carcinomatous

structure.

Dr. JOHN C. DACOSTA: I would like to ask Dr. Clark if cases such as he has described do not sometimes recover after the removal of the polypoid mass. I had a case some few years ago in which I removed a mass larger than a big orange from a woman's uterus. The symptoms were such as those Dr. Clark described. The pathologist pronounced the specimen a sarcoma and said that the uterus should be removed at once. The woman refused operation, and recovered perfectly. In all these years she has remained well and strong.

I have not seen the condition which Dr. Clark speaks of, but I have seen different forms in the same tumor. There is now upstairs in the museum a specimen of fibroma and fibrosarcoma extended to the uterus, while in the fundus the condition is that of pure sarcoma. The growth was removed by me in 1891.

Dr. CLARK: Answering the question of the president, I feel that taking such a case as this, where microscopically the growth is so definitely outlined, the pedicle stopping so abruptly, I cannot conceive of such a case when thoroughly curetted to have such a result. It would not be the plan of treatment which I should feel was the one to pursue. Under the circumstances of that case such a thing could be possible.

In regard to the recovery of Dr. Baer's cases I think his statement is entirely correct.

I am not in a position to refute Dr. Noble's statement from a statistical standpoint, but taking this and the other case which I recall operating on in 1895, another case in Cullen's recent book, two of Olshausen's, and the four cases of Dr. Noble, we have a creditable showing in individual clinics. With the small number of cases at our hands it is difficult to say definitely as to statistics.

After investigating this case I should have felt perfectly content had only the upper part of this tumor been removed, but in view of the fact that I look upon all malignant growths surgically, I make it a rule to remove all anatomically possible. I felt in this case, as under the same circumstances I should have felt in Dr. DaCosta's, that it

was safer to operate. I think Dr. Baer's method was the proper one in his case.

Dr. Shoemaker's experience as to the course of these tumors I think is the common one. Up to within two years ago we did not know whether there was sarcomatous degeneration of them. Williams has worked the matter up carefully. Pick and Klebs of Berlin have stated that there is such a thing as the degeneration of one tumor into another. We have good authority, however, for believing that the majority are merely coincident and that very seldom one is transferred over into the other.

Dr. CHARLES P. NOBLE: I had an experience within the last month which might be of interest. It was not a uterine case, but a breast case. The patient had a myxoma of the upper outer quadrant of the left breast, which she had carried for eight years. The growth became sarcomatous and grew rapidly for two months before operation. The pathologist reported it to be a myxoma which had undergone sarcomatous degeneration. The sarcoma had involved also the pectoral muscles. Official Transactions.

FRANK W. TALLEY,
Secretary.

PÆDIATRICS.

UNITED STATES.

General Subcutaneous Emphysema.

A. C. COTTON (Archives of Pediatrics, September, 1900) was called to see a child seven years old who had the following history: The patient had had all the diseases of childhood (including scarlet fever and diphtheria) except measles during the first five years of life, but from all had made a good recovery. Eight months previous to seeing her she had measles, had not been strong since and had a persistent cough. One month ago she had bronchitis with daily rise of temperature and night sweats. Five days before examination a ridge appeared over the right clavicle during a hard coughing spell, and spread in all directions. There was no history of convulsions or oedema. Urine scanty, turbid, containing albumin, pus cells, casts and bacteria. Dyspnoea was extreme and the child maintained a sitting posture, bending a little forward. The face was swollen and waxy, the lips cyanotic, and there was great distension of the skin over the neck, chest and trunk. Pressure elicited distinct crepitation and left no pitting. There was hyper-resonance over the greater part of the chest. There was no gastro-enteric disturbance. No radical treatment, such as incision of the skin, was permitted, and the infiltration of the skin gradually extended over the whole body, with increasing dyspnoea and cyanosis. Six days later she died, but no post-mortem could be obtained. The undertakers reduced the enormous distension by puncturing the skin, the air escaping.

Etiology. During a violent expiratory paroxysm some of the delicate air cells rupture and air escapes into the connective tissue surrounding the lobules or under the visceral pleura, giving rise to interlobular emphysema. The air may extend along the connective tissue to the neck, face and general cutaneous surface. Molin reports a case where immediate relief was afforded by incising the integument and inserting drainage tubes. The child recovered. The tendency is towards a fatal termination either from this condition alone, or from the disorder, which it complicates. Where the point of entrance of air to the subcutaneous tissue is within reach, as after tracheotomy or external lesions, the extension of the emphysema might possibly be pre