CLINICAL NO I KS. T K.IITIA It V HVIMItI.ITIC Ul.rK.ltH OK TIIK I.ICO; VAUINAI. II VHTK.HKi TOMV KOB OANKRIt OK TIIK UTKIIUH; IIRMOBK- IIAOH' IJl,< K.ll OK TIIK StoMaiii; In- ki.amki* Bunion; llk.matokui,i‘om. CIIAKI.KH <; It KKN OIIMMTON, M.l*. Mo- i‘on, M MV IN'liMlil from Anyntl niilulHtr. Vol. M. ANNA 1 ,H OK <; VNKCOI.OIIV ANII I'KOIATHV Itoxtol), IHHM, CLINICAL NOTES. Tertiary Syphilitic fleers of Ley; Vaginal Hysterectomy for Cancer of the Uterus; //emorrhagic Ulcer of the Stomach; Inflamed Bunion; Ifematokolpos. CIIAIM.KH (JRKKN CI’MSTO.V, M.J). Cask I.—A young married woman of thirty years of age had contracted syphilis from her husband -ix years ago. At the pres- ent time the patient presented a large tertiary ulcer, situated on the* autero-internal aspect of the right log. The ulcer was the cause of much pain, more especially when the patient was in bed. No other specific lesions were present. The local treatment con- sisted in mild antiseptic wash to keep the part clean, and the following powder, freely applied over the ulcer every second day: I* Hydrarp. sozoiodol. 1.0 Orthoform. Bismuth, benzoat, na 15.0 The orthoform was a local amesthetic of considerable power, and had given, in this case, much relief to the patient. Am ji general treatment the patient was taking two grammes of the iodide of sodium daily in a potion, and one of the following pills night and morning: n Inp. hydrarp. Sapon. im*d. I*ulv. liquirit. rad. 1$ yo M. et fl pil. no. i.x. Consp. prrh. ti(]iiirit. An alum month-wash lias 1 ordered to prevent stomatitis. The patient was rapidly improving under this treatment. Cask II.—Carcinoma of cervix uteri. A patient aged fifty- five years had complained of a foul-smelling discharge from the CLINICAL NOTES. vagina for the past two months, but no other symptom was mentioned by the patient. Examination showed a large irregu- lar neoplastic infiltration of the anterior lip of the cervix uteri. The broad ligaments and vaginal culs-de-sac were soft and appar- ently not invaded by the neoformation. The most important indications for vaginal hysterectomy for uterine cancer are given by the extent of the lesion, and each case requires a complete and methodical examination. Vaginal hys- terectomy is indicated, no matter how small may he the new growth. Secondary invasion of the corpus uteri alone is not a contra- indication, but when the entire cervix is the seat of the growth, surgical interference should only he adopted when we are sure that the parametrium, hroad ligaments, vaginal culs-de-sac are not secondarily invaded, and also that the uterus is movable and can he drawn down. In cases where we are sure that the growth has extended beyond the limits of the uterus, vaginal hysterec- tomy is contra-indicated. The most malignant anatomical forms of uterine cancer are the interstitial and ulcerating, and require much prudence on the part of the surgeon in operating for these types. The vegetating form has a much less rapid progress, and consequently vaginal hysterectomy will give splendid results. The more or less rapid progress of carcinoma uteri gives us no particular indication for operation, because all will depend upon the extent of the lesion. Age is not a contra-indication for the radical vaginal operation, provided that the patient is in a sufficiently good physical condi- tion to withstand the interference. Hemorrhage is a most decided indication for hysterectomy, hut if the loss of blood he great the general condition of the patient should first he improved by injections of artificial serum given once or twice daily. The following is the serum employed: 1* Xatrii chlorid. 1.0 Xatrii phosphat. Xatrii glycerophosphat. aa. 2.0 Aq. flest. 300 c.c. Locally the thermocautery might he used or a tight tamponade with suhgallate of bismuth gauze soaked in a 10 per cent solution CLINICAL NOTES. 3 of Fcrripyrine was of value. After a few days, when the patient had recovered from the hemorrhages, the uterus could he re- moved. When albumin is present in the urine it most probably indi- cates that there is an interstitial nephritis from compression of the ureters and is an absolute contra-indication for a radical opera- tion, for it signifies that the neoplastic infiltration has extended beyond I he uterus. Shooting or distant localized pains are usually due to extension of the neoplastic infiltration but localized pains over the region of the uterus have not such a serious prognostic meaning. ('ask lII.—An elderly woman complained of great pain in the right foot, which on examination was found red, oedematous and painful on pressure, especially over the metatarso-phalangeal joint of the great toe. The bursa of this joint was swollen and fluctuation could be elicited, but the skin was intact. The treatment ordered was rest of the foot in the horizontal position and the following lotion to be kept constantly applied to the entire foot by means of absorbent cotton: n Ammon, hydroehlor. 5.0 Tinct. i ■ 11;t.)..n. 8.0 Aq. dost. 150.0 M. D. S.—For external use. The treatment of acutely inflamed bursitis by the above was often followed by most excellent results.and when the patient was shown five days later all inflammatory phenomena had disap- peared and the patient could walk with comfort. Cask I\r.—A chlorotic young woman of nineteen years stated that she had vomited a large quantity of blood on the previous evening. For some weeks she had experienced much pain after meals, and for the last few days had eaten little for this reason. Palpation of the abdomen revealed a tender q»ot localized near the pyloric extremity of the stomach, and the diagnosis of hemor- rhagic ulcer of the stomach was made. A distinction should be made between an acute hemorrhage, which may kill the patient, and chronic hemorrhage which occurs from time to time for several months, and which reduces the pa- tients strength from loss of blood and the difficulty of feeding 4 CLINICAL NOTES. such cases. When only one hemorrhage has occurred the patient soon recovers and may not again have another. The chronic form is very obstinate to all medical treatment. In acute hemorrhage, the indication for surgical interference is not certain on account of the uncertainty of the prognosis, the gravity of the operation and the weakened condition of the pa: tient. However, the right to surgically interfere is based upon amount of blood lost ami particularly if it recurs in spite of an absolute diet. Advanced age or great anemia are contra- indications for operation. In any case of acute hemorrhage the object in operating is to make a hemostasis, either by attacking the ulcer itself or ligating the ruptured vessel. If no lesion can he found on the external aspect of the stomach a free gastrotomy should lx* done, in order to carefully examine the entire mucous membrane of the stom- ach. When the ulcer is small and only seated in the gastric mucosa, a simple suture of the ruptured vessel is all that is re- quired, but when we are dealing with a Callous ulcer which has caused the rupture of the coronary artery, the vessel is to he ligated and the ulcer exsected and the wound sutured if the con- dition of the patient will allow of it. In cases of chronic hemorrhage, operation is always proper, when a well directed medical treatment remains without result. When the ulcer is in the pylorus or the upper part of the duo- denum. gastroenterostomy will put the parts at rest, the hemor- rhages will cease and the ulcer will cicatrize. An ulcer of the stomach should be treated by excision and suture. On one point I would, however, insist, when considering the question of opera- tion for a chronic ulcer of the stomach, and that is whether it may not be due to syphilis—a syphilitic lesion of the stomach; and in all such cases, that are obstinate to all well-directed medical treatment, such as an absolute milk diet, bicarbonate of sodium, etc.,subcutaneous injections of some form of mercury should first be tried and in many instances a most remarkable and rapid cure will result, because syphilis of the stomach is not a rare condition as I have been able to find out for myself, and Fournier, Dieula- foy, Chiari and (Jaillard have demonstrated. Cask V.—A healthy, well-nourished girl of sixteen is brought to us because she has not menstruated, ami for the past nine CLINICAL NOTES. 5 months she has complained regularly every four weeks of much discomfort and a certain amount of pain in the pelvis; the pain lasts for several days. The patient also says that she has pain at stool and that when urinating slie has a rather severe burning pain in the region of tin* bladder. Examination showed that the vaginal entrance was completely closed by a thick imperforate hymen, which protruded between the labia, and when pressed upon gave a distinct sensation of fluc- tuation. Bimanual examination with two lingers in the rectum revealed tin* presence of a round, soft elastic mass, extending almost to the umbilicus. Diagnosis was hematokolpos. Under ether narcosis, an incision of tin* hymen gave i-sue to a large amount of thick dark blood, and tin* mass felt by bimanual examination had disappeared. Tin* vagina was irrigated with with line catgut. Examination mu* week later showed that the vaginal wall- were somewhat thickened, that the uterus was slightly enlarged and that the cervix was hypertrophied. Hot vaginal irrigations were ordered to be* continued once daily for two week- and tin* patient was discharged. 87 I Beacon Street, Boston, Mass. Annuls GYNECOLOGY AND PEDIATRY. .1 monthly journal of (l\inrrolotj>iy Obstet- rics, Alnhaninal Snryertf ami the /Htctuwn of ChlUfrrn •h rntnl to reliable clean nwryrrjf, accurate iliaiiuosi*, (noI urnnthlr therapeutics. Suf>u > tphoM I'ruf Sf.no y*tr ri:ni.iiMin> »v KKNfXT W CtluniNO. M. I>. II MIIKKWOOP-UtiNK. M l> ins NKwmutY srnosro.v, .v.i.v.v.