and that another benefit will have been conferred upon suffering humanity by the resources of therapeutic art." Professor Clay has recently published several cases in which he claims a cure by the use of this remedy. Palliation. There comes a time in the progress of cancer of the uterus that the patient is prostrated by the septic effects, caused by absorption of gangrenous products at the surface of the degenerating mass. When this is the case we may often relieve the patient more by removing all the dead and dying tissue with a sharp curette and thermo-cautery than in any other way. To do this the vagina should be dilated with Sims's or Simon's speculum until the parts are thoroughly exposed. Then with the sharp curette we should gouge out and remove in detail all the diseased substance down to the solid tissue of the cervix, and then cauterize the whole surface with the thermo-cautery. In this way, for a time, we get rid of the hemorrhage, the fetid discharge, and often the distressing pain. After this the patient's general health will almost always be greatly improved, and she will have a happy respite from her terrible suffering. This operation may be repeated once or oftener, as the conditions seem to justify. One who has never tried this method of relieving the patient would very naturally be deterred from resorting to it by fear that the hemorrhage would be dangerously profuse. A trial, however, will prove to him that this apprehension is groundless. If the curetting part of the operation is done briskly there will not generally be much hemorrhage, and the benefits resulting from it will far exceed the ill effects of the loss thus incurred. I mention this as the first and most important palliative measure to which we can resort, as the comfort of the patient will be promoted to a greater extent than by a resort to any other. Palliation of the pain, smell, and debility, is the object of the most of our treatment. For pain we use local remedies, introduced into the vagina. Opium, belladonna, cicuta, hyoscyamus, and Indian hemp, may all be used locally. The best form for their application, is that of a bolus of five grains of pul. opii. We may instruct the patient to introduce the finely powdered opium through a small glass tube, with a piston of whalebone and cotton. It is applied thus to the ulcerated part and to the walls of the vagina in the neighborhood, and very effectually acts as an anodyne. Ten grains of the extract of hyoscyamus may be used as a bolus, or two grains of ext. belladonna; and so on with all the anodynes. A grain of morphia may be mixed with the ext. hyoscyam. to great advantage. Medicated injections often soothe the diseased part very much also. The watery extract of opium may be thrown into the vagina by a small syringe, and allowed to remain, the patient lying on her back for a length of time. Hydrocyanic acid in solution, gtt. xx to a pint of water, passed through the vagina, has a very pleasant effect sometimes. Injections of vapors of the anaesthetics are highly recommended, particularly by Professor Simpson. Carbonic acid gas and chloroform are those most used. The chloroform vapor may be passed through the vagina by the ordinary perpetual syringe, made by the Union Rubber Company. The chloroform should be placed in the bottom of a large bottle, while the receiving-tube of the syringe may be passed through the cork and made air-tight with wax. The other end, being inserted in the vagina, high enough to almost come in contact with the disease, the pumping may be commenced. The vapor will be caused to rise in the bottle quite rapidly under the exhausting influence of the syringe. Care should be taken not to let the tube deep enough in the bottle to come in contact with the chloroform, lest this fluid, instead of its vapor, pass through the instrument. The vapor thus delivered into the vagina causes a sense of heat and glow, which very soon seems to replace the pain. When properly done, patients experience great relief from this gaseous injection. The same apparatus will do to convey carbonic acid gas to the parts. The gas is generated by mixing in the bottle carb. soda and tart. acid, and then pouring a little water upon it. Although I have never yet tried the effect of great cold to the part, I have no doubt it would be very effective in relieving the pain. It should be applied through the speculum directly to the parts diseased, and no other. A small amount of the freezing mixture, of two parts pounded ice and one part common salt, in a small muslin bag, is the means used by Professor Simpson. It is thought this cold not only relieves the pain, but that it retards the advance of the disease somewhat. The contact should be continued until the parts assume a pale, bloodless appearance, when this is practicable, and may be used twice or three times in twenty-four hours. With the local remedies for pain may be mentioned the subcutaneous injection of morphia over the sacrum, or in the iliac region. All local remedies for pain will, after awhile, fall short of the relief demanded by our suffering patients, and we will be under the necessity of introducing them into the system in a more effective manner. We must resort to their internal use. I need not mention the anodynes to which we would resort in such cases; they are well known. to the profession. I would, however, caution the student not to use opium when any of the others will answer the purpose. Indian hemp will be found to do this more frequently than any of the others. They will all fail, eventually, and opium will prove the great blessing in such cases. And let me add the further caution: to commence with as small doses as will answer the purpose; and while we deal liberally enough with the drug to get its good effects, increase it slowly as possible, for with all our precautions in this respect we will be under the necessity of giving it enormously. The anaesthetics are too evanescent to be relied upon for main remedies, but they will render the influence of opium more prompt, and perhaps lasting. The hemorrhage of cancer will sometimes require prompt interference. I think, however, that, although the bleeding is always ultimately exhausting, it is seldom immediately dangerous from its copiousness. I have generally, when the hemorrhage required interference, depended upon the introduction of small pieces of ice frequently repeated. It is often very grateful to the patient as well as hæmostatic. Dr. Simpson recommended powdered tannin introduced through the speculum and placed on the part; but he places more dependence on a paste made of perchloride of iron and glycerin. If the bleeding should be very alarming, notwithstanding these means, the tampon would be our last resort. The offensive odor emanating from the disease makes it very desirable to have some means of correcting it. I should remark, with reference to the plans often resorted to, that they are more or less injurious to the patient and attendant, viz., the burning of sugar, myrrh, etc., in the room. This should be done very sparingly. For the air, chloride of lime, and good ventilation will do better than all other expedients. We do not wish to make a stronger smell less offensive, to be sure, but we desire to remove the effluvia. Burnt sugar simply fills the room with various other less offensive gases, while we breathe with them the original cause of the trouble. Chlorine, disengaged from the chloride of lime, probably destroys the material floating in the air that offends the sense of smell. But the emanation may be lessened by the use of carbolized water as a wash and injection. Frequent changes of the linen and bedding of the patient are matters of cleanliness that, of course, will readily suggest themselves. Septicemia is the condition which most commonly causes the greatest suffering and hurries the patient towards a fatal issue. Any palliative measure, therefore, which enables us to stay or modify its course, will prove a source of great relief. The absorption of the liquid products of the necrosed and sloughing tissue eliminated from the surface of the ulcer is the cause of the septic fever; hence a most important item in the palliative treatment of cancer is to keep the surface of the ulcer as free from dead and fungous substance as possible. This may and ought to be done by removing it with the sharp curette as often as necessary. When we operate for the re moval of the necrosed substance and fungus, the parts should be well exposed by Sims's or Simon's retractor speculum, the vagina thor oughly washed out, and then freely sponged with the tincture of iron. This will enable us to see the line of demarcation between the sound and dead tissue. Then with Simon's spoon every portion of the rotten substance should be freely removed. During the operation frequent washing away of the blood will be necessary, that we may see what we are doing. When the ulceration is extensive, and making its way toward the bladder or posterior peritoneal cul-de-sac, it will require care to avoid opening one of these cavities. Although I have done this palliative operation a great many times, I have not seen an excessive loss of blood or any other serious consequence follow it. It is always better, however, to be prepared with means by which to check the bleeding, and probably the best is the thermo-cautery. If this, or some other form of cautery, cannot be commended, and hemorrhage is sufficient to require an hæmostatic, a tampon of cotton, saturated with a solution of the persulphate of iron, may be advantageously used. It is surprising how much relief this little operation generally affords. The patient will often be so much improved as to indulge in the hope that she is recovering from her loathsome disease. In a greater or less time, however, the symptoms will return, and may be again relieved by the operation. When a case is advancing slowly, this process of cleansing the ulcer may be profitably and safely resorted to a number of times. We ought not to try to remove any of the tissue beneath the ulcerated surface, but confine the operation to the scraping away of the necrosed substance. This same operation is applicable to cases in which there are frequent hemorrhagic discharges. It generally checks, and sometimes permanently, losses of this kind, especially if followed by the use of the actual cautery or the thermo-cautery. The history of cancer discloses many disappointments in so called cures of this terrible malady. The more recent discoveries of this kind are jaborandi and the Chian turpentine. The former temporarily tempted the credence of the more sanguine of the profession, but after repeated trials has been condemned as utterly worthless. The Chian turpentine, which, on account of the great respectability of its early advocate, seemed to hold out a faint hope that we were on the threshold of a valuable discovery, has been found wanting also. That the progress of cancerous deposit will ever be arrested by medicine is a problem for the future. That true cancer of the uterus can be cured by any kind of surgical operation is yet to be proven. Cancerous deposit in the uterus, if not the result of blood disease, is a focus from which widespread contamination emanates in every direc tion, to an extent that surgery cannot reach. Such is the melancholy paucity of our resources in cancer of the uterus. Scarce as they are, however, they may afford the sufferer great comfort; and we should fall short of our duty if we did not industriously employ them, as the best the profession can afford. |