LIST OF CONTRIBUTORS VOL. XVII. H. MELVIN ALLEN, M.D., of Philadelphia, Pa. A. CLAUS, M.D., of Ghent, Belgium. WILLIAM S. GOTTHEIL, M.D., of New York. WILLIAM B HOPKINS, M.D., of Philadelphia, Pa. I. M. KOCH, M.D., of Philadelphia, Pa. J. MOUNT BLEYER, M D., F.R.A.M.S., Naples, of New York. A. M. PHELPS, M.D., of New York. WILLIAM S. PRICE, ESQ., of Philadelphia, Pa. ALBERT E. ROUSSEL, M.D., of Philadelphia, Pa. A. ROUTIER, M.D., of Paris, France, EMIL SCHNEE, M.D., of Carlsbad and Nice. H. H. SHERK, M.D., of Cramer Hill, N. J. JOHN V. SHOEMAKER, A.M., M.D., LL.D., of Philadelphia, Pa. SAMUEL WOLFE, A.M., M.D., of Philadelphia, Pa. The psoriasis is of recent occurrence. About three months ago an eruption appeared upon both legs. It came out at nearly the same time on each, the right limb being affected rather earlier than the left. When first developing it was attended with some itching and burning sensations. The lesions have always been dry. They soon became covered with grayish scales, and when the man first came under observation his limbs presented a typical picture of psoriasis. It first attacked the outer side of the legs, but has spread to the inner surfaces. The patient states that he enjoys good general health, and is strong. He cannot, however, be called very robust. His appetite is not very good; his bowels are regular. He is not dyspeptic, and has never had rheumatism or syphilis. He does not know of any rheumatism or psoriasis as occur * Delivered at the Medico-Chirurgical Hospital of Philadelphia. No. I ring in his family. Small spots of psoriasis exist upon his hands. Here, as in other patients whom I have shown you, we obtain the same history of the psoriasis developing first upon the leg, in front of or just below the knee. Moderate itching attended the beginning of the disease, but soon subsided. In this respect, also, the history agrees with that of other cases. As regards its evolution, it is distinguished by being rapid and diffuse. In a few weeks' time numerous patches appeared and coalesced, so as to form an almost uniform surface of diseased action. The scales have, for the most part, been detached, leaving the front of each leg almost covered by a dry, slightlyraised, somewhat-rough, dark-red and shining eruption. This man was directed to sponge his face every night with hot water and to wash every morning with naphthol soap. In respect to the psoriasis, he was placed upon the wine of antimony in doses of 5, increasing to 10, minims three times a day. As a local application to the psoriatic patches, he was ordered an ointment composed of 1 drachm of salicylic acid and an ounce of the ointment of the nitrate of mercury. I The color of the lesions is less bright than when the patient first came under observation, and there is but a slight tendency to the reproduction of fresh scales. Alopecia and Psoriasis.-H. M., male, aged 37 years; an iron-worker. About ten years ago this man's hair began to fall in spots or patches. The hair was originally thick. The baldness began on the vertex. The denuded spots were at first roundish, but as they grew larger adjacent spots coalesced. 5375-6 About two years after the affection began the patient had an attack of typhoid fever. After recovery from that illness he noticed that his hair fell more rapidly than before. The loss, however, was gradual and slow. Until two years ago he had a little hair upon the side of his head. Within the last nine months the hair upon the chin and cheeks has begun to fall. The left side of his mustache has become decidedly thinner than the right. The eyebrows have also fallen. The man wears a wig when he goes abroad, though he cannot endure it when at work on account of sweating of the scalp. He has always perspired freely upon the head from the time of his youth. He is unable to give any cause for this total loss of hair. The man has not a very vigorous look, but he states that he is able to perform his daily work, which requires considerable strength. He has never had syphilis. His appetite and digestion are good, and he sleeps well. Some years ago he had his scalp shaved several times, but no benefit resulted from the procedure. He has always perspired freely upon the body. The patient is habitually constipated. This case, beginning as alopecia circumscripta, is an example of the complete baldness which occasionally results from the progress of that affection. The whole scalp has been involved by the extension and coalescence of the various patches. The disease has attacked also the hairy parts of the face, and the man fancies even that latterly the hair upon his legs has become thinner. As in most cases of alopecia circumscripta, the patient was originally endowed with an abundant growth of hair. The beginning does not, however, precisely correspond to the history of most cases. There had been no premonitory symptoms calling attention to the scalp, and in this respect the present case agrees with the general rule. The loss of hair is itself the first and only symptom. The fall of the hair is generally abrupt and rapid. The patient is surprised some day to find that the hair comes out upon the brush and comb. Within a short time a patch or patches of baldness have developed. Here the progress has been much more gradual. Some cases are attended by itching, but in this, as many others, that sensation has been absent. The bare scalp is pale, thin, smooth, and soft to the touch. Most cases of alopecia circumscripta are M. Sig. Rub well into the scalp twice a day. By a curious coincidence it happens that this patient also, the third of a series, is afflicted with a co-existent psoriasis. Small scaling patches have, during the last three months, developed in front of each knee. The disease is in its incipiency, and the lesions are good. examples of the early stage. Eczema Capitis.-S. M., male, 35 years of age, a porter, first noticed, between five and six months ago, an eruption upon the back of his head. The affected spot was at that time about the size of a cent. It caused a good deal of itching. Since that time other spots have appeared upon the top of the head, and have enlarged with considerable rapidity. They have not been attended by suppura. tion, but gave rise to some sticky moisture which dried into crusts. From time to time the crusts would fall, but would soon be renewed. Similar spots have also appeared upon the sides of the head. They have not caused the hair to fall. There is likewise a small patch of eruption upon the root of the nose and another at the tip. Each of these is covered by a thin, brownish crust. The patches upon the scalp are of oval outline. The incrustation is of a yellowish-brown color. Beneath the crust the surface is red and moist. The man has suffered for two months from pain in the back and hæmorrhoids. He thinks that he is not as strong as he was formerly. He has had rheumatic pains in the back, hips, and thighs. He is habitually temperate as regards liquor, and does not use tobacco. The digestion is good at present, although he has been troubled by dyspeptic symptoms. This is a well-marked case of eczema of the scalp. The subjective symptom of itching has been prominent. This manifestation is much common and persistent in eczema, wherever located, than in psoriasis, and, for more that reason, may be regarded as of some diag- | pain or discomfort in cutting the sutures; so nostic import in doubtful cases. In the pres- that, having this accomplished, we can remove ent instance the disease is limited almost them quickly, without subjecting the patient strictly to the scalp. When it begins in that to a long-continued strain, and, after thorsituation it is very apt to spread to the fore-oughly cleansing the wound and drying it, we head or neck. In this case there has been no again seal it up. We have had an excellent continuous extension to other parts. The treatment of eczema of the scalp requires removal of the crusts and scales by means of oil and the further application of sedative or slightly stimulant oils, lotions, or ointments. Bismuth is a good remedy, and naphthol may be used when some irritant effect is desired. It is needless to add that we should endeavor to eliminate the cause and correct any deviations from the general health. In the present case the patient was treated by means of codliver-oil locally, and a drachm of the syrup of hydriodic acid was given three times a day. result. The wound has united throughout, without the slightest symptom of inflammatory condition about it. It is exceedingly gratifying when we remember that she had extensive adhesions, and there was some danger of bleeding into the peritoneal cavity, with the possibility of sepsis resulting. Ovarian Papilloma.-The next patient entered the hospital seven weeks ago with a marked abdominal distension. Her condition at the time she entered was exceedingly enfeebled. She suffered from abdominal distension, was very weak, and presented a very discouraging outlook for operation. The rapid growth led us to fear there was either malignant disease of the ovary or a papillomatous cyst which had ruptured. On opening the abSARCOMA OF THE OVARY; OVA- domen we found the latter to be the case, and RIAN PAPILLOMA; DELAYED the contents had escaped into the peritoneal MENSTRUATION; OVARIAN cavity, giving rise to ascites. We removed CYST; ECTOPIC GESTATION; the mass, as well as a fibroid from the uterus, DISPLACED KIDNEY.* BY E. E. MONTGOMERY, M.D., Professor of Clinical Gynecology, Jefferson Medical College; GE ENTLEMEN: This patient underwent an operation a week ago to day for the removal of a sarcoma of the ovary. You remember we had a large tumor filling up the abdomen, associated with ascites. A portion of the tumor had begun to undergo disintegration. I show you here her temperature record. It had reached 101° F. the second day, and subsequent to that did not exceed 1000 F. This morning it was normal. I bring her before you to examine the wound and remove the sutures. This is the first time the dressing has been removed. In removing these sutures you notice I raise them up and cut all the sutures before I attempt to withdraw any. I do this for the reason that if each suture were cut and withdrawn the patient would become very nervous, and by the time the last one was reached she would hardly be able to control herself. There is but little * Clinical lecture delivered at the Jefferson Hospital. which was as large as a fist. The latter Her convales wound become infected. The disease ex- tinguish between papilloma and malignant dis- | profuse. She suffers from a constant dull, achease, especially when we observe how other ing pain upon the right side of the abdomen, tissues may become infected and the disease extending into the corresponding groin; appeextend. So extensive has this become in some tite has been fair, bowels regular, and she cases, rendering it impossible to remove the noticed, about two months ago, that the abdodisease, that papillomata have been regarded by men began to be much larger than formerly. some pathologists as a form of malignant dis- At this time she was confined to her bed for a ease. It is found, however, that if we are able week with severe pain in the abdomen. As to remove the base of supply the disease dis- the abdomen is exposed we notice an enlargeappears. In this patient there was a rupture ment which is nearly symmetrical, possibly of the sac and escape of its contents into the projecting a little to the left. This enlargement peritoneal cavity, the irritating character of is more particularly developed in the lower which developed an acute ascites, and the con- part of the abdomen and in a greater degree dition of the patient rapidly became danger- transversely than in a vertical direction. It is ous. It certainly would have been fatal if she accompanied with no variation or interference had been permitted to continue much longer with the menstrual function. Palpating over without resort to operation. the abdomen we are enabled to distinguish a mass filling up the lower part of the pelvis, over which a sensation of fluctuation can readily be distinguished. No particular irregularity is demonstrated; and as the distension is uniform and the sensation of fluctuation marked, we are enabled to determine that we have to deal with what is known as a cyst, this probably being a single cyst, which affords the greater wave of fluctuation. As I make pressure over the right side it gives rise to a sensation of slight crepitation. This peculiar sensa. tion is probably due to some roughening of the cyst-wall or of the peritoneal surfaces, which lie in contact and rub over one another. As I percuss over the surface you will notice an absence of resonance. You will remember that I had a case before you two weeks ago, in which there was resonance over the entire surface of the distension. In this case, however, resonance is absent. If this were simply a case of ascites, we would expect to find resonance over the summit of the distension because the intestines, being filled with gas and lighter than liquid, float up and come in contact with the most superior portion of the distension, but in this patient there is absence of resonance at this point. Higher up you have noticed a difference in the sound. There is more resonance on the right than upon the left side, from which we infer that the tumor has probably developed from the left ovary and, as it has increased in Ovarian Cyst.-I now show you a patient size, has pushed the intestines upward and to 20 years of age, a dressmaker, single, whose the opposite side, as a result of which we have family history presents no special symptoms; she the dullness on the left side. Of course we has enjoyed good health as a child. Puberty cannot say absolutely, in any case, that because occurred at 12; menstruation was regular, last-resonance is more marked on the one side the ing three to four days; always painful, at times | tumor has developed from the ovary of the Delayed Menstruation. This patient is 20 years of age, whose family history is negative; she has never menstruated. Every two weeks, however, she has a profuse mucous discharge from the vagina, which continues for a day at a time, and is attended with a feeling of pelvic discomfort and fullness. She has coronal headache, a fair appetite, her bowels are regular, and she sleeps well. She has been married one year and has never been pregnant. Examination discloses the uterus as small and undeveloped. So far as the ovaries are concerned, whether they are rudimentary or fully developed, our examination is negative, as we have been unable to palpate them. There are numbers of cases in which the development of the individual is slow, and the patient may go on to 23 or 24 years of age before menstruation occurs. There are some individuals in whom it does not take place until subsequent to marriage, when the increased excitement induced by the sexual relations leads to the development of the sexual organs. In some patients menstruation may not take place until subsequent to gestation, so that the performance of the function of menstruation is preceded by gestation. In this patient we will make a more careful examination, possibly under an anesthetic, in order to determine whether her ovaries are rudimentary and are the cause of the delayed performance of the function. |