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About two years after the affection began the curable. In a person of the age of this papatient had an attack of typhoid fever. After tient, and in whom the baldness is so comrecovery from that illness he noticed that his plete, the prognosis must be guarded. The hair fell more rapidly than before. The loss, treatment adopted in the present case was however, was gradual and slow. Until two as follows:years ago he had a little hair upon the side of

☆ Sulphuris sublimati,

gr. c. his head. Within the last nine months the Potassii bitartratis,

3ss. hair upon the chin and cheeks has begun to M. et ft. capsulæ no. XXX. fall. The left side of his mustache has Sig.: One capsule four times a day. become decidedly thinner than the right. The R Ungt. hydrargyri nitratis, • zss. eyebrows have also fallen. The man wears a

Lanolini,

Zss. wig when he goes abroad, though he cannot

Acidi salicylici,

3j. endure it when at work on account of sweating

M. Sig. : Rub well into the scalp twice a day. of the scalp. He has always perspired freely By a curious coincidence it happens that upon the head from the time of his youth. He this patient also, the third of a series, is afis unable to give any cause for this total loss of flicted with a co-existent psoriasis. Small scaling hair. The man has not a very vigorous look, patches have, during the last three months, but he states that he is able to perform his developed in front of each knee. The disease daily work, which requires considerable is in its incipiency, and the lesions are good strength. He has never had syphilis. His examples of the early stage. appetite and digestion are good, and he sleeps Eczema Capitis.-S. M., male, 35 years of well. Some years ago he had his scalp age, a porter, first noticed, between five and shaved several times, but no benefit resulted six months ago, an eruption upon the back of from the procedure. He has always perspired his head. The affected spot was at that time freely upon the body. The patient is habitu- about the size of a cent. It caused a good ally constipated.

deal of itching Since that time other spots This case, beginning as alopecia circum- have appeared upon the top of the head, and scripta, is an example of the complete baldness have enlarged with considerable rapidity. which occasionally results from the progress of They have not been attended by suppura. that affection. The whole scalp has been in- tion, but gave rise to some sticky moisture volved by the extension and coalescence of which dried into crusts. From time to time the various patches. The disease has attacked the crusts would fall, but would soon be realso the hairy parts of the face, and the man newed. Similar spots have also appeared fancies even that latterly the hair upon his upon the sides of the head. They have not legs has become thinner. As in most cases of caused the hair to fall. There is likewise a alopecia circumscripta, the patient was origi- small patch of eruption upon the root of the nally endowed with an abundant growth of nose and another at the tip. Each of these is hair. The beginning does not, however, pre-covered by a thin, brownish crust. The cisely correspond to the history of most cases. patches upon the scalp are of oval outline. There had been no premonitory symptoms The incrustation is of a yellowish-brown color. calling attention to the scalp, and in this Beneath the crust the surface is red and moist. respect the present case agrees with the general | The man has suffered for two months from rule. The loss of hair is itself the first and pain in the back and hæmorrhoids. He thinks only symptom. The fall of the hair is gener- that he is not as strong as he was formerly. ally abrupt and rapid. The patient is surprised He has had rheumatic pains in the back, hips, some day to find that the hair comes out upon and thighs. He is habitually temperate as rethe brush and comb. Within a short time a gards liquor, and does not use tobacco. The patch or patches of baldness have developed. digestion is good at present, although he has Here the progress has been much more been troubled by dyspeptic symptoms. gradual. Some cases are attended by itching, This is a well-marked case of eczema of the but in this, as many others, that sensation has scalp. The subjective symptom of itching has been absent. The bare scalp is pale, thin, been prominent. This manifestation is much smooth, and soft to the touch.

common and persistent in eczema, Most cases of alopecia circumscripta are wherever located, than in psoriasis, and, for 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.

more

result. The wound has united throughout, The treatment of eczema of the scalp re- without the slightest symptom of inflammatory quires removal of the crusts and scales by condition about it. It is exceedingly gratifymeans of oil and the further application of ing when we remember that she had extensive sedative or slightly stimulant oils, lotions, or adhesions, and there was some danger of bleedointments. Bismuth is a good remedy, and ing into the peritoneal cavity, with the possinaphthol may be used when some irritant bility of sepsis resulting. effect is desired. It is needless to add that Ovarian Papilloma.-The next patient enwe should endeavor to eliminate the cause tered the hospital seven weeks ago with a and correct any deviations from the general marked abdominal distension. Her condition health.

at the time she entered was exceedingly enIn the present case the patient was treated feebled. She suffered from abdominal distenby means of codliver-oil locally, and a drachm sion, was very weak, and presented a very disof the syrup of hydriodic acid was given three couraging outlook for operation. The rapid times a day.

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.*

which was as large as a fist. The latter By E. E. MONTGOMERY, M.D.,

growth had a small pedicle; so the operation Professor of Clinical Gynæcology, Jefferson Medical College; of myomectomy was done by cutting through Gynæcologist to Jefferson and St. Joseph's Hospitals; Ob the pedicle and stitching up the surface, coverstetrician to the Philadelphia Hospital; President of the Alumni Association, Jefferson Medical College.

ing it with the peritoneum. She did well for ENTLEMEN: This patient underwent a week after the operation, when facial ery

an operation a week ago to-day for the sipelas developed. Upon inquiry we found removal of a sarcoma of the ovary. You re

there was erysipelas in the family before she member we had a large tumor filling up the

came to the hospital. In addition to that, the abdomen, associated with ascites. A portion

resident physician, who administered the an. of the tumor had begun to undergo disintegra- ästhetic, was at that time in the medical ward tion. I show you here her temperature record.

and in attendance upon erysipelas. You can It had reached 101° F. the second day, and readily appreciate that erysipelas developing in subsequent to that did not exceed 1000 a patient just a week after ovariotomy was not F. This morning it was normal. I bring

a pleasant complication. With it we had her before you to examine the wound and re

elevation of temperature which reached a maxmove the sutures. This is the first time the

imum of 103° F. This was of short duration, dressing has been removed. In removing

soon became normal, and at no time did the these sutures you notice I raise them up and wound become infected. The disease excut all the sutures before I attempt to withdraw tended over a good part of. the head, but the any. I do this for the reason that if each

Her convales

swelling was not very severe. suture were cut and withdrawn the patient cence subsequently has been rapid, and she is would become very nervous, and by the time in a much better condition and looks better than the last one was reached she would hardly be when she entered the hospital. It is a comfort able to control herself. There is but little to realize that this patient suffered from a papil

loma of the ovary rather than from malignant * Clinical lecture delivered at the Jefferson Hospital. degeneration. It is sometimes difficult to dis

GE

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 Delayed Menstruation.—This patient is 20 mass filling up the lower part of the pelvis, years of age, whose family history is negative; over which a sensation of fluctuation can she has never menstruated. Every two weeks, readily be distinguished. No particular irreghowever, she has a profuse mucous discharge ularity is demonstrated ; and as the distension from the vagina, which continues for a day at is uniform and the sensation of fluctuation a time, and is attended with a feeling of pelvic marked, we are enabled to determine that we discomfort and fullness. She has coronal head. have to deal with what is known as a cyst, this ache, a fair appetite, her bowels are regular, and probably being a single cyst, which affords the she sleeps well. She has been married one year greater wave of fluctuation. As I make pressand has never been pregnant. Examination ure over the right side it gives rise to a sensadiscloses the uterus as small and undeveloped. tion of slight crepitation. This peculiar sensa. So far as the ovaries are concerned, whether they tion is probably due to some roughening of the are rudimentary or fully developed, our ex- cyst-wall or of the peritoneal surfaces, which amination is negative, as we have been unable lie in contact and rub over one another. As I to palpate them. There are numbers of cases percuss over the surface you will notice an in which the development of the individual is absence of resonance. You will remember slow, and the patient may go on to 23 or 24 that I had a case before you two weeks ago, in years of age before menstruation occurs. which there was resonance over the entire surThere are some individuals in whom it does face of the distension. In this case, however, not take place until subsequent to marriage, resonance is absent. If this were simply a case when the increased excitement induced by the of ascites, we would expect to find resonance sexual relations leads to the development of the over the summit of the distension because the sexual organs.

In some patients menstruation intestines, being filled with gas and lighter than may not take place until subsequent to gesta- liquid, float up and come in contact with the tion, so that the performance of the function most superior portion of the distension, but in of menstruation is preceded by gestation. In this patient there is absence of resonance at this patient we will make a more careful ex. this point. Higher up you have noticed a difamination, possibly under an anæsthetic, in ference in the sound. There is more resonance order to determine whether her ovaries are on the right than upon the left side, from which rudimentary and are the cause of the delayed we infer that the tumor has probably developed performance of the function.

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 opposite side, for the reason that, as an ovary ectopic gestation, and on the following Friday increases in size and becomes heavy, it gravi. this was confirmed by operation. I now show tates to the lower portion of the pelvis and, you the temperature record, which, prior to there increasing in size, it may push the intes- the operation, reached, for several days, a tines up on the same side as that from which it maximum of 104° F.; subsequent to its originated. We can say, however, that here performance the maximum has been 101° F.; we have a cyst, for the absence of resonance this morning it is 99° F. This patient, over the entire surface of the tumor indicates from a diagnostic point of view, has prethat it does not result from free fluid within sented much of interest, and has afforded us the abdominal cavity. There is a certain a great deal of gratification. You remember amount of resistance to the hand. The mass that the patient suspected herself pregnant, can be picked up and pulled from one side to and was satisfied that an abortion took place the other, and in so doing sensation of crepi- in February, 1893. Subsequently her abdotation is recognized, indicating that the rapid men continued to enlarge, and she later recog. development of the tumor has produced a nized foetal movements. Her menstrualion certain amount of irritation and peritonitis. after this supposed miscarriage did not return Further, that it is a cyst is evident from the until the following October. Subsequent to distinct fluctuation we are able to detect. this date, until she came under our observaPlacing the hand on one side we feel a wave tion, the last of March, 1894, she menstruated of fluctuation. The absence of resonance and regularly. Her abdomen had become as large presence of Aluctuation indicate that we have as a woman between the seventh and eighth fluid confined within a sac. It is true that we months of pregnancy. The abdominal dismay have an abdomen so distended with fluid tension is centrally situated, projecting, possibly, that the mesentery will be too short to permit a little to the right. The tumor was regular the intestines to float to the surface, or the in outline until we reached the left side, low mesentery itself may be contracted by inflam- down, when a projection or more firm, resistmatory adhesions so that the intestines are ing mass could readily be distinguished. The withheld from the abdominal surface. In tumor itself had an elastic feel, and upon perthese cases superficial percussion will give dull-cussion fluctuation could readily be distinness, while pressing the hand well down upon guished. It differed from an ordinary cystic the abdomen we will find resonance. In other iumor, however, in the fact that its entire surwords, the intervening layer of fluid by this face was resonant, naturally leading us to action is displaced, and the abdominal wall is expect that the sac contained air or gas. Our pressed down against the air-containing intes- palpation did not enable us to recognize any

Here, however, we are not able to solid mass excepting that situated upon the accomplish this displacement, for the reason left side of the abdomen. By vaginal exam. that we have a mass within the abdominal ination the cervix was felt high up behind the cavity. Having determined that we have an symphysis, where it had been pushed by the ovarian tumor, the question for consideration mass, which had extended deeply into the is, What shall be done for her relief? The only pelvis and was a part of the abdominal tumor. method of treatment in such cases that affords This mass was so closely connected with the the slightest probability for permanent relief uterus posteriorly that it was difficult to say would be the removal of the cyst. If we that it was not a part of it. The question of should attempt to relieve her by emptying the interest became, What was the character of cyst, we would find that it would soon again the abdominal distension present in this fill, producing a similar.train of symptoms, and patient? The fluctuation would lead us to the withdrawal of so large an amount of fluid suspect that we had an ovarian or fibro-cystic from the system has a depressing influence tumor. On the other hand, its surface was upon the patient; so we shall advise this patient resonant, while in an ovarian or fibrous cyst to undergo the operation of ovariotomy. dullness is present. Its walls also seemed too

Ectopic Gestation.—The next patient is thin, and fluctuation was too distinct to lead one in whom we have had a great deal of us to believe it was a fibroid growth. In careinterest. She was examined before you two fully analyzing the symptoms presented, we weeks ago to-day, and a diagnosis made of were forced to the conclusion that we had to

tine.

deal with a case of ectopic gestation, where duced into the sac-wall; but, as this was the
probably the period of gestation had been only suture infected, we feel that we have been
completed, and the foetus had died, undergone fortunate. The convalescence has been as
maceration, as a result of which there had rapid as could have been expected.
been a development of gas in the sac, causing Displaced Kidney.- The patient is 38, mar-
resonance upon percussion. We were led to ried; has a good family history ; puberty oc-
this conclusion by the history of the case, curred at 17; menstruation every two weeks
which comprised the supposed pregnancy and and lasting two days, scanty and painful; was
abortion at the second month; the subsequent married when 18 years

of
age

and has never been enlargement of the abdomen, associated with pregnant. Three years since she underwent abfoetal movements and absent menstruation; dominal section, for what cause she is unable finally, cessation of fætal movements with a to inform us, but states that she is no better return of the menstruation, and, at a late than she was before the operation. She suffers date, presence of resonance over the sac. from pain in the abdomen, especially on the That this was engendered by decomposition of left side just below the last rib, and continuous the sac-contents was rendered still more prob. pain in the back. She has not menstruated able by the marked elevation of temperature since the operation, her appetite is poor, and from which this patient had been suffering bowels regular. Upon examination we find the during the last two weeks,-an elevation asso- ribs and crest of the ilium lie almost in conciated with loss of flesh, strength, and appe- tact; we can hardly press the finger between the tite, and a depressed, anxious appearance of lower rib and iliac crest. This is one of those the countenance.

cases in which operation on the kidney through This association of symptoms led me to the loin would be exceedingly difficult. As commit myself to you that we had to deal you look at this left side you will notice some with a case of ectopic gestation. When the desquamation of the skin, evidently a result of abdomen was opened a large, red, fleshy a recent blister. The patient complains of looking mass was found, which was apparently more or less distress in this region. She also closely associated with the intestines and speaks of having noticed a mass situated in the omentum, and below with the posterior surface left side of the abdomen, which increases and of the uterus. This mass was opened, when decreases in size. The question becomes, What there was at once a gush of dirty, greenish is the character of the growth, if any, which looking fluid, and the limbs of the foetus were has given rise to these symptoms, and from quickly seized and a macerated folus at full what has the growth itself arisen? We recogterm withdrawn.

The placenta was found nize that such a growth, even if this patient attached to the anterior wall, and, as a conse- had not the scar over the abdomen indicating quence, was removed with its basal wall that the peritoneum had been involved, is not attached. Examination disclosed the remain- probably a result of ovarian disease, as it is ing portion of the sac was associated with the situated too high. We are not likely to have intestines, so much so as to render it unwise to ovaries displaced upward unless the tumor is attempt its enucleation. The sac and abdom- so large that it can no longer find a position in inal cavity were thoroughly washed out, the the pelvis. So we disavow the probability of sac itself packed with several layers of iodo- this being an ovarian growth. The organs form gauze and the peritoneal surfaces attached which may possibly furnish a tumor in the to the parietal peritoneum, the wound above lateral region are the kidney, the spleen, the closed; in this way the peritoneal cavity was omentum, or the wall of the descending colon. shut out from any possibility of infection from These are situated upon the left side. Now, the sac cavity. The gauze packing was per- this patient, in addition to the symptoms she mitted to remain four days, when it was has already given, complains of being exceedremoved, and two rubber drainage-tubes, of ingly nervous, has frequent attacks of palpitation good size, inserted to the bottom of the sac of the heart, difficulty in breathing, and a sen. behind the uterus, and the cavity then washed sation of faintness. I can distinctly feel, al. out two or three times daily with a sulphurous- though the abdominal muscles are not very acid solution. At one time there was a stitch- much relaxed, a mass close to the spine, which abscess at the point where the suture was intro. I is not very movable, seems to be more or less

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