and the X-ray, the former daily and the latter every other day. This was followed out as the following statement will show: Jan. 24th.-Coley's fluid, two minims, by hypodermic, and X-ray, fifteen minutes. Jan. 25th.-Coley's fluid, three minims. Jan. 26th.-Coley's fluid, four minims. Jan. 27th.-Coley's fluid, six minims; reaction; chill; temperature, 103; X-ray, fifteen minutes. Jan. 28th.-Coley's fluid, six minims; slight reaction. Jan. 29th.-Coley's fluid, seven minims; decided reaction; temperature 103 1-2; X-ray, fifteen minutes. Jan. 30th.-Coley's fluid, six minims. Jan. 31st.-Coley's fluid, seven minims; X-ray, fifteen minutes; tumor much softer. Feb. 1st to 28th.-Coley's fluid given daily; reaching a maximum of 16 minims with a reaction about every third day; X-ray every alternate day. Original mass not getting any larger, but other glandular swelling appearing in the left cervical region. March 1st to 31st. Same treatment; glands in the right cervical region becoming involved; the X-ray reduces some of the enlargements, but has no effect on the original mass; the upper part of the left thorax is markedly dull on percussion. April 1st to 30th.-Same treatment; reaction every third or fourth day; dulness in left thorax spreading; complains of restless nights, owing to profuse perspirations. May 1st.-Glands in left axilla are becoming tender and enlarged. May 5th. Coley's fluid, fifteen minims; reaction; tempera ture, 104. May 6th. Coley's fluid, twelve minims; X-ray to all affected parts; glands in neck small and knotty; glands in axilla much enlarged and painful; complains of pain in arm when walking. May 10th. Treatment same; no change in axillary glands; left cervical markedly reduced; right cervical, chain of enlarged glands extending from below the ear to clavicle. May 11th to 31st.-Treatment same; dulness in thorax extending; spleen markedly enlarged. June 1st to 26th.-Treatment same (Coley's fluid every alternate day); extension is gradual; thoracic dulness more marked. June 27th.-Discontinued Coley's toxins. July 1st to Aug. 5th.-X-ray every alternate day. Condi tion about the same. Patient went to Muskoka for change Aug. 5th. Aug. 25th.-Scarcely any noticeable change since Aug. 5th; cervical glands more enlarged; thorax about same condition. Sept. 1st. Resumed X-ray treatment; exposing each side of neck, thorax and axillæ. Thorax examined: Area of dulness much greater than a month ago. Heart: Apex displaced 3-4 inch to right. The whole left side is larger than right side, seemingly due to fat deposit; pulse, 98; respiration, 22; cough present at night. Sept. 30th.-Result of the month's treatment not encouraging; gradual extension of disease; cough very troublesome; dyspnea at times distressing; heart's action increased; pulse 110; some difficulty in swallowing. Thorax, dulness over entire left side; respiratory sounds very faint; heart displaced 1 I-2 inches to right (at apex); X-ray burn on left side above the nipple. Oct. 3rd.-X-ray discontinued for a few days to allow the burn to granulate. Oct. 12.-Dr. Dickson examined patient, advising persistence with X-ray, as it appears to hold the growth in check. Nov. 11th.-Visited Dr. Morton in New York regarding the use of X-ray with quinine fluorescence. Nov. 19th. Commenced treatment advised by Dr. Morton, giving fifteen grains of bisulphate of quinine an hour before X-ray exposure; exposure lasting forty-five minutes; patient three feet from tube, using a very high vacuum tube. Patient's condition at this stage could scarcely be any worse; dyspnea very distressing; coughs at every attempt at conversation; heart's action very weak and rapid; pulse, 130-135; thorax, complete dulness over whole left side; mucous rales in right bronchi; heart displaced at apex about three inches to right (this is what the apex beat would indicate); patient unable to lie down; general condition getting markedly worse; cervical and axillary glands much enlarged; pain in left arm very acute at times; spleen greatly enlarged, can be readily felt three inches below the last rib; mesenteric glands apparently not affected, nor are the inguinal glands; patient's weight, 124 pounds. Dec. 1st. No marked change. Dec. 9th.-Patient says that last night was the first night for many weeks that he has had a good rest. No cough. Examined thorax: Undoubted improvement; axillary glands nearly normal; cervical glands much smaller; area of dulness about same. Dec. 16th.-Improvement during the last week has been. most marked; heart displacement only 3-4 of an inch at apex; pulse, 88; respiration, 20; no dyspnea; cough entirely disappeared. Chest examination: Right side normal; left side, dulness not so marked, but still general. No enlarged glands, save in the left axilla, this part being protected from the ray on account of the burn, which is still troublesome. Dec. 23rd.-Patient says he feels perfectly normal, except for the inconvenience of the X-ray burn. - General condition good; weight, 135 pounds. Jan. 1st, 1904. Still improving; right side, normal; left side, respiratory sounds more distinct, especially in axillary line and behind; dulness not so marked save towards apex. Heart Percussion not satisfactory on account of general dulness, but heart appears to be in normal position; pulse, 80; respiration, 20; no disagreeable symptoms whatever; patient says he feels quite normal. Feb. 4th.-Stopped X-ray to-day for a week. Feb. 9th.-No change. sumed treatment. Ray burn seems to be healing; re Feb. 18th.-Patient says he has "caught a cold." Has been. sneezing; nasal discharge; had a chill last evening; complains of feeling chilly; frontal headache; limbs and backache, etc. Feb. 18th.-Visited patient to-night; has all the symptoms of grippe; temperature, 102; pulse, 120. Examination of chest: Breathing a little harsh on the right side. Feb. 19th to March 18th.-Patient rapidly developed a pericarditis with effusion; edema becoming general, especially over the back and abdomen and scrotum; very little in the lower extremities; no enlargement in cervical, axillary or the inguinal glands; heart weakness very marked; dyspnea very distressing. This persisted until March 18th, when the patient died. It will readily be observed that in the case of this patient that Coley's toxin had no effect whatever on the disease, other than a possible softening of the original mass, and which was only temporary. It will also be observed that the X-ray as at first used had no effect, except on the superficial glands, and that it was impossible to keep pace with the rapid progress of the disease. Also we see the great danger of ray burn to the patient, especially when it is necessary to expose several parts during one treatment. One ray burn may be a very serious matter, and cause a delay possibly of weeks in the treatment, which is a very serious matter when we consider that success, if it is possible, depends upon the continuous treatment. With the aid of quinine fluorescence the great danger of ray burn is very slight and it is possible to expose the patient to the influence of the ray every day, from forty-five minutes to an hour. Quinine per se has no effect in this disease. It is solely on account of its fluorescent properties that it is useful in connection with the X-ray, which may be demonstrated by taking a solution of quinine bisulphate, say, one grain to the ounce, and place inside a fluoroscope which has been wrapped in several thicknesses of black paper, and exposing to the X-ray, when the bottle of quinine solution will be seen most distinctly fluorescing. Quinine bisulphate is used in preference to the other salts of quinine, on account of its solubility, being soluble in one to twelve of cold water, while the sulphate is only soluble in one to seven hundred and forty cold water. The quinine should be given in large doses, commencing at ten grains, increasing up to fifteen or twenty grains daily, an hour before exposure to the X-ray, and the treatment kept up daily. The tube should be one of high vacuum. This is all important. A low tube will not give good results, according to Dr. Morton. By a high tube is meant one that will at least have resistance sufficient to back a six or eight-inch spark. The patient should be placed about three feet from the tube, and the exposure should last from thirty to forty-five minutes, or even one hour, according to the severity of the case, the patient being turned from time to time, so that all the affected parts may be exposed. This treatment should be persisted in as long as good results are obtained. As to just what tissue change takes place I am not prepared to state. In some situations a decided softening occurs, the enlarged glands becoming normal so far as one can judge, while in others the enlarged glands shrink and become quite fibrous. This corresponds to the theory of some authorities, that a fatty degeneration ensues in some cases, while a change to fibrous tissue occurs in others. I am sorry that I was unable to obtain a post-mortem examination in this case, and thereby determine what changes actually did take place, yet I am convinced that great good may come from the use, especially the early use, of quinine fluorescence in all cases of sarcoma, but on the other hand, unless used properly and with a powerful X-ray apparatus, using a high vacuum tube, anything but good results may ensue. CASE OF HYSTERECTOMY FOR FIBROID TUMOR OF THE UTERUS: RECOVERY.* BY A. LAPTHORN-SMITH, M.D., Mrs. years of age, consulted me at the Montreal Dispensary for an enlargement of the uterus, which she had noticed only about three months ago. She was a very ill-looking woman. Her skin was sallow, her eyes sunken, her cheeks hollow. She had a heart murmur, a very weak pulse, generally emaciated, albumen in the urine. Altogether she was in such poor condition that when I sent her into the Western Hospital, for removal of the uterus by abdominal section, my house-surgeon telephoned me to come and see her again, as he hardly thought she would stand an anesthetic. Nevertheless, I decided to operate, for she was having profuse menstruation for the last five years, lasting five days every month, and I felt sure that bad and all as her condition was, it would certainly not be better until the cause of the trouble was removed. Like other gynecologists who have watched the course of a large number of fibroid tumors, my opinion as to the harmlessness. of these tumors has undergone a great change during the last ten years. Formerly we never thought of removing them until they had attained a very large size, and even then we were inclined to delay operative interference from year to year and depend upon medical or electrical treatment, in the hope either of diminishing the hemorrhage or arresting the growth of the tumor, or even of carrying the patient along until the menopause should arrive; but after a time we found that the menopause did not come on at the usual period, but kept up for five, ten, or even fifteen years longer-if the woman lived that long. Moreover, we found that many of the women who had fibroid tumors, even after the flow had stopped, continued to fail in health, generally dying in ten to twenty years before their time from disease of the kidneys, due to pressure of the tumor on the ureters, or from constipation and indigestion, owing either to pressure on the stomach and intestines, or, perhaps, by reflex action, due to irritation of the great sympathetic nerve. Others died from dilatation of the heart, due to defective nutrition, causing dilatation and then failure of the valves to meet, so that the blood regurgitated into the lungs and venous *Read before the Medico-Chirurgical Society of Montreal, March 24th, 1905. |