Imágenes de páginas
PDF
EPUB

astringents can be used with some advantage, but surgery is the only sure relief.

"Surgery of the Air Passages in Children." Dr. J. Homer Coulter, of Chicago, said the subject is one of especial importance because of the percentage of deaths from diseases of the air passages during childhood, because the respiratory and circulatory functions are being crowded to their vital capacity, and because reflexes in childhood are more prominent and frequent than in adult life.

The first paper read before the Surgical Section was by Dr. J. M. Ball, of St. Louis, entitled "Report of Some Cases of Ophthalmic Surgery." The author reported several cases of injury to the eye in which the proper surgical treatment proved satisfactory. One case of interest was a pseudo-glioma removed by enucleation. The specimen was exhibited. Another was the case of a man, sixty years of age, who had been given sixty grains of quinine within twelve hours, in whom the next morning there was total blindness. A diagnosis of quinine amaurosis was made.

Dr. Wheelock inquired if there could not possibly be a syphilitic infection in the case of amaurosis reported, to which the author replied that such a possibility had been eliminated from the diagnosis.

"To Drain or Not to Drain."-Dr. Arch. Dixon, of Henderson, Ky., read this paper. For some time past drainage after abdominal section had been growing less and less in favor. There were, wounds which required drainage, and others which did not. Aseptic wounds did not require it, but contaminated or infected wounds did. The author reviewed the arguments against the use of drainage in the peritoneal cavity. Drainage was not effective in removing infection; infection might occur through the drainage tube. The removal of the tube was painful, bladder complications were possible, hernia might result, and frequent removal of the tube was necessary.

Dr. Goldspohn called attention to the two methods of abdominal operations-one in which the smallest possible opening was made, and the other in which a large wound was made. He pointed out the advantages claimed for each method of operating.

Dr. Cordier said that if two cases exactly alike were taken, and the operation, surroundings and care of each be identical, one

drained and the other not, we would almost invariably obtain more satisfactory results in the case in which drainage was employed.

"Pelvic Disease without Local Symptoms." -This paper was read by Dr. Henry P. Newman, of Chicago. The speaker said that pelvic disease of an aggravated type was often present without noticeable local symptoms; that reflex symptoms began in mere functional disturbance, and might become so serious as to endanger the life and health of the patient, and give rise to misdirected treatment which did not recognize the causes of the real trouble. It was necessary to understand the relative importance of pelvic irritation, and of certain obstinate and severe affections of more distant organs. This was very essential to a correct diagnosis in many cases. In all cases of chronic invalidism in the female, failure to exclude pelvic disease, in the same manner as we excluded diseases of the other important organs, was unscientific and reprehensible. The cause of medicine would be advanced when practitioners made comprehensive diagnoses.

"Postoperative Hernia in Appendicitis."Dr. Robert T. Morris, of New York, read a paper on this subject.. Operators for appendicitis were now using a much smaller incision than formerly, in order to avoid the unfortunate effects of a hernia. These hernias were caused by the fact that the lines of muscle traction at this point were different in different muscles. A pad over the seat of operation induced hernia by bringing on absorption of the new connective tissue as it was being formed. The margin of each muscle should be separated with the greatest care in operating; care should likewise be taken in dividing the peritoneum. In closing the wound each different layer of muscular tissue, as well as the peritoneum and fascia, should be united with the same tissue from which it was separated at the beginning, so that the lines of muscular traction would not be disturbed, and hernia was not so likely to be produced. No bandage or pad should be applied. The patient should be kept in bed for at least twenty-one days following the operation.

Dr. John Young Brown, of St. Louis, made some remarks on appendicitis, in which he said conservatism had given place to knowledge in this disease. This knowledge was sufficiently comprehensive and accurate to af

ford a satisfactory working basis. Infectious appendicitis should be isolated, for the same reason that a case of diphtheria was isolated.

Dr. Morris, of New York, said that making a date to operate in a case of appendicitis was certainly undesirable. The surgeon could not always wait until the third day. Rigor meant that toxins were entering the circulation and producing an impression upon the sympathetic system.

"Tuberculin in Dermatology" was the title of a paper by Dr. A. Ravogli, of Cincinnati, in which the author drew the following conclusions: 1. Tuberculin is a valuable aid in dermatology, both as a diagnostic and therapeutic measure. 2. In lupus it acts remarkably well as a systemic treatment, particularly in conjunction with other means for the purpose of reducing infiltrations. 3. After a large number of injections he has never had any bad effects. 4. Old tuberculin has given him more marked reaction, both general and local, than the new. 5. In cases in which ordinary remedy had an influence, tuberculin promptly caused a disappearance of the eruption, healing of the ulcerations, and a general improvement in the condition. 6. If relapses occur after the use of the remedy has been discontinued, we are not justified in blaming the remedy therefor. 7. To insure recovery, tuberculin must be used in small doses for a long time at short intervals.

Dr. A. W. Brayton, of Indianapolis, cited the clinical history of two cases of tuberculosis papillomatosa cutis now under his care in the City Hospital at Indianapolis. One, a healthy man of twenty-eight, had a patch two inches in diameter on the instep and a second patch the size of the palm on the buttock, just external to the anus; the patches had been growing ten months, the dendritic and papillary growths overlying the sound skin; they were very foul. On removing the excretion covering the growths by immersion in warm normal salt solution, numerous maggots appeared. Under ether narcosis the areas were cut and scraped out clean. Dr. F. B. Wynn found giant cells in the sections. Cure was nearly complete at the present time. The morbid growths were the duplicates of those in Prince Morrow's case, shown and described in the Journal of Cutaneous and Venereal Diseases, November, 1888. The source of infection is not known.

The second case is that of a colored man of

forty years, in advanced phthisis. The nodules are plainly the result of auto-infection. They average an inch in diameter, are an eighth to a quarter of an inch in elevation, and occur at the angles of the mouth, the borders of the nose, the chin, and on the back of the neck and inner aspect of the thighs. The patient is a victim of congenital ichthyosis, and had infected the open fissures in the skin of the legs and arms with sputum carried on his fingers. The nodules had been a year in growing. The cases were of the extremest interest, as no similar ones had been observed in the Hospital or Dispensary before.

"Further Observations in the Use of Hydrogen Dioxide in the Treatment of Blepharitis Marginalis."-This was the title of a paper by Dr. S. C. Ayres, of Cincinnati. This disease, unchecked, produces gradual destruction and atrophy of the hair bulbs from ulceration. Mercurial ointments have long been used, and are well adapted to some cases, but irritating to others. An alkaline wash is very beneficial in softening the crusts, but in hydrogen dioxide the author thinks we have a remedy which both softens and dissolves. After using the remedy, with a dressing probe or scoop the crusts can be lifted off. The dioxides will always be a valuable adjunct to other rational measures in the treatmen of this disease.

Dr. Max Thorner, of Cincinnati, said he had used this remedy extensively, and had seen the results from its use in Dr. Ayres's hands, and almost invariably he had most satisfactory results. However, in recent years the remedy had fallen into disuse.

"Hypertrophied Faucial Tonsils."-Dr. J. F. Barnhill, of Indianapolis, presented this paper. It was strange that the laity still had absurd notions relative to the functions of the various tonsils. The system suffered little or nothing from ablation of normal glands. The author's classification of cases was: (1) those in which the patient claims never to have suffered inconvenience from the tonsils; (2) those in which there is quinsy or tonsillitis one or more times a year; (3) a small, flat, yet pathological gland. In all cases the diseased crypts should be cleared out. The patient was a most valuable assistant. The bad results of pathological tonsils were enumerated, and they were stated to be a cause of reflex neuroses and to act as obstructive

bodies, as absorbents, and as auto-infectious bodies. Various methods of treatment and removal of the tonsils were considered, and the merits of each were pointed out.

"Tobacco Neuroses."-Dr. Zenner, of Cincinnati, read a paper on this subject. In very many instances tobacco is only one of the many causes of the existing malady. Among the other factors often conjoined with tobacco and which make the diagnosis more difficult are alcohol, coffee, mentral strain, worry, etc. Syphilis also often plays an important part. The neuroses traced to tobacco are functional diseases of the heart, amblyopia, tremor, vertigo, neurasthenia, some forms of neuralgia, rarely angina, and the lesser nervous disturbances, epilepsy, and various psychoses; even paresis has been attributed to it, although without sufficient reason in every case. The treatment is entire abstinence from the use of the weed. The mere lessening of the amount usually fails altogether. Frequently entire abstinence for a year or more permits a return to the use of tobacco in moderation without harm.

A very instructive and exhaustive paper was read by Dr. Homer M. Thomas, of Chicago, entitled "Experimental Work on the Penetrability of Vaporized Medicaments in the Air Passages." Do vapors enter the alveoli of the lungs? All observers thus far have questioned such a possibility. The greatest difficulty has been in the mechanism of the instruments for vaporization, in that they have failed to break up the oil in sufficiently fine particles for it to enter the alveoli. The author related in detail the results of his experiments, mostly on animals, during the past two years, and gave his reasons for believing that under proper conditions the medicament will enter the healthy lung, even to the alveoli. A variety of microscopical slides were exhibited, taken from the lung of a patient in whom inhalation had been practiced shortly before death, which plainly showed the oil globules in the alveoli.

Dr. C. A. Johnson, of Chicago, followed with a paper on the same subject. He related his experience in the use of the instrument in forty tuberculous cases, and directed attention to the point that the solution employed must be a weak one, as too strong a solution produces irritation and consequent hypersecretion. The first symptom of im

provement was relief from the dyspnoea, and the next a lowering of the temperature.

"Epistaxis in the Most Serious Form, with Report of a Case Necessitating Ligation of the Common Carotid."-Dr. Max Thorner, of Cincinnati, the author, said that in using the term epistaxis, reference was made to hemorrhages in which blood comes from the nose, and those cases in which it merely passes through the nose. In the latter category is included bleeding from the pharynx, naso-pharynx, the accessory cavities, larynx, lungs and stomach, as well as in cases of fracture at the base of the skull. The author considered serious cases only, those in which the ordinary styptics fail to check the hemorrhage. He referred to four cases in which the radical operation of tying one or both carotids was practiced, two of which proved fatal. The paper closed with a reference to a case in his own practice. It was that of a man struck with an iron ring across the bridge of the nose and right side of the face. Unconsciousness and profuse bleeding from the nose followed. The patient was removed at once to the hospital and the nose plugged. During the next eighteen days the nose was tamponed repeatedly both anteriorly and posteriorly, but each time after removal of the tampons the hemorrhage started afresh within seventy-two hours. The patient becoming almost exsanguinated, with high pulse and increased temperature, an operation was decided upon. The common carotid was ligated. The hemorrhages did not recur, and the patient was discharged one month after the operation.

A. H. Cordier, of Kansas City, read a paper entitled "Some Phases of Extra-Uterine Pregnancy." This condition was not recognized and diagnosticated as it should be by the general practitioner. The application of common sense and good judgment was the best guide to the successful termination of ruptured tubal pregnancy. If a blood vessel was injured and bleeding, it should be tied. The diagnosis was usually not very difficult. A very important point was the menstrual history, and this should be thoroughly investigated. The pathology of these cases was of little value at the bedside. A tube having once ruptured would continue to give trouble. The dangers of the condition far outweighed the dangers of good surgery employed in these cases. Operation should be performed

at the earliest possible moment. Clots did not always form. No case was devoid of danger until the bleeding vessel was firmly tied.

"The Treatment of Suppurating Fistulous Tracts."-This paper was read by Dr. E. J. Senn, of Chicago. The primary dressing should not be disturbed for four or five days, when it is removed and repeated if necessary. Nitrate of silver or other caustics should not be used, as the granulations are only superficially destroyed, leaving a necrotic area, which should be avoided. If the granulations are persistently sluggish, the wound should occasionally be packed with gauze saturated with balsam of Peru, as this agent stimulates the regenerative capacity of embryonal cells without impairing the vitality of the surrounding tissues. In the author's hands most obstinate fistulæ have yielded under the treatment suggested when previous antiseptic irrigation over estimated periods of time proved of no value.

October College Clinics at St. Vincent's Hospital, Indianapolis.

The clinics of the Central College of Physicians and Surgeons opened Tuesday, September 28th, with Drs. J. A. Sutcliffe and S. E. Earp as clinicians. These clinics are held weekly on Tuesday, from 2 to 4 in the after

noon.

Among the cases in October Dr. Sutcliffe presented a case of undescended testicle combined with congenital inguinal hernia. Castration was performed and the canal closed up with silk worm gut, left in to become encysted. Dr. Thomas Eastman presented a case for ovariotomy. The operation was neatly and quickly done, the patient suffering no nausea and no shock. Dr. Eastman is an advocate of ether narcosis in abdominal section.

The clinics of the Medical College of Indiana commenced October 1st. They are held every Friday afternoon, from 1 to 3:30. Dr. Joseph W. Marsee is clinician in charge. Of the more important cases may be mentioned a case of morbus coxarius in a young man twenty-four years old. Dr. J. R. Weist, of Richmond, had previously made several curettements. Excision of the joint was performed. Plaster dressing, with window, and free drainage was advised. A case of tubercular knee-joint in a boy five years old, on whom exsection was performed last November, was presented for thigh amputation, ex

cision having failed to stop the ravages of the disease. In a case of tubercular synovitis in a man twenty-two years old, and in a case of typical hip-joint disease, second stage, girl five years old, rest-enforced by plaster casts and tonics-was advised. In a case of pes covus, with varus inclination, the plantar fascia was cut and foot put up in plaster. Extensive skin grafting, on account of burns on arms and legs, was performed by Thiersch's method. Mayer's dressing of collars of gauze above and below and thin splints between were used on the grafts. Dr. Morrison presented two cases of senile cataract and operated on the same with good results. F. W. FOXWORTHY, Reporter.

City Hospital Clinical Notes. Report of a Case of Hysteria in a Male-Observations on the Case by Drs. Minor Morris, R. C. N. Cook and E. C. Reyer.

DR. MORRIS'S OBSERVATION.

In the evening of August 30th, while sitting in front of my residence, I noticed a passing pedestrian suddenly faint at the next gate, where some neighbors were gathered. My first impression was naturally of an epileptic seizure, and on hastening to him I found him semi-conscious and complaining of pricking pains in his right arm and leg, speaking slowly and with effort. He was carried into my house, and in a few minutes recovered himself, stating how he came to be in the locality; that he had walked all day hunting work, without anything to eat, and was recently convalescent from typhoid. I at once telephoned for the ambulance to remove him to the Hospital. He complained of a very severe headache, and, taking a small drink of water, relapsed into profound unconsciousness. The respiration became very slow and shallow; pupils moderately dilated and inactive to light; pulse 86 and of fair volume. The right arm and leg became entirely relaxed, offering no resistance to manipulation or deep pin punctures. The possibility of a. graver lesion in the brain or embolus or hemorrhage, as rarely follows typhoid, suggested itself. Dr. W. H. Haynes, who was near, was asked to see him, and Dr. Thomas, of the Dispensary, soon arrived with the ambulance. There developed an entire relaxation of the left side, and soon after tonic contraction of the digital extensions of the hands. For a short interval divergent strabismus was pres

ent. The respirations continued shallow and slow, the pulse unchanged. It was now about two hours since the onset, during which time there were severe remissions, with an effort to speak, and in this condition he was removed to the City Hospital.

CLINICAL NOTES OF THE HOUSE PHYSICIAN, DR. COOK.

G. G., male, white, twenty-five years of age; trained nurse by occupation. Was admitted to City Hospital August 30, 1897, in an unconscious condition, having fallen on the street, and sent in with suggestion of cerebral hemorrhage. His own and family history in regard to health, obtained later, was good. He had had several of exanthematous diseases in childhood; general health good up to period of attack of typhoid fever, about seven weeks previous to admittance and three weeks since convalescence. On admission he was unconscious; respiration weak and spasmodic; corneal reflex very sluggish; pupils responded equally to light; pulse 80 per minutes and of good volume and strength; temperature 100.4 degrees F. The voluntary muscles of trunk and neck were in state of tonic contraction, that upon the left side being much more marked. The head was drawn slightly to right and backward; teeth clenched. The left arm was drawn to side and arm partially reflexed at elbow. The hand at wrist, the fingers and thumb at metacarpo-phalangeal joint and phalanges extended in position seen in tetany. The left leg was rigid in extension, with the foot in a well-defined equino-varus position. There was no paralysis of motion, nor hyperæsthesia, but partial analgesia of left side of body and right side of face existed. No increase of facial or fore-arm reflexes; patellar reflex more pronounced on left side than right, but this relation was reversed twenty minutes later. No heart murmurs; stomach apparently empty; liver and spleen of normal dimensions; abdomen slightly retracted. Bladder distended moderately. Catheterization removed twelve ounces of pale straw-colored urine of specific gravity of 1.012; no albumen, but earthy phosphates rather abundant.

At the end of an hour coma had given way to a mere partial stupor, from which he could be aroused to indicate seat of pain in head and to give information regarding his condition in writing. Speech was still in abeyance. Somewhat later in attack he attempted to talk through his clenched teeth; his enunciation was very poor and words uttered in

an explosive manner. During this condition the contraction in left hand and arm relaxed under command to perform certain passive motions by assistance of right hand; when allowed to rest, contraction gradually but quickly reappeared. The tonic contractions lasted for two or three hours, gradually disappearing. He was able to take some nourishment on night of admission.

On August 31, 1897, he had a second attack similar to but not as severe as the first one. During this attack he could relax and move arm and hand by command from physician; later in the attack he could give concise answers in writing, but seemed unable as before to articulate. He complained of a "lump" rising in his throat, stopping at larynx and causing inability to speak; that his head felt as if some one were driving a fork into the right parietal region-which was relieved by pressure or cold applications-and of his right eye and supra-orbital region hurting him severely; that his back was very tender, and it pained him intensely after lying on it for a short time. He ate heartily on second day, and sat up quite a while. Toward evening he fell from his chair to floor in an oncoming attack, without injury to himself. The attack lasted only about one-half hour.

September 1, 1897, only slight attack, from which he soon recovered. Complained of melancholy. From this time until discharged, September 6, 1897, he only had one or two mild attacks. In walking he dragged his left leg for two or three days after first attack. His urine was slightly increased in amount, and an excess of amorphous phosphates was present; the specific gravity was 1.012.

The treatment consisted of asafoetida gr. 8 t. i. d.; electricity (Faradic); cold douches, temperature about 50 degrees F.

OBSERVATIONS ON THE DIAGNOSIS AND

PATHOLOGY BY DR. REYER.

As the severe forms of hysteria are met with much more rarely in the male, a diagnosis is not so readily arrived at as would be the case with a similar symptom complex in the female. It might be of interest to rehearse the points which led up to a diagnosis in this instance:

1. His age, twenty-five years, in the absence of evidences of syphilis, opposed diagnosis of apoplexy. Moreover, embolism was improbable in the absence of heart murmurs.

2. Occupation, nurse, with previous residence at a hospital.

« AnteriorContinuar »