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, 1910

, Vol. V.

ETIOLOGY AND DIAGNOSIS.

Three Points of Importance in Intestinal Obstruction.- Dr. W. J. Mayo (Lancet-Clinic) says: "In acute intestinal obstruction I think there are three points so important that every surgeon of large experience must have had them brought to his mind time and again. First, do not give cathartics to a patient if you suspect

intestinal obstruction. I have noticed particularly that the cases that have been brought to us practically in a moribund condition, have had catharsis early, and thereby their chances of recovery have been diminished to a very serious extent. Second, do not give opium, because it Second, do not give opium, because it masks the symptoms, and our only hope of recovery from operation lies in getting the patient to operate on early. Third, do not give food."

The Diagnosis of Trichinosis.1-Thomp

son says that there should be no difficulty in determining promptly a correct diagnosis of trichinosis based upon the observation of the following symptoms: 1. Acute onset usually with vomiting and abdominal cramps. 2. A high grade of eosinophilia, invariably present; usually above thirty per cent. and frequently much higher-even above eighty per cent. 3. A high grade of temperature, often reaching 104° F. or more, and lasting, in lessening degree, for two to six weeks. 4. Puffiness of the eyelids and face, with pains in the eyes occurring in one-fourth of the cases. Dyspnoea and diaphragmatic breathing occurring without cyanosis in about onefourth of the cases. 6. The generalized muscle pains, cramps, soreness, and prostration, causing sometimes deceptive apparent immobility. 7. The sudden occurrence of symmetrical circumscribed corneal hæmorrhages in a patient whose bloodvessels are not degenerated, should give rise to a suspicion of trichinosis.

5.

'W. G. Thompson, M. D., Amer. Jour. of Med. Sciences, Aug., 1910.

TREATMENT.

The Successful Treatment of Tuberculous Fistulae. There is little or no doubt that oxidation and allied conditions often act inimically upon aërobic as well the fact that many a chronic case of empyas upon anaerobic bacterial lesions, and ema is hastened in its healing by oxygen put into the wound by means of a sterilized an oxygen glass cannula attached to cylinder is familiar enough. There are certain other conditions, however, in which the application of oxygen in this way is less easy, and the use of certain oxidizing agents may be resorted to instead. The effectiveness of potassium permanganate crystals inserted into a snake-bite immediately after its occurrence is known to many people who have lived in the Tropics. It is probable that potassium permanganate acts in a somewhat similar way when it is used in the manner advocated by Dr. Scobie for the cure of tuberculous fistulæ.

Amongst other cases he had a male patient, twenty-eight years of age, who suffered from tuberculosis of the left lung and from two tuberculous areas in the re

gion of the anus. These were situated to the left of the anal aperture, each being half an inch in length and apparently healed, but examination in a good light showed that they were still discharging a little pus; to the right of the anus there was a bluish unhealthy-looking swelling about the size of a bantam's egg, the resi

due of an ischio-rectal abscess which had been incised but which had filled up again. When opened it discharged a tablespoonful of thick pus. Careful probing of all three lesions did not reveal anything in connection with the bowel. The patient was in a very emaciated condition, and would allow of no further operative treatment. Crystals of potassium permanganate were introduced into the healthier of the two fistulæ after it had been carefully washed out. The patient experienced a sharp pain lasting about a minute, but there was no other discomfort; the treatment was continued for three weeks, the crystals being allowed to dissolve slowly in the feeble discharge. The result was a per'The Hospital, July 16, 1910.

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thus encouraged, packed the other in the same way twice a week, and in two months' time it also healed up finally. The ischiorectal abscess was now washed out with hot, freshly made permanganate solution, the interior being thereafter filled with crystals of permanganate of potash. The cavity being larger than the others had been, the patient experienced more pain, and this lasted about an hour after the crystals were inserted, but the effect on the discharge was considerable and marked. The general health of the patient continued good, and the cavity steadily shrunk up until presently there was no pus visible except at intervals of a week or ten days, and in due course the wound healed as the others had done.

Constipation in Childhood.1-To combat constipation in infancy, Poynton says it may be quite sufficient to use manna, which should be dissolved in hot water and strained through muslin. This remedy, no doubt, often fails, but it is very satisfactory when effectual, and for this reason worthy of trial. Some light massage along the colon will help these cases. Salines are most valuable remedies. The secret of the successful use of salines lies in their regular employment, in sufficient dosage to produce a thorough relief of the bowels. The initial dose must be an experiment, but once ascertained, it should be persisted with until a regular habit had been established and then should be diminished cautiously. If too little is given, griping pains and distention may result, and if too much, the motions will become unduly frequent and liquid.

A likely prescription for a child 2 years of age would be:

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dose of calomel or grey powder before commencing the saline treatment. Castor oil is well known as a very safe aperient, but has the disadvantage of intensifying the constipation if used in occasional doses. In spite of this it is invaluable when it is necessary to clear away curds in milk dyspepsia, and it can then be followed by mild salines. If a small and delicate infant has to be treated, the castor oil can be given with an equal part of pure olive oil. Castor oil has another useful function in young children, when there is irregularity of action of the bowels. In this particular class. of cases there is at one time constipation, at another diarrhea. Small doses of this drug given once, twice or thrice a day will often correct either of these irregularities. Five minims given in a mixture with a carminative twice a day is an average dose for a child of 12 months.

When the constipation is associated with deficient hepatic action, indicated by pallor of the stools, grey powder is a useful remedy, and this may be combined with powdered rhubarb as follows:

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Tuberculosis of the Elbow.1- Sever concludes his valuable paper as follows: Tuberculosis of the elbow occurs early in life and often after trauma.

There is an equal chance in a given case of abscess formation. The disease may appear in the head of the radius or in the olecranon or in the lower end of the humerus, and later invade the joint.

The best treatment is rest and fixation with the arm at a right angle and the forearm midway between between pronation and supination. Ankylosis is to be expected in

1H. M. Sever, M. D., Boston, Med. and Surg. Jour., May 19, 1910.

, 1910

, Vol. V.,

at least one-half of the cases, with very slight to good motion in the other half.

Resection of the joint is only to be done after careful consideration of individual cases and when the whole joint is disorganized from disease, or ankylosed in a bad position.

Ankylosis is to be expected following resection of the elbow joint.

The average course of the disease is about two and one-half years.

The Treatment of Burns.1 There are four things to demand attention in the successful treatment of burns, says Fancher, any one or all of which may be required in a given case; first, to combat shock if it exists; second, to relieve pain and nervous excitability; third, to prevent infection and to protect exposed living tissue; and fourth, to assist Nature in her work of repair.

1. Shock, which often occurs as a result of severe burns, is treated on general principles too well known to the profession to be discussed in this paper. Some one has said, "Shock is shock," meaning that regardless of its cause, shock must be treated in the same manner under all conditions.

2. To relieve pain and nervous excitability, it is usually necessary to give a hypodermic injection of morphin and atropin and then to immerse the burned area, if it be on an extremity, in cold water to which has been added a tablespoonful of bicarbonate or chlorid of sodium to the gallon. It is not necessary for the water to be ice-cold. A temperature of from 50 to 60 F. is preferable.

If the burned area cannot be immersed in water on account of its location it may be covered with a light smooth cloth which has been dipped in the solution; then by gently and continuously mopping this cloth the same result will be obtained.

This water-bath may be continued for some time or until the systemic effect of the morphin is manifest.

In institutions where trained assistants are always at hand the whole bath may be

'H. L. Fancher, M. D., Chattanooga, Tenn., Jour. A. M. A., July 2, 1910

used and continued for many days if a large area of the surface of the body is burned.

3. Protection of the tissues and prevention of infection demands our greatest efforts and must be kept in mind from the beginning. Nature puts forth her greatest efforts, and the system will exhaust its entire resources to accomplish this end; but Nature cannot prevent the invasion of pus-producing micro-organisms-the surgeon can.

I wish here to condemn two things often done, and at least sanctioned by most of our text-books: first, puncturing blisters immediately after a burn and second, the use of carron oil and other remedies of its kind as a protecting dressing.

A blister is a non-irritating protection to the delicate underlying structures, and the surgeon can furnish none.

When the patient is fairly comfortable the bath may be discontinued, and the burned area with the surrounding surface sprayed or mopped with peroxid of hydogen. The entire surface should then be mopped dry with gauze. Then strips of gauze which have been previously soaked in the following solution should be applied over the entire area.

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Over this a thin layer of cotton should be applied. The dressings should be kept in position by loosely applied adhesive strips or a roller bandage. This dressing soon dries and may remain for several days, or until it becomes soiled; at which time remove all soiled or wet dressings, spray with peroxid, mop dry and reapply fresh gauze soaked in the picric acid solution.

After the third day the larger blisters should be opened and the fluid contents mopped away and fresh dressings applied. This treatment is applicable to all burns whose severity is not great enough to cause sloughing.

If sloughing does occur as a result of charred tissue or later as a result of infection, the dead tissue should be removed as rapidly as it becomes separated, and the underlying exposed surface sprayed with

peroxid, and mopped with the picric acid solution; over this should be applied small strips of rubber tissue which have previously been soaked in 1:1000 bichlorid solution. The dressing should be finished as before suggested.

The picric acid solution, by its slight astringent action, limits the exudation of serum by constricting the congested superficial capillaries, and does not interfere with the development of new epithelium. Its germicidal action prevents infection, and in my hands has never produced any systemic toxic effect.

The rubber-tissue strips furnish a nonirritating covering to the denuded surface, and do not interfere with granulation in their removal. If the rubber tissue is applied in narrow strips, the edges being allowed to overlap, the dressing more perfectly conforms to the irregularities of the surface. The dressing should be changed as often as it is necessary to keep the surface clean and free from pus.

1

The Non-Operative Treatment of Hemorrhoids. By the proper use of certain measures the pain can be relieved, inflammation diminished, and the size of the piles reduced, and they may remain so for weeks or months, until some cause starts up the inflammation again. Nothing can be expected from this line of treatment in the way of a permanent cure. It is only palliative at best, but a great deal or almost entire relief can be afforded for some time; therefore it is proper to adopt this treatment if there is any good reason, owing to the condition of the patient, why the hemorrhoids should not be removed.

To obtain good results from this line of treatment, it is necessary, as far as possible, to correct any existing disease of the heart, blood vessels or liver, and any debilitated condition of the system which may exist, but all medication should be avoided that will induce constipation. Remove any obstruction of the colon or rectum, which may exist from pressure by other organs or from constipation. If necessary to overcome the latter, give a small dose of a saline cathartic every morning to obtain

'W. H. Hodson, M. D., Int. Jour. of Surgery, Aug., 1910.

one or two movements, such as a teaspoonful of Epsom salts, Carlsbad salts, sal hepatica, phosphate of sodium or seidlitz powder. These not only remove any hard irritating fecal matter that may be in the bowels, but they exert a beneficent effect upon disease of the liver and portal system which is so frequently associated with hemorrhoids.

The local treatment consists in reducing the inflammation and strangulation of the piles as soon as possible. To accomplish this the patient should be put to bed, and hot poultices or ice bags applied to the parts, whichever feels the most comfortable, or soothing applications may be used, as lead and opium wash or witch hazel. I have frequently had good results from the application of antiphlogistine when the piles have been external and strangulated. The following ointments may be employed: Morphin. sulph.

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, 1910

, Vol. V.,

that the latter disease also reacted favorably to this preparation.

This led them to test the possible usefulness of the oil for ordinary cases of ringworm, and so far the results have been most happy. The hair is cut closely around in order to identify the patches, the application of the oil being made twice a day by means of a camel-hair brush. This is continued for a few weeks, as the case indicates. No irritation is produced, while the preparation is most pleasant to use. Not only is the spread of the infection prevented, but that the fungus is being destroyed with certainty is recognized. in two or three weeks, by commencing development of fine hairs.

THERAPEUTIC NOTES.

If

An Antidote for Alcohol.-Hennell, in the Electric Medical Journal, lays great stress on the good results which can be obtained by the use of ammonium chloride in the treatment of alcoholism in all its phases. According to the author, 30 grains of the drug dissolved in a drachm of water and given at one dose, followed by a copious draught of water, not only will counteract the effects of the alcohol and sober the patient rapidly, but will prevent the onset of delirium, and overcome the craving for alcoholic stimulants. after the ingestion of the drug the patient has not quieted down in the course of two or three hours, some hypnotic, such as chloral hydrate or a bromide mixture, should be given. As a rule, when the patient awakes after this treatment there will be felt no craving for alcohol. The author points out that while 30 grains may seem a very large dose of ammonium chloride to give in view of the gastrointestinal irritation which it is said to produce, when given as an antidote for alcohol only a single large dose is administered and that this is followed by a copious draught of water.

The Treatment of Multiple Abscesses. -In many cases it has been found that

abscesses may be completely dispersed by the following method, which has been very successful for abscesses in the neck. The skin having been scrubbed with a boiled nail-brush, several layers of gauze soaked in ether are placed upon the prepared area and the compress covered with oiled silk and bandage. Frequently a corner of the dressing is raised and enough ether poured on to moisten the gauze. In a few days cure may be looked for almost with certainty.

Alum and Ingrowing Nails.- According to the American Journal of Clinical Medicine, every case of ingrowing toe-nail can be cured in five days by the free application of dry powdered alum. No pain attends this form of treatment, and the destruction of the diseased tissue results in the formation of a hard resistant nonsensitive bed for the nail with a cure of the ingrowing tendency. The non-toxicity of the alum, its easy application, and the good results obtained from it render it the treatment of choice, at least in cases where no operative measures are contemplated. A soap-and-water fomentation is first applied for twenty-four hours, and then the alum is applied to the space between the nail and its bed; a tampon of cotton-wool is next placed on the alum, and the applications repeated daily. Suppuration rapidly ceases, the parts dry up, and pain and discomfort vanish almost at once. At any rate, the method would seem worthy of trial.

Trichinosis. Oedema with slight erythema (The Hospital) over the swollen tender muscles is very suggestive. In its most characteristic form the oedema occurs in the eyelids and over the eyebrows, and when this appears early in the disease its diagnostic value is considerable. In the hands and feet oedema usually occurs late.

Camphoric Acid and Night Sweats.The night sweats of phthisis (The Hospital) are probably due to a variety of factors, acting directly or indirectly through the nerve centres. Camphoric acid, given

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