Page images
PDF
EPUB

furnish me with any data which will make the record complete for this year is urged to do so. This will save the secretary a little of the double burden which this second editing of the annual volume will impose. The burden of the secretary's work for the year is the editing of this volume. This second editing if complete, will be greater than the first. This will delay the volume at least ninety days' Please give these requests

more.

prompt attention.

FINLEY ELLINGWOOD, M. D.,

Secretary.

Clinical Department

EDITED BY MRS. J. M. COVERT, M. D.

SPECIAL CLINIC. Service of Dr. Trowbridge. This patient, aged eighteen, of Jewish parentage, came to the office ten days ago and we found that she was suffering with a deviated septum and enlarged tonsils. Think ing it better not to perform both operations at the same time, we decided to remove the tonsils in the office and then refer her to this clinic.

We find on examination that the septum deviates to the left to quite a degree. This has produced hypertrophied turbinated bodies, which interfere a good deal with breathing, and the patient complains that she does not breathe through her nose while sleeping.

are several, and which one is re-
sponsible for this patient's trouble
we are unable to say. I have seen
this operation performed a few
times with cocaine anæsthesia; but,
judging from the amount of noise
the patient makes when so operated
upon, if I were to be operated upon
I should insist upon having com-
plete anæsthesia. This is what we
intend to do today.

The patient has been prepared for
anæsthesia in the usual manner, and
as soon as she is completely under
the influence of the chloroform we
bring her forward until her head
hangs over the end of the operat-
ing table. This is for the purpose
of keeping the blood from running
down the throat, as these operations
are always attended with a great
deal of hemorrhage.

We first make an incision from before backward with a pair of cutting forceps made for the purpose and with another pair of forceps we make first an incision downward and then upward, thus making a crucial incision in the septum. We now pass this nasal forceps into the nostrils so that the septum shall be between its two prongs, and by pressing the handle together we can squeeze the septum straight. It is advisable to push the septum a little farther over than we want it, for it is quite likely that it will spring back a little towards its old. position. We now have two nasal splints carefully sterilized, one

The causes of deviated septum slightly larger than the other. We

[ocr errors][ocr errors][ocr errors][ocr errors][merged small][merged small][merged small][merged small][merged small]

will put the larger one in the left nostril, which pushes the septum a little to the right. The smaller splint we will place in the right nostril. This holds the septum firmly between the two, a little to the right of the median line.

In three days these splints should be removed, cleansed and put back into the nostrils again. After that they should be cleaned at least every other day. The splints should be worn about four weeks, by which time the septum will have grown together again sufficiently strong to keep the position in which it has been held while healing.

You will notice that the splints are hollow and perforated at various points in contact with the mucous membrane.

SURGICAL CLINIC.

Service of Dr. Billig. Patient, a single woman, aged twenty, always robust and healthy previous to recent illness.

History: admitted to hospital October 23d. General condition very poor; pulse one hundred and twenty, weak and thready; temperature 103, respirations irregular, facial expression one of great distress; pain over right ileac region intense; slight leucorrhea, reddish brown, and very offensive. Microscopic examination revealed gonococci, staphlococci and streptococci.

On October 25th the pain in the right ileac region developed more markedly and the general condition

was such that we decided she was too weak to be operated upon. The abdomen was distended and very tender, the recti muscles firmly contracted; respirations irregular, ranging all the way from twenty to sixty in an hour's time, due to fixation of diaphragm to protect the inflamed organs within the abdomen; no cough; lungs clear; heart gives a soft, blowing, hemic murmur, heard at apex.

November 1st, abdomen flat; general condition greatly improved; pulse 90 to 100, temperature 99 to IOI, respirations 20 to 40, lungs clear, urinalysis negative; bimanual examination revealed enlarged tubes and ovaries.

Diagnosis. Salpingitis, ovaritis, adhesive pelvic peritonitis and possible appendicitis.

Operation. Incision was made. down the median line below the umbilicus, through the rectus muscle and fascia, especial care being taken in incising the peritoneum, the omentum and intestines being adherent on account of the peritonitis.

Since some of the signs pointed to appendicitis, the appendix vermiformis was sought and found adherent to the right tube and ovary, and inflamed from contact. It was deemed expedient to remove it.

The peritoneal covering was peeled back to the corium and the appendix ligated on either side of the proposed section. After section. the stump was cauterized with 95 per cent carbolic acid, followed by

alcohol. The peritoneal cuff was drawn up over it and surrounded with a purse string including the serous coat of corium.

Next the left fallopian tube was located and found to be inflamed and swollen; also its ovary. After carefully ligating the ovarian and uterine arteries, the tube was excised as near to the fundus of the uterus as possible. After cauterizing the raw surfaces with carbolic, the stumps were drawn together that no raw surfaces might be left. The broad ligament was thus shortened and the uterus held in normal position.

The right side was then explored, the right tube and ovary brought to view and found to be more congested and swollen than the left. The same process of removal was observed as before.

The abdominal cavity was thoroughly sponged out and, since. the omentum is liable to form adhesions with the uterus and cause trouble, the inflamed portions of it were ligated and removed.

The peritoneum was closed by continuous suture with chromicized catgut, and the superficial opening closed with deep interrupted sutures of silkworm gut.

Examination of the excised portions showed, in addition to the high degree of inflammation, a considerable amount of pus in the right tube and a lesser amount in the left tube, in which the inflammatory process had been operating for a

lesser time. The ovaries were enlarged, inflamed and cystic. The serous and lymphoid coats of the appendix were inflamed and distended, more so where adherent to the tube and ovary.

MEDICAL CLINIC.

Service af Dr. Thornton.

This woman before you suffers with the malady with which twentyfive per cent of all the people in England are afflicted. What is it? No, not "pneumonia" in that land. of smoke and damp breezes. Yes, "rheumatism." Rheumatism is one of our common, everyday diseases; yet I am always fearful of the consequences when I have rheumatism to treat. Only a little rheumatism, the knee perhaps, but who can foresee what the outcome may be? I want to impress upon you the importance of treating this as a serious disease. Cheadle is authority for the statement that ninety-five per cent of all organic heart lesions. are caused by it.

While our clinicians are examining this patient, let me ask you the nature of rheumatism. Six years ago in this place I gave it as my opinion that rheumatism was of germ origin. Some, then, felt inclined to dispute me but have since accepted the germ theory. For several years now two Englishmen, Poynton and Payne, have been working to isolate the germ and establish its identity. They do not agree with the Italian scientist Ac

halme, that it is a bacillus but place it among the cocci, calling it the diplococcus rheumaticus. With this germ they have been able to reproduce the various manifestations of rheumatism in the human body.

Other germs produce conditions which simulate rheumatism. The joints seem to be particularly fitting places for them to make disurbance and set up an arthritis. If you aspirate some of the fluid, you may not find the diplococcus rheumaticus, but the pneumoccoccus or the gon

ococcus.

It is now generally believed that the germ finds entrance through the tonsils. Tonsillitis may be the sequel of the invasion but, as far as our observation goes, rheumatic attacks are preceded more or less closely by a tonsillitis.

What complications will we find growing out of rheumatism? "Heart lesions" most assuredly and greatly to be feared when Our patient is a child. The heart fibres are two tender and unresisting.

Our clinicians diagnose the heart lesion in this patient as mitral regurgitation. They find the apex impulse too far to the left. This indicates what? "Dilatation of the left ventricle."

What did you hear with your stethoscope? What did you hear with you fingers? Train your fingers to get the impulse of the hear over the apex. You will learn to detect more than you can possibly get with the stethoscope.

There were rings left where you placed your stethoscope. What is the meaning of that? "Oedema."

The history sheet says, "trace of albumen, a little sugar, hyaline casts"-indicative of nephritis, the most common form of which in these cases is parenchymatous.

What shall our treatment be? Rest, from the very start, is imperative. In acute articular rheumatism, immobilize the part. A splint cr plaster of paris cast would secure absolute rest in arthritis, but the laity ordinarily will not submit to this treatment. I tried it on a patient not very long ago, and now the other fellow is taking care of the case!

The theory is all right, but it seems to be impracticable.

Dressings, What shall we use? Sometimes I blow hot and sometimes I blow cold. Sometimes hot applications afford most relief; then again cold is most grateful. Some seasons it is hot, other seasons it is cold. As our Prof. Whitford says we must use the "epidemic remedy." In the culture of the diplococcus rheumaticus lactic and formic acids are formed. This suggests alkalies, such as potassium or sodium salts. Sodium salicylate is very generally used. In England they give twenty-five grains every two hours to a child and forty grains to an adult. To prevent the cyanosis and other untoward results they give strychnia. A very good form in which to use it is the U. S. P. Elix. Salicylate Comp.; or you may give ten grains

of sodium salicylate in spirit of nitrous ether; or combine it with ten grains of sodium bicarbonate; or you may combine it with citrate of potassa to get stimulation of the kidneys, as well as alkaline reaction of urine.

Pain in the muscles on motion gives us the indication for macrotys, while pain in the joints indicates bryonia. What as to the diet of our patient? You say exclude meat. Many say give skimmed milk. I go further and give them skimmed water. In other words shut off all food-the "absolute diet" of hospital regime until the system has rid itself of the toxins and is ready to take care of food.

CHEWING GUM IN FEVERS. The necessity of a stimulant to the salivary glands is often apparent to the physician in severe fe

vers.

The salivary glands play quite quite an important part in continued fevers, yet they are not considered in the treatment of the case. One of the first and most important restrictions in the patient's dietary is to drop all solid food from the list at the physician's first request, and just then the salivary glands begin to lapse into torpid condition. which very often results in an inflammation and, finally, suppuration, and that disagreeable dryness to the tongue and fauces so uncomfortable to the patient. For the relief of this trouble I have found

nothing of so much importance as some nice form of aromatic chewing-gum, which relieves the thirst and dry mouth, improves the appetite and digestion, and restrains nausea, if any. Hence some of the most disagreeable accompaniments of the disease are mitigated. I believe also that it materially aids. the absorption of the medicine when the alimentary tract is so impaired by the incessant fever.

I do not claim originality in this treatment, although I have never found any reference to anything of the kind. However, it may have been regarded as too simple to need mention; still it is, in my estimation, quite important in any continued fever.

THE COMPANION AS A CHRISTMAS Gift.

Can you think of a gift more certain to be acceptable than a year's subscription to THE YOUTH'S COMPANION? Is there any one, young or old, who, having once had the paper in his hands and looked through it, did not wish to possess it for his very own? It is a gift which, far from losing its freshness as Christmas recedes into the past, grows more delightful, more necessary to one's enjoyment week by week.

The boy likes it, for it reflects in its pages every boyish taste and every fine boyish aspiration. The father likes it, not only for its fiction but for its fund of information of the practical sort. The girl likes

« PreviousContinue »