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are very firm and hard. By slow, careful sawing movements with the tips of the fingers, I can gradually separate the mass from the bowel. I am afraid of working a hole through the rectal wall, and do not want to burst the sac which is very tense and thin. I finally succeed in removing the mass, tying it off with catgut from the uterus and broad ligament without rupture. The pelvis is wiped dry, the hemorrhage from torn adhesions soon ceases. The purple tube, and inflamed mass, including a cystic ovary on the left side is also removed. The abdominal wound is closed in the usual manner.
NOTE.— The sac, opened by a student, was distended with foul smelling, greenish pus. We feel that by avoiding rupture of this sac, we escaped the inevitable necessity for drainage. Two weeks after the operation the woman sat up in bed and in three weeks returned to her home perfectly convalescent.
Tinea tonsura ns. (College amphitheater, Prof. G. W. Spencer.)
This patient, Harry D—- aged 13 years, has an affection of scalp particularly. You observe that the disease appears as circular patches covered with stumpy hair, dry and irregularly distributed, also considerably elevated above the surrounding scalp, in consequence of an accumulation of debris, the result of disease. There is one, as you see, on the left cheek. There are three on the right leg of the same character, only having a different appearance because of the absence of a thick growth of hair.
Treatment.–First cut the hair closely, then shave the scalp for a space of at least one inch around each patch, thus preventing spreading, as well as facilitating observation. Second, soften the accumulation by applying carbolized vaseline for two days; then scrub the spots with a solution of green soap. If there is still debris remaining, repeat the process again and as many times thereafter as may be necessary to thoroughly remove the products of the disease. Third, apply bi-chloride of mercury, 1 to 2000. If the application produces inflammation, apply hot water packs for one hour, twice daily, and in the interim, carbolized vaseline. After the inflammation is reduced if there is any appearance of the disease still remaining, repeat the treatment.
Oct. 31st. This patient has now had seven day's treatment as instituted one week ago, and you observe that the patches are swollen and much inflamed. For the next week we shall order hot packs for one hour, twice daily, and in the interim apply carbolized vaseline.
November 7th. Today, the patches are nearly free from inflammation and the disease has disappeared with the exception of two places where there seems to be some activity. We shall advise the same treatment continued, but confined closely to the above mentioned spots.
November 14th. Today this case, to all appearance, is cured, although it will need to be seen occasionally for some weeks, to be sure that the parasite is entirely destroyed. We shall give him a certificate, in order that he may return to school.
A d vanced phthisis with tubercular mening itis. (City Hospital, Prof. A. B. Schneider.)
Mr. T. B. aet. 38. Wire drawer. Family history: Parents are both living and well. Four brothers and three sisters are living and well. One brother and one sister died of tuberculosis. Personal history: this is not reliable. The patient's mind wanders and his statements are not clear. It is quite probable that the chills and fever and the rheumatism of which he speaks are intimately associated with the cough of which he complains.
Present condition : Only the important pathologic signs will be called to your attention. The patient was of good physique but he is anemic and greatly emaciated. His pupils are equal but react very sluggishly both to light and accommodation. You will remember that the history of syphilis was negative. The mouth is very dry and foul, the tongue is dry and brown and protruded with great difficulty. The skin is dry and hyperesthetic, but presents no eruption. There is tenderness in the lumbar region of the spine, and contraction, but not marked rigidity, of the cervical muscles. Kernig's sign is positive. The reflexes are active. The pulse counts 120, is weak but regular. Respirations vary from 28 to 36. The temperature has varied for the past few days from 99° to 102°, being highest in the evening. Blood, sputum and urine examinations have not yet been recorded.
The thorax is rather long and narrow. The supra and infra clavicular spaces are sunken. Expansion excites coughing and is deficient especially on the left side. There is retraction of intercostal spaces in the left infra clavicular region. Vocal fremitus is increased over both apices. Percussion shows marked dulness over the left apex and as low as the fourth rib anteriorly, with a tympanitic area about three inches in diameter below the clavicle. The tympanitic sound is intensified when the patient holds his mouth open. There is dulness behind, as low as the angle of the scapula. On the right side the dulness extends to the third rib in front and to the spine of the scapula posteriorly. Ausculation shows coarse rales over the entire posterior surface of thorax. There are bronchial breathing and numerous crepitant rales over the upper portion of thorax on both sides, extending lower on the left side than on the right, corresponding to the area of percussion dulness. Vocal resonance is increased over the same area, amounting to bronchophony. In the left infra clavicular region there is marked amphoric respiration.
These physical signs are indicative of an advanced tuberculosis affecting both lungs, with cavity formation in left upper lobe. This condition gives the key to the meningeal symptoms, which are doubtless those of a tubercular meningitis. Lumbar puncture seems unnecessary to substantiate the diagnosis, especially since the fluid which would be obtained would probably prove the condition only by its neg. ative character.
For the irritability and muscular soreness and stiffness, the great thirst and dryness of mouth and tongue and the troublesome cough, Bryonia 3x is the remedy best indicated. A dose of Tuberculinum 30x every third or fourth day can be given in nearly all tubercular cases with profit, as an intercurrent remedy.
The prognosis in this case is unfavorable and death will probably not be long delayed.
Typhoid fever complicated with broncho-p neumonia and salpingitis. (City Hospital, Prof. A. B. Schneider.)
K. P. Nurse girl. Aet. 18.
This case is here for diagnosis, the question arising as to the advisability of an operation for salpingitis. The patient presents nothing of interest in her family history. She was here for several weeks about three months ago, suffering with chancroids and right inguinal bubo. Three weeks ago she was admitted with a history of a week's illness, comprising principally chills and fever, headache, pain in the back and diarrhoea. On admission the abdomen was found to be swollen, tympanitic and tender. There was slight dulness in the right inguinal region and some bulging of the right fornix. The left inguinal region was especially tender. The spleen was enlarged and palpable and the area of liver dulness normal. Bronchitis was marked and cough very distressing.
The chart which I hold up for your inspection shows the typical temperature curve of typhoid fever, descending to normal on the twenty-first day, as nearly as we can reckon from the history given, and continuing a slightly subnormal course morning and evening to
the present time, which is the end of the fourth week. The pulse and respiration however, show evidence of complications. Respirations are recorded throughout the febrile period as ranging from 28 to 36, declining during the past week to 22. It is hardly to be doubted that there existed in this case a complicating broncho-pneumonia, especially since we find recorded in the treatment emollient applications to the chest, the administration of oxygen, and exploratory puncture of the left thorax, which however was without result. The pulse ranged from 128 to 100, at which latter rate it has continued since defervescence occurred.
The remedies recorded are Baptisia 2x, Bryonia 3x, Tartar Emetic 3x, Colocynth 3x.
Examination shows dulness on percussion with broncho-vesicular breathing over the right apex, with numerous dry and moist rales throughout the thorax. This condition merits special attention because of the debilitated state of the patient and the known susceptibility of the colored race to tuberculosis. The persistently rapid pulse may be sufficiently accounted for by this condition alone. The heart sounds are normal with the exception of rather marked accentuation of the second pulmonary tone. The hepatic and splenic areas of percussion dulness are normal. The abdomen is soft and pliable. There is no marked tension nor tenderness in the right inguinal region, and only slight dulness, which is due to remnants of the inguinal lymphatics, which can be felt. There is marked tenderness in the inguinal region however, with dulness on percussion; and careful palpation reveals a considerable swelling, due unquestionably to inflamed left uterine adnexa.
The patient tells me that she was given plums to eat last Sunday, the day on which she had the severe paroxysm of abdominal pain which raised the suspicion of salpingitis, and which was so promptly relieved by Colocynth 3x.
This patient will be kept under careful dietetic control for another week and then remanded to the gynecologist. The pulmonary fault must however, be carefully watched and the patient should not be lost sight of by this department. I will ask Dr. Patton to keep track of this case. The diagnosis of typhoid fever in this case is based upon the typical temperature curve, the enlarged spleen and the characteristic diarrhæa.
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