WESTERN MEDICAL REVIEW Published Monthly by WESTERN MEDICAL REVIEW COMPANY, Omaha, Nebr. Per Annum, $2.00 The WESTERN MEDICAL REVIEW is the Journal of the Wyoming State Medical Society and is sent by order of the Society to each of its members. OFFICERS: Dr. A. G. HAMILTON, Thermopolis, President DR. W. H. ROBERTS, Cheyenne, Secretary All matter for publication in this section should be sent to FRED W. PHIFER, M. D., Editor, Wheatland, Wyo. COLLABORATORS-SUBJECT TO REVISION. Pestal, Joseph. Douglas; Keith, M. C.; Casper; Marshall, T. E., Sheridan; Nelson, N. D.; Shoshoni; Wicks, J. L., Evanston; Wiseman, Letitia, Cheyenne; Young, J. H.. Rock Springs. Vol. XVI. CHEYENNE, WYO., FEBRUARY, 1911. No. 2. EDITORIAL. In the diagnosis of mammary tumors always compare the affected with the normal breast. In injuries about the head don't forget that a slow pulse very often indicates a brain lesion. In so-called epidemics of sore throats in families or communities watch closely for a scarlet eruption. Don't overlook the fact that we may get a positive Widal reaction in a number of diseases besides typhoid. In scalp injuries it is always best to leave a small drain. Scalp wounds are usually dirty wounds and should be so treated. So-called sprains of the wrist and ankle are more often fractures so that in the absence of the X-Ray to help us, we may very often save ourselves embarrassment by treating for fracture. Constipation in women is so often due to mechanical obstruction that I have made it a rule never to treat them for con stipation until I have made a thorough examination and satisfied myself as to the cause. Many ways and means have been devised and suggested for keeping trace of gauze sponges in abdominal work. Personally I have found that though it has its disadvantages, still on the whole nothing is superior to the five yard roll of sterile gauze. As it becomes stained, cut off and throw aside the soiled portion. The use of small gauze mops around an abdominal wound is sure to cause trouble in time. Anaesthesia. Ether and chloroform are the most universally used of all anaesthetics, the real stand-bys of the physician and surgeon, and for this reason will be almost exclusively considered in this short article. I claim no originality for anything that I may say, but justify mysely in recounting more or less my own personal experience because I find that it is somewhat typical, and may therefore, be of interest and benefit to others. Some twelve years ago, as a student, I was taught to give chloroform by the drop method with an Esmarch inhaler or some similar apparatus. Ether, however, was administered in a totally different manner, either with gas through an elaborate rubber bag arrangement; or often with the aid of a hurriedly devised cone made of paper and a towel, which was stuffed with gauze or cotton. The patient's face was covered closely with. this, all air being excluded by means of a surrounding towel; can after can of ether was poured into this cone, while the patient's struggles were forcibly restrained by several assistants until the deep stage of anaesthesia was reached. During the operation, pounds of ether were administered (I have heard of as many as eleven being used), and the consequent profuse secretions in the respiratory passages gave all sorts of trouble. Asphyxiation was frequent, and the tongue forceps had to be resorted to, while an assistant would sponge out the mouth every few minutes. After the operation, the patient would be the victim of deadly nausea, and the distressing retching would last for hours, doing untold harm in the operative field and always adding materially to the danger of the dreaded shock, to say nothing of the ether-pneumonia and other complications that might follow. It is not surprising therefore that many anaesthetists and surgeons preferred the perils of chloroform, despite the fact that the operation had very often to be suspended while heroic measures were resorted to in order to resuscitate the patient. I have known a patient to be kept under chloroform anaesthesia for as much as two or three hours, and then the surgeon would meekly take the blame for losing the patient under the knife. Or if the patient did not die on the table or soon after, he was days and days getting over the shock of the anesthetic, though in those days it was attributed wholly to the operation. In my own case I endured this when I was compelled to do so, as would be the case, for example, when the anaesthetist was the doctor who had referred the case to me and consequently felt that he had the right of choice in the matter but finally insisted upon ether for deep anaesthesia, using either chloroform or gas to eliminate the excitable stage, though of course this still did not do away with the other objectionable features of ether. After a time, however I resorted to what I now know as the drop method of administering ether. I cannot remember how or when I arrived at this solution of my problem, though as I said in the outset I claim no originality whatever for it; but it certainly has proved to be the answer to the anaesthesia question so far as I am concerned, and I am sure it has very much lessened my operative mortality rate. The patient is prepared in the usual way for the operation, and if necessary a small dose of morphine and atropine may be given hypodermically the night before to insure rest. A half hour before the operation, unless especially contraindicated, a similar hypodermic is given, the size of the dose depending upon the age, idiosyncrasy, etc., of the patient. The face is thoroughly annointed with unguentum aquac rosae or petrolatum. The anaesthetic apparatus consists of a small Esmarch inhaler and an ordinary four ounce prescription bottle, with a shallow groove cut in the cork so that the liquid will drop slowly. If it drops more rapidly than is desired insert one or two toothpicks in the groove. This, with a couple of towels, is all the apparatus needed throughout the operation. Commence the anaesthesia with chloroform, drop by drop, holding the mask clear of the face to avoid choking the patient or giving too much at once, meanwhile instructing the patient to breathe deeply. Have the room absolutely quiet, and the anaethetist can often obtain a happy effect, through suggestion by himself breathing deeply and audibly. In a very few minutes the patient begins to relax. Withdraw the chloroform, and at the same time substitute ether, giving it in precisely the same manner as you did the chloroform, but gradually letting the mask settle snugly down over the mouth and nose. After a sufficient time has elapsed to allow all the chloroform to evaporate from the mask fold a towel around the edges of the mask, leaving bare only enough of the cheek and ear to enable the anaesthetist to watch the color of the face. Allow the ether to drop about one hundred to one hundred and twenty drops to the minute, and inside of fifteen minutes the patient is ready for operation. The rate of drops to the minute can be lowered and the anaesthetic regulated as required. I, as a rule, prefer just as small an amount of anaesthetic as will produce relaxation, and it is surprising how little this will sometimes prove to be. I have frequently gone through an abdominal operation of an hour's duration on less than one drachm of chloroform and a quarter of a pound of ether. Of course, the amount depends upon both the idiosyncrasy of the patient and character, as well as the length of the operation, but since beginning this method I have never used more than one pound of ether during a single operation. My patient is waking by the time he has reached his bed and the old time retching and vomiting is a thing of the past. Some patients are not nauseated at all; most of them are not sufficiently so to actually vomit, and very seldom does the vomiting amount to enough to call for remedial measures in so far as the anaesthetic is at fault, so if I have an unusual amount of post-operative vomiting I immediately look for some other cause. I have now come to realize that patients that I have lost in the past might have been saved if the proper anaesthetic had been properly administered. F. W. Phifer. ABSTRACTS. Ear Disease, and Its Prevention. In a communication to the New York Medical Journal, Dr. Albert Bardes deals with the subject of Ear Disease and Its Prevention. Since it is estimated that over two-thirds of our fellow countrymen have aural troubles and since much of this is due to the neglect of parents who think the child will "out-grow" the ear-ache or of the patient himself who is inclined to scout the idea that ear ache is a serious affection-until it becomes. so! too much stress can scarcely be laid upon this subject. Otitis Media is usually a secondary complication of an infectious disease, as measles, scarlet fever, and grippe. It is more common in children because the Eustachian tube of a child is relatively shorter than in an adult, so that infectious matter is readily carried into the middle ear through such forced expiratory efforts as crying, coughing and sneezing. Recurring attacks of ear ache in a child suggest some obstructive disorder in the upper air passages, probably adenoids and large tonsils. Surf bathing is a common source of ear trouble in summer time, both from the impact of the water on the drum head and from snuffing the water up through the nose. Of late years many middle ear diseases are caused by the indiscriminate use of the nasal douche when the nose is blocked-precisely the condition for which the douche is prescribed the douching fluid, carrying with it infectious material, is drawn up into the ear. An ear ache should always be given serious consideration, since we are dealing with an infection near the brain which may at any time assume alarming proportions. If the symptoms are light we may attempt to abort the infection by rest, hot applications, fluid diet, a laxative and possibly a small dose of morphia; more masking the symptoms. Frequent irrigations with warm bichloride solution, one to five thousand are usually soothing. Do not put anything else into the ear. Under no conditions should the suffering be allowed to last longer than twenty-four hours without surgical intervention. The incision, preferably under anaesthesia, should extend from the distended drum head into the periosteum of the canal wall, and perhaps through Shrapnell's membrane. This depletes the inflamed area besides draining it and promoting repair. The first discharge may be serous and scanty, but the symptoms will decrease in proportion as the discharge increases. If the incision in the drum-head fails to effect a cure, then the open mastoid operation should be performed without delay and before the patient becomes too weak. The advantages of an early operation are that it saves the hearing and checks the progress of the disease. Caution in the Use of Fuller's Earth or Kaolin. Kaolin or Fuller's earth or bolus alba, as it is called there, has been used considerably in Germany as a dressing for wounds. It is sterilized by baking for several hours to a temperature of from 170 to 200 degrees Centigrade. Zweifel used it considerably as a dressing for the umbilicus with perfect satisfaction. But recently four of the babes developed tetanus; and three died, and Zweifel thinks that the cause was the bolus alba which was not properly sterilized. We ought to take this as a warning in using kaolin pastes-to use those only of reliable manufacturers, who are sure to sterilize their kaolins thoroughly.-Therapeutic Medicine. |