תמונות בעמוד
PDF
ePub

examination of the base of the wound. A blunt instrument through the wound at each dressing will, avert the disaster and will not retard repair.

When the reparative power of the patient or the extensive inroads of the disease do not warrant such a radical procedure, a wise course to adopt is to pack the main sinus or stretch, if necessary, the chief tract, and freely irrigate with a stimulating or antiseptic solution until the lateral sinuses are healed or the inroads of the disease so abridged that a radical operation may be confidently counseled.

Indeed this palliative plan will often prove very gratifying when the patient's fancy or physical condition absolutely forbid operative measures.

In the horse-shoe fistula the branching tracts should as far as possible be opened into one main tract, even though more than one operation is necessary, then the main passage may be repaired by a single incision of the sphincter.

Upon the management of the patient after an operation about the rectum depends largely the success of the undertaking.

Rest in bed is imperative in all cases except in advanced tubercular subjects who require some exercise to maintain the reparative power.

Firm dressing should be used to aid in controlling muscular spasm, and the value of sulphonal in this indication I find, has not disappointed my claims put forth over three years ago for this drug.

Cough should be controlled on account of its disturbance of the levator ani, appropriate tonics used, the bowels kept free after the second day, and every surgical detail be accompanied by scrupulous aseptic management.

The following cases seen within the last twelve months illustrate some of the points in the history of superior-pelvic-rectal abscess.

T. F., aet. 20, single; history, tubercular. Presented with a large abscess showing some perineal oedema and fullness, and some induration over Poupart's ligament on the left side and in the lumbar regions. Temperature 101°, expiration prolonged on left side apex; no cough.

Free incision revealed a small amount of pus; irrigation and packing was followed by some improvement. A chill, high temperature, and a rapid development of a painful induration in left inguinal region was noted, and the perineum was freely laid open and explored, the superior abscess cavity drained, and uninterrupted recovery followed.

The deep packing and frequent irrigations during convalesence left a straight sinus with a hard lining membrane which was incised with fistulatome, prompt and complete repair following.

T. P., aet. 34, married, negative history. Presented with a deep pelvic abscess which developed six months after a successful appendectomy.

The abscess was freely opened and curetted, tubercle bacilli being found in the soft tissue removed by the curette. Copious discharge followed although good drainage and frequent irrigation was kept

up.

When repair had progressed sufficiently the patient was sent to the coast for a few months, returning entirely well.

When these abscesses are large and show a tendency to burrow above Poupart's ligament or through the sciatic notch, they should be evacuated at these points, although the perineum generally allows of freer drainage, and promises a more rapid repair.

PESSARY IN BLADDER

On August 9th, 1893, in the evening, Mrs. R., mother of two children, the younger four weeks old, came to me in company with her husband to consult me about a "womb supporter" which she said

she had placed in position the morning of the 8th, and which was giving her great distress. I inquired as to the kind of supporter and learned that it was a "French Pessary Prevention." I made a digital examination and found nothing foreign in vagina. Noticed, however, that pressure upon anterior wall of vagina caused severe pain. Brought the finger in contact with urethral orifice and as gently as possible passed it on into bladder and came in contact with the supporter. Dragging the pessary down with finger, the index and middle finger of left hand was introduced into vagina and the offending body held in close contact with the pubic arch. Removing the finger, the forceps was introduced and the lower edge of pessary grasped and it was then dragged away. After the removal of pessary the woman then told me that she had had trouble in "passing water," and that it was colored with blood. She, however, kept this to herself until trouble was over with.

A. I. MITCHELL, M. D., MACEDONIA, Iowa, Aug. 11, 1893.

INGROWING TOE-NAILS.

By E. A. BENTON, M. D., Central City, Neb.

On page 218, Vol. 1, Third Series, International Clinics, Prof. Gersten, in a clinical lecture delivered at the New York Polyclinic, gives his method of treating ingrowing toe-nails as follows: First disinfect the part, then with the knife slit up a flap of this hypertrophied tissue, cutting from the proximal end. Remove the flap as far as the root of the nail. Detach the damaged portion of nail with a scissors and remove with a dressing-forcep, scrape away all granulations and apply your dressing.

This is all done under artificial anæmia and local anesthesia; it is borne very well by the patient."

This is in exact accord with my former treatment, before I found a treatment that pleases myself and patients much better. I have this to say for Prof. Gersten's treat. ment: It has the elements of thoroughness and success (the latter of which is very important), and the trouble is not as liable to return as after removing the nail, of which treatment Prof. Gersten also speaks.

There is one other feature about the

matter that I have missed since adopting my present method of treatment, viz: a fair-sized bill for surgical treatment. My present method of treating ingrowing nails is so simple, devoid of pain and display, that patients are unwilling to pay much for it, although they are relieved of a very painful affection, and are usually very grateful; which gratitude must be taken for nine-tenths of what the charges used to be for the treatment of such cases by surgery. My present treatment has been uniformly successful with my patients for the past ten years.

Treatment:-Disinfect the part, remove all crusts, raise the detached or undermined portion of the nail as much as possible. Crowd the hypertrophied integument back from the nail and drop three or four drops of sol. subsulphate of iron into the space thus obtained, and with a pointed probe work the iron to the very bottom of the trouble. Then wrap the toe in absorbent. cotton and let the patient go about his business, only keep all pressure off by wearing a large shoe or slipper. Direct him to return in three days, when you will repeat the operation. Usually three applications, if thoroughly done, are sufficient for a cure. The pain and soreness decreases from the first treatment and no detention from business is required.

DEAF MUTISM AND PREVENTABLE DEAFNESS. KNOWLEDGE GAINED BY AN EXAMINATION OF THE EARS AND UPPER AIR PASSAGES OF 135 DEAF MUTES.*

By F. S. OWEN, M. D., Omaha.

Speaking generally, mutism is the direct result of partial or complete loss of hearing: one is the natural sequence of the other. Yet the defects of the auditory apparatus cause no change, except indirectly, in the organs of speech, as anatomical changes, are not found more frequently in the larynx of the deaf-mute than in the larynx of the person possessed of good hearing. and speech, except those that naturally result from disuse of the organ.

*Read before the Nebraska State Medical Society, May, 1893

[blocks in formation]

Pursuant to a request of Prof. J. A. Gillespie, and to a desire on my own part for the data I would obtain, I have carefully examined, in the past six months, the ears and upper air passages of the 135 deafmutes, pupils of the State School for the Deaf and Dumb, located at Omaha.

The hearing power and pathological changes of membranæ tympana are shown in the following general table, in accord with the supposed causes assigned for their loss of hearing.

I especially call your attention to the so

*St. John Roosa's Treatise on Diseases of the Ear, p. 687.

called congenitally deaf. It is in this class of cases that an abnormality of the labyrinth, the auditory nerve or brain has been often assumed to be the most frequent cause of the deafness; but a careful study of the figures of this column will reveal the fact that the lesion at least began in the middle ear in a large percentage of the cases. Which is evidenced by the large number (34 out of 60) who have perception of the sound of the tuning fork through bone and aerial conduction, and by the richness of the pathological changes in the membranæ tympana.

Although it has been stated by Schwartze that in two out of every five new-born children, the tympanum will be filled with pus, and by other investigators that otitis media accurs with astonishing frequency in the new-born, yet this does not account for all those commonly supposed to be congenitally deaf. It re

+Troeltsch's Diseases of the Ear in Children, p. 40. Hartman's Diseases of the Ear, p. 156.

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

*One became suddenly deaf at 10 years of age. Two, cause unknown at 4 and 3 years. Four, no record of cause. Two, unknown sickness at 6 months. One, unknown sickness at 1 year. One, unknown sickness at 3 years. *Consisted of kernels of wheat, a piece of cotton, a pebble, and a stick of wood.

quires no proof to show that many commonly placed in this category, when found to be deaf at the end of one or two years of age without a recognized cause, are not of the truly congenital class. I am convinced after a careful study of these cases, judging on the one hand by the strong predisposition to disease of the middle ear existing at this age and the peculiar difficulty attending the recognition of the same, and on the other by the present active nature of the disease and relative pathological changes and amount of hearing power, that at least in a small contingent the inception of the disease is to be dated some time after birth.

The gross lesions of the drum-head in those deaf from scarlet fever show that in the great majority of cases the disease first manifested itself in the middle ear and the internal became affected secondarily; so, also, we have a similar picture in those deaf from cerebro-spinal meningitis, though the percentage of middle ear disease is not so great; yet the pathological changes in the drum head and relative hearing power show that in a large percentage of the cases the disease had its starting point in the tympanum.

Space will not permit me in this paper to draw deductions from the figures under each heading of this table in detail, but a cursory glance will show that the anatomical changes in the membranæ tympana and relative hearing power evince the truth of the statement that in the great majority of the cases the defects in the auditory apparatus either exist or started in the middle ear.

Below I append a table representing the pathological changes found in the upper air passages, the totals of which are placed under the separate headings representing the various methods taught. The pupils of the manual class are instructed by means of the manual alphabet, pantomine and the sign language. Those of the oral

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

*The nucleus of one consisted of a wild plum pit; that of the other was a piece of shell of a nut.

It is interesting to note the prevalence of hypertrophy of the lymphoid structures of the fauces and naso-pharynx, especially that of the naso-pharynx as characterized by adenoid vegetations. At first sight this seems like an astonishing number, but it appears to be less exaggerated when we remember that adenoids are a frequent sequel of the exanthameta to which many of these children owe their deafness, and that they are the predisposing cause of the deafness in many instances in which a "cold," an "earache," an exanthem, or whatever disease is supposed to be the direct cause.

+Pritchard's Diseases of the Ear, p. 40.

In the light of these facts and Bosworth's statement that 60 to 70 per cent. of all catarrh in children is due to adenoids, and Meyer's statement that 74 per cent of those having adenoids are hard of hearing, and Swinburn's‡ report that 40 cases in 176 cases of deafness are due to adenoids, it is not surprising therefore that so great a percentage of young deaf-mutes should have adenoid growths; and the influence they may have exerted either directly or indirectly as a causative factor of deaf-mutism can be fully appreciated.

That so large a percentage of those abnormalities should occur in the oral class may seem inconsistent, but it will be observed that the vocal organs of this class, with one exception, are normal; and then it must be remembered that every child who shows the least capability of articulating speech is placed in this class, and so important to the child are the advantages of this method, and so persistently is the oral method taught, that he is retained in this class in spite of the defective speech and slow progress that these obstructions would necessarily occasion; and other things being equal, his progress in acquiring speech is proportional to his freedom from these growths and other abnormalities of the nose and fauces that go to obstruct these resonant chambers.

It is scarcely necessary in this connection to suggest the importance of clearing these parts from their various obstructions. Since the importance to the person, blessed with good hearing, to have these chambers that have to do with the quality of the voice and the acquisition of good speech, freed from marked obstructions, cannot be gainsaid; how much greater then is the importance to the person who cannot hear, and at the best acquires speech under the greatest disadvantage, to

*Medical Mirror, Jan., 1893, p. 36.

+Buck's Manual of Diseases of the Ear, p. 171. Medical Mirror, Jan. 1893, p. 36.

have these organs placed in the best possible condition.

Much good can be done along this line for these unfortunates, and intelligent treatment will enable the majority of those to whom the sign language alone is otherwise possible, to learn articulate speech, and the gulf that would inevitably separate the mute from his fellow man will thus be bridged over.

In this State there are about 500 deafmutes, or about 1 to every 1,500 of the population; 340 of these have at some time been pupils at the State school. Practically speaking these 135 from whom these tables are made will represent fairly well the entire number as to the relative defects of the auditory apparatus and the diseases causing the same, though from the whole number there would, perhaps, be a slight increase in the percentage of those deaf from some brain affection.

That so small a percentage (7 out of 135) should be found deaf from so common a disease as scarlet fever, where Caiger§ tells us 12.9 per cent. of the cases have otitis media, and that none should result from diphtheria, where Hermann Wendt|| tells us 20 per cent. of the cases have the middle ear affected by the specific process, reflects great credit upon the methods of treatment employed in these diseases by the profession.

A marked contrast, however, to the small percentage of the above named diseases as a cause of the deafness, is seen in the large percentage of those deaf from cerebro spinal meningitis. Since the pathological process affecting the middle ear in this disease does not differ essentially from that occurring as a complication of other diseases, the large percentage is, perhaps, at least in part, due rather to the difficulty of recognizing the complication of aural disease than to the

§London Lancet, June 6, 1892. Troeltsch, p. 46.

« הקודםהמשך »