Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 86

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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Examination of the blood showed a red cell count of 4,- 100,000, white cells 10,000, and hæmoglobin 78 per cent. The urine and faces were normal. A Wassermann test, done

on the blood serum, gave a negative result. X-ray plates of the hands showed no abnormality.

The child was kept on graded doses of thyroid extract in the belief that the condition might be an atypical form of cretin- ism, but after two months, there being no improvement, the drug was discontinued. Small doses of diuretic drugs com- bined with digitalis failed to affect the œdema. The tongue remained as on admission, large and protruding. The greatest difficulty was encountered in finding a modified milk suitable to the child's delicate digestive organs. There were several gastrointestinal upsets with vomiting, diarrhea and a tem- perature of 101º F. The weight remained about as on admission with occasional fluctuations. The temperature, aside from the gastric upsets, was normal or slightly below ; the pulse rate was normal. In January the child seemed weak and feeble, and on the 9th of the month her temperature rose suddenly, with a profuse diarrhea and vomiting. There was no improvement in the condition and exitus occurred next day.

Autopsy (Dr. Whipple) .- The interesting points in the autopsy findings are as follows : a very inconspicuous thymus, there being practically no tissue where the gland should be. Normal heart valves, but an open ductus Botalli, measuring about one millimeter in diameter. An acute diffuse cellular myocarditis. No special hypertrophy of the ventricles. Scattered areas of broncho-pneumonia in both lungs. The left ureter appeared normal at its entrance into the bladder and as far as followed up to the brim of the pelvis. Here it was lost and no remnant of kidney tissue was found in this area. The left adrenal was close to the diaphragm and appeared normal. The right kidney was very large, about the size of two normal kidneys. There was a single distorted pelvis coming from the anterior median portion of the ir- regular kidney mass, the long axis being nearly parallel with that of the vertebral column and lying almost completely to the right of the vena cava, which crossed over its mesial surface. The kidney substance looked in no way abnormal. An acute enteritis throughout the ileum was found.

The thyroid was small, pale, and uniform on section. The bone marrow appeared normal. Unfortunately, no permission to examine the brain could be obtained.

RANSVERSE FRACTURE OF THE BODY OF THE ISCHIUM IN 1893; TERMINAL DISPLACEMENT IN 1902; DIAGNOSTICATED IN 1909.

By NORVELLE WALLACE SHARPE, M. D.,

St. Louis, Mo., U. S. A.

The case herewith detailed is not classified as unique, but extreme rarity and interest.

Fractures of the ischium, participating in a general pelvic Ish, are not notably rare.

Fractures of the ischium, without coincident pelvic fractures complications are considerably more infrequent, and are thy of record.

Fractures of the body of the ischium, the result of direct impact, and without coincident pelvic fractures or compli- cations, producing but moderate disability and remaining undiscovered for an extended period of time, are not only noteworthy on account of interest and rarity, but specially merit consideration in conditions which involve a differential diagnosis.

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JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 2%

The following dicta from Scudder, Keen, and Stimson are recorded as suggestive :

Scudder, " Treatment of Fractures," 1910; "fractures of sacrum, coccyx, symphysis pubis and ischium are extremely rare."

Keen, "Keen's Surgery," Vol. II, 1907; "fractures of the ischium, sacrum, and coccyx . . .. are very rare."

Stimson, " Fractures and Dislocations," 1907; "fracture of the ischium is one of the rarest of fractures of the pelvis. Malgaigne collected only six cases and his list has not been since increased by any reported in detail. In some of the cases almost the entire ischium was broken off, in others only the tuberosity. Experiment indicates that a fracture may pass into the cotyloid cavity. In three of Malgaigne's cases the cause was a fall upon the buttocks; the fourth a gunshot fracture, the fifth caused by an explosion, the sixth due to

Transverse fracture of body of right ischium (about 1/4 size of original plate). Note $%" overlap of the caudad fragment (cf. Section 2 of Dr. Carman's report).

forceps manipulation, in a case formerly with the pelvic ring fractured, and ischium was broken. In the simple cases there was little or no displacement; in the gunshot fracture the frag- ment was displaced downward more than 2 inches by contrac- tion of ham-string muscles, the displacement persisted but does not appear to have interfered materially with the move- ments of the limb."

H. D. B., aet. 64, has led an active mercantile life, relieved by field and water sports abundant in quantity and choice in character. The patient is vigorous and well muscled, 5 feet 5 inches in height, weight 165 pounds, he exhibits a substantial amount of adipose. For some years has " had trouble with right leg "; an attack of left " sciatica " in 1901, and more or less so-called "sciatic pains" on both sides since. Right hip and thigh became troublesome in 1903; keep up in my shooting "; " friends noted a slight

drag," etc. Pains now began in hip, back, knee and foot. rarely at night, but more or less constant when walking; this pain and " consciousness of having a hip " have thus existe seven years. Patient has consulted numerous physicians bot in the States and abroad, the various diagnoses leaning to som: form of sciatic involvement. In 1909 an X-ray examination was made at a New York up-state sanitarium, and a diagnosis of " trochanter split and piece off of one side," rendered.

For the aforesaid " sciatica " relief has been sought through applications of electricity, liniments, Swedish movements, massage, " light treatment," leucodescent lamps, etc., but all without avail.

The trouble, not disabling, but ever present, remained with- out improvement, indeed it grew worse.

His condition was brought to my attention last Novemb: (1909) ; before any examination was made, he was referred te

KEY TO PLATE .- Contrast sharp angulation at a (caused by cephalad displacement of caudad fragment) with normal graceful periphery of obturator foramen.

Carman (St. Louis) for a searching X-ray exploration. 3 diagnosis of fracture of right ischium was returned. Ats later consultation (April 29, 1910), an effort was made ti discover an anamnesic clue that would indicate when the fra- ture had occurred and how it had remained so successfully un- discovered.

Patient's record shows that in 1897 he sustained a severe fall on a marble floor; a critical orientation of the facts coinc. dent with and sequent to this accident leads to the conclusion that in no manner should it be considered the cause of the fracture. An antecedent accident proved more promising: in truth the only casualty in the record that warrants series consideration. The details are:

In 1893, while fishing, patient sustained a severe f. striking his right buttock on "a pointed rock " (in shape. I take it, akin to a cypress .knee, familiar to those who shred

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fish in the swamp and overflow lands of the South) ; there nediately followed intense local pain (patient states that " was almost paralyzed "), this remained for several hours, by the following morning merely the ordinary sensations a severe contusion were present. No essential disability owed, and though moderate discomfort was more or less stantly in evidence he continued an active life, including shooting and fishing. For this discomfort, during the seeding years, he was subjected to the various forms of .tment above noted.

n 1902 while indulging in some " physical culture " exer- s (ordered for the existing trouble), during which the it leg was extended and the thigh flexed sharply on the omen, " something snapped" within the right pelvis. s sensation was distinctly experienced by the patient, and ond peradventure, his memory in this regard being quick- 1 by the fact that he recalls having announced to a relative : as a result of this incident, he was " done with physical ure " and allied forms of treatment.

n 1903 hip and thigh became more troublesome, he could maintain his former speed and endurance in a day's shoot, his disability became patent to his friends (as noted re).

[ost careful questioning fails either to shake the evidence recorded or to introduce any other accident that might reasonable probability be held to have definite etiologic ificance.

he conclusion is therefore compelled that this ischium was tured in 1893, and remained undiscovered for sixteen 's. i. e., up to November, 1909.

he interesting question arises, is it not possible, during energetic movements of the "physical culture " episode 902, that the overriding of the caudad fragment (see y photograph) was developed; and that antedating said de (i. e., 1893-1902) the fragments had remained in fair inal apposition, maintained either by a reasonably intact steal bridge or an elastic fibrous bond, competent for all ary demands, but which yielded to the sudden violence of

with consequent overriding. Furthermore, is it not ble that this overlapping displacement, once established 02 has continued, without reduction, to the present day ? is remarkable that in a man, very intelligent, capable of ; a lucid description of facts and symptoms, anxious to ain himself in the pink of condition, comfortably well- and under the observation of numerous physicians; it leed remarkable that such a fracture should remain brered for sixteen years. There are two possible expla- B : first, X-ray orientation had not been developed to its È accuracy in the earlier years of his disability, and as a was neither frequently recommended nor often em- ¡ second, the combination of a well-to-do patient, ex- fly solicitous regarding his physical condition, present- syndrome readily assignable to "sciatica " with no gly exceptional or highly suggestive clue leading toward justive examination and a more exact diagnosis-this Ition probably proved the pit into which " all fell." It

is stated that at no time during these many years was a rectal examination made.

Obviously : Haec fabula docet rationem examinem sine cura culpam gravem esse.

Present Condition .- Pain is moderate when seated or in bed, but constant when walking, it is accentuated during damp or unsettled weather. He uses a stick, and evidently " nurses " the right leg during locomotion, for excursion of the knee is automatically limited. States that he is liable to stumble over small obstacles; the resulting "jars " are painful, radiating down the thigh. Can definitely identify (and claims to have always been able to definitely identify) a relatively sensitive area, i. e., the tuberosity of the right ischium and peri-ischial structures. He continues to engage in a fairly active life but, handicapped as above, has eliminated the more vigorous forms of his customary sports.

Comparative measurements show relative dextral symptosis :

Right.

Left.

Circumference calf

14" 141/4"

Circumference thigh lower 1/3

1534" 17"

Circumference thigh middle 1/3 2016" 211/"

Mid. symphysis to postmesial line. 18" 21"

Ant. Sup. Spine Ilium to Internal Malleolus.

311%" 3134"

The mid-symphysis postmesial measurement is particu- larly interesting in that it records dextral gluteal change.

Rectal examination reveals an area of the right ischium sensitive to pressure. This area exhibits a moderate entad boss, which accurately corresponds to the overlap of the caudad fragment of the ischium (see X-ray photograph).

Dr. Carman, to whom full credit must be accorded for sup- plying the correct X-ray diagnosis, in his report calls atten- tion to-

1. A spear-like exostosis springing from the superior edge of the acetabulum; furthermore the articulation outline is indistinct.

2. There is fully a 2-inch overlap (original plate practically life-size) ; the caudad fragment seen partly through the acetab- ulum, partly through the femoral head, being shown mesad to that extent.

3. If patient had not been so stout, a series of perspective views might have been obtained that would have afforded data regarding character of displacement and union.

Based upon Section 1 of Carman's report it would seem to be evident that a moderate hypertrophic arthritis is present. It is entirely conceivable that a portion of the gluteo-femoral syndrome is due to exacerbations of this condition.

Technically, it is entirely possible that pressure pains might be largely, if not wholly, relieved in such a condition by an attack directed toward the overlapping fragments.

THE JOHNS HOPKINS HOSPITAL BULLETIN.

It Is issued monthly. Volume XXII is now in progress. The subscrip- tion price is $2.00 per year. (Foreign postage, 50 cents.) Price of cloth- bound volumes, $2.50 each.

A complete index to Vols. I-XVI of the Bulletin has been issued. Price, 50 cents, bound in cloth.

Orders should be addressed to THE JOHNS HOPKINS PRESS, BALTIMORE, MD.

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JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 20

PERI-TONSILLAR ABSCESS.

By MACTIER WARFIELD, M. D., Instructor in Laryngology, Johns Hopkins University.

This abscess is always painful, and at times dangerous. The laryngologist rarely sees one outside of a hospital, for the great majority of them come to the general practitioner, who either treats them after the method generally given in the text-books, a method often unsuccessful, and always dangerous, or frightened by its dangers and mindful of past failures, bears with resignation the sufferings of his patient until the abscess opens of itself. My excuse for this paper is that I wish to present a method of opening these abscesses, one which I have used for some time, that has never failed me, and which I believe to be perfectly safe, hoping that others may try it, in order that we may arrive at a correct judgment as to its value.

By a peri-tonsillar abscess, I mean one which is the result of an infection of the loose connective tissue immediately about the tonsil which presents the symptoms with which we are familiar as belonging to quinsy. Since it is supposed that the starting point of the infection may be anywhere in the peri-tonsillar connective tissue, the resulting abscess has no definite position where we may always look to find it. As it is also accompanied by great swelling and œdema of the mucous membrane over it, the area over which we can get fluctuations is therefore increased, and as the mouth can barely be opened, and hardly anything can be seen of the throat, it becomes impossible to definitely locate the abscess and find its point of greatest fluctuation. Examination by the finger affords the most accurate information, but this gives so much pain that few patients will submit to it.

In opening an abscess the procedure usually given in the text-books is this: when in any particular case an incision is decided upon, it is not attempted, as a rule, to definitely locate the abscess, but the incision is made at a site which experience has shown to be the usual point of greatest swelling, and where pus can be found. This incision is begun at a point opposite the junction of the uvula with the soft palate and about three-eighths of an inch external to the inner border of the anterior pillar of the fauces, and is carried from above downwards about one-third the distance from the point of origin to the lower border of the tonsil. The knife is wrapped to within a half inch of the point, and is plunged into the swelling to the depth of half an inch, care being taken not to wound the tongue on withdrawing it. Often when there have been unmistakable evidences of the presence of pus, and when the incision has been carefully made, the abscess is not opened.

There is hardly anything which occasions the physician greater chagrin than a failure of this kind, or does more to lower his reputation with his patient, who has had his pain increased instead of receiving the promised relief from suffer- ing, and who now considers the doctor the cause of all his troubles. This incision is not without danger. In making

it the ascending pharyngeal artery has been cut and the carotid also. Bosworth says that he never opens a per: tonsillar abscess without a certain feeling of nervousness ». that account.

To permit the abscess to open spontaneously has also its ds :- gers. Abscesses have burst in sleep, and the pus entering t' air-passages has drowned the patient. Pus has burrowed deaz and found a way out in the axilla, or entering the pleural cavi: has caused death. Most abscesses, when let alone, open di themselves between the fifth and tenth day, but at times this does not happen for five or six weeks, and by that time the patient is reduced to a pitiable condition from pain and war: of food and sleep. Sometimes, either through fear of accident. or because of former failures, the patient or his family mi! not allow the abscess to be opened.

In a long service in the throat clinic of the Johns Hopkin- Hospital, it has been possible for me to see a large number «. peri-tonsillar abscesses, and to make observations which har- led me to hold opinions as to their origin, and the best ws; of opening them, which differ from those usually held.

In the first place, instead of considering that the infectiec may enter, and the abscess arise at any point in the per .- tonsillar connective tissue, it seems quite evident that it almaya starts from the same point, and that point is in the supti- tonsillar fossa, and that the abscess is always the result of th extension of the infection to a cavity which opens into th: fossa. This cavity or space is in the connective tissue, an? extends outward along the superior border of the tonsil, and downward along its outer border, thus bounding it on tw? sides. The abscess begins at the supra-tonsillar fossa, and a: pus continues to be formed it occupies first that part of the cavity which is above the tonsil and then the part on its outer border. As the part on the outer border of the tonsi. becomes distended with pus, it forces the tonsil out of it- usual position, and pushes it inward over towards the urula. making it appear as if it were swollen itself, but its increase in size is only apparent and not real, for the abscess is nere: within the tonsil, but external to it.

The chief causes of peri-tonsillar abscesses are acute follicular tonsillitis, imperfectly removed tonsils and rheuma- tism. After an attack of acute tonsillitis, the pain and fever usually disappear at the end of three or four days, and the patient thinks he is getting well. But it is often only the lul' before the storm. At the end of twenty-four or thirty-sir hours, he feels a sudden sharp, stabbing pain in one tonsil. and that is the beginning of the abscess. The swollen tonsil has carried an inflamed crypt into the supra-tonsillar foss?, and infected it. Or the fossa may be infected by the small chronic abscesses which are the result of leaving parts of ton- sillar crypts behind in removing a tonsil.

The abscess which is the result of the acute rheumatic

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action, starts as a small, circumscribed, deeply inflamed area r the supra-tonsillar fossa and the adjacent anterior pillar. can be aborted if seen very early by the use of salicylate of a.

Whatever the cause of the abscess may be and whether it is ge or small, it can always be located in the supra-tonsillar ja, which itself can easily be found even where the throat very much swollen and distorted. This then is the place re the abscess is to be opened in every case.

The necessary incision is made with a curved bistoury, ch is held parallel to the soft palate, with the edge of the le looking forward, the back towards the posterior pillar,

the point directed outward towards the ear. The point ntered in the supra-tonsillar fossa, in the angle between

the pillars of the fauces as high up as possible, and is passed outward until it meets with an elastic resistance, which is the abscess. This is entered, and the knife is brought out straight forward through the anterior pillar. As a rule the knife does not have to enter more than a half inch to reach the abscess. The cut in the anterior pillar is through swollen mucous membrane and does no harm. A bent probe can then be passed through the opening made in the abscess, over the tonsil and to its outer side, thus demonstrating the exist- ence of the cavity there. As the ascending pharyngeal artery and the carotid are at the back of the knife, they are in no danger of being cut.

This incision, then, has these advantages: it is perfectly safe, it is easily made, and it is always successful.

JMMARIES OR TITLES OF PAPERS BY MEMBERS OF THE HOSPITAL OR MEDICAL SCHOOL STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN.

LEY, F. C., and GOLDSBOROUGH, F. C.

'he renal activity in pregnant and puerperal women .- J. Am. M. Ass., 910, Iv, 2058.

LEY, F. C., and WINTERNITZ, M. C.

'he catalytic activity of the blood in the toxemias of pregnancy .- Am. . Obst., 1910, 1xil, 961. R, J.

'he effect of securing the vagi or the splanchnics or both upon gastric motility in the rabbit .- Am. J. Physiol., 1910, xxv, 334.

'he prophylactic action of atropin in immediate anaphylaxis in guinca igs .- Ibid., 1910. xxvi, 439.

he effect of vagus section upon anaphylaxis in guinea pigs. Second ommunication .- J. Exper. M., 1910, xii, 638.

R, J., and LEWIS, P. A.

a cause de la mort dans l'anaphylaxie aiguë du cobaye .- Compt. rend. oc. d. biol., 1910, Ixviii, 99.

he physiology of the immediate reaction of anaphylaxis in the guinea g .- J. Exper. M., 1910, xii, 151.

, J., and MELTZER, S. J.

he respiratory changes of pressure at the various levels of the pos- rior mediastinum .- J. Exper. M., 1910, xii, 33.

ER, L. F.

troduction to diseases of the nervous system .- Ogler's Modern edicine, 1910, vil, 17.

lapters on the treatment of cerebrospinal fever, cholera and plague. Musser and Kelly's System of Therapeutics, 1910.

le methods of examining the blood of greatest importance for the neral practitioner .- International Clinics, 1910, 20th s., lv, 20.

i some of the triumphs of modern medicine .- Empire Club Addresses, ronto, 1910.

roxysmal-arteriospasm with hypertension in the gastric crises of es .- Am. J. M. Sc., 1910, cxxxix, 631.

e importance of the eugenic movement and its relation to social glene .- J. Am. M. A88., 1910, liv, 2017.

e prevention of racial deterioration and degeneracy, especially by tying the privilege of parenthood to the manifestly unfit .- Maryland J .. 1910. Tiff, 291.

ctrocardiography and electrophonography as aids in clinical diag- Is .- Canad. J. M. & S., 1910.

B, L. F., HIRSCHFELDER, A. D., and BOND, G. S.

: electrocardiogram in clinical diagnosis .- J. Am. M. A88., 1910, 1350.

, J. M.

erior poliomyelitis and its treatment by muscle ironing .- Albany Ann., 1910, xxx1, 207.

E. B.

iding, or nocturnal orgasms in women as a cause of headaches and erical attacks .- Trans. Georgia State M. Ass., 1910.

OOD, J. C.

nt progress in surgery .- International Clinics, 1910, 20th s., 1, 252. 'ery of extremities, shock. anesthesia, infections, fractures, dislo- ns and tumors .- Progressive Medicine, 1910, iv, 163.

gn bone cysts, ostitis fibrosa, giant cell sarcoma and bone aneurism je long pipe bones .- Ann. Surg., 1910, lil, 145.

medical and surgical aspects of tumors, including inflammatory neoplastic formation .- Wisconsin M. J .. 1910, ix, 115.

at progress in surgical treatment of malignant growths .- J. Am. 38., 1910, lv, 1537.

cal treatment of cutaneous malignant growths .- Thid., 1910, Iv,

BLUMER, GEORGE.

Report of a case of rapidly fatal septicemia due to the staphylococcus albus .- Yale M. J., 1910, xvi, 265.

A report of two cases of typhoid fever beginning with unusual throat symptoms .- Ibid., 1910, xvi, 452.

Food intoxication, snake poisoning, etc .- Musser and Kelly's System of Therapeutics, 1910.

BOGGS, T. R.

Alum baths in typhoid fever .- J. Am. M. Ass., 1910, liv, 2124.

BOND, G. S.

Effect of various agents on the blood flow through the coronary arteries and veins .- J. Eopcr. M., 1910, xil, 575.

BOND, G. S., BARKER, L. F., and HIRSCHFELDER, A. D.

The electrocardiogram in clinical diagnosis .- J. Am. M. A88., 1910, IV, 1350.

BREM, W. V.

Hexamethyleuamin in the treatment of a case of meningococcus menin- gitis .- N. York M. J., 1910, xcii, 816.

Studies of malaria in Panama : 1. Clinical studies of malaria in the white race .- Arch. Int. M., 1910, vi, 646.

BREM, W. V., and ZEILER, A. H. .

A study of hemoglobin of colored laborers in Panama .- Arch. Int. M., 1910, v, 569.

Ipecac in the treatment of intestinal amebiasis .- Am. J. M. Sc., 1910, cxl, 669.

BROWN, T. R.

The bacteriology of urinary infections with the urinary findings in these conditions .- Osler's Modern Medicine, vi, 218-235

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 86

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189