CLINICAL REPORTS. GLEANINGS FROM ANN ARBOR CLINICS. SURGICAL CLINIC AT UNIVERSITY OF MICHIGAN. Professor of Surgery and Clinical Surgery in the University of Michigan. CASE I.-RODENT ULCER. Mr. C. W. B., age sixty-nine, admitted to the hospital on November 3, giving the following history: About six years ago a small lump made its appearance on the back of his head, which in a year began to ulcerate. It was treated by applying caustic plasters, after which the surface healed over; but broke out again in a short time, and spread until it involved the greater part of the back of his head. He has suffered some pain, but general health is fair. Professor Maclean diagnosed the case rodent ulcer, and recommended the application of Iodoform and cosmoline. This application improved the condition of the ulcer; but as the patient was desirous of a speedy recovery, he was placed under chloroform on the 9th, and by means of a Volkman's spoon the surface of the ulcer was scraped down to the occipital bone, leaving it bare to the extent of the palm of one's hand. Chloride of zinc was then applied to the surface quite freely. It was then dressed with a poultice for a few days, until the slough separated. To-day when he was presented to the class the entire surface of the occipital bone was covered with healthy granulations, they having sprung up through the bone, and the edges of the sore were inverted. Patient states that he feels very well. Further treatment will consist in introducing a large number of skin grafts. CASE II.-CHRONIC ABSCESS. Mr. D. C., age twenty-one, presents the following history: About a year ago he suffered from a pain in the right side, which continued until last spring, when it was more severe and somewhat periodical. It was now about the size of a hen's egg and located over the seventh rib. It was diagnosed a chronic abscess, due probably to some injury the patient had received no tenderness in the spinal column. A fine trochar was then introduced, and a capillary drainage tube attached to the canula which passed down into a basin containing a one 42 TALIPES EQUINO-VARUS-EXOSTOSIS-HEMORRHOIDES. to twenty solution of carbolic acid; but it slipped out during the night. He was then brought before the class again on November 9 and a free opening made, when upon passing the finger into the abscess a portion of the rib was found bare. An oakum tent was then introduced and a pad of oakum applied, which was held in place by a bandage. When examined to-day before the class, the wound was almost entirely closed and no dead bone was to be found. Since the above has been written the patient has been heard from and is almost well. CASE III.-TALIPES EQUINO-VARUS. The patient, an infant fourteen weeks old, was admitted to the hospital November 26, when upon examination before the class it was found to be a case of congenital talipes equino-varus. Chloroform was administered, and the tibialis anticus and tendo achillies in both feet were divided, also some bands of tense plantar fascia. A pad of cotton wool and a bandage constituted the dressing. The dressing was removed to-day, when it was found that the feet were very much improved. A strip of adhesive plaster about one inch wide was then wound about each foot so as to hold it in place, and then fastened to the leg. A bandage was then applied. The parents advised to have this dressing changed about every three eays, and reapplied under the direction of a competent physician. CASE IV.-EXOSTOSIS. Master A. G. T., age fifteen, admitted to the hospital to-day, gave the following history: About one year ago he had an exostosis removed from the distal phalanx of the great toe, but the growth returned in a few months. The patient being placed under chloroform, an attempt was made to save the nail and the shape of the toe, but as the whole of the phalanx was involved it was removed and the skin trimmed off, making a flapp operation. The toe was then dressed with a pad of dry cotton and a bandage. CASE VI.-HEMORRHOIDS. Mr. R. C., age thirty years, presented himself before the class to-day. He has been troubled for some time with hemorrhoids, both external and internal. The patient leaning over a table, his buttocks were separated and upon slight straining an internal hemorrhoid came down. A curved needle containing a long double ligature was passed through. Each half of the hemorrhoid was tied separately. The external ones were removed by means of curved scissors and artery forceps. CASE VII.-STRICTURE. Mr. S. E., age forty years, contracted gonorrhoea eight years ago which lasted about three months. He says that he recovered from this without any trouble, but three years after he suddenly had some difficulty in passing his water. He passes water more frequently during the day than at night-constant dull pain at the neck of the bladder-stream drops off short at the end of the penis, and much smaller than natural-never passed any blood. Five years ago he applied to a physician, who diagnosed stricture and passed a sound after he had the patient on the table three hours. November 18 he was examined before the class, when two strictures were found. Symes' stricture staff was passed through the outer one; but as there was considerable tenderness and some bleeding, although no force was used, Professor Maclean thought it best to wait for a few days without making any further effort. Patient again examined to-day, when, after several of Gouley's whale-bone bougies were passed down to the stricture one finally passed through both and into the bladder. Gouley's number four tunnelled staff was now threaded on the whalebone conductor and passed through the strictures into the bladder. A number five was next passed in without any trouble. Reported by GEORGE F. HEATH. M. D., House Surgeon to University Hospital, University of Michigan. CASE 1.-REMOVAL OF MALIGNANT GROWTH FROM THE THROAT AND CHIN. H. J. B., age fifty You will recognize this patient as one brought before you about four weeks ago, and will recall to mind the main facts in the history of the case; how two years ago he noticed a small lump just under the angle of the jaw on the right side; that for the first six months it grew very slowly, was free from pain and freely movable-increasing then in size it subsequently grew to the size of a walnut; this was removed last August, and six weeks later again made its appearance, and this time increased to size of hen's egg very rapidly, the chin becoming involved in the mass, and suppuration soon began. The growth was slightly movable on the jaw and gave him no pain. About this time a portion of the growth was removed for diagnostic purposes and microscopical examination showed many small round nucleated cells and some epithelial nests. This together with the fact of its quick return after the previous operation was positive evidence of malignancy, and it was only by the earnest solicitation of the patient and the hopes that by a thorough operation the disease could be eradicated that I was induced to interfere. As a considerable portion of the chin was invaded, it was necessary to remove it along with the growth, and great care was taken in dissecting the mass from the mucous lining of the mouth. The hemorrhage was slight until the lower and deeper parts were removed, when a branch of the external carotid, probably the lingual was divided close to its origin. The artery was taken up and ligature applied. Owing to large amount of integument removed the wound gaped to considerable extent, the edges were drawn together and held by hare-lip needle and figure eight suture. One week after the operation, while straining, secondary hemorrhage occurred which was stopped by simple pressure. The next morning after dressing, hemorrhage again came on. The patient was immediately placed under chloroform and the incision enlarged and the bleeding point seized with the forceps; this upon examination proved to be the common carotid. Ligatures were applied above and below, and the lower part of the wound stitched up and dressed with a pad of cotton and bandage. The wound which I was unable to close at the time, you see is now nearly grown together and filled with healthy granulations, and, best of all, I see no signs of the growth returning. His temperature, at no time, has risen above 1034°, and then but for about three hours, and all the medicine he has taken is about forty grains of quinia, and the same amount of salycilic acid and two or three injections of morphia, a simple dry dressing of cotton lint and bandages constitutes all the treatment he has had. He is looking rather pale from confinement; a change of air will be beneficial and he can go home. This class has now seen within the last two months in this clinic, two of the most prominent arteries that are tied, successfully operated upon; the other operation I refer to is the case of femoral aneurism in which I tied the external iliac. CASE II.-POTASSIUM IODIDE IN SYPHILITIC HEMIPLEGIA. Julius H., age thirty-two. This patient on the stretcher before you, has been sent to this clinic from the poor house of Muskegon, Michigan. You will notice his general appearance, the vacant expression of his countenance, on his breast and back the copper colored spots peculiar to the secondary stage of syphilis are noticeable on his back are two bed sores each as large as my hand which tell of close confinement, in bed; there is paralysis of motion in right inferior extremity and arm, the latter flexed upon the body and from disuse almost anhylosed. I saw him a few minutes three days ago and he told me a pretty straight story as follows: How about two and one-half years ago he contracted syphilis; that about three weeks later one sore appeared on the glans which was removed by caustics; that he has had pain in his bones and other concomitant results of the syphilitic virus. To others he has told contradictory stories, and his speech and actions show conclusively the confused and clouded state of the patient's mind. About six weeks ago he was suddenly seized with hemipegia of right side with loss of control of the sphincters, the contents of his bowels and bladder passing off involuntarily, and in this helpless condition we see him now. I have no doubt of the pathology in this case, of the existence of gummata, or gummy deposits pressing on the brain, interfering with its function, producing paralysis, and believing that no other medicine acts as effectively in removing these deposits as large and free doses of the iodide of potassium, I ordered him on Monday to take one drachm of this daily in divided doses for a few days. This amount will then be still further increased, if found necessary, and I shall be surprised if we do not find rapid improvement in the case. Cleanliness, good diet and persevering treatment are important factors in the management of patients in this condition. Since writing the above I note the following facts in this case: December 1.-Patient taking the iodide of potassium in twenty grain doses three times a day; his mind is clearing up and many points in his history obtained only confirming the diagnosis of Prof. Maclean; patient is somewhat irritable and asked for papers to read; no control over sphincters. December 3: Noticeable improvement to-day. Yesterday raised right arm from body and to-day raised it to his head; not able to move right limb; says he feels much better; appetite and digestion good. Is now taking ninety grains of the iodide daily. December 4: Still improving; to-day wrote a letter to his mother, using right hand; uses his right hand considerably; general appearance much better; has good control over bowels and bladder. December 5: Walked with some aid to clinic room this noon and presented to class. December 6: Still improving; was removed to general ward to-day, from which he had been kept, owing to filthy condition, with slight assistance walking the distance, some seventy-five feet. December 27: Patient continued to improve rapidly, during last two weeks has taken daily walks on grounds surrounding the hospital. Has continued to take the iodide of potassium in thirty grain doses three times a day. His bed sores have healed and he says he "feels like a new man." He was dismissed to-day and returned home. |