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“ The association of suppuration in ought to have been done at the time of the frontal sinus with ethmoidal and the operation, and as I supposed, I did antral disease may well repay discus do, i. e., open directly into the nose and sion,” says Greville MacDonald.
drain also through the cavity. I have Let us
now return to our case. As had several other cases of chronic embefore shown, there were most insuffi. pyema of the frontal sinus, none of cient grounds for the diagnosis of the which had either ophthalmos frontal sinus empyema, much less to un other disturbances of vision, neither did dertake so serious an operation as the they suffer much from supra-orbital neuexternal treatment demands. In point ralgia. Since writing the above, I have of fact I made but a tentative diagnosis - drained the sinus directly into the nose and was led to the classical operation by forcing a large trochar from the exmerely by the desire to follow the ternal wound through the anterior ethmaxim, “When one finds pus, give it moidal cell by way of the infundibulum free exit and don't stop until you do, of the nasal cavity of that side. Through and remove the cause. I made the this wound I have introduced a drainusual incision below the supra-orbital age tube through which the wound is ridge, joining it with a perpendicular in- daily washed with antiseptic Auids. cision on that position of the face form The object is to keep open this fistulous ing the internal wall of the orbit; turn track so long as there is any pus to be ing aside this triangular flap, I raised seen or dead bone to be felt. the periosteum with the elevator and A sense of fulness and discomfort asafter controlling the hemorrhage, which sociated with one-sided discharge of illwas inconsiderable, I now followed smelling, thick muco-purulent matter, my fistula into the frontal sinus, en or “catarrh” as my patients called it, larging it so as to introduce a sterilized and came to be treated for, were the silver Eustachian catheter. Immediately main symptoms of these cases. Some there was a gush of pus. I then en of them had also several small polypi, larged the opening still more, but could and the others more or less hypertrofind neither granulations nor necrosed phy of the middle and inferior turbibone in the frontal. But turning the nates which were first radically treated. probe toward the ethmoid, I got dead The diagnosis was readily established bone and with chisel and raw-hide mal- by carrying the same along the infunlet enlarged the whole cavity so as to dibulum to the opening of the frontal introduce my little finger. Feeling dead sinus, which was followed by a free disbone towards the ethmoid, I gouged charge of pus over the anterior end of and curetted as much as I considered the middle turbinated bones. Now these safe, and after cleaning with sterilized cases were all treated by the intranasal water and packing with iodoform gauze, method. That is, by removing all imI closed up the wound, leaving space at pediments to free drainage, carrying the base in the neighborhood of an old
fis- hydrogen dioxide (or other antiseptic tulous opening, for the exit of pus. The clearing solutions) into the sinus through wound did well, primary union result the middle meatus. When H, O, is ing in all except that portion of the used, it is followed by a thick frothy wound designed for drainage. The pus and finally after no more frothy pus fourth day after operation a great deal follows the application, a sterilized Eusof edema set in over the root of the nose tachian catheter is carried up and by and over both eyebrows, but subsided the air-bag the cavity is cleared. This in a few days. Granulation tissue formed usually suffices, and in a few weeks, very exuberantly, so much so that I sometimes only one week, the empyema was forced to curette much of it
away. is cured. The wound is washed out daily and Now the object of this paper is to call packed with iodoform gauze.
your attention to several factors. As there seems still to be much necro The relative frequency of this trouble. sis of the ethmoid, I shall do what 2. That frontal sinus and antrum dis.
ease very frequently come together. under proper precaution is not so very 3. That we must not rely implicitly formidable. When so operated on (exupon the classical signs and symptoms ternally) one should never leave the as shown by my meager experience. case until they establish free discharge 4. To ask what relation the occipital into the nose. As Dundas Grant has neuralgia has to the malady. 5. That lately shown, this can be easily accomthe question is not which is the better plished by passing a pewter wire from method, the intranasal or external, the wound into the nose and slipping but either, according to the case at issue. over it thin rubber tubing, which will When practical, every case should be perfectly drain the
perfectly drain the cavity. Finally, treated through the nose, but when it is from what I saw and what I can le arn found not to furnish a reasonable hope from the results of others, no importance of cure we should not hesitate to resort can be attached to the electric trans-ilto external surgery, as the operation lumination.
Rockville, Md. “ Festina lente" should be our motto since, I heard tuberculin as highly exunless we wish to lose the respect and tolled in the treatnient of tuberculosis as confidence of our lay brethren. In antitoxine was in the management of olden times the physician was more diphtheria at the late meeting of that cautious than he is at the present day body in Baltimore. Unless antitoxine and specifics had to be tried before they proves a safe and reliable remedy, which were proclaimed such. On looking I fear it will not, the regular profession over my grandfather's account books, will receive a blow from which it will those of the late Dr. James Anderson,
be hard to recover. of this place, I find that although If we do not wish to gain the unenviJenner declared in 1796 that vaccina able reputation of pretenders there tion rendered mankind proof against should be some concert of action among smallpox, he did not begin to vaccinate us in regard to such agents as antitoxbut continued to inoculate up to 1814. ine. They should be thoroughly tested This ta ess on his part was no proof before being endorsed by the medical that he was not progressive, for he was profession. What the fatality from diphone of the incorporators of the Medical theria is will be hard to determine but and Chirurgical Faculty of Maryland my mortality record shows a death rate and he did not hesitate to puncture the of about twenty-five per cent. Taking liver, drain an abscess located therein, into account those cases that I know to and thereby save the life of his patient have been diphtheritic and were not and that too when the symptoms were treated at all, would bring the mortality very obscure.
down to fifteen per cent. It has not Some years ago, Chian turpentine was been an uncommon experience with me pronounced a specific in the treatment to be called to a case of laryngeal diphof cancer and put to the test throughout theria and find that all the other memthe civilized world has proved a signal bers of the family had had the disease failure. Not long after the turpentine and recovered without any treatment experience comes the announcement whatever. that sulphuretted hydrogen forced into Dr. Jacobi has said, and with truth, the bowel would arrest tubercular con that there are more cases of diphtheria on sumption and that too proved a failure. the street than in bed. The younger the While attending a meeting of the Amer child the more apt is this disease to ican Medical Association, some years assume the laryngeal form. I have
never lost a diphtheria patient except great mistake in substituting hydrogen where the larynx was invaded when first peroxide for the persulphate of iron, seen and never saved but one where carbolic acid and glycerine as a local such was the case.
application in the treatment of diphtheTwo years ago two boys eight and ten ria. The former merely removes he years of age were attacked by diphthe pus, whilst the latter in my hands has ria. They were treated by a competent always arrested the spread of the memphysician, and both died. I was called brane. in consulcation to the last one of these I hope that antitoxine may prove to cases and whilst there was asked up be all that is claimed for it, for the stairs to see a family, a mother and six medical profession has not the influence children, down with the same disease. I that it once had either individually or gave general directions as to their treat collectively. The Medical and Chirurment but saw them no more. They gical Faculty of Maryland, in by-gone every one recovered though no physi- days, had the right to say who should cian was in attendance. Had antitoxine and who should not practice medicine been employed their recovery would no in this State and the physician held a doubt have been attributed to that place in the esteem of the people not agent. I think physicians have made a even second to that of tlie parson.
TRANSIENT CLUBBING OF FINGERS cases previously published, two by DURING EMPYEMA. - Schon (British Moigard. Medical Journal) reports the following case : A girl, aged 10, presented symp HOUSEHOLDERS AND SANITATION.toms of a localized pneumonia in the A question of equal interest to owners upper part of the lower lobe of the left of house property and to their tenants lung, which later spread over the whole was decided in court last week. The lung. As the disease did not progress
plaintiff, says the Lancet, who, acting in the orthodox manner and the tem upon the assurance of an agent, had perature kept high an empyema was taken a furnished residence at Sandgate, suspected. On the seventeenth day of attributed a sore throat and other illness illness there were physical signs of fluid, afterwards occurring in his family to and pus was withdrawn by the aspira- damp and effluvia due to insanitary contor. The following day the usual oper
ditions. Evidence was adduced for and ation was performed, and the same even against this theory, and a verdict was ing the temperature was normal, and re finally given in favor of the defendant. mained so throughout the illness. Some The case, into the merits of which we time after the operation the deformity of do not enter, is, as we have said, doubly the fingers was noticed. This became very instructive. It ought to emphasize a marked; the terminal phalanges were en necessity always incumbent upon tenlarged both from side to side and in the ants on making a change of residence – dorso-volar direction; the nails were namely, that of providing for thorough abnormally convex, but their color nat inspection of all sanitary arrangements ural. The deformity quickly disap in a new abode. Such forethought, unpeared, and by the time the sinus had fortunately, is not too common, and closed the patient's fingers were quite this is the more to be regretted since the normal again. The author regrets his services of a qualified inspector can be neglect to make a bacteriological exam readily obtained and at small cost, ination of the pus evacuated from the while the consequences of an oversight pleura, as he thinks this affection must in regard to this matter may be serious in some way be connected with pyoge in the highest degree. House-owners nic bacteria or their products. It has on their part will find that it is true been noticed in connection with other wisdom and true economy in the end to suppurating processes, as, for instance, test their property periodically, with a by Marfan in a case of pyelonephritis. view to its timely repair. The author has found only four similar
SUMMARY OF THE EXAMINATION HELD BY THE BOARD OF MEDICAL
EXAMINERS OF MARYLAND, MAY 2, 3, 4, 1895.
A general average of 75 being required, it will be seen from the above table that of seventy
five applicants, eight were unsuccessful.
2. How are the vertebrae divided ? Name the peculiar vertebrae of each region.
3. Nanie the branches of the thoracic and of the abdominal aorta.
4. How are the articulations classified ?
5. Where are the kidneys situated ? Give their relations.
6. Name the various objects seen on the under surface of the cerebrum.
7. Give the names and location of the four sets of valves found in the heart.
8. Give the position of the heart and its valves with relation to the walls of the chest.
PHYSIOLOGY. 1. Describe the gastric juice and tell what it contains.
2. Give a summary of the digestive changes in the small intestine.
3. What are the supposed functions of the ductless glands?
4. What are the functions of the skin ? 5. What nerves inhibit the heart's action ?
6. What circumstances influence the heart's action in a healthy adult ?
7. Give the several supposed origins of the colored blood corpuscles, and also the origin of the colorless corpuscles ?
PRACTICE. 1. What is the supposed cause, and what are the types and treatment of intermittent fever?
2. What are the physical signs, the most frequent complications and the treatment of pleuritis ?
3. What are the symptoms, diagnosis, complications and treatment of acute rheumatism?
4. What are the diagnostic characteristics of the sputa of acute bronchitis, acute phthisis and of typical pneumonia ?
5. Differentiate apoplexy, epilepsy and acute alcoholism.
6. What are the causes, symptoms, diagnosis and treatment of ascites?
PATHOLOGY. 1. Describe the morbid changes in the spleen in typhoid fever.
2. What are the principal pathological changes in acute miliary tuberculosis ?
3. What are the varieties of cardiac hypertrophy and upon what causes does it depend ?
4. Give the pathology of acute myelitis.
5. What post-mortem changes are found in cholera infantum ? 6. Give the pathology of locomotor ataxia.
SURGERY. 1. What is the treatment for fractures of the shaft of the humerus ?
2. What is an intracapsular fracture of the femur ? How diagnosed ? Its surgical treatment?
3. What is a compound fracture?
4. How may a dislocation of the femur upon the os pubis be reduced ?
5. What is meant by a subglenoid dislocation of the humerus and how may it be reduced ?
6. How may calculus of the bladder be detected ?
7. What is a hemorrhoid ?
8. Give three different niodes of amputation.
OBSTETRICS. 1. Name and describe the various positions of a vertex presentation.
2. In the progress of all vertex presentations what are the movements of the head ?
3. What causes flexion ?
7. Into what is it generally converted spontaneously?
8. How would you manage a case of placenta previa ?
GYNECOLOGY. 1. Name and describe the various displacements of the uterus.
2. What are the physical signs of cervical endometritis ?
3. What are the physical signs of uterine cancer ?
4. Wherein is the uterine sound a dangerous instrument ?
CHEMISTRY. 1. What are the properties of carbon dioxide ?
2. How are carbonates formed ? What is the composition of sodium carbonate ?
3. Name some of the principal compounds in which sulphur occurs in nature. How is it obtained from its ores ?
4. What is meant in general by fermentation? Give a well known example.
5. Write the formulas for (a) Magnesium sulphate. (6) Potassium nitrate. (c) Ammonium chloride.
6. How is glycerine obtained ? What are its properties?
7. Give a general account of (a) Starch, (b) Cellulose, (c) Carbolic acid.
1. What precautions should be observed in the management of a case of contagious disease, with reference to the patient and the public?
2. In the hygiene of the infant what are the most important points to be observed during hot weather ?
3. What are the differences, if any, between contagious and infectious diseases ? Name one or more of each class. : 4. Explain the difference between antiseptics and disinfectants, and name one or more of each class.
5. In what manner can it be determined that water is unsafe for drinking purposes ? By what methods can such water be purified ?
6. While exposed to cholera what important personal precautions should be observed to lessen the risk of the infection ?