« ForrigeFortsæt »
By DUDLEY TAIT, M. D. Visiting Surgeon to the French Hospital and to California Woman's Hospital.
(Presented at the California Academy of Medicine.) I desire to call your attention to a case of disease of the thyroid gland of interest from a diagnostic and operative point of view:
Of 12 years' growth, the tumor, as shown by the accompanying photograph, occupies & space extending from the hyoid bone to the sternum, overlapping the latter 13 inobes. The left side is more involved than the right, toward which the larynx is displaced. Palpation showed a hard mass, more resistant than the habitual cystic goitre, but giving evidence of the presence of liquid. A small exploratory punc
ture showed a liquid possessing all the characteristics of that of uncomplicated cystic goitre. The patient's voice had been gradually affected during the previous six months; respiration was impeded during exertion, and very frequently even during rest. Enucleation was advised.
Expecting a very simple case, I met with considerable surprise. The tumor had all the appearance of a simple hypertrophy, with enormously dilated blood vessels. Its size precluded the possibility of the preliminary ligation of the inferior thyroids; the various vessels were, therefore, ligated, as the dissection proceeded. Sixteen ligatures were required, including two placed on the remnants of the right lobe.
The specimen shows clearly the mistake in diagnosis. It is a case of hypertrophy of the glandular tissue and blood vessels; in the center there exists a cyst, surrounded by glandular tissue one inch in thickness in some points. Another detail of interest is the use of silk ligatures, which were not boiled at the time of operating but some time previously. I had occasion to regret it, for on two different occasions, two or three months after the operation, a purulent collection occurred to the right and left, and in front of the trachea, about one inch above the sternum. By careful curetting, under cocaine, I was enabled to remove the cause, & septic ligature, in each case, after which the parts were rapidly restored to their normal condition. It may interest physicians to note that the pulse rate before the operation was 100; it is now only 80.
By P. M. WHITE, M. D., Los Angeles. For the past ten years I have met with almost universal success in the treatment of varicose and chronic syphilitic ulcerations of the skin through the use of sponge grafts. My method of procedure is as follows: Preliminary to dressing, oedema is removed as far as possible by the usual remedies. Next, small incisions are made in the edges of the ulcerations (provided they are indurated), thereby thinning them. Silk sponges of the finest quality are secured and cut precisely to conform to the depth and circumference of the sore. The sponge is thoroughly saturated with almost any antiseptic solution and pressed neatly and firmly into the ulcer. (Great caré must be taken that the sponge fits accurately into the ulceration.) Thin adhesive strips are brought over the sponge and fastened to either side, to keep the sponge steady and in position till granular union is well under way. Over this I apply a single layer of cheesecloth or mosquito-netting, which prevents to an extent the next dressing (absorbent cotton) from adhering to the sponge and obstructing free escape of pus. Over the whole is placed a well-fitting roller bandage (where position permits its use) and the patient is advised to keep the part quiet.
Within ten days or two weeks an examination reveals the following: The cedema surrounding the sore has disappeared, and the cartilaginous ring in which were made small incisions has given place to pliable and healthy skin. Frequently the discharge of pus is materially increased, and much pain is induced if traction is made upon the sponge. In the course of two or three weeks, if the sponge is gently elevated from its circumference, beautiful granulations are found springing up into its meshes, and bleeding is readily produced upon slight irritation. If the sponge remains undisturbed, it is gradually absorbed. If the edges are interfered with, granulation first disappears from the circumference, and a strong layer of cicatrical tissue is substituted in that portion of the sore.
As may be supposed, all cases of chronic ulceration do not immediately respond to this novel treatment. Where the granulations are strong and vigorous, no renewal of the graft is necessary; but when the ulcer is extremely indolent and the discbarge sanious, granular stimulation with the sponge is slow, and several attempts may be necessary to secure the connection between sponge and granulations. All of the dressings except adhesive strips and sponge should be changed daily, till the sponge is firmly adhered, and the latter should be kept moist with any antiseptic solution (except bichloride of mercury).
Regarding the theory of action of sponge graft, very little has been said as yet: whether the sponge acts as an antiseptic in preventing the deposition of organic matter from without, or whether it has some peculiar property inherent in itself in gen