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CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.
STATED MEETING, JANUARY 15, 1906.
REPORT OF CASES.
ADENOIDS. DOCTOR WILLIAM R. LYMAN: I do not intend to discuss the subject of adenoids fully, but rather to report some observations based upon a study of the records of the Otolaryngologic clinic at the University Hospital for the year 1905; to compare them briefly with our accepted opinions; to call attention to the frequency with which this disease is accompanied by serious complications and to emphasize the importance of early treatment.
During the year 1905 there were examined one hundred and fortyfive cases of adenoids, of which number seventy-nine also had chronic hypertrophy of the faucial tonsils; in fact, in many cases it was the tonsilar condition which brought the patient to the clinic for relief. Many of the patients were college students, which fact is of importance in the interpretation of data to be brought forward later. As to sex. there were ninety males and fifty-five females. The preponderance of males as compared with other statistics is explainable by the fact that this clinic draws largely from the student body for its material. For purposes of convenience the following tabulation sets forth the number of patients per semidecade: From 1-5 years old 9 From 5-10 years old
39 From 10-15 years old
31 From 15-20 years old From 20-25 years old
6 One is at once struck by the small number of cases found in the first semidecade of life, during which period we are informed the greatest number of patients present themselves to our observation. The greatest number of any single semidecade was that between the ages of five and ten. Fully thirty-six per cent of our cases occurred between the ages of fifteen and twenty-five. One case was that of an adult fiftyseven years old. These figures are quite at variance with those ordinarily set forth, but the fact admits of ready explanation. The presence of nasopharyngeal abnormalities is often overlooked by the parents. The significance of adenoids in children is not widely or fully appreciated and a large per cent of the patients of this clinic were University students, which latter fact alone accounts for the variation.
Of importance is the time of year during which the greatest number of patients presented themselves for treatment. The records for April
and May show an enrollment of thirty-five cases, which suggest the relationship of adenoids to the nasopharyngeal disturbances so frequent in early spring. The patients in general complained of the classical symptoms of the condition–difficult nasal respiration, mouth-breathing with its characteristic facial expression, and, to quote Doctor Schadle, “The open mouth, the pinched nose, the drawn down inner canthi, elevated eyebrows, corrugated skin of the forehead, the distorted chest, the altered voice, the apparent defective development—both mental and physical.” There may be added: protruding upper teeth, and high palatal arch; repeated attacks of sore throat, which is generally due to the associated tonsilar hypertrophy; a fullness and the sensation described as something dropping in the back of the throat; a seromucoid discharge from the nostrils; the statement of the parent that the child is apparently affected with a continuous cold in the head; a voice thick and without resonance, such letters as m and n not being pronounceable; and, frequently, palpability of the submaxillary and cervical lymph glands.
Adenoids are characterized by the occurrence of complications directly due to the condition. Among those most prominently met were the following: Deafness of varying degree in sixty-five patients, some complaining of only slight stuffiness of the ears and occasional tennitus, both of which conditions were more marked when the patient had a cold. Many could hear the whispered voice, if at all, only a fraction of the normal distance, which is twenty-one feet. There were about thirty patients who had discharging ears at the time of examination, and many more cases in which the examination showed evidences of previous suppuration. The presence of adenoids was a marked factor in the susceptibility to the acute infectious disease, particularly measles, scarlet fever, and whooping-cough; repeated attacks of tonsillitis, pharyngitis, and acute rhinitis, the patients taking cold at the least exposure; a constant dry, hacking cough; gastrointestinal disturbances, manifested by a rapacious appetite and alternating constipation and diarrhea; retarded mental development, many of the children being several grades less advanced in school than normal children of similar ages; while several cases showed defective development of the chest, resulting in pigeon-breast.
The treatment has been complete removal of the growth, this being done under primary ether anesthesia with the patient in the sitting position. The instruments used were the adenoid forceps, when the tissue was abundant, followed by the Beckmann curet, and all small portions remaining were removed with the finger.
The results have been without exception favorable. There has been no case of hemorrhage. Those cases accompanied by ear complications have been very satisfactory both as to the improvement in hearing and the cessation of the discharge. The improvement in the general condition was very noticable, and this was especially true in the young patients.
Among the reasons for the removal of adenoid vegetations may be mentioned: The prevention of pathological conditions of the ears and the beneficial effect upon the ear complications; the establishment of free nasal respiration, thus doing away with mouth-breathing and its attendant disadvantages; the marked and rapid improvement in the patient's general health. The last two conditions were much more striking in the young patients. The removal of a constant source of infection, statistics showing that one case in five have tubercle bacilli either in the substance of the growth or upon its surface, and, as already mentioned, the presence of adenoids increases the susceptibility of the patients to the acute exanthemata.
The dangers of the operation, if correctly performed, are very slight and the beneficial results as marked as those derived from any operation.
ANN ARBOR MEDICAL CLUB.
STATED MEETING, APRIL 18, 1906.
REPORTS OF CASES.
RETENTION OF URINE.
Doctor CYRENUS G. DARLING: I wish to report two cases to show some methods of treating retention of urine. A man, seventy-five years old, had been using a catheter for five years because of enlarged prostate and cystitis. One day he was unable to pass the soft rubber catheter that he was accustomed to employ, and attempted to insert an old one which had been about the house for some time, because it was smaller. The tip had already been broken off. He not only failed in the attempt at satisfactory insertion but when he tried to withdraw the instrument it broke, leaving a piece of unknown length in the bladder. To still further complicate matters he threw the withdrawn fragment into the fire. He then called his physician who secured three fragments of catheter, probably all that had not been previously removed; still the physician was not able to gain acress to the bladder because of the injury which the patient inflicted upon himself. I saw patient about thirty-six hours later, when I found the bladder enormously distended because no urine had been passed. The pulse was weak and he presented all the signs of a septic condition. I decided to drain the bladder but patient was in no condition to take an anesthetic. I then made a suprapubic incision under local anesthesia (Schleich's solution). A large amount of very offensive urine was allowed to flow slowly away, and the patient was immediately relieved but was already so septic that he did not improve. He became gradually weaker and died on the following day. The second case was that of a boy eight years old who fell astride of a stick, completely severing the urethra. This was followed by infiltration of the perineal tissues and retention of urine. The physician failed to find the opening of the torn urethra and reached the bladder by puncturing with a trochar through the perineum along the supposed line of the urethra, and introducing a tube for the purpose of forming a new urethra.
After the tube was removed the new urethra remained for some weeks, but gradually contracted until no urine could be passed except by drops. Patient was brought to the University Hospital in this condition. For immediate relief suprapubic puncture was employed. The following day I attempted to find the end of the torn urethra by a perineal incision, but failed. I was obliged to resort to retrograde catheterization by incising the bladder, finding the urethral opening and introducing a catheter into it. This was carried anteriorly until the tip could be felt in the perineum, where the end was exposed by an incision. The other end was treated in the same way. Because of a large amount of cicatricial tissue no attempt was made to suture the ends but an English catheter was placed in the canal and kept there for a few days until the ends were approximately united. The wound in the bladder was closed. The patient left the hospital with a good urethra. When the catheter fails, retention of urine may sometimes be relieved by putting the patient in a warm bath, by using a general anesthetic to relax spasm, or by suprapubic puncture or incision. These latter may frequently be employed when a general anesthetic would not be safe. Incision should be made when it is necessary to drain the bladder. The use of Schleich's solution completely anesthetizes all of the tissues except the bladder wall. This is opened with a single, rapid incision. Puncture is so easily and safely performed that there are but few reasons why it may not be employed. Retention must always receive prompt treatment when cystitis is present or more serious conditions may follow, as in the first case reported. Retention from rupture of the urethra is treated by early perineal incision, with suturing of the torn ends, or holding in place by catheter as mentioned in the second case.
AN UNCOMMON FRACTURE. DOCTOR IRA D. LOREE: This fracture is not uncommon from the fact that it does not occur frequently but because it is not often diagnosed. In the past fracture of the carpal bones has, no doubt, many times been overlooked, but with the great advantages offered by the radiograph the true nature of many wrist sprains is coming to light. This patient was sent to me by Doctor Yutzy. His accident happened while scuffling, which resulted in a fall and striking upon his hand. Whether or not he fell upon it in a way to produce flexion or extension he could not tell. The seat of injury was too far forward to be a Colles' fracture, and while deformity and crepitus were absent, there was too much pain, and swelling in the soft parts, not to interpret a broken bone. The radiographs which I pass around readily reveal the seat of difficulty in the os magnum and scaphoid. To properly diagnose this condition both wrists should be photographed, as sesamoid bones may be mistaken for fracture.
CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.
MORTALITY AFTER PROSTATECTOMY. In Jama, Volume XLVI, Number XIX, Tenney and Chase give some interesting observations on the results of prostatectomy. Age of itself, they state, is no argument against the operation, but their figures show better than any amount of argument the desirability of early operation. The convalescence of elder patients was in marked contrast to that of the younger patients. In studying seventy-three deaths fatal periods were noticed. There were twenty-three deaths, or more fatalities in the first forty-eight hours than in any other two days. Another period of mortality includes the seventh, eighth and ninth days, which showed twelve deaths. On the thirteenth and two following days there were six deaths, and on the twentieth to twenty-second days inclusive, there were seven deaths. Two-thirds of all the deaths came during these fatal periods. Contrary to statements by Moullin, Richardson and others that patients with stone in the bladder are more favorable subjects for operation than others, their list contains one hundred seven cases complicated by vesical calculus with a mortality of thirteen or twelve per cent, as compared with 8.6 per cent mortality among the cases without stone. The inferences drawn from a comparison of mortalities with ages were that the older men are less likely to stand the shock and loss of blood in the operation, and that the younger men stand the sepsis, uremic complications and confinement less well than the elders. Believing that the result is not so much a problem of speed or technic in the operation, they lay great stress upon the preparation of the patient, the anesthesia, and the careful and intelligent attention almost constantly during the first forty-eight hours, and the same sort of attention later at frequent intervals until his convelescence is well established.
F. B. W.
FAT INDIGESTION IN INFANTS. LOWENBURG (Medical Bulletin, November, 1905) says that an excess of fat may not infrequently be a source of indigestion. Infants thus fed vomit from half to an hour after feeding. The vomited material has an odor of butyric acid and is sour. Diarrhea is a frequent