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The Summer Course in Otclaryngology was given in three divisions :
(a) Examination and diagnosis of the commoner forms of ear, nose, and throat conditions with especial reference to treatment. Access to patients was possible during whatever time was at the student's disposal. Careful hearing tests were made and their importance demonstrated. All methods of diagnosis and treatment were illustrated and opportunity given to students to acquire proficiency in them.
(b) Demonstrations of the anatomy of the ear and operative technique of ear and mastoid operations. This was conducted in the clinical laboratory. All operations were demonstrated and abundant material provided for practice.
(c) Demonstrations of the anatomy and exercises in diagnosis and treatment of diseases of the nasal accessory sinuses. The value of transillumination and the x-ray in diagnosis were taught and their application demonstrated. Operations were performed upon the cadaver.
The following shows the amount of clinical material used in the Summer course: Patients presented,
94 Conditions presented,
. 171 Operations performed,
4 Microtia, Polyotia, Microtia with complete atresia of external canal, Acute suppurative otitis media, Acute secretory otitis media,
6 Chronic catarrhal otitis media,
8 Sclerosis of middle ear,
5 Chronic secretory media, Chronic suppurative otitis media with cholesteatoma,
4 Simple chronic suppurative otitis media, Effect of suppurative otitis media,
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CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.
STATED MEETING, OCTOBER 3, 1906.
REPORTED BY DAVID M. KANE, M. D., SECRETARY.
REPORT OF CASES.
ANEURYSM OF THE AORTA. Doctor Frank SmithIES: I wish to report a case of aneurysm of the arch of the aorta, and demonstrate the findings upon the patient. The case is one which recently came under notice in Professor Dock's clinic. The present affection is of about one year's standing, the patient's most troublesome symptoms being sharp, lancinating pains in the left back, scapular region, aggravated by lying down, and more
Dulness over pulsating tumor
FIGURE I. DULNESS OUTLINES ON THORAX-CASE ANEURYSM OF AORTIC ARCH. severe at night; feelings of discomfort in the precordium; pains in the arms, particularly the left; "dizzy spells;" dyspnea when lying down ; irregularity of heart beat; anorexia.
The examination revealed a noticeable, pulsating prominence in the thorax, over the left, upper anterior region, centering over the second intercostal space, parasternal line, extending inwards to the midsternal line, outwards to just beyond the midclavicular line, upwards, almost to the clavicle, and below, into the third intercostal space. The prominence was almost one centimeter higher than the corresponding region on the opposite side of the thorax. The pulsation was heaving, synchronous with the apex beat, and strongest in the second intercostal space, left parasternal line. No prominence or pulsation was to be seen in the back. The palpation revealed no definite tracheal tug. There was tenderness over the entire tumor area, especially over the second intercostal space, left midclavicular line, and in the back along the spine of the left scapula. Over the tumor there was a strong systolic
pulsation, with slight suggestion of being expansile, followed by a diastolic shock of moderate intensity. The radial pulses were unequal, the right being considerably fuller than the left, which was rather difficult to make out. The percussion is very painful to the patient. An area of dulness corresponding to the area outlines in Figure I herewith was obtained. There was no distinct dulness in the back. Auscultation disclosed a systolic, softly blowing bruit at the apex of the heart, faintly transmitted to the left axilla ; an aortic second sound prolonged and forcible; the pulmonic second moderately accented. Over the tumor area there was a loud, systolic bruit, followed by a diastolic sound of moderate intensity. Auscultation of back, scapular region, revealed similar findings, but less pronounced. No Drummond's sign. Lungs were negative. Figure II shows the results of radioscopy. The fluoroscope disclosed the heart's apex in the fifth intercostal space, midclavicular line. An indistinctly pulsating mass was seen to the left of the sternum in the second and third intercostal spaces, extending outward to the midclavicular line. Blood pressure on entering hospital: right radial-systolic 139, diastolic 103; left radial-systolic 118, diastolic 86. Ten days later : right radial-systolic 142, diastolic 115; left radial-systolic 141, diastolic 112.
The diagnosis of aneurysm of the aorta, with main enlargement at junction of transverse and descending portions of the arch, with probable diffuse dilation of the entire arch was suggested.
Treatment, consisting of rest in bed, ice-bag, anteriorly, over the tumor, with ice-coil to back over painful area, increasing doses of iodid of potassium, light diet, and regulation of the bowels, has shown an encouraging improvement in the patient's condition. The tumor mass has evidently become smaller, the patient's subjective symptoms have become less marked, the systolic bruit and the diastolic shock are less distinct, and there has been a relative fall in the diastolic blood-pressure, although the general pressure is increased. The patient's pharyngeal mucous membrane shows moderate injection, doubtless due to the iodid of potassium, of which the dosage has been carried as high as grams 2.5, thrice daily. The patient's appetite has greatly improved, and she expresses the wish to return home to take up her daily tasks on the farm. This is deemed inadvisable at the present stage, and treatment along the lines already laid down is directed to be continued.
BRONCHIECTASIS. Doctor Hugo A. FREUND: I wish to report a case of bronchiectasis that has been progressing for some years. The condition was preceded by an empyema for which the patient had been aspirated in the Medical Clinic two years ago. At that time there was consolidation of the lower left side. Not long after a cough developed and since that time he has been raising a foul-smelling sputum in large quantities. This has had the characteristics of a bronchiectatic sputum in that it had the three layers usually met with, and the nauseating carion odor.
At present the entire left side of the chest is lower than the right and does not move on respiration. The breathing over the side, which is absolutely dull on percussion, is of a bronchial quality below, and becomes amphoric at the third rib. In connection with this the clubbing of the fingers, which is marked, is of interest. With the idea of finding some traces of the early empyema or of reaching one of the surface pockets of purulent material an exploratory puncture was made in the ninth interspace, in the posterior axillary line. After penetrating a dense wall for about three-quarters of an inch some clear serum fol