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out removing the bronchoscope, the child's head was immediately lowered to facilitate the escape of the fluid. Breathing was greatly improved, and, as careful examination failed to show any more foreign material, the child was returned to bed in good condition.

Examination of the foreign body showed it to be a piece of so-called wiener wurst of which the little chap was very fond. A passing neighbor had given it to him without his parent's knowledge and in his eagerness, part of it had gone the wrong way. The patient had a good night, temperature 100, pulse 130, respiration 22, at 8 a. m. There was a slight rise of temperature in the afternoon, and in the evening it suddenly went to 104.6, respiration 56, pulse not countable with the usual physical signs of pneumonia, due apparently, in spite of our precautions, to a general aspiration of the broth like fluid into the deeper structures of the lungs. Dr. W. O. Bridges kindly took charge of the medical phase of the case and through his skilful treatment the child made an excellent recovery. Several times during the course of the pneumonia the child was seized with violent attacks of spasmodic coughing lasting for half an hour or more, accompanied with alarming disponea and cyanosis, evidently secondary to the bronchial irritation. These alarming symptoms subsided with the improvement in the pneumonia and the child has had no further trouble.

Case 2. Patient, a child of 2 years, had been referred to Dr. J. P. Lord of Omaha, with history of having choked while eating a piece of chicken. Dr. Lord sent the patient to the Clarkson Hospital and asked me to do a bronchoscopy. The child was undersized, poorly nourished, very nervous and had a wheezy, choking respiration; Ether was given and the bronchoscope passed not without some difficulity-larnyx, trachea and bifurcation normal. Right bronchus normal- left bronchus free to itsbifurcation, one branch of which was apparently blocked by a whitish mass. This was removed and was evidently a piece of some kind of mascerated animal substance and the patient returned to bed and special precautions taken to avoid lung complications.

The subsequent history was most surprising. The father a densely ignorant foreigner, had attempted to stop us in the midst of the operation, insisting that the child was going to die anyhow. Shortly after returning to my office the nurse called up to tell me that the father insisted on taking the child to his home out in the state, as he had to thrash next day and couldn't "waste any more time in Omaha." Arguments were fruitless. He fin

ally consentinng however, to take a nurse who was sent back the next day. I could not get in touch with the case but heard indirectly several months later that the child was living but could get nothing definite as to its condition. Nature surely is kind.

I am sure we all appreciate that through the introduction of bronchoscopy the mortality following foreign substances in the deeper air passages has been greatly reduced. (From between 50 and 75% to less than 10%) That the exact location of such foreign body can be determined in almost every instance. That early diagnosis and prompt operative measures are of vital importance both for surgeon and patient, and that careful postoperative watchfulness should be observed even in the appar ently simple cases.

DISCUSSION.

Dr. H. B. Lemere, Omaha:

We have just heard two papers that I think are of supreme interest, papers that bring you up to date with the modern methods of attacking these troubles that exist in the upper air passages and in the oesophagus, and I think that these papers are of such importance that a discussion should be carried on to the best advantage and under the best circumstances, and for that reason I take the liberty to suggest that the papers be discussed at the present time when those are here, who have heard the papers, and when their contents are vividly before the society.

I had the pleasure when returning from the east, where I had been in attendance on the American Medical Association, to visit Dr. Jackson of Pittsburgh. He has a very large practice along the lines of direct laryngoscopy and bronchoscopy and the results he has obtained are wonderful. These results, however, are in the possession now of laryngologists all through the country in the large centers, and this fact enables the patient, at the present time, to get much more prompt treatment and relief than formerly. I also heard Dr. Jackson at the American Medical Association report several cases of foreign bodies in the trachea and bronchial tubes, which had caused considerable trouble when they fell into the hands of the laryngologists. He reported that these cases had been cleared up, and the patients returned to their homes.

The doctor has mentioned several points of extreme practical importance in regard to foreign bodies in the nose, and also in regard to sandburs in the larynx. I think his objections to forceps are well taken where the long jawed forceps are in question, but if you have a short jawed instrument I think the objections are removed.

Correspondence Schools for Nurses

The Journal of the A. M. A. for May 31, has an editorial which closes as follows: "It is the duty of physicians to discourage those who contemplate taking a correspondence course in nursing. In the end women so taught will be a disappointment to themselves, an irritation to physicians and a danger to the public."

Celiotomy in a Child Three Hours Old.

In the American Journal of Surgery for March, 1913, is an article by Q. W........ of Louisville on Celiotomy in infancy and childhood. The youngest child operated on as reported by the writer is a babe of one day operated on for hemorrhage of the umbilical artery. The operation was done without an anesthetic and was successful. The exceeding rarity of such operations leads us to report the following case. The child was born at 6 a. m. after a rather protracted but normal labor, attended by Dr. Brooks. At the birth it was observed that a tumor about two and one-half inches by a possible three inches was present at the umbilicus of the baby. Closer observation disclosed that this consisted of a portion of the intestines protruding through the umbilicus and covered with the peritoneum only. At the upper part of this tumor and connected with it was a sausage like tumor the size of the adult thumb, and four or five inches long. At 9 o'clock a. m., or when the child was three hours old, it was prepared for operation. No anesthetic was given. The peritoneum covering the intestines was slit up when it was readily seen that the sausage like tumor was the transverse colon and the small intestines were crowded into it (invagination). To all appearances the transverse colon had been forced through the umbilical opening and was adherent at this point. As the pressure from within continued the small intestines were forced up against the other gut and finally made way through. As the coil of intestines was drawn out a hole that would admit the end of the thumb was apparent in the colon.

This opening in the large bowel was closed with catgut. The child had cried but very little up to this time, but sufficient straining had occurred to force about half the intestines outside the body. In order to return these the abdomen was opened three or more inches and to successfully close the rupture through the umbilicus the latter was removed. The opening in the abdomen was closed with through and through silk worm gut sutures. The child had a stormy time for a day or two, but thought better of the world and concluded to live. At the present time it seems in a normal condition, the bowels functionating properly.

We believe this the youngest infant (three hours) upon which a successful celiotomy has been done. As this operation included the reduction of an invaginated bowel and a suturing

of the intestine as well we think it worthy of being recorded. It might be interesting to state in connection with the possible cause, that the mother was laced down to the very lowest notch up to the very time of delivery. The child was near maturity if not quite to the 280th day.

A. B. ANDERSON AND EARL B. BROOKS,
Pawnee City, Neb.

Typhus

J. F. Anderson, Washington, D. C., (Journal A. M. A., June 14), gives a review of the history and literature of the so-called Brill's disease and its identification with thyphus fever. This shows that the assertion made by Anderson and Goldberger early in 1912, that typhus is actually present at all times in certain large cities of the United States, has been verified and that the disease is even more wide-spread. Taking the ratio given by Roger Lee that one in forty-seven cases of continued fever lasting over seven days in the Massachusetts General hospital was typhus as applying also to other large cities of the country, Anderson gives the probable number of cases occurring in New York, Baltimore, Chicago, Philadelphia and Washington and supports these estimates by certain hospital figures in these cities. It is probable that there have been as many unrecognized cases as cases diagnosed and that the disease is even more widespread than the figures would indicate. While the disease as generally observed has had a low case mortality and no great tendency to spread, there is a possibility of its becoming virulent and epidemic, which must be considered. Guinea-pigs are quite susceptible to typhus when inoculated intraperitoneally with blood of patients in the active febrile stage and he suggests as a means of collecting more accurate data the use of such inoculations from blood of patients with continued fever giving a negative Widal and blood-culture; especially in cases of sudden onset, atypical eruption, intense headache, apathy and prostration. He believes that such methods would prove, if carried out, that typhus is more prevalent in our large cities than has heretofore been generally believed.

Medical Men and Morals.

G. Pernet points out that it is not the doctor's duty to investigate reputations; he has to investigate and treat disease. In a recent case the Lord Chief Justice pointed out that a court of law was not a court of morals. Clergymen and priests seem to be ambitious to treat disease, but that, of course, is not their function-ne sutor. It is well to understand that syphilis is no more sinful than measles, typhoid fever, or small-pox, and to remember that it is of vital importance to the community that syphilis should be treated quickly and adquately.-Clinical Journal. London.

Simple Means for Enlarging a Contracted Pelvis.

Freudenthal describes a measure with which he found that the pelvis opened enough to permit the birth of a living child when preceding pregnancies had always required the sacrifice of the child. A cushion was placed under the patients sacrum and the knees were drawn up to the middle of the abdomen during each labor pain. As the patient was unable to do this herself it was done by the attendants, one on each side, each forcibly pressing the patient's knee against the center of the abdomen, the legs turned outward. By this passive fixation of the femurs the gluteal and other muscles attached to the trochanters pulled the ilium outward on each side. This apparently streched the ligaments of the sacroiliac articulation, the promontory sank backward and the whole pelvis became enlarged.-Berl. Klin. Woch.

Potassium Permanganate

In a preliminary communication (Journal A. M. A., July 19), W. M. Barton, Washington D. C., reports his discovery of the anesthetic effects of potassium permanagate on the genitourinary mucosa. He had observed that in irrigating subacute and gonorrheal urethritis that the primary sensitiveness following injection soon disappeared after the use of permanagate irrigation, and he therefore tried this treatment to reduce the sensitiveness prior to the passage of sounds in a case of stricture. This experiment showed that anesthesia of the mucous membrane of the urethra could be completely and satisfactorily

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