Document B8QgK88rzQKMbaJErVkv9Lk0m

T2Z UJfCKT,] MU. N. HHrttON : tOOINS POW0UU LK CUUONIC OTOU&HCKA. [urt. 10. 1931 G31 intect tympmic membrme but with hitula into the by migration inward* of the periphery of the perfora meitoid proceee, on the poeterior or isperior well of tion. to that the letter eeeumee e central poeition. the oeeeout meetu*. A mettoid operetion will be where it may remain patent or may completely close neoeiaery ior thit clew. oeer. wtinnyT or THE MaJtOIHaL rXBTOKaTIOK. The tympanic membrane has a perforation, which extends to and involves the annulus tympanicus and is associated with granulations, which are sasaile, pedunculated, or may be simulated by pouting mucous membrane. The posterior superior quadrant is the-eommon site. After thorough eleansing of the meatus, it is often possible to aspirate secretions from the attic. The meatus is thoroughly cleansed by syringing and mopping. All adherent sloughs are I have also found the powder cure cases where there has been e oantral perforation, but not with the dramatio effect of sine ionisation. Cases of oentrnl perforation with granulations on the periphery of the perforation are cured by the powder. If there is any aotive discharge the powder never cakes or obstructs. It acts as a sponge, absorbing secretions. It only remains in situ if the discharge has oaased. urusuriaTivx csex kxfobts. removed and the pent-up secretion aspirated with the Single speculum. Any large granulation is removed after the application of cocaine and adrenalin. The meatus is filled with absolute alcohol for ten minutes and then thoroughly dried by mopping. A 1 per eent. iodine in boric acid powder is insufflated into the meatus, filling it completely. The patient is instructed not to touch the ear, except to mop out any discharge with a ootton-wool applicator. He is seen at intervals of four days at first, but later at intervals of seven days, when the ear is again insufflated with the iodine powder without any further preliminary treatment with aloohol. This is repeated until the ear heals-- usually within two months. The treatment is painless and the iodine does not produce any effect on the skin of the meatus. If the powder is still to be seen at the weekly visit, the discharge has diminished to a minimum or has ceased completely. To obtain a view of the tympanic membrane it will then be necessary to remove the powder by syringing. If the lesion is present (in the Ossa 1.--A boy, afed 7, bad bed right sad left esr du- ebsege tot two 70s.n, with oeoasionsl blosdmg from tho right tar but no pain. Wbea sms on Nor. iitth, 1930. be bad septic teusua and edsnoids. Tbs right msetus vss full of offiwriv, pus : wbea this was removed s marginal perforation, rituatsd in the upper posterior quadrant of the drum, was aaan. Exaaariv* gtoaulationa aunounded and occluded the pt rforation, which involved the annulus tympanicus. Bs nations oould be aspirated with the ffiegie ipwoluB. The wr vm rise pert ud dried. Absolute Alcohol wee applied for ten minutes ; the exoeee wee mopped away sod the meatus filled with 1 per cent, iodine in bone acid powder. On Dee. let no djsenarge was complained of, And the mmtm wme moist. It was filled again with iodine powdor. On Dee. 8th there wee no rilechery, but there wee no tree* of the powder in the meet ns Silver nitrate wee Applied to the granulations, end iodine powder ini& apphoa. On Dee. 18th the enr wee dry end iodine powder vm reapplied. On Jen. 18th. 1831, the enr wee dry. end on Jen. 83th the perforation was healed, end the child heard normally. He bed Also bed pus In tbe left meatni, the condition bein? the eeme ee in the right eer. with Attic granulations. Tho treatment was identical with thet of the right eer. And within the mme period the discharge had dried up ooapietely and the perforation had healed. early stages it is often present but quiescent, present ing a pale picture, compared with its congested red appearance at the commencement of treatment) the powder ie again insufflated. If there is any doubt whether there is any discharge or not, the powder test should be applied. This oonsista of in.nfH.ting boric powder and seeing the ear next week. The preeenoe of the powder, undisturbed and enow-white, is proof positive of the absence of any discharge in No treatment is oamed out in the interval between the attendances, but the frequency of insufflations must depend on the rapidity with which the discharge appear*. Oan 8.--A. girl, egod 9, had had purulent, offensive discharge from tho right oar, but no pain, tor 12 moatii*. She had bad her tonsils Mid adenoids removed sis month* previously. When seen on Nov. 4th, 1030, she had a marginal perforation occupying the poetero-eupenor quadrant of the tympanic membrane and annulus. surrounded by exuberant granulations, from which, after the ear bad been thoroughly cleaned, offensive secretions, the interim. Effect* of tin Iodim Powder.--The profuse discharge rapidly abates, often after the first application, tho ear remaining free from any overt discharge. Thus, as far as the patient it concerned, a " cure " of the otorrhma has been wrought. He is freed from indistinguishable from choleeteatomatous debris, could be aspirated with the use of the Biegle speculum. Absolute alcohol was applied for ten ; the meatus was dried and filled with iodine powder. On Nov. 11th there waa marked improvvaant: the pus was not so profuse m amount and not oitoneivo. Tito muatue was again filled with iodino powder. On Nov. litii there was no discharge, and the meefnt was moist. Iodine powder was reapplied then, a troublesome discharge and is rid of tho ritual of a daily aural toilet. Though at this stage otoscopy would reveal the abeenoe of any powder and the focus is still active, tho patient ie delighted with the results. Parents are pleased that no active treat ment ie -required from them at home. The tester and again on Dec. 8ad and 9th. On Jan. 27th, 1031, tbe ear was dry, a dry perforation ramalning. Oan 3.--A girl, aged 11. had had purulent discharge from both ease continuously for seven years. Tbsre was no pain. She had been attending the out-patient department of a teaching hospital for months, but bad novor had tonsils or adenoids removed. When seen on May 9th. 1930, both of the discharge will disappear, and within a week or two the otorThcee beoomes inodorous, gradually muoo-purulant, mucoid, and. in suoosesful esses, finally eaaees completely. The sessile granulations shrink up, ee does the oedematous prolapsed mucous membrane pouting down from the attic region and from the periphery of the perforation. A rapid spitheliaation oeeun, and within a few weeki will be complete. I have repeatedly observed a curs of the etenhoa in oases with a marginal perforation with granulations, llany of these esses had failed to react to all other forms of active treatment end it appeared that only operation was left, yet the iodine powder cleared up the condition. It is interesting that these eases heal care had the meatus full of offensive pus. This was cleaned. Adherent offensive slough ooeupiod the depth of tho moatus. deep to which the entire mssfns was oocupied by a perfora tion which extended to tbe annulus tympanicus in all visiblo dirootions. Granulations muted from tbs margins, and pus oould bo aspirated from tho attic. For the three subsequent months she was trested with repeated sine ionisations with little effect, tbs Trwsf'ir being found to have a purulent slough in-lte depth each week. It was derided to adviee operation. When tte iodine powder treatment name under my notice this case was one of the earliest put on it. In the meanwhile the tonrils and adenoids were removed. On Sept, 18th the condition of both eats was tbe same as in May. Alcohol was applied for ten minutes, followed, after drying, by the iodine powder. This was repeated each ereek to both ears for six weeks, at the end of which period both ears were completely free from discharge. Thi patient was seen again in December. 1930, when the ease were dry and there wac a complete rmHbUic ed iategyam of both tympanic membranes. The mother commented on DUP 1141936 *iafe3ag- . Cv\ 32 m iahowt,] CLTNICSL AXD XABOBAVOBY KOTXS. W . IS, 1931 Um tact that this wee the lint time lor seven Teen thet the ' powder wee i nan (Tinted et weekly intervals, end within e een hed oeeeed tram driahargtng. Six months later the month the eer nee led to dleehene. end the petieat wee very ear wen etill dry. [ Impremefi The eer dried up completely. Ossa 4.--A women, seed 38, hed hed discherte tram the latt oer for many Teen, noomsitatiag e daily eurel toilot I have treated over 500 ooeee with Terr gratifying to keep the eer eleen end tree tram odour. There tree no reeuits. The vast me iority of theae oaaee were between pain. A perforation wee observed through Shrapnel's the agee of 5 and IS. Unfortunately, it it not pouible membrane, merked by the ueuel sontinol granulations end extending on to the roof of the osseous mc-'iu It wes ooeerad by e yellow edherent slouch, end e bent probe to foretell which cases will respond to the iodine powder treatment or which will prove a failure. dotoctod booo. Tins granulations onuid bo sucked out of tho Many oases respond, much to tho observer's surprise ; perforation. Alcohol wee eppUed, followed by iodine while other*, in whioh a good result should ensue, powder, end the treetment wee repented on Sept. 37th. One weok Inter tho eer hed not rue in tho interne}, though fall. But the treatment it well worth a trial before then wee no trace of eny powder left In the meetus. The i reoourse to the radical operation. / CLINICAL AND LABORATORY NOTES CASE OF right axilla friction was heard. A taniatlva diagnosis of pulmonary tubarculaaia was mads, with possible new-growin fji/nu ASBESTOS-LIKE BODIES lotos or a coal-kxxxb who had wosxxd nr asbxstm, xitxi euparvantng. In tha next 48 hour* a peaittve sputum test was obtained. A blood Waaaarmasn taken about this time was negative. The Widal naction we* positive to Bacillus typhosus 1 In 100. Badiographic examination of the cheat reported : " A* rBr Fhahx E. Ttlxcoti, M.D., F.B.CJ*. Lohd., tha patient waa unable to ait up satisfactory examination was impossible. Tha (Urn taken shows displacement of the D.P.H., nonBHon or ranuune keoicinz in tsk UHtmaMm or Mjjvcauurrxft; bonojusy niYuioixn, uAvammmM BOYiX ZXrULMAJlY; JjiH heart and mediastinum towards the right aids. There is a large irregular opacity in the right lower chaat. with mottling in tha upper and middle lobes. There is some mottling also visible in the left middle and lower lobes. Tbs appearances era not typical of tuberculosis, t neoplasm" Tbs urine contained a trace of albumin. The pulee-rato John Shaw Dunn, HJO.Glaso., moons moraatoa or f*tuoloot sxd noun sxatokt ix m mnvusrrv; smnos bohobasy rsnoioooT, nasnwiaa norsL mrauttxr. at first eras 90-100, but later rasa to 110-190. The range of temperature was morning, 98'; avsning. 99*-100*. He gradually got weaker, and died on April 14th- Thai autopsy waa bald on the 15th. A synopsis of the post-mortem findings follows, with a description of the histology and aome notes Ik March of this year a man, aged 71 yean, was on these findings by one of us <J. S. D.). seen in oonaultation with a doctor ten miles from Manchester, and was later admitted to the Manchester AirOXT OF AUTOFST. Boyal Infirmary under the care of one of us (F. E. T.). The doctor who had attended him reported that he had had several attacks of hemoptysis in the pre ceding month, but as several rocont sputum tests had -had negative results the case had not been accepted Lymph glands ; Thoracic and abdominal glands along spinal oolumn are heavily anthraooaad. Pericardium : About 100 c.cm. excess fluid. Heart (400 g.): Enlarged ', myocardium, hypertrophy, Fw. 1. by the local tuberculosis authorities. The man himself said he was a coal-miner, end had -as a young man worked in Alabama in mines. On -consulting books of reference it was found that no -asbestos is found in Alabama, which is noted for ooal And iron, " Alahams iron " being famous all the world over. In 1923 it is stated that 80 per cent, of the asbestos produced came from that part of Quebec which is south of the St. Lawrence. Alabama and Lancashire mines were the only minee ho had ever worked in. These points later became of interest and importance owing to the curious findings at the post-mortem and in the histological examina tions of portions of tissue removed thereat, and later examined by one of us (J. 8. D.). On aawnssnartea oa silmiaairiii to tha hospital tbs man was vary thin. obvtnosly much antedated. and vary weak. There was a biatory oi typhoid lovar in Daoornbar, lulu, and at operation (or a strangulated inguinal hornia in Daoneabar, 1990, sinoa which time bit baalth had novor iuily recovered. On Fab. 19th, 1931, ha had his Qrat baamoptyaia, spitting up "about lour pints" of blood, whilt a (aw hour* later a ascend lunmoptvaia occurred. A -oougb had baen eoaatanl anea than, whilst tha sputum ramainod blood-tinged and night swaate occurred. A waek holora ailmkwion a rigor oecurrad, and dalirium (ollowad. And penuried up to tha liras oi adinnanun. Examination of tha chaat showed nothing abnormal on tha iaft aids bayond tha praaanra o( a law rides and rfaonehi ovar the lower part of tha left lung behind. On tits right was ansal vo duloww, more below. Wall below tbs npex at tbs back and to tho outer aido were signs of oavita- lion. Thu arna ol dulmwa aurrauntiinK the ervn of cavitation igavu no ovideuoo at softening to auscultation, but thorn eras rather an ahaaana of breath sounds- how down in Use Aeboetoe-Hko iiodks in Uw Inner, allowing forms, with rounded sad*, la Fig. 3 the aantral ooro oan Uv clearly distinguished. ( x 400.) more markad right shin , tricui. V, throe Ungers ; mitral V, two fingara ; aorta, early atheroma. Bight and left plonnh: Bach 300 e-ern.. strawcoloured ilnid. ltiglit lung (WKl g.) i Whole of lowur and lowor iiaif of upper ioix* era firm, almoet black witli wlnto Ad at apex of lower lobe a aavity oonteuung DUP 1 141937 ffimmrnwemmm&mmmmmtowmmmMmis*: it***1- ; r .OIXIOAI. ARD LABOSATOBT Rons. 19. 1931 633 land STtdstto* a! tubsrcW. Lmtt lung (1S80 g.l: kdi degree of softness. u though Mm* invasion wot present. Both limp heavily Lott consolidated only in iu lower lob*. COKKXXT. The main point of interest in the case is the occurrence in the lungs of bodies which somewhat No ytmorroalitise evident in sir pews*s. General appear- resemble those that hare been described in the lungs inte suggest s chrome fibroid tubercle, poeeibly associated ylth a neoplasm. fttomaeh : Nil. Smell intestine : Some smell tuberculous Fio. 3. ulcers in lower ileum. Large intestine : Tuberculous uloum- tion of encum. lurcr <11V,0 c :: Kodsrate passive rongsstion. Pancreas : Nil. Spleen (340 g.): Kalersnd end moderately firm. Hyper- i pleeie end congestion. Thyroid: Nil. Adrenals: NIL RightHbdnsv (180 g.l: Congested. Lett kidney (100 g.): Congested, urinary bledder : diTertieule present. Genital glands ; Kiddle lobe ol prostate quite epprociebly enlarged. Awafeeriral dtegneetsChronic fibroid tuberculosis of lunge. Pulmonery esbsstosis. HISTOLOGICAL XXAKIXATION. The extensive eooeolidation of the' lower lobes of both hinge wes found to be dne to cssesting tuber culosis with very diffuse distribution ; it appeared to represent s rapid ljmphstic spresd, end in largo srees it completely obscured the lung-structure. Tubercle bacilli were present in moderate numbers. Fio. 2. of asbestos worker*. They simulate these in size and general shape, especially in the rounded swellings at the ends ; in colour; and in their abundant content of free iron. They differ from the familiar asbestos bodies in being usually coarser and less regular, in possessing a black core of opaque material, and in the absence of any appearance of segmentation. It is presumed that they are minute fragments of some other iron-oontaining mineral, which have been inhaled into the lungs and undergone some chemical change under the influenoe of the tissue fluids resulting in the formation of a peripheral lamina from the iron-containing part. They do not appear to have caused a very serious fibrous reaction in the lungs in this esse. GALLOP RHYTHM: There wss fairly marked anthraooeis, the pigment in fine granules, being mostly aggregated in the ns ouvical sioxincaRCx m cxbtaih cascsBT C. Bt.iti.iwti LxVICX, M.B. STSNET, peribronchial connective tissue. V.R.C.P. Lom>., The upper parts of the upper lobes were almost ssssrsxt frisk-ax airs raTOoiax-nr-ousoi or osiuuo- free from tuberculous, and so it was possible to reoognise a moderate patchy overgrowth of fibrous anno DsraBTMSXT, st. aaoBows osrtai. : vktsicun tv oOTwanmra, vioioaia aamu. row asmsaxM. i tissue in these areas. This was mature in type, but not very dense, and did not form laminated nodules. Gaixof rhythm has long been known to be a Hare and there in the fibrous tissue were scattered serious eardiao sign. The name is best reserved for soma minute brownish bodies singly or in groups of the true gallop rhythm where the first bean sound fivo to ton (Figs. 1 and 2). Tlioy were mostly elondor is reduplicated (uu-): for, in agroomont with rods with bulging ends, and they measured from Gse's teaching, a doubling of the seoond sound (--uu > SO to 70 microns in length by 2 to 6 microns in is properly termed canter rhythm. It is important thickness. On high-power examination, it oould he to differentiate between the two, for canter rhythm seen that most of these bodies had a black opaque is heard in many conditions none of which is att central oore, while the brown w,twHi (ormed an serious ss those which yield gallop rhythm. Theseouter lamina and was seim-transparent (Fig. 3). two rhythms are easily eoniused. for evon it. There was no appearance of the regular segmentation slight degree of tachycardia may appear to accentuate which commonly occur* in asbestos bodies. On the middle eomponent of the three (u--u); and treatment with potassium ferrocysnide and hydro during the varying phn*n of respiration this accentua chloric acid, the brown material took on an intense tion will ssem to move sometimes to the third, blue colour, evidencing an abundant content of eomponent (uu--), sometimes to the first (--uu). tree iron. The bodies were subsequently reoog- It is hen desired to draw attention to a special ttised in all pans of the lungs, though nowhere variety of gallop rhythm, and to emphasise tho numerous. importance of its reoognition. For aooording to tha DUP 1141938 634 CLDCICAL AXD MMmnw inn, [OR. 18, 1931 age nt which it appears it may be the only sign which peri passu the gallop rhythm became less dear. either allows for the provision oi adequate treat* Consequently, for purposes of confirmation it is meet or lead* to a oorrect diagnosis and a more dear neoessary to take an electrocardiogram on the same prognosis. Thi* special vansty it a reduplication day ou which the gallop rhythm is dearly heard. of the firet sound, dearly heard, over a email area Figs. 1 and 2 are electrocardiograms from s typical close to the left border of the sternum at the second ease. intercostal space or third cartilage. In many ease* Can I.--Girl, e(*d 1G, **ec ic out-patwm dime at it will be heard at all the auscultatory areas ; but St. Georgs'* Hospital, on Jam 80th, IMS, complaining if it is not audible at this localised spot, it is unlikely of mild rhaumatic pain* in l*c* and arm* ; bssdaclws , to be beard elsewhere. There are, of ooune, many oases where gallop rhythm is heard at the mitral area, easily fatigued. No DTssthlesSQns* or cyanosis. No history ot sesrlat tsvsr or definite rhsumstie nw. On **..,tion, tachycardia, lid, panristint with r**t and not due yet not at the base; these belong to a different category. to aarvousaam. Taapsretur* normal. Hart normal in da*, regular rhythm-: sound* normal except (or reduplica ACUTX^xsxmcaTUX. tion ot ths first sound at th* second late interspace naar the The significance in acute rheumatism varies with stsraam; an murmurs. OUnioal disgnnsu : First dsgra* A-V block, probably rheumatic. Oonflrmad by slsetro- the age of the patient. In children and young oardiogram (Fig. 1). on earn* day. Admitted to hospital person* it is almost always associated with delayed conduction from auricle to ventricle, the electro* for rsst In bad, no apodal trsstmsnf Hsarp-rat# gradually slowed, gallop rhythm bream* Ism clsar. On day after admission, airopin* sniphate gr. 1/26, subcutaneously, i cardiogram showing a lengthened P-K intarral. produesd bo efiset ou th* P-B Interval. Fsb. 12th; These two faaturse, gallop rhythm and long P-B OUnioslly normal, no gallop rhythm. Bsetrocaidiogram interval, are frequently the earliest svidanos of normal (Fig. 2). November, 1980: Signs ot ssriy mitral sUnosb Blwti nnsfilliigiam i P-B normal. rheumatic carditis. Tachycardia, about 120 per Effective treatment was denied to another girl minute, is usually present, while the temperature may in the first instanoe, owing to ths true nature of her not be raised above 99* T. The diaoovary oails for trouble being unrecognised. Now after several yuan' immediate rest in bed; the earlier this is obtained, observation, gallop rhythm is still in svidenoe and the the more quickly dots the P-B interval oloae. P-B intarral remains abnormally long. Administration of full doaee of salicylate* in addition Qjja I.--4Hrl* 10, mum to oat-potent clinic at appears to hasten the closure. If treatment is delayed Vlotoxi* BoopiUl on Msy Otb, 1917, oownUining of w| or imperfectly earned out, the P-B interval may -*--s- with loss of oonsdousassi for *-e ssooaris Hoar1st yjffiiin jrtrminflntily ]oojgtst flllrm nfthlB will thtt Mfilt. Mid this tsvsr at sga of T, No rhuumsHo history. Oa axaaunatioa pula* 120, psrsistsat, legular. Tssnpscaturv normal. Haart normal in Waa. Apical tat sound loud and slappiag. It is probable that th* lengthened P-B interval Whmt ----ladaaluetad at auhaonary arts Blsctro* is doe to an infiltration of the auricolo-ventrioular junction rather than to vagal effect, for atropine cardiogram eooSrmad ritniral diagnosis of first dagres ilwiiiinfli A-V bioek. P-B -- 0*2S asooad tor rata -- 126 nr miaots. Tbs pareats rstosii admission to th* Victoria produces no alteration szoept in occasional cases. Hospital and sought advio* at anothsr hospital, whara However, th* sAact of atropine on th* P-B intarral apparsally tha nature of bar troubls was mot moogaissd, is a complex one, and as yst imperfectly understood. Bound-photographs seam to show that ths earlier of and ao rsst was ordsrsd. April. 1928: BsTuruad to Victoria Hospital, still suffering bom fainting atterks Gallop rhythm still prsssot. the two abort components is produced as a result Kiactrocardiogram i P-B -- 0*2* asooad tor rata -- 110 of auricular contraction ooeamng outside its usual taming in tbs cardiac eyele. No suhsagoant trsstmsat. howsvar. ba* baaa sffsetlvo. and tbs -tii**al stats aad tha sBctroeardtogram ramaia pracuc- Eighteen eases of this nature have rsoantly bean ally snnhsnfirl at th* pcessat tims observed in patients under the age of U years. In each case a bngthaned P-B interval was BUX9LB*BBAVCB BLOCK. confidently predicted prior to electrocardiogram. In adults of middle age and older this form of Confirmation was dearly obtained in 17 ease*; the gallop rhythm usually indicates a block in one branch eighteenth proved within normal limits. 'With oarly of tho bundle of His. It is moro oloarly heard when treatment, aerial electrocardiogram* on suoeesaive the right branch (old nomenclature) is affected. days revealed a rapid closure of the P-B interval; Pig. I is the electrocardiogram from a ease of this DUP 1141939