Document V3j8ampwdEJ2abmrwp9GV84Q8

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 inwards 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 a oantral perforation, but not with the dramatio effect of sine ioniistion. Cases of oontral 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, abeorbing secretions. It only remains in situ if the discharge has oeased. UFBxsnriaTivx cess kxfobts. removed and the pent-up secretion aspirated with the Ossa 1.--A boy, aged 7, bad bed right sad left ear dis Single speculum. Any large granulation is removed charge tot two rears, with oeoasioul bloedicg from tho after the application of cocaine and adrenalin. The right ear but no pain. When seen on Nor. iitth, 1930. he bed septic tonsils and adenoids. The right meatus wee meatus is filled with absolute alcohol for ten minutes full of offensive pus : when this was removed e marginal and then thoroughly dried by mopping. A 1 per eent. perforation, situated in the upper poeterior quadrant of the iodine in boric acid powder is insufflated into the meatus, filling it completely. The patient is instructed drum, was seen- Exasariv* granulations surrounded end occluded the pt iteration, which involved the annulus tympanicus. Bs nations oould bt aspirated with the not to touch the ear, except to mop out any discharge Sitffle ipwoluB. with a ootton-wool applicator. He is seen at intervals of four days at first, but later at intervals of seven The ear vm cleaned and dried. Absolute alcohol vu applied for tea minutes ; the exoaee waa mopped away and the meatus filled with 1 per cent, iodine in bone acid days, when the ear is again insufflated with the iodine powder. On Dee. let no dieeftarg* wee complained of, and the powder without any further preliminary treatment mmtm wna moist. It wae filled again with iodine powdor. with aloohol. This is repeated until the ear heals-- usually within two months. On Dee. 8th there wae no dlechery*, but there was no trace of the powder in the meatus, Silver nitrate wae applied to the granulations, and iodine powder again epplioo. On The treatment is painless and the iodine does not Dee. 18th the ear wae dry and iodine powder wae produce any effect on the skin of the meatus. If the powder is still to be seen at the weekly visit, the reapplied. On Jan. 18th. 1831. the ear wae dry. and on Jan. 83th the perforation was healed, and the child beard normally. discharge has diminished to a minimum or has ceased He bad also had pus In the left meatus, the condition being completely. To obtain a view of the tympanic membrane it will then be necessary to remove the the aame ae in the right ear. with attic granulations. Tho treatment was identical with that of the right ear, and within tbs aame period the discharge bad dried up completely and powder by syringing. If the lesion is present (in the tbs perforation bad heeled. 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 No treatment is earned out in the interval between tbo attendances, but the frequency of insufflations must depend on the rapidity with which the discharge appear*. Oan 8.--A. girl, agod 9, had had purulent, offensive discharge from tho right oar, but no pain, tor 12 montii*. She had bad her tonsils Mid adenoids removed sis month* test should be spplied. This oonsista of inn<Hat.ing previously. When seen on Nov. 4th, 1030, she had a boric powder and seeing the ear next week. The preeenoe of the powder, undisturbed and enow-white, marginal perforation occupying the poetero-eupenor quadrant of the tympanic membrane and annulus. surrounded by exuberant granulations, from which, after is proof positive of the absence of any discharge in the ear bad been thoroughly cleaned, offensive secretions, the interim. indistinguishable from choleeteetomatous debris, could be Effect* of tin Iodim Powder.--The profuse discharge aspirated with the uee of the Biegle speculum. Absolute alcohol was applied for ten ; the meatus was dried rapidly abates, often after the first application, and filled with iodine powder. On Nov. 11th there wae tho ear remaining free from any overt discharge. Thus, as far as the patient it concerned, a " cure " marked inprovvasnt: the pus was not so profuse in amount and not oJTonstvo. Tito muatus was again filled with indino powder. On Nov. lith there was no discharge, and the of the otorrhma has been wrought. He is freed from meeritt was moist. Iodine powder was reapplied then, a troublesome discharge and is rid of tho ritual of a and again on Dec. 8ad and 9th. On Jan. 27th, 1031, the daily aural toilet. Though et this stege otoscopy ear was dry, a dry perforation ramalning. would reveal the abeenoe of any powder and the focus is still active, the patient ie delighted with the results. Parents are pleased that no active treat Oan 3.--A girl, aged 11. had had purulent discharge from both ease continuously for seven years. There was no pain. Bho had been attending the out-patient department of a teaching hospital for menthe, but bad novor had tonsils ment is -required from them at home. The tester or adenoids removed. When seen on May 9th, 1930, both of the discharge will disappear, and within a week or two the otorThcea beoomes inodorous, gradually ear* had the meatus full of offensive pus. This was cleaned. Adherent offensive slough ooeupiod the depth of tho meatus, deep to which the entire meatus was oocupied by a perfora muoo-purulant, mucoid, and. in suooassful eases, tion which extended to the annulus tympanicus in all visiblo finally cesses completely. The sessile granulations directions. Granulations muted from the margins, and shrink up, as does the oedematous prolapsed mucous pus could bo aspirated from tho attic. For the three subsequent months she was treated with repeated suae membrane pouting down from the attic region and ionisations with little effect, tbs Treat"it being found to have from the periphery of the perforation. A rapid a purulent slough in-its depth each week. It was derided spitheliaation oeeun, and within a few weeks will be complete. to advies operation. When tfcw iodine powder treatment name under my notice this eeee was one of the earliest put on it. In the meanwhile the tonrils and adenoids were I have repeatedly observed e cure of the otenhoa removed. On Sept. 18th the condition of both can was the in oases with a marginal perforation with granulations, same as in May. Aioohol was applied for ten minutes, followed, after drying, by the iodine powder. This was llany of these cases had failed to react to all other repsated each week to both ears for six weeks, at the end of forms of active treatment and it appeared that only which period both care were completely free from discharge. operation was left, yet the iodine powder cleared up the eoudition. It is interesting that these cases heal Thi patient wae aeen again in December. 1930, when the ease were dry and there wae a complete rmHbUic ed iategyam of both tympanic membranes. The mother commented on DUP 1141936 Cv\ 32 m ia*o*t,] CLTNICSL AXD LABOBATOBY KOTXS. W . IS. 1931 Um tact that this wee the lint time lor seven Teen thet the ' powder wee inenffleted et weekly intercede, end within e een hed oeeeed tram discharging. Six months latar the month the eer nee led to dleehene. end the patient wee very ear wen etill dry. [ Impremefi The eer dried up completely. Oasb 4.--A women, seed 38, hed hed discherte tram the latt oer for many Teen, noomsitating 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-'ni 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. datoctod bona. Tins granulations onuid bo sucked out of tho Many oases respond, much to tho observer's surprise ; perforation. Alcohol wee eppUed, followed by iodine powder, end the treetment wee repented on Sept. 37th. One weok Inter tho eer hed not rue in tho interne}, though while other*, in whioh a good result should ensue, 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 ASBESTOS-LIKE BODIES fji/nu lotos or a coal-kxxxb who had xitxi wosxxd nr asustos. rBr Fbahk E. Ttucoti, M.D., F.B.CJ*. Lohd., D.P.H., nonBHon or ranuune keoicinz in tsk trxmuiHrr or Mjjvcauurrxft; bonojusy ruYiuot**, maitviimtm BOYiX IXTiMMAXY; JjiH John Shaw Dunn, HJO.Glaso., mocnm noramo* or pstwoloot axo Mosaic axstokt ix - TUX mnvMusurnrwr; isamanomsoxraoln. omeurJatTuttramr.oiDoart, right arUla friction was heard. A tentative diagnosis of pulmonary tuberculosis was mads, with possible new-growth supervening. In tbs next 48 hours a poaittv# sputum test was obtained. A blood Wsessrmane taken about this time was negative. The Widal reaction was positive to Bacillus tfpAonu 1 la 100. Badiograpbic examination of tbs chest reported : " As tbs patient was unable to sit up satisfactory examination was impossible. Ths Aim taken shows displacement of tho heart and mediastinum towards tbs right side. There is a large irregular opacity in tbs right lower chest, with mottling in tbs upper and middle lobes. There is some mottling also visible in tbo left middle and lower lobes. Tbs appsaranoss an not typical of tuberculosis, t neoplasm." Tbs urine contained a trees of albumin. Tbs pulee-rato at first eras 90-100, but later rase to 110-190. The range of temperature was morning, 98'; evening. 99*-100*. He gradually got weaker, and died on April 14th. Tbsi autopsy was bald on tbs 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 ns <J. S. D.). seen in oonaultation with a doctor ten miles from Manchester, and was later admitted to the Manchester BXTOXT OF AUTOFST. Boyal Infirmary under the care of one of us (F. E. T.). Lymph glands ; Thoracic and abdominal glands along The doctor who had attended him reported that he had had several attacks of hemoptysis in the pre spinal oolumn are heavily antbraooaed. Pericardium : About 100 c.cm. excess fluid. Heart (400 g.): Enlarged ; myocardium, hypertrophy, ceding month, but as several rocont sputum tests had -had negative results the case had not been accepted 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 Flo. 1. .consulting books of reference it was found that no Asbestos is found in Alabama, which is noted for ooal And iron, " Alabama 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 mammMiou oa silmiseiriii to tbs hospital tbs man was vary thin, obvioosiy much emaciated. and vary weak. Tbsrs was a blatory oi typhoid lovar in Daoornbar, lulu, aad of oilsration (or a strangulated inguinal bornia in Dsoosabar, 1990, linos which time bis baalth had novor iully recovered. On Feb. 19th, 1931, ha had his Qnt imraoptyais, spitting op "about lour pints" of blood, whiis a (sw hours hirer a ssronri lucmoptvsi* occurred. A -cough had basn eoastant rinse than, whilst tbs sputum rsmainod blood-tinged and night sweets occurred- A wsek bofora adrakwion a rigor occurred, and dalirium (ollowad. Asliostos-Hko luniks in Uw innes. allowing forme, with rounded And punuriod up to tbs liras oi adinheuun. Examination of tbs chast showed nothing abnormal on ths ktt aids aads. In Fig. I tbs eentral ooro oan Uv oiearly distinguished. ( x M0.) bsyond ths prsssnra o( a law rides and rfaonehi ovar the lower part of ths lift lung behind. On tits right was mote marked right sido , tricui. V, three fingers ; mitral V, nasivo dulnan, man ----' below. Well below tbs two Angara ; aorta, early atheroma. Apex at tbs back and to tbo outer sido were signs of osvita- Bight and loft pionno: Bach 300 ocm.. straw- Sion. Thu ama of dulmwn surraundinK tiio arve of cavitation coloured fluid- ltiglit lung (WKl g.) i Whole of lowur and igavo no ovidenoo oi softaainx to auscultation, but thorn luwor iialf of upper ioix* era firm, almost black with white eras ratbar an has one oi hrsatb sounds- boa down in tbs Ad at apex of lower lobs a savity containing DUP 1 141937 .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 COKKXXT. The main point of interest in the case is the Lott consolidated only in iu lower lob*. occurrence in the lungs of bodies which somewhat No ytmorroalitise evident in sir pews*s. General appearinte suggest s chrome fibroid tubercle, poeeibly associated ylth a neoplasm. fttomaeh : Nil. Smell intestine : Some smell tuberculous ulcers in lower ileum. Large intestine : Tuberculous uloum- resemble those that hare been described in the lungs Fio. 3. 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 cascs- BT 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 free from tuberculous, and so it was possible to reoognise a moderate patchy overgrowth of fibrous assnssnroosxOtDTswfraraBinsTmkM-rSaaX,xTv, aiosiritos. aairaaaoTBaOoawomsiauxo-.nsrrro-towaui.sa:osmvi ksoatrsxMico.usinuutov- 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 appear* it may be the only sign which peri passu the gallop rhythm became less dear. either allow* 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 fiwt 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-petwm dime at it will be heard at all the auscultatory areas ; but St. Georgs'* Hospital, on Jam 90th, IMS, complaining if it is not audible at this localised spot, it is unlikely to be beard elsewhere. There are, of ooune, many oases where gallop rhythm is heard at the mitral area, yet not at the base; these belong to a different category. of mild rhaumatic pain* in l*c* and arm* ; headaches , easily fatigued. No BTssthlsssnns* or cyanosis. No history ot sesrlst tsvsr or dafiaiu rhsumstie nw. On **..,- tion, tachycardia, lid, parsisrlng with r**t and not due to asreousaam. Tsapsretur* normal. Hart normal in da*, regular rhythm-: sound* normal except (or reduplica ACUTX^xsxmcaTUX. The significance in acute rheumatism varies with tion ot ths first sound at th* aaoond late interspace naar the stsraam; an murmurs. OUnioal diagnnsu : First degree A-V block, probably rheumatic. Oonflrmad by eleetro- the age of the patient. In children and young oardiogrsm (Fig. 1). on earn* day. Admitted to hospital person* it is almost always associated with dalayad conduction from auricle to ventricle, the electro* for rsst In bad, no apodal tresfmenf Heart*rate 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. These two faaturse, gallop rhythm and long P-B interval, are frequently the earliest svidanos of rheumatic carditis. Tachycardia, about 120 per minute, is usually present, while the temperature may not be raised above 99* T. The diaoovary oails for immediate rest in bed; the earlier this is obtained, the more quickly dots the P-B interval oloae. Administration of full dose* of salicylate* in addition appears to hasten the closure. If treatment is delayed produced no efiset on th* P-B Interval. Feb. 12th; OUnioslly normal, no gallop rhythm. Bsetroosidiogram normal (Fig. 2). November, 1980: Signs ot ssriy mitral sUnosls Elwfi nnsrilliigism i P-B normal. Effective treatment was denied to another girl in the first instanoe, owing to the true nature of her trouble being unrecognised. Now after several yuan' observation, gallop rhythm is still in evidenoe and the P-B intarral remains abnormally long. Qjja I.--4Hrl* 10, mum to oat-potent clinic at Vlotoxi* BoopiUl on Msy Otb, 1917, oownUining of w| or imperfectly earned out, the P-B interval may yjffiiin jrtrminflntily ]oojgtst Mid this flllrm nfthlB will thtt Mfilt. It is probable that th* lengthened P-B interval is doe to an infiltration of the suricolo-vsntrioular junction rather than to vagal effect, for atropine produced no alteration szoept in occasional cases. with loss of oonsrioosnsss for 2-4 tsooaris Sesrlst favsr at age of T, No rhnumsHc history. Oa axaaunatioa pulse 120, persistent, regular. Tssnpscature aonnaL Heart aoemai in risa. Apical first sound loud and slappiag. ytist --loduefuetad at buhaonary arts Blactro* oardiogram soaSmesd clinical diagnosis of first degree ilwimufli A-V bioek. P-B -- 0*2S esoood tor rate -- 126 per miaut*. Tbs parents refused sdmisaioa to th* Victoria Hospital and sought advios at another hospital, where However, th* sAact of atropine on th* P-B intarral is a complex one, and as yet imperfectly understood. Bound-photographs seam to show that ths earlier of the two abort components is produced as a result apparently th* aatar* of her trouble was aot recognised, sad ao rest was ordered. April. 1928: Belttrued to Victoria Hospital, still suffering trom fainting attarks Gallop rhythm still present. BsctxncarriIngram i P-B -- 0*2s ssoond tor rut* -- 110 of auricular contraction ooeamng outside its usual taming in tba cardiac eyele. No safasaqoant treatment.bowsvsr.ba* been effective, and the -nt*al state and the sBctroeariUogrsm remain practic Eighteen eases of this nature hsv* recently bean ally snnhenfsrl at th* present time observed in patients under the aga of U yuan. In each case a bngthaned P-B interval was BUX9LB*BBAVCB BLOCK. confidently predicted prior to electrocardiogram. In adults of middle ago and older this form of Confirmation was dearly obtained in 17 eases; 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 hoard 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