Shout Outs

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Robin, Survive the Journey, is this week's host of Grand Rounds. Her theme is “Participatory Medicine”. You can read this week’s edition here.

When I chose the theme for this week's Grand Rounds, I chose it because it is near and dear to my heart. Before I knew what it was called, I was looking for a "participatory medicine" model. Long before I heard the term "ePatient", I was one.

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Geripal is the host of the  October's edition of Palliative Care Grand Rounds, the monthly best of the Palliative Care blogs.

Welcome to Palliative Care Grand Rounds! This monthly blog carnival highlights some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. As this month's host of Palliative Care Grand Rounds, we will give our own "GeriPal spin," incorporating posts that feature the intersection between geriatrics and palliative care. Topics are sorted by heading. Thanks to our readers for suggesting posts. Have fun reading!

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Congratulations to pediatric surgeon Dr Chris Coppola, Made a Difference, who made the following announcement this past week (photo credit):

I got some very exciting news this week; our book is now available for pre-order on Amazon!

I anticipate it will be released 1 NOV, and after that it should also be available at our publisher, NTI Upstream.

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There is a very nice article on proper care of surgical instruments in the “throw-away” publication Surgical Products, September 2009 issue, p 8-10: “In For the Long Haul by Derek Lashua.” This is just an example of the information in the article:

This trouble-shooting guide below will help determine the cause(s) of instrument staining problems.

• Brown/Orange Stains: Most brown/orange stains are not rust. This stain color is the result of high use of chlorhexidine, improper soaps and detergents, baked-on blood or soaking in saline.
• Dark Brown/Black Stains: Low pH (less than 6) acid stain. May be caused by improper detergents and soaps and /or dried on blood.
• Bluish-Black Stains: Reverse plating may occur when two different types of metals are ultrasonically processed together. For example, stainless steel instruments processed with chrome instruments may cause a stain color reaction. Exposure to saline, blood or potassium chloride can also cause this bluish-black stain to occur.
• Multi-Color Stains: Excessive heat caused by a localized “hot spot” in the autoclave.
• Light and Dark Spots: Water spots from allowing instruments to air-dry. With slow evaporation, minerals from water are left on the instrument’s surface.
• Black Stains: Possible exposure to ammonia.

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I very much enjoyed this inspirational article by Matt Damon in this past Sunday’s Parade Magazine:  “We Can Move Mountains” (photo credit)

When I was a boy, my mom had a magnet on the refrigerator with a little picture of Gandhi along with a quote from him. It said: “No matter how insignificant what you do may seem, it is important that you do it.” As a child, I was raised to believe that, and to this day I do my best to live it.

The above article is part of the Make Your Giving Count! Join America's Giving Challenge 2009.  Every little bit counts, like Intueri’s raising money for the MS Society or my small part in helping her or Dr Rob & Zippy raising money to “Stamp out Children’s Brain Cancer!”

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H/T to @murzee for the link (via twitter) to this absolutely wonderful essay on Joy! I hope you’ll read the entire essay.

What does it mean to be commanded to be joyful?…….It seems to me that joy is something different. Joy can be cultivated. And joy can coexist with sorrow……..Joy is deeper than happiness.

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Thanks to @Geek2Nurse

Smart mama--she knew just what to do! RT @dreamingspires: WOW video footage of Elephant giving birth http://bit.ly/46smpU

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Tonight Dr Anonymous will have a pre-BlogWorld Expo Show. Come join us. The show starts at 10 pm EST.

Upcoming Dr. A Shows

10/16: Live from BlogWorldExpo (5 pm ET)
10/17: Dr. A Show: Sat Nite (9 pm ET)
10/22: Dr. A Show: Post BlogWorld Expo

1908 View of Solid Tumors of the Breast

I continue to be fascinated by the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD.  As October is Breast Cancer Awareness Month, I’m going to share the section from the book on that topic.
Solid Tumors of the Breast
Hypertrophy

Sometimes during adolescence one of the breasts will become abnormally firm and larger than its fellow and rather more sensitive to pressure, but without acute pain.  The enlargement is diffuse and uniform, and there is no adhesion of the breast to the structures either beneath or superficial to it.  Such a condition has a tendency to resolve in the course of time.  This return to the normal state may be hastened by an application of ichthyol ointment.

Adenoma

An adenoma or an adenofibroma of the breast is a tumor which is composed of a localized increased growth of glandular and fibrous tissue.  There are several types of such tumors distinguishable microscopically, but as no adenoma is composed only of glandular tissue and no fibroma is without a certain increase in glandular tissue, and as both of these often contain cysts, an exact differential diagnosis between them is not always possible, nor has it more than a pathological significance.  The tumor is generally painless and is first noticed by the patient during a bath or by accident.  In other cases there is a little pain in the tumor.

Treatment – Such tumors are essentially benign, but they may also change their type of growth into one which has a tendency to spread into the surrounding tissues.  Hence they should be removed, or at least carefully watched from month to month in order to be sure that they are not growing.  Puncture with a hypodermic needle, and aspiration, will differentiate between a cystic and a solid tumor if fluid is obtained.  A negative aspiration is not conclusive.  If the tumor is small and freely moveable, a local anesthetic will often suffice; but otherwise, and especially if the patient is more than thirty years of age, she should be told beforehand of the possibility of a major operation and should be given a general anesthetic.  If the growth is found to be malignant, the operation should be continued until it includes the removal of the breast and dissection of the axillary and clavicular regions, and the excision of one or both pectoral muscles, according to the judgment of the surgeon.  It is of great assistance at such times to have a pathologist present, who, by making frozen sections of even a small, freely movable tumor which has been growing but a few months and is painful.  This is especially the case if the patient is a woman more than thirty years of age.

The Early Diagnosis of Malignant Tumors of the Breast

The treatment of malignant tumors of the breast is quite out of the range of minor surgery, but the importance of a correct diagnosis in the early stages is so great and these tumors are so often first seen in ambulatory practice, that the diagnostic points should be emphasized. 

In examining a patient’s breast these points should be observed:

Palpation – The patient should lie flat on the back with both breast exposed for the sake of comparison.  Some examiners prefer to have the patient sit upright, but the recumbent position is better for a thorough examination.  Each breast should then be thoroughly examined by rolling its substance between the palmar surface of the fingers and the wall of the thorax.  The aim of the examination is to determine the presence of any nodules or other irregularities.  If there are multiple nodules in both breasts, the case is probably one of chronic mastitis.   The same is probably true of multiple nodules in one breast, for if these are cancerous, the disease will of necessity be far advanced, and some of the other symptoms will be present.  A single nodule in one breast, or in each breast, may or may not be cancer.  It should be further examined.

Retraction of the Skin – This is best shown by pushing the breast, but not the tumor, toward the suspected part of the skin.  Retraction of the skin, under these circumstances, is one of the most reliable signs of cancer.

A Flattening of the Normal Curve of the Breast Over the Tumor --  This is determined by sighting across it with the eye on the same level.  If present it is an indication of malignancy.

The Presence of One or More Enlarged Glands in the Axilla or Between the Breast and Axilla – This is not one of the earliest signs.  Both Axillae should be palpated.  If the glands in each are equally enlarged, and only one breast contains a nodule, the axillary glands are presumably non-cancerous.

Retraction of the Nipple – This is an early sign of cancer only when the disease begins under or near the nipple.  In other cases the growth may be well advanced before retracting the nipple.

Hemorrhage from the nipple, either spontaneous or occurring when the nipple is gently squeezed, is a symptom of value if there is no inflammation or other obvious explanation of its occurrence.

Failure to Withdraw Fluid through a Fine Aspirating Needle  --  A long hypodermic needle is sufficiently large.  Fluid indicates cystadenoma in most cases, though some cancers contain fluid. 

The importance of carcinoma of the breast is so great that, unless the examiner can be sure that the tumor is of a benign character, he had better assume it to be malignant.  In doubtful cases a section should be removed for microscopical examination.  This may be successfully done with cocaine, unless the patient is of a nervous disposition.  If the tumor is malignant, an extensive removal of breast and axillary gland and pectoral muscles and fascia is indicated.

Carcinoma beginning in the nipple, so-called Paget’s disease may be mistaken for eczema.  There is redness and scaliness, followed by a shallow ulceration with a slightly indurated base and narrow indurated margin.  It is inexcusable to neglect such a condition, since the microscopic examination of a small section of the affected skin will reveal the true nature of the disease.

Sarcoma – Sarcoma of the breast differs somewhat from carcinoma in its gross characteristics inasmuch as it usually develops at a greater distance from the nipple and forms a diffuse swelling deeply situated beneath the skin, and often extending beyond the margin of the breast in one or more broad lobules before the surgeons’ advice is sought in regard to it.  It grows rapidly, without pain, and forms new nodules by continuity rather than through the lymphatic system; hence the axilla may be entirely free although the tumor has grown to a diameter of two inches or more.  Such a freedom of the axilla is never seen in carcinoma of the breast of a similar size.  Sarcoma grows more rapidly than carcinoma, and a thorough and early removal is, therefore, not less important. 

Tuberculosis may be mistaken for a malignant tumor (see p 180).  -- From p 180: 

Tuberculosis of the Mammary Gland – One of the less common situations for tuberculosis is the mammary gland.  Because of its rarity, and because of the similarity of the lesion in its general outline to carcinoma of the breast, this mistaken diagnosis is often made.  There will generally be a history of tuberculosis in the patient, or examination of the corresponding lung may show that the primary trouble was located within the chest and has worked outward.  If an ulcer or sinus exists its appearance will keep an observant  man from making a wrong diagnosis.  There will be in the edges of the tubercular ulcer none of the active growth which is always seen in the edges of a carcinomatous ulcer.  The axillary glands are usually enlarged if an ulcer exists.

Treatment – In tuberculosis of the breast it is quite unnecessary to remove more than the affected part.  Usually the whole gland is diseased at the time of operation, but unless the axillary glands are plainly diseased it is wrong to subject the patient to the extra shock of an axillary dissection.  On account of the possible involvement of an underlying rib, a general anesthetic is preferable.  If the disease is plainly limited to the freely moveable breast=gland, a complete removal can be satisfactorily effected under local anesthesia if the patient’s temperament warrants it.

Related posts:

Breast Self-Exam (October 10, 2009)
October – Breast Cancer Awareness Month (October 2, 2008)
Mammograms  (October 13, 2008)
ARM Technique (October 15, 2008)
Breast Reconstruction—Part I (October 2007)
Breast Reconstruction – Part II (October 2007)

SurgeXperiences 308 – Call for Submissions

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

There is no host yet for SurgeXperiences 308 (October 18th) so if you would like to do the honors, please, let Jeffrey know.   Don’t let that keep you from making your submissions.   The deadline for submissions is midnight on Friday, October 16th.  Be sure to submit your post via this form. 

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.   If you would like to be the host  in the future, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

BWE 2009 Autograph Quilt

As promised last week, here’s the autograph quilt for BWE.  The quilt is going to be used as a door prize.  It has 64 white spaces for attendee’s autograph (name and blog title).  I used batiks in blue, green, and brown shades.  The quilt is machine pieced and quilted.  It is 43 in square.

Here you can see some of the fabrics used.
Here is the quilt label on the back of the quilt.

See you all in Las Vegas next week!  Looking forward to meeting you all as well as gathering autographs. 

 

Breast Self-Exam

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

October is “breast cancer awareness month.”  I first wrote this post on the self-exam in  July (2007).  It remains relevant, so I will simply re-post it.

Recently a small study at Leo Jenkins Cancer Center, North Carolina found that most women with breast cancer had found their own tumors through self examination. "Conclusions: Most breast cancers (75%) were found by self-examination, even among women who had regular mammography. We did not find any demographic factor that predicted mammography as the primary method of tumor identification. These findings suggest that self-examination remains an important method of breast cancer identification." Photo credit.
The Five Steps of a Breast Self Exam:

1. Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Look for any changes in the size, shape, and color. Look for any dimpling, puckering, or bulging of the skin. Has the nipple changed position or become inverted? Is there redness, soreness, a rash, or swelling?
2. Now, raise your arms and look for the same changes.
3. While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).
4. Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a regular grid pattern, so that no areas are missed.Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage.
5. Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

If you find any changes, lumps, or nipple discharge, then call your physician. Schedule an exam and mammogram. For a video teaching guide, check out the Susan G Komen web site. Breast cancer is the most common cancer in women, but it can be successfully treated. The key? Early detection.

Related posts:

October – Breast Cancer Awareness Month (October 2, 2008)

Mammograms  (October 13, 2008)

ARM Technique (October 15, 2008)

Breast Reconstruction—Part I (October 2007)
Breast Reconstruction – Part II (October 2007)
Breast Cancer Reconstruction Webcast  (April 2008)
Silicone Implants and Health Issues (March 2008)

Pumpkin Carving Safety Tips

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

It’s that time of year again!  Here’s a reposting of  my post from last year.  Enjoy, but be careful!

Carved pumpkins can be works of art, but carving one incorrectly can leave you with cut fingers. Minor cuts will often stop bleeding on their own or by applying direct pressure to the wound. Most of these cuts and scraps will be minor and can be treated by washing with soap and water initially. After this initial care, keep the wound clean and dry while it heals.

However, if the bleeding continues after 15 minutes or if you lose the ability to move the finger properly (very likely a tendon injury), then seek medical attention at a hospital emergency department. (photo credit--Headless Horseman)

Let's prevent the injuries. Keep these tips in mind:

• Carve in a clean, dry, well-lit area.
  If your tools, hands or cutting table are wet, this can cause slippage and lead to injuries.
• Always have adult supervision (without alcohol use)
  Children under age five should never carve. Instead, allow kids to draw a pattern or face on the pumpkin and have an adult carve. Allow the child to be responsible for cleaning out the inside pulp and seeds. They can use their hands or a spoon for this. Children, ages five to ten, can carve but only with adult supervision.
• The right way to cut.
  You should always cut away from yourself in small, controlled strokes. A sharp knife is not necessarily the best tool because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is placed incorrectly when the knife dislodges from the thicker part or slips.
• Use a pumpkin carving kit.
  Special pumpkin carving kits are available for purchase and include small serrated saws that are less likely to get stuck in the thick pumpkin. If the saw does get stuck and then becomes free, it is not sharp enough to cause a major cut. Fewer injuries occur with use of carving kits. (photo credit)

Here is a link for instructions and patterns for pumpkin carving at Spook Master.  For some amazing photos of carved pumpkins, check out this Tayyerit Presents.  You can find photos from 1998 to present.  Absolutely amazing!

Here are just some fun photos I found:

Happy Halloween (video of Jim Hendricks, bbc.co.uk)

Ping the Pug (photo credit)

Once carved, it is important to remember to KEEP dogs and cats away from Jack o'Lanterns or lighted candles as they could knock them over and start a fire.

Have a safe Halloween season!

Shout Outs

 Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Pallimed is this week's host of Grand Rounds. You can read this week’s edition  here.

Welcome to Grand Rounds, a weekly round-up of the best of the medical blogosphere.  We here at Pallimed (Drew, Lyle, Amy, Amber and myself) are honored to be hosting Grand Rounds for the 3rd time.  For the history books here are the 2007 (theme: prognostication) and 2008 editions.  The theme this week is "The Art of Medicine and Nursing" in honor of our sister blog Pallimed: Arts and Humanities.

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 7) ! You can find the schedule and the COS archives at Emergiblog. (photo credit)

Welcome to the latest version of Change of Shift, the nursing blog carnival!
Lots of topics this week: H1N1 is on a lot of minds these days, there are a couple of posts for new grads and it looks like one particular blogger is going to have to re-evaluate her opinion on a certain Showtime show (cough!).

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Dr Val presents us with this informative interview: Can You Name The 10 Vaccines That Adults May Need?

Have you been checking out Dr Rob’s podcast, House Call Doctor? If not, here’s a good one to start with: How to Find a Good Primary Care Doctor, Episode 16: September 30, 2009.

It would be nice if there was find your dream doctor dot com that worked a lot like the match-making sites you see advertised all over the place. But despite the fact that there isn’t such a website, you can use some of their principles to narrow down your search. …….

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H/T to scanman and DrVes for this interesting topic of food examples in radiology. Check out this tweet:

Updated Food Examples in Radiology http://bit.ly/3RtU6B with Selections from the Buffet of Food Signs in Radiology http://bit.ly/31DGp210:29 AM Sep 30th

And this article:

Selections from the Buffet of Food Signs in Radiology. Clare J. Roche et al. November 2002 RadioGraphics, 22, 1369-1384.

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Dr. Joshua Swimmer who goes by kidneynotes on twitter, ask this

Did I miss anything on this list of kidney diseases? http://ping.fm/n4rso

I don’t think it did. It’s an impressive list with links to more information on each disease. Check it out. Maybe bookmark it.

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H/T to Dr Charles for the link to an exhibit entitled Dialogues with Darwin held at the American Philosophical Society Museum:   “amazingly good online museum tour in which you can get the same virtual experience as seeing the originals.”

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This week is Dr Anonymous will have special guests: international medbloggers Bongi and ScanMan. Come join us. The show starts at 9 pm EST.

Upcoming Dr. A Shows

10/13 : Dr. A Show: Pre-BlogWorld Expo Show
10/17 : Dr. A Show: Sat Nite (9pmET)
10/22 : Dr. A Show: Post BlogWorld Expo

I would LOVE to see and touch this piece of cloth on exhibit at the American Museum of Natural History.

A spectacular and extremely rare textile, woven from golden-colored silk thread produced by more than one million spiders in Madagascar, goes on display Wednesday, September 23 in the Museum's Grand Gallery. This magnificent contemporary textile, measuring 11 feet by 4 feet, took four years to make using a painstaking technique developed more than 100 years ago.

Circumcision from the Historic Viewpoint

There has been recent debate over whether circumcision should be made mandatory as a way to prevent the spread of HIV, so I thought I would share the section on circumcision from the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD.

Circumcision

This little operation can be performed in a number of ways.  The practice among the Hebrews when circumcision is performed as a religious rite is to draw the foreskin well forward, to cut it off with one stroke of a long knife, to immerse the penis in wine held in the mouth of the rabbi to stop the hemorrhage, and then to wrap it in linen rags.  It is not surprising that dangerous hemorrhage and infection sometimes follow this procedure, and a few lives have been lost in consequence.

Equally reprehensible is the practice among some surgeons of trying to perform this little operation in the shortest possible time.  For this purpose clamps have been devised to hold the foreskin so that both the external and reflected portions can be cut away by a single stroke of the knife.  It is obvious that the amount of skin thus removed cannot be controlled with certainty, and even if the line of incision be a perfectly smooth circular one, a thing which rarely happens, the adjustment in length of the external and internal portions of the prepuce is at best uncertain.  There is no part of the body concerning which most patients are more sensitive, so that the surgeon ought to be willing to give up a few minutes of his time in order to secure a perfect result.

[When I was taught to do this procedure as a medical student on the pediatric surgery service, the attending often told me “Make it look good so he won’t be embarrassed on a car date.”]

An extensive experience, both in the performance of this operation and in the observance of the operation as performed by others, has convinced the writer that a perfect result is most likely to be attained in the following manner:  The patient, if a very young baby, requires no anesthetic, or ether may be given.  A local anesthetic had better not be employed in patients under six or eight years of age, as it will not remove the fright of an infant or a young child.  The parts should be carefully washed with soap and warm water and a weak solution of bichlorid of mercury 1:2,000 or weaker.  Two sharp nosed artery clamps should be fixed upon the orifice of the foreskin to the right and left of the dorsal median line.  If the orifice is too small to permit this, it should first be snipped dorsally with a pair of scissors.  Traction being upon the clamps, the foreskin is drawn well beyond the head of the penis and one blade of a straight scissors is passed between the head of the penis and the foreskin.  An incision is made which extends nearly back to the reflection of the foreskin.

In drawing the foreskin forward in this manner there is danger that its outer portion will be cut farther back than will its inner portion; hence, after the first clip of the scissors the traction upon the clamps should be relaxed and the reflected portion of the foreskin should be cut farther if necessary.  Two clamps are then placed upon the orifice of the foreskin at its lower edge and an incision is made between them.  This incision is far shorter than the dorsal one.  The two clamps on the left side are then drawn outward and left half of the foreskin is removed, care being taken that the incision through the inner layer of the foreskin shall be nearly parallel to the corona of the glans, and that the incision through the external layer shall be directly opposite to it when only slight traction is made upon the clamps.  The best result is obtained when the portion of the inner layer which is left is a third or a half of an inch in width.  The right half of the foreskin is next cut away.  Any bleeding points are clamped and tied if necessary with very fine catgut.  If the hemorrhage can be stopped by pressure, so much the better.  The edges of the external and internal layers of the foreskin are then approximated by eight or twelve stitches of fine black silk.  The sum of the penis, the third and fourth in the middle of the right and left sides respectively.  In each of the four spaces thus marked off two or three stitches should be placed.  When sutured in this manner the foreskin will not be drawn unevenly in any direction.  If preferred, the stitch at the frenum and the dorsal stitch may be introduced before the sides of the divided foreskin are removed.  These stitches, if left long, will serve as retractors.  In infants no dressings is required, except a little sterile gauze placed between the penis and diaper.  The mother should be told to keep the penis clean by letting a little cooled boiled water run over it after each urination.  In four or five days the stitches should be removed. 

Silk is better than catgut, the latter gives way sometimes and is, besides, more irritating to the tender skin.  In older persons the skin should be well retracted and a circular bandage of sterile gauze wound around the penis behind the glans.  If this becomes soiled with urine it should be immediately changed.  Attention on the part of the patient will usually prevent this accident.  A  good precaution is to lie down to urinate, turning almost upon the face.  This prevents any backward dripping of the urine. Dressed in the manner described, the two cut edges of skin are closely approximated, and will unite with the minimum amount of adhesions.

Complications and Late Results

Painful Micturition – The disability following a properly performed circumcision is very slight.  There may be a little burning during the passage of urine for one or two times.  In an adult, if an erection occurs, it will only be painful in case the dressing is too tight.  It can be relieved at once by loosening or removing the bandage.

Hemorrhage is unlikely if all bleeding points have been ligated.  If it does take place it is usually subcutaneous, and opportunity should be given for the escape of the blood through a gap in the skin incision.  If bleeding is free, and is not controlled by digital pressure or cold, the skin wound should be opened sufficiently to permit proper ligation of the bleeding vessel.  This does not delay complete repair nearly as much as the presence of a subcutaneous hematoma.

Edema is usually due to faulty technique, either mal-approximation of the skin, tearing of the tissues, or hemorrhage beneath the skin.  It shows itself chiefly about the frenum, and may persist long after the wound is healed.  It will ultimately disappear.  Its disappearance may be hastened by hot applications, counter-irritants, pricking with a glover’s needle, etc.

Infection – If the wound becomes infected it should be drained at once by the removal of one or two stitches, by soaking the penis frequently in a mild, hot antiseptic solution, and by wet dressings of creolin 1:200, borolyptol 1:4, etc.   Retraction is likely to follow the removal of stitches, so that in a suppurative case they should be allowed to remain until granulations have fixed the skin edges in contact.

Retraction of the skin of the penis, so that its cut edge is everywhere separated from the cut edge of the mucous membrane, takes place in some cases of infection; and sometimes without infection, if so much skin has been removed that there is undue tension upon the sutures.  The immediate result is a circular band of granulations, over which new epithelium will creep in the course of a couple of weeks.  The ultimate result is generally good, although the immediate result is so discouraging.  The skin of the penis is capable of great stretching, so that erection is not permanently interfered with, even by the removal of too much skin.

Irregularity in Outline  --  An uneven section of the skin should be corrected at the time of operation, but if not noticed then it is better to correct it by a subsequent operation than to allow a patient to go away dissatisfied.  A common error is to leave too much skin at the frenum.  This projects beneath the tip of the penis and catches the last drops of urine, besides being unsightly.

If circumcision is performed to aid the patient in overcoming the habit of masturbation, superfluous skin about the frenum should never be left, since it is most abundantly supplied with sensory nerves, and especially invites manipulation.

Recurrence of Phimosis  --  If the inner layer is left long, say half an inch or more, and the suturing or the dressing has been carelessly done, it may happen that the inner and the outer layers of the foreskin will firmly unite for a distance of a quarter of an inch or more from their free edges.  There will then be formed a strong hand of cicatricial  tissue completely encircling the penis, which by its contraction may so reduce the orifice of the foreskin as to render necessary a second operation.

SurgeXperiences 307 is Up!

 Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Robin, survive the journey, is the host of this edition of SurgeXperiences. You can read this edition here.

Welcome to the October 4, 2009 edition of SurgeXperiences. There is quite a variety of posts. I thought I'd give you a snapshot view of each blog just in case you haven't already seen them. Enjoy!

The host of the next edition (308), October 18, has not been announced. The deadline for submissions is midnight on Friday, October 16th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Hope Quilt

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This post was initially meant to promote this quilt and help sell it.  I am grateful and amazed to tell you that it SOLD just two days after listing it for sale on Etsy!  So instead I will simply tell you about the quilt.

I was asked by Intueri to make a quilt to help her raise money for Multiple Sclerosis Society.  She is running the New York Marathon and raising money in honor of her friend who has MS.    If you would like to donate, then direct message Intueri on twitter for details or as she puts it:

And, lastly, if you’d like to sponsor me for the New York City marathon (all proceeds will go to the MS Society), have your people call my people (here or here) and we’ll do lunch.

The quilt is 15 in X 23 in.  It is machine quilted and pieced.  This was my first attempt to do “letters.”  I enjoyed it.  The “lucky you” in the “H” is from a nephew’s old blue jeans.

Here is the back of the quilt.  There is a 4 in sleeve for hanging the quilt.
This photo is just to show the “lucky you” ribbon better.

For more information on Multiple Sclerosis please visit the MS Society website.

Writing on Autograph Quilts

When I first thought about collecting the autographs of my fellow medical bloggers attending the BWE in Las Vegas, I started out with this small quilt.  I wanted a quilt with minimal or no white with neutral colors that might look okay in most decors.  I went with blues and browns.  This quilt is 22.5 in square, machine pieced and hand quilted.
Here is the back with the quilt label.

I thought I would be able to find pens/ink that would work on the darker colors.  As you can see from my samples here, I was wrong.   I wrote on several of the fabrics, then washed the samples.  All the inks are “permanent” and “acid-free”The Sharpie fine tip in black and blue both work on some of the blocks, but not the darker browns. 
I have made another autograph quilt (to be shown next week) with white strips to be written on.  As you can see from this sample, the white gives us many more choices for individual signatures.

Historical Tx of Otitis Media

I want to share this section of the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD (1908) mainly because I want to share the photo of the “angular knife for incision of the tympanic membrane” with you.

Otitis Media

This is a common disease of childhood, usually following a cold in the head. The prominent symptom is earache. Every physician ought to be able to recognize the bulging outward of the membranum tympani and to relieve the pressure by incision of the membrane at the most favorable situation – viz., the inferior and posterior portion. The introduction of warm olive oil into the external meatus will sometimes relieve pain, and the application of external heat may also be tried; but the pain of a severe earache, unless relieved by puncture of the membrane, usually demands the internal administration of morphine. The membrane usually ruptures spontaneously in the course of a day or two. Pain is then relieved, and a muco-purulent discharge begins and continues for a time. After it ceases the membrane soon heals over. While the discharge continues, the treatment consists in cleanliness. The ear should be syringed gently once or twice a day with warm normal salt solution, and wiped dry with absorbent cotton.

Unfortunately, this simple termination is not the only one which is possible, for inflammation of the middle ear may extend to the mastoid cells, and result in abscess within the cavity of the mastoid bone. If prompt drainage is not instituted, the suppuration may extend into the lateral sinuses and to the membranes of the brain, causing the death of the patient. Hence the necessity of early recognition of the disease and prompt treatment before these serious complications have arisen.

The external ear should be cleansed by washing it with small cotton swabs wet with a warm antiseptic solution, and the membrane anesthetized by the instillation of a few drops of a ten per cent solution of cocaine. An ear speculum should then be introduced, the membrane inspected by reflected light or a headlight, and incised in its lower and posterior portion by means of a long slender scalpel bent in the handle at an angle.

Figure 18 shows the normal membrane, and the correct size of an incision, which should be sufficient length to permit the escape of the pus and mucus. Figure 19 shows a good knife for making the incision.

When the incision has been made through the bulging membrane, a few drops of pus and mucus and often a little blood will escape. Irrigation is not necessary, but the auditory canal should be sponged clean with cotton-tipped probes dipped in a warm antiseptic solution. In the case of a nervous or restless child, it is best to perform this operation in general anesthesia. The incision can then be more accurately made.

The after treatment consists in cleanliness. The canal should be wiped or washed clean, and the inner ear protected from temperature changes by a small cone of dry absorbent cotton introduced after each cleansing and as often as the previous cone becomes moist.