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CASE OF HEPATICO-BRONCHIAL FISTULA
5
gradually gained strength, and she was to-day thirty miles, by road and rail, to New Mills.
has
moved
.
Oct. 15th.-She came at my request to show herself. The wound has apparently healed, but she has three timesi noticed blood on her linen opposite the cicatrix, during the: period of menstruation. I thought there might be some fistulous opening into the uterus, but though I sought carefnlly with a probe, I was unable to find any. The scar is: somewhat puckered, 31 inches in length, 1 inch below and 241 inch above the umbilicus. She has grown fat, but only measures 26 inches over the hips down to pubes (as you measure for an inguinal truss) ; 8linches across from one: anterior supra-spinous process to the other. The finger, when inserted into the vagina, feels in contact with the bones: all round. She weighs 733lb., but is so small and childlike that she is allowed to travel for half fare on the:
membrane of the windpipe. Frequently during this period more than eighty ounces of pure bile (measured after subsidence) was coughed up in the twenty-four hours, resembling very much the whipped yelk of an egg, but settling down into a dark-green fluid. On one occasion this quantity was coughed up in seven hours. The pulse was generally quick, but there was no rise in temperature and no shivering mucous
except
on one
occasion to be afterwards mentioned.
Bowels
opened most days by aperient or naturally, and always contained some bile. The appetite improved, and nourishment was regularly taken in large quantities in the shape of raw eggs, beef-tea, milk, &c. Opium and Indian hemp were given freely to relieve the distressing cough. Sometimes an interval of a day or two occurred during which no bile was coughed up, and one lasted as long as four days-from May
29th to June 3rd. June 10th. -A good deal of thick viscid mucus is now I heard from her on the anniversary of the operation. She: coughed up, as well as bile. The patient feels better, and continues well, is regular every month, and still notices a says if only the cough could be stopped she should feel quite few drops of coloured discharge from the cicatrix at eachwell. She does not emaciate. At 4 P.M. she vomited about period. The child is alive, and is a very large child for his; a pint of most offensive matter, and felt better. Microage. scopic examination shows this to consist almost entirely of Baslow, Derbyshire. pus-cells. llth.-More pus vomited during the night. Patient again expectorating bile. Feels better. Pulse 84; tongue clean. condition of the patient remains unaltered. CASE OF HEPATICO-BRONCHIAL FISTULA A 15th.-The small haemorrhage occurred from the rectum, probably hemorrhoidal. From this time enemata were used, inBY W. E. GREEN, M.R.C.S. ENG., L.S.A. stead of aperient medicines. The quantity of bile coughed G. I-, aged sixty-three, by occupation an inn-keeper, up averages a pint daily, but the quantity of mucus with it increases. a well-nourished and active woman, has suffered for many 26th.-ll A.M.: During the past ten days there has been years from occasional attacks of biliary colic. During thE a gradual improvement in the patient’s condition, and she last two years these attacks have been more frequent andis now able to sit up. The daily motion contains a proper severe. When suffering from an attack she is generally proportion of bile. The appetite has improved, and now meat and fish are relished, as well as large quantities slightly jaundiced. Has always vomited bile, while the both of liquid nourishment. There had been no expectoration of motions have also contained a moderate quantity of bile. bile for two to last night, when a slight return No gall-stones have been found, although frequently lookedl took place, and this morning she is coughing up phlegm in. for. She has enjoyed good health during the intervals, which are scattered pieces of bright orange-looking stuff,, but since her last attack some months ago has frequently about as large as millet-seeds. These were carefully examined with the microscope, but nothing special made out.. suffered from severe pain in the back when lying down. Present illness commenced on May 16th, 1875, with a The cough gives so little trouble now, and the pain is so slight, that the patient is able to dispense with the use of general feeling of malaise ; and the next day she could opiates.-10 P.M.: Has been coughing and expectorating bile incessantly during the last four hours. hardly attend to her usual duties. On May 18th I was called in, and found the following: 28th.-Again vomited a quantity of greenish pus. a behind July 12th.—During the past fortnight the expectoration of of : severe the symptoms complained pain right bile considerable but decreasing quantities continues, the sixth shoulder, opposite rib; slight cough, accompanied with in occasional intermission of a few hours, or at most two with a little expectoration, which, during the last two days, or three days. Pulse 88. The last thirty-six hours the has contained small clots of dark blood. A careful physical cough has been troublesome, accompanied with considerable examination shows nothing to account for this. Pulse 76 ;; pain and " oppression of the chest." This morning a large quantity of pus was again vomited. temperature normal. 17th.-Patient complains that she gets weaker, and has Patient feels better; less cough, no more blood; 19th. loss of appetite. The quantity of bile decreases, and great tongue clean; bowels have acted, the motion natural in the phlegm gets thicker and more mucous in character. appearance. From this time the cough and expectoration gradually 20th.-Has coughed up some green bitter fluid, and is: ceased, the appetite was better, and the patient improved feeling very much better. A chemical examination of this: in every respect. The bowels acted naturally, and the fluid showed it to be bile, which was thought to have been motions contained a proper proportion of bile. About the vomited during a paroxysm of coughing. second week in August she left home for change of air, re21st.-The patient was found sitting up in bed coughing turning at the end of three weeks quite well, and able to incessantly, and bringing up large mouthfuls of frothy bile. follow her usual avocations, which are at times heavy, and This had been going on for some hours, and the patient extending always over several hours. felt much exhausted. Pulse 108 ; temperature normal; Remarks.-Cases of biliary fistula of this description tongue clean. (The bile, after settling, measured over occur so rarely that I feel justified in recording this parforty ounces, and was natural in colour and free from ticular case. In the whole of my experience I have never phlegm.) On physical examination, the percussion note was met with another, and have read but of two similar ones. clear, except over the lower two inches of the right lung One of these is mentioned by Murchison in his work on posteriorly. Auscultation detected large bubbling rales in "Diseases of the Liver,"and was not complete, inasmuch the right lung; and when the stethoscope was placed about as the perforation was only into the right pleura, which was three inches below the right nipple fluid could be heard full of pus and bile combined, and was not discovered until gurgling, as if passing upwards from the liver with each after the death of the patient. The second example was a inspiration. Hepatic dulness greater than natural. Pressure complete case of fistulous communication between the caused no pain. The heart-sounds were healthy. Kidneys liver and right lung, occurring in the clinique of M. acted naturally, and the urine was healthy. Bowels opened Laubelene, of Paris, and described by him to the Societ6 Medicale des I-Iôpitaux. A brief mention of this case is daily, and motions contain some bile ; great anorexia. The patient continued much as follows until June 10th:- recorded in THE LANCET of Oct. 2nd, 1875, at which time At times suffering most distressingly from cough and ex- the above notes had been made. His case was in many pectoration of bile. The cough would sometimes be incessant respects similar to this one, and occurred independently of for more than twenty-four hours; at such times sleep was any hydatid disease. out of the question, and the pain and rawness of chest very I was rather puzzled to account for the bile seeking for great, owing to the cough and passage of bile over the itself a passage through the right lung. My first impression
railway.
,
,
,
. ,
days previous
,
.
-
,
’
,
6 was that it might be caused by hydatid disease of the liverr, illness ; by the fact that only on one occasion was there any but careful and repeated examination of the expectorate(d rise in temperature or shivering (and that but for a few hours), matters failed to discover any cysts or booklets of echinococcii. and by the condition of the pulse, which rarely rose to 100 It was, therefore, necessary to seek further for an explanaL- per minute, and then only during severe paroxysms of tion, and it occurred to me that the cause must have beern coughing. mechanical- i. c., an obstruction of the bile-duct. Nowr, The patient is at the present time in the enjoyment of such obstruction may have been produced either by pressune excellent health, and has never since had a return of her from without or from something within the duct itself. former attacks of biliary colic. Pressure from without may have been caused by an abscess ; Belgrave House, Sandown, I.W. but I was not inclined to adopt this theory, for the followinga reasons :-lst. Abscess of the liver is a disease seldom me1 with in this country, and still more rarely in a person whc has not been resident in a hot or in a malarious climate, CASE OF SCIATICA, TREATED BY NERVE2nd. Abscess of the liver still more rarely occurs withoui STRETCHING. elevation of temperature and shivering, and no such were ever in this in severa] the symptoms present patient BY ALEX. W. MACFARLANE, M.D. attacks of biliary colic which I attended during the twc previous years. I was therefore reduced to the theory that WITHOUT any desire to enter upon the consideration of the obstruction was within the duct, and probably caused the pathology and treatment of sciatica, I wish, while nerveby the impaction of a large gall-stone, from the fact that had had repeated stretching is still on its trial, to record a case of that disease during the last few years the patient attacks of biliary colic, and that in neither of the later that was under my care last year for ten months, in which attacks in which I attended her could any gall-stones be this method of treatment was successfully employed. discovered after the pain passed away, although carefully Mrs. X. is twenty-nine years of age. When sixteen years and repeatedly searched for. old she suffered from slight lateral curvature of the spine, The next thing, if possible, is to decide as to the position which to a extent still exists ; and since that of the and the clue to this is furnished by the time she hasvery slight occasionally suffered from spinal tenderness, fact that the bile was never entirely absent from the which has always yielded to tonics and counter-irritation of motions. various kinds. With this exception she has been a very It is probable that the obstruction was in the large duct woman. She has never borne children, but has no leading from the right lobe, for the following reasons : healthy uterine disturbance. (1) Any obstruction in the ductus communis would probably On the 26th January, 1877, I found her labouring under a have been total to cause the bile to force a new passage for attack of sciatica, which had come on after a very itself ; that it was not so is proved by the circumstance that chill;painful from that time until the 3rd November it was and there was never any severe jaundice present during this or uninfluenced by treatment, although most perseveringly either of the previous illnesses, and that at no time was bile applied-locally, morphia injected hypodermically, acocompletely absent from the motions. (2) Any obstruction nite, belladonna, by chloroform and cantharidine líniopium, in the left lobe account for the would hardly daily ments, leeches, fly blisters frequently applied, acupuncture, occurring loss of such an immense quantity of bile. The obstruction hot douching, actual cautery, and galvanism; internally, by must therefore have existed in the right lobe, and its modus iron, chloride of ammonium, strychnine, arsenic, quinine, operandi was probably as follows : the bile, having accumu- phosphorus, iodide of potassium, zinc, actea racemosa, turlated behind the obstruction, and failing of any other passage, in large doses, purgatives, &c. &c. These were all pentine action and adhesion between set up inflammatory ultimate and when I say "tried," I mean they were taken in tried; the parietes of the liver and the diaphragm, followed by even large, doses, and continued sufficiently long to perforation and escape of the bile into the right pleura, full, show they were inert. The only improvement that took making for itself a passage through the right lung. was a transient one, when, at the seaside, she was There is little doubt that the escape was into the pleura place hot salt-water douches. having and thence into the lung, and that the pleura acted as a I was at last driven to propose stretching the nerve. reservoir for the bile ; for if the communication had been Before undertaking the operation, Professor Gairdner, of direct into the lung the expectoration of bile would probably who saw the patient, agreed with me that the list Glasgow, have been continuous, but this was not the case. Sometimes of remedies had been exhausted. I performed the operation, there was a cessation of bile expectoration for some hours, under on Nov. 3rd, stretching the antiseptic precautions, and on one occasion even for days; and after one of these nerve thoroughly, though I failed to lift the leg off the table. intervals the attack was always preceded by the expecto- The wound healed the first intention. Since that time of as if the had been ration bloody mucus, parts temporarily till now (July 3rd),by more than eight months, not the healed and again forcibly separated. Again, before each ’, return of pain has been experienced. fresh attack, dulness on percussion could be detected risingI slightest This was a severe and protracted case, and a suitable one posteriorly for some inches; whilst after the paroxysm, by for testing the treatment ; the result has been all that could means of the stethoscope, fluid could be heard trickling and be desired. I have stated that I the operation tinkling as if falling into a cavity during each deep inspira- under antiseptic precautions, whichperformed to some may appear to tion. have been unnecessary, as clean-cut wounds usually heal by With regard to the vomiting of pus I can only suggest the first intention. I submit, however, that such wounds, that this may have been an effort of nature to remove the treated without antiseptics, may occasionally suppurate, obstruction. An abscess must have formed, which opened and even the patient’s life; with the antiseptic endanger into either the stomach or the duodenum, instead of seeking treatment I believe this danger to be highly improbable, if a passage through the fistula already established by the bile. not impossible. The lives of patients suffering from sciatica I believe the abscess to have formed after the obstruction are not in and nerve-stretching cannot yet be underrather than before, because the only evidence of taken as adanger, commencedand certain cure; therefore without antiseptics I increase of temperature which occurred should hesitate to shivering perform this operation, that might posthroughout the attack was on June 3rd, exactly one week sibly not effect a a cure, and even endanger life. Such conbefore the abscess first emptied itself. though apparently trifling, are of great conseThe following points in this case are also worthy of notice: siderations, to patients, as it is important that they can be first, the small amount of constitutional disturbance caused quence assured that, though the operation fail, their life will not be by the continual loss of such an immense quantity of bile; jeopardised. secondly, the trifling irritation set up in the bronchial tubes Kilmarnock. by the constant passage of aforeignfluid through them. There was rarely any cough except at the time the bile was being BEQUESTS ETC. TO MEDICAL CHARITIES.-Mrs. expectorated, at which time it was most distressing, frefrom twelve to Elizabeth hours without Burmester, of Devonshire-place, bequeathed quently lasting twenty-four cessation, and each cough accompanied by a mouthful of j6500 to the Middlesex Hospital, and £ 500 to the Hospital for Consumption, Brompton. The Rev. Augustus Clissold yellow froth. The small amount of constitutional disturbance was shown has given jE500 to the Charing-cross Hospital. The All by the remarkable manner in which the strength and the Saints Convalescent Hospital at Eastbourne has received weight of the body were maintained throughout the entire £ 105 from the Prison Charities’ Committee.
obstruction,
finally
gradually gained strength, and she was to-day thirty miles, by road and rail, to New Mills.
has
moved
.
Oct. 15th.-She came at my request to show herself. The wound has apparently healed, but she has three timesi noticed blood on her linen opposite the cicatrix, during the: period of menstruation. I thought there might be some fistulous opening into the uterus, but though I sought carefnlly with a probe, I was unable to find any. The scar is: somewhat puckered, 31 inches in length, 1 inch below and 241 inch above the umbilicus. She has grown fat, but only measures 26 inches over the hips down to pubes (as you measure for an inguinal truss) ; 8linches across from one: anterior supra-spinous process to the other. The finger, when inserted into the vagina, feels in contact with the bones: all round. She weighs 733lb., but is so small and childlike that she is allowed to travel for half fare on the:
membrane of the windpipe. Frequently during this period more than eighty ounces of pure bile (measured after subsidence) was coughed up in the twenty-four hours, resembling very much the whipped yelk of an egg, but settling down into a dark-green fluid. On one occasion this quantity was coughed up in seven hours. The pulse was generally quick, but there was no rise in temperature and no shivering mucous
except
on one
occasion to be afterwards mentioned.
Bowels
opened most days by aperient or naturally, and always contained some bile. The appetite improved, and nourishment was regularly taken in large quantities in the shape of raw eggs, beef-tea, milk, &c. Opium and Indian hemp were given freely to relieve the distressing cough. Sometimes an interval of a day or two occurred during which no bile was coughed up, and one lasted as long as four days-from May
29th to June 3rd. June 10th. -A good deal of thick viscid mucus is now I heard from her on the anniversary of the operation. She: coughed up, as well as bile. The patient feels better, and continues well, is regular every month, and still notices a says if only the cough could be stopped she should feel quite few drops of coloured discharge from the cicatrix at eachwell. She does not emaciate. At 4 P.M. she vomited about period. The child is alive, and is a very large child for his; a pint of most offensive matter, and felt better. Microage. scopic examination shows this to consist almost entirely of Baslow, Derbyshire. pus-cells. llth.-More pus vomited during the night. Patient again expectorating bile. Feels better. Pulse 84; tongue clean. condition of the patient remains unaltered. CASE OF HEPATICO-BRONCHIAL FISTULA A 15th.-The small haemorrhage occurred from the rectum, probably hemorrhoidal. From this time enemata were used, inBY W. E. GREEN, M.R.C.S. ENG., L.S.A. stead of aperient medicines. The quantity of bile coughed G. I-, aged sixty-three, by occupation an inn-keeper, up averages a pint daily, but the quantity of mucus with it increases. a well-nourished and active woman, has suffered for many 26th.-ll A.M.: During the past ten days there has been years from occasional attacks of biliary colic. During thE a gradual improvement in the patient’s condition, and she last two years these attacks have been more frequent andis now able to sit up. The daily motion contains a proper severe. When suffering from an attack she is generally proportion of bile. The appetite has improved, and now meat and fish are relished, as well as large quantities slightly jaundiced. Has always vomited bile, while the both of liquid nourishment. There had been no expectoration of motions have also contained a moderate quantity of bile. bile for two to last night, when a slight return No gall-stones have been found, although frequently lookedl took place, and this morning she is coughing up phlegm in. for. She has enjoyed good health during the intervals, which are scattered pieces of bright orange-looking stuff,, but since her last attack some months ago has frequently about as large as millet-seeds. These were carefully examined with the microscope, but nothing special made out.. suffered from severe pain in the back when lying down. Present illness commenced on May 16th, 1875, with a The cough gives so little trouble now, and the pain is so slight, that the patient is able to dispense with the use of general feeling of malaise ; and the next day she could opiates.-10 P.M.: Has been coughing and expectorating bile incessantly during the last four hours. hardly attend to her usual duties. On May 18th I was called in, and found the following: 28th.-Again vomited a quantity of greenish pus. a behind July 12th.—During the past fortnight the expectoration of of : severe the symptoms complained pain right bile considerable but decreasing quantities continues, the sixth shoulder, opposite rib; slight cough, accompanied with in occasional intermission of a few hours, or at most two with a little expectoration, which, during the last two days, or three days. Pulse 88. The last thirty-six hours the has contained small clots of dark blood. A careful physical cough has been troublesome, accompanied with considerable examination shows nothing to account for this. Pulse 76 ;; pain and " oppression of the chest." This morning a large quantity of pus was again vomited. temperature normal. 17th.-Patient complains that she gets weaker, and has Patient feels better; less cough, no more blood; 19th. loss of appetite. The quantity of bile decreases, and great tongue clean; bowels have acted, the motion natural in the phlegm gets thicker and more mucous in character. appearance. From this time the cough and expectoration gradually 20th.-Has coughed up some green bitter fluid, and is: ceased, the appetite was better, and the patient improved feeling very much better. A chemical examination of this: in every respect. The bowels acted naturally, and the fluid showed it to be bile, which was thought to have been motions contained a proper proportion of bile. About the vomited during a paroxysm of coughing. second week in August she left home for change of air, re21st.-The patient was found sitting up in bed coughing turning at the end of three weeks quite well, and able to incessantly, and bringing up large mouthfuls of frothy bile. follow her usual avocations, which are at times heavy, and This had been going on for some hours, and the patient extending always over several hours. felt much exhausted. Pulse 108 ; temperature normal; Remarks.-Cases of biliary fistula of this description tongue clean. (The bile, after settling, measured over occur so rarely that I feel justified in recording this parforty ounces, and was natural in colour and free from ticular case. In the whole of my experience I have never phlegm.) On physical examination, the percussion note was met with another, and have read but of two similar ones. clear, except over the lower two inches of the right lung One of these is mentioned by Murchison in his work on posteriorly. Auscultation detected large bubbling rales in "Diseases of the Liver,"and was not complete, inasmuch the right lung; and when the stethoscope was placed about as the perforation was only into the right pleura, which was three inches below the right nipple fluid could be heard full of pus and bile combined, and was not discovered until gurgling, as if passing upwards from the liver with each after the death of the patient. The second example was a inspiration. Hepatic dulness greater than natural. Pressure complete case of fistulous communication between the caused no pain. The heart-sounds were healthy. Kidneys liver and right lung, occurring in the clinique of M. acted naturally, and the urine was healthy. Bowels opened Laubelene, of Paris, and described by him to the Societ6 Medicale des I-Iôpitaux. A brief mention of this case is daily, and motions contain some bile ; great anorexia. The patient continued much as follows until June 10th:- recorded in THE LANCET of Oct. 2nd, 1875, at which time At times suffering most distressingly from cough and ex- the above notes had been made. His case was in many pectoration of bile. The cough would sometimes be incessant respects similar to this one, and occurred independently of for more than twenty-four hours; at such times sleep was any hydatid disease. out of the question, and the pain and rawness of chest very I was rather puzzled to account for the bile seeking for great, owing to the cough and passage of bile over the itself a passage through the right lung. My first impression
railway.
,
,
,
. ,
days previous
,
.
-
,
’
,
6 was that it might be caused by hydatid disease of the liverr, illness ; by the fact that only on one occasion was there any but careful and repeated examination of the expectorate(d rise in temperature or shivering (and that but for a few hours), matters failed to discover any cysts or booklets of echinococcii. and by the condition of the pulse, which rarely rose to 100 It was, therefore, necessary to seek further for an explanaL- per minute, and then only during severe paroxysms of tion, and it occurred to me that the cause must have beern coughing. mechanical- i. c., an obstruction of the bile-duct. Nowr, The patient is at the present time in the enjoyment of such obstruction may have been produced either by pressune excellent health, and has never since had a return of her from without or from something within the duct itself. former attacks of biliary colic. Pressure from without may have been caused by an abscess ; Belgrave House, Sandown, I.W. but I was not inclined to adopt this theory, for the followinga reasons :-lst. Abscess of the liver is a disease seldom me1 with in this country, and still more rarely in a person whc has not been resident in a hot or in a malarious climate, CASE OF SCIATICA, TREATED BY NERVE2nd. Abscess of the liver still more rarely occurs withoui STRETCHING. elevation of temperature and shivering, and no such were ever in this in severa] the symptoms present patient BY ALEX. W. MACFARLANE, M.D. attacks of biliary colic which I attended during the twc previous years. I was therefore reduced to the theory that WITHOUT any desire to enter upon the consideration of the obstruction was within the duct, and probably caused the pathology and treatment of sciatica, I wish, while nerveby the impaction of a large gall-stone, from the fact that had had repeated stretching is still on its trial, to record a case of that disease during the last few years the patient attacks of biliary colic, and that in neither of the later that was under my care last year for ten months, in which attacks in which I attended her could any gall-stones be this method of treatment was successfully employed. discovered after the pain passed away, although carefully Mrs. X. is twenty-nine years of age. When sixteen years and repeatedly searched for. old she suffered from slight lateral curvature of the spine, The next thing, if possible, is to decide as to the position which to a extent still exists ; and since that of the and the clue to this is furnished by the time she hasvery slight occasionally suffered from spinal tenderness, fact that the bile was never entirely absent from the which has always yielded to tonics and counter-irritation of motions. various kinds. With this exception she has been a very It is probable that the obstruction was in the large duct woman. She has never borne children, but has no leading from the right lobe, for the following reasons : healthy uterine disturbance. (1) Any obstruction in the ductus communis would probably On the 26th January, 1877, I found her labouring under a have been total to cause the bile to force a new passage for attack of sciatica, which had come on after a very itself ; that it was not so is proved by the circumstance that chill;painful from that time until the 3rd November it was and there was never any severe jaundice present during this or uninfluenced by treatment, although most perseveringly either of the previous illnesses, and that at no time was bile applied-locally, morphia injected hypodermically, acocompletely absent from the motions. (2) Any obstruction nite, belladonna, by chloroform and cantharidine líniopium, in the left lobe account for the would hardly daily ments, leeches, fly blisters frequently applied, acupuncture, occurring loss of such an immense quantity of bile. The obstruction hot douching, actual cautery, and galvanism; internally, by must therefore have existed in the right lobe, and its modus iron, chloride of ammonium, strychnine, arsenic, quinine, operandi was probably as follows : the bile, having accumu- phosphorus, iodide of potassium, zinc, actea racemosa, turlated behind the obstruction, and failing of any other passage, in large doses, purgatives, &c. &c. These were all pentine action and adhesion between set up inflammatory ultimate and when I say "tried," I mean they were taken in tried; the parietes of the liver and the diaphragm, followed by even large, doses, and continued sufficiently long to perforation and escape of the bile into the right pleura, full, show they were inert. The only improvement that took making for itself a passage through the right lung. was a transient one, when, at the seaside, she was There is little doubt that the escape was into the pleura place hot salt-water douches. having and thence into the lung, and that the pleura acted as a I was at last driven to propose stretching the nerve. reservoir for the bile ; for if the communication had been Before undertaking the operation, Professor Gairdner, of direct into the lung the expectoration of bile would probably who saw the patient, agreed with me that the list Glasgow, have been continuous, but this was not the case. Sometimes of remedies had been exhausted. I performed the operation, there was a cessation of bile expectoration for some hours, under on Nov. 3rd, stretching the antiseptic precautions, and on one occasion even for days; and after one of these nerve thoroughly, though I failed to lift the leg off the table. intervals the attack was always preceded by the expecto- The wound healed the first intention. Since that time of as if the had been ration bloody mucus, parts temporarily till now (July 3rd),by more than eight months, not the healed and again forcibly separated. Again, before each ’, return of pain has been experienced. fresh attack, dulness on percussion could be detected risingI slightest This was a severe and protracted case, and a suitable one posteriorly for some inches; whilst after the paroxysm, by for testing the treatment ; the result has been all that could means of the stethoscope, fluid could be heard trickling and be desired. I have stated that I the operation tinkling as if falling into a cavity during each deep inspira- under antiseptic precautions, whichperformed to some may appear to tion. have been unnecessary, as clean-cut wounds usually heal by With regard to the vomiting of pus I can only suggest the first intention. I submit, however, that such wounds, that this may have been an effort of nature to remove the treated without antiseptics, may occasionally suppurate, obstruction. An abscess must have formed, which opened and even the patient’s life; with the antiseptic endanger into either the stomach or the duodenum, instead of seeking treatment I believe this danger to be highly improbable, if a passage through the fistula already established by the bile. not impossible. The lives of patients suffering from sciatica I believe the abscess to have formed after the obstruction are not in and nerve-stretching cannot yet be underrather than before, because the only evidence of taken as adanger, commencedand certain cure; therefore without antiseptics I increase of temperature which occurred should hesitate to shivering perform this operation, that might posthroughout the attack was on June 3rd, exactly one week sibly not effect a a cure, and even endanger life. Such conbefore the abscess first emptied itself. though apparently trifling, are of great conseThe following points in this case are also worthy of notice: siderations, to patients, as it is important that they can be first, the small amount of constitutional disturbance caused quence assured that, though the operation fail, their life will not be by the continual loss of such an immense quantity of bile; jeopardised. secondly, the trifling irritation set up in the bronchial tubes Kilmarnock. by the constant passage of aforeignfluid through them. There was rarely any cough except at the time the bile was being BEQUESTS ETC. TO MEDICAL CHARITIES.-Mrs. expectorated, at which time it was most distressing, frefrom twelve to Elizabeth hours without Burmester, of Devonshire-place, bequeathed quently lasting twenty-four cessation, and each cough accompanied by a mouthful of j6500 to the Middlesex Hospital, and £ 500 to the Hospital for Consumption, Brompton. The Rev. Augustus Clissold yellow froth. The small amount of constitutional disturbance was shown has given jE500 to the Charing-cross Hospital. The All by the remarkable manner in which the strength and the Saints Convalescent Hospital at Eastbourne has received weight of the body were maintained throughout the entire £ 105 from the Prison Charities’ Committee.
obstruction,
finally