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MILTON UNION INFECTIOUS HOSPITAL, SITTINGBOURNE.
630
days after the operation. Before resorting to the operation of vaginal lithotomy, the following points bearing upon the
future
were
taken into consideration: (a) The amount of
haemorrhage. Whilst, fortunately, a clean incision in the middle line of the anterior wall of the vagina caused no troublesome bleeding, the vascularity of the parts in
have quinine in full doses in combination with bicarbonate of potash, the same diet, and brandy as usual. 21st.-Temperature: 2 AM., 106°; morning, 98°; evening, normal. To continue the quinine and potash. Each rise in temperature was associated with a cold and then a hot stage. From this date the patient had no other attack, the temperature never rising above normal till Jan. 29th, when the thermometer marked 99°. On Jan. 30th the brandy was withdrawn and the patient put on full diet, and he was discharged convalescent on Feb. 7th. Remarks by Dr. SMITH.-My best thanks are due to Mrs. Hoadley, the matron, for the very careful manner in which she took the temperatures and recorded them in the charts. is an aguish place, I have not in Although Sittingbourne my experience of fourteen years’ practice here met with an example of that disease. Two cases of typhoid fever have come under my care within the last three years, in which the patients have had second attacks of typhoid separated by a distinct interval of some months.
a woman six months and a half advanced in pregnancy was well shown by the very free oozing which followed on the introduction of a hook to elongate the anterior wall, and the result of the lacerations of the pulpy mucous membrane following on mere introduction of strips of iodoform gauze. (b) The possibility of the scar yielding during or interfering with labour. The belief that any such untoward events would be prevented partly by the rapid healing of the wound and partly by the scar being small, median, and in the long axis of the vagina, was abundantly justified by the event. (c) The risk of a vesicovaginal fistula. With the facilities which anaesthetics afford for careful suturing of the wound this complication should met with. Even in cases where nowadays be the edges of the wound have been bruised by the difficult extraction of a large stone, it will probably be possible to secure union by first paring them before the introduction of sutures. For very large calculi the supra-pubic method will be chosen. Mr. Barwell has shown that in all cases of female children where the stone cannot be extracted by the ROYAL MEDICAL & CHIRURGICAL SOCIETY. urethra it should be taken out above the pubes. By a remarkable coincidence, this surgeon met with, during seven Clinical Signi fccznce of Colourless Stools. months, no fewer than three cases of vesico-vaginal fistula AN ordinary meeting of this Society was held on in women, dating to the extraction of calculi during infancy and youth by different surgeons. He points out how recal- March 26th, the President (Sir Edward Sieveking) being in citrant to treatment these fistulae are, lying as they do in the chair. A paper by Dr. T. J. WALKER, communicated by Sir the midst of hard, thick, cicatricial tissue. This case has been published, as I was unable to find any similar history. Andrew Clark, was read, on the Clinical Significance of Colourless or Clay-coloured Stools, unaccompanied by jaundice, their connexion with disease of the pancreas, and MILTON UNION INFECTIOUS HOSPITAL, on the part played by the pancreas in eliminating bile from the intestines. After referring to the accepted views SITTINGBOURNE. of the significance of clay-coloured stools, the author gave A CASE OF TYPHOID FEVER. of two cases in which, during life, a persistent particulars (Under the care of Dr. T. SOMERVILLE SMITH.) symptom was the absence of colour in the faeces, and in ALTHOUGH it has been a recognised fact for many years which the diagnosis made of obstruction of the pancreatic that typhoid fever may at its commencement resemble ague, duct, with a healthy condition of the bile duct, was confirmed by the necropsy. From these cases he concluded:o and ague at the beginning of the attack simulate typhoid, 1. That the formation of hydrobilirubin, the colouring it is not often that ague develops in a patient actually matter of the faeces, depended on the mutual reaction of suffering from the latter disease. M. Boudin held the the bile and pancreatic fluid, under the influences met intestinal tract. 2. That in disease a opinion that prolonged exposure to malaria conferred with in the of pancreatic fluid would, equally with a dedeficiency in from and went so far as ’individuals ; immunity typhoid ficiency of bile, cause the pathological condition of colourto say that by residing in a marshy country, a person less or clay-coloured stools. 3. That, since, according to acquires an immunity from typhoid in proportion to the the most recent physiological researches, that portion only length and degree of his residence. He gave as examples of of the coloured constituents of the bile which had been this the instances in which Algerian regiments had escaped converted into hydrobilirubin was excreted in the fseces, from typhoid when other regiments quartered in the same while the unchanged bilirubin, bilifuscin, and biliverdin town, but which had not been to Algeria, suffered severely were absorbed, it followed that if hydrobilirubin could not fromthatdisease. He considered the diseases "antagonistic."2 be produced without the aid of the pancreas, that organ C. Wiz, aged twenty-five, was admitted on Dec. 29th, must have an important ?-4le in regulating what proportion 1888, suffering from typhoid fever. He had never had ague, of the bile entering the intestines should be absorbed and but had suffered from haematemesis once and from in- what thrown off in the faeces. Dr. Walker then pointed digestion for four months while following his trade as a out that these conclusions received confirmation from the baker; but he is now a bargeman, and has enjoyed good records of other published cases, that Claude Bernard health since he changed his occupation. recognised that the pancreas had a part in causing the The patient was on the ordinary diet of milk, sodacolour of the faeces, and that the state in which the bile water, and beef-tea. He progressed favourably until the pigments were found in the meconium of the foetus, while morning of Jan. 16th, 1889, nineteen days after admission. the pancreatic function was in abeyance, also accorded The temperatures were all taken very carefully at 8 A. M. in with these conclusions. He further pointed out that the fact the morning and 5 P.M. in the evening. of the pancreas influencing the excretion of the bile in the Jan. 16th.-Morning temperature 99’1°. Had a shivering ffeces would, if accepted, reconcile the discrepancy between fit, followed by the hot and sweating stages of ague, sick- the clinical observation that certain drugs produced copious ness, headache, sleeplessness, and delirium. He was given bilious stools, and the physiological observation that these quinine in full doses, with an acid, and morphia drops to drugs had little or no influence on the secretion of bile by procure sleep at night. Evening temperature 1041°. To the liver; and that the same fact would explain those have five ounces of brandy daily. hitherto inexplicable cases in which, with no evidence of 17th.-Temperature: 2’A.M., 105°; morning, 100 3°; 2P.M., arrest of the bile-secreting functions of the liver or of obstruction of its ducts, the symptom of white or clay106°; evening, 1001°. To continue the quinine and acid. 1044°. To coloured stools was persistently present. In conclusion, 18th.-Temperature: morning, to 105°; evening, continue the medicine. Dr. Walker indicated the practical importance of the views he had endeavoured to establish in the treatment and 19th.-Temperature: morning, 98’1°; evening, 101°. 20th.-Temperature: morning, 97’2°; evening, 105°. To diagnosis of pancreatic disease and of all forms of bilious disorder. 1 Med. Chir. Trans., vol. lxix., p. 342. Dr. GEORGE HARLEY said that the paper required serious 2 Murchison : Continued Fevers," 1885. Trousseau : Clin. Méd., vol. ii. Boudin : Traité des Fièvres Intermittentes. Traité de Geographic consideration, many points in it referring to matters proved, and many to others still doubtful. He quoted several inMédicale.
very rarely
Medical Societies.
placed
"
days after the operation. Before resorting to the operation of vaginal lithotomy, the following points bearing upon the
future
were
taken into consideration: (a) The amount of
haemorrhage. Whilst, fortunately, a clean incision in the middle line of the anterior wall of the vagina caused no troublesome bleeding, the vascularity of the parts in
have quinine in full doses in combination with bicarbonate of potash, the same diet, and brandy as usual. 21st.-Temperature: 2 AM., 106°; morning, 98°; evening, normal. To continue the quinine and potash. Each rise in temperature was associated with a cold and then a hot stage. From this date the patient had no other attack, the temperature never rising above normal till Jan. 29th, when the thermometer marked 99°. On Jan. 30th the brandy was withdrawn and the patient put on full diet, and he was discharged convalescent on Feb. 7th. Remarks by Dr. SMITH.-My best thanks are due to Mrs. Hoadley, the matron, for the very careful manner in which she took the temperatures and recorded them in the charts. is an aguish place, I have not in Although Sittingbourne my experience of fourteen years’ practice here met with an example of that disease. Two cases of typhoid fever have come under my care within the last three years, in which the patients have had second attacks of typhoid separated by a distinct interval of some months.
a woman six months and a half advanced in pregnancy was well shown by the very free oozing which followed on the introduction of a hook to elongate the anterior wall, and the result of the lacerations of the pulpy mucous membrane following on mere introduction of strips of iodoform gauze. (b) The possibility of the scar yielding during or interfering with labour. The belief that any such untoward events would be prevented partly by the rapid healing of the wound and partly by the scar being small, median, and in the long axis of the vagina, was abundantly justified by the event. (c) The risk of a vesicovaginal fistula. With the facilities which anaesthetics afford for careful suturing of the wound this complication should met with. Even in cases where nowadays be the edges of the wound have been bruised by the difficult extraction of a large stone, it will probably be possible to secure union by first paring them before the introduction of sutures. For very large calculi the supra-pubic method will be chosen. Mr. Barwell has shown that in all cases of female children where the stone cannot be extracted by the ROYAL MEDICAL & CHIRURGICAL SOCIETY. urethra it should be taken out above the pubes. By a remarkable coincidence, this surgeon met with, during seven Clinical Signi fccznce of Colourless Stools. months, no fewer than three cases of vesico-vaginal fistula AN ordinary meeting of this Society was held on in women, dating to the extraction of calculi during infancy and youth by different surgeons. He points out how recal- March 26th, the President (Sir Edward Sieveking) being in citrant to treatment these fistulae are, lying as they do in the chair. A paper by Dr. T. J. WALKER, communicated by Sir the midst of hard, thick, cicatricial tissue. This case has been published, as I was unable to find any similar history. Andrew Clark, was read, on the Clinical Significance of Colourless or Clay-coloured Stools, unaccompanied by jaundice, their connexion with disease of the pancreas, and MILTON UNION INFECTIOUS HOSPITAL, on the part played by the pancreas in eliminating bile from the intestines. After referring to the accepted views SITTINGBOURNE. of the significance of clay-coloured stools, the author gave A CASE OF TYPHOID FEVER. of two cases in which, during life, a persistent particulars (Under the care of Dr. T. SOMERVILLE SMITH.) symptom was the absence of colour in the faeces, and in ALTHOUGH it has been a recognised fact for many years which the diagnosis made of obstruction of the pancreatic that typhoid fever may at its commencement resemble ague, duct, with a healthy condition of the bile duct, was confirmed by the necropsy. From these cases he concluded:o and ague at the beginning of the attack simulate typhoid, 1. That the formation of hydrobilirubin, the colouring it is not often that ague develops in a patient actually matter of the faeces, depended on the mutual reaction of suffering from the latter disease. M. Boudin held the the bile and pancreatic fluid, under the influences met intestinal tract. 2. That in disease a opinion that prolonged exposure to malaria conferred with in the of pancreatic fluid would, equally with a dedeficiency in from and went so far as ’individuals ; immunity typhoid ficiency of bile, cause the pathological condition of colourto say that by residing in a marshy country, a person less or clay-coloured stools. 3. That, since, according to acquires an immunity from typhoid in proportion to the the most recent physiological researches, that portion only length and degree of his residence. He gave as examples of of the coloured constituents of the bile which had been this the instances in which Algerian regiments had escaped converted into hydrobilirubin was excreted in the fseces, from typhoid when other regiments quartered in the same while the unchanged bilirubin, bilifuscin, and biliverdin town, but which had not been to Algeria, suffered severely were absorbed, it followed that if hydrobilirubin could not fromthatdisease. He considered the diseases "antagonistic."2 be produced without the aid of the pancreas, that organ C. Wiz, aged twenty-five, was admitted on Dec. 29th, must have an important ?-4le in regulating what proportion 1888, suffering from typhoid fever. He had never had ague, of the bile entering the intestines should be absorbed and but had suffered from haematemesis once and from in- what thrown off in the faeces. Dr. Walker then pointed digestion for four months while following his trade as a out that these conclusions received confirmation from the baker; but he is now a bargeman, and has enjoyed good records of other published cases, that Claude Bernard health since he changed his occupation. recognised that the pancreas had a part in causing the The patient was on the ordinary diet of milk, sodacolour of the faeces, and that the state in which the bile water, and beef-tea. He progressed favourably until the pigments were found in the meconium of the foetus, while morning of Jan. 16th, 1889, nineteen days after admission. the pancreatic function was in abeyance, also accorded The temperatures were all taken very carefully at 8 A. M. in with these conclusions. He further pointed out that the fact the morning and 5 P.M. in the evening. of the pancreas influencing the excretion of the bile in the Jan. 16th.-Morning temperature 99’1°. Had a shivering ffeces would, if accepted, reconcile the discrepancy between fit, followed by the hot and sweating stages of ague, sick- the clinical observation that certain drugs produced copious ness, headache, sleeplessness, and delirium. He was given bilious stools, and the physiological observation that these quinine in full doses, with an acid, and morphia drops to drugs had little or no influence on the secretion of bile by procure sleep at night. Evening temperature 1041°. To the liver; and that the same fact would explain those have five ounces of brandy daily. hitherto inexplicable cases in which, with no evidence of 17th.-Temperature: 2’A.M., 105°; morning, 100 3°; 2P.M., arrest of the bile-secreting functions of the liver or of obstruction of its ducts, the symptom of white or clay106°; evening, 1001°. To continue the quinine and acid. 1044°. To coloured stools was persistently present. In conclusion, 18th.-Temperature: morning, to 105°; evening, continue the medicine. Dr. Walker indicated the practical importance of the views he had endeavoured to establish in the treatment and 19th.-Temperature: morning, 98’1°; evening, 101°. 20th.-Temperature: morning, 97’2°; evening, 105°. To diagnosis of pancreatic disease and of all forms of bilious disorder. 1 Med. Chir. Trans., vol. lxix., p. 342. Dr. GEORGE HARLEY said that the paper required serious 2 Murchison : Continued Fevers," 1885. Trousseau : Clin. Méd., vol. ii. Boudin : Traité des Fièvres Intermittentes. Traité de Geographic consideration, many points in it referring to matters proved, and many to others still doubtful. He quoted several inMédicale.
very rarely
Medical Societies.
placed
"