510 Olinical and other Notes

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510 Olinical and other Notes

condition to that of the mouth. There is no history of intestinal dis-turbance in any of the attacks.

The treatment adopted was to put the patient on 15 grains of sod. salicyl thrice daily, to coat the lip with glycerine of borax and keep the mouth clean with a mouth wash of 1 in 2,000 perchloride of mercury. ,The hand lesions were protected with cotton wool.

The interest of the case lies in the very close resemblance which the mOllth lesions have to that of secondary syphilitic patches, the patient being sent to hospital diagnosed "syphilis," but here the history and ,course of the disease and the striking eruptions on the hands cleared up

all doubt as to the nature of the malady.

The excellent photograph of this case was taken by Private J ones, of 20th Company, R A.M.C., Bulford Camp.

NOTES ON SIX CONSECUTIVE CASES OF DYSENTERY TREATED BY ANTI-DYSENTERIC SERUM.

By LIEUTENANT S. E. LEWIS.

Royal Army Medical Corps.

CASE I.-Gunner S., admitted on February 28th, about 11 a.m., com-plaining of diarrhoea with intense pain during the motion, but he had not noticed whether he had been passing blood. Since 4 p.m. yesterday he states that he has had about thirty stools. Temperature 99'2° F. Pulse 96, weak. On examination, patient lies curled up and looks very ill. ,Tongue coated, breath foul. Some pain on pressure over the lower portion of the abdomen. Heart's sounds quick and feeble. Nothing else abnormal detected. Treatment: Put on a plain milk diet with three bottles of soda and brandy;

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iv. At 6 p.m.: Has had fourteen stools, small, and consisting of blood and 'mucus; complains greatly €)f tenesmus. Treatment: The abdomen having been sterilised, 20 cc. anti-dysenteric 8erum were injected into the subcutaneous tissue of the abdomen by means of a sterile syringe; also ordered pulv. ipecach., grs. x.

March 1st.-Was delirious, and trying to get out of bed all last night. Temperature this morning 101° F. Pulse 96. Motions, nine during the night of similar character to those passed yesterday, and three of these were passed in bed.

-Patient is now quite himself, tenesmus not nearly so marked, looks better, lies comfortably in bed.

March 3rd.-Stools have greatly decreased in number,'and now con-sist of blood clot, mucus, and liquid falces. States he is now quite free from pain. Temperature normal. Treatment: Milk decreased, ordered barley water and beef-tea. Pulv. ipecach. co., grs. x., at night.

I may as well mention here that in all these cases milk was decreased

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on June 28, 2021 by guest.

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Olinical and othel' Notes

511

on the day after admission, i.e., as soon as diagnosis was certain, and half a pint of barley water and two pints of beef tea substituted.'

March 5th.-Only two stools last night, liquid, but entirely free from blood and mucus ..

March 8th.-Stools average two a day since last note,'and, with the exception that they are somewhat loose,are quite natural. Is now allowed up for four hours, and put on stewed chicken diet.

March 9th.-Is to-day covered with a rash like measles, and intensely irrItating; was ordered calcium chloride, grs. xl.

March 10th.-Rash faded, irritation not nearly so marked. Patient continued to improve, the rash had completely gone on the 12th, and he was discharged to duty on the 20th.

The serum was prepared by the Lister Institute of Preventive Medicine, and was obtained from horses highly immunised against the dysentery bacillus of Shiga and Kruse and toxins elaborated by the bacillus.

CASE 2.-April 2nd. Lance-Corporal McL., admitted to-day com-plaining of "diarrhma and passing blood with great pain while at stool." States he has been" two days ill and has been going to the rear every ten minutes and passing only blood and slime." 'On' examination, abdomen somewhat distended, but quite flaccid; slight pain on pressure in the left iliac region. Temperature 99° F. Pulse 84. Put to bed; ordered plain milk and soda. At 6 p.m.: Has had three motions, small, and consisting of blood and mucus; has suffered greatly from tenesmus. Treatment: Skin and syringe having been sterilised, 20 cc. serum injected.

April 3rd.-Temperature 1040 _{F. Pulse 100. Motions: Fourteen last}

night, of much the same character. Now complains greatly of headache. Treatment: Sponged. Temperature falling to 101'8° F.; ordered brandy with caffeine and phenacetin.

April 4th.-Temperature 98'60 _{F. Pulse 66. Was very restless all last} night, but says he now feels better. Passed seventeen stools last night consisting of blood, mucus, and blood clot. He is now almost free from tenesmus.

April 5th.-Nineteen stools during the night, blood in all being in the form of clot. The latter motions also contained liquid falces. He is entirely free from pain and says "if the diarrhma would only stop he would be all right."

April 6th.-There were only nine stools during the night, all free from blood, but there is still a little mucus. He is, however, to· day covered with a rash similar to former case, arid very irritating. Ordered calcium chloride, grs; xxx.

April 8th-Rash has disappeared; only one stool yesterday, semi, , formed, and quite free fronl mucus.

,From this date, till his discharge on the ,19th, there were no symptoms worthy of record.

CASE 3.-April 23rd. Lance-Corporal L., admitted this morning

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512 Olinicaland other Notes

about 11 a.m., complaining of passing blood and mucus, with some pain during the motion. States he has been two days ill, and on the 21st he had about fifteen stools, and yesterday about twelve. Very analmic. Tongue coated. On examination, temperature 98° F. ; pulse 96, weak; respiration 20. Sweating freely; great pain on slight pressure. in the left iliac region; abdomen not tympanitic, heart's sounds weak, lungs normal. 6 p.m.: Four stools since admission, small and consisting of blood, mucus and traces of falces. Complains greatly of tenesmus. Treatment : Was placed on plain milk diet with soda and brandy, 3iii., also mag. sulph., 3ii., four times during the night, and to be given every two hours to-morrow.

April 29th.-This treatment was continued till to-day. There has been on an average about ten stools in twenty-four hours, each intensely painful; character unchanged~ To-day, 20 cc. of the serum were injected, with the usual precautions.

April 30th.-Slept fairly well last night. Temperature rose to 100'2° F, Pulse 100. Six stools during the night.

May 2nd.-States he feels ever so much better now and certainly has lost his anxious expression. There is now no tenesmus, and the three motions last night consisted largely of liquid falces, mucus, and traces of blood clot.

May llth.-Has on an average ten stools a day now, entirely free from blood and mucus. Is still very analmic and somewhat emaciated. Is now getting fish, eggs, &c.

May 15th.-Was to-day put on stewed chicken.

Although patient has now quite recovered, he remains in hospital and he is still very analmic. He continued to gain in weight and strength until May 29th, when diarrhcea again started and blood and mucus appeared in the stools. Serum was for the second time injected, diarrhcea and other symptoms of dysentery ceased two days afterwards. He was discharged to duty on June 1st. , It will be noticed that iLlthough 40 cc. were injected no rash of any kind appeared.

CASE 4.-May 6th. Private R. was admitted this morning

com-plaining of diarrhcea, accompanied with blood and mucus, of severe pain in the rectum, greatly increased while at stool, and of pain down the }jack of both legs. Illness began yesterday morning, and says he has been going to stool two or three times an hour since. Noticed blood and mucus in the stools this morning, so reported sick. On examination, tempera-ture 97'6° F.; pulse 80, feeble. Abdomen somewhat tympanitic, pain on slight pressure all over; no rigidity, no tumour or other abnormality. Treatment: Bed, plain milk and soda, brandy, 3ii. 6 p.m.: Twenty-one stools since admission, small and consisting of blood and mucus. Tenes-mus has been very marked. Lies curled up in bed, has a very anxious look and is sweating freely. It is very evident that he is suffering and has suffered greatly since admission. Treatment: The usual precautions

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Olinical and other Notes

513

were taken and 20 C.c. of the serum injected, also ordered pulv. ipecac. co., grs. x., and brandy, 5ii.

May 7th.-Eight motions last night; no change in character. Did not sleep at all. Temperature this morning 99.80 _{F. Complains of headache.} May 8th.-Eleven stools yesterday, aud uine during the night. Traces of fal(Jes in all those passed during the night, and blood is all in. form of clot. Looks a different man; states he is entirely free from pain. Tem-perature rose last night to 100.80 _{F., but is now normal.}

May 10th.-Five stools yesterday and only one during the night; these were all free from blood, and the motion last night was also free from mucus.

May 16th.-He is now convalescent; stools quite normal. Was to-day put on stewed chicken diet.

May 24th.-Was to-day discharged to duty. On the 18th a very irritating rash, similar to other cases, appeared on legs, arms and buttocks. Calcium chloride, grs. xxx., was ordered, and the irritation, ten hours afterwards, was ever so much less. Rash had gone on the 21st.

CASE 5.-May 10th. Private B. was ad~itted to-day complaining of passing blood and mucus, of tenesmus, and pain all over the abdomen. Illness began on the 8th with diarrhrna. On that day he had about twelve stools, on the 9th about twenty, and was in " agony" while at stool, the pain causing him to cry out and sweat. freely. ,This morning he began to pass blood in large quantities, so he reported sick. On examination he is analmic, and has a pinched expression. Seemed in great pain. Tongue coated, breath foul, lungs normal, heart's sounds som6-what faint. Temperature 97'80 _{F. Pulse 78, weak. Treatment: Bed,} plain milk and soda, brandy, jiv. When seen again in the evening~ he was lying doubled up in bed, and seemed in great pain. Since admission there have been seven stools, all small, and consisting of liquid blood and mucus. Tenesmus has been a marked feature. Treatment : The ab-domen and syringe were sterilised and 20 cc. anti-dysenteric serum injected. He was also ordered a Dover's powder,grs. x.

May lIth.-Seems somewhat better to-day; does not complain so much of pain, and tenesmus was not so marked with the four mo'tions during the night. Temperature 980 _{F. Pulse 72. ,}

May 12th.-Eight stools during the day yesterday, all containing blood in the form of clots. Four motions during the night, consisting of blood clot, mucus and traces of falces. States he is now quite free from pain. Lies naturally in bed. Temperature last night 100'20 _{F., and he}

was then complaining of headache, for which caffein and phenacetin ,were ordered. Temperature this morning sub-normal. Pulse 80, good.

May 14th.-At 6 p.m. yesterday he passed a motion entirely free from blood, but still containing mucus. Is now entirely free from tenesmus. Had a good night; no motions.

May 18th. Only one stool, quite natural, a day now. This mOl'mng

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514 Olinical and' other Notes

l;te is, covered with a rash, similar in:all respects to the other cases. His hands were to-day bandaged, as he had caused bleeding in places, the, rash being very irritating. Ordered cal. chloride; grs. xl.

May 20th.-Rash has almost disappeared, and there is no irritation. Was put on stewed chicken yesterday.

May 24th.-Discharged to duty to-day.

CASE 6.-May llth.-Private W. was admitted to-day, complaining of "terrible pain while at stool," of diarrhrea, and "passing blood and elime." Illness began suddenly yesterday morning with pain in the abdomen, then diarrhrea and tenesmus commenced. First noticed blood in the stools this morning. Since yesterday he has had about thirty stools. On examination,. a well7,developed man; tongue dry and coated. Lungs normal. Heart's sounds weak, but quite free from murmur. Pain on slight pressure all over the abdomen, 'which was somewhat tympanitic. No other abnormality discovered. Lies doubled up in bed, sweating freely. Temperature 98·4 F. Pulse 80, weak. Treatment: put to bed, ordered plain milk and soda. 6 p.m.: patient has had seven stools, the first small, and ~onsisting, of blood only, others of blood and a large amount of mucus. The usual precautions were taken, and 20 cc. serum injected.

May 12th.-Four stools during the night; tenesmus less. No change in character of motions. Temperature normal.

May 13th.-Looks ever so much better. Temperature last night

100'4° F. Had a severe headache then, and so was ordered caffein and

phenacetin. Temperature this morning sub-normal. Twelve motions yesterday, consisting of clotted blood, mucus, with traces of falces. Only one during the night; does not complain of pain.

May 15th.-He is now quite free from tenesmus. Four motions last night, consisting of liquid falces and mucus. 6 p.m.: only one stool since 9 a.m. this morning, liquid in character, but free from blood and mucus.

May IS.-Patient is now convalescent. Was put on solid food to-day. May 19.-Last night was covered with a rash, and was complaining greatly of the irritation. Cal. chloride, grs. xxx., ordered, and this was repeated this morning as there was still a good deal of irritation .

. May 24th.-Rash had disappeared on the 22nd; discharged to duty

to-day. '

Remarks.-These six cases were evidently all due to Shiga's bacillus.

In the first three cases a bacillus having the same staining, micro-scopical and cultural properties was observed; that is to say, it was decolourised by Gram's method; but stained readily with ordinary aniline dyes, it was rod:shaped, had oval ends, but 1 cannot say whether it was motile or not. On gelatine plates a whitish delicate growth with slightly wavy margins was noticed. Stools from every case were examined for amrebal, but' none' discovered.'

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ERRATA.

VOL. VII., No. 5, November, 1906: In the" Report of a CasE) of Femoral and Inguinal Hernia on the Same Side," &c., by Major F. J. W. PORTER, D.S.O., R.A.M., page 515, the words" latter" and" former," which appear in the first paragraph, Rhould be transposed.

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Olinical

dni

other Notes

515

The' advantages of this method of treatment are, I think

:'-(1) The almost, immediate relief from tenesmus; (2) Its rapid bene-ficial action; blood 'first disappearing from the stools and then mucus; (3) freedom from relapse of the disease, all patients haye remained quite well; (4) the absence of nausea, vomiting and depression, &c., caused by the treatment with ipecacuanha in large doses. The disadvantages, if such a, word' can be used,' are none' of them serious. "

It will be noticed that ther.e w,asaslight rise of temperature, head-ache, &c., in each case a,fter the injection. In one case temperature rose to 104° F., but fell to 100°8 F. after sponging. These" disadvantages," however,only lasted a day or two.

There:was some delirium in Qne case, only Jasting for a night.

A rash appeared in every case except one, and was very irritating, but this could be r~adily controlled by calcium chloride in large doses.

REPORT OF A CASE OF FEMORAL AND INGUINAL HERNIA ON THE SAME SIDE, IN WHICH RADICAL CURE OF THE FORMER WAS DONE BY A NEW METHOD.

By MAJOR F. J. W. PORTER, D.S.O. Royal Army Medical Corps.

PRIVATE S. was admitted to the Military Hospital, Colchester, on January 20, 1906, with a femoral and an inguinal hernia on the right side. The latter was well marked, and had been present for several years. The former was a large bubonocele.

The femoral hernia was exposed by the usual vertical incision. The walls of the crural canal were developed to an extraordinary degree,. and formed a very distinct sac. This contained'. a structure which' at first sight looked like a coil of intestine, but closer examination showed it to consist of a sac proper, coated thickly with fatty tissue. The inguinal hernia was now dealt with by extending the first incision upwards and outwards, and the aponeurosis of the external oblique divided over the inguinal canaL There being no proper sac, the conjoined tendon and muscles were.: drawn . across by kangaroo tendori, and sutured near Poupart's ligament after MacEwen'smethod, and the divided aponeurosis sutured with the same material. Before doing this, the sac of the femoral hernia was seized in a pair of forceps and pushed from below uPW/1rds; out of the crural canal. The structures which lay between it and the.upper edge of Poupart's ligament were then scratched through; the sac pulled out, transfixed and tied with kangaroo tendon. The excess was.crit.away, and the stump dropped.' Three deep sutures of kangaroo tendon were then' passedthr.:mgh the :crural ring, Poupart's ligament,

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