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when roused by unusual pain to a semi-conscious and more or less delirious condition.
The physician in charge had given a doubtful prognosis. The family were in despair, and requested him to ask me in consultation. This he declined to do, alleging as a reason his obligations to the Massachusetts Medical Society. He was then dismissed. The patient at this time (Sept. 10) was lying on his back, his legs extended, face flushed, conjunctivæ injected, pupils contracted, tongue dry, with red edges and brownish coating in the centre, skin dry and moderately warm, pulse 110, weak, respiration 16, temperature 102.5.
The abdomen was inflated ver its whole extent, its muscles rigid, its surface uneven from the coils of portions of the inflated intestine. The desire to urinate was frequent, the discharge scanty, difficult, and distressing; occasional subsultus in both upper and lower extremities.
Believing that Opium had been used in excess, I ordered it stopped until there should be further need for it, and prescribed Merc. Sol. three-grain powders every four hours. During the interval after the first dose there was perspiration (while sleeping) for the first time in three days. During the night pain became severe, when an enema of Aqueous Ext. of Opium was given. This failing to relieve, a pill left by my predecessor was administered. Within half an hour after it was swallowed, a large quantity, nearly, and perhaps quite, two quarts of yellowish fluid was vomited. Soon after there was a discharge from the bowels of semi-solid, ochre-colored fecal matter.
From this time on, under Merc. Sol.3 every four hours, and Laudanum in twenty-drop doses occasionally, as needed for pain (it was required three or four times in the twenty-four hours), there were discharges from the bowels, increasing in frequency for two days, until they were as often as once an hour and had become dark, watery, and offensive. The patient had grown restless, pupils dilated; there was delirium, with excitement; the tongue had lost its coating and was red; thirst intense. The Merc. Sol. was now stopped and Nitric Acid in water given; five-drop doses every two hours. Belladonna 1, in five-drop doses, to be used occasionally when needed for delirious excitement.
Under Nitric Acid the diarrhoea subsided within twenty-four
hours, and there was apparent improvement in general condition. The abdomen less tympanitic and less tender. Milk was taken with relish. Pulse 70, temperature 100. The effect of the Belladonna in quieting the delirium and restlessness was quite marked.
This improvement continued, and he took milk freely till the night of the 17th of September (thirteenth day of the peritonitis) when, after a large, soft, ochrous stool (the first of any kind for four days), there was suddenly a new and severe access of pain and tympanites, affecting chiefly the upper part of abdomen.
Large and frequent doses of Laudanum were now required to get ease from pain. There was great weakness and intense thirst. He lost desire and ability to urinate, and his bladder was emptied with catheter. Arsenic + x every four hours. In the course of two days the whole abdomen again became largely inflated. There was greatest tenderness in left iliac region, which was also somewhat dull on percussion. An enema of warm water was followed by a large stool of the same smooth, ochre-colored, semi-solid fecal matter before described; with this also came jelly-like matter and traces of blood. This movement of the bowels was followed by some temporary aggravation of the suffering. Thinking some fecal matter might yet remain, another enema of warm water was given, but it returned without causing any fecal discharge. After the stool the dulness of the left iliac region was gone.
On the night of the 20th of September (sixteenth of peritonitis), he woke from sleep soon after midnight in great agony from loss of breath and precordial distress. His friends thought he was dying. Laudanum relieved him The next night there was another attack of the same kind at the same hour. Arsenic, which he had been taking for four days, was now stopped, and no further attack of this kind occurred. On the 25th of September (twenty-first of peritonitis) an eruption of red spots appeared over epigastric region, resembling those of typhoid.
For a week there was no material change in his condition. He took but little nourishment, mostly milk, and a few beef-tea injections. When dozing, breathed very slowly, at times almost ceased breathing. There would be a prolonged expiration, succeeded by a long interval before inspiration. At times when sleeping a
"jumping" of the heart. His breath became very offensive, with putrid (not stercoraceous) odor. Occasional hiccup and subsultus. The abdomen kept inflated, at times extremely so, at others less, when the impression derived from the touch was that of deadness, a kind of putty-like yielding. It was agreeable to the patient to have gentle friction over it with the hand. This was so from the beginning. At times a tinkling sound of fluid dropping could be heard within the abdomen. Meanwhile a constant and free use of Laudanum had to be kept up to relieve the pain. Carbo veg. x was also used during this period.
On the 1st of October (the twenty-sixth day of peritonitis) I thrust an aspirating needle into a coil of intestine that was prominent to the right of the umbilicus. There was a forcible rush of gas through it, which could be heard and felt (by hand over needle), while the whole house was filled with its exceedingly pungent, putrid odor. The tension of the abdomen was at once relaxed in the neighborhood of the puncture, and soon after in other parts. Great relief followed this operation. Two days later, the tympanites having returned and again become distressing, I punctured another prominence to the left of umbilicus. This was followed as before by a large discharge of offensive gas, accompanied by a slight oozing of yellowish fecal fluid. This time the discharge continued until there was a general collapse of the abdominal walls. The relief which followed was more complete than before. After the operation an enema of soap and water with olive-oil was given. About eight hours later there was a small stool, the first for fifteen days. This was followed by pain, which an opiate enema instantly relieved.
The next day another enema of same kind, with a little of solution of Carbolic Acid added, caused a large, light-colored discharge of gummy matter. Was easy after it, but during the following night had pain and some knotting up of intestines, which required an opiate enema, and under which all subsided.
The next day a spontaneous movement of bowels occurred. The pulse, which during the entire course of the disease had ranged from 100 to 110, fell to 92. Temperature, which had been about 102, fell to 100. From this time on, convalescence was assured. The appetite soon became voracious, the bowels acted normally. Strength has returned but slowly. It has been
somewhat delayed by a curious circumstance. After the convalescence began to be established, inflammatory action set in at the seat of the punctures made for the subcutaneous injections forty days previously. On the leg a group of confluent pustules formed around each puncture, from which ulcers were developed. On the forearm were abscesses with similar sequel. None of these had entirely healed at the date of my last visit, Dec. 6th.
Feb. 15, 1879, the subject of the above case called upon me, looking ruddy and sound. He declared that he never was so stout and never so well as now.
A sore on his arm and another on his leg still remain unhealed. Serous matter oozes from them, forming a thick flat brownish crust. One on the leg has healed, leaving a depressed cicatrix, as large as a silver half-dime.
Since Dec. 6, 1878, until within three weeks, he has been taking six drops of Muriate Tinct. of Iron daily.
The sores have had no local treatment.
A CASE OF CANCER.
BY C. W. SCOTT, M. D., LAWRENCE, MASS.
(Read before the Mass. Hom. Med. Soc., Oct. 9, 1878.)
MRS. N. P. F. called upon me in the early part of January, 1872, for advice and treatment. She was born June 17, 1845; married at the age of twenty-three years, and has never borne children; is of a nervo-bilious temperament, and, we may say, has been an invalid from birth. In infancy she was sickly, and in childhood puny, until she arrived at the age of fifteen years, when she became more fleshy and seemed more healthy generally. Previous to her fifteenth birthday, she was in the habit of fainting away almost daily, the attacks occurring most frequently in the forenoon soon after rising. This difficulty gradually wore away after her fifteenth birthday. She was not croupy in childhood, and never has had a fever of any kind; has always been troubled with "humor," face broken out a greater part of the time between the age of twelve and twenty-five; in childhood was somnambulistic, and has always been addicted to talking during sleep. She was never required to work like other mem
bers of the family, but was kept out of doors, and allowed free play and amusement, her parents wisely believing that this course offered the best chance of raising her.
After maturity, until the age of twenty-two, she had frequent attacks of "ulcerated sore throat," also a cough most of the time. At this age a change took place; the cough and throat trouble disappeared, and a very troublesome diarrhoea supervened, which never yielded to any treatment.
Previous to this, for many years, at times, there was a semipurulent discharge from the navel, small in quantity, and often drying into a scab, this condition continuing to the date of her death.
In early life she was vaccinated with virus taken from a younger brother, who is still living, but sickly, and showing unmistakable indications of humor of some kind.
The youngest sister of her father, the mother of a family, died in 1867, of cancer of the womb, aged forty-five years. The daughter of another sister of the father died in 1874 of cancer of the breast, aged forty-two years.
About five years previous to January, 1872, Mrs. F. consulted an old-school physician, who gave her a prescription consisting mainly of pills of a very cathartic nature. To use her expression, they nearly physicked me to death." From this time forward, the diarrhoea became greatly aggravated, never ceasing more than a few days at a time, and always accompanied by severe pains in the bowels, especially just before and during stools. The appetite was variable, sometimes voracious, at other times moderate or absent. Thus it continued during the entire period of her illness. The stomach tolerated nearly all kinds of food, though she had a better appetite for, and apparently was in better condition when she ate early vegetables, "greens," etc.
During the eleven years in which she suffered from constant diarrhoea, she consulted fourteen physicians of various schools, sometimes with apparent benefit for a few weeks, but never with a cessation of the difficulty.
Occasionally, during the past six years, I have been called upon to treat her for attacks of indigestion, sore throat, acute catarrhal difficulties, dysmenorrhoea, etc., the old difficulty continuing uninfluenced by these attacks.