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The calculated dates of attack were the 4th, 5th, 11th, 12th, 19th, and 21st March, the last case being that of a brother of the proprietor who lived and worked on the premises. In the time which elapsed between the first and last of these notifications, only sixteen other cases were reported from the whole district with a population of about 67,000. There was another circumstance which made more definite the attribution of the outbreak to the milk supply. A list of the customers was obtained shewing that 154 households were supplied, and it was found that in most instances the milk was scalded before delivery, but that 22 householders preferred to obtain the milk fresh. All the cases outside of the dairy occurred among persons belonging to these households.
In various ways the history of this small outbreak was an interesting one. The man who is assumed to have distributed the infection had not an unusually severe attack, judging from the period of stay in hospital, though his ability to take up work was delayed by an attack of pleurisy. His illness apparently began on 1st December, and the last cases among his customers occurred on 11th, 12th, and 19th March, so that even allowing fourteen days of incubation, full three months elapsed between the beginning of his illness and actual infection in these cases. As soon as suspicion was excited, precautions were at once taken, and when the second case occurred on 21st March, these were renewed, and the outbreak, so far as concerned this focus of infection, was at an end. And warning was further taken, and return to work on the part of this patient was prohibited for three months after discharge from the hospital. This was, perhaps, a straining of powers, since the maximum time of seclusion, contemplated by the Victorian Health Act, is fixed at three months. It is not stated, of course, at what date or stage of illness the period of three months begins to count, and advantage may thus be taken of this vagueness. With the knowledge we now have of the duration of infectivity, in more than one of the infectious diseases, it is apparent that the limit of three months, whether from the beginning of the attack or from the establishment of convalescence, does not err on the side of over-strictness.
[Read at the Intercolonial Medical Congress at Hobart.]
AT the meeting of the Benevolent Asylum (Melbourne) committee on April 4th, the chairman said the committee should consider what should be done in the matter of the £25,000 legacy recently left to the institution by the late Mr. J. Hingston. The committee should decide whether the building was to be removed from its present site or not. It was decided that the matter be considered at next meeting.
CASES of gastric fistulæ are apparently not of frequent occurrence. Sydney Martin, in his book on "Diseases of the Stomach," does not mention their existence, but Robson and Moynihan in their work on the " Surgery of the Stomach" devote a chapter to the condition. The fistulæ may be internal, i.e., between the stomach and some other abdominal or thoracic organ, or open externally. They are either traumatic or due to a perforating ulcer, simple or malignant. I am doubtful whether my first case should come under the heading of this paper, as I made an opening myself into a subphrenic abscess which afterwards became a fistula. The history of the first case is as follows:
Miss G., t. 25, from Grunthal, who had consulted me several times previously for anæmia, called on February 6th, 1899, and it was then noted that she looked ill, and complained of pain in the left hypochondriac region, made worse by taking food or breathing. She came again on March 1st, and was then much better. Dr. C. Mainwaring saw her for me on April 13th, and she then complained of pain after food and between her shoulders, but no vomiting. She was brought down on April 27th, having driven 18 miles in a buggy. She was greatly collapsed, with a feeble, thready pulse, and a dusky expression and a temperature of 103° F., and gave a history that, whilst vomiting the night before, she had experienced a sudden, violent, pelvic pain. The breathing was so difficult that I was afraid she would die in my consulting room, and I had the greatest trouble in persuading her friends to leave her in the private hospital, as they were most anxious to take her back the long drive.
Dr. Poulton saw her with me in the afternoon, and we found the abdomen distended and tender over the region of the appendix, and although we did not think the symptoms pointed altogether to a perforation of that organ, we bore that in mind. She recovered from the collapse and the abdominal distention gradually receded, but never actually flattened. The temperature rose each night to 101° F. or 102° F., and on May 4th she developed a parotitis on the right side, followed by a similar condition on the left; these went down, but her temperature still remained high at high.
On May 9th there was tenderness below the left rib cartilages, and I thought a fullness; but a few hours afterwards neither Dr. Poulton nor
myself could find any physical signs in this region. Impaired resonance now appeared in the left axilla as high as the eighth rib, but this dulness was most peculiar, as it would be absolutely dull in the morning and hypere sonant in the afternoon. On May 13th it was decided to explore here under an anesthetic, and Dr. G. Hayward having administered gas and ether, a hollow needle was inserted in the eighth interspace in the mid-axiliary line, and about 3ii. of foul-smelling pus withdrawn. An inch of the ninth rib was then resected, and a small flat cavity entered, which contained foul pus. The cavity could be extended inwards by gently insinuating the finger, and appeared to be going below the arch of the diaphragm and above the stomach and spleen. A tube was inserted and a dry dressing applied. The nurse was told to look out for the contents of the stomach on the dressing, and they appeared at the first changing.
Borthwick, nine weeks ago, and has been in bed ever since; but she does not think that she has lost much flesh. The swelling became much larger after Dr. Borthwick saw it, and he recommended exploration, but the proposal was refused. Six weeks ago she had rigors followed by night sweats, and fourteen days ago a foul smelling discharge of pus occurred from the umbilicus. Her present state showed a pale face, but fairly well nourished body. There was a swelling about the size of a fatal head at term, placed above the umbilicus, tender in the upper portion, with a fulness to be traced below the umbilicus on the left side. The swelling was movable laterally under an anesthetic. The umbilicus presented a central perforation, which admitted a probe for one inch, and discharged a thin, foul smelling pus. Nothing else abnormal could be detected in the abdomen, and the lungs were healthy. The heart's apex beat could not be felt, the sounds were clear at On the following morning, on removing the the apex and base, but a systolic murmur could dressing and giving the patient milk to drink, it be heard over the xipho-sternal articulation. immediately came out through the drainage The urine was of a good colour, acid, 1020, with tube, shewing a perforation of the stomach no albumen, sugar or bile. The axillary teminto a subphrenic abscess. The patient gradu-perature was 99-6° F. The pulse 116, soft and ally improved, but the stomach contents still escaped from the wound, but in varying quantities, and on May 24th it was noted that if the patient remained on her back or on the left side the fluid contents of the stomach escaped, but if the patient lay on the right side she soon suffered a peculiar dull pain, only relieved by turning on her back and allowing the drain to act. On June 4th it was observed that the patient was becoming decidedly emaciated with a high evening temperature, and her friends took her home to the country, where she lingered for a few weeks and died practically of starvation. Unfortunately no post-mortem examination could be obtained.
The second case was Mrs. A., æt. 64, seen at Burnside with Dr. Borthwick on September 4th, 1901. The patient was a very anæmic and somewhat emaciated woman, complaining of a discharging sinus at the umbilicus. Her past history was good; seven years before she had been operated upon by the late Dr. Way for varicose veins. Her present illness dated back two years, when she first noticed an uncomfortable sensation in the upper abdomen, which was soon followed by increasing weakThere had never been any vomiting of blood or coffee grounds, and only a few attacks of retching. A swelling in the abdomen in the neighbourhood of the umbilicus was first noted about a year ago, but only became painful during the last few weeks. She was seen by Dr.
compressible. She was admitted to the private
The contents of the stomach continued to escape for several days, together with pus, but
the opening gradually closed, and would remain so for a few days and then burst out afresh. The swelling remained much the same in size, and the patient went home at the end of a month and eventually died; Dr. Borthwick telling me that the swelling increased in size before her death. No post-mortem was obtained. The third case is not altogether a certain diagnosis, and it only struck me what was its nature whilst writing this paper. I will give it for what it is worth.
Miss O., t. 18, sent to me by Dr. Davies, of Yorketown, on September 27th, 1901, complaining of a bad cough, more especially at nights when lying down, the cough having been present about two months. During this time the patient had been losing flesh, but had never coughed up any blood or hydatids, and had not suffered from night sweats. She was a very anæmic girl, but fairly well nourished. Her breathing was short, and on examination there was found to be dulness on the right side, from the hepatic region up to the right nipple, and extending round to the angle of the scapula behind. There were a few crepitations in front, with tubular breathing below and to the left of the right nipple. The breathing in the axilla and posteriorly was almost inaudible, and the vocal resonance and fremitus absent in these situations. The heart's apex beat could not be localised. Her heart's sounds were normal, and her urine was free from albumen and sugar. She was admitted to the private hospital, and on the night of her admission her temperature was 103° F. Next morning she had coughed up about half a pint of what looked like frothy expectoration on the surface, with a creamy material below. Dr. J. C. Verco saw the patient with me in the afternoon, and we both thought that the physical signs pointed to a hydatid cyst on the convex surface of the right lobe of the liver, and we decided to explore with an aspirating needle, and drew off about 6 ozs. of ordinary serous fluid from the posterior axillary line, but this made no difference to the physical signs in front. I had the expectoration examined, and the report said no signs of hydatid, no tubercle bacilli; but there were plenty of yeast cells and starch granules and debris. After aspiration the temperature kept down, but the physical signs remained the same, and the patient returned home. She came to see me again on December 10th, and the physical signs were still the same with the exception of an enlarged gland in the right supraclavicular fossa, which made me suspect a new growth in the lungs. I had the expectoration again examined, and the report came back again
-no tubercle bacilli, no signs of echinococcus, but starch granules, yeast cells, and what appeared to be partially-digested food. I must say that I was at a loss for a diagnosis, and the girl returned home, and Dr. Davies told me a few weeks later that he was certain that it must be pulmonary tuberculosis, but since reading Robson and Moynihan I have come to the conclusion that it is a case of gastric fistulæ opening into the right lung.
In the first case, there can be very little doubt but that the patient had a gastric ulcer, which ruptured during the night of April 26th, 1899, during a violent attack of vomiting; and instead of the patient dying in a short time, adhesions formed, and a subphrenic abscess followed. It is almost impossible to say whether the perforation in this case occurred on the anterior or posterior surface of the stomach; but I am inclined to think it was on the former, not only from the acute collapse and abdominal pain which occurred, but from the condition found at the operation. Probably what happened is this: a perforation took place on the night of April 26th, but not enough to flood the peritoneal cavity; adhesions formed between the great omentum and the anterior abdominal wall and liver; the contents then made their way up on the left side of the falciform ligament of the liver, and formed the peculiar cavity my finger went into. This cavity at times must have been full of gas and at others full of fluid from the varying dulness and hyperesonance. So much was this the case that I thought Dr. Poulton would think I had turned my physical signs topsyturvy, for whenever I had found the side dull in the morning he found it hyper-resonant in the afternoon. I presume when we turned the patient on the right side the escaped contents of the stomach began to digest her internal organs, whatever may have formed the right wall of the cavity giving rise to the dull pain. This was always relieved by allowing the contents to escape on turning the patient on to her back or left side. The attack of parotitis coming on in the case is of interest, especially when considered in connection with Stephen Paget's paper on this condition following abdominal injuries, and bears out what he says about the inflammation of the parotid occurring in other abdominal injuries than those connected with the pelvic viscera.
The second case is an example of idiopathic gastric fistulæ. This condition is extremely Murchison could only find 25 such cases extending over three centuries. From the age of the patient one would expect the ulcer to
have been malignant in origin, but of this I am uncertain. There was the history of the two years' illness, with the slowly growing swelling and the pultaceous mass, which was SO markedly non-vascular, and did not appear to be malignant. The idea I formed at the time, and which I still believe to be the correct one, was that a rupture of a gastric ulcer took place slowly on the posterior wall of the stomach into the lesser omental cavity, and that this cavity became filled with a kind of lymph, which gradually suppurated, became adherent to the neighbourhood of the umbilicus and perforated here. What struck both Dr. Poulton and myself was the amount of lateral movement that could be obtained, and also the localised swelling which could be so plainly mapped out by the finger in the swelling and the hand outside. Of course the condition may have originated in a malignant ulcer, and yet the material our fingers went into might have been lymph, lowly organised and breaking down.
With regard to the third case, I would rather say no more here, as probably future developments may make matters clearer; but my present idea is that it is a case of duodenal ulcer, which has formed a retroperitoneal abscess, and this has passed upwards, through or behind the diaphragm, and after entering the right pleura has burst into the right lung.
[Read before the South Australian Branch, British Medical Association, March, 1902.]
ADIPOSIS DOLOROSA (DERCUM'S DISEASE). By E. Angas Johnson, M.D., M R.C.S., Assistant
Physician to the Adelaide Hospital.
MRS. H., æt. 32, nullipara, who was born in and has never been out of this colony, consulted me in November, 1901, for her "stoutness," which she said was attended with great pain, especially at menstruation. The menses are regular, but scanty, and last only two to three days.
Previous History.-Always strong and well. Influenza two winters ago. No history of syphilis, alcohol, rheumatism, or traumatism. Thirteen years ago was married, and at that time she weighed 7 st. 9 lb. Eight years ago she noticed that her stomach was getting larger, and very tender on pressure (the pain being compared to that of a bruise). Then the hips, chest, arms, and legs got bigger. Pains of a neuralgic nature under the left shoulder, which have been worse since the influenza; also neuralgic pains on crown of head, across the
forehead, and particularly over the left temporal region. There are frequent hot flushes of the face, followed by cold, clammy sensations; also giddy sensations, with a feeling as if she is going to fall forwards. Locomotion is difficult, and a very short walk is followed by great breathlessness and palpitation, her nervous equilibrium being upset over most trivial matters. When she "catches a cold," the pain in the chest is so severe that she cannot sleep on its account. Standing for any length of time causes severe pain in the ankles and knees (which don't swell); this also prevents sleep.
Since both her sister and self were employed by my parents before they were married, I have been able to notice the excessive development of adipose tissue more carefully than had I not known her so long. At that time she was a very thin girl, and her sister was almost twice as stout; so that by contrasting the present measurements of their two bodies the increase will be self-evident.
On Examination.-A very stout woman, with a slow, waddling gait (which Professor Watson very aptly terms an ambulatory lipoma). The hair is normal, the face is not affected, and looks small comparatively. The eyes are normal, the sight unaffected. The thyroid gland is normal so far as it can be felt. The Chest: The walls are infiltrated; the mammæ are very large, soft and doughy; the lungs normal; the heart, the sounds are weakly heard, but no murmur detected. The temperature is normal, the pulse 96. The Abdomen : The abdominal walls are very much infiltrated, so that whilst in the recumbent position big folds of fat are produced. This is tender on manipulation or slight squeezing, the pain, as already noted, is likened to that which follows a bruise, the skin bruising on very slightly squeezing it. Urine: The quantity not increased; specific gravity, 1010; no albumen, no sugar, no deposit. Per
Vaginam Professor Watson said the vagina was small, and the uterus infantile. The Extremities: The hands and feet are normal, except for a slight fulness of the thenar, hypothenar, and plantar eminences. The reflexes are normal. There are no enlarged veins or abnormal tenderness over the big nerve trunks. No muscular wasting can be detected. The headache, vertigo, palpitation, and sleeplessness are intensified at menstruation.
15th February, 1902.-The weight is 13 st. 7 lb.
Treatment. Slight massage, combined with thyroid tabloids, which will both be gradually increased.
5th March, 1902.-Patient has not been weighed since, but the affected areas already seein firmer to the touch (and not so doughy).
Although morphia is condemned, it was the only drug that relieved the severe neuralgic pains which preceded her last menstrual attack one week ago. Professor Watson very kindly saw this patient in consultation with me, and confirmed the diagnosis.
Unfortunately, the patient won't allow a photograph to be taken of her, but from a picture in the Medical Review, Vol. III., page 676, a fair idea of her appearance can be got, Mrs. H. being about twice as fat, the hips being very prominent.
CLINICAL AND PATHOLOGICAL NOTES.
An Obscure Case.
A MALE child, aged 7 years, was admitted to Prince Alfred Hospital, Sydney, on July 3rd, 1901, with a history of six days' illness with vomiting and abdominal pain, attributed by his parents to his having eaten some meat. had always been delicate, suffering from "weak digestion," and was said to have had "erysipelas of the head and inflammation of the brain" two years previously. On admission he was in an extremely collapsed condition, extremities cold, semi-conscious, pulse barely perceptible, respirative sighing, and temperature sub-normal; tongue dry and furred, abdomen retracted and hard, and marked tenderness over the epigastrium and left hypochondrium was present. The bowels were constipated. There was no squint or indication of cranial nerve involvement. The vomiting was urgent, and nutrient enemata were not retained. The temperature only reached 101° on one occasion. The stomach was washed out with saline solu
tion, and then with Condy's fluid, and subcutaneous injection of one pint of saline solution was administered. Hypodermic injection of strychnine grain every three hours; hypodermic of morphia of a grain on one night, and later a mixture of bismuth sub-carbonate and soda bicarbonate completed the treatment adopted, and which resulted in rapid convalescence and cure.
The child was re-admitted on October 23rd, 1901, in practically the same. state as when admitted on July 3rd; this illness also ensuing upon his having some meat for the first time since his first attack. The symptoms were practically the same, but though similar treatment was adopted, he never rallied, and died 30 hours after admission.
A post mortem examination was made by Dr. Cleland a few hours after death. The stomach and intestines presented no macroscopic signs of any disease. The liver was slightly softer than normal, and showed some fatty change on microscopic examination. kidneys were pale, but otherwise showed no gross change in structures; but the epithelium of the tubules showed considerable fatty degeneration. All other organs of the body, including the nervous system, appeared perfectly normal.
Cultures were taken from the spleen, which grew on agar in twenty-four hours as dense, white spherical colonies, consisting of a bacillus staining somewhat irregularly and faintly with methylene blue, and sometimes slightly curved. From the liver two colonies only, of a similar but stouter bacillus, were obtained.
The points of interest in the case are:1. The very severe gastric symptoms, without corresponding post mortem appearances of inflammation of the gastric mucosa. 2. The total absence of post mortem appearances of gross pathological changes. 3 The readiness with which the symptoms cleared up in the first attack under lavage of the stomach and saline injection, as opposed to the utter failure of the same treatment on the second occasion. 4. The trivial nature of the supposed cause, and absence of any other known etiological factors. 5. The fact that the attacks might have passed for cerebral disturbances, while the large size of the head and the doubtful history of inflammation of the brain would have supported the theory, whereas the post mortem examination revealed a very large, but, macroscopically at any rate, a perfectly healthy brain.
C. BICKERTON BLACKBURN, M.B, CH.M.,