SUMMARY OF THE TRANSACTIONS

OF THE

COLLEGE OF PHYSICIANS OF PHILADELPHIA.

FROM SEPTEMBER 1, 1858, TO FEBRUARY 2, 1859, INCLUSIVE.

1858, Sept. 1. Intermittent Lochia.-Dr. CORSE read the following account of a case of this affection:

I attended Mrs. J— in her confinement, which presented no unusual symptom; the delivery was effected in what is usually considered to be a favourable manner. After delivery, the secretion of milk was established on the third day, with a slight chill and a smart fever, familiar in the lying-in chamber under the name of milk fever. Upon its subsidence, the breasts filled with milk, and lactation was comfortably established.

Coincident with the gush of milk, the lochia underwent the usual diminution in quantity and change in quality from deep red to pale; and in the course of four or five days the sanguineous character had almost disappeared, leaving the usual straw-coloured or yellow discharge. On the eighth or ninth day, at 9 o'clock A. M., the patient was seized with great pain in the lumbar region; this, in the course of half an hour or a little more, extended down the sacrum to the coccyx, and then a gush of blood or bloody discharge took place, which continued to flow as long as the pain. lasted, which was nearly an hour; it then ceased with a subsidence of the pain.

I was immediately sent for, but did not reach her until after the pain had left and the flow ceased. The pulse was good, tongue clean, and all appearance of a comfortable and safe state presented.

The next day, at the same hour, the same symptoms came on, and ran the same course. I was again sent for, but only got to the patient in time to learn the history of a paroxysm in no respect different from the preceding; and seeing no indication for medicine, I gave none.

The third day I was again sent for, and was too late again; but, on my arrival, heard a repetition of the story, describing a paroxysm which rán precisely the same course. I made a very particular inquiry into all the attending circumstances-sleep, food, discharges of bowels, bladder, etc. All was perfectly satisfactory.

Next morning I called just after the time when the paroxysm should

VOL. III.-NEW SERIES.

20

NO. VII.

come, and found her suffering great pain; the pulse not disturbed; tongue clean; surface normal in temperature; facial aspect exhibiting pain, but colour unchanged; nothing of the pallid cheeks and purple lips common in ague; hands and feet of usual temperature; in short, nothing but her words. to indicate disease, except the sanguineous discharge from the vagina. A per vaginam examination did not reveal any change whatever in the uterus; it was not tender to the touch, swollen, or hot. The os was patulous to the extent that is usual from the eighth to the twelfth or fourteenth day after delivery. There were no inflammatory symptoms in the uterus or adjacent parts; the vagina was soft, moist, and cool; no mechanical obstacle to the exit of the lochia was observable; the character as well as the quantity of the discharge was totally changed during the paroxysm. The case, to me, being new, left me to speculate as to its nature.

I began my investigation by inquiring into inherited peculiarities, idiosyncrasy, and previous diseases. I thus learned that about a year ago she had spent some weeks, during the summer and fall, a short distance below Salem, New Jersey, and there had had the chills; she had been quite cured, however, and had not had them since. This brought to mind two cases of dysentery, formerly under my treatment, in which the dysenteric symptoms returned at regularly recurring periods. The first was a quotidian, which ran on nearly a week before I awakened to a knowledge of its nature; the other was a tertian; both of which were treated with antiperiodics, and both yielded to the treatment. I therefore, after closely inquiring into the state of the general organism, considered it expedient, in the absence of any special contra-indication, to apply the antiperiodic plan of treatment to this case.

It is well known that the puerperal state is one that contra-indicates very active treatment of any kind, and especially of stimulation or excitation. Inflammation of the uterus, puerperal mania, or meningitis, might be brought on or occur coincidently, therefore I adopted a moderate course to begin with. Eight grains of quiniæ sulphas, with one grain, each, of opium and ipecacuanha, were made into four pills, and one given every hour, beginning at 5 o'clock A. M.; by this plan all of them were to be taken by 8 o'clock A. M., one hour and a half before the paroxysm.

My next visit being made after the period for the usual diurnal attack, I found the patient comfortable and cheerful, and learned that the discharge was diminished in quantity and the attendant suffering greatly ameliorated. Not a single unpleasant symptom had been caused by the quinia; I therefore increased the quantity to twelve grains, which, with one grain, each, of opium, and ipecac., I had made into four powders, and gave one every hour, beginning, as before, at 5 A. M. On my next visit I learned that the patient had missed both pain and discharge. I then ordered twelve grains of quiniæ sulphas, to be divided into twelve pills, one to be taken every hour, beginning at 5 A. M., until four should be taken each

day. This terminated the treatment without any unpleasant symptom as the result, the patient having ever since continued well.

Oct. 6. Large Dose of Opium taken by a Child, without Fatal Consequences. Dr. HAYS related to the College the particulars of a case in which a child, not quite six years old, was given a powder containing seven and a half grains of opium with the same quantity of prepared chalk (the former having been, by mistake, substituted for rhubarb, which had been ordered). Dr. H. did not see the patient until fourteen hours after the powder had been administered. He was told that the child, after taking the medicine, had seemed much excited; this was followed by restlessness and drowsiness, which continued at the time of Dr. H.'s visit. No vomiting had taken place. The narcotism was at no time very profound; it gradually wore off, and at the end of three days had entirely disappeared. Drs. CONDIE, GRISCOM, and PAUL mentioned several cases in which large 'doses of laudanum had been taken by children without serious mischief.

Nov. 2. Vesico-vaginal Fistula.-Dr. R. K. SMITH read the following report of a case of vesico-vaginal fistula successfully treated, by D. HAYES AGNEW, M. D., of Philadelphia :

Frances Hargraves was admitted into the Philadelphia Hospital, Blockley, suffering from a vesico-vaginal fistula. The following account of the accident was obtained from the patient: In January, 1858, she gave birth to a child. Her labour was exceedingly difficult and prolonged, to aid which ergot was freely administered by her medical attendant. After delivery, for several days, she found herself unable to pass urine; which continuing to accumulate, and not being relieved by instrumental interference, she suddenly felt a large gush of water escaping from the vagina, since which time her urine has continued to flow by this route. Calling the attention of her physician to this condition of things, he suggested the necessity of an operation for her relief, which was accordingly performed in May, 1858. This failing, a second one was tried two or three weeks subsequently, with a similar result. The operation adopted was, I presume, that of Dr. Sims, with the button of Bozeman, as she described the employment of silver wires and a lead plate. Since the accident, she informs me, she has never menstruated; but alleges that, when the period comes round, a very copious flow of urine takes place, and continues for two or three days. About the 1st of July I was invited to see her by Dr. Robert K. Smith, the present chief resident physician of the Philadelphia Hospital, and, in company with himself and Dr. Elwood Wilson, made an examination. An extensive transverse rent was discovered, extending from one side of the vagina to the other, certainly one inch and a half in extent. Through this protruded a large amount of thickened and inflamed mucous membrane of the bladder, and along its edge the marks of

the old sutures were quite visible. At the suggestion of Dr. Smith, and her own earnest entreaty, I concluded to attempt her relief by another operation. As the last, however, had been done only three weeks previous, it was deemed most prudent to delay any efforts of the kind for six or eight weeks. The edges were soft, extensible, and deficient in callosity or density, which showed that they had not fully recovered from the recent attempt to cure. There was evidently not sufficient resistance in the tissue to maintain the tension of sutures for any length of time. To favour the desired condition, the parts were directed to be brushed over with a strong solution of tannic acid in glycerine every day. On the 23d of August I proceeded to operate, in the presence of Drs. Smith, Wilson, Levis, McClellan, Darby, Nichols, and the internes of the house. The bowels having been previously well emptied, the patient was thoroughly etherized, and, being supported on her breast and knees, lever speculæ were inserted along the lateral and posterior walls of the vagina, and the parts drawn well asunder; the edge of the fistula was seized by a pair of rat-toothed forceps, drawn well down, and pared by means of a long-handled straight bistoury. The greatest difficulty at this stage of the procedure was in freshening the angles of the wound, in consequence of the obstinate protrusion of large folds of the vesical mucous membrane. Succeeding, however, to my satisfaction, nine needles armed with sutures of fine silver wire were introduced by means of a forceps admirably constructed by Mr. Gemrig for this purpose, the two ends of which wires were brought out of the vagina and given in charge of assistants. These were next passed through a lead plate or button, having in it a number of holes corresponding to the sutures, and modified for reasons which I shall presently state. This being accurately adjusted, and the wires well tightened, pellets of shot were slipped down over each to the button, and firmly compressed by a pair of strong dressing-forceps, thus securing my ligatures in position. The long ends of the wires protruding from the vagina were well wrapped with adhesive plaster, to prevent excoriation, and a catheter was carried through the urethra into the bladder; the patient was placed on her side, an anodyne being administered, and a diet of arrowroot and cream ordered. She was then left in the care of Dr. Cowsins, one of the resident physicians of the house, to whose careful and judicious management I owe much of my success. The whole operation consumed about two hours, and though she was kept completely under the influence of the anesthetic, with her head and trunk dependent, no inconvenience whatever was experienced, not even the ordinary nausea. It is unnecessary to give the notes of this case as kept from day to day, nothing of any interest having occurred until September 1. It is sufficient to say that her bowels were kept confined by the exhibition of a pill night and morning, containing a quarter grain of opium, the catheter was removed daily and cleansed, and the position on the side was carefully maintained. No constitutional disturbance whatever occurred,

very little local soreness was experienced, and no leakage discovered from the vagina. On Wednesday afternoon, September 1, being ten days after the operation, I proceeded to remove the plate and sutures, in the presence of Drs. Wilson, Levis, McClellan, and Richardson. The shot were clipped, the button withdrawn, and the wires severally picked out, when we had the pleasure of learning that complete union had taken place. As a precautionary measure, the catheter was allowed to remain for eight days longer, and the patient confined to bed on the side. On the twelfth day her bowels were gently moved, and again locked up for five or six days. Ten days after the removal of the ligatures she was allowed to walk about.

Fig. 1.

Remarks. It will be seen from the above details that the operation in this case was that of Dr. Sims, varying only in the employment of the Bozeman button as modified by myself. To that modification I am disposed to attribute the success in this particular case. The proneness of the mucous membrane of the bladder to project through a fistula into the vagina I suppose has been noticed by every one who has seen a case of the accident. When the ordinary button is used, it is impossible for the surgeon to determine whether a portion may not have insinuated itself between the edges which he is approximating, and thus defeat the desired union. I think this may explain the failures which often occur. To obviate the possibility of such an occurrence, I requested Mr. Gemrig to make me such a button (lead) as is represented in the annexed cut, in which there is a centre-piece with holes through which to pass the ligatures, and between this and the circumference on either side two halfmoon shaped pieces are cut out. The advantage is obvious. When it is placed in position, the operator can readily see if there be anything interfering with the accurate adaptation of the parts. Had I not adopted this button, I feel satisfied failure must have ensued, as I was obliged to press back in two places small portions of the mucous membrane of the bladder, which had worked down between the approximated edges of the wound, and which were easily discovered through the portions of the button cut out. This case proved also very conclusively, to my mind, the value of the metallic over the silk suture. There was scarcely a trace of suppuration, the ligatures being all well in place on the day of their removal, ten days subsequent to their introduction. This fact would induce me, in another case, to dispense with the button altogether, as, I believe, is now practised by Dr. Sims, simply twisting the wires, or otherwise to employ the twisted suture, using silver pins, and protecting their ends by shot.

Dr. R. K. SMITH stated that he had not seen this case since the middle of September. At that time he had been satisfied, with Dr. Agnew, that the cicatrization was complete, and the fistula entirely closed.

Since then the patient had been repeatedly and very carefully examined

20*