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silver. I also stretched the sphincter. The bowels were kept quiet for two or three days and that was the last of the trouble.
Case III. A lady had been suffering for about two years as she thought with a case of chronic dysentery. She too had the characteristic discharges. At first there was very little pain, but she had more than the usual amount of uneasiness after an action. This, however, she attributed to internal hemorrhoids. Not knowing any better and being advised against an operation of any kind for her piles, she had borne the ever increasing pain like a martyr, until at the time she consulted me life was a perfect burden to her. She often sought a secluded spot to let her bowels move, so she could give way to her feelings without disturbing anyone. When I told her she had an ulcerated bowel, and that I could cure her with an operation, she actually wept, and insisted upon the operation at my earliest convenience. The following day I divulsed the sphincter, removed a fecal impaction which was greatly aggravating her suffering, scraped, scarified and cauterized two large irritable ulcers, one posterior the other anterior, applied or inserted a pledget of cotton anointed with vaselin, and dusted with iodoform and a little powdered opium. The cotton was removed the following day, and the third day I gave her a small hypodermic of morphia and a large dose of salts. The morphia was to make her tolerate the salts until it had done its work of softening before allowing the bowels to move, and when they did move without pain or uneasiness I think she was the most grateful person I ever saw. From this time on there was no further trouble.
Case IV. A prominent gentleman in Trenton had suffered with rectal ulcer for fifteen years. He told me had not had a natural action of normal consistency for five years, but had taken large enemata every day, with which there would pass considerable washings each time. Then he had taken a great deal of salts, which would cause copious, watery discharges, all of which contained more or less fecal matter. When I first saw him he was suffering from indigestion and urticaria, and, strange to say, he was apparently relieved of both, and I had left the city when his bowels attempted to move, and, as might have been expected, it threw him into a spasm of pain. Dr. Faucett saw him in my absence, and recognizing the trouble had attempted to break up and remove the impaction with his finger, but on account of the pain was compelled to desist. It was in this condition that I found him on my return one day later. This was my first knowledge of any real trouble
with his rectum; he had frequently said his bowels were not like anybody else's, and that he was afraid he would have trouble moving them on account of the milk diet that I had kept him on for about four to six weeks, but had never designated any fixed trouble in any part of the tract.
It took several days to convince him of the necessity of an operation. Under anesthesia I found the sphincter drawn as tightly as could be around the anus. The pouch was filled to its limit with hard, dry fecal matter. After divulsing both sphincters (and this was one case in which the internal sphincter was a factor to be overcome) I removed the impaction, washed the gut and found the largest, deepest ulcer it has ever been my lot to see in any rectum. On the anterior wall it was about two-thirds of an inch wide by two and one-half inches in length and one-fourth of an inch in depth. The posterior wall was a perfect honeycomb of ulcers, the sulci running very deep into the tissues. I divided. some of the intervening tissues, trimmed the overhanging edges, scraped and scarified the base of all the ulcers and cauterized the whole thing with nitrate of silver. The insertion of cotton dusted with iodoform and pulverized opium completed the job. It took him fully three days to react from the effects of the chloroform, and about this time he began to suffer pain in the rectum again. I gave him two ounces of sulphate of magnesia and one-fourth grain of podophyllin to move the bowels, which started what might be termed a mushy flow. With this flow the pain became very much intensified, it requiring from one and one-half to two grains of morphia hypodermatically every twenty-four hours to relieve him. Upon examination I was very much surprised to find the pouch of the rectum again distended with hard, dry, fecal matter, notwithstanding this flow of feces was going on all the time. His nurse would attend to him from fifteen to thirty times in twenty-four hours. He was again very slow to consent to another operation, but finally yielded. This time I found, if possible, a worse impaction than at the first operation, which I carefully broke up and removed. After thoroughly cleansing the gut I found it in about the same condition as at first. I again scraped and scarified the base of all the ulcers and carefully cauterized the ulcerated area and took special pains to stretch the sphincter muscle. At this operation I discovered a small fistula which opened about one and one-half inches up the gut. I laid that open and inserted the cotton as before described, and put him to bed. The flow was held in check while the tampon was in the rectum, but set up as freely as ever as soon as the cotton was
removed. This I thought did away with the necessity of giving a saline. The cotton was removed at the end of twentyfour hours, and the rectum well douched with normal salt solution, after which I would use a wash of fld. ext. hydrastis 31, to water ii. This wash was sometimes passed off and sometimes retained. There was but little actual pain after this operation, but he had the opium habit to some extent, which required some attention. For thirty-three days I visited this man at 9 A.M. each day and douched his rectum with the salt solution, after which I would use the hydrastis wash each time. Eight days after the second operation I gave two ounces of sulphate of magnesia, and the pouch again filled with hard, dry, fecal matter. But the rectum was so much improved that I removed the impaction this time without an anesthetic. Five days later it was filled and removed in the same way, and in three more days the process was repeated again. After this there was no more hard, dry feces passed.
In fact I think we had caught up with the grinding. This was the 20th of February, 1902; my first visit was made about the 7th of September, 1901. The patient was now eating heartily, enjoying his meals, and could have an action from his bowels like anybody else, so after doing two operations, removing five fecal impactions and visiting him four hundred and twelve times, I dismissed the case as cured.
In the treatment of this case I am indebted to Dr. J. T. Faucett, of Trenton, for valuable assistance and advice.
THE DIAGNOSTIC SIGNIFICANCE OF A CHILL.*
B. F. TURNER, M.D.
Ir is a matter of common observation that in this part of the Mississippi Valley, where the malarial infections comprise so large a proportion of the prevailing sickness, the idea of a chill as associated with such infections obtains an unwarranted hold, not only upon the minds of the laity, but of many physicians as well. Moreover, in the physician's life the distractions, the worries and the fatigues, together with a physiological amount of that very human attribute, indolence, all conspire to blunt his alertness and cultivate within him routine habits
* Read before West Tenn. Med. & Surg. Assn., Jackson, May 19, 1904.
and laxness in diagnosis. The purpose of this paper is, therefore, that of a reminder of a number of conditions other than malarial infections which are characterized by a chill, the neglect of which may lead us far astray in our therapeutic endeavors.
A chill is essentially a disturbance of the nervous system. In its complete development it is characterized by sensations of coldness radiating along and outward from the spinal column, of motor disturbance called shivering which may become so violent as to transmit rapid shaking motion to surrounding objects, and of disturbance of the vasomotor apparatus supplying the skin. Pain, hyperpyrexia, subnormal temperature, disturbances of the pulse and other phenomena which frequently are associated with a chill, are not necessarily physiologically identified with it. All of the elements comprising a chill are not always present. The degree of severity of the development of these various manifestations is extremely variable and is not proportional to the severity of their cause.
The malarial chill is mainly distinguished by its periodicity. A history of recurrent chills on alternate days is safe enough ground upon which to base a diagnosis of this infection, while the microscope for blood examinations now affords us a certain means of identifying it in those rarer cases of mixed infection in which the paroxysms are daily or irregular.
The infectious diseases are mostly ushered in with a chill. Especially is this to be noted in la grippe. This singular and insidious disease steals upon us like a thief in the night, and the first intimation we have of its approach may be "a chill that shakes the bed." The chill is more than likely to mark the onset of scarlet fever, measles, small pox, yellow fever, and often even typhoid. To commit one's self to a diagnosis of "malaria" and after prescribing the customary calomel and quinin, to witness within a day or two the development of a pronounced eruption of one kind or another, may be embarrasing.
Tonsillitis is usually ushered in by a most pronounced chill. I can think of no disorder which is more frequently incorrectly diagnosed. The same might be said, however, of many of the varieties of acute local inflammation, especially that of acute lobar pneumonia and acute hepatitis.
The onset of the acute disorders of the digestive system is very frequently marked by severe chills and a pronounced rise of temperature. Doubtless the abdominal surgeons present will certify to the large number of cases of appendicitis which begin with this symptom.
The irregular chills, with exacerbations and remissions of temperature and sweating which characterize the presence of pus, should be more accurately interpreted. I know of no error more frequently committed and none less excusable than this one of overlooking a possible accumulation of pus somewhere.
Acute congestive nephritis is often marked by a most distressing chill at the onset, and uremic conditions in general are very likely to manifest themselves thus.
The chill, i. e., the violent shivering, minus the disturbance of temperature and pulse, which is due to emotional tension, is a familiar phenomenon. We hear one speak of having had "a nervous chill," and this is, all things considered, rather an accurate expression.
The above summary by no means exhausts the list of conditions which may be characterized by the occurrence of chills, but it embraces, I think, the commonest ones. If it be suggested that all of these are matters of everyday knowledge or should be, I would here reply that there is need of a protest against what might be called a calomel and quinin habit. Among the above-mentioned disorders acute congestive nephritis is one in which, according to recent views of pathology, the administration of quinin would do positive harm. Pneumonia is one which demands quick and accurate diagnosis and vigorous treatment from the earliest possible moment, and treatment moreover which is far removed from the routine calomel and quinin. An attack of acute indigestion demands a brisk purgative, preferably castor oil, but no quinin, while a rigor due to upsetting of the emotions is easiest handled with a dose of apomorphia, and so on. But when, at the end of a day's work, you sit down and make a mental résumé of what you have done, in about what proportion of your cases have you prescribed calomel and quinin? I beg to repeat that there exists a sort of routine treatment of