AlexanderD. Pithie
1910 The Lancet  
THE patient in the following case was a married woman who was confined prematurely of an eight months' child on June 4th, 1909, and made a fair recovery. Her highest temperature during the first month was on the fifth day, when it was 990 F., with a pulse-rate of 102. In the right breast she had no milk, and in the left only a little, but not enough for the child, who accordingly had to be fed with the bottle. The left breast ached from the time the child was put to it till the time of sitting
more » ... p, when it felt so heavy that the nurse supported it with a sling on the tenth day, after which it was more comfortable. At the end of the first month the patient menstruated, when the left breast became very tender and ached, a lump appearing which was so tender to the touch that she could only lie on her back. The district nurse then advised hot fomentations for four days, when the pain became less, but when the next period came on the pain was worse, and at the time of the third period, or about Sept. 4th, there was found a lump of the size of a walnut, which became inflamed and shiny, forming an abscess, which broke on Sept. 25th, and offensive thick yellow pus was discharged. She still continued the fomentation for ten days. The nurse saw her on Oct. 5th, and kept her in bed ; the temperature was normal, but the patient was very weak and on that night she had a rigor, with sickness and faintness. When called to see the patient on Oct. 7th I found her in an almost collapsed condition, with a temperature of 103° F. and a pulse-rate of 100, the temperature rising that night to 104 8°. The breast was red but not swollen, the redness being more of a skin rash. To the left of the breast there was an opening which was evidently superficial, as a probe could not be inserted to any distance, but no evidence of pocketed pus could be found. No other condition to account for the high temperature could be detected. Strychnine and quinine were administered and the temperature gradually came down till the llth when it suddenly rose again to 105°. This time not only the breast but also the whole of the chest and upper part of the abdomen became covered with the rash which was of a bright red colour. The right breast also became painful and a painful spot appeared on the left shoulder. No evidence of suppuration was to be found. The patient at this time had the appearance of a person in extremis. I then injected 10 cubic centimetres of Allen and Hanburys' polyvalent antistreptococcic serum in the walls of the abdomen, repeating the injection in ten hours. As the vomited I decided to give it per rectum, which was carried out for the remainder of the treatment. For the first three days she retched after each dose of serum, but then tolerance was established and the nausea passed off. Administration of serum was carried out three times a day until the 15th when it was given twice daily, and then once a day till the 18th, when it was stopped, the temperature being normal and the pulse-rate 88. Her condition otherwise was very good and all appearances pointed toward a sure convalescence. On the 26th, however, the temperature once more began to increase, being 100 ' 20 in the morning and rising to 102 -40 the next morning, when a small superficial lump was found on the left breast. Again the whole of the chest and neck was covered with the rash. On the 27th serum was given twice, and on the following day three times, when the temperature came down to 97 ' 80, serum being given once daily and for the last time on the 30th. The patient then made a slow but satisfactory recovery, and is now quite well. The points of interest in this case are the evident absorption of septic matter from a mastitis without any evident collection of pus ; the prompt and satisfactory action of the serum after quinine had been given without good effect; and, finally, the recurrence of the symptoms in a few days after the serum had been stopped, and the controlling power of the serum when again resorted to. This leads me to think that in similar cases it would be well to continue the administration of serum for some time after all symptoms had subsided, if even in smaller or less frequent doses. Mr. H. CoL1 rn.so read a paper on the Analysis of 197 Cases of Duodenal Ulcer operated upon by Mr. Moynihan (1900-1908. Sir T. LAUDER BRUNTON said that with regard to the season it had been his experience that gastric and duodenal ulcer-he could not distinguish them in his list of cases-was much more common in two periods of the year. He had not noticed it so much in mid-winter, but much more in autumn and spring. And the reason which he had assigned to himself was that people put off . too long their winter clothing and so were chilled in autumn, and they put off their winter clothes too early in the spring, and in each case a chill was liable to result. Many years ago, when he was working at the physiology of the subject for Burdon Sanderson's "Hand-book for the Physiological Laboratory," he made very many experiments upon the stomach and upon the intestine. He tried, and in vain, to make gastric ulcers. He put a ligature round a small portion of the mucous membrane of the stomach which he had previously opened, and then closed the wound, keeping the animal under narcosis, and allowed it to remain four or five hours. He thought that at the end of that time an ulcer would be found at the spot where the blood-supply had been stopped by the ligature. But in none of the cases was he successful. Mr. Moynihan had left out reference to one part which he (Sir Lauder Brunton) would like to supplementnamely, the cause of the pain. The pain came on between two and four hours after the stomach had commenced to discharge its acid contents. Those acid contents came over the , duodenum and smarted the ulcer, causing intense pain by the acid acting on the bare surface. This pain could be , relieved by not putting anything into the stomach which , causes a reflex contraction of the pylorus, the acid juice : from the stomach was thus prevented from flowing into the duodenum, and any acid which was already there was . quickly neutralised by the alkaline juice of the duodenum itself, possibly partly by some of the bile. That might be imitated by giving bicarbonate of soda in large doses. Time i was a very important facto,r in the diagnosis, as Mr. , Moynihan had said. Sometimes one might be misled as i to the nature of the lesion, and yet be right as to its position. l In one case which was brought to him the symptoms were . pain four hours after feeding, and he thought there must be l something wrong in the duodenum, but it did not yield l in the ordinary way to the administration of alkalies, . and he said he was doubtful as to whether it was ulcer or not, i but he thought it must be something wrong with the l duodenum. He never saw the case again. Eighteen months afterwards there was a description in THE LANCET of an l operation on that patient. From that it turned out that he , was right as to the position of the lesion, but it was a kink , and not an ulcer. Time had also been very valuable to him in diagnosing duodenal ulcer when the diagnosis for a time r would have been very doubtful. As an example he might mention that he was once asked to see a patient who was suffering from severe lumbago. On examination he found G that the so-called lumbago was limited to the right loin ; it i did not extend round the back. It came on between two and 1 three hours after a meal and was again stopped by food. T He (Sir Lauder Brunton) concluded that it was a duodenal ulcer, and told the doctor that it could be perfectly well ascertained whether it was duodenal ulcer or not by giving a large quantity of bicarbonate of soda, and if it was duodenal , ulcer, by neutralising the acid of the gastric contents one would stop the pain. The doctor tried it and the pain ceased immediately, so that there was some doubt as to the
doi:10.1016/s0140-6736(01)73614-8 fatcat:rljl4wjn5fhedatezqg72d2qym