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Rigor. Slight Rigor. Erysipelas about Wound. Local Cellulitis of Arm. Sweating. Rigor after Operation. Before Operation. Temperature Table in a Case of Intra-Venous Injection of Milk, followed by Suppurative Phlebitis. 1st Day. 2d Day. AM. P.M. A.M. P.M. Temp. F. 106' 105' 104' 103' 102' lor 100' 99° 9S° 97° A SUCCESSFUL CASE OF INTRA-VENOUS INJECTION OE MILK. BY | W. E. BULLARD, M. D., NEW YORK, VISITING PHYSICIAN TO THE DEMILT DISPENSARY. [REPRINTED EROM TRE NEW YORK MEDICAL JOURNAL, AUGUST, 1878. NEW YORK: D. APPLETON AND COMPANY, 549 & 55 1 BROADWAY. 1878. A SUCCESSFUL CASE OF INTRA-VENOUS INJECTION OF MILK. John M., aged twenty-eight years, native of New York, carpenter. Patient has always enjoyed good health up to three months ago, when he complained of slight pain in the umbilical and epigastric regions; this was referred to dyspepsia, but he did not seek advice for it. Food taken into the stom- ach would occasionally increase the above-mentioned symp- tom. Patient naturally anaemic; but this condition gave him no trouble. On the morning of May 26, 1878, while on a visit at a friend's house, he was suddenly seized with a feeling of great oppression over the stomach, and almost immediately vomited a quantity of partly digested food, mixed with dark blood, some of which was clotted. Great relief was at once experi- enced ; and after returning to his home and resting till even- ing, he again went out calling with his sister. During this visit he drank a glass or two of beer, and soon afterward the same desire to vomit compelled him to retire, and again dark blood, with lighter blood mixed with it, was vomited. The quantity raised at this time was considerably larger than in the morning. 4 This second attack left him very weak. He went imme- diately home and lay down, but was obliged to rise three or four times during the night, to either vomit, or have a passage from the bowels, and now dark blood showed itself in the matters passed per rectum. On the following morning a teacupful of pure blood was vomited, and at different times during the day smaller quan- tities were either passed per rectum, or vomited. He had, by this time, become extremely weak, and was unable to sit up in bed without feeling faint. A request having been left at the dispensary for a physi- cian, my assistant, Dr. J. J. Buckley, called upon the patient at twelve o'clock the same day and found him in the condi- tion above described. The doctor estimated the quantity of pure blood thrown off just before his arrival to have been one pint. A haemostatic was ordered, together with an opiate, and perfect rest and quiet enjoined. I saw the patient, with the doctor, the next day. Condi- tion worse. No rest had been obtained during the.night. Severe frontal headache was complained of, and vertigo on attempting to rise. A feeling of nausea was experienced at times; but the vomiting of blood had ceased. The stools still showed evidence of decomposing blood. Countenance perfectly blanched. The conjunctiva, lips, tongue, and inside of mouth were pale, the entire body, in fact, presenting marked exsanguination. Temperature in the mouth, 99£° ; pulse, 140, very weak and compressible. Ordered fluid extract of ergot, in half-drachm doses, to be given if haemorrhage recurred, and left directions to apply pieces of ice over the stomach if any bleeding was suspected; happily these remedies were not required. A hypodermic injection of morphine was given to insure rest. The diagnosis made at this time was haemorrhage from a tWjulcer of the stomach. The heart and lungs were examined and found healthy. There was heard over the aorta a soft anaemic murmur. For the next two days the patient's condition remained nearly the same. No more blood was vomited, and the evacuations from the bowels were only slightly tinged with black blood. 5 May 31st.-Patient growing weaker and can take nothing into the stomach but small quantities of milk. Rest had not been obtained for two nights, on account of the excessive headaches. His condition in the evening (of same day) was considered critical. At this time the trial of the injection of milk was suggested to me by my associate, Dr. Hanks, and I determined to give my patient the benefit of its use. I was led the more readily to do this on account of the brilliant results obtained by Prof. Thomas, in three reported cases, full accounts of which had been published only a short time previous, in the May (1878) number of this Journal. Accord- ingly, the next morning I performed the operation, being kindly assisted by Drs. H. T. Hanks, T. E. Satterthwaite, J. P. Munn, and Horatio Bridge. A new milch cow was obtained, and driven to the yard of the rear tenement where my patient lived. The apparatus used was similar to that described by Dr. Thomas, consist- ing of an eight-ounce glass funnel, a rubber tube 18 inches long, and a silver canula such as is used in transfusion of blood. One end of the tube was slipped over the small end of the funnel, the other secured safely to the canula. This appara- tus was kept in carbolized water until required, and, before being used, was thoroughly washed with warm water. Two layers of carbolized muslin gauze were tied around the mouth of the funnel, and similar layers over the top of a large glass graduate, the latter being placed in a vessel of warm water, and the milk, when needed, strained direct from the cow into the graduate. The cephalic vein of the left arm was then exposed, and, after some difficulty, the canula introduced, and 7 ounces of warm milk allowed to flow into the vein. Time of the injec- tion, about three minutes. The funnel was raised above the arm as high, as possible. The wound was closed with two sutures, and carbolized cloths applied under a roller band- age. During the injection the patient experienced great fullness in the head, and complained of feeling faint. A hypodermic injection of a drachm of brandy was immediately given, and 6 this same quantity repeated fifteen minutes after, when soon the unpleasant symptoms passed away. The pulse was 125, temperature 100°, before the operation; and immediately after- ward the former had increased to 132, and was stronger, while the latter remained the same. Half an hour afterward patient had a marked chill, lasting fifteen minutes. The tempera- ture rose to 103^°; pulse, 150. This fever-stage was fol- lowed by profuse sweating, and at the end of two hours the temperature had fallen to 101°; pulse, 130. 4 p.m.-Patient feels much better; the headache is less severe, and some sleep has been obtained. Milk and small quantities of beef-tea were allowed, and tablespoonful doses of brandy given every two or three hours. June 2d, 8 a. m.-Marked improvement in all the general symptoms. Patient says he feels stronger, and his voice and actions confirm the statement. Some sleep obtained during the night. Temperature, owing to some local cellulitis around the wound, has risen to 104f°; pulse remained the same as on the previous afternoon. The subsequent history of this case is interesting, and may prove instructive. On the third day following the operation the cellulitis of the arm had increased in extent. There was some pain and swelling in the lymphatic glands of the axilla. The skin over the bicipital region was tense and shining, and an erythema- tous blush appeared about the wound, and gradually spread over the upper part of the arm. The sutures were taken out, and the wound allowed to gape. Cloths, wet in a weak solu- tion of carbolic acid, were first applied to the swollen part; but these were soon changed for a mixture consisting of col- lodion and camphor (about equal parts). This was painted over the inflamed surface, and gave great relief. Wound granulating slowly. 4^--Slight, chilly sensations were experienced this morn- ing, followed by a rapid rise in temperature, till 106° was reached. Quinine was ordered, 5 grains being given every four hours. 5th.-Chill at 3 p. m., followed by fever and sweating. Patient is taking an exclusive milk diet, from three to four 7 quarts being consumed daily. At the end of the first week from operation, the condition was much improved as regards strength, notwithstanding the high fever and sweats. 9th.-Slight chill at 5 p. m., followed by a more pronounced rigor at 9 p. m., both these rigors being succeeded in regular order by fever, sweating, and rapid fall in temperature. Qui- nine given in larger doses, but its administration did not seem to have any effect subsequently in either reducing the fever or controlling the chills. 10th.-Patient seen by Dr. Satterthwaite, at my request. We found his condition somewhat worse. Wound looked un- healthy, an ichorous discharge ran from it, and the lower portion was covered with a layer of false membrane, which was greenish in color. Pyaemia was at this time feared. 12th.-Induration of arm increased. Two soft points, in- dicative of suppuration, were felt along the course of the cephalic vein, just above the wound. 15th.-Opened a superficial abscess, and about a table- spoonful of healthy pus was evacuated; the cavity left was thor- oughly disinfected. The forearm now began to swell, es- pecially on its outer side. The radial vein could be felt under the fingers as a hard cord. Fluctuation was soon perceptible at different places along the course of the vein, and, on in- cision, small quantities of healthy pus removed. After this the arm did well. July 2d.-Patient reported at the dispensary this morning, feeling well and quite strong. In regard to the unpleasant features developing in this case, viz., the cellulitis and subsequent phlebitis, I can sug- gest two possible causes for their occurrence: 1. During the operation the canula did not at first enter the vein, but passed between it and the cellular tissue; con- sequently, about a drachm of milk ran into these tissues. This accident was quickly remedied, and the canula introduced safely into the vein. 2. I was called to visit a patient on the afternoon of the day of operation, and found a woman suffering from severe erysipelas of the leg. Was obliged to open an abscess; and, although every precaution was used in the way of disinfection 8 before returning to my first patient, still contagion may have been carried from the one to the other. Whatever may have been the cause of the unfavorable symptoms in this case, they would in no wise deter me from the use of injections of milk in the future, should its employment be indicated ; but I should use greater care. In conclusion, I would state : 1. That the permanent effects of the introduction of milk directly into the circulation in this case fully justified its use; 2. If my diagnosis of the disease was correct, a wider range is given to the class of cases in which " intra-venous lacteal injections" can be used. The accompanying diagram indicates the temperature variations, and presents a condensed history of the marked features of the inflammation of the vein. APPLETONS' JOURNAL: An Illustrated Monthly Miscellany of Popular Literature. 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