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Hospital Reports. Manchester Royal Infirmary. Cases Reported under the Terms Proposed bythe AssociationAuthor(s): MedicusSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 16, No. 8 (Apr. 14, 1852), pp.188-190Published by: BMJStable URL: http://www.jstor.org/stable/25493356 .

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18B CASE OF STRANGULATION OF THE JEJUNUM, BY MR. BAILEY.

way of intestinal absorption, is much less constant and

ineasureable than that by the stomach. I have ascer

tained this by a large number of observations. The

atate of the mucous membrane of the colon is subject'

to much more variations than that of the mucous

membrane of the stomach; and, besides that, much

will depend if, and how long, the injection remains

within the bowels, or how much of it has been voided

after a certain time. Thus, in two children of a good

ponstitution, both two years old, the same dose given

by injection may produce very different results, accord

ing to the length of time during which the liquid is

retained within the rectum ; and for the same reason in

the one three drops of the tincture will produce

narcotism, whilst in another the double quantity will

remain without effect upon the brain. If we can

suppose that the injection will be absorbed, we may administer only the double of what we would give by the mouth.

Digitalis, frequently employed as an antiphlogistic, in

particular against acute affections of the brain, I have

been fully satisfied does not answer that indication.

As a diuretic, it must be postponed to many other

remedies of the kind; this action of it being particu

larly inconstant in children. The unique real indica

tion of digitalis is the nervous hyperethisy of the heart, unconnected with inflammation or aneurism. The best

mode of administering it is by two doses daily, at the

interval of twelve hours. The single doses may be for

the third year a quarter of a grain, for the fifth one

third of a grain, and for the eighth year half a grain, which can be considerably augmented. Commonly, too

small doses are prescribed.

CASE OF STRANGULATION OF THREE FEET OF THE JEJUNUM,

BY A RENT IN THE MESENTERY, PRESENTING NO SYMPTOMS OF THE DISEASE FOR SEVERAL HOURS, AND THEN TERMINATING VERY RAPIDLY.

By CHARLES BAILEY, Esa., Chippenham.

Read at the Quarterly Meeting of the Bath and Bristol Branch, March 25,1852.

Henry Tayler, aged 25, was on the 13th of March, 1852, in perfect-health; in the evening of that day, after partaking of a hearty supper, he was returning home

about a quarter of a mile distance, when at the half

way of his return he fell over some large stones which had been carelessly left on the foot-path; he got up, did not feel much hurt, went into an adjoining house, and partook of some warm beer, and smoked a pipe of

tobacco; after sitting about half an hour went home to

bed, did not complain, but slept soundly till six o'clock; came to his employment a little before eight. Feeling some uneasiness about the bowels, he was induced to

seek their relief; this was effected, and urine was also

voided. Directly upon this the pain became severe, and

he Tetoitetl Beveral times; the ejected contents had not

4nd<#gone digestion, as the food of the last meal" of the |

preceding day was unaltered. Frequent rigors, cramp, thread-like pulse, cold extremities, and leadened coun

tenance. When I was first apprized of his illness I

found that thirty drops of the tincture of opium had

been given in a little warm brandy and water, and was

rejected. Being ignorant of the fall of the previous

night, and conceiving he was labouring under spasmodic colic, I gave him a pill, consisting of two grains of

opium and two of calomel; this remained, but still there was no abatement of symptoms. He then related the

circumstance of his fall, but said he was sure that would not have anything to do with his present painful con

dition. I again examined him, could find no tender

ness, but he complained of a fulness and tension*

Being put into bed, after warm appliances to the abdomen and feet, with doses ofthe compound spirits of aether and

small quantities of tincture of opium, a little reaction

took place, yet no abatement of pain, therefore, listening to the entreaties of the poor fellow to do more for him, I reluctantly took away ten or twelve ounces of blood, and he expressed himself relieved. Small quantities of

fluid now remained on the stomach. Another dose of

calomel only was given, and shortly after one ounce of

castor oil; this remained, without any more sickness, which led me to hope the result would have been

different, but in about three hours he breathed his last,

having endured seven hours severe pain.

The following day my young friend, Dr. W. Colborne, examined the body. No external appearance of injury.

On opening the abdomen, more than a pint and a half

of bloody serum was found; intestines much inflated; on placing aside the omentum and colon, there was

seen a considerable portion (three feet) of the jejunum in a state of mortification, with much discoloration of

the connected parts. By carefully carrying on the

examination, it was discovered that the mortified part of the jejunum was strangulated, or rather had been so, in a wound or rent of the fold of the mesentery, through

which the intestine had fallen, and its functions been

destroyed. No injury had been inflicted on any other

organs of the abdomen. Other parts of the body not

examined.

MANCHESTER ROYAL INFIRMARY.

CAS E S

Reported under the terms proposed by the Association.

By Medicus.

Fungfis Hcematodes after Fracture.

Grace Faulkner, aged 39, factory operative,

Duckinfield, was admitted into the Manchester Royal

Infirmary, under Mr. Wilson, October 10, 1850. She

states that on the 16th of August, 1850, she fell down, her arm twisted under her, and fractured both radius

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MANCHESTER ROYAL INFIRMARY. 189

and ulnar. She applied to a quack doctor, who said it ] was "

out," not broken, and put on a plaster and |

bandages. The first dressing remained on a week,

during this time it swelled considerably, and was at times

exceedingly painful. On the seventh day the dressings were removed and similar ones substituted, but put on

more loosely. The pain continued, and when these

were removed, a small tumour, about the size of a

marble, was perceived; to this some embrocation was

used, the pain, however, continued, and after some

time, proper medical advice was sought. The true

state of the case, as far as the fracture was concerned, was then discovered, and various means used, but the

tumour continued to increase, the pain persisted, and

was so severe as to prevent her sleeping. When admit

ted, the tumour was about the the size of an orange, of a livid hue, soft andNfluctuating in parts, the veins

around it are much enlarged, and the hand slightly ?edematous; the pulse at the wrist much the same as

on the other side; general health tolerably good.? Ordered Cataplasma Lini and opiate at bed-time.

20th.?At a consultation to-day it was agreed to

puncture,the tumour, which is rather larger; general

opinion that it is fungus hsematodes.

21st.?It was punctured to-day, and a quantity of

bloody serum poured out; there was some bleeding afterwards, which was stopped by pressure.?Continue remedies.

27th.?Tumour much increased in size; fungous

granulations project from where the puncture was made; it is much darker in colour, and there is evident fluctu

ation in several parts; her health is suffering, apparently from the air of the hospital.?Some medicine was

ordered, and she was sent into the country. December 11th.?She was readmitted much im

proved in health; tumour rather larger; she is a little

feverish. Ordered a saline mixture, with morphia. She refused any operation to be performed on it, and

after a trial of various remedies, her health again

suffering, she was sent into the country on the 6th

January, 1851.

January 27th.?Readmitted; tumour much enlarged, dark in colour; skin over it much stretched and glazed; health much improved.

February 6th.?At a consultation it was agreed to

make an incision into the tumour, and then, if necessary, remove the arm. ?

7th.?The patient being placed under the influence

of chloroform, an incision was made into the

tumour, and, as there could be no doubt as to its

nature, it was at once removed by amputating the arm above the elbow ; eight or nine ligatures were

applied as the arteries were much enlarged, and the

wound dressed temporarily with wet lint. At night, no

haemorrhage having occurred, it wras dressed, no sutures

being used. An opiate at bed-time. Two or three

days after the operation, she had an attack of feverish

ness, which was relieved by salines and an antimonial.

At intervals she had attacks of dyspnoea, which were

immediately and singularly relieved by opium. March 5th.?She has continued to progress without

any symptom worthy of note; a small abscess has formed in the stump, which has been opened.

24th.?The abscess has healed rapidly, and she was

discharged cured to-day.

Robert Rand, aged 13, weaver, Heywood, was

admitted in the Manchester Royal Infirmary, under Mr.

Ransome, February 10, 1851. He states that sixteen weeks previous to his admission he was knocked down, and his thigh fractured four inches above the knee; it was set by a surgeon the next day; it was excessively

painful for a week, at the termination of which period the medical attendant readjusted the apparatus, leaving it on this occasion for a fortnight. At the end of eight

weeks from the accident happening, he removed the

splints, and merely applied a plaster and bandages. The

boy states that during the time the splints were applied, he had great pain, and there was considerable swelling. The medical attendant continued to apply bandages and

plasters once a fortnight up to the time of the boy

coming to the hospital. At the present time there is a

tumour of livid hue, which has dull aching pain in it,

extending from the knee to within three inches of

Poupart's ligament; large veins run over it, and

fluctuation is distinct in some parts ; the glands in the

groin are much enlarged, and rather tender; he sleeps

badly, and his general health is bad; he is seized at

times with dyspnoea, which, like the former case, is

greatly relieved by opium. 21st.?The tumour has ulcerated in one or two places,

and discharges bloody serous fluid; his appetite is

failing, and his health giving way fast; the glands are

becoming more implicated. March 6th.?At a consultation it was agreed that an

operation was inadmissible; the tumour increased, and

glands are worse.

10th.?He was discharged incurable, the principal medicines which he had taken being opiates.

The points of interest in these cases I take to be their

evident origin in the injury, the age of the parties, and

the singular attacks of dyspnoea from which both

suffered.

Gangrene ofthe Leg from Aneurism ofthe Aorta.

William Green, aged 43, labourer, Manchester, was admitted into the Infirmary, January 23, 1852.

He states that he has always had good health until

thirteen weeks before admission, when he took cold and

had inflammation ofthe lungs, from which he recovered.

On the _lst of January, whilst going to his work, he

suddenly felt a severe pain in the right knee, which

quickly extended down the leg, and it became numb and

cold. He went home, sat by the fire, and got some one

to rub the leg ; whilst sitting by the fire> so imperfect was sensation, that he allowed the limb to be burnt

rather severely, and was not aware of the circumstance

till it was pointed out to him.

At the time of his admission the leg was red, cedema

tous, raised into large blisters, and traversed by red

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190 MANCHESTER ROYAL INFIRMARY.

lines, extending as high as the knee. On the calf of

the leg, where he suffered it to be burnt, there is a

slough about four inches square, and another on the

foot, of smaller extent. He has no sensation as far as

the knee, but he complains of pain above on pressure

nearly to the hip. Pulse full, quick, and irregular; has some cough and pain in the chest; perfectly sen

sible and answers questions rationally.?Ordered one

grain of opium every three hours, poultice to leg, also

a febrifuge mixture; he was put on extra diet, and a

full dose of opium given at bed-time.

24th.?He was delirious during the night; inflam

mation active, and seems extending up the leg; bowels

open; pulse quick, and irregular. 25th.?He is much worse; inflammation has extended

np the leg, and he has no sensation in the limb above

the knee; thigh painful on pressure, red lines extending

upwards ; pulse quick and weak.?Continue remedies.

Ordered Vin. Rubri, oz. vj., daily. 26th.?He continues much the same.

27th.?He is worse; has been very delirious; face

sunk; abdomen tympanitic; pulse weaker ; tongue

dry.?Ordered a mixture of bark, ammonia, and opium; beef-tea ad libitum.

28th.?A somewhat indistinct line of demarcation

begins to be perceptible below the knee; he is exceed

ingly restless and answers questions incoherently;

pulse weaker and irregular.?Continue remedies.

29th.?He is evidently sinking ; limb much the same.

30th.?He continued to get worse; the line of demar cation is more distinct; he has delirium, hiccup, vomiting, and is sinking rapidly. He died about three

o'clock, p.m.

Post-mortem twenty hours after death.?Lungs inflamed, and very adherent; an aneurism of the arch

of the aorta about the size of an orange, containing coagula, which were very loose; left ventricle was

enlarged; abdominal viscera healthy; limb gangrenous to the knee. On laying open the large vessels a

large clot of blood was found blocking up the popliteal artery, also another in the external circumflex artery, and one in the superficial external circumflexa ilei. Rest of the viscera healthy.

In this case there is no doubt that a portion of the loose coagulum from the aneurism of the aorta had

been carried on with the current of blood, and being arrested at the spots above stated, cut off the circulation

completely from the lower part of the limb.

Carbuncle and Saccharine Urine,

John Broadbent, aged 66, of Manchester, packer, was admitted as a patient of the Manchester Royal Infirmary December 12th, 1851. At this time he

presented, on examination, a large carbuncle on the back of the neck; it had a quaggy feel, and when

pressed pus exuded from numerous cribriform openings. His tongue was moderately clean, and his pulse weak. A crucial incision was made into the tumour, poultices

subsequently applied, and a mixture ordered, containing

bark, ammonia, and opium. He stated, on the ques tion being put to him, that he thought the quantity of urine increased; it was ordered to be measured, and a

portion reserved for testing the following day. The urine measured five pints, specific gravity 1.031. Tested

by being boiled with liquor potassae, it produced the

deep colour so characteristic of diabetic sugar. Boiled with sulphate of copper, and excess of potass, it yielded

immediately the red oxide. A portion was put on one side for about forty-eight hours, and when examined by the microscope showed an abundance of torulae.

The subsequent treatment was conducted on the

ordinary principles of surgery. Tonics were given, with a generous diet and stimulants. Stimulating applications were applied to the wound. The patient recovered rapidly, and in a few days not a trace of sugar could be discovered in the urine. The sugar remained for sixteen days after he came under treatment, in variable quantity, and continued steadily diminishing, as follows:?

Dec. 17. Urine four pints and a half. Sp. gray. 1.031. ? 21. ? four pints .. .. ? 1.030. ? 25. ? four pints .. .. ? 1.026. ? 29. ? three pints and a half. ? 1.02S. Slight ijfccation. ? 31. ? less than three pints. ? 1.024. No sugar.

John Owen, aged 62, of Manchester, green-grocer, was admitted a patient of the Manchester Royal Infirmary November 21st, 1851. At the time of his

application he presented a large carbuncle at the back of the neck. He was exceedingly ill; bowels confined;

pulse weak and rapid. The tumour presented the usual venous hue and cribriform openings; it was

freely opened. Ordered a stimulant poultice. A full

dose of calomel given, the bowels well opened, and then a tonic mixture of bark, ammonia, and opium administered. The urine was ordered to be measured, and kept for examination.

The man is improved this morning; the pulse has

improved in quality, and the wound looks as well as

could be expected; he has had some delirium in the

night; urine measured five pints and a half, specific

gravity 1.034; the tests mentioned before were applied, and the presence of sugar easily demonstrated. There was nothing after this in the case particularly worthy of notice; the case improved rapidly under good diet, stimulants, and tonics, and the sugar disappeared from

the urine in eight days. A trace was again to be

found on the tenth day, after which no more could be

discovered.

These cases are of interest as showing the presence of sugar, but a comparatively short time has elapsed since it was first pointed out, and it has been repeatedly

questioned. In these cases there could be no doubt as

to the existence of the sugar; it was freely poured out,

easily found, rapidly diminished under treatment, and

ultimately disappeared altogether.

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