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DIABETES SUCCESSFULLY TREATED.
were separated or torn from their attachments to the heart or the pericardium, their torn vessels would necessarily let blood escape. Thus, then, we are able to account, not only for the mode of formation of these shaggy, fringy bands, but for the presence of blood and of bloody fluid found in the pericardium, as well as for the deep staining of the heart’s surface with blood. There is another point worthy of notice in the case of M. A. F-, whose heart was also covered with shaggyfringed bands of lymph, as in this case-viz., that the greatest relief was acknowledged to have taken place after the first blister had fairly risen. It is probable this relief may have occurred coincidently with the rupture of these bands by the gradual distension of the pericardial sac, and thus the heart left comparatively free to act without hindrance by the adhesions previously existing. In F-’s case, the largest adhesive bands were to be seen at the apex of the heart, where the greatest amount of motion naturally takes place, and where the adhesions would be most stretched by such motion. In H-’s case, they were left unbroken only at the base, and near the large vessels, where the motion is so much less than at the apex. The redness of these bands is probably owing to the great and continued motion of the heart, continually rupturing newly-formed fragile capillary vessels within their structure.
rheumatism, with effusion into the pericardiunm, accompanied with pleurisy. CASE 3.-(Notes by Mr. Milson, clinical clerk. )-Martha G-, aged seventeen, servant, admitted Feb. 25th, 1859. Had had rheumatic fever when seven years old; has been ill for a fortnight, and was carried to bed immediately on ad-
supposition would enable
us better to understand the complete being of a nature to be easily
recovery of the case, the fluid
absorbed. The patient being now convalescent, the sounds of the heart The young are to be distinctly heard by the stethoscope. woman presents an extraordinary contrast to her appearance on admission: her bloated look and dark complexion have entirely disappeared, as well as her former distressed expression. In explanation of the way in which, I believe, relief takes place in consequence of bleeding, I wish you to understand that by venesection we reduce the heart’s force-the heart’s power; and consequently, we reduce the velocity-the force-of the blood in the small inflamed vessels in that part of the pleura where effusion of lymph commences, simultaneously with the localization of the inflammation. The costal pleura, from being more freely supplied with nerves, is more sensible of pain than the pulmonary pleura; and I believe it is the costal pleura which is the great seat of pain in pleurisy. It is important to observe that in the two former cases there had been no evidence of rheumatic inflammation having attacked the joints; whereas in this last the joints were first affected. We infer from this that in the first two cases the disease was localized in the heart and pericardium wholly; whereas in this girl’s case the heart affection may be regarded as a complication. The joints were, to the very last, serving as a diversion, conducing to her greater chances of recovery.
Acute
DIABETES
SUCCESSFULLY TREATED.
By ARTHUR
HILL
HASSALL, M.D.,
PHYSICIAN TO THE ROYAL FREE HOSPITAL.
mission. The knees and wrists were much swollen. For a week she has been suffering from extreme shortness of breath, THE following case of diabetes, possessing certain features and has been obliged to be propped up in bed in order to of interest and importance, is, I think, worthy of being reher that time she has sufon back. breathe, resting During fered great pain all over the chest. She now complains ofcorded:pain in the limbs, and over the chest, but especially at the John K-, aged thirty-seven, a compositor, was admitted lower part of the sternum, extending over the cardiac region. under my care, as an out-patient, at the Royal Free Hospital, On percussion great dullness is experienced over the heart, extending around to some distance. On examination by the in September, 1858. At my request, he furnished me with stethoscope, the heart’s sounds are very distant, muffled, andthe subjoined account, in writing, of his case :can scarcely be distinguished. Pulse quick and small; counte" For two months previous to my discovering that I cast nance dark and bloated; mammæ very large, apparentlymore urine than I ought to do-namely, about June--I exswollen; sibilant râles all over the chest, but especially on theperiencecl very bad health. After eating my meals, I felt an left side.-Diagnosis: Pericardial effusion, accompanied by in- oppressiveness at the chest-an uncomfortable sensation, as if flammation of the bronchial membrane, especially on the left I were blown out with wind. I took no notice of these sensaside. tions, because, after a little rest, they went away. A little Feb. 26th.-Breathing very difficult and noisy; sibilant. while afterwards I felt very thirsty, and drank as much as I 27th.-Cough troublesome, with increase of pain over the! could get; finding that I made more urine than usual, and heart; pain and crepitation in the lower lobe of the left lung, fancying that it was on account of the unusual quantity of with increased difficulty of breathing. drink that I took. I then had beatings of the heart, at times 28th.-Pain on the left shoulder and down the arm nearly absence of mind, not knowing what I did, but soon recovering gone; crepitation in the lung less marked. myself ; very nervous; not getting sleep at night-waking March 3rd.-The breathing again difficult, and the alæ nasievery hour to cast water; pains in the shin-bones when in bed; in continual action. pains across the loins in the day; passing urine every two 4th.-Still complains of difficulty in breathing-" cannot hours. Found that I lost flesh; very little but always " get her breath." thirsty; gums very sore after eating, sometimes bled; pains Up to that time, the treatment had been by leeches daily, up the spine of the back." and calomel, with compound ipecacuanha powder, in small To this account a few additional particulars may be apdoses, repeated three times in the day, without any constitu- pended. The patient is a short but stout, well-formed man, of tional action being induced. Mustard cataplasms were now rather sanguine temperament. When he first presented himapplied to the knees, and a large blister was put upon the left self at the hospital, the chief features about him denoting illside. ness were, his sunken eyes and somewhat wasted appearance. On the 5th, the pain and difficulty of breathing, and the On inquiry into his habits and mode of life, with a view to disoppression at the scrobiculus cordis, still persisting, eight cover the cause of his malady, I found that, as a compositor, ounces of blood were taken from the arm, with marked, imme(a very unhealthy occupation,) he worked, for about eight diate relief, after which the breathing became easy, and the months previous to becoming ill, about 100 hours a week, distressing cough gradually disappeared. Under the continued working on Sundays and much at night. The night-work use of the calomel and opium she progressively recovered. being trying, he had recourse about twice a week to stimulants, On the llth, there was a slight return of pain and swelling taking usually about three quarterns and a half of gin. The in the joints, especially in the wrists; in the right wrist, fluc- room in which he worked was strongly lighted with gas, and tuation could be detected in the sheath of the extensor was occupied by about thirty other compositors. No hereditary tendons. tendency to diabetes could be traced. I wish you to observe that there was no extreme smallness I prescribed for him, on the 18th of August, as follows :of the pulse-no irregularity as in the other cases; and thus, Camphorated tincture of opium, one scruple; acetate of potass, probably, no adhesions of the heart to the pericardium. When one scruple; infusion of quassia, one ounce; syrup of orange, there is no valvular disease, I conceive these irregularities, as one drachm. One ounce to be taken four times daily. noticed in the cases of F- and H-, to arise from the Strict rules were enjoined respecting his diet and mode of adhesions interfering with the free action of the ventricle. living. He was directed to take fresh meat twice or thrice daily, Perhaps in this girl’s case a lower grade of inflammation was and occasionally fish, poultry, eggs, and milk; in place of bread, present, which resulted in the effusion of serum only; or the to eat only the specially-prepared bran biscuits; to partake freely state of the constitution may have been less sthenic. This of all the green vegetables, and to eat at breakfast waterorpqser ____
-
-
appetite,
385
to avoid all farinaceous
articles,
as
Since the 15th of November, when he discontinued the medicine, I have seen him every few days, and his urine has kept since, and is now, entirely free from sugar, and this although about three months ago he was allowed a little beer, and to resume his ordinary diet, including brown wheateu bread.
ordinary bread, pastry,
and everything containing flour, starch, or arrowroot of any kind; to abstain generally from fruit, especially the sweeter kinds, as all the dried fruits; and, amongst vegetables, not to eat potatoes, artichokes, parsnips, or carrots. These regulations were rigidly adhered to throughout the treatment of the case. From the combined effects of regimen
puddings,
On presenting himself at the hospital the other day, in reply to " I am quite well; my question, how he was? he remarked, the is in him how he knew there no the I asked and medicine, urine." patient speedily improved. This steady sugar amendment is well exhibited in the following table. I should this? when he answered, " I can always tell whether there is state that for several days before the registry of the urine was sugar or not by tasting my urine :" thus fulfilling the old saw, " De gustibus non est disputandum." commenced, its specific gravity was found to be over 1040. The out-patient department of the Royal Free Hospital Table showing the Density and Quantity of Urine voided. affords a wide field for the study and treatment of urinary affections ; and I therefore propose, from time to time, to place on record some of the more interesting cases which fall under my observation, especially cases of that most singular of dis-
orders, diabetes.
Wimpole-street, April,
1859.
ON A CASE OF STRANGULATED RIGHT FEMORAL HERNIA. OPERATION ON THE FOURTH DAY OF RECOVERY.
BY ALFRED
* All those marked with the asterisk were found from sugar.
on
analysis to be free
There were one or two circumstances which I particularly One was, the noticed in many of the samples examined. rapidity with which the sugar became decomposed when the urine was kept in a corked bottle for three or four days. As soon as the cork was removed and the urine was shaken, the carbonic acid escaped in such quantity that the urine frothed up like bottled beer, carrying the urinometer up Another circumstance with it sometimes several degrees. worthy of remark was the great variation in the colour of different samples of the urine. The majority of the samples were, as indeed they ordinarily are in diabetes, of a pale-straw colour, but yet others frequently occurred of a deep brown. I could never satisfactorily account for this great difference; there was no marked disturbance of the functions of the skin, lungs, or liver, to explain it; indeed, no evidence of organic disease! of any kind was to be detected in this case. I noticed, however, that the sugar in the brown urines less readily became decomposed than in the paler samples. On the 4th of October I changed the medicine a little, andL prescribed as follows :-Camphorated tincture of opium, one! scruple; spirit of camphor, ten minims; phosphate of soda, five grains; infusion of quassia, one ounce: to be taken thrice a day. Disulphate of quinine, two grains; confection of roses, in sufficient quantity : to be made into pills, and taken three: times a day. This medicine he continued until the 15th oif November, when he had perfectly recovered; he had gainedL considerably in flesh and strength, and his urine had been foir some time quite free from sugar, and was reduced in amountt to a normal standard. ,
,
386
STRANGULATION;
FLEISCHMANN, ESQ., M.R.C.S., Wrexham.
I AM induced to offer a few remarks upon the following case, because I feel that the operation for hernia has been unduly surrounded with supposed difficulty and danger. In recent cases of strangulation, practitioners are, I fear, prone to wait, and indulge the too often delusive hope that long-continued taxis may supersede the knife; whilst, where strangulation has existed for some days, the case is looked upon as hopeless, and it may be the patient dies unaided and unrelieved. On Saturday afternoon, November 6th, 1858, I was summoned to a remote country district to see a woman who was suffering under all the symptoms of strangulated hernia. I found they had existed for four days. Fæcal vomiting and hiccup had set in; her pulse was 120, but her countenance did not betoken excessive anxiety. The hernia was on the right side, and clearly femoral. Sixteen years ago, she had ruptured herself by lifting a heavy weight; it then appeared as a marble, and was down during the day, and up at night. She never wore a truss. She was of spare and weakly habit, aged forty-four years, and had borne two children. For the last few days she had been dyspeptic, and vomited her food. On Wednesday, Nov. 3rd, whilst vomiting and straining violently, the rupture descended more than usual. She tried to replace it, but failed. Application was made to an unqualified practitioner, who sent her some mercury-and-chalk with rhubarb, which, however, strange to say, produced no marked effect. The symptoms grew more and more urgent, till, on Saturday, Nov. 6th (the fourth day of strangulation), she sent to seek further help. The tumour was of stony hardness. Reduction being out of the question, I decided upon operating with as little delay as possible. I called in consultation Mr. Griffiths, a surgeon of extensive practice and deserved celebrity, who most kindly attended, and rendered me most valuable assistance. He also tried taxis, but, like myself, soon abandoned the attempt. The operation was a straightforward one, and presented no features worthy of particular note. The sac was opened. The intestine was livid in hue, and incipiently gangrenous. Several ounces of straw-coloured serum escaped from the peritoneal cavity. The stricture was firm, and required free division. After the operation she had a full dose of ammonia and opium. I sat with her all night; she was free from pain, and slept well. In the morning her pulse was 106. The remission of all her urgent symptoms was complete. Nov. 8th.—Pulse 100; no pain in the wound; tongue clean; lives upon strong beef-tea, and takes small doses of ammonia and henbane. 9th.-Pulse 104; not the slightest pain nor uneasiness in the wound. I left well alone. 10th.-Pulse 112; no pain, but a feeling of stiffness in the wound. I dressed it, and was gratified to find the upper third united by primary intention, and the remainder looking very healthy. The discharge was sufficient, though not abundant. The bowels not having acted, I gave a simple enema, which, however, did not bring much away.
rheumatism, with effusion into the pericardiunm, accompanied with pleurisy. CASE 3.-(Notes by Mr. Milson, clinical clerk. )-Martha G-, aged seventeen, servant, admitted Feb. 25th, 1859. Had had rheumatic fever when seven years old; has been ill for a fortnight, and was carried to bed immediately on ad-
supposition would enable
us better to understand the complete being of a nature to be easily
recovery of the case, the fluid
absorbed. The patient being now convalescent, the sounds of the heart The young are to be distinctly heard by the stethoscope. woman presents an extraordinary contrast to her appearance on admission: her bloated look and dark complexion have entirely disappeared, as well as her former distressed expression. In explanation of the way in which, I believe, relief takes place in consequence of bleeding, I wish you to understand that by venesection we reduce the heart’s force-the heart’s power; and consequently, we reduce the velocity-the force-of the blood in the small inflamed vessels in that part of the pleura where effusion of lymph commences, simultaneously with the localization of the inflammation. The costal pleura, from being more freely supplied with nerves, is more sensible of pain than the pulmonary pleura; and I believe it is the costal pleura which is the great seat of pain in pleurisy. It is important to observe that in the two former cases there had been no evidence of rheumatic inflammation having attacked the joints; whereas in this last the joints were first affected. We infer from this that in the first two cases the disease was localized in the heart and pericardium wholly; whereas in this girl’s case the heart affection may be regarded as a complication. The joints were, to the very last, serving as a diversion, conducing to her greater chances of recovery.
Acute
DIABETES
SUCCESSFULLY TREATED.
By ARTHUR
HILL
HASSALL, M.D.,
PHYSICIAN TO THE ROYAL FREE HOSPITAL.
mission. The knees and wrists were much swollen. For a week she has been suffering from extreme shortness of breath, THE following case of diabetes, possessing certain features and has been obliged to be propped up in bed in order to of interest and importance, is, I think, worthy of being reher that time she has sufon back. breathe, resting During fered great pain all over the chest. She now complains ofcorded:pain in the limbs, and over the chest, but especially at the John K-, aged thirty-seven, a compositor, was admitted lower part of the sternum, extending over the cardiac region. under my care, as an out-patient, at the Royal Free Hospital, On percussion great dullness is experienced over the heart, extending around to some distance. On examination by the in September, 1858. At my request, he furnished me with stethoscope, the heart’s sounds are very distant, muffled, andthe subjoined account, in writing, of his case :can scarcely be distinguished. Pulse quick and small; counte" For two months previous to my discovering that I cast nance dark and bloated; mammæ very large, apparentlymore urine than I ought to do-namely, about June--I exswollen; sibilant râles all over the chest, but especially on theperiencecl very bad health. After eating my meals, I felt an left side.-Diagnosis: Pericardial effusion, accompanied by in- oppressiveness at the chest-an uncomfortable sensation, as if flammation of the bronchial membrane, especially on the left I were blown out with wind. I took no notice of these sensaside. tions, because, after a little rest, they went away. A little Feb. 26th.-Breathing very difficult and noisy; sibilant. while afterwards I felt very thirsty, and drank as much as I 27th.-Cough troublesome, with increase of pain over the! could get; finding that I made more urine than usual, and heart; pain and crepitation in the lower lobe of the left lung, fancying that it was on account of the unusual quantity of with increased difficulty of breathing. drink that I took. I then had beatings of the heart, at times 28th.-Pain on the left shoulder and down the arm nearly absence of mind, not knowing what I did, but soon recovering gone; crepitation in the lung less marked. myself ; very nervous; not getting sleep at night-waking March 3rd.-The breathing again difficult, and the alæ nasievery hour to cast water; pains in the shin-bones when in bed; in continual action. pains across the loins in the day; passing urine every two 4th.-Still complains of difficulty in breathing-" cannot hours. Found that I lost flesh; very little but always " get her breath." thirsty; gums very sore after eating, sometimes bled; pains Up to that time, the treatment had been by leeches daily, up the spine of the back." and calomel, with compound ipecacuanha powder, in small To this account a few additional particulars may be apdoses, repeated three times in the day, without any constitu- pended. The patient is a short but stout, well-formed man, of tional action being induced. Mustard cataplasms were now rather sanguine temperament. When he first presented himapplied to the knees, and a large blister was put upon the left self at the hospital, the chief features about him denoting illside. ness were, his sunken eyes and somewhat wasted appearance. On the 5th, the pain and difficulty of breathing, and the On inquiry into his habits and mode of life, with a view to disoppression at the scrobiculus cordis, still persisting, eight cover the cause of his malady, I found that, as a compositor, ounces of blood were taken from the arm, with marked, imme(a very unhealthy occupation,) he worked, for about eight diate relief, after which the breathing became easy, and the months previous to becoming ill, about 100 hours a week, distressing cough gradually disappeared. Under the continued working on Sundays and much at night. The night-work use of the calomel and opium she progressively recovered. being trying, he had recourse about twice a week to stimulants, On the llth, there was a slight return of pain and swelling taking usually about three quarterns and a half of gin. The in the joints, especially in the wrists; in the right wrist, fluc- room in which he worked was strongly lighted with gas, and tuation could be detected in the sheath of the extensor was occupied by about thirty other compositors. No hereditary tendons. tendency to diabetes could be traced. I wish you to observe that there was no extreme smallness I prescribed for him, on the 18th of August, as follows :of the pulse-no irregularity as in the other cases; and thus, Camphorated tincture of opium, one scruple; acetate of potass, probably, no adhesions of the heart to the pericardium. When one scruple; infusion of quassia, one ounce; syrup of orange, there is no valvular disease, I conceive these irregularities, as one drachm. One ounce to be taken four times daily. noticed in the cases of F- and H-, to arise from the Strict rules were enjoined respecting his diet and mode of adhesions interfering with the free action of the ventricle. living. He was directed to take fresh meat twice or thrice daily, Perhaps in this girl’s case a lower grade of inflammation was and occasionally fish, poultry, eggs, and milk; in place of bread, present, which resulted in the effusion of serum only; or the to eat only the specially-prepared bran biscuits; to partake freely state of the constitution may have been less sthenic. This of all the green vegetables, and to eat at breakfast waterorpqser ____
-
-
appetite,
385
to avoid all farinaceous
articles,
as
Since the 15th of November, when he discontinued the medicine, I have seen him every few days, and his urine has kept since, and is now, entirely free from sugar, and this although about three months ago he was allowed a little beer, and to resume his ordinary diet, including brown wheateu bread.
ordinary bread, pastry,
and everything containing flour, starch, or arrowroot of any kind; to abstain generally from fruit, especially the sweeter kinds, as all the dried fruits; and, amongst vegetables, not to eat potatoes, artichokes, parsnips, or carrots. These regulations were rigidly adhered to throughout the treatment of the case. From the combined effects of regimen
puddings,
On presenting himself at the hospital the other day, in reply to " I am quite well; my question, how he was? he remarked, the is in him how he knew there no the I asked and medicine, urine." patient speedily improved. This steady sugar amendment is well exhibited in the following table. I should this? when he answered, " I can always tell whether there is state that for several days before the registry of the urine was sugar or not by tasting my urine :" thus fulfilling the old saw, " De gustibus non est disputandum." commenced, its specific gravity was found to be over 1040. The out-patient department of the Royal Free Hospital Table showing the Density and Quantity of Urine voided. affords a wide field for the study and treatment of urinary affections ; and I therefore propose, from time to time, to place on record some of the more interesting cases which fall under my observation, especially cases of that most singular of dis-
orders, diabetes.
Wimpole-street, April,
1859.
ON A CASE OF STRANGULATED RIGHT FEMORAL HERNIA. OPERATION ON THE FOURTH DAY OF RECOVERY.
BY ALFRED
* All those marked with the asterisk were found from sugar.
on
analysis to be free
There were one or two circumstances which I particularly One was, the noticed in many of the samples examined. rapidity with which the sugar became decomposed when the urine was kept in a corked bottle for three or four days. As soon as the cork was removed and the urine was shaken, the carbonic acid escaped in such quantity that the urine frothed up like bottled beer, carrying the urinometer up Another circumstance with it sometimes several degrees. worthy of remark was the great variation in the colour of different samples of the urine. The majority of the samples were, as indeed they ordinarily are in diabetes, of a pale-straw colour, but yet others frequently occurred of a deep brown. I could never satisfactorily account for this great difference; there was no marked disturbance of the functions of the skin, lungs, or liver, to explain it; indeed, no evidence of organic disease! of any kind was to be detected in this case. I noticed, however, that the sugar in the brown urines less readily became decomposed than in the paler samples. On the 4th of October I changed the medicine a little, andL prescribed as follows :-Camphorated tincture of opium, one! scruple; spirit of camphor, ten minims; phosphate of soda, five grains; infusion of quassia, one ounce: to be taken thrice a day. Disulphate of quinine, two grains; confection of roses, in sufficient quantity : to be made into pills, and taken three: times a day. This medicine he continued until the 15th oif November, when he had perfectly recovered; he had gainedL considerably in flesh and strength, and his urine had been foir some time quite free from sugar, and was reduced in amountt to a normal standard. ,
,
386
STRANGULATION;
FLEISCHMANN, ESQ., M.R.C.S., Wrexham.
I AM induced to offer a few remarks upon the following case, because I feel that the operation for hernia has been unduly surrounded with supposed difficulty and danger. In recent cases of strangulation, practitioners are, I fear, prone to wait, and indulge the too often delusive hope that long-continued taxis may supersede the knife; whilst, where strangulation has existed for some days, the case is looked upon as hopeless, and it may be the patient dies unaided and unrelieved. On Saturday afternoon, November 6th, 1858, I was summoned to a remote country district to see a woman who was suffering under all the symptoms of strangulated hernia. I found they had existed for four days. Fæcal vomiting and hiccup had set in; her pulse was 120, but her countenance did not betoken excessive anxiety. The hernia was on the right side, and clearly femoral. Sixteen years ago, she had ruptured herself by lifting a heavy weight; it then appeared as a marble, and was down during the day, and up at night. She never wore a truss. She was of spare and weakly habit, aged forty-four years, and had borne two children. For the last few days she had been dyspeptic, and vomited her food. On Wednesday, Nov. 3rd, whilst vomiting and straining violently, the rupture descended more than usual. She tried to replace it, but failed. Application was made to an unqualified practitioner, who sent her some mercury-and-chalk with rhubarb, which, however, strange to say, produced no marked effect. The symptoms grew more and more urgent, till, on Saturday, Nov. 6th (the fourth day of strangulation), she sent to seek further help. The tumour was of stony hardness. Reduction being out of the question, I decided upon operating with as little delay as possible. I called in consultation Mr. Griffiths, a surgeon of extensive practice and deserved celebrity, who most kindly attended, and rendered me most valuable assistance. He also tried taxis, but, like myself, soon abandoned the attempt. The operation was a straightforward one, and presented no features worthy of particular note. The sac was opened. The intestine was livid in hue, and incipiently gangrenous. Several ounces of straw-coloured serum escaped from the peritoneal cavity. The stricture was firm, and required free division. After the operation she had a full dose of ammonia and opium. I sat with her all night; she was free from pain, and slept well. In the morning her pulse was 106. The remission of all her urgent symptoms was complete. Nov. 8th.—Pulse 100; no pain in the wound; tongue clean; lives upon strong beef-tea, and takes small doses of ammonia and henbane. 9th.-Pulse 104; not the slightest pain nor uneasiness in the wound. I left well alone. 10th.-Pulse 112; no pain, but a feeling of stiffness in the wound. I dressed it, and was gratified to find the upper third united by primary intention, and the remainder looking very healthy. The discharge was sufficient, though not abundant. The bowels not having acted, I gave a simple enema, which, however, did not bring much away.