THE LONDON HOSPITAL MEDICAL SOCIETY.

389 be placed in a basin of water like the larger one. He did not intend it to supersede the latter, which was better adapted for exact observations; but, practically, it would answer as well, and had the advantage of great portability. It was made by Mr. Ferguson. The elastic tube and the valves He consiwere five-eighths of an inch in internal diameter. dered it of great importance that all the passages through an inhaler should be at least as wide as the human trachea. Some writers had recommended three-eighths as sufficient. Now, the area of a tube of three-eighths of an inch was to one of five-eighths only as nine is to twenty-five. Many ether inhalers were very faulty, from the deficient size of tubes and apertures, and from offering obstructions by sponges, and if used even without ether, would put a patient in danger from obstructed respiration. In saying this he did not mean to blame any one, for the subject of inhaling with the mouth and nostrils closed was perfectly new. He did not believe that ether would produce illness that would end fatally after two days; and if the fatal case or two related had really resulted from the inhalation, it must have been from deficiency of air, and not from the ether. STRANGULATION OF INTESTINE.

Dr. COLEY read a paper, which will be found in another column. In the discussion which ensued, two points mainly occupied the attention of the members: one was, the safety, or otherwise, with which the peritonæal cavity might be opened, and the means we at present possessed of diagnosticating the seat and nature of such obstructions as might appear to call for the knife of the surgeon. It was generally thought that we had had too much dread of opening the abdominal cavity, and that recent operations had undoubtedly given an evidence of this; for, with proper precautions, and under proper circumstances, the operation of ovariotomy had been found no more fatal than the ordinary capital operations of ,surgery. With respect to our diagnosis of cases of obstruction in the intestinal tube, it was quite clear that we did not at present possess such definite and unequivocal means of knowing the nature of the obstruction as would warrant the surgeon resorting to operation until all the usual means of relief had been employed.

to flex the limb above a certain angle, he felt a considerable pain on either side of the joint. As soon as he was able to get about, he had made forhim a kind of leather pad, placed over the anterior surface of the knee, and attached bv straps above and below the joint, by the aid of which he was able to stand and walk about much better. Notwith-

attempted

standing this, the knee was "constantly giving way," causing him to fall down, and then, to use his own phrase," it pains him horribly." On examination, the whole of the left knee, when compared with the right, was very much swelled. The patella was

situated much lower than in the natural state; its surface was excessively flat, and appeared to be nearly half as large again as its fellow on the opposite side; the depression nearly always seen on either side of the patella was entirely obliterated. About an inch above the patella, there was a very deep tranaverse indentation, nearly reaching across the anterior surface of the thigh in that part, appearing much more evident when the limb was extended; and immediately above this, there was a tumour, which had a flattened appearance, and was about the size of the patella itself: he stated, however, that it was not so large as it had been. Flexion and extension were very limited, partly on account of the pain experienced at the time on either side of the joint, the patella during either act being

immoveable.

The joint was supported with strips of plaster, and he was then informed, in consequence of the length of time that had elapsed since he had received the injury, it was doubtful whether much could be done to restore the limb to its proper functions. He has not appeared at the hospital since. To show the comparative rarity of rupture of the rectus, Mr. South, in his Translation of Chelius’s Surgery, says,I have seen one instance of that very rare accident." It seems that in this case the muscle was ruptured an inch or two above the patella, and the upper part of the muscle contracted very much. The treatment consisted in bandaging the upper portion of the thigh, and in the course of a few days, the spasm of the muscle relaxed, and it then united with the lower portion. The patient was well in six weeks. In the twenty-eighth volume of the Medical Gazette, Mr. Grantham relates a case (quoted by South in Chelius’s Surgery) where, at the end of six weeks, there was "a very large swelling," in consequence of the rectus femoris being drawn one-third up the thigh. The divided ends of the muscle could not be made to unite. THE LONDON HOSPITAL MEDICAL SOCIETY. In the twenty-ninth volume of the Medical Gazette.. also, Mr. Jones mentions a case, where, on examination, the tendon of FEBRUARY 12, 1847.—MR. LUKE IN THE CHAIR. the rectus femoris was found ruptured close to the patella. It was treated in the same manner as a fractured patella, and the Mr. BRUSHFIELD read a case of patient recovered the use of the limb. RUPTURE OF THE TENDON OF THE RECTUS FEMORIS, CLOSE TO Mr. Liston, in one of his lectures, in the first volume of THE PATELLA. THE LANCET, for 1844, says, 111have seen the quadriceps William -, aged thirty-seven, a labourer, was admitted femoris torn across. An old man was carrying a bottle of wine in each hand down to the cellar; both his feet slipped at an out-patient, under Mr. Curling, on December 16th, 1846. About four months ago, he fell from a loft to a depth of the same time, and in his efforts to save himself, both the about fifteen feet, in which fall his left foot first struck the tendons were torn across, close to the insertion of the extensor ground, the leg being at the time semiflexed; he immediately muscles of the leg. It is seldom that the tendon of the patella felt a severe tensive pain in the left leg, and on closer inquiry, is torn." he stated that he also had a slight pain and numbness above Dr. LITTLE then read a case of the left knee, of which he took but little notice at the time. Notwithstanding the pain, he felt no difficulty in walking; but INTESTINAL OBSTRUCTION CAUSED BY UNNATURAL ADHESION OF a short time after the accident, on stepping across a ditch THE APPENDIX CÆCI, AND ITS CONVERSION INTO A SPECIES OF about two feet wide, he felt a very acute pain above the left THROUGH WHICH THE ILEUM HAD BECOME INCARCERATED. RING, knee, the leg at the same time " giving way under him," and it was then with very great difficulty that he succeeded in I was requested, on the 23rd Jan., to see John E-, aged reaching home,having," he says," to drag his leg after him." seventeen, of muscular, well-developed frame, who had passed On arriving home, finding the left knee extremely painful, he seven days without evacuation from the bowels. He had of examined it, and it then appeared very much swelled and in- late enjoyed good health, although when thirteen years of age flamed, particularly at the upper part, in which part, however, subject to attacks pf vertigo, often succeeded by syncope of notwithstanding the swelling, there was a deep transverse in- several minutes’ duration. The patient stated, his bowels had dentation ; he then went to bed, and the knee soon turned of been regularly relieved up to the 17th inst.; that on the 18th a dark, livid colour. A medical man was sent for, who applied and 19th he felt very ill, vomited, and had several paroxysms a long, straight splint to the posterior part of the joint, by of abdominal pain, for which he took stimulants, anti-spasmeans of a bandage, which was ordered to be kept constantly modics, and purgatives. On the third day he was bled to sixwet with a cold lotion; and, as far as I could learn, an occa- teen ounces, with temporaryrelief, but the pains soon returned, sional purgative, and the re-adjustment of the splint two or compelling him to resort to the prone position, and to apply three times, was the treatment adopted. In attempting to forcible compression to the abdomen; he then took calomel walk down stairs, ten days after the accident, he found that and opium. During the fifth and sixth days the belly swelled he could not rest on the left leg, in consequence of its " giving and became exquisitely tender, and lie vomited frequently, way under him," although at the time the splint was still re- the paroxysmal pains not having subsided. On the seventh tained in its place by the bandage. day, the countenance anxious; tongue dry and coated; pulse After being confined to the house about six weeks, he left 100, firm; tensive pains and vomiting as before; urine scanty, off wearing the splint, and then observed a considerable high-coloured. Ordered, eighteen leeches to the abdomen; to swelling above the indentation, which, however, has decreased be followed by a large blister; the blistered surface to be in jsize very much, and also soon afterwards found that if he dressed with mercurial ointment, which was rubbed also into ____

390 the

thighs

and arms;

quarter of a grain, no more

ment at

than one time.

calomel, two grains; opium powder, a to take every two hours; warm bath, or two teaspoonfuls of cold fluid nourish-

and

a

24th.-Relieved in every respect; slept during the night; paroxysms fewer; less tension of the abdomen; sickness better. Repeat leeches, pills, and bath. In the course of the evening he was removed into the hospital, where a similar plan of treatment was adopted. On the 25th, he presented the following symptoms :-Position supine; knees drawn up; countenance shrunken, collapsed, and expressive of extreme prostration; severe pain in the abdomen, which was greatly distended and tympanitic, the slightest pressure in any part causing increase of suffering; constant vomiting of highly offensive matter resembling liquid faeces in odour and colour; respiration thoracic; tongue brown, dry; pulse small, weak, and frequent. Warm water enemata brought away a small quantity of faeculent matter, resembling but far less offensive than that vomited. 26th.-Pain on pressure and tension of abdomen much less;

vomiting continues; pulse small, rapid, intermittent;

ex-

tremities cold.

27th.—Hiccough; skin bedewed with cold, clammy sweat; pulse scarcely perceptible. Death.

extremities cold; Post-mortem

examination.-Body

well

formed;

not

wasted;

abdomen tympanitic; no peritonscal effusion; stomach and intestines distended with gas; duodenum and upper part of jejunum highly congested; lower part of small intestine much darker; the ileum, especially towards its termination, almost black. On the right side, inferiorly, the omentum adhered to the lower part of the ileum, and the adhesion involved the appendix casci, which encircled and constricted the termination of the ileum, and a fold of the same intestine. The

;hat had the cleft in the appendix been complete, the intes;ine would have been liberated, and might have resumed its ’unctions. The case, he thought, suggested matter for reftec. tion, as to the injury that may possibly result in similar cases from too energetic reduction of inflammation by abstraction )f blood and mercurial affection of the system. He admitted the necessity of combatting the inflammation in such cases by usual antiphlogistics; but believed, that if a correct diagnosis of the precise nature of such a stricture could b& ascertained, it would be better to refer the patient to the chance of a favourable natural issue by ulceration, and restoration of a passage through the tube. He (Dr. Little) had been unable to trace the previous existence of any peritonitis from which the adhesion of omentum, appendix emci, and intestine, had resulted. It appeared almost certain, from examination of the diseased parts, that the terminal part of the ileum had long passed through the unnatural ring, and that the addi. tional convolution found incarcerated had passed through the ring at a later period. Even this convolution bore evidence in a considerable narrowing of the gut immediately beneath the stricture, that it was not a stranger in the situation when discovered. The case also afforded an additional illustration of the futility of administering drastic purgatives in cases of obstinate obstipation, with colicky pains, which do not yield to moderate use of purgatives. Reliance should then be placed upon soothing, anodyne, and sedative remedies. Mr. ADAMS considered it probable that in this and similar cases the incarcerated intestine had been accustomed to its evil position, but that danger to life only resulted when an accidental change in the state of contents of intestine, ingestion of improper food, or some otherwise trifling derangement of function of the tube, precipitated the fatal disturbance. Dr. LITTLE afterwards related a case of strangulation of small intestine through abnormal opening in mesentery in a young child, in which the child played as usual, apparently in perfect health, the day before its death. The child, who was an inmate of the Infant Orphan Asylum at Wanstead, attended by Mr. Toulmin, of Hackney, and himself, awoke in pain during the night, speedily collapsed, and sank within seven hours of the apparent time of seizure. He was not aware of any case upon record of death succeeding with so great rapidity to intestinal strangulation.

adherent part of the appendix was the point corresponding to the junction of its middle and inferior third. A circular ring, about an inch in diameter was thus formed, and which embraced the above-mentioned parts of the ileum. This portion of ileum was highly inflamed, non-adherent; the stricture, although tight, permitted an additional portion of intestine being drawn through the accidental ring. At the point of connexion of the appendix vermiformis with the omentum and ileum, an abscess of the size of a small walnut existed, the parietes of the abscess, consisting partly of omentum and Mr. DEBERT HowELL read a partly of the proximate portion of the strangulated intestine, CASE IN WHICH DEATH WAS CAUSED BY EATING RAW RICE. and partly by the large intestine, so that it was easy to perMaria W-, a servant, aged twenty-two, previously in ceive that had life been longer protracted, suppuration and ulceration might have formed a route for the passage of the moderate health, but pale and anaemic, was taken suddenly contents of the intestine, and a spontaneous cure might have ill with pain in the chest, while walking out in the evening of been effected with the sacrifice of the intermediate portion of December 17th, 1846. At half-past seven, half an hour from the tube. The terminal third of the appendix largely dis- the attack, she was suffering severe pain in the left hypotended with puriform fluid, and partly detached by ulceration; chondriac region, attended by great restlessness. Percussion the remaining organs perfectly healthy. The diseased parts over the region of the stomach was not unusually loud. On were exhibited to the Society, and hare since been deposited inquiry, it proved that she had eaten in the afternoon, before her tea, a tumblerful of raw rice, mixed with milk, which in the museum of the hospital. Dr. LITTLE remarked that this case exemplified the too she had been in the habit of eating, as well as arrow-root, common course of intestinal obstruction depending upon insago, &c., in a raw state. The pain evidently arising from carceration of the gut by abnormal bands of mesentery, or distention, caused by swelling of the rice in contact with the other sources of stricture. The symptoms being at the onset tea, and aided by the heat of the body, half a drachm of similar to those of colic, inflammation supervening, the con- sulphate of zinc was administered as an emetic, which failing tents and secretions of the upper part of the alimentary canal, to act, was repeated after twenty minutes. The stomach was and of the liver and pancreas, being rejected by the mouth, then relieved, first of what appeared to be tea and wash, and formation of gas, speedily amounting to tympanitis, these afterwards, at intervals, of a large quantity of half-swollen acute symptoms lasting eight or ten days, followed by collapse rice, equal in bulk to an ordinary dmner-plate, piled; and she of twenty-four or thirty-six hours, and death. I-Ie thought felt considerable relief from pain. The stomach-pump was the case of peculiar interest, as the abscess and ulceration in not employed in this case, because it did not appear calculated immediate connexion with the strangulated parts, indicated to relieve the stomach of its half solid contents; in similar the mode in which spontaneous cure might sometimes be cases, however, it might prove useful by favouring the escape effected—namely, by the formation of a communication be- of gas. At eleven the following morning the pain increased tween the parts of the alimentary canal situated above and suddenly, violently, with cold extremities, small feeble pulse, below the incarceration. Practical observers have long great abdominal tenderness; and she died at four P.M. On noticed that the most desperate cases of intestinal obstruction, examination of the body, extensive peritonscal inflammation apparently correctly diagnosed to depend upon internal stran- presented itself, with deposition .of lymph agglutinating the gulation, do occasionally, to the surprise of the medical at- intestines, and a copious effusion of turbid serum into the tendant, recover, leaving him enabled merely to guess at the cavity of the abdomen. The stomach and duodenum were mode of resolution. In this particular case recovery might empty, with the exception of a few grains of raw rice at the also have ensued by another process. It was remarked atthe pylorus, and perfectly free from inflammation. The small autopsy, that the stricturing part of the appendix vermiformis intestines were gorged throughout with a quantity of the same raw material that she had been in the habit of eating, appawas not adherent to the incarcerated intestine, it was even possible to draw out the latter from beyond and beneath the rently rice, arrow-root, &c., some raw and hard, and in parts stricturing appendix vermiform. It was also observed that so distending the intestine as to give the sensation to the above the point where the appendix was united to omentum fingers of feeling a bag of marbles, and some in a half and intestine, it was nearly severed by ulceration, rendering digested state. The large intestines were loaded with fseces. The heart was small, the lungs healthy. It is remarkable a spontaneous separation of the stricture imminent; and aE the subjacent fold of ileum was non-adherent, it was evident that the stomach was perfectly free from inflammation.