NOTE ON A CASE OF RUPTURED INFERIOR VENA CAVA : VITALITY AFTER SEVERE INJURY

Adrian Caddy
1901 The Lancet  
years of age, no less than three of them died. The indications on which I lay most stress as being of serious import are vomiting, uncontrolled by drugs and diet, and restlessness. The frequency of the stools and the persistence of blood and mucus in them are also indicative of the severity of the attacks. Treatment.-The treatment must be directed to maintaining the strength of the patient and stopping the diarrhoea and vomiting. Warmth and rest in bed are essential. Diet is all-important, for
more » ... n face of the complete anorexia and vomiting it is extremely difficult to get the child to retain sufficient food. Thin arrowroot made with water is retained fairly well. Other foods of value are albumin-water, meat juice, peptonised milk, milk diluted with a thin farinaceous flaid, and unsweetened condensed milk. In the worst cases nothing is retained long, the vomiting being due to reflex irritation or toxaemia and not to any gastric cause or the nature of the food. Stimulants are essential and may be used .freely. Brandy is the best. Of drugs I found hydrochlorate of cocaine (in doses of one-hundredth of a grain) the most useful to stop the vomiting, and salicylate of bismuth in large doses for the diarrhoea. Other drugs were tried, but the above gave the best results. Urotropine was given with a view to disinfecting the alimentary canal but it exerted no influence on the offensive character of the stools. Opium by the mouth did not seem to be beneficial, and enemata of starch and opium were only of slight value. Rectal irrigation was tried in one case unsuccessfully. Theoretically irrigation of the large intestine would be beneficial by washing out mucus, micro-organisms, and other deleterious matters present. Practically it is very difficult to carry out efficiently in children and is strongly objected to. In view of the fact that the pathological process is more than a superficial one irrigation is unlikely to be of any great benefit. If used, a weak solution of boric acid is the best. Silver nitrate should not be employed. The only organisms isolated were the bacillus enteritidis sporogenes and the bacillus coli communis. The former. was obtained from the colon in anaerobic milk culture after heating to 80' C. for 10 minutes. It was virulent on a guinea-pig. The latter came out in almost pure culture in aerobic cultures on gelatin and agar-agar. Its virulence was not tested, but various chemical tests were applied and they showed that it was the ordinary bacillus coli communis and not Gartner's bacillus enteritidis. _ Micrro8copical exantination.-The contents of the colon, stained with methylene blue and Gram's method, show a vast number of micro-organisms of very various kinds of which short bacilli, resembling bacillus coli communis, are the most abundant. Very few streptococci can be recognised. Sections of the colon show a high degree of congestion. The mucous membrane is ulcerated away in many places, exposing the submucosa but not the muscular coat. At such places especially there is an infiltration with round cells, but this does not involve the muscular coat. The epithelium of the colon is desquamated in many places, including Lieberkiihn's crypts. The submucosa, on the whole, shows very little infiltration, except where actually laid bare by ulceration. Sections stained for micro-organisms show plenty on the surface of the mucous membrane and in the crypts, but they do not extend deeply into the mucous membrane. They are chiefly bacilli resembling the bacillus coli communis. Upper Brook-street, W. PRESENTATIONS TO MEDICAL MEN.-Mr A. B. Pngh, for some time house surgeon of the Huntingdon County Hospital, on his leaving the neighbourhood has been the recipient of a travelling clock, subscribed for by 1bO people of Godmanohester and Huntingdon, in recognition of his kind attention and medical skill.-At a meeting held at the Westminster Palace Hotel on May 15th Mr. E. L. Jacob, M.R.O.S. Eng., who has recently resigned the office of medical officer of health of the Surrey United Sanitary District, after 27 years' active service, was presented with a silver tea and coffee service by the gentlemen with whom his official work brought him into close association. The county treasurer, Mr. Francis H. Beaumont, of Buckland Court, Betchworth, presided. The meeting was well attended and comprised a large number of professional brethren and officials. A BOY, aged eight years, was brought to the casualtyroom of the Royal Free Hospital on Feb. 28th, 1901, with a history of being run over by a dustcart. The first thing we noticed was a large lacerated wound on the outer side of the right knee-joint, with a tear in the capsule of the joint. The left knee-joint had a worse wound about three inches square on the inner side completely denuding the bone and exposing the semilunar cartilage which was quite loose between the femur and tibia. The boy, when first seen, did not appear to be much hurt and sat up and talked freely about a pain in his left side. On examining his thorax the majority of his ribs seemed to be fractured. He then gradually got worse, becoming very pale, with a pulse of 140 and very thirsty. He gradually became unconscious, and finally died two and a half hours after admission. At the necropsy extensive bruising was found all over the front of the thorax. The left ventricle of the heart had a large bruise on its anterior surface. There was a pint of blood in the left pleural cavity, there was a laceration of the base of the lung two inches long, and there were seven fractured ribs on the left side. On the right side six ribs were fractured and there were four ounces of blood in the right pleural cavity. In the abdomen the inferior vena cava was discovered completely torn across; there was no rupture of the liver or injury to the diaphragm, the tear in the vein being between the liver and diaphragm. There were 12 ounces of blood in the peritoneal cavity and a slight bruise of the transverse colon. All the other organs were uninjured and healthy. The interest of this case lies in the fact of the boy's power of living after such extensive injuries for two and a half hours, excluding the time required to bring him to hospital (20 minutes), the injuries including the rupture ofthe largest systemic vein of the body, laceration of the lung, and bruising of the left ventricle of the heart.
doi:10.1016/s0140-6736(01)81918-8 fatcat:h3njgfrzdrhz3mdpduwranpa64