ST. BARTHOLOMEW'S HOSPITAL

Willett
1882 The Lancet  
780 only slightly tender to pressure. The only history was that for two years previously he had had pain " across the pit of the stomach and through to the loins," seldom absent for many days at a time, and for the last month or so getting worse, but never accompanied by vomiting. He was very doubtful whether it had been at all influenced by what he ate. He had never passed blood by the bowel; he had not been losing fleah. No further haemorrhage occurred that day, and at 10 P. M. he seemed very
more » ... . M. he seemed very comfortable. Soon after midnight the bowels became uneasy, and in the course of the next four hours he passed by the bowel between a pint and a half and two pints of dark clotted blood. Sept. 25th.-Very blanched and prostrate, but no further loss of blood. Slept much during the day, swallowing nothing but ice, iced beef-tea, and the perchloride of iron. 26th.-Remained undisturbed until 3 A.M., when he was seized with violent epigastric pain, fainted, and died in a few minutes. At the post-mortem examination the stomach and intestines were found full of blood. The sole lesion discoverable was a small deep ulcer, of the diameter of a split pea, cleanpunched out of the otherwise healthy mucous membrane of the duodenum. At the bottom of the ulcer was a small perforation in the pancreatico-duodenal artery. The other abdominal organs were healthy. The chest could not be examined. Remarks.-This case illustrates well the occasional extreme difficulty of diagnosing duodenal ulcer. Chronic complaints of pain at the pit of his stomach, with scarce any tenderness, along with ability to take food and maintenance of his bodily nutrition and appearance of health, had gained for this unfortunate man the reputation of a confirmed hypochondriac, and at one time of a malingerer. But duodenal ulcer may run a fatal course with even greater latency of symptoms than occurred in this case. In the Transactions of the Pathological Society, vol. ix., the late Dr. Murchison records a case of a finely developed man who died suddenly of peritonitis from a perforated ulcer of the duodenum, and who up to the time of his fatal attack had enjoyed excellent health, and never suffered from vomiting or any pain whatever after food or at other times. Oxford. aged fifty-four, stated to have taken a small packet of Battle's vermin-killer at 4.40 A,M. on Wednesday, Feb. 15th, 1882. When seen at 8.45 A.M. he was lying on his back in bed, bathed in perspiration, countenance dusky, lips livid, pupils contracted. Pulse 130 ; arms and abdominal muscles flaccid ; legs rigid, calves hard as a board, soles of feet curved. Complained of a feeling of suffocation and intense thirst. An emetic of sulphate of zinc was given, and warm milk and water. On attempting to raise him to take the liquid violent spasms came on, the arms, neck, and jaw becoming stiff. Soon after taking the emetic he vomited copiously ; he was then ordered twenty grains of hydrate of chloral every two hours. After the first dose of chloral the spasms were less frequent, and the rigidity gradually subsided ; after the third dose he was much improved, but the" legs still continued rigid, the muscles of the neck were painful, and the mouth was opened with difficulty. His chief complaint, the intense thirst, was relieved by sucking ice. On the third day he was convalescent. On becoming calmer the following history was obtained from the man :-He had been drinking freely for some time previously ; had eaten no food for a few days, and was very depressed. Went to bed on the afternoon of the 14th inst. in drink, and being restless during the night, and scarcely knowing what he did, went downstairs about 4.40 A.M., mixed a packet of vermin killer with all the laudanum he could find (about a teaspoonful and a half), then added some rum, and having swallowed it he rinsed the glass with more rum and drank it. He went back to the bedroom, walked about for half an hour, then lay down. First spasm came on about 5.30, and recurred regularly every half hour, com. mencing in the legs and shooting through the body. Each spasm drew him up, and he felt as if his hands and arms were frozen to his chest. His housekeeper, who slept in an adjoining room, stated she first heard him cry out about 6 A M., but she took little notice of it, as he often made noises when in drink. She heard him several times, and went to him at 8 A.M. She found him in bed, staring and grinning at her; his head was thrown back over the pillow; he seemed to be resting on his heels and the back of his head. Was stiff and immovable, and his body was arched like a bridge; hands fast to his side. The first quantity of urine passed was accidentally lost, but from the second (about four ounces) one-twentieth of a grain of strychnia was obtained. No strychnia was found in his vomit. On ex. amining a threepenny packet of Battle's vermin killer I found it to be a slaty blue colour, weighing fourteen grains, composed of wheat, starch, and three-quarters of a grain of strychnia. The case is interesting, as after a poisonous dose of strychnia, taken under the most favourable conditions for absorption, fifty minutes elapsed before any symptoms ex. hibited themselves, and the man was alive four hours after, although no treatment whatever had been adopted. No doubt a fatal result was prevented, and the intensity of the symptoms modified, by the laudanum which was added for the purpose of making the dose more deadly. A case is reported in THE LANCET of 23rd December, 1871, where a packet of this vermin killer was taken with two drachms of laudanum and some binoxide of mercury. When seen three hours after there had been no strychnia symptoms, but dangerous narcotism. In the case of J. Wthere was no narcotism, but severe spasms, which were almost imme. diately relieved by the hydrate of chloral. (Under the care of Mr. WILLETT.) Nulla autem est alia pro certo noscendivia, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Procomium, FOR the notes of this interesting case we are indebted to Mr. Mason, house-surgeon :— Anne C-, aged forty-eight, was admitted on Jan. 28th last, with scirrhous tumour occupying the greater part of the left breast. The skin was not freely movable over the mass, but the latter was not adherent to the deep structures. The axillary glands were largely involved. There was a similar growth in the right breast, about the size of a large hen's egg. This was freely movable, and had no attach. ment to the skin; nor were the glands involved. The woman looked healthy, and had no family history of cancer, except from her father's sister. The personal history was indefinite, the affection of the left breast having been noticed about six months. She had a right femoral hernia of three years' standing, for which she wore a truss during the day. On lying down the rupture always returned without much diffi. culty, though she had been sick sometimes from it. The internal organs were healthy. On Feb. 1st operations on the breasts were performed. Over the left breast it was necessary to remove an oval piece of skin about three inches across, and about thirty hard glands, mostly very small, were removed from the axilla. The tumour was removed from the right breast by vertical incision, four inches long. Two deep button sutures were used for the wound on the left side, drainage-tubes were inserted, and both wounds were closed by silver wire. The
doi:10.1016/s0140-6736(02)21973-x fatcat:6c57hzdbovcmlanhd3tud6a6eu