PATHOLOGY AND PRACTICE OF MEDICINE.
Peritonitis from Injury—Recovery.—It is our pleasing duty to record
a case of severe injury to the abdomen, followed by very acute peritonitis,
where, by the agency of opium, a recovery was obtained, which, under
the circumstances, might have hardly been expected. It is by
watching cases of this nature that we become convinced of the inesti-
mable value of opium, and it may safely be asserted that innumerable
lives have been saved by this powerful therapeutic agent. Mr. G.
Mitchinson, the dresser, was kind enough to furnish us with ample de-
tails touching this very instructive case, and we forthwith proceed to
lay them before our readers.
The patient is a stout, healthy-looking little boy, five years and
a-half old, who was brought to St. Bartholomew’s Hospital on the 10th
of July, and placed in Kenton Ward, under the care of Mr. Stanley.
The poor little fellow had, a few moments before his admission, been
knocked down by a cart, the wheel of which was distinctly seen by
several persons to have passed over the abdomen across the umbilicus.
Immediately after the accident, the boy is said to have got upon his feet,
and to have run some paces ; but he soon bent the body forward, and
lay down.
When he was brought to the hospital, he kept tossing from side to
side, and seemed to suffer excruciating pain in the abdomen. The re-
spirations were forty in a minute, suppressed and very short; the pulse
about 140, and small; but he was so restless that the arterial pulsations
could hardly be counted. The child had not vomited or passed any
blood per anum; he stated that he had emptied his bladder about half
an hour before the accident, and had just had his dinner. This latter
statement can hardly be correct, as it is not very likely, as the dresser
observed, that a child in that walk of life should dine at six.
However this may be, the little patient was at once given seven
minims and-a-half of tincture of opium, and warm stupes were care-
fully applied to the abdomen. These means having given no relief, in
about an hour the same dose of laudanum was repeated; the general
symptoms remained the same; there was no vomiting, and the child
was quite conscious. The patient remained in the same state during
the next hour, rolling about in great agony. Neither the chest nor
abdomen appeared to move much during respiration, which was short,
frequent, and catching: the face waspale, but the extremities warm. As
he was now inclined to doze, no more opium was given, though the
child did not fall asleep, and went on tossing about, and moaning and
crying with the pain in the abdomen. The same dose of laudanum was
therefore repeated, and two ounces of wine given besides. In the
night he was very restless; about an hour after the last dose of opium the
child went to sleep, but woke several times, and complained bitterly of
pain in his belly.
The bowels were not open towards the morning, nor was there any
urine passed; a little retching took place, and the patient expectorated
a small quantity of dark-coloured blood. During the day sleep was
obtained ; the pupils were, however, contracted, the respiration irregular
though more natural and nasal. The pulse improved somewhat in
volume, (130, intermittent), and the patient expressed himself as feeling
better. On the third day, no urine had been passed since admission;
an elastic catheter was therefore introduced into the bladder, and about
eight ounces of clear and apparently healthy urine drawn off. The
catheter was secured in theuretha, and about one ounce of turbid urine
gradually drained away, loaded with an abundance of white flocculi.
When the patient awoke, about noon of the third day, he complained
of great pain in the abdomen, and the respiration again became short
and hurried; the child was given seven minims and a-half of tincture
of opium, and two ounces of port wine; the urine on examination was
found loaded with an abundance of lithates. Some milk and arrowroot
were now taken with but little appetite, and the dose of laudanum, to-
gether with the wine, was repeated, but the child went on complaining
of as much pain in the abdomen as before. On the fourth day he was
somewhat quieter, and dozed a little; the pain and restlessness, however,
soon returned, and the former was constantly referred to the abdomen.
Tincture of opium, seven minums and a-half, and two ounces of wine.
Towards the evening of this day, the ingestion of the opium was fol-
lowed by marked relief: in fact, the child generally fell asleep about
half an hour after taking each dose, and on awaking expressed himself
relieved, although the pain never ceased, and after remaining awake a
short time, it became so urgent, that he was afraid even to cough. He
had, however, a little sleep for about two hours, after which time he
was very restless and in pain.
The bowels had not been moved since admission; there was no vo-
miting, and the urine dribbled through the catheter. The same dose of
opium and wine was repeated, and the patient now expressed great
anxiety to have his medicine administered. On the fourth day there
was not much alteration, except a fit of coughing, which occasioned a
great increase of pain; the opium was repeated. The pulse was now
120, regular, soft and slightly improved in volume; the tongue somewhat
furred and dry; the bowels still confined; and the urine passing through
the catheter. No pain in the chest. In the afternoon the child fell into
a deep sleep, which lasted three hours; on awaking he expressed him-
self as feeling much better, though coughing still caused much pain in
the umbilical region. The pulse improved in volume, and was soft and
compressible; the puipls not being so contracted as heretofore. Opi-
um and wine repeated.
On the fifth day the patient seemed free from, pain, and the counte-
nance was somewhat more natural and less expressive of uneasiness;
the fits of pain, however, soon returned; the face became again extremely
anxious; the pulse harder, and the respiration hurried. The opium and
wine were repeated three times in the day without subduing the pain,
which was still much complained of. Bowels still confined. Thus the
patient went on for the next three days improving a little at times, but
ever being subject to severe attacks of abdominal pain; the bowels re-
mained inactive until the tenth day after admission, when, after a good
night, he awoke considerably better, did not take his usual dose of
opium and had a copious alvine evacuation. The pulse fell to 74, was
soft and compressible, and the abdomen began to bear moderate pressure.
The next few days were marked by gradual improvement, the child
seldom required medicine, and did not experience any pain but when
he committed some dietetic indiscretion; and about twenty days
after admission the little patient left the hospital, to all appearance
perfectly well, and has since remained so.
This case beautifully illustrates the rule of practice which states that
the great point in the treatment is to support the system under the in-
tense irritation excited by the visceral inflammation, and that no substance
is so well calculated to effect this as opium. We are likewise advised,
in contusion of the abdomen to avoid purgatives and enemata; this pre-
cept was here applied with the utmost strictness, as no alvine evacua-
tion took place for nine days. Many would have been tempted to add
a little calomel to the opium; but when we recollect the intense inflam-
mation which must have existed to give rise to such continued pain, we
are driven to admit that the least excitement in the shape of peristaltic
motion might have raised the inflammation to a fatal degree.
It would appear from this case, that it was a favorable circumstance
that the wheel, instead of passing across the hypocondrium, pressed
upon the umbilical region, for the liver and spleen offering in the first
place greater resistance than the convolutions of intestines, are more
likely to be lacerated, which circumstance is almost always followed
by the death of the subject. It is interesting to observe what large
quantities of opium are borne under a high state of irritation of the
system ; the patient, a boy five years and a half old, took about twenty-
two minims of laudanum per diem for about ten days without any un-
pleasant symptoms, and even without an unusual amount of sleep. In
witnessing such a case as the preceding, the question naturally arises,
whether the inflammation of the peritonaeum has left any traces in the
abdominal cavity, and whether the probable fibrinous exudations will
eventually be absorbed, or interfere with the regular action of the
bowels. The answer probably lies between the two extremes. We
cannot close the report of this valuable case without adverting to the
close connexion between medicine and surgery which is here illustrated,
and we concur in the received opinion that a man cannot be a good
surgeon, unless he at the same time be a good physician.—Lon. Lancet.