"WMS: Mr. Marshall's clinical-pathological case presentation on "strangulation of a portion of the ileum"

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PDF from photocopy, courtesy of the Taubman Medical Library, University of Michigan. Partial transcription below; the PDF contains the entire minutes.

Mr. Marshall stated, that cases of strangulation of the intestine were comparatively of rare occurrence, one or two only being related previous to the commencement of the last century. Cases of intus-susceptio, however, were much more frequent. This might be inferred from the numerous specimens in most museums of pathological anatomy in this and other countries. Dr. Copland was the first who had treated the subject systematically. Mr. Marshall proposed to divide cases of strangulation into two kinds--viz., those arising from a band or bands of lymph, thrown out during inflammation of the peritonæum, and remaining quiescent, so to speak, until a fold of intestine becomes incarcerated by these bands. The second kind consisted of those arising from adventitious bands, produced by a prolongation of peritonæum, or mesentery, as in the following case, which occurred to himself:--

Mrs. O----, twenty-four years of age, a woman of good constitution and healthy aspect, in the eighth month of her first pregnancy, was seized on Saturday morning, March 21st, with severe pain, extending over the whole of the belly, of an intermitting character, becoming aggravated at intervals, varying from a quarter to half an hour. The pain was accompanied by sickness and vomiting; but there was little or no tenderness on pressure on the abdomen. . . .

22nd.--She had slept very little during the night; . . . .

23rd.--She had passed another restless night, with general aggravation of the symptoms; . . . .

24th.--Ten a.m.: Had vomited a considerable quantity of dark-green fluid during the night, but not possessing any fæcal smell. The pain was somewhat abated, but was still general, and not local. A state of collapse soon followed, and the patient died in about four hours after, and about eighty-six hours after the time of her being first attacked.

Post-mortem examination, twenty-four hours after death.--The abdomen was found much distended by gaseous matter; a considerable quantity of fluid escaped on making the first incision into the abdomen. . . .

Dr. Snow considered it a congenital malformation, as there were no signs of old inflammation, and but a very little recent lymph. The appendix was adherent by a mesentery of its own, leaving an aperture through which the thumb could pass. The strangulation, however, was caused by a separate band. In the Mémoires de l'Académie de Chirurgie, he found a case exactly resembling this, where a band three fingers' [42/43] breadth long, and one inch from the cæcum, was attached to the appendix and the mesentery. He thought that the pushing of the uterus may have caused the bowels to become strangulated; and this he considered borne out by M. de la Faye, (vol. iv.,) in whose case strangulation was brought on by change of posture. The man had had several attacks of pain previous, which were probably owing to the bowel becoming strangulated for a short time. Dr. Snow then showed the impropriety of active purging in cases where suspicious pains have existed before. At the post-mortem of Mr. Marshall's case, the uterus had to be opened before the seat of strangulation sould [sic] be seen; the colon was turned over; the ilium lay on the outside of it, requiring the parts to be reversed, after the band was broken, before they could be placed in their proper position the tongue was red and dry; the mucous membrane of the stomach a little softened. He then mentioned a case where the appendix vermiformis was found with a mesentery attached to it, in an embryo; another, where the cæcum and appendix were both found in an umbilical hernia; and a third case where the appendix was in the pelvis.

In answer to a question by Mr. Brooke, Mr. Marshall said that the pain in his case was general, and not at all local.

Mr. Brooke mentioned, . . . .

Mr. Clarke remembered a case . . . .

Mr. Norman would not trust too much to local pain, . . . .

Dr. Chowne doubted . . . .

Mr. Hancock considered . . . .

Dr. Coley asked . . . .

"Medical Societies. Westminster Medical Society," Lancet 1 (2 January 1847): 42-43.

The discussion, beginning with "Dr. Snow considered . . .," was published in LMG 39 (8 January 1847): 75-76. The editors eliminated the prior portion on the grounds that "this case was fully detailed by Dr. Snow in the last volume [1846] of the Gazette, page 1049.