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CONTRIBUTIONS TO PRACTICAL SURGERY.
masses filling the lower part of the bladder. Tubercle, already deposited in the tissues of the bladder, offered a condition in which the ulcerative process might most readily commence, and a fistulous opening be quickly esta.
circumstances, with the other kidney unaffected, this condition gelatinous
might havecontinued for years. I have had one case of the kind under observation for the last nine years ; and I have a of a sacculated kidney with the calculus impacted preparation of the ureter, the duration of the symptoms during in the head life being spread over an interval of nearly seventeen years ; so that the rapid and fatal issue of this case must be attributed to the process of ulceration set up in the substance of the kidney, occurring in an individual in whom there existed, as the result proved, an overwhelming tubercular diathesis. This tubercular dyscrasia was forcibly exemplified by the wide sphere over which this product was deposited, existing in a crude state in the lungs, spleen, mesenteric glands, and prostate, and in an active state of ulceration in the kidney and bladder. Rayer (Trccete des M aladies des Reins, vol. iii. p. 643 et seq.) has recorded several cases of tubercular deposit in the bladder aecompanying tubercle of the kidney; but the peculiar feature
blished.
An exudation of
plastic lymph on the surface
of the
bladder, as well as on the intestine, surrounding the ulceration, effectually preserved the peritoneal cavity from any infiltration
of the contents of the bladder. In these cases, we cannot permit ourselves to hope that the result of treatment can be other than palliative. When the suppurative process in the kidney arises from tubercular ulceration, its exhausting effects rapidly reduce the vital powers, and neither nutritive substances, cod-liver oil, nor other medicinal agents, can be expected to arrest the fatal process. Of the remedial means most productive of benefit, opium in the form of Battley’s solution, or the preparations of morphia, yield the most satisfactory results.
of this present case consists, not so much in the presence of tubercle in the bladder, or its wide diffusion in other organs of the body, as in the tubercular ulceration in the bladder, and the fistulous communication which was established between CONTRIBUTIONS TO PRACTICAL SURGERY. the bladder and the intestine. Cases in which fistulous comBY JOHN ERICHSEN, ESQ., munication has taken place between sacculated kidneys with PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE, AND SURGEON TO obstructed ureters and the large or small intestines, although THE HOSPITAL. rare, are not without example. Rayer mentions several. Two such cases have occurred under my own observation. In one III. remarkable case, the particulars of which I propose to comON ABDOMINAL EMPHYSEMA. municate hereafter, a large encysted and sacculated right EMPHYSEMA of the subcutaneous cellular tissue of the trunk kidney opened a passage for its contents into the contiguous ascending colon, and a temporary cure was effected by what is looked upon as one of the most certain signs of thoracic was supposed to be a violent diarrhcea. But I am unacquainted injury, and its occurrence from other causes than wounds of with any analogous case of a fistulous opening between the the lungs or pleura is scarcely, if at all, recognised by writers bladder and rectum caused by tubercular ulceration in the on surgery. My object in this communication is to show that mucous membrane of the former. it may arise without any injury of the chest, by the escape Upon a careful consideration of the contents and condition of flatus from a ruptured or wounded intestine into the subof the bladder, I think it will not be difficult, to a certain peritoneal cellular tissue, and thence into the more superficial extent, to account for the amount of obstruction to the escape cellular planes of the trunk; and that it may thus become imof the contents of the bladder through the urethra, which must portant, or possibly the sole evidence of serious abdominal have pre-existed, and operated as the direct cause of this injury. So far as I have been able to ascertain, the remarks fistulous ulceration. Up to the last week of his life, the patient on this subject in surgical writings are of a very incidental never experienced any difficulty in passing urine; the frequency character, and not commensurate with the importance of this of micturition was not accompanied by any condition that in- lesion as a diagnostic sign of intestinal injury. Haller alludes dicated obstruction or difficulty; and at the post-mortem ex- to it as occurring in a case of abdominal injury; and Morgagni the amination, although tubercles were observed in the prostate, states that in a case of stab of the abdomen, perforating yet these were granular and inactive, and the gland was not colon, "a beginning emphysema was brought on."" The only practitioner who, to my knowledge, has treated of enlarged to an extent sufficient to form any impediment to the free passage of the contents of the bladder. Within six days "abdominal emphysema" asa special symptom is Dr. O’Ferrall, .of the patient’s death, it was observed that he no longer passed of St. Vincent’s Hospital, Dublin. That gentleman, in March, his urine voluntarily, and it was reported in the ward-book 1854, published, in the Dubligi Hospital Gazette, a very valuthat what little was passed seemed to dribble away from the able practical lecture on Abdominal Emphysema, consequent the next day, the diarrhoea, as it was reported, in, and it was at once conjectured that a communication had somewhere been effected between the kidney and intestines; but the opening had taken place between the bladder and rectum, and not between an obstructed and sacculated kidney. So long as the urinary passages are free, such ulcerative communications are little likely to be formed. There was no stricture of the urethra; there was no prostatic disease sufficient to cause retention of the contents of the bladder. How, then, did the bladder fill, and through what cause were its contents forced to an outlet by the lower bowel ? At the bottom of the bladder, adherent to the mucous surface, and filling the space between the ureter of the right side and the opening of the urethra, was found a gelatinous coagulum, of a true jelly-like consistence and colour, and in the lower part of which some earthy, gritty matter was found. This gelatinous exudation constituted, I believe, the proximate cause of the obstruction to the escape of the contents of the bladder, and the consequent retention led to the fistulous communication with the rectum. I think this opinion is corroborated by the observations of Sir Benjamin Brodie. In his work on " Diseases of the Urinary Organs," (p. 134,) he mentions a case in which a mass of lymph, of the consistence and appearance of jelly, was found in the urine. The patient suffered from frequent micturition, and had a deposit of pus in his urine, and on the occasion when this gelatinous matter passed, he suffered from symptoms which were thought to indicate the passage of a renal calculus. The pain suddenly ceased with the escape of this jelly-like fibrine, but the patient subsequently died, and Sir Benjamin Brodie concluded that the immediate cause of this patient’s death had been retention of one of these fibrinous
urethra;
upon Diseases of the Intestines, especially Malignant Disease of the Rectum, Hernia, and Ileo-csecal Abscess; but in that communication he makes no mention of this condition as a consequence of abdominal injuries. The two following cases will illustrate the importance of this symptom in the diagnosis of intestinal injury. CASE 1.-A man about thirty years of age was admitted into the hospital, under my care, in February, 1854, having been squeezed between the buffers of two railway carriages about half an hour previously. He had been struck on the pit of the stomach and the small of the back. On examination, no bruise of skin, or fracture of ribs or spine, or positive sign of injury, could be detected; but the patient was collapsed, and complained of pain in the abdomen. There was some retching, but no vomiting. From the nature and the seat of the injury, and the severity and the continuance of the collapse, there could be little doubt that he had sustained rupture of some one or other of the abdominal organs; but no positive signs existed to indicate which one in particular had suffered. He was accordingly kept quiet in bed, opiates administered, and the urine, which was untinged by blood, drawn off. On the following day, some emphysematous crackling was noticed in the subcutaneous cellular tissue of the right flank, and this gradually crept upwards and forwards, so as to occupy a conextent of the side of the abdomen and lower and back siderable part of the chest, as high as the scapula. These parts presented the ordinary characters of emphysema, being somewhat tumified, doughy and crackling on pressure. There was no discoloration of the integuments. The state of depression continued, notwithstanding the administration of stimulants, and the patient died about forty hours after the accident. masses. On examination after death, it was found that the anterior Nothing can be more calculated effectually to obstruct the margin and the under surface of the liver were lacerated to escape of urine by the natural passage than one of these some extent, and that a considerable quantity of blood had
suddenly
on
set
573
of
been extravasated into the peritonseal cavity. The intestines cellular tissue until the more subcutaneous layers are at first presented no appearance of being injured, but, on closer reached. There is another way in which this abdominal emphysema," inspection, it was found that the posterior part of the duodenum, at about the juncture of the descending and transverse might occur-viz., by the escape of flatus into the peritonaeal portion, was ruptured to the extent of an inch behind the cavity from the wounded intestine, and thence into the subcuperitoneum; the laceration in no way implicated that part taneous cellular tissue at the edges of an oblique wound through of the duodenum which was invested by serous membrane. the abdominal wall. That would appear to have been the way No extravasation had taken place into the peritonseal cavity; in which it occurred in the case related by Morgagni, as quoted but a considerable effusion of thin, bilious-looking intestinal by Mr. Travers ("Injuries of the Intestines," pp. 26 and 27:)matter had been extravasated into the sub-peritonseal cellular " The transverse and oblique muscles were perforated with a tissue in the loin, for some distance around the ruptured gut, wound that would admit two fingers, and between them the and the flatus from this had found its way through the cellular air had entered, so that a beginning emphysema was brought planes until it had reached the subcutaneous cellular tissue, on. This air had got out of the colon, which was wounded, when it had given rise to the emphysema which had been into the cavity of the belly, and had distended it; nor had air noticed during life. There was no injury to any of the organs alonecome forth, but excrement also."" When the emphysema happens in this way from a previously within, or to the parietes of the chest; no fracture of any ribs. The practical interest of this case lies in the fact of the existing tympany, the mechanism of its occurrence would emphysema being the only sign of intestinal injury. There appear to resemble that of a thoracic emphysema, resulting was no wound penetrating the abdominal cavity, nor injury to from a previously-formed pneumothorax. the lungs or ribs; hence the air which became extravasated Welbeck-street, Cavendish-square, December, 1855. into and widely diffused through the cellular tissue could have come from no other source than the ruptured gut. The peculiar and very unusual situation of this injury in the only portion of ON A the small intestine that is uncovered by peritoneum prevented the occurrence of the more ordinary signs of intestinal injury- CASE OF PENETRATING WOUND OF THE viz., feculent or tympanitic extravasation into the cavity of THORAX ; the peritoneum. WITH OBSERVATIONS. In such a case as this the suspicion would naturally arise on the occurrence of emphysema, that the chest had been inBY DAVID BOSWELL REID, JUN., ESQ., jured ; but the first appearance of the effused air in the abdoHOUSE-SURGEON TO UNIVERSITY COLLEGE HOSPITAL. minal rather than the thoracic wall, the absence of pneumothorax and of all stethoscopic indications of thoracic lesion, would enable the surgeon to make a satisfactory diagnosis as to DupUYTBEN, in his Essay on Wounds of the Heart, states that " the diagnosis of wounds of the heart is difficult enough the seat of the injury that furnished the air. CASE 2.-A young man was admitted under my care last to establish, because the signs arerarely united. It is this unDecember with a pistol-bullet wound of the abdomen. The certainty which has caused the non-recognition of the cure of ball had entered close to the navel, and had traversed the body, perhaps a pretty considerable number of penetrating wounds." being extracted from under the skin to the left of and close to In the following case there was good reason to suspect wound the lumbar spine. From the course the bullet had taken, there of the heart :William D-, aged twenty-one, was admitted into Unicould be little doubt that the intestines had been traversed, but there was no positive sign of the occurrence of such an versity College Hospital, at half-past ten P.M., on the 21st of injury by the escape of fseces or flatus through the external July, 1855, under the care of Mr. Erichsen. His friends stated aperture. A few hours after admission, however, emphysema that he received a stab in the chest from a knife half an hour began to show itself in the left flank. This gradually extended before admission, and that the blade was long, narrow, pointed, forwards and upwards, so as to occupy a very considerable and sharp, and had penetrated from an inch to an inch and a half, extent of surface on the left side of the body. The emphy- but that little or no external hemorrhage had occurred. On sematous swelling presented the usual doughy crepitation so admission he was found in a state of general uneasiness and characteristic of this morbid condition, differing in no way anxiety, complaining of pain in the region of the wound on infrom what is observed about the chest or neck in cases in spiration ; face pale, but said to be naturally so; surface warm; which the cellular tissue of these regions is inflated from a puiss 112, regular, and moderately strong; respirations 28; wound of some part of the respiratory organs. The patient mucous membranes natural; thirst. A simple incised wound, died about twenty-four hours after admission. On examining half an inch long, was found in the fourth left intercostal space, the body, it was found that the small intestine had been about an inch from the sternum; its direction was perpentraversed, and the upper part of the rectum wounded by the dicular to the ribs. The wound was inflicted by a young bullet. It was from the wound in the rectum that the flatus woman, whom the patient had provoked, and was made by a had escaped through the meso-rectum into the cellular tissue deliberate thrust in the antero-posterior direction, the knife of the loin, and thence into that of the trunk generally. being removed afterwards gently by the patient; no haemorIn this case the occurrence of emphysema, though interest- rhage nor haemoptysis; cardiac dulness quite natural, the ing as a pathological phenomenon, was less important as a superficial commencing at the fourth left cartilage; second diagnostic sign than in the former instance, the direction of the sound accentuated at left apex; peculiar rumbling noise heard bullet leaving little doubt that the bowel had been wounded; near the apex, and along the adjoining portion of the left lung; though of this, as in the former instance, the occurrence of both lungs healthy; closure of wound, and rest.-Five minutes to twelve P.M.: The pulse 92, regular: respirations 28; impulse emphysema was the only positive evidence. There are but two morbid conditions with which " abdominal in the vertical line of the nipple, fifth space; percussion note, emphysema" can be confounded--viz., thoracic emphysema, pulmonary only to the lower border of the third left cartilage; and the putrefactive emphysema from gangrene of the cellular heart sounds at base healthy; at the left apex first sound very tissue. indistinct, the second loud; rumbling sound as before; other From thoracic emphysema it may be distinguished by the symptoms the same. absence of all sign of injury about the chest, by its spreading July 22nd.-Quarter past eight A.M.: The pulse 96, regular, more slowly, and probably by its being seated, or at all events moderately full and strong; respirations 24; expression trancommencing, in a lower part of the trunk-rather the abdo- quil ; sense of weight in the cardiac region impeding full inminal than the thoracic wall. spiration ; shooting pain below the nipple; skin warm and From the putrefactive emphysema of the cellular tissue, con- moist; tongue furred; thirst; no appetite; dozed off many sequent on low cellulitis or gangrene, the distinction would times during the night; bulging of prascordial region; second necessarily be easy, in the absence of all precursory inflamma- left space less clear than last night; first sound at left apex tion and of all concomitant signs of suppurative slough. scarcely audible; the second distinct ; no friction; lungs The mechanism of "abdominal emphysema" appears to be healthy. Ordered, calomel and colocynth, ten grains; make simple. When the wound in the intestine is so situated, as in into twopills; to be taken immediately. Eight leeches to be both the instances related, that it communicates directly with applied over the cardiac region. After this the chest became rethe sub-peritonsea.1 cellular tissue, the flatus, by the compression lieved ; pulse 80 and softer, and the bowels were opened; carto which all the abdominal contents are subjected during expi- diac dulness increased. To have chloride of mercury, two ration, will be forced into the contiguous cellular tissue, and a grains; opium powder, a quarter of a grain, every four hours. fresh portion being pumped in at each respiratory movement, 23rd.-Passed a quiet night; general condition the same; the inflation will gradually extend through the different planes prascordial region more prominent, and percussion note de-
574
circumstances, with the other kidney unaffected, this condition gelatinous
might havecontinued for years. I have had one case of the kind under observation for the last nine years ; and I have a of a sacculated kidney with the calculus impacted preparation of the ureter, the duration of the symptoms during in the head life being spread over an interval of nearly seventeen years ; so that the rapid and fatal issue of this case must be attributed to the process of ulceration set up in the substance of the kidney, occurring in an individual in whom there existed, as the result proved, an overwhelming tubercular diathesis. This tubercular dyscrasia was forcibly exemplified by the wide sphere over which this product was deposited, existing in a crude state in the lungs, spleen, mesenteric glands, and prostate, and in an active state of ulceration in the kidney and bladder. Rayer (Trccete des M aladies des Reins, vol. iii. p. 643 et seq.) has recorded several cases of tubercular deposit in the bladder aecompanying tubercle of the kidney; but the peculiar feature
blished.
An exudation of
plastic lymph on the surface
of the
bladder, as well as on the intestine, surrounding the ulceration, effectually preserved the peritoneal cavity from any infiltration
of the contents of the bladder. In these cases, we cannot permit ourselves to hope that the result of treatment can be other than palliative. When the suppurative process in the kidney arises from tubercular ulceration, its exhausting effects rapidly reduce the vital powers, and neither nutritive substances, cod-liver oil, nor other medicinal agents, can be expected to arrest the fatal process. Of the remedial means most productive of benefit, opium in the form of Battley’s solution, or the preparations of morphia, yield the most satisfactory results.
of this present case consists, not so much in the presence of tubercle in the bladder, or its wide diffusion in other organs of the body, as in the tubercular ulceration in the bladder, and the fistulous communication which was established between CONTRIBUTIONS TO PRACTICAL SURGERY. the bladder and the intestine. Cases in which fistulous comBY JOHN ERICHSEN, ESQ., munication has taken place between sacculated kidneys with PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE, AND SURGEON TO obstructed ureters and the large or small intestines, although THE HOSPITAL. rare, are not without example. Rayer mentions several. Two such cases have occurred under my own observation. In one III. remarkable case, the particulars of which I propose to comON ABDOMINAL EMPHYSEMA. municate hereafter, a large encysted and sacculated right EMPHYSEMA of the subcutaneous cellular tissue of the trunk kidney opened a passage for its contents into the contiguous ascending colon, and a temporary cure was effected by what is looked upon as one of the most certain signs of thoracic was supposed to be a violent diarrhcea. But I am unacquainted injury, and its occurrence from other causes than wounds of with any analogous case of a fistulous opening between the the lungs or pleura is scarcely, if at all, recognised by writers bladder and rectum caused by tubercular ulceration in the on surgery. My object in this communication is to show that mucous membrane of the former. it may arise without any injury of the chest, by the escape Upon a careful consideration of the contents and condition of flatus from a ruptured or wounded intestine into the subof the bladder, I think it will not be difficult, to a certain peritoneal cellular tissue, and thence into the more superficial extent, to account for the amount of obstruction to the escape cellular planes of the trunk; and that it may thus become imof the contents of the bladder through the urethra, which must portant, or possibly the sole evidence of serious abdominal have pre-existed, and operated as the direct cause of this injury. So far as I have been able to ascertain, the remarks fistulous ulceration. Up to the last week of his life, the patient on this subject in surgical writings are of a very incidental never experienced any difficulty in passing urine; the frequency character, and not commensurate with the importance of this of micturition was not accompanied by any condition that in- lesion as a diagnostic sign of intestinal injury. Haller alludes dicated obstruction or difficulty; and at the post-mortem ex- to it as occurring in a case of abdominal injury; and Morgagni the amination, although tubercles were observed in the prostate, states that in a case of stab of the abdomen, perforating yet these were granular and inactive, and the gland was not colon, "a beginning emphysema was brought on."" The only practitioner who, to my knowledge, has treated of enlarged to an extent sufficient to form any impediment to the free passage of the contents of the bladder. Within six days "abdominal emphysema" asa special symptom is Dr. O’Ferrall, .of the patient’s death, it was observed that he no longer passed of St. Vincent’s Hospital, Dublin. That gentleman, in March, his urine voluntarily, and it was reported in the ward-book 1854, published, in the Dubligi Hospital Gazette, a very valuthat what little was passed seemed to dribble away from the able practical lecture on Abdominal Emphysema, consequent the next day, the diarrhoea, as it was reported, in, and it was at once conjectured that a communication had somewhere been effected between the kidney and intestines; but the opening had taken place between the bladder and rectum, and not between an obstructed and sacculated kidney. So long as the urinary passages are free, such ulcerative communications are little likely to be formed. There was no stricture of the urethra; there was no prostatic disease sufficient to cause retention of the contents of the bladder. How, then, did the bladder fill, and through what cause were its contents forced to an outlet by the lower bowel ? At the bottom of the bladder, adherent to the mucous surface, and filling the space between the ureter of the right side and the opening of the urethra, was found a gelatinous coagulum, of a true jelly-like consistence and colour, and in the lower part of which some earthy, gritty matter was found. This gelatinous exudation constituted, I believe, the proximate cause of the obstruction to the escape of the contents of the bladder, and the consequent retention led to the fistulous communication with the rectum. I think this opinion is corroborated by the observations of Sir Benjamin Brodie. In his work on " Diseases of the Urinary Organs," (p. 134,) he mentions a case in which a mass of lymph, of the consistence and appearance of jelly, was found in the urine. The patient suffered from frequent micturition, and had a deposit of pus in his urine, and on the occasion when this gelatinous matter passed, he suffered from symptoms which were thought to indicate the passage of a renal calculus. The pain suddenly ceased with the escape of this jelly-like fibrine, but the patient subsequently died, and Sir Benjamin Brodie concluded that the immediate cause of this patient’s death had been retention of one of these fibrinous
urethra;
upon Diseases of the Intestines, especially Malignant Disease of the Rectum, Hernia, and Ileo-csecal Abscess; but in that communication he makes no mention of this condition as a consequence of abdominal injuries. The two following cases will illustrate the importance of this symptom in the diagnosis of intestinal injury. CASE 1.-A man about thirty years of age was admitted into the hospital, under my care, in February, 1854, having been squeezed between the buffers of two railway carriages about half an hour previously. He had been struck on the pit of the stomach and the small of the back. On examination, no bruise of skin, or fracture of ribs or spine, or positive sign of injury, could be detected; but the patient was collapsed, and complained of pain in the abdomen. There was some retching, but no vomiting. From the nature and the seat of the injury, and the severity and the continuance of the collapse, there could be little doubt that he had sustained rupture of some one or other of the abdominal organs; but no positive signs existed to indicate which one in particular had suffered. He was accordingly kept quiet in bed, opiates administered, and the urine, which was untinged by blood, drawn off. On the following day, some emphysematous crackling was noticed in the subcutaneous cellular tissue of the right flank, and this gradually crept upwards and forwards, so as to occupy a conextent of the side of the abdomen and lower and back siderable part of the chest, as high as the scapula. These parts presented the ordinary characters of emphysema, being somewhat tumified, doughy and crackling on pressure. There was no discoloration of the integuments. The state of depression continued, notwithstanding the administration of stimulants, and the patient died about forty hours after the accident. masses. On examination after death, it was found that the anterior Nothing can be more calculated effectually to obstruct the margin and the under surface of the liver were lacerated to escape of urine by the natural passage than one of these some extent, and that a considerable quantity of blood had
suddenly
on
set
573
of
been extravasated into the peritonseal cavity. The intestines cellular tissue until the more subcutaneous layers are at first presented no appearance of being injured, but, on closer reached. There is another way in which this abdominal emphysema," inspection, it was found that the posterior part of the duodenum, at about the juncture of the descending and transverse might occur-viz., by the escape of flatus into the peritonaeal portion, was ruptured to the extent of an inch behind the cavity from the wounded intestine, and thence into the subcuperitoneum; the laceration in no way implicated that part taneous cellular tissue at the edges of an oblique wound through of the duodenum which was invested by serous membrane. the abdominal wall. That would appear to have been the way No extravasation had taken place into the peritonseal cavity; in which it occurred in the case related by Morgagni, as quoted but a considerable effusion of thin, bilious-looking intestinal by Mr. Travers ("Injuries of the Intestines," pp. 26 and 27:)matter had been extravasated into the sub-peritonseal cellular " The transverse and oblique muscles were perforated with a tissue in the loin, for some distance around the ruptured gut, wound that would admit two fingers, and between them the and the flatus from this had found its way through the cellular air had entered, so that a beginning emphysema was brought planes until it had reached the subcutaneous cellular tissue, on. This air had got out of the colon, which was wounded, when it had given rise to the emphysema which had been into the cavity of the belly, and had distended it; nor had air noticed during life. There was no injury to any of the organs alonecome forth, but excrement also."" When the emphysema happens in this way from a previously within, or to the parietes of the chest; no fracture of any ribs. The practical interest of this case lies in the fact of the existing tympany, the mechanism of its occurrence would emphysema being the only sign of intestinal injury. There appear to resemble that of a thoracic emphysema, resulting was no wound penetrating the abdominal cavity, nor injury to from a previously-formed pneumothorax. the lungs or ribs; hence the air which became extravasated Welbeck-street, Cavendish-square, December, 1855. into and widely diffused through the cellular tissue could have come from no other source than the ruptured gut. The peculiar and very unusual situation of this injury in the only portion of ON A the small intestine that is uncovered by peritoneum prevented the occurrence of the more ordinary signs of intestinal injury- CASE OF PENETRATING WOUND OF THE viz., feculent or tympanitic extravasation into the cavity of THORAX ; the peritoneum. WITH OBSERVATIONS. In such a case as this the suspicion would naturally arise on the occurrence of emphysema, that the chest had been inBY DAVID BOSWELL REID, JUN., ESQ., jured ; but the first appearance of the effused air in the abdoHOUSE-SURGEON TO UNIVERSITY COLLEGE HOSPITAL. minal rather than the thoracic wall, the absence of pneumothorax and of all stethoscopic indications of thoracic lesion, would enable the surgeon to make a satisfactory diagnosis as to DupUYTBEN, in his Essay on Wounds of the Heart, states that " the diagnosis of wounds of the heart is difficult enough the seat of the injury that furnished the air. CASE 2.-A young man was admitted under my care last to establish, because the signs arerarely united. It is this unDecember with a pistol-bullet wound of the abdomen. The certainty which has caused the non-recognition of the cure of ball had entered close to the navel, and had traversed the body, perhaps a pretty considerable number of penetrating wounds." being extracted from under the skin to the left of and close to In the following case there was good reason to suspect wound the lumbar spine. From the course the bullet had taken, there of the heart :William D-, aged twenty-one, was admitted into Unicould be little doubt that the intestines had been traversed, but there was no positive sign of the occurrence of such an versity College Hospital, at half-past ten P.M., on the 21st of injury by the escape of fseces or flatus through the external July, 1855, under the care of Mr. Erichsen. His friends stated aperture. A few hours after admission, however, emphysema that he received a stab in the chest from a knife half an hour began to show itself in the left flank. This gradually extended before admission, and that the blade was long, narrow, pointed, forwards and upwards, so as to occupy a very considerable and sharp, and had penetrated from an inch to an inch and a half, extent of surface on the left side of the body. The emphy- but that little or no external hemorrhage had occurred. On sematous swelling presented the usual doughy crepitation so admission he was found in a state of general uneasiness and characteristic of this morbid condition, differing in no way anxiety, complaining of pain in the region of the wound on infrom what is observed about the chest or neck in cases in spiration ; face pale, but said to be naturally so; surface warm; which the cellular tissue of these regions is inflated from a puiss 112, regular, and moderately strong; respirations 28; wound of some part of the respiratory organs. The patient mucous membranes natural; thirst. A simple incised wound, died about twenty-four hours after admission. On examining half an inch long, was found in the fourth left intercostal space, the body, it was found that the small intestine had been about an inch from the sternum; its direction was perpentraversed, and the upper part of the rectum wounded by the dicular to the ribs. The wound was inflicted by a young bullet. It was from the wound in the rectum that the flatus woman, whom the patient had provoked, and was made by a had escaped through the meso-rectum into the cellular tissue deliberate thrust in the antero-posterior direction, the knife of the loin, and thence into that of the trunk generally. being removed afterwards gently by the patient; no haemorIn this case the occurrence of emphysema, though interest- rhage nor haemoptysis; cardiac dulness quite natural, the ing as a pathological phenomenon, was less important as a superficial commencing at the fourth left cartilage; second diagnostic sign than in the former instance, the direction of the sound accentuated at left apex; peculiar rumbling noise heard bullet leaving little doubt that the bowel had been wounded; near the apex, and along the adjoining portion of the left lung; though of this, as in the former instance, the occurrence of both lungs healthy; closure of wound, and rest.-Five minutes to twelve P.M.: The pulse 92, regular: respirations 28; impulse emphysema was the only positive evidence. There are but two morbid conditions with which " abdominal in the vertical line of the nipple, fifth space; percussion note, emphysema" can be confounded--viz., thoracic emphysema, pulmonary only to the lower border of the third left cartilage; and the putrefactive emphysema from gangrene of the cellular heart sounds at base healthy; at the left apex first sound very tissue. indistinct, the second loud; rumbling sound as before; other From thoracic emphysema it may be distinguished by the symptoms the same. absence of all sign of injury about the chest, by its spreading July 22nd.-Quarter past eight A.M.: The pulse 96, regular, more slowly, and probably by its being seated, or at all events moderately full and strong; respirations 24; expression trancommencing, in a lower part of the trunk-rather the abdo- quil ; sense of weight in the cardiac region impeding full inminal than the thoracic wall. spiration ; shooting pain below the nipple; skin warm and From the putrefactive emphysema of the cellular tissue, con- moist; tongue furred; thirst; no appetite; dozed off many sequent on low cellulitis or gangrene, the distinction would times during the night; bulging of prascordial region; second necessarily be easy, in the absence of all precursory inflamma- left space less clear than last night; first sound at left apex tion and of all concomitant signs of suppurative slough. scarcely audible; the second distinct ; no friction; lungs The mechanism of "abdominal emphysema" appears to be healthy. Ordered, calomel and colocynth, ten grains; make simple. When the wound in the intestine is so situated, as in into twopills; to be taken immediately. Eight leeches to be both the instances related, that it communicates directly with applied over the cardiac region. After this the chest became rethe sub-peritonsea.1 cellular tissue, the flatus, by the compression lieved ; pulse 80 and softer, and the bowels were opened; carto which all the abdominal contents are subjected during expi- diac dulness increased. To have chloride of mercury, two ration, will be forced into the contiguous cellular tissue, and a grains; opium powder, a quarter of a grain, every four hours. fresh portion being pumped in at each respiratory movement, 23rd.-Passed a quiet night; general condition the same; the inflation will gradually extend through the different planes prascordial region more prominent, and percussion note de-
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