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UNIVERSITY COLLEGE HOSPITAL.
HOSPITAL MEDICINE AND SURGERY.
478
on the right gluteal region. On the next day the minal section at an early stage of the disease, and we still contents of both were becoming purulent, and their bases continue to do so. In the early stages, if the operation be inflamed. On Nov. 7th the inflammation around the large performed immediately on failure of injection of air or fluid bleb on the left leg was increasing rapidly, with oedema extend- to effect relief, the intestines may be found on exposure to be ing for a distance of two or three inches around it. No fresh free from adhesion and the reduction may be effected rapidly eruption now appeared. On the following day the patient and through a small incision. Cases of recovery after abdominal section for intussusception at the age of seven months was ordered tincture of perchloride of iron in ten-minim doses every four hours ; the eruption seemed to be healing a are rare. Dr. Kammererand Mr. Howard Marsh3 have, little, with less inflammation. The patient’s condition however, recorded successes at the age of six months. Few gradually improved till Nov. 14th, although very little heal- diseases require more prompt surgical treatment than intusing took place in the skin eruption, the bases of most of susception if life is to be saved. A female child aged seven months was admitted to the lesions being inflamed, and oedema was present over both tibiae, especially the left. In the morning the patient had University College Hospital on Dec. 14th, 1893. She had The recently suffered from constipation, for which aperients had an attack of vomiting, with severe vertical headache. temperature still kept at from 98° to 99°. On examining the been given. On the day before admission, between 4 and urine it was found to contain albumen, and under the micro- 5 P.M., the child appeared to be suffering severe pain ; she scope blood corpuscles and some epithelial casts were seen. screamed, clenched her hands, and became "black in the The headache, with sickness two or three times a day, face "; she also "strained and heaved." Soon after this, continued, and on the morning of Nov. 17th the patient was on changing the diaper, the child’s mother noticed that found to be delirious at times, complaining much, when blood and " slime " were being passed from the bowel. A conscious, of pain in the head. Both legs were markedly medical man prescribed something for diarrhcea, and on (Edematous, and the skin of the face seemed a little puffy. seeing the child again about noon on the following day sent No signs of fluid in the peritoneal or pleuritic cavities could her to the hospital. No vomiting occurred in the interval be detected. The skin eruption remained in much the same between admission and operation. The discharges from the condition. The urine contained blood corpuscles and blood rectum had a distinctly ammoniacal and fishy" smell. casts. The temperature was found to be 104 2° and the pulse The intussusception could be felt extending from the 90. Three grains of sulphate of quinine were given every left costal margin to the pelvic brim, and by rectal four hours, and an ice-bag was applied to the head. At examination the end of it could be felt a little below the 9.30 P.M. the temperature was 105°, the pulse 90, and the latter level. Preparations were being made for attempting optic discs were blurred. The patient was sponged with reduction by the pressure of water run into the bowel tepid water, which reduced the temperature to 103’2°. On from an irrigator, when Mr. Barker remarked that he conNov. 18th the morning temperature was 105° and the evening sidered the smell of the rectal discharges to be suggestive of temperature 104 2°, both being reduced temporarily by tepid gangrene of the gut and that he had previously observed it sponging. The pulse was 120 and the respiration 30 ; inspi- in gangrenous intussusceptions. Mr. Pollard thereupon deterratory crepitations were audible over the base of the left lung. mined to perform laparotomy at once. The operation of The bowels were opened four times in the morning, the motions median laparotomy was begun at 2.30 P.M. (twenty-two being loose, yellowish, and flocculent. The urine contained hours after the onset of symptoms). The intussusception blood corpuscles and casts. On the following day the morn- was drawn into the wound. The gut looked healthy. As ing temperature was 104 2° and the evening temperature much as possible was reduced by pushing up the intussuscep. 102’2° (after sponging); the pulse was 120. Inspiratory moist turn, as originally advocated by Mr. Hutchinson. After as sounds could be heard over both apices ; both legs were much as possible had been reduced outside the wound the osdematous. On the 20th the temperature was 103’2°, the intussusception was returned into the abdomen, and the respiration 36, and the pulse 120. The patient was very invaginated gut was pressed along the course of the transdelirious and was kept in bed with difficulty. On the 21st the verse and ascending colon into the right loin. As no further patient was still very delirious and restless. The temperature reduction could be effected by intra-abdominal manipula. was 102’4°, the respiration 40, and the pulse 120. He lingered tions the intussusception was again, though with some till the next day, when he sank gradually. No post-mortem difficulty, brought through the wound. The reduction of the remainder of the intussusception required pressure, and, examination was obtained. indeed, as much as it seemed safe to use. After the reducChurch.road, Rickmansworth. tion of the jileo-csecal valve the csecum itself still remained. invaginated. The last point to be reduced was on the right side of the extremity of the csecum, where the bowel was dark-coloured and coated with a small patch of lymph. It was, however, thought safe to return it into the abdomen. OF The laparotomy wound was stitched up and dressed antiseptically. Half a minim of tincture of opium was ordered to be given every four hours. This dose was continued for five days, and then it was gradually diminished and finally BRITISH AND FOREIGN. omitted on the twelfth day. Three drachms of a mixture, ic Nullaautem est alia pro certo noscendi via, nisi quamplurimas et mor- equal quantities, of milk and barley water were at first given borum et dissectionnm historias, turn aliorum turn proprias collectas every hour. The quantity was gradually increased until, on habere, et inter se comparare.-MORGAGNi De Sed. et Caus. Jtfo)’&., the seventh day, an ounce of milk and half an ounce of lib. iv. Procemium. barley water were given every two hours. The bowels acted naturally on the day after the operation. The child waS’ UNIVERSITY COLLEGE HOSPITAL. restless and febrile, owing apparently to teething, for a feB! CÆCAL INTUSSUSCEPTION IN AN INFANT AGED SEVEN days. The wound healed by first intention, and the child was sent home on the seventeenth day after the operation. MONTHS; REDUCTION AFTER LAPAROTOMY; - Remaps by Mr. BILTON POLLARD.-This was a case of RECOVERY; REMARKS. csecal intussusception. The caecum had first of all been (Under the care of Mr. BILTON POLLARD.) into the ascending colon, and then the ileo-csecal invaginated THERE are some surgical conditions which a few years ago valve and the ascending colon followed. Recovery does not were regarded as being incurable and invariably fatal, whilst generally follow the reduction of an intussusception after I believe the now scarcely a day passes without examples of a record of laparotomy in a child as young as this one. their successful treatment. Intussusception is hardly in this mortality of laparotomy is largely due to the delay which ir caused the trial of other methods of reduction. If category, for its treatment ic still unsatisfactory; yet the water through succeeds it is, of course, a most simple ani results are more encouraging than they were, a position we perfect method of treatment. If, on the other hand, it fails, think due either to the earlier resort to abdominal section on the operation itself probably adds to the shock of the disease the failure of other methods, or, in special cases, to the resort itself, and the delay which is necessary in order to test to abdominal section without the trial of other methods. As the effect of the water pressure certainly increases the gravity Mr. Bilton Pollard remarks, it is important that cases should be reported in order that the profession may have more certain 1 THE Jan. 26th, 1889 ; Nov. 29th, 1890; and May 23rd and grounds to go upon in treating this dangerous condition. We June 13th,LANCET, 1891. 2 Med. 3 In 1875. have for some years advocated a more frequent resort to abdoRecord, New York, 1890 ; p. 114.
smaller bleb
A Mirror
HOSPITAL
PRACTICE,
-
pressure
474
HOSPITAL MEDICINE AND SURGERY.
In this case, as there was a suspicion of close to the margin of the sternum, and from it blood was of the case gangrene having occurred, I proceeded at once to laparotomy, oozing. On a careful examination no trace of the needle and I am glad I did so, for, considering the force which was or thread was found, and no abnormal sound was heard on needed to reduce the last part of the intussusception, it is auscultation. The wound was closed with collodion and quite unlikely that the pressure of a column of water from cotton-wool. From the imperfect history obtainable and the three to four feet would have done so, and the delay which the absence of important symptoms it was considered probable attempt would have occasioned, if it had not made reduction that the child had been merely pricked and that the needle impossible, might at least have interfered with the successful had fallen out. A few minutes later the mother arrived result of the case. It is important that all cases of intus- and was so clear in her evidence that it was at once decided susception reduced by one method or the other should be to make a slight exploration in the hope that the head of the reported in order that more certain grounds may be obtained needle might be still embedded in the intercostal muscles. The child was now lying quite still and apparently comfortfor deciding upon the best method of treatment. able. Chloroform was given shortly before 2 P.M.—i.e., less than an hour after the accident-and an incision about an inch long was made through the skin in the third left interBEDFORD GENERAL INFIRMARY. costal space. The needle could not, however, be felt in the PENETRATING WOUND OF THE HEART; DEATH IN THIRTY- intercostal muscles, and it was not considered advisable to go any deeper. The wound was closed by a single suture. NINE HOURS. The chloroform was well taken and was not accompanied Under the care of Mr. F. A. FIELD.) The patient or followed by any sickness or other trouble. THE study of wounds of the pericardium and heart is always was very comfortable, quiet, and sleepy all the afternoon of interest, and the following contribution to our knowledge and evening. She took a cup of milk at 4.30 PM. and of cases in which a foreign body has lodged in the heart another at 7 P.M. The temperature at 6 P.M. was 98° F. She began to cry about 10 P.M , and was then very restless itself and produced death is not of less interest than the few for about three hours. She vomited once at 4 A M. on Dec. others of a similar character that have already been recorded 21st. After this she was given milk and soda water, taking in THE LANCET or that can be found scattered through a pint of milk and half a pint of soda water in the course of the pages of professional literature. Fischer collected the night. She slept well during the latter part of the night and was evidently easier again. At 8 A.M. the a series of forty-seven examples of these wounds, in which was 98 2°. During the whole of the morning the foreign body lodged in the heart or pericardium. temperature she was fairly comfortable, lying quietly on her back. The Of these, seventeen were caused by needles, one by a heart sounds were ; no pericardial friction was heard. pin, one by an iron pin, one by a thorn, one by an The chest was not muffles examined, as it was considered thoroughly iron one an one a two by stylet, by file, ivory toothpick, more to keep the patient at rest. During the important by bones, one by a wooden peg, one by the point of a morning she took two cups of milk, and at 12 30 P.M. a dagger, twelve by bullets, one by shot, one by a piece of a little tapioca pudding and another cup of milk for dinner. In two cases the needle was extracted and the gun, &c. From the favourable condition of the patient it now patient recovered ; but in one of these the evidence of pene- seemed likely that the needle had avoided wounding tration of the heart is not satisfactoly. Once a needle two the heart or great vessels. At 130 P.M.—i.e., twentyinches long was found encapsuled in the substance of the four hours and a half after the injury-the patient almost ventricle, and once a needle was found covered with lymph after six years’ lodgment. The majority of cases proved suddenly became very much worse, pale, collapsed, and and in fact presented most of the symptoms present in fatal, but occasionally life may be prolonged; in one of quiet, of internal haemorrhage. She rallied slightly Fischer’s cases death ensued nine months after injury, patients dying and became very restless, remaining pale, uneasy, and very cardiac symptoms having supervened only during the last weak till her death. At 3 30 P.M. the had risen twenty-two days of life. In one instance death was due to to 101°. At 8 P.M. it was 100°. Thetemperature was now respiration laceration of the cardiac wall and coronary vessels by fricmore and more rapid and shallow. At 11 P.M. the tion against the point of the needle. In more recent times becoming was 132 to the minute. The patient was weaker other cases of similar injury have been recorded: for in- respiration and in pain, with evidence of nausea, and the case was seen Dr. down on which could cut a stance, foreign body Wyman to be hopeless. Two minims of tincture of opium were now be felt under the skin in the cardiac region of a child eight with a little carminative medicine, but only procured months old and extracted a needle; the child recovered. We given her a few minutes’ sleep. She had no other sleep during the have recorded in THE LANCET a fatal case of penetrating She vomited twice between 1A.M. and 2 A.M. The wound by a needle, with haemorrhage into the pericardium, night. at 2 A M. was 102-8°. She died at 3.50 A.M temperature the patient being a lunatic. Those interested in the subject i.e., thirty-nine hours after the accident and fourteen hours will read with advantage the communication on "Survival minutes after the onset of severe symptoms. and twenty after Gunshot Wounds and other Injuries of the Heart" from Post-maorterrz examination eleven hours after death.-On Surgeon-Major Curran which was published in THE LANCET,1 the chest in the usual manner a small quantity and the letter from Dr. O’Connell2 which followed it For opening of blood was foundjust inside the chest-wall, beneath the notes of this case we are indebted to Mr. F. A. Field, the puncture in the third left intercostal space, and the resident surgeon at the infirmary. tissues of the anterior mediastinum were bloodstained A girl aged three years and two months was admitted into from that spot down to the anterior attachment of the the Bedford General Infirmary on Dec. 20th, 1893, suffering where there was a small but definite clot. from a punctured wound of the heart. On the afternoon of the diaphragm, There was no apparent wound of the internal mammary same day the patient was seated on a hearth-rug, fully dressed, The pericardium was distended with bloodstained and playing at sewing with her three sisters, who were all artery. fluid containing a few loose shreds of lymph, but no clots. small children. No one else was present at the time of the The heart was transfixed from before backwards by an accident, and the exact manner in which the wound was ordinary unbroken sewing-needle. The head of the needle Just not PM is known. before the mother’s atten1 received was just out of sight beneath the visceral layer of the perition was attracted by screaming, and on running into the room cardium, midway between the auriculo-ventricular groove : the child of in the found chest. She she showing signs pain and the and nearly half an inch to the right of the undressed her and found on the front of the chest a small anterior apex, inter-ventricular groove. It thence passed through the l was from the wound which bleeding slightly; hanging prick, ventricular wall into the cavity of the right ventricle, where The needle was invisible, was a very short piece of thread. it transfixed the base of the anterior papillary muscle and but its head could be felt through the skin, projecting verti-entered the right side of the ventricular septum midway cally about half an inch to the side of the wound. On its anterior and posterior margins; it thence the the head of needle but the the thread moved, pulling , continued in the substance of the septum, just missing child screamed as if in pain; so she desisted, and started the cavity of the left ventricle, and emerged an eighth of to bring it to the infirmary, a distance of only half a mile. an inch to the left of the posterior inter-ventricular groove, Meeting her husband on the way, she handed the child to him. midway between the auriculo-ventricular groove and the On admission the child was attended to at once. She wasS The point projected for nearly half an inch beyond apex. on evidently not in severe pain and only cried being examined. heart. The needle was just over one and a half inches A puncture was present in the third left intercostal spacee long and is accounted for as follows : in the right ventricular wall, one-tenth of an inch ; in the cavity of the 1 THE LANCET, April 2nd and 9th, 1837. 2 THE right ventricle, one-third of an inch ; in the septum, twoLANCET, July 16th, 1887.
l
between
’
the -
478
on the right gluteal region. On the next day the minal section at an early stage of the disease, and we still contents of both were becoming purulent, and their bases continue to do so. In the early stages, if the operation be inflamed. On Nov. 7th the inflammation around the large performed immediately on failure of injection of air or fluid bleb on the left leg was increasing rapidly, with oedema extend- to effect relief, the intestines may be found on exposure to be ing for a distance of two or three inches around it. No fresh free from adhesion and the reduction may be effected rapidly eruption now appeared. On the following day the patient and through a small incision. Cases of recovery after abdominal section for intussusception at the age of seven months was ordered tincture of perchloride of iron in ten-minim doses every four hours ; the eruption seemed to be healing a are rare. Dr. Kammererand Mr. Howard Marsh3 have, little, with less inflammation. The patient’s condition however, recorded successes at the age of six months. Few gradually improved till Nov. 14th, although very little heal- diseases require more prompt surgical treatment than intusing took place in the skin eruption, the bases of most of susception if life is to be saved. A female child aged seven months was admitted to the lesions being inflamed, and oedema was present over both tibiae, especially the left. In the morning the patient had University College Hospital on Dec. 14th, 1893. She had The recently suffered from constipation, for which aperients had an attack of vomiting, with severe vertical headache. temperature still kept at from 98° to 99°. On examining the been given. On the day before admission, between 4 and urine it was found to contain albumen, and under the micro- 5 P.M., the child appeared to be suffering severe pain ; she scope blood corpuscles and some epithelial casts were seen. screamed, clenched her hands, and became "black in the The headache, with sickness two or three times a day, face "; she also "strained and heaved." Soon after this, continued, and on the morning of Nov. 17th the patient was on changing the diaper, the child’s mother noticed that found to be delirious at times, complaining much, when blood and " slime " were being passed from the bowel. A conscious, of pain in the head. Both legs were markedly medical man prescribed something for diarrhcea, and on (Edematous, and the skin of the face seemed a little puffy. seeing the child again about noon on the following day sent No signs of fluid in the peritoneal or pleuritic cavities could her to the hospital. No vomiting occurred in the interval be detected. The skin eruption remained in much the same between admission and operation. The discharges from the condition. The urine contained blood corpuscles and blood rectum had a distinctly ammoniacal and fishy" smell. casts. The temperature was found to be 104 2° and the pulse The intussusception could be felt extending from the 90. Three grains of sulphate of quinine were given every left costal margin to the pelvic brim, and by rectal four hours, and an ice-bag was applied to the head. At examination the end of it could be felt a little below the 9.30 P.M. the temperature was 105°, the pulse 90, and the latter level. Preparations were being made for attempting optic discs were blurred. The patient was sponged with reduction by the pressure of water run into the bowel tepid water, which reduced the temperature to 103’2°. On from an irrigator, when Mr. Barker remarked that he conNov. 18th the morning temperature was 105° and the evening sidered the smell of the rectal discharges to be suggestive of temperature 104 2°, both being reduced temporarily by tepid gangrene of the gut and that he had previously observed it sponging. The pulse was 120 and the respiration 30 ; inspi- in gangrenous intussusceptions. Mr. Pollard thereupon deterratory crepitations were audible over the base of the left lung. mined to perform laparotomy at once. The operation of The bowels were opened four times in the morning, the motions median laparotomy was begun at 2.30 P.M. (twenty-two being loose, yellowish, and flocculent. The urine contained hours after the onset of symptoms). The intussusception blood corpuscles and casts. On the following day the morn- was drawn into the wound. The gut looked healthy. As ing temperature was 104 2° and the evening temperature much as possible was reduced by pushing up the intussuscep. 102’2° (after sponging); the pulse was 120. Inspiratory moist turn, as originally advocated by Mr. Hutchinson. After as sounds could be heard over both apices ; both legs were much as possible had been reduced outside the wound the osdematous. On the 20th the temperature was 103’2°, the intussusception was returned into the abdomen, and the respiration 36, and the pulse 120. The patient was very invaginated gut was pressed along the course of the transdelirious and was kept in bed with difficulty. On the 21st the verse and ascending colon into the right loin. As no further patient was still very delirious and restless. The temperature reduction could be effected by intra-abdominal manipula. was 102’4°, the respiration 40, and the pulse 120. He lingered tions the intussusception was again, though with some till the next day, when he sank gradually. No post-mortem difficulty, brought through the wound. The reduction of the remainder of the intussusception required pressure, and, examination was obtained. indeed, as much as it seemed safe to use. After the reducChurch.road, Rickmansworth. tion of the jileo-csecal valve the csecum itself still remained. invaginated. The last point to be reduced was on the right side of the extremity of the csecum, where the bowel was dark-coloured and coated with a small patch of lymph. It was, however, thought safe to return it into the abdomen. OF The laparotomy wound was stitched up and dressed antiseptically. Half a minim of tincture of opium was ordered to be given every four hours. This dose was continued for five days, and then it was gradually diminished and finally BRITISH AND FOREIGN. omitted on the twelfth day. Three drachms of a mixture, ic Nullaautem est alia pro certo noscendi via, nisi quamplurimas et mor- equal quantities, of milk and barley water were at first given borum et dissectionnm historias, turn aliorum turn proprias collectas every hour. The quantity was gradually increased until, on habere, et inter se comparare.-MORGAGNi De Sed. et Caus. Jtfo)’&., the seventh day, an ounce of milk and half an ounce of lib. iv. Procemium. barley water were given every two hours. The bowels acted naturally on the day after the operation. The child waS’ UNIVERSITY COLLEGE HOSPITAL. restless and febrile, owing apparently to teething, for a feB! CÆCAL INTUSSUSCEPTION IN AN INFANT AGED SEVEN days. The wound healed by first intention, and the child was sent home on the seventeenth day after the operation. MONTHS; REDUCTION AFTER LAPAROTOMY; - Remaps by Mr. BILTON POLLARD.-This was a case of RECOVERY; REMARKS. csecal intussusception. The caecum had first of all been (Under the care of Mr. BILTON POLLARD.) into the ascending colon, and then the ileo-csecal invaginated THERE are some surgical conditions which a few years ago valve and the ascending colon followed. Recovery does not were regarded as being incurable and invariably fatal, whilst generally follow the reduction of an intussusception after I believe the now scarcely a day passes without examples of a record of laparotomy in a child as young as this one. their successful treatment. Intussusception is hardly in this mortality of laparotomy is largely due to the delay which ir caused the trial of other methods of reduction. If category, for its treatment ic still unsatisfactory; yet the water through succeeds it is, of course, a most simple ani results are more encouraging than they were, a position we perfect method of treatment. If, on the other hand, it fails, think due either to the earlier resort to abdominal section on the operation itself probably adds to the shock of the disease the failure of other methods, or, in special cases, to the resort itself, and the delay which is necessary in order to test to abdominal section without the trial of other methods. As the effect of the water pressure certainly increases the gravity Mr. Bilton Pollard remarks, it is important that cases should be reported in order that the profession may have more certain 1 THE Jan. 26th, 1889 ; Nov. 29th, 1890; and May 23rd and grounds to go upon in treating this dangerous condition. We June 13th,LANCET, 1891. 2 Med. 3 In 1875. have for some years advocated a more frequent resort to abdoRecord, New York, 1890 ; p. 114.
smaller bleb
A Mirror
HOSPITAL
PRACTICE,
-
pressure
474
HOSPITAL MEDICINE AND SURGERY.
In this case, as there was a suspicion of close to the margin of the sternum, and from it blood was of the case gangrene having occurred, I proceeded at once to laparotomy, oozing. On a careful examination no trace of the needle and I am glad I did so, for, considering the force which was or thread was found, and no abnormal sound was heard on needed to reduce the last part of the intussusception, it is auscultation. The wound was closed with collodion and quite unlikely that the pressure of a column of water from cotton-wool. From the imperfect history obtainable and the three to four feet would have done so, and the delay which the absence of important symptoms it was considered probable attempt would have occasioned, if it had not made reduction that the child had been merely pricked and that the needle impossible, might at least have interfered with the successful had fallen out. A few minutes later the mother arrived result of the case. It is important that all cases of intus- and was so clear in her evidence that it was at once decided susception reduced by one method or the other should be to make a slight exploration in the hope that the head of the reported in order that more certain grounds may be obtained needle might be still embedded in the intercostal muscles. The child was now lying quite still and apparently comfortfor deciding upon the best method of treatment. able. Chloroform was given shortly before 2 P.M.—i.e., less than an hour after the accident-and an incision about an inch long was made through the skin in the third left interBEDFORD GENERAL INFIRMARY. costal space. The needle could not, however, be felt in the PENETRATING WOUND OF THE HEART; DEATH IN THIRTY- intercostal muscles, and it was not considered advisable to go any deeper. The wound was closed by a single suture. NINE HOURS. The chloroform was well taken and was not accompanied Under the care of Mr. F. A. FIELD.) The patient or followed by any sickness or other trouble. THE study of wounds of the pericardium and heart is always was very comfortable, quiet, and sleepy all the afternoon of interest, and the following contribution to our knowledge and evening. She took a cup of milk at 4.30 PM. and of cases in which a foreign body has lodged in the heart another at 7 P.M. The temperature at 6 P.M. was 98° F. She began to cry about 10 P.M , and was then very restless itself and produced death is not of less interest than the few for about three hours. She vomited once at 4 A M. on Dec. others of a similar character that have already been recorded 21st. After this she was given milk and soda water, taking in THE LANCET or that can be found scattered through a pint of milk and half a pint of soda water in the course of the pages of professional literature. Fischer collected the night. She slept well during the latter part of the night and was evidently easier again. At 8 A.M. the a series of forty-seven examples of these wounds, in which was 98 2°. During the whole of the morning the foreign body lodged in the heart or pericardium. temperature she was fairly comfortable, lying quietly on her back. The Of these, seventeen were caused by needles, one by a heart sounds were ; no pericardial friction was heard. pin, one by an iron pin, one by a thorn, one by an The chest was not muffles examined, as it was considered thoroughly iron one an one a two by stylet, by file, ivory toothpick, more to keep the patient at rest. During the important by bones, one by a wooden peg, one by the point of a morning she took two cups of milk, and at 12 30 P.M. a dagger, twelve by bullets, one by shot, one by a piece of a little tapioca pudding and another cup of milk for dinner. In two cases the needle was extracted and the gun, &c. From the favourable condition of the patient it now patient recovered ; but in one of these the evidence of pene- seemed likely that the needle had avoided wounding tration of the heart is not satisfactoly. Once a needle two the heart or great vessels. At 130 P.M.—i.e., twentyinches long was found encapsuled in the substance of the four hours and a half after the injury-the patient almost ventricle, and once a needle was found covered with lymph after six years’ lodgment. The majority of cases proved suddenly became very much worse, pale, collapsed, and and in fact presented most of the symptoms present in fatal, but occasionally life may be prolonged; in one of quiet, of internal haemorrhage. She rallied slightly Fischer’s cases death ensued nine months after injury, patients dying and became very restless, remaining pale, uneasy, and very cardiac symptoms having supervened only during the last weak till her death. At 3 30 P.M. the had risen twenty-two days of life. In one instance death was due to to 101°. At 8 P.M. it was 100°. Thetemperature was now respiration laceration of the cardiac wall and coronary vessels by fricmore and more rapid and shallow. At 11 P.M. the tion against the point of the needle. In more recent times becoming was 132 to the minute. The patient was weaker other cases of similar injury have been recorded: for in- respiration and in pain, with evidence of nausea, and the case was seen Dr. down on which could cut a stance, foreign body Wyman to be hopeless. Two minims of tincture of opium were now be felt under the skin in the cardiac region of a child eight with a little carminative medicine, but only procured months old and extracted a needle; the child recovered. We given her a few minutes’ sleep. She had no other sleep during the have recorded in THE LANCET a fatal case of penetrating She vomited twice between 1A.M. and 2 A.M. The wound by a needle, with haemorrhage into the pericardium, night. at 2 A M. was 102-8°. She died at 3.50 A.M temperature the patient being a lunatic. Those interested in the subject i.e., thirty-nine hours after the accident and fourteen hours will read with advantage the communication on "Survival minutes after the onset of severe symptoms. and twenty after Gunshot Wounds and other Injuries of the Heart" from Post-maorterrz examination eleven hours after death.-On Surgeon-Major Curran which was published in THE LANCET,1 the chest in the usual manner a small quantity and the letter from Dr. O’Connell2 which followed it For opening of blood was foundjust inside the chest-wall, beneath the notes of this case we are indebted to Mr. F. A. Field, the puncture in the third left intercostal space, and the resident surgeon at the infirmary. tissues of the anterior mediastinum were bloodstained A girl aged three years and two months was admitted into from that spot down to the anterior attachment of the the Bedford General Infirmary on Dec. 20th, 1893, suffering where there was a small but definite clot. from a punctured wound of the heart. On the afternoon of the diaphragm, There was no apparent wound of the internal mammary same day the patient was seated on a hearth-rug, fully dressed, The pericardium was distended with bloodstained and playing at sewing with her three sisters, who were all artery. fluid containing a few loose shreds of lymph, but no clots. small children. No one else was present at the time of the The heart was transfixed from before backwards by an accident, and the exact manner in which the wound was ordinary unbroken sewing-needle. The head of the needle Just not PM is known. before the mother’s atten1 received was just out of sight beneath the visceral layer of the perition was attracted by screaming, and on running into the room cardium, midway between the auriculo-ventricular groove : the child of in the found chest. She she showing signs pain and the and nearly half an inch to the right of the undressed her and found on the front of the chest a small anterior apex, inter-ventricular groove. It thence passed through the l was from the wound which bleeding slightly; hanging prick, ventricular wall into the cavity of the right ventricle, where The needle was invisible, was a very short piece of thread. it transfixed the base of the anterior papillary muscle and but its head could be felt through the skin, projecting verti-entered the right side of the ventricular septum midway cally about half an inch to the side of the wound. On its anterior and posterior margins; it thence the the head of needle but the the thread moved, pulling , continued in the substance of the septum, just missing child screamed as if in pain; so she desisted, and started the cavity of the left ventricle, and emerged an eighth of to bring it to the infirmary, a distance of only half a mile. an inch to the left of the posterior inter-ventricular groove, Meeting her husband on the way, she handed the child to him. midway between the auriculo-ventricular groove and the On admission the child was attended to at once. She wasS The point projected for nearly half an inch beyond apex. on evidently not in severe pain and only cried being examined. heart. The needle was just over one and a half inches A puncture was present in the third left intercostal spacee long and is accounted for as follows : in the right ventricular wall, one-tenth of an inch ; in the cavity of the 1 THE LANCET, April 2nd and 9th, 1837. 2 THE right ventricle, one-third of an inch ; in the septum, twoLANCET, July 16th, 1887.
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