CLINICAL LECTURE ON SURGERY

767 orifice. On the second sound ; being of necessity instantaneously mortal, bruit vocal," as physiologists call it, Imay even admit of a cure. Wounds of the heart from a pointed inshall not dwell, ,because, though presenting many phenomena of the most interest- strument comc particularly under this ing kind, it is not directly connected with head, as we may conclude from acupullcof the heart, which was tried so often our present subject. At our next meeting I will follow up at Warsaw during the time of the cholera, the question of the human voice, considered without auy effect on the disease, but at as a musical instrument, and show under the same time without any injury to the what circumstances the bruits of the tra- patient. In this operation the delicate of the instrument separates, and chea and larynx are modified or altered. the fibres of the tissues, without occasioning much pain, or any solution of continuity; hence, when it is withdrawn, the parts return to their natural state, the CLINICAL LECTURE ON SURGERY opening closes, and not a drop of blood is lust. It is not, therefore, surprising that DELIVERED BY a simple prick of the heart is susceptible of cure ; but wecan conceive that a forBARON DUPUYTREN, tunate result can seldom take place when the wound is made by a pointed cutting Duriny the Session of 1834, at the

undeviating

or

"

ture

point distends

. instrument,

or

by

a

cutting

one

alone,

which must practise an opening more or DIEU, less large, in penetrating to the cavities of Revised (before trauslatiou) by the Barou himself in the the heart. Whenever the wound is of any fasctculi of lus "Lecous Orales de Cliniquc Chirur as for example a few lines, either in size, gicale," pubhshcd periudic.illy by G. Baii:iere, Paris. the auricle or the ventricle, it becomes instantly the cause of death, from the quanof blood poured into the cavity of the ON WOUNDS OF THE HEART,—THEIR tity chest at the moment of the wound. Some AND VAIIIETIES, CAUSES, SYMPTOMS, that death may not TREATMENT: AND ON MUTILATION OF facts, however, prove be so instantaneous as is commonly imaHOTEL

PARIS.

I

THE GENITALS.

gined.

The following case is of additional A FEW years ago it was considered as a fact placed beyond any doubt that wounds value, as it shows how the patient was of the heart were necessarily mortal, cured of a wound of the heart, which was and various theses were presented to the not recognised during life, and was only Faculty of Medicine on the inevitable discovered after the death of the patient, and instantaneous mortality of these inju- produced hy another affection :ries. Even at present, in spite of the number of facts and observations collected at CASE 1.—Stabs in the Heart and Stomach the Hotel Dieu, and in other hospitals, the proceeding to a Cure, complicated with contrary opinion is far from being gene.fatal affection of the Brain. rally admitted ; yet it is a fact well established by the examination of the body Geray, thirty-four years of age, by proafter death, that wounds of the substance fession a metal founder, generally enjoyof the heart are not beyond a chance of ing good health, was brought to the Hotel cuie, however deeply they may have pene- Dieu ou the 5th of November 1831, to trated, or whatever be the cavity of which undergo treatment for various wounds the parietes are injured. We need not go which he had received. From our infar to seek for proofs of this assertion ; quiries into the history of the accident, balls, or manifest cicatrices, have been we learned that he had visited his mistress found in the hearts of animals killed in the day before in a state bordering upon the chase ; individuals presenting all the intoxication, and engaged in a quarrel rational symptoms of wounds of the heart with some individual whom he met there, have been perfectly cured; and, finally, during which Geray received two stabs of who can forget the case of the soldier in a knife, one in the belly, the other in the whom, six years after the cure of his chest. Although severely wounded, he wound, was found a ball imbedded near was able to walk and defend himself for the apex of the heart in the substance of sometime, but at length he fainted, and the right ventricle, and in part covered vomited occasionally, without throwing by the pericardium? Hence all well-inany blood ; the wound of the chest, on structed surgeons of the present day admit contrary, furnished a great quantity that penetrating wounds of the auricles orof this fluid. On the patient’s arrival at ventricles, ii they be small, so far from the Hotel Dieu, the existence of the two

up

; the

768 wounds in the chest and abdomen was

On the 8th he remained in the

same

immediately recognised; his face was state. Cupping behind the ea?-s;vegetable pale, sunken, and agitated; the whole broth. surface of the body was colourless ; the 9. The patient does not complain of his pulse regular and extremely feeble; the head until his attention is drawn to it. If, pulsation of the heart was also regular, when one eye is shut, an object be prebut almost imperceptible ; there was a sented before the opposite one, it is ohgeneral spasmodic trembling of the body, served that the left eye has much less power yet the feebleness of the patient seemed of vision than the right. He has not yet

rather the effect of some nervous affec- had an evacuation; the wounds look than of the loss of a healthy; the chest is sonorous on the quantity of blood. Each wound was about left side, and when the stethoscope is apsix or seven lines in length ; they wereplied near the wound, it seems to the situated, one at the base of the chest on ear as if the air had to overcome some the left side, between the fourth and fifthobstacle in filling the chest, and was preribs ; the other three or four fingers’ cipitated rapidly into a cavity. The pnlbreadth above the umbilicus on the same of the heart remains regular, and side ; the first was perpendicular to the the general state of the patient is the same direction of the rihs, and increased a little as on former days. Cuyping behind the on the inferior edge of the cartilage of the Pzcrgative clyster. 10. There is no amelioration of the fourth ; the second wound was nearly cerebral symptoms ; sensation and motion transverse; they both appeared to been made by a cut and thrust instrument are more perfect in the left lower exof some kind. The wound on the chest the pulse regular but frequent ; still bled a little, and there was no symp- no stool ; respiration the same as on fortom of its having penetrated into the mer days. Vegetable broth, with Sulph. cavity; the whole of the left side was Sodœ;Sinapisms to the feet;Purgative sonorous, the respiration even and regu- clyster. In the evening all the symptoms lar; there was no cough or spitting of became aggravated, with congestion of the blood; the woundof the abdomen did not brain and violent agitation; the pulse was give issue to any solid, liquid, or gaseous regular but very frequent ; and the heart was soft, although the beat matter; the strongly and reaularly. Fifteen patient had not been to stool for some leeches belzind the ears; Sinapisms to the time, and there did not exist the slightest feet. 11. The muscles of the neck and back sign of effusion into the chest. The pain caused by the wounds was very slight, have become stiff; those of the paralysed and the patient was quite tranquil. parts, on the contrary, are flaccid ; the chylon plaster to the wounds; Wine and circulatory system presents the same state as yesterday. Purgative lavement; water for drink. with Sulphate of S’orla and one grain b’’oth, On the 6th the abdomen and chest re of Tartar Emetic. mained in the same state; the skin was The medicine has produced a good warm, and the pulse a little more but the bladder does not act; stools, loped. Bleeding to eight ounces. In the convulsive motion of the lips every now evening his mistress came to see him, and and and then the memory remainsperfect, then;; the perfect, memory remains her visit agitated the patient considerably. and the patient answers all questions cor7. Wounds in the same state ; rectly but very slowly. The face is aland has become dark-coloured ; skin hot; and the pulse a little accelerated. Bleeding to eight ounces. The blood was signs of congestion in the chest; and the drawn at half-past nine o’clock;and at pulse has commenced to beat irregularly. eleven symptoms of congestion towards For the two last days the patient has comthe brain manifested themselves ; thereplained of pain in the back and posterior was loss of consciousness; great agitation part of the neck, where the muscles are and convulsive motion of all the muscles extremely stiff. Barley-water with G2cm; In the evening the of the left side of the body. Sensation and Setolt in the neck. voluntary motion were also lost, though congestion in the chest became more some slight trace of both remained in the marked; the countenance more altered; left lower extremity. The moutli was the pulse thready; and, finally, the patient turned to the left side, and the tongue lsro- died on the 13th at eight o’clock in the jected from the mm:.!;, and a;so deviated to ti.e left side. There was a tendency A transverse somnokence, but the patient answered Necropsy. — Abdomen. wound of six or seven lines in length rectly wh w slr..t;en to. He complained sutne pain in the lead. about three inches to the left of Simpisms tothe feet; Anedyne d ght. the umbilieus; there was a slight effusion

considerable

tion,

sation

ears;

I

have

tremity ;

belly

Dya-

On the

chest

12.

deve- many

the

tered

morning. to corof

existed

-

769 of blood into the cellular tissue which That the brain was slightly softened. unites the peritoneum to the abdominal 4th. Finally, that these wounds, which one parietes. The stomach, which lay con- would imagine ought to have been instancealed beneath the false ribs, had been pe- taneonsly mortal, did not prevent the panetrated near its great curve by a wound tient from living for eight days, and might, two lines in length ; the edges of this perhaps, have been susceptible of a cure, wound were nearly in contact, and partly had they not been complicated with a closed up by mucus ; the organ itself was dangerous atfection of the brain. You see, therefore, that wounds of the not inflamed, and did not contain any blood. There was no effusion into the heart are not, as has been said, instantly cavity of the peritoneum, which latter mortal; however, iii considering tljc poswas perfectly healthy. Thorax:—There sibility or impossibility of a enre, we niiist was a wound six or seven lines in length, take into account the depth to which the perfectly similar in form to that of the instrument has penetrated; the direction abdomen, situate between the fourth and of the wound with relatioll to the fibres fifth left ribs ; the sub-serous cellular which are injured, and the parietes of the tissue near the wound, as well as the left part; the extent of the wound ; the form of side of the mediastinum, contained a good the instrument which has produced it; and deal of extravasated blood. The cavity of; the presence of foreign bodies &c. in the the chest contained about four ounces of wound. ii’e shall enter into a few details blood ; the intercostal artery which passes on these different points. along the lower edge of the fourth rib Wounds of the heart vary according had been wounded, and supplied the bloodto their extent and seat; they may be found in the left pleura. The pericar- superficial or deep, the first involving dium was penetrated by a wound three only a portion of the substance of the and a half lines in extent; and the heartheart, the latter penetrating into its cahad also been wounded near the vity. There are cases on record of wounds line, a little to the right of the left ven- which have penetrated several cavities the same time. The direction -of the tricle, into the cavity of which the instrument had passed, a transverse cut, wound may be transverse to that of the number of fibres, or may interwhich bore some resemblance to a bow; it was three lines and a half in length by aline ’sect them in various degrees of obliin height. The external fibres were much hence mise the different tendenmore separated than the internal ones, of such wounds to form an Matus. and the separation gradually diminished When an instrument has divided transtowards the cavity of the ventricle, so that a great number of fibres, the openthe most internal were in contact with ing will be larger, and the tendency to the each other, and closed the wound. The !effusion of blood must be greater than cavity of the pericardium contained about when the wound is made parallel to the Brain:—The arachan ounce of serum. fibres. Put as the heart is comnoid membrane was very dry. There exof different layers of fibres of differisted a slight but sensible depression on directions, it is evident, that in case the middle of the right hemisphere, where of a wound penetrating to one of its cavithere appeared several points of ramollisif one set of fibres tend to separate sement, with some injection of the white the edges of the wound, another set will substance. The spinal marrow was quite tend to bring them together. Thus, for let us suppose a wound passing healthy. olliquely into the cavity of the left venRemarks.—The case which you have tricle from the median line; this will dijust heard, proves that wounds of the vide the three layers of fibres which comheart, although excessively dangerous, yet pose the ventricle: the superficial and offer some chances of cure. In connexion middle layers are directed downwards and with legal medicine, it also gives rise to to the left bide; the deep layer, much several important reflections. It resultsthicker than the other tv, o, crosses them from an examination of the facts, 1st. front left to right ; the instrument, then, That the wound of the abdomen, which will cut transversely the fibres of the deep had penetrated through the abdominal la) er, while it merely separates those of partietes to the cavity of the atomacll, the superncial and middle; beace the exwas produced by a pointed and cutting in* tent of the o;)Ct:i’:g will be much dinii2nd. That the wound of the ished, an obstacle to effusion of blood, strument. chest, made ii), a siu.i:ar weapon, had tra- created, and the wound will be closed at verged the parietes of the chest, divided first in a temporary manner, and, finally, the intercostal artery, injured the pericar- afterwards permanently. and heart, and gave rise to an ett"uThe extent of the wound must also inium 9ion of blood into the left pleura. 3rd.’ nueuce i’s chances of obliteration ; it de-

middle

at

making

greatest

quity ; cies

versely same

posed ent ties,

example,

770 of course, on the form and size of sequence of his own misconduct, resolved to destroy himself: on one occasion his the weapon, and on the strength which it is impelled. Thus the wound is project was disturbed as he walked torounded when made by a bullet; linear wards the river for that purpose ; he was when the cutting instrument is not thick ; then thrown into prison for some crime, or ragged, if occasioned by an angular and and fancying that he was altogether lost n to the world, he possessed himself of an irregular body. Any part of the may be wounded, but the left cavities are old knife and amputated the penis close less exposed than the right, and the to its root ; although the instrument was ventricle more commonly than its corre- very blunt, he used such force and persesponding auricle. The aortic ventricle is Ireraiiee, that the section was complete, also more exposed to injury than the pul- upon which he threw the amputated pormonary. Anatomy explains these differ- tion into the privy : there was very little ences ; sometimes the wound takes place hemorrhage. It was soon noticed that in the groove where the coronary artery the prisoner grew pale and lost blood is lodged, and gives rise to very dangerous every day, and he was brought to the Hotel hemorrhage. From the thickness of the Dieu. Six ligatures were applied to the parietes of the left ventricle, this latter is dors-al, bulbous, and cavernous arteries; a less subject to injury than any other of large catheter was placed in the urethra, the cardiac cavities, and the edges of and the wound dressed simply. The pawounds in this portion of the heart have tient was watched with great attention, a greater tendency to close on each other. for his present state of tranquillity might Wounds of the heart may he complicated be only temporary, and it was our duty to by several accidents which do not of neces- guard against any new attempt at suicide. sity belong to them; as, for example, the di- He passed some days in this quiet state, vision of an intercostal artery or some large but delirium soon came on ; the patient vessel; an extensive opening in the parietes got up in the dark, tore off all his dressof the chest; a wound of the lung, the ings, and ran about the ward during the diaphragm, the abdominal viscera, &c. We night. (Bleeding from the foot;Anodyne The delishould also take into account the moral lazement; Laxative draught.) state of the patient at the moment he was rium continued, the face sunk, and the wounded, his age and general health. patient’s strength gave way rapidly. The We cannot at the same time doubt that urine, which flowed between the urethra wounds affecting the substance of the and catheter, was charged with purulent heart are, in general, extremely danger- mucus; but the wounded parts showed a ous. To arrive at this conclusion, we disposition to cicatrize; the pulse was have only to look at the consequences of slow, the extremities cold, respiration free; these wounds, or the circumstances with there was no cough or expectoration. which they are complicated. Amongst The symptoms of cerebral excitement inthese accidents we find hemorrhage as the creased during the three last days, and chief, either primary or secondary, derived the patient died in a sub-apoplectic state, from the cavities of the heart, its super- three weeks after his mutilation. ficial vessels, or from some of the trunks which supply the chest or its parietes ; inNecropsy.-The membranes of the brain flammation of the heart or pericardium, were gorged with blood and serum; the and other organs ; sudden suspension of brain itself was much injected and very pulsation in the heart. But however dan- iiard. When we raised up. the sternum, a gerous these accidents may be, it is not large ecchymosis was seen at the pericarthe less certain, that in many cases they dium, which cavity was half filled with do not cause instantaneous death ; that in liquid blood: in seeking the source of this others they may be overlooked or mis- hemorrhage, we discovered several small taken, and that in some circumstances wounds, each closed with a black fibrinous they are susceptible of a cure. I have clot, on the anterior surface of the ventrialready related to you one remarkable cles. The truth was now suspected, and case, to which I can add many others an attentive examination did not leave the least doubt of the origin of these wounds. from the practice of this hospital. In the centre of the ecchymosis which ocCASE 2.—Treated for Suicidal Amputation cupied the anterior superior part of the of tlce Penis, ending fatally from Cere- pericardium, we found two small penetratLral Disease, and disclosing, after Death, in, 0 wounds, obliterated by false membranes: again, on examining the anterior numerous clused Wounds of tlae .1-lea),t. wall of the chest we discovered, between the A man, forty years of age, tall, and of cartilages of the second and third left ribs, a sombre expression of countenance, a cicatrix of a small wound ; it was nearly being reduced to a state of distress, in con round, and was not more than a line and

pends,

with

heart

right

771 half in diameter: beneath the skin, beT’oluntary Mutilation of the Genital Orintercostal muscles and gam, is an accident which we have often was a large spot of ecchymosis extending to see : it constitutes a very curiforwards and downwards. The variety of suicidal monomania. Iudiinto the pleura was marked by a brown viduals who attempt to destroy themselves this manner, are generally of an amarecl spot surrounded by false membrane: the anterior edge of the lung had not been tory temperament ; the predominance actouched. The heart was wounded in fiveSquired by the genital system affects the and the patient imagines that a or six different points, the greater number) severe wound cannot be inflicted on those in the right ventricle, clearly into its cavity: one wound had sunk into ; organs without extinguishing life. All who have written upon madness, the septum, another had reached the left ventricle without penetrating it. The speak of these mutilations, and regard them little dangerous in themselves ; but indisubstance of the heart was pale, and gave way easily under the fingers: the yen- viduals in this state require the greatest tricles contained a few dark fibrous clots. watchfulness on the part of the attendants ; The whole gastro-intestinal mucous surfact they generally succeed in destroyface was the seat of a chronic inflamma-ing themselves afterwards : we have to tion, and there were several old ulcers’, apprehend an explosion of mania in which about the ileo-caecal valve. The liver, sanguinary ideas may occasion the most spleen, and kidneys, were healthy. The dreadful consequences; we have seen seprevious history of the case was now in- veral of these patients turn upon others the quired into, and we discovered that when fury of which they themselves had been the patient had mutilated himself at the the first victims. One would irnagine they police office, they found on his person, be- have no sensation of pain ; an old knife, sides the knife, a long needle, commonly the blade of which saws rather than cuts, used by workmen of his profession : this must produce horrible agony, hut nothing was taken away, and since that time he stops them. The lacerated arteries bleed could have had no instrument of the kind. little; they are closed by the contraction Hence it may be concluded that the of the skin and corpora eavernosa, or the is arrested by syncope; and in attempt at suicide was made at twenty-five days before his death : thea great number of cases a spontaneous state of the external cicatrix also corrobo- cure takes place. rated this opinion. The fine sharp instruThese wounds do not always include the ment had been driven vertically upon the same parts, are of the same extent; somethe scrotum is the seat of injury, and heart, and when it arrived at that organ, it had penetrated the substance in several one or two testicles are somepoints, as was proved by the number of times the penis is cut off more or less comwounds : the narrowness of the openings pletely, at various distances from the root ; occasioned by the needle, had not given finally, in some cases the whole genital rise to any hemorrhage ; that is, the blood apparatus is swept away. I once saw a man of middle age, who contained in the right ventricle was not effused into the pericardium: the small had been reduced to despair by the ill-conquantity of blood (about three ounces) duct of his daughter: he made a large incifound there, seems to have escaped from sion along the base of the scrotum and the substance of the heart. In this case penis, which he detached for two-thirds of the pulse of the patient, though examined their thickness; the divided parts were every day, never presented any remarkable united by sutures and healed, but the corthe region of the heart was not pora cavernosa were obliterated at the of division. The patient was cured of the seat of any pulsation or extraordinary sound; there was not any fainting, dvsp- his wound and mental affection, but ever ncea, or, in a word, any symptom which afterwards presented the singular phenomenon of a semilateral erection, which could lead us to suspect any injury of the penis a form extremely bizarre. important a viscus. I also remember the case of a young boy, Remarks.-This observation is not remarkable on account of the length of half idiot, in whom the corpora cavernosa time which elapsed from the time of the were completely obliterated at the middle ; wound to the death of the patient ; but it he amused himself one day by placing a gives rise to several reflections connected very tight ligature round the middle of his with the peculiar mutilation which the penis, which remained there for fifteen unfortunate man inflicted on himself. Al- days ; the skin of the penis and the urethra though these are not exactly connected became gangrenous; an artificial opening with the present subject, I shall take this was formed, and the posterior portion of the opportunity of making some practical ob- corpora eavernosa, being a!one permeable the blood, alone entered into erectiorr. scrvations on the point. a

tween the

pleura,

opening occasion ous in

penetrating:

intellect,

authors

as

in

leasthemorrhage

Itimes

anomaly:

point

so!

only!Igave

to

removed;

772 The depressing passions, and chiefly! wounds, mostly about the precordial rejealousy, are often the cause of these muti- gion. The wounded man discharged blood lations. An old man married to a from the mouth, and a great quantity flow. giddygirl, thought that her conduct was noted from the wounds. When brought to the

young

exactly correct; he resolved to destroy Hotel Dieu on the Sth of March 1832, remarked that a good deal of air also himself, and completely amputated

both1caped from the testicles, with their integuments ; he was

same

we es-

orifices, proving in

cured, but drowned himself in a short time! the clearest manner that the weapon had

’penetrated

into the cavity of the chest. afterwaids. Itis not easy to conceive by what aberra- The respiration was very short and feeble, tion of intellect an unhappy jealous man the pulse small, irregular, and the patient can deprive himself voluntarily of virility.! so weak that it was out of the question to There is in this strallge resolution a mys- bleed him ; but when his strength was tery of the human heart to puzzle moral- recovered a little, venesection was pracists. Does it arise from injured pride ? tised, and repeated each time that the Is it a punishment voluntarily symptoms became worse. through remorse, and sustained as the ex- Thirty-six hours after the accident, we piation of faults which a weak mind ex- noticed a remarkable phenomenon; the aggerates ? Weleave the question to those patient commenced to expectorate thick who have the care of the soul, and pass to spittle mixed with blood and pus. It was now judged necessary to dress the wound, other matters.. The depressing both to avoid the introdclction of air, and are not always the cause’of this mutila- to arrest the hemorrhage ; this practice tion. was conformable with the principles laid A great German shoemaker, with a pid face, and intellect certainly weakened, down by several surgeons for the last fifteen or twenty years, and especially by frequently experienced an access of 1B1. LARREY. The respiration did not venereal orgasm, during which he ted the scrotum. Several deep scars indi- seem to suffcr from the means employed, but state of the patient appeared cated very extensive wounds ; but being satisfied with the results which he rather improved. However, dangerous obtained, and more especially with being!symptoms soon came on, and the patient his own executioner, he soon found an as-! died on the 1 Ith of March, three days sistant to satisfy his intentions. A prosti- after his attempt at suicide. The danger tute, seizing the moment of the venereal of his position had’never been concealed from us, but the fatal termination was spasm, divided the scrotum with a knife, and removed the testicle in a certainly hastened by a visit which his dexterous manner. The wounded man mistress paid him, and by the interrogascarcely perceived his loss, such was the tories of the police magistrate; in fact, ecstasy in which he lay plunged; but on about three hours after these two visits, the appearance of hemorrhage he state of the patient became rapidly brought to the Hôtel Die2c where with a worse, and he soon expired. simple dressing the woundwassoon We might multiply examples of these Necropsy.-I have brought the injured wounds, inflicted under various circum- parts here, and will proceed to examine stances; what has been said, however, is them before you ; here are the integusuificient to prove that they arc ill general ments covering the precordial region, and of little consequence ; the individuals seem you will readily see the marks of five triin these cases gifted with a degree of in- angular wounds. From the history which sensibility which becomes a real obstacle the patient gave us the file had a trianto the development of inflammation. We gular form also, but you should not forget the same time that a round instrnnow resume our original subject, with an at observation, which bears some resel1l- I llleut may produce a triangular wound. blance to the preceding, and is still more This, which is a new fact in legal tnedieine, should always be remembered by intcresting, medical men, when they give evidence CASE 3.-Ti’i?,ee Penetrating Wounds of on cases of this kind. Continuing the the Heart, progressing to a Cure, termi- examination, we found two wounds above nating fatatly from effusion around the the breast, and three b2low it. They Lung, the result of Mental Re-excitement. are all regular witlz the exception of one, which proves that they had been A man, about thirty yealof age, made each by a single stroke. You driven to despair by misfortune, resolved should, however-, remember that some inupon destroying himself. For this pur- dividuals possessed hy the demon of suipose he procured a file, sharpened the cide, after haviug plrlnged a weapon into pcint and inflicted with it five or six the body, turn it about in all clirections,

inflicted

passions stuthe

mutilanot!

sharp very

was the

healed.

the

773

an irregular form to the two hours after having received three’ sometimes withdraw it, and pernetrating wounds of the organ, and the again pierce the organ, so as to make a two preceding observations show that liie greater number of wounds internally than may be prolonged much longer, Inad.’iexternally. In the present instance the tion to these I might quote anumberof uppermost wound seems to have been atller cases to prove that individuals made with more violence than any of the affected with wounds which penetrate the others, for it divided one of the an- whole thickness of the right vcntric-’e, other penetrated between the Intercostal may live two, three, four, five, six, eight, spaces, and gave rise to a considerable ex- or fourteen days; other ohservations, not travasation of blood within the cavity of less curious, which yon find in the thesis the pleura. The right side of the chest of M. SANSON, show how some patients contains air and dark-coloured blood, wounded in the left ventricle die within partly coagulated and partly liquid ; the five hours, while others, in whom both whole quantity, if we reckon what was ventricles were injured, survived for five, lost by the wound, may be estimated at or even twenty days. In the presence of three or four pints. This blood would facts so numerous and well authenticated, to acknowledge that we cannot refuse certainly have found its way to the rior had we left the wound open, wounds of the heart are not necessarily of closing it hy dressings. The lung, coinThe case of the soldier of whom I pressed on all sides, as in cases of spoke in the commencement of the lecture is still more conclusive ; because it leaves pyema, was no longer liernleable to no The left side of the pericardium is doubt of the possibility of their as you see, in three or four points, and being cured. contained about a spoonful of blood and The symptoms of wounds interesting pus resulting from inflammation. The in- the heart are not all of the same imporstrnment had also injured the left ven- tance ; some are very uncertain, others tricle in three different places, and all’ more characteristic ; the appearance of these wounds had penetrated into its the precordial region ought to fix our cavity. Is the lung on the left side alsoattention in the first instance; if there be injured ? I have no doubt of it, but, to be any wound in this part, we have reason to sure, we will proceed to inflate it. You see be anxious, and still more so when sympthat air escapes from three distinct points, toms of hemorrhage set in, as general and that these correspond exactly with theweakness, fainting, smallncss of the pulse, wounds of the thorax. The right general paleness, cold extremities, cold

and thus

wound,

give

or

ribs;

exteinstead

mortal.

emair. pierced,

velltri- sweats,

cle contains a little dark-clotted blood, vomiting, anxiety, oppression, and but does not present the least trace of the sensation of extreme weight about wound. We will now divide the left ven- the diaphragm. Writers have also enutricle longitudinally, and lock on the merated amongst the signs of wounds of side for the wounds corresponding with the heart, a peculiar trembling of the external marks ; but nothing is more organ, weakness of the arteries, inequality feebleness cf the pulse, excessive fever, cult than to distinguish the wounds these cases, for the point of the instru- crepitation, and a peculiar bruit. The is extremely ment may have struck on some of the diagnosis of these carneae columnae which line the cavity in difficult, because the symptoms are rarely such numbers ;however, as we examine together in sufficient number ; and the interior of the ventricle, we find a. this uncertainty has led us perhaps to small clot of blood adhering to it, which ’ overlook many cases of cure in wounds of has evidently been formed during life; the heart. as you see, a stylet passes from the extcrThe treatment is the same as for all nal orifice, and shows how the clot closes a deep wounds of the chest accompanied small wound; the same thing takes by lesion of some of the large vessel ; in two other points. bleeding, repose, simple dressing to the wound, so as to arrest the heRemarks.—These different lesions, and morrhage and prevent the entrance of the marks of inflammation of the pleuræ, air; the patient’s drink should be slightly sumcientiy account for the patient’s death ; ’ acidulated. The bleeding must be graduhut here a question arises,-whence cameated, and repeated according to thestrengtli the blootl which flowed from the wound,’of the patient and the difficulty ofrespiraand which we found in the chest? It was tion; venesection diminishes the mass of furnished not by the lung, but by an in-. blood, and combats inflammation of the tercostal artery which was opened The pericardium, heart, or other injured orcase just related is a new proof that gans. «’e can readily conceive the neceswounds of the heart are not necessarily sity for observing strict repose: it is also some importance to close the external tno:’k’1.l; the patient, in fact, lived

a inthe

difli-in and

injuries

united

and,

i

place

viz.,

seventy.of

774

opening in

so as to ar- conceivably short period, signs appear of externally, and check suppuration having taken place. This internal hemorrhage; however great the region is the seat also of carbuncle of an symptoms of oppression may be, we acute or chronic kind, of what has been should never permit the blood to flow termed gangrenous abscess, -a disease externally, unless indeed the patient be which is always fraught with much misthreatened with immediate suffocation: in chief and danger, and one which requires treatment of the general and this dangerous emergency, we must let a little blood escape in order that the patient local kind. The complicated case which may breathe; but it is important to re. is under the care of my friend Mr. CoorFR, member that the external orifice should in one of the private wards, appears to me never be opened until the internal he- to have had its origin in such a state of morrhage is arrested, which is shown by the cellular tissue. a

proper manner,

rest the flow of blood

energetic

the return of heat and colour to the external surface : up to this period any operation would be useless, nay injurious; for the evacuation of the blood accumulated in the chest would be calculated to give rise to fresh hemorrhage. Finally, the action of cold may be employed, and made

Abscess near the verge of the anus may be traced to injury from within or from without. It is occasionally attributable to the impulse communicated to the parts in those who labour under affections of the

harassing cough, but a preju-

chest,has,accompanied by frequently, anything I Cupping-glasses, primary and dicial effect

as general as possible. on the affection. The especially when employed over the wound, II most common, immediate, and exciting should be avoided ; repeated bleeding is cause, is an inflammatory attack of hemuch inferior to cupping, and the appli- f morrhoidal tumours. This may be attrication of the glass over the wound would butable to a variety of circumstances. Irrecertainly bring on the hemorrhage. ItI gular living, disordered bowels, exposure has been recommended to give such medi- to cold and moisture. The patient, subject I to piles, has sat down, perhaps, on the wet cines as are proper to diminish the pulsations of the heart, as belladonna, digitalis; grass, after violent exertion, or he has they may be useful, but I fear they will be travelled far in bad weather in the erect found insufficient, whenever any position, without an opportunity of empcation exists, it must be treated in the tying the bowels, on the top of a coach,

compli-

same

general

manner.

CLINICAL SURGERY. LECTURES DELIVERED AT THE

NORTH LONDON HOSPITAL, BY

seated on wet straw. He is soon after seized with shivering, with swelling, and pain about the fundament. He has a smart attack of fever, and in a very short time thereafter an abscess is discovered. in this situation, as in many others, you are not to look quietly on, and wait the signs of the formation of matas described in surgical work.,:. The the swelling, the redness and fluctuation: ‘ Tumor albescens, mol-

Now for ter,

thickening,

lis fluctans, pruriens," a good description of a pimple on the face, certainly not of an acute abscess, unless ma-

ROBERT LISTON, Esq., naged in a slovenly way. Your patient Surgeon to the Hospital, and Professor of Clinical will, all the while, be suffering the most Surgery in the University of London. and violent pain. You look to

tormenting the

history

LECTURE Y1II.

of the case, the duration of may

the symptoms ; you know that pus be formed and bounded

by a cyst, and of matter may, in fact, be IN ANO. established within forty-eight hours, or As a consequence of most of those disrelief; object is to give from his burning fever, eased states of the extremity of the bowel to free the intense suffering. You examine by which I have brought under your notice lately, induration of the cellular tissue the side of the anus, where perhaps you takes place to some extent, and this, in discover a tender part, which feels like many instances, is followed by the secre- the point of one’s finger. It passes deeption of purulent matter. Induration may ’ ly, a firm band, by the side of the bowel. for some time precede the formation of From that, if you pass a. narrow bistoury abscess, and the purulent deposit may be carefully, you will permit to escape much of the cold or chronic kind ; or, again, the more well-digested purulent secretion of a action preceding it is vivid, and, in an in- most unsavoury odour than you could ABSCESS NEAR THE

ANUS.—FISTULA

that

a

depot

less. Your

his

patient

instant