428

found to be fractured ; several of the trueribs on the right side were broken nearto their angtes, and it was discoveredthat the second, third, and fourth ribswere also fractured near to theirjunction with the sternum. The patientexperienced much pain when pressurewas made upon the fractured portions,and the act of inspiration was difficultand painful.As the constitution, generally, had sus-

tained a severe shock, and as there wasconsiderable depression of all the vitalpowers, venesection, which appeared tobe indicated from the extent of injurydone to the ribs, was not had recourse tountil after a lapse of two or three hours,at which period re-action had takenplace. Sixteen ounces of blood were thenabstracted from the arm, and in the even.ing twelve ounces, by means of cuppingupon the chest.

Nov. 9. There is very great difficultyin respiration ; the countenance is anx-ious, and somewhat of a livid hue. The

depression of the sternum was apparenton the right side, at that part where thefractured ribs were separated. The pa-tient had been copiously bled from thearm previous to our visit, which had re-duced the pulse, for it was now compres7sible.In the evening, about five o’clock, we

found the symptoms very urgent; respi-ration performed with great difficulty,and the livaity of the countenance in-creased. The " mucous guggle," uponinspiration, was distinctly audible to theby-stander, and upon applying the earto the chest the sound of air rushingthrough fluid was very perceptible ; not-withstanding the present symptoms indi-cated a wound of the lungs, two usualsymptoms were absent, namely, hæmop-tysis and emphysema. The patient’spulse at this period was upwards of 130beats in a minute, and contracted, andthere was a full expansion of heat onthe surface of the body.Soon after the date of the preceding

report the patient was bled freely fromthe arm, and cupping glasses were ap-plied to the chest. The symptoms werecertainly much alleviated by venesection,and this was observed of the formerhleedings. The poor man, however, expired about half- past seven o’clock in theevening, being a period of about thirtyhours from the receipt of the injury.

Post-mortem Examination.The thorax was laid open, and therewas found to be an effusion of upwardsof a pint of fluid on the right side of thechest, which appeared to be nearly pmc

venous blood; the right lungs were col.lapsed and felt solidified, and there wasa small wound on the fore part of thelungs. Upon inflating them by meansof a pair of Irellows introduced into thetrachea, this wound was found to be

opposed to the fractured portion of thesecond rib, which was broken immediatelyat that part where it becomes cartilage-nous. It is somewhat singular, that thethird, fourth, and fifth ribs were fracturedthrough their cartilages, because theseparts were not ossified and were readilycut through with a scalpel. The left lungswere healthy, but there was a slight quan-tity of serous effusion into this side ofthe chest. It may be remarked, that thewound in the right lung had not pene-trated deeply, and it was situated at thethin sternal margin of the lobe.

ST. THOMAS’S HOSPITAL.

Case of Rupture of the Intestine, producedby violent Contusion of the Abdomen.A poor Irishman, who had received

severe injury to the abdomen, was broughtto the Hospital on Monday afteruoon,Nov. 21, about four o’clock, and was ad.mitted into Williams’ Ward, under thecare of Mr. Tyrrell. The patient was aman of spare habit, apparently about 40years of age, and the accident occurredunder the following circumstances;-A large stone, supposed to weigh nearly

8 cwt., which was placed some distanceabove the poor man, fell from its situa-tion, at a time when he was engaged iusome laborious occupation beneath; theline of direction, however, in which thestone was falling was altered by its

striking against some projecting body,and falling thus obliquely it struck againstthe abdomen of the patient. He wasknocked down by the force of the blow,but he speedily recovered himself, jump-ed up, and ran across the road ; he soon,however, became exceedingly faint, andwas conveyed to the Hospital about halfan hour after the receipt of the injury.On admission, the following symptoms

were present :-The pulse was exceed-ingly feeble, and the respiration slowthe countenance pale, and the lips ex-sanguineous; the whole surface of the bodywas cold, and there was great prostrationof strength. From this combination osymptoms it was evident the system hadsustained a severe shock, against whichnature was feebly struggling. The poorman was quite conscious, and he com-plained of much pain in the abdomen,more especially in the pubic region. Itwas ascertained that he had emptied his

429

Madder about ten minutes previous to

the occurrence of the accident.The patient was placed in bed, cover-

ed with warm clothing, and bottles, filledwith hot water, were applied to the feet.There was something peculiarly charac-teristic in the position of the patientwhen in bed ; he lay on his right side,with his thighs bent upon the body ; it is

worthy of remark, that there was at thisperiod no tumefaction of the abdomen;the integuments were slightly ecchy-mosed.t At five o’clock the radial pulse had notrallied in the slightest degree ; there was,however, a little warmth on the surfaceof the body. The dresser introduced acatheter, but could not pass it furtherthan the prostate gland. At the con-clusion of the surgical lecture Mr. Greenvisited the patient, (this was about nineo’clock.)

, The abdomen was now considerablydistended, and the patient complaining ofexcruciating pain ; the pulse had not in-creased either in force or frequency. Mr.Green succeeded in passing a catheter,and drew off about three-quarters of apint of urine tinged with blood. He di-rected warm fomentations to be appliedto the abdomen, and thirty drops of lau-dannm to be taken immediately in cam-phor julep; this his stomach almost in-stantaneously rejected.

’

At midnight the dresser visited the pa-tient, and found him still complaining ofagonising ’pain; there was great thirst,.and he frequently and eagerly drank oftoast and water. Pulse still feeble.

22. At nine o’clock in the morning wefind that no improvement has taken placein the condition of the uatient: the cir-cttlatiom is stilllangnid. The poorman ex-presses great apprehension of death; theabdomen is very much distended and pain-ful upon pressure, and the same positionis observed as at first, namely, lying onthe right side with the thighs Hexed. Thepain is still excruciating and thirst un-abated. During the night a small quan-tity of turbid urine was passed, and thepatient obtained about three hours’ sleepfrom a dose of laudanum which was ex-hibited to him by the dresser at midnight.At three p.m., we found the poor man

evidently fast sinking, the pulse at thewrist was scarcely distingutshable, thepain, distension of the abdomen, andother symptoms enumerated above con-tinue unabated. ’

At six p.m., the, pulse had entirely for-saken the wrist, the taper of life, how-ever, continued faintly glimmering formany hours, and it was thought advisableby the dresser to administer some stimu-

lant, in order to fan that spark of life(hopeless task!) which yet remained;with this view the dresser applied to theapothecary for some wine, about half-pasteight o’clock in the evening. Mr. Whit-field with that laudable anxiety for thepatient’s welfare, which so peculiarlycharacterises him in the discharge of hisarduous duties, requested Mr. Whitfield,junr. to visit the poorman. Be it remem-bered at this period the pulse was notperceptible at the wrist, the extremitieswere cold, and the features collapsed.the following plan was directed :

Twenty-four leeches to be applied to theabdomen, and the warm fomentations to becontinued !At ten o’clock, according to the report

of Mr. Tyrrell’s dresser, which was readat the Clinical lectnre, the patient wasevidently dying, this we suppose was notthe opinion of Mr. Whitfield, junr., for hedirected the further application of twelve

’ leeches to the abdomen ! ! /At eleven o’clock the patient expired,

during the application of the last leeches.Post-mortem Examination.

On laying open the abdomen, the peri.tonemn lining the parietes, and also thatportion investing the intestines, was

found in a - state of extreme vascularity,and this more especially on the right sideof the abdomen. A layer of soft yellow-isit lymph was spread over the whole sur-face of the peritoneum, and the convo-lutions of the small intestines were gluedtogether by means of this adhesive mat-ter. There was a considerable quantityof a brownish-coloured fluid in the cavityof the abdomen, in which were portionsof alimentary matter, and upon tracingthe intestines, a rupture zvctc found in thejejunum, about three hands’ breadth fromthe termination of the duodenum. The

opening in the intestine was of sufficientsize to admit of the little finger. Theduodenum was found to be filled withhalf-digested food; its internal surfaceand also that of the stomach presented ahealthy appearance. In addition to theextreme vascnlarity of the peritoneal co-vering of the intestines, there were, indifferent parts, distinct spots of ecchy-mosis or extravasation ; the mucous mem-brane was free from disease.

ST. BARTHOLOMEW’S HOSPITAL.

Morbid Anatomy-Typhus Fever.Last week, Dr. Latham sent Mr. Stan-

ley some extensively diseased intestines,(taken from a female who had died theday previously of typhus 1’ever,) which