731

GENERAL HOSPITAL, PENANG.

DEATH BY HÆMORRHAGE FROHI A WOUND

OF THE SPLTEN, AND PERITON EAL IN-

J(’RY.

[THE following case has been drawn up byDr. CONWELL, the officiating surgeon at

Alalacca, as a model of such reports of casesin which post-mortem examinations are

made, as are required of the medical officersia the East India Company’s service at Pe-nang and its dependencies. The officersof this government are bound to write afaithful history of every case which theyattend, whether in private or public prac-tice, which afterwards becomes public pro-perty, and is required by the governmentwith the professed object of improving me-dical knowledge. The present report is

exceedingly comprehensive, and may affordprofessional men an useful text, or guide,in recording such dissections as they maybe anxious to preserve at ample length. lihas evidently been drawn up with muchcare.]A man, apparently about 22 years of age,

and recently employed as a ship Lascar, wasbroughtinto the General Hospital about half-past one o’clock A M., on the morning of the16th January, said to have fallen down a wellwith a bottle in his hand, at 11 o’clock P.M. onthe 15th, from which he received two trans-verse wounds in the left hypochondriacregion, about an inch below the ribs, thelargest about three inches and a half in

length, the lips of the smaller half an inchapait, an inch in length, and nearly in a

line with the former. Through the largest,a great portion of the small intestines pro-truded, and at the time of his admission intothe hospital, they were in a state of high in-flammation, and covered with sand. Theywere cleaned and returned into the abdominal

cavity. The wound was brought togetherby sutures and superficially dressed. He

appeared to have lost a considerable quan-tity of blood. His pulse was 140, verysmall and hard. Tongue not observed : skincold and moist.—Treatment. He answeredquestions with d!fliculty, but rationally; hecomplained much of abdominal lain. Ve-nesection was performed, and 32 ounces ofb:ood drawn from the arm. Warm fomen-tations were applied over the abdomen. Helingered until ten minutes before five, andthen he expired. T he foregoing particularswere reported to me by assistaut-surgeonWard, M.D., and 1 proceeded with ins as-sistance to examine the body.—Inspection.lia’.f-pastone p,M.,16th Jan., 18z8. The bodywas extended horizontally for examination ;the subject is of a middle size, black, verv

muscular, has caffre features, and apparentlywas in the recent enjoyment of perfecthealth. With the exception of the two

wounds already described, no marks of ex-ternal injury are apparent; the tongue wasnot (but should have been) removed, andminutely inspected.

AUTOPSY.

Thoracic Cavitg.-Itemoving the sternalarch, the lungs present a healthy colour, butare not perfectly collapsed ; both afford

crepitus. The pleura is generally pale, andthere are very slight adhesions on both sidesof the lower pleuro-pulmonary surfaces tothe diaphragm.—Heart. The pericardium,laid open, contained about an ounce of fluid -the heart removed, and the right and leftcavities laid open ; both ventricles andauricles are empty. The internal appear-ance of the heart is natural, its musculartissue bloodless, but firm ; the valves natu-ral—Anteries. Laying open the aorta, it hasan ivory colour, with a tendency to a streakof blush on each side of the intercostal arte-

ries ; the coats are thin. The common iliacsare of an ivory colour, but the external andinternal iiiacs are marked with small trans-verse rug:e or striæ.—Mucous Membrane ofthe Pulmonary Tubes Pulmonary Tissue.Laying open the larynx and trachea, themucous membrane is found pale, and this iscontinued through its pulmonary ramifica-tions, which on both sides are healthy, yetthe parenchyma posteriorly and inferiorlyis slightly engorged with blood, but sectionsof its tissue only present a blush ; other-wise its appearance is perfectly healthy andnatural.—Abdominal Cavity, Peritoneum.On laying open the parietes of the abdomi-nal cavity, the perttoneum is found partiallyadhering to the omentum around the wounds,and dark sero-sanguineous fluid issues large-ly from the incision. The entire peritoneal

! sm face of the stomach and small intestines! is of a brick-red colour from capillary injec- tion. The abdominal cavity contains muchefl’used blood, and in proceeding to removethe viscera, ten ounces of coagulated bloodate iound near (and which appear to have

issued ftom’) the sljleen, as tt is woundedon its external comex surface near its cen-tre, extending from the anterior towards theposteiior margin, (corresponding with the

large external wound,) then turning up-wards, and forming the segment of a circle.A piece of the glass of a French bottle isfound deeply embedded in the wounded pa-renchyma of the spleen. The spleen is verylarge, and weighs 13 ounces one drachm.The colour of its internal tissue is a lightpuce, with white dots.-E.z-terzzal Contu-siozz. At the superior part of the externalwound, about the centre, there is a patch of

732

ecclynlosis, showing that this part had sus-tained a severe bruise.—The liver is of thenatural size, soft and flaccid ; sections of itstissue pale and bloodless, but in its generalappearance natural, yet coarse. It weighs4 ounces avoirdupois. The gall-bladdercontains five dlacl2ms of healthy bile. 7’itepancreas is pale, diminished, and weighstwo ounces three drachms and a half. Thekidneys are natural, and their parenchymapale.—Mysentery. TLe mesenteric glandsare enlarged, and their internal tissue vas-cular. The ur2nary bladder contained tenounces of urine. Its internal mucous coatpale; no columnar elevations. The prostategland is natural. Laying open the œsopha-gars, its cuticular lining is pale, and it ter-minates abruptly in the cardiac orifice,twelve ounces of half digested rice werefound in the stomack. The mucous tissue iof tle stomach is l,ale and corrugated, withthe appeaiance ot small sunken stride in theinferior part of the small curvature.—Duo-denum, jejunum, cœcum, colon, sigmoidflexure, and rectum. Passing the pyloric ori-fice, the surface continues pale, and the ruga?irregular, until it has received the commonduct. The rugse tben become transverse andwell developed ; fourteen inches from theduct, the rugæ assume a slight blush, buttlley continue vell developed, with occa-sional Small tortuous terminations. Pro-gressively, the rugm ot the ilium becomesmaller, less regular, and the blush assumesa darker red; towards the centre of theilium, there is a, honeycomb ulcer fiveinches ill length, and the three lumbriciwere removed from the superior part of theilium. Progressively, numerous consider-able honeycomb ulcers are observed. Themucous coat becomes extremely thin, andthe ruga3 sparingly and scantily developed,until they (the rugae) altogether cease. Thesurface becomes a brick-red colour, and themucous coat is apparently altogetller disor-ganised. Numerous small white tuberclesare here ol)se;ved, studded in the muscularcoat, towards the cœcum and cccco-iliac

valve; and there are no traces of rugæ.The cœcum is contracted extremely ; its in-ternal surface pale. The mucous coat 01the large intestines is pale, with small con-torted, film, irregular rugaa in parts only.-Cranial cavity. Removing’ the scalp andskull cap, the dura mater was extensivelywounded by the saw oil both sides. Thearachnoid is quite transparent; the piamater is natural: the cerebral tissue isflaccid. Sections through the centrum ovale,parallel with the corpus callosum, show veryfew bleeding points. The cortical substanceis well marked. Separating the corpus cal-losum and fornix in the centre, and turning.the extremities relatively backwards and

fol w ardp, shows the plexus choroides on both

sides slightly blanclted, and bath contam a little fluid. The anterior surface of he thalami on both 6im areI slightiy softened. The optic nerves are

! wasted and very small. The vessels the pons varolii are injected. The tiss of the cerebellum is soft. The odontad

process is large.—Spinal canal. Removingthe anterior arch of the spinal cotunfn, s"parating the intervertebral nerves, aiid re-

moving the chord in its theca, the tissue lining the canul opposite the hearand in the lumbar region, is injected withsanguineous gelatinised fluid. Layingolenthe dura materof the chord anteriorly, thereare a few adhesions of the arachnoid, The

capillary vessels of the inferior half of thissurface are injected. About the centre ofthe chord, a small fasciculus of nerves aris.

ing from the right side, extends obliquelydownwards and to the left, and is there lostin a fasciculus of nerves from the left side ;the fasciculus arising on the left side, passedobliquely downwards and to the right, andhaving united itself with that fasciculus justmentioned opposite the centre of the chord,it returns to the left. Laying open the mater posteriorly, some adhesions of thearachnoid are observed. The capillariesthroughout on this surface are irregularlynjected. The pia mater, throughout thewhole extent, is dark and slaty. The equinalnerves are also darker than usual in health.—Chord’s tissue. The organisation, colour, audconsistence of the chord are apparently na.tural,

RESUME, OR ANALYSIS OF THE AUTOPSY.

Thoracic Cavity.—The pulmonary vesselscontain very little blood; one ounce of sercusfluid in the pericardium ; all the heart’s cavi-ties quite empty ; its tissue pale. The de-

scending aorta internally has a stteas of

blush ; external and internal are

marked with transverse striœ.—Aldominal

cavity. Blood efi’used and coagulated fromthe spleen, which has an incision about uscentre, and a piece of glass is extractedfrom the bottom of the wound in the spleen,and dark blood continues oczing from it.the peritoneal capillaries are injected wititblocd ; the liver is blootiless and pale ; t: kidneys pale. Stomach contained half

-,ested food ; its mucous coat rale aHJ rugated with striae in the small curvaturemucous sutface at nrst pale ; irregular after the duct well developed, soon assuringa blush ; ini’eriorly, irregularly tortuous,flamed, affected with honeycomb d;in, luses the rugæ, IlEd the mucous partially, or altogether disorganised.— nial cavity. Membranes and cerebral pale, natural; the thalami softened nerves wasted ; cerebral a

flaccid.—Exinal canal. 1 j

733

the canal is injected with semi- gelatinisedsero-sanguinec liS fluid an tt-l iorly in the the{ a;adhesions of the arachnoid, and inferiorly onthe chord, capillary engorgement ; poste-riorlv there are adhesions of the arachnoid : :’,capillaries throughout are injected irregu-Lrir. The pia mater throughout is slaty ;the eqmnal nerves dark. The external cel-luiar substance is copious, and muscular sys-hm well developed.The information afforded hy the foregoing

is to be analysed, and divided into four con-.-iderations, with a view to confer accuracyaud promptitude in recognising the symp-toms of diseases, in reasoning on theircauses, origin, courses, effects, their modesof termination, and the principles calculatedto influence their cure.—The first considera-tion embracesa review of the tissues actuaUydiseased, or altered by injury, the ordinarycauses of disease in each one of these tissues,the order in which they apparently com-menced, and their probable courses.-Thesecond embraces a review of the influenceapparently exercised by the diseases sl.eci-fied in this case over the general health, theeffects which the treatment adopted werelikely to have produced ; and causes of anymarked symptoms previously cbserved.-The third embraces a review contrasting allthe foregoing information, and showing whatthe diagnosis should actually have been ateach time when formed, what should havebeen the indications of cure, and what wouldI;ave been the best course of treatment to

accomplish that object.—The fourth em-braces a review of what is considered to havebeen the more immediate cause of death, andof the mode in which animai life, in this in-stance, terminated.

First Consideration examined.—The cere-bral and nervous tissues, the spinal arach-noid, the condensed cellular tissue lining thearteries, and the intestinal mucous mem-brane, were the parts diseased.—The peri-toneum, and the parenchyma of the spleen,and its envelol;e, with the abdominal pa-rittes, were the parts altered by injury.—Excesses either in drinking, eating, sexualiutercuurse, or exposure to the sun, to

wet and cold, or sudden vicissitudes of

temperature, usually produce difeases ofthe serous, - mucous, cerebral, and ner-

Tcus thsues; und hence doubtless of thevascular capillary system, (including thelasa vasnrum,) and the cellular tissues.-T Le softening of the thalami, wasting of theterres, and adhesions of the arachnoid, wereapparently all connected, by their originatingfrom common causes, er a common cause;and they vere the most ancient of diseasedaffections, as the former would occupy some-:rs in attailling its present state.—Mostprobably an engorgement of the vascular

entering into the composition of the

thalami, impaired the capillary action of

that part, by interfering with the perviouscondition ct its very delicate system of ves-sels ; and hence, as the circulation became

progressively less perfect, the natural orga-nisation of the tissue felt under the influenceof the new !aws imposed by the change fi omorganic capillary action, and in the sameratio that capillary action became impaired,or its limits circumscribed, the cerehialtissue became softened as a necessary con-sequence in a corresponding extent.-Itseems uncertain whether the original affec-tion of the thalami was then extended to the

optic nerves, or that they wasted from thesoftening of the thalami only ; of thesetheories, the latter is probably nearest thefact, as the consequence of the extension ofimpaired capillary action, from the thalamito the tissue of the optic nerves.

It appears by the experiments of mylearned friend M. Magendie, that there is

always some fluid in the spinal theca. I al-

ways found fluid, but they were cases of dis-ease, and to that cause I then attributed the

presence of fluid. It seems obvious that theexistence of fluid in excess, or the presenceof adhesions, must indicate a deranged actionof the exhalants of this surface. It is pro-bable that the fluid exhaled in disease, mayhave properties different from those possess-ed by fluid of the same part in a healthystate. In the present case, it seems veryprobable that a morbid effusion took placeinto the theca, soon after the thalami be.came ergorged; because, a considerable

lapse of time must have been required to

admit of that fluid becoming condensed intofalse membranes and forming adhesions,which existed in this case. Moreover, theslaty colour of the pia mater clearly evi-denced deranged cal)illaiy action.The peritoneum, in conditions of inflam-

mation, exerc ses that kind of marked influ-ence over the cerebral serous membranes,that the intestinal mucous membrane doesover the pulmonary ; or, vice versâ. For

this reasnn, peritoneal inflammations, whennot rapidly reduced, have a direct tendencyto occasion meningeal engorgement and

rapid effusion, which latter frequently ter-minates in death. In this instance, not-withstanding the very extensive peritonealinjury which occasioned a brick-red injec-tion of the peritoneal (apillaries, there wasno approach to cerebral engorgement or

effusion in consequence of the extensiveluss of blood.—The condensed cellular tissue,hning the arteries, is subject to all modidi-cations of sanguineuus engorgement and in-Dtimniation, and consequently to ulceration,softening, and disorganisation of its tissue.In certain morbid statc-s, the In ing of theaorta often resembles mucous ni, mbrane bya humid, glistening, spongy appearance ;

734

and it is then darker than the interior of thearteries in health, specks of ulceration areobserved on its surface, generally ofirregutaiform, and the superficies of the ulcer iscoated with a puriform substance, givingthe idea of a syphilitic ulcer. The streakof blush in the aorta, and decomposition ofthe lining membrane in the iliacs, in thepresent case, most probably ensued to thatmorbid action which resulted from the en-gorgementof the vascular system of the tha-lami, and the accumulation of blood in thevasa vasorum of the aorta continued of achronic or passive kind, whereas, in theiliacs, the deranged or impaired capillaryaction of the vasa vasorum, terminated inthe softening and decomposition of the liningof that part.-The intestinal mucous tissueis of very great extent, performs the mostimportant oilices, and in conditions of ine-gular life, becomes peculiarly subject to

various causes, which induce modifications

I’of inflammation, engorgement, ulceration,and softening- of its tissue. The blush onthis surface, the irregular and inflamed rugaehoneycomb ulcers, disappearance of rugae,disorganisation of the mucous coat in the

present case, all indicate preceding capillaryengorgement, which progressively derangingthe natural capillary action of that part, andthe tissue influenced by those laws, to whichthe existence of varied degrees of passiveengorgement or active inflammation subject-ed each part, became either ulcerated, soft-ened, and disorganised, or as the affectionextended upwards, the vessels progressivelybecame dilated by sanguineous engorge-ment.-The wound obviously must have

produced copious haemorrhage from the

spleen, but no special morbid change couldhave ensued immediately in that tissue be-yond the direct solution of continuity, andthe general effects resulting from abstractionof blood from the vessels ; peritoneal capil-lary injection necessarily commenced fromthe period of the iniurv.Second Consideratiõn e.xamined. - The

softening of the thalami, and the wastedstate of the optic nerves, show that the

sight was particularly impaned.—The in-

jected tissue of the spinal canal, the adhe-sions of the arachnoid in the theca, and thedark colour of the pia mater on the chordposteriorly, and on the equinal nerves, indi-cate—the former, excess of previous exhala-tion-the latter, a chronic stage of disease inthe capillaries of that part. All these indi-cations mark that the energies and functionsof the nerves, both of animal and organiclife, have been, in this individual’s case,greatly deteriorated and deranged.—Theblush in the aorta and strias indicates, theformer a febrile state or tendency, the latteran impaired vascular condition, which, ac.cording to observation, succeeds either to

! the course of some lingering affection, b

! an active disease.-I have detected thu

blush in many cases, and it seems tome in.timately and extensively connected Withmorbid action.-Bichat behead that aquarter of those who died had disease of e e

h’mngmembraneof the arteries.—The blush,irregular rugae, the inflammation, honey.comb ulcers, thinness, and apparenoy ulte.rior decomposition of the mucous intestinalcoat, indicate that the individual experi-enced much general ill health, with a maynervous condition of mind and body.—Thenatural state of the external cellular andmuscular tissues, indicates that the digest!refunction and the absorbent and lymphaticsystems continued healthy, so far as to pre.vent, up to the period of death, any unduewasting of parts.—The symptoms that at.

tended the progress of these diseases areutterly unknown, and the effects of treat.

ment, if anv. are equally so.-In referenceto the wound of the abdominal parietes, peri.toneum and spleen, and the protrusion ofthe intestines, there is no exact history ofthe extent to which he lost blood ; but asthere was little or no pulmonary, cerebral,or organic engorgement of any kind, exceptthe capillaries of parts injured, it may heconsidered that the haemorrhage was veryconsiderable.—The absence of delirium andof coma, indicated there was little or no

cerebral engorgement or effusion, and thecontinuance of vascular action for a con.siderable period after the accident, togetherwith the loss of blood, concur to account forthe capillary system of the spleen, and theparenchyma or tissue of all the great andimportant organs, containing very little

blood, notwithstanding the food remainedimperfectly digested in the stomach.

Third Consideration examined. - Theconsiderations involved necessarily separateinto those affecting certain tissue, notimme-diately concerned, perhaps, in hastening thedeath, and those injuries received by theaccident which did uriquestionahly producedeath.-The anterior history of the case

embracing the symptoms, the diagnosis andtreatment are wanting; but a very import-ant observation arises, which is, that an in-dividual may have all the external ordutaryappearances of health, and continue the dis-charge of his usual labours for a considtr-able period, after the most serious diseaseshave commenced their ravages on tissues of

parts performing the most important officesin the maintenance of animal life —Ad-

mitting the diagnosis to have been engorge-ment and a tendency to softening of thecerebral tissue, either of the thalami, or illtheir vicinity, and chronic ini!ammat)un andulcers of the intestinal mucous membrane.—Indications of Cure. - ist. lteuuce th e

column of circulating blood sufficiently IJ

735

telax all the vascular system, to stimulatethe heart to draw in resources from all ex-treme parts to enable the extreme circulatorycapillaries to contract themselves, and to sti-mulate the extreme absorbents more especial-ly of’ the diseased part to increased action.. To occasion a determination from the partsnrcted by forcing a concentrated determina-tion to some neighbouring part. 3rd. The

giving a continued series of shocks to thecapillary system, to call all their energiesfoicibly into action. 4th. Perhaps to effectsome change in the fluids ; the blood ? 5th.

Dfterge the mucous intestinal coat, of thethickened viscid mucus that in most mor.bid conditions adheres tenaciously to itsentire surface, closing the openings of themore delicate vessels, agglutinating the folli-cles and rugae ; and being in effect inter-

posed between the mucous coat and the in-testinal contents, it prevents that surfacefrom exercising a healthy action on the ali-mentary substances thus imperfectly pre-sented.-Aledical Treatment. 1st indica.tion. Venesection, subsequently tbeocca-sional application of leeches, especiallyaround the rectum. 2nd. This would beeffected by a series of blisters, and even-tually, issues, or setons. 3rd. This wouldbe effected especially by a series of blisters.4tli. Alteratives, as small doses of mercu-ri.!!s, antimonials and the continued abstrac-tion of serum by cantliarides vesications,undoubtedly produce such marked effects asto warrant an opinion that in certain morbidconditions, the fluids are rendered more

healthy, and capillary action is improved.5th. Either repeated doses of ipecacuanhalarge or small, with or without pil. hydrarg. or combined with nitrate of potass. In other cases where there is a more marked febrile tendency, nitrate of potass (thishas been recommended by Hillary on thediseases of Barbadoes, and I have found itextremely useful in the diseases of Penang)1 ser. muriate of ammonia, gr. xv. ; aqua2 oz.; taken twice a day is most extremelyuseful. The return of the intestines and

bleeding actually practised, were obviouslythe most appropriate means for recovery ;but in the case of such extensive injury,their advantages would be comparativelyslight, and perhaps as regards the bleeding,only in a small ratio with its extent.

Fourtit Consideration examined.—A Ilarge quantity of blood was very suddenly poured out from the wounded spleen, all theorgans from that moment suffered a largereduction from the columns usually distri-Luted to them the rational faculties werenot abolished (but the animal powers weak-ened because the cerebral tissue was not

engorged; on the reverse, it received a

smaller supply of blood. In a general col-lapse of the system, in sinking, however

produced, and obviously in all cases wherevascular action is enfeebled, the tissue of allothers the most subject to, and the mostendangered by engorgement, is the pulmo-nary parenchyma; and the parts next in.succession the most endangered, are thecerebral tissue, aud the pia mater of thatsubstance, and of the chord. The absolute

reduction of the general circulating column,general exhaustion from the loss of blood,and the nervous exhaustion resulting fromthe injury, and its effects progressively ag-gravated by (perhaps the disease) the par-tial failure of the cerebral energies from aninstifficiedt supply of blood, and the conse-quent inability of the heart to draw in sup-plies, more especially those distributed tothe pulmonary tissue, or to distribute themin sufficient and equal proportions especiallyto the brain ; the operation of these causesnecessarily conspired, to render the circula-tion less and less perfect at every systole.The heart acting more feebly and sendingforth a column still more diminished, yetsome of which would no longer be returnedagaiu to the centre ; by degrees the columnmore and more diminished, the brain no

longer received a supply sufficient for themaintenance of life, the current ceased alto-gether, and the heart having thrown out itslatest supply into the arterial tubes, that

organ remained empty, no farther supplywas determined to the lungs or brain, andas with the progressive failure of suppliesthe powers of life declined in the same ratio,so with the cessation of the current, animallife terminated.N. B. The humoral pathology is not en.

tered into, because the schools are undecidedon that question. Investigation is recom.mended, and the experiments and results aresolicited from the profession.

HOPITAL BEAUJON.

EXTIRPATION OF A CANCEROUS BREAST-

HÆMORRHAGE FROM A LARGE ARTERY

EFFECTUALLY ARRESTED BY TORSION OF

THE VESSEL.

A FEMALE, about forty-five years of age,was, on the !4th of July, admitted, on ac-count of a tumour of the left breast. Shestated that she had not menstruated forseveral years, but had enjoyed excellenthealth up to the last eighteen months, whena very painful tumour had formed on theleft breast. On examination, it appearedthat the lower and external half of thebreast exhibited a hald bilobular tumour,firmly adhering to the skin, which, at thelower portion of the breast, had become in-durated, uneven, and inflamed. The tumour