1855.] Perforating Ulcer of the Stomach. 275 skin cool, with the pulse feeble and rapid. She was tossing about in bed, as if in great pain; and from her general appearance it seemed as though she must soon die unless speedy relief was obtained. The pain which commenced at the epigastrium, 'she now described as being over the whole abdomen, having gradually extended downwards. The abdomen was hard and tympanitic, almost like a board in its feel. Upon making inquiry, I found that her bowels had been freely opened the previous afternoon, and upon examination, not being able to discover any tumor, I was satisfied that it was not a case of strangulated hernia. There had been no vomiting from the commencement of the attack. It is unnecessary to state all our thoughts and conjectures in reference to the nature of the case; perforating ulcer of the intestine, intus-susception, and various other diseases, passed before our minds; but it was evident that no positive diagnosis could be formed. The treatment was simple: anodyne externally, by fomentations to the bowels, and their free exhibition internally. At 9 o'clock in the morning I saw her again. Her condition was somewhat altered. She was more quiet, complained of less pain, and partial reaction had taken place; the skin being warmer, and the pulse rather firmer, but still rapid. The other symptoms, however, remained unchanged. The abdomen was tense, hard, and tympanitic, with an aspect of prostration and distress as though she had some grave, internal disease that could not be reached. Leaving her for awhile, I was sent for in great haste, about 1 o'clock, with a message that she was dying. I went immediately, and found that she was indeed in articulo, collapse having suddenly occurred within an hour. She died while I was in the room, having been ill only 15 hours from the commencement of her attack. The postmortem examination was made the next morning, at 9 o'clock, by Dr. H. Weeks Brown. Upon opening the abdomen, a puff of gas escaped with considerable violence, and of a very unpleasant odor. There was in the peritoneal cavity about a pint of serum with flocculi floating through it. The surface of the intestines was extensively inflamed, exhibiting the results of inflammation in its different stages, from the slightest pinkish hue, to the deepest red, and the dark purplish shade of approaching gangrene. The most careful examination of the intestines did not bring to light any perforation, nor was there any signs of intus-susception. We were about giving up the search, when one of the gentlemen present, in turning over the stomach, found the cause of the whole difficulty. About an inch from the pyloric extremity of the stomach, and partly hidden by one of the folds of the stomach, was discovered an opening, which from its appearance was at once ascertained to be a perforating ulcer. The stomach, with the inflamed intestines, were sent to Professor Clark, of the College of Physicians and Surgeons, who exhibited them at a meeting of the N. Y. Pathological Society, and made some interesting remarks upon the case. He stated that the situation of the ulcer in this specimen was the place where perforation was most apt to occur; and, what was singular and confirmatory of the fact, Dr. C. D. Smith, on the same evening exhibited a specimen, and read its history, where the perforation was almost in the same spot. The symptoms, Professor C. stated, varied very much in different cases. In the case of Dr. Smith, the pain was not excessive, neither was there distention of the abdomen, but rather a flattened appearance. In the case under consideration, on the contrary, there was much tympanity and excessive pain. The case of Dr. S. occurred in a robust, vigorous man, with but few premonitory symptoms; whilst the other was attended by symptoms for some time previous to her death, rendering her pale and sickly from their effects. Another circumstance worthy of consideration is the rapidity of the case and the suddenness of the death:-fifteen hours from the commencement of the attack, and after partial reaction, a sudden collapse, and death. Since the occurrence of the above case, a similar one has been brought to my notice, in the practice of another physician, showing that these cases, though rare, may be more frequent than has been generally supposed by the profession. 16 West Washington Place. Case of Gunshot Wound of the Neck. Ligature of the Common Carotid Artery. Recovery. By CHARLES E. ISAACS, M. D., Demonstrator of Anatomy in University Medical College. About the middle of last January, I was requested to meet Professor Willard Parker, in consultation upon the case of a man who had been admitted into the Hospital on Blackwell's Island, with a severe gun-shot wound. On inquiring into the circumstances, we ascertained that, sixteen days previously, the patient had attempted to destroy himself, by placing the muzzle of a pistol, loaded with a conical ball, near to the angle of the jaw, and then discharging it. The ball entered about an inch below the angle of the jaw, producing a moderately sized external wound, but tearing the parts within extensively. The hæmorrhage, which was profuse, was restrained at the time by compresses, bandage, &c., &c., but continued to recur at intervals of two or three days, up to the period at which we were called in to see him. On removing the dressings, a small quantity of dark blood, mixed with semipurulent matter, issued from the wound. From the appearance of the parts and that of the discharge, and in consideration of the great space of time which had elapsed since the occurrence of the injury, we hoped to control any future hæmorrhage without the necessity of resorting to an operation; we therefore directed the compression to be kept up as before, and the patient to be carefully watched, &c., &c. However, on the next day the hæmorrhage recurred in such a furious manner as to render it evident that some operation was now required to save the life of the patient, who was much enfeebled by the loss of blood. Accordingly, on consultation with Dr. Parker and Dr. Sanger, Physician-in-Chief of the Hospital, it was determined to make an attempt to secure the vessels at the point wounded, and as the necessary opening and dilatation of the wound would no doubt be attended with great loss of blood, it was thought best previously to tie the common carotid, with a view of checking or diminishing the hæmorrhage from the wounded vessels when the cavity made by the ball should have been opened by the knife. With the kind assistance of Dr. Parker, I then proceeded to ligature the carotid just below the point where it is crossed by the omo-hyoid muscle. I then dilated the wound by cutting outwards as far as the edge of the sterno-mastoid, upwards and inwards towards the lower border of the inferior maxillary bone, and downwards so as to reach the incision previously made for the carotid. Turning out the coagula rapidly with the finger, the hæmorrhage became very profuse. Sponges were pressed into the wound, so as to arrest the bleeding, aided in some degree by firm pressure on the sides of the wound by the fingers of the assistants. The most accessible vessels were first secured; then, by gradually withdrawing one sponge after another, others were tied, and so on, till nearly the whole of the hæmorrhage was arrested. The finger could now pass in the track of the ball, through the base of the tongue, so as to reach the region of the arteries of the external carotid of the opposite side, which had been wounded by the ball, and were now pour ing out blood, but in small quantity. As these were at such distance from the surface, and situated, as it were, at the apex of a deep conical cavity, they could not be fairly seen, or reached by a ligature. Compression was therefore relied on for the arrest of blood from this source. Careful and cautious research failed to detect the ball, which had not passed out of the body. The parts were now brought together by sutures, adhesive strips, &c., and moderate compression was made on the wound. The patient was carefully watched, but the bleeding did not The wound healed rapidly, and without interruption, and at the end of a few weeks he was discharged from the Hospital, cured. recur. Bospital Reports. BELLEVUE HOSPITAL. Case of Cirrhosis and Fatty Kidneys, not recognized during life. By HENRY B. SANDS, M. D., Senior Assistant Surgeon, Bellevue Hospital. MARY Foley, æt. 25, a domestic, was admitted into Bellevue Hospital July 3d, 1854, under the care of Dr. Thomas F. Cock. Her history, as given by herself, was as follows: Born in Ireland, she had lived there until she came to this country, five years ago; had never been married, was of temperate habits, and had usually enjoyed robust health; the only illness she ever before suffered being typhus fever, which she had whilst in Ireland. She acknowledged an hereditary tendency to phthisis, her mother and many of her mother's relatives having died of that disease. In March last she was living in Westchester county, and was there seized with chills and fever, the paroxysms occurring every other day. These attacks continued unchecked for a month, and afterwards recurred at irregular intervals, until three weeks previous to her admission into the Hospital, when they ceased altogether. At about the time the fever subsided, she noticed swelling of her feet, and soon after of her leg; the swelling increased, and shortly before her admission her abdomen also enlarged. The catamenia had been absent since the accession of the ague. Condition when admitted.-General aspect good; countenance pale, otherwise natural; skin warm and moist; no jaundice, either of the skin or conjunctiva; tongue slightly furred, except at tip and edges; appetite moderate; bowels regular; pulse 108; urine normal in quantity, of acid reaction, and containing no albumen; considerable swelling of the lower extremities and dropsy of the abdomen; no oedema of the face or upper extremities; no enlargement of the superficial abdominal veins; no abdominal tumor discoverable. On physical examination of the chest, a distinct bellows murmur was heard with the first sound of the heart at the junction of the third left rib with the sternum; an indistinct systolic murmur was also audible at the apex; no hypertrophy. Diagnosis.Probable valvular disease of the heart and enlargement of the spleen; the dropsy depending on cardiac disease, enlarged spleen, or anemia, most probably on all these causes conjoined. Treatment.-Good diet, 4 oz. gin daily, potass. iodid. grs. v. 3 times a day. July 8th.-Swelling of abdomen and lower extremities undiminished; evidence of moderate pleural effusion in right chest. Same treatment continued, with the addition of a blister to the right side, and potass-acet., eight grs., infus. digitalis, three drachms, three times a day. July 10th-Cough without expectoration, and dyspnoea, assuming a paroxysmal character, have been present during the past two or three days. The fits of dyspnoea are usually relieved by dry cups to the chest, and the internal administration of small doses of morphine and Hoffman's anodyne. Physical examination of Chest.-On right side, posteriorly, dullness on percussion from base of chest upwards to a level with the 6th rib, over dull space no respiratory murmur, no resonance of the voice. On left side, sounds on auscultation and percussion normal, except anteriorly, just under the clavicle; here a crepitant râle is heard in inspiration, diminished resonance on percussion, and exaggerated resonance of the voice. Treatment.Omit potass. iodid.; cal. et opii.,gr. every 2 hours. July 11th.-Pulse 112, small and weak; respiration 44, labored; paroxysms of dyspnoea recurring oftener and with greater severity; tongue brown, inclined to dryness; bowels confined; gums tender and slightly swollen; urine scanty, high colored, not albuminous. Treatment.-Omit cal. et opii; brandy, oz. every 3 hours; pulv. purgans, gr. xv. every 2 hours until the bowels are moved. July 12th.-Six powders were given before any effect was produced, the patient then had four or five copious, watery stools; general condition not improved; hands slightly edematous. Physical examination of the chest indicates an increase of effusion on right side, the dullness extending as high as the 3d rib; voice and respiration absent over dull space, bronchial just above it. On left side subclavicular dullness, extending and increasing; bronchial respiration and bronchophony also here audible. Same treatment continued, with addition of fomentations of digitalis and juniper to the abdomen. From this time she grew more rapidly worse, and died at 10 o'clock on the afternoon of the 15th inst. For two days previous to death, the pulse and respiration were very rapid, the tongue dry and brown, the face swollen, and the mind wandering and delirious, Sectio Cadaveris.-18 hours postmortem. Surface pale, except face and dependent portions, which are congested; abdomen and lower extremities greatly distended by serum; upper extremities slightly so; head not examined. Thorax, right side, pleura completely filled with clear, yellowish serum, except space occupied by the lung, which was crowded upward so that its inferior surface was on a level with the second intercostal space anteriorly; posteriorly, at a somewhat lower level. A few old adhesions between the posterior surface of the lung and the thoracic walls; right lung carnified in no part; crepitant; color externally that |