Chapter XII (1)

SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN.

Injuries of the lung or bronchus are always serious, but contrary to the general idea, recovery after extensive wound of the lung is quite a common occurrence. Even the older writers report many instances of remarkable recoveries from lung-injuries, despite the primitive and dirty methods of treatment. A review of the literature previous to this century shows the names of Arcaeus, Brunner, Collomb, Fabricius Hildanus, Vogel, Rhodius, Petit, Guerin, Koler, Peters, Flebbe, and Stalpart, as authorities for instances of this nature. In one of the journals there is a description of a man who was wounded by a broad-sword thrust in the mediastinum. After death it was found that none of the viscera were wounded, and death was attributed to the fact that the in-rush of air counterbalancing the pressure within the lungs left them to their own contractile force, with resultant collapse, obstruction to the circulation, and death. It is said that Vesalius demonstrated this condition on the thorax of a pig.

Gooch gives an instance of a boy of thirteen who fell from the top of a barn upon the sharp prow of a plough, inflicting an oblique wound from the axilla to below the sternum, slightly above the insertion of the diaphragm. Several ribs were severed, and the left thoracic cavity was wholly exposed to view, showing the lungs, diaphragm, and pericardium all in motion. The lungs soon became gangrenous, and in this horrible state the patient lived twelve days. One of the curious facts noticed by the ancient writers was the amelioration of the symptoms caused by thoracic wounds after hemorrhage from other locations; and naturally, in the treatment of such injuries, this circumstance was used in advocacy of depletion. Monro speaks of a gentleman who was wounded in a duel, and who had all the symptoms of hemothorax; his condition was immediately relieved by the evacuation of a considerable quantity of bloody matter with the urine. Swammerdam records a similar case, and Fabricius ab Aquapendente noticed a case in which the opening in the thorax showed immediate signs of improvement after the patient voided large quantities of bloody urine. Glandorp also calls attention to the foregoing facts. Nicolaus Novocomensis narrates the details of the case of one of his friends, suffering from a penetrating wound of the thorax, who was relieved and ultimately cured by a bloody evacuation with the stool.

There is an extraordinary recovery reported in a boy of fifteen who, by falling into the machinery of an elevator, was severely injured about the chest. There were six extensive lacerations, five through the skin about six inches long, and one through the chest about eight inches long. The 3d, 4th, 5th, and 6th ribs were fractured and torn apart, and about an inch of the substance of the 4th rib was lost. Several jagged fragments were removed; a portion of the pleura, two by four inches, had been torn away, exposing the pericardium and the left lung, and showing the former to have been penetrated and the latter torn. The lung collapsed completely, and for three or four months no air seemed to enter it, but respiration gradually returned. The lacerated integument could only be closed approximately by sutures. It is worthy of remark that, although extremely pale, the patient complained of but little pain, and exhibited only slight symptoms of shock. The pleural cavity subsequently filled with a dirty serum, but even this did not interfere with the healing of the wound and the restoration of the lung; the patient recovered without lateral curvature.

Bartholf reports a case of rapid recovery after perforating wound of the lung. The pistol-ball entered the back 1 1/2 inches to the right of the spinous process of the 6th dorsal vertebra, and passed upward and very slightly inward toward the median line. Its track could be followed only 1 1/4 inches. Emphysema appeared fifteen minutes after the reception of the wound, and soon became pronounced throughout the front and side of the neck, a little over the edge of the lower jaw, and on the chest two inches below the sternum and one inch below the clavicle. In four hours respiration became very frequent, short, and gasping, the thoracic walls and the abdomen scarcely moving. The man continued to improve rapidly, the emphysema disappeared on the seventh day, and eighteen days after the reception of the wound he was discharged. There was slight hemorrhage from the wound at the time, but the clot dried and closed the wound, and remained there until it was removed on the morning of his discharge, leaving a small, dry, white cicatrix.

Loss of Lung-tissue.--The old Amsterdam authority, Tulpius, has recorded a case in which a piece of lung of about three fingers' breadth protruded through a large wound of the lung under the left nipple. This wound received no medical attention for forty-eight hours, when the protruding portion of lung was thought to be dead, and was ligated and cut off; it weighed about three ounces. In about two weeks the wound healed with the lung adherent to it and this condition was found six years later at the necropsy of this individual. Tulpius quoted Celaus and Hippocrates as authorities for the surgical treatment of this case. In 1787 Bell gave an account of a case in which a large portion of the lung protruded and was strangulated by the edges of the thoracic wound, yet the patient made a good recovery. Fabricius Hildanus and Ruysch record instances of recovery in which large pieces of lung have been cut off; and it is said that with General Wolfe at Quebec there was another officer who was shot through the thorax and who recovered after the removal of a portion of the lung. In a letter to one of his medical friends Roscius says that he succeeded in cutting off part of a protruding, livid, and gangrenous lung, after a penetrating wound of the chest, with a successful result. Hale reports a case of a penetrating stab-wound in which a piece of lung was removed from a man of twenty-five.

Tait claims that surgical treatment, as exemplified by Biondi's experiment in removing portions of lung from animals, such as dogs, sheep, cats, etc., is not practical; he adds that his deductions are misleading, as the operation was done on healthy tissue and in deep and narrow-chested animals. Excision of diseased portions of the lung has been practised by Kronlein (three cases), Ruggi of Bologna (two cases), Block, Milton, Weinlechner; one of Kronlein's patients recovered and Milton's survived four months, but the others promptly succumbed after the operation. Tuffier is quoted as showing a patient, aged twenty-nine, upon whom, for beginning tuberculosis, he had performed pneumonectomy four years before. At the operation he had removed the diseased area at the apex of the right lung, together with sound tissue for two cm. in every direction. Tuffier stated that the result of his operation had been perfectly successful and the patient had shown no suspicious symptoms since.

Rupture of the Lung Without Fracture.--It is quite possible for the lung to be ruptured by external violence without fracture of the ribs; there are several such cases on record. The mechanism of this rare and fatal form of injury has been very aptly described by Gosselin as due to a sudden pressure exerted on the thoracic wall at the moment of full inspiration, there being a spasm of the glottis or obstruction of the larynx, in consequence of which the lung bursts. An extravasation of air occurs, resulting in the development of emphysema, pneumothorax, etc. Subsequently pleurisy, pneumonia, or even pus in the pleural cavity often result. Hemoptysis is a possible, but not a marked symptom. The mechanism is identical with that of the bursting of an inflated paper bag when struck by the hand. Other observers discard this theory of M. Gosselin and claim that the rupture is due to direct pressure, as in the cases in which the heart is ruptured without fracture of the ribs. The theory of Gosselin would not explain these cardiac ruptures from external violence on the thoracic walls, and, therefore, was rejected by some. Pare, Morgagni, Portal, Hewson Smith, Dupuytren, Laennec, and others mention this injury. Gosselin reports two cases terminating in recovery. Ashurst reports having seen three cases, all of which terminated fatally before the fifth day; he has collected the histories of 39 cases, of which 12 recovered. Otis has collected reports of 25 cases of this form of injury from military practice exclusively. These were generally caused by a blow on the chest, by a piece of shell, or other like missile. Among the 25 cases there were 11 recoveries. As Ashhurst very justly remarks, this injury appears more fatal in civil than in military life.

Pyle reports a case successfully treated, as follows:--

"Lewis W., ten years old, white, born in Maryland, and living now in the District of Columbia, was brought in by the Emergency Hospital ambulance, on the afternoon of November 10th, with a history of having been run over by a hose-cart of the District Fire Department. The boy was in a state of extreme shock, having a weak, almost imperceptible pulse; his respirations were shallow and rapid, and his temperature subnormal. There were no signs of external injury about his thoracic cavity and no fracture of the ribs could be detected, although carefully searched for; there was marked emphysema; the neck and side of the face were enormously swollen with the extravasated air; the tissues of the left arm were greatly infiltrated with air, which enabled us to elicit the familiar crepitus of such infiltration when an attempt at the determination of the radial pulse was made. Consciousness was never lost. There were several injuries to the face and scalp; and there was hemorrhage from the nose and mouth, which was attributed to the fact that the patient had fallen on his face, striking both nose and lip. This was confirmed subsequently by the absence of any evidences of hemoptysis during the whole period of convalescence. The saliva was not even blood-streaked; therefore, it can be said with verity that there was no hemoptysis. Shortly after admission the patient reacted to the stimulating treatment, his pulse became stronger, and all evidences of threatened collapse disappeared. He rested well the first night and complained of no pain, then or subsequently. The improvement was continuous. The temperature remained normal until the evening of the fifth day, when it rose to 102.2 degrees, end again, on the evening of the sixth, to 102.3 degrees. This rise was apparently without significance as the patient at no time seemed disturbed by it. On the eighth day the temperature again reached the normal and has since remained there. The boy is apparently well now, suffers no inconvenience, and has left the hospital, safe from danger and apparently free from any pulmonary embarrassment. He uses well-developed diaphragmatic breathing which is fully sufficient."

Pollock reports the case of a boy of seven, whose lung was ruptured by a four-wheeled cab which ran over him. He was discharged well in thirty-two days. Bouilly speaks of recovery in a boy of seventeen, after a rupture of the lung without fracture. There are several other interesting cases of recovery on record.

There are instances of spontaneous rupture of the lung, from severe cough. Hicks speaks of a child of ten months suffering with a severe cough resembling pertussis, whose lung ruptured about two weeks after the beginning of the cough, causing death on the second day. Ferrari relates a curious case of rupture of the lung from deep inspiration.

Complete penetration or transfixion of the thoracic cavity is not necessarily fatal, and some marvelous instances of recovery after injuries of this nature, are recorded. Eve remarks that General Shields was shot through the body by a discharge of a cannon at Cerro Gordo, and was given up as certain to die. The General himself thought it was grape-shot that traversed his chest. He showed no signs of hemoptysis, and although in great pain, was able to give commands after reception of the wound. In this case, the ball had evidently entered within the right nipple, had passed between the lungs, through the mediastinum, emerging slightly to the right of the spine. Guthrie has mentioned a parallel instance of a ball traversing the thoracic cavity, the patient completely recovering after treatment. Girard, Weeds, Meacham, Bacon, Fryer and others report cases of perforating gunshot wounds of the chest with recovery.

Sewell describes a case of transfixion of the chest in a youth of eighteen. After mowing and while carrying his scythe home, the patient accidentally fell on the blade; the point passed under the right axilla, between the 3d and 4th right ribs, horizontally through the chest, and came out through corresponding ribs of the opposite side, making a small opening. He fell to the ground and lay still until his brother came to his assistance; the latter with great forethought and caution carefully calculated the curvature of the scythe blade, and thus regulating his direction of tension, successfully withdrew the instrument. There was but little hemoptysis and the patient soon recovered. Chelius records an instance of penetration of the chest by a carriage shaft, with subsequent recovery. Hoyland mentions a man of twenty-five who was discharging bar-iron from the hold of a ship; in a stooping position, preparatory to hoisting a bundle on deck, he was struck by one of the bars which pinned him to the floor of the hold, penetrating the thorax, and going into the wood of the flooring to the extent of three inches, requiring the combined efforts of three men to extract it. The bar had entered posteriorly between the 9th and 10th ribs of the left side, and had traversed the thorax in an upward and outward direction, coming out anteriorly between the 5th and 6th ribs, about an inch below and slightly external to the nipple. There was little constitutional disturbance, and the man was soon discharged cured. Brown records a case of impalement in a boy of fourteen. While running to a fire, he struck the point of the shaft of a carriage, which passed through his left chest, below the nipple. There was, strangely, no hemorrhage, and no symptoms of so severe an injury; the boy recovered.

There is deposited in the Museum of the Royal College of Surgeons in London, a mast-pivot, 15 inches in length and weighing between seven and eight pounds, which had passed obliquely through the body of a sailor. The specimen is accompanied by a colored picture of the sufferer himself in two positions. The name of the sailor was Taylor, and the accident occurred aboard a brig lying in the London docks. One of Taylor's mates was guiding the pivot of the try-sail into the main boom, when a tackle gave way. The pivot instantly left the man's hand, shot through the air point downward striking Taylor above the heart, passing out lower down posteriorly, and then imbedded itself in the deck. The unfortunate subject was carried at once to the London Hospital, and notwithstanding his transfixion by so formidable an instrument, in five months Taylor had recovered sufficiently to walk, and ultimately returned to his duties as a seaman.

In the same museum, near to this spike, is the portion of a shaft of the carriage which passed through the body of a gentleman who happened to be standing near the vehicle when the horse plunged violently forward, with the result that the off shaft penetrated his body under the left arm, and came out from under the right arm, pinning the unfortunate man to the stable door. Immediately after the accident the patient walked upstairs and got in bed; his recovery progressed uninterruptedly, and his wounds were practically healed at the end of nine weeks; he is reported to have lived eleven years after this terrible accident.

In the Indian Medical Gazette there is an account of a private of thirty-five, who was thrown forward and off his horse while endeavoring to mount. He fell on a lance which penetrated his chest and came out through the scapula. The horse ran for about 100 yards, the man hanging on and trying to stop him. After the extraction of the lance the patient recovered. Longmore gives an instance of complete transfixion by a lance of the right side of the chest and lung, the patient recovering. Ruddock mentions cases of penetrating wounds of both lungs with recovery.

There is a most remarkable instance of recovery after major thoracic wounds recorded by Brokaw. In a brawl, a shipping clerk received a thoracic wound extending from the 3d rib to within an inch of the navel, 13 1/2 inches long, completely severing all the muscular and cartilaginous structures, including the cartilages of the ribs from the 4th to the 9th, and wounding the pleura and lung. In addition there was an abdominal wound 6 1/2 inches long, extending from the navel to about two inches above Poupart's ligament, causing almost complete intestinal evisceration. The lung was partially collapsed. The cartilages were ligated with heavy silk, and the hemorrhage checked by ligature and by packing gauze in the inter-chondral spaces. The patient speedily recovered, and was discharged in a little over a month, the only disastrous result of his extraordinary injuries being a small ventral hernia.

In wounds of the diaphragm, particularly those from stabs and gunshot injuries, death is generally due to accompanying lesions rather than to injury. Hollerius, and Alexander Benedictus, made a favorable diagnosis of wounds made in the fleshy portions of the diaphragm, but despaired of those in the tendinous portions. Bertrand, Fabricius Hildanus, la Motte, Ravaton, Valentini, and Glandorp, record instances of recovery from wounds of the diaphragm.

There are some peculiar causes of diaphragmatic injuries on record, laughter, prolonged vomiting, excessive eating, etc., being mentioned. On the other hand, in his "Essay on Laughter (du Ris)," Joubert quotes a case in which involuntary laughter was caused by a wound of the diaphragm; the laughter mentioned in this instance was probably caused by convulsive movements of the diaphragm, due to some unknown irritation of the phrenic nerve. Bremuse gives an account of a man who literally split his diaphragm in two by the ingestion of four plates of potato soup, numerous cups of tea and milk, followed by a large dose of sodium bicarbonate to aid digestion. After this meal his stomach swelled to an enormous extent and tore the diaphragm on the right side, causing immediate death.

The diaphragm may be ruptured by external violence (a fall on the chest or abdomen), or by violent squeezing (railroad accidents, etc.), or according to Ashhurst, by spasmodic contraction of the part itself. If the injury is unaccompanied by lesion of the abdominal or thoracic viscera, the prognosis is not so unfavorable as might be supposed. Unless the laceration is extremely small, protrusion of the stomach or some other viscera into the thoracic cavity will almost invariably result, constituting the condition known as internal or diaphragmatic hernia. Pare relates the case of a Captain who was shot through the fleshy portion of the diaphragm, and though the wound was apparently healed, the patient complained of a colicky pain. Eight months afterward the patient died in a violent paroxysm of this pain. At the postmortem by Guillemeau, a man of great eminence and a pupil of Pare, a part of the colon was found in the thorax, having passed through a wound in the diaphragm. Gooch saw a similar case, but no history of the injury could be obtained. Bausch mentions a case in which the omentum, stomach, and pancreas were found in the thoracic cavity, having protruded through an extensive opening in the diaphragm. Muys, Bonnet, Blancard, Schenck, Sennert, Fantoni, and Godefroy record instances in which, after rupture of the diaphragm, the viscera have been found in the thorax; there are many modern cases on record. Internal hernia through the diaphragm is mentioned by Cooper, Bowles, Fothergill, Monro, Ballonius, Derrecagiax, and Schmidt. Sir Astley Cooper mentioned a case of hernia ventriculi from external violence, wherein the diaphragm was lacerated without any fracture of the ribs. The man was aged twenty-seven, and being an outside passenger on a coach (and also intoxicated), when it broke down he was projected some distance, striking the ground with considerable force. He died on the next day, and the diagnosis was verified at the necropsy, the opening in the diaphragm causing stricture of the bowel.

Postempski successfully treated a wound of the diaphragm complicated with a wound of the omentum, which protruded between the external opening between the 10th and 11th ribs; he enlarged the wound, forced the ribs apart, ligated and cut off part of the omentum, returned its stump to the abdomen, and finally closed both the wound in the diaphragm and the external wound with sutures. Quoted by Ashhurst, Hunter recorded a case of gunshot wound, in which, after penetrating the stomach, bowels, and diaphragm the ball lodged in the thoracic cavity, causing no difficulty in breathing until shortly before death, and even then the dyspnea was mechanical--from gaseous distention of the intestines.

Peritonitis in the thoracic cavity is a curious condition which may be brought about by a penetrating wound of the diaphragm. In 1872 Sargent communicated to the Boston Society for Medical Improvement an account of a postmortem examination of a woman of thirty-seven, in whom he had observed major injuries twenty years before. At that time, while sliding down some hay from a loft, she was impaled on the handle of a pitchfork which entered the vagina, penetrated 22 inches, and was arrested by an upper left rib, which it fractured; further penetration was possibly prevented by the woman's feet striking the floor. Happily there was no injury to the bladder, uterus, or intestines. The principal symptoms were hemorrhage from the vagina and intense pain near the fractured rib, followed by emphysema. The pitchfork-handle was withdrawn, and was afterward placed in the museum of the Society, the abrupt bloody stain, 22 inches from the rounded end, being plainly shown. During twenty years the woman could never lie on her right side or on her back, and for half of this time she spent most of the night in the sitting position. Her last illness attracted little attention because her life had been one of suffering. After death it was found that the cavity in the left side of the chest was entirely filled with abdominal viscera. The opening in the diaphragm was four inches in diameter, and through it had passed the stomach, transverse colon, a few inches of the descending colon, and a considerable portion of the small intestines. The heart was crowded to the right of the sternum and was perfectly healthy, as was also the right lung. The left lung was compressed to the size of a hand. There were marked signs of peritonitis, and in the absence of sufficient other symptoms, it could be said that this woman had died of peritonitis in the left thoracic cavity.

Extended tolerance of foreign bodies loose in the thoracic cavity has been noticed. Tulpins mentions a person who had a sponge shut up in his thoracic cavity for six weeks; it was then voided by the mouth, and the man recovered. Fabricius Hildanus relates a similar instance in which a sponge-tent was expelled by coughing. Arnot reports a case in which a piece of iron was found in a cyst in the thorax, where it had remained for fourteen years. Leach gives a case in which a bullet was impacted in the chest for forty-two years. Snyder speaks of a fragment of knife-blade which was lodged in the chest twelve years and finally coughed up.

Foreign Bodies in the Bronchi.--Walnut kernels, coins, seeds, beans, corks, and even sponges have been removed from the bronchi. In the presence of Sir Morrell Mackenzie, Johnston of Baltimore removed a toy locomotive from the subglottic cavity by tracheotomy and thyreotomy. The child had gone to sleep with the toy in his mouth and had subsequently swallowed it. Eldredge presented a hopeless consumptive, who as a child of five had swallowed an umbrella ferrule while whistling through it, and who expelled it in a fit of coughing twenty-three years after. Eve of Nashville mentions a boy who placed a fourpenny nail in a spool to make a whistle, and, by a violent inspiration, drew the nail deep into the left bronchus. It was removed by tracheotomy. Liston removed a large piece of bone from the right bronchus of a woman, and Houston tells of a case in which a molar tooth was lodged in a bronchus causing death on the eleventh day. Warren mentions spontaneous expulsion of a horse-shoe nail from the bronchus of a boy of two and one-half years. From Dublin, in 1844, Houston reports the case of a girl of sixteen who inhaled the wooden peg of a small fiddle and in a fit of coughing three months afterward expelled it from the lungs. In 1849 Solly communicated the case of a man who inhaled a pebble placed on his tongue to relieve thirst. On removal this pebble weighed 144 grains. Watson of Murfreesboro removed a portion of an umbrella rib from a trachea, but as he failed to locate or remove the ferrule, the case terminated fatally. Brigham mentions a child of five who was seized with a fit of coughing while she had a small brass nail in her mouth; pulmonary phthisis ensued, and in one year she died. At the postmortem examination the nail was found near the bifurcation of the right bronchus, and, although colored black, was not corroded.

Marcacci reported an observation of the removal of a bean from the bronchus of a child of three and a half years. The child swallowed the bean while playing, immediately cried, and became hoarse. No one having noticed the accident, a diagnosis of croup was made and four leeches were applied to the neck. The dyspnea augmented during the night, and there was a whistling sound with each respiratory movement. On the next day the medical attendants suggested the possibility of a foreign body in the larynx. Tracheotomy was performed but the dyspnea continued, showing that the foreign body was lodged below the incision. The blood of one of the cut vessels entered the trachea and caused an extra paroxysm of dyspnea, but the clots of blood were removed by curved forceps. Marcacci fils practised suction, and placed the child on its head, but in vain. A feather was then introduced in the wound with the hope that it would clean the trachea and provoke respiration; when the feather was withdrawn the bean followed. The child was much asphyxiated, however, and five or six minutes elapsed before the first deep inspiration. The wound was closed, the child recovered its voice, and was well four days afterward. Annandale saw a little patient who had swallowed a bead of glass, which had lodged in the bronchus. He introduced the handle of a scalpel into the trachea, producing sufficient irritation to provoke a brusque expiration, and at the second attempt the foreign body was expelled. Hulke records the case of a woman, the victim of a peculiar accident happening during the performance of tracheotomy, for an affection of the larynx. The internal canule of the tracheotomy-tube fell into the right bronchus, but was removed by an ingenious instrument extemporaneously devised from silver wire. A few years ago in this country there was much public excitement and newspaper discussion over the daily reports which came from the bedside of a gentleman who had swallowed a cork, and which had become lodged in a bronchus. Tracheotomy was performed and a special corkscrew devised to extract it, but unfortunately the patient died of slow asphyxiation and exhaustion. Herrick mentions the case of a boy of fourteen months who swallowed a shawl-pin two inches long, which remained in the lungs four years, during which time there was a constant dry and spasmodic cough, and corresponding depression and emaciation. When it was ultimately coughed up it appeared in one large piece and several smaller ones, and was so corroded as to be very brittle. After dislodgment of the pin there was subsidence of the cough and rapid recovery.

Lapeyre mentions an elderly gentleman who received a sudden slap on the back while smoking a cigarette, causing him to start and take a very deep inspiration. The cigarette was drawn into the right bronchus, where it remained for two months without causing symptoms or revealing its presence. It then set up a circumscribed pneumonia and cardiac dropsy which continued two months longer, at which time, during a violent fit of coughing, the cigarette was expelled enveloped in a waxy, mucus-like matter. Louis relates the case of a man who carried a louis-d'or in his lung for six and a half years.

There is a case on record of a man who received a gunshot wound, the ball entering behind the left clavicle and passing downward and across to the right clavicle. Sometime afterward this patient expectorated two pieces of bone and a piece of gum blanket in which he was enveloped at the time of the injury. Carpenter describes a case of fatal pleuritis, apparently due to the presence of four artificial teeth which had been swallowed thirteen years before.

Cardiac Injuries.--For ages it has been the common opinion relative to injuries of the heart that they are necessarily fatal and that, as a rule, death immediately follows their reception. Notwithstanding this current belief a careful examination of the literature of medicine presents an astounding number of cases in which the heart has been positively wounded, and the patients have lived days, months, and even recovered; postmortem examination, by revealing the presence of cicatrices in the heart, confirming the original diagnosis. This question is one of great interest as, in recent years, there has been constant agitation of the possibility of surgical procedures in cardiac as well as cerebral injuries. Del Vecchio has reported a series of experiments on dogs with the conclusion that in case of wounds in human beings suture of the heart is a possible operation. In this connection he proposes the following operative procedure: Two longitudinal incisions to be made from the lower border of the 3d rib to the upper border of the 7th rib, one running along the inner margin of the sternum, the other about ten mm. inside the nipple-line. These incisions are joined by a horizontal cut made in the fourth intercostal space. The 4th, 5th, and 6th ribs and cartilages are divided and the outer cutaneous flaps turned up; pushing aside the pleura with the finger, expose the pericardium and incise it longitudinally; suture the heart-wound by interrupted sutures. Del Vecchio adds that Fischer has collected records of 376 cases of wounds of the heart with a mortality two to three minutes after the injury of 20 per cent. Death may occur from a few seconds to nine months after the accident. Keen and Da Costa quote Del Vecchio, and, in comment on his observations, remark that death in cases of wound of the heart is due to pressure of effused blood in the pericardial sac, and, because this pressure is itself a cheek to further hemorrhage, there seems, as far as hemorrhage is concerned, to be rather a question whether operative interference may not be itself more harmful than beneficial. It might be added that the shock to the cardiac action might be sufficient to check it, and at present we would have no sure means of starting pulsation if once stopped. In heart-injuries, paracentesis, followed, if necessary, by incision of the pericardium, is advised by some surgeons.

Realizing the fatality of injuries of the heart, in consequence of which almost any chance by operation should be quickly seized by surgeons rather than trust the lives of patients to the infinitesimal chance of recovery, it would seem that the profession should carefully consider and discuss the feasibility of any procedure in this direction, no matter how hypothetic.

Hall states that his experience in the study of cardiac wounds, chiefly on game-animals, would lead him to the conclusion that transverse wounds the lower portions of the heart, giving rise to punctures rather than extensive lacerations, do not commonly cause cessation of life for a time varying from some considerable fraction of a minute to many minutes or even hours, and especially if the puncture be valvular in character, so as to prevent the loss of much blood. However, if the wound involve the base of the organ, with extensive laceration of the surrounding parts, death is practically instantaneous. It would seem that injury to the muscular walls of the heart is much less efficient in the production of immediate death than destruction of the cardiac nervous mechanism, serious irritation of the latter producing almost instantaneous death from shock. In addition, Hall cites several of the instances on which he based his conclusions. He mentions two wild geese which flew respectively 1/4 and 3/4 of a mile after having been shot through the heart, each with a pellet of BB shot, the base in each instance being uninjured; in several instances antelope and deer ran several rods after being shot with a rifle ball in a similar manner; on the other hand, death was practically instantaneous in several of these animals in which the base of the heart was extensively lacerated. Again, death may result instantaneously from wounds of the precordial region, or according to Erichsen, if held directly over the heart, from the discharge of a pistol containing powder alone, a result occasionally seen after a blow on the precordial region. It is well, however, to state that in times of excitement, one may receive an injury which will shortly prove fatal, and yet not be aware of the fact for some time, perhaps even for several minutes. It would appear that the nervous system is so highly tuned at such times, that it does not respond to reflex irritations as readily as in the absence of excitement.

Instances of Survival after Cardiac Injuries.--We briefly cite the principal interesting instances of cardiac injuries in which death has been delayed for some time, or from which the patient ultimately recovered.

Pare relates the case of a soldier who received a blow from a halberd, penetrating the left ventricle, and who walked to the surgeon's tent to have his wound dressed and then to his own tent 260 yards away. Diemerbroeck mentions two instances of long survival after cardiac injuries, in one of which the patient ran 60 paces after receiving the wound, had complete composure of mind, and survived nine days. There is an instance in which a man ran 400 paces after penetration of the left ventricle, and lived for five hours. Morand gives an instance of survival for five days after wound of the right ventricle. Saucerotte speaks of survival for three days after injury to the heart.

Babington speaks of a case of heart-injury, caused by transfixion by a bayonet, in which the patient survived nine hours. Other older cases are as follows: l'Ecluse, seven days; the Ephemerides, four and six days; Col de Vilars, twelve days; Marcucci, eighteen days; Bartholinus, five days; Durande, five days; Boyer, five days; Capelle, twenty six hours; Fahner, eleven days; Marigues, thirteen days; Morgagni, eight days; la Motte, twelve hours; Rhodius, Riedlin, two days; Saviard, eleven days; Sennert, three days; Triller, fourteen days; and Tulpius, two and fifteen days; and Zittman, eight days.

The Duc de Berri, heir to the French throne, who was assassinated in 1826, lived several hours with one of his ventricles opened. His surgeon, Dupuytren, was reprimanded for keeping the wound open with a probe introduced every two hours, but this procedure has its advocates at the present day. Randall mentions a gunshot wound of the right ventricle which did not cause death until the sixty-seventh day. Grant describes a wound in which a ball from a revolver entered a little to the right of the sternum, between the cartilages of the 5th and 6th ribs, and then entered the right ventricle about an inch from the apex. It emerged from the lower part, passed through the diaphragm, the cardiac end of the stomach, and lodged in the left kidney. The patient remained in a state of collapse fifteen hours after being shot, and with little or no nourishment lived twenty-six days. At the postmortem examination the wounds in the organs were found to be healed, but the cicatrices were quite evident. Bowling gives a case of gunshot wound of the shoulder in which death resulted eleven weeks after, the bullet being found in the left ventricle of the heart. Thompson has reported a bayonet wound of the heart, after the reception of which the patient lived four days. The bayonet entered the ventricle about 1 1/2 inches from the left apex, traversing the left wall obliquely, and making exit close to the septum ventriculorum. Roberts mentions a man who ran 60 yards and lived one hour after being shot through both lungs and the right auricle. Curran mentions the case of a soldier who, in 1809, was wounded by a bullet which entered his body to the left of the sternum, between the 2d and 3d ribs. He was insensible a half hour, and was carried aboard a fighting ship crowded with sailors. There was little hemorrhage from his wound, and he survived fourteen days. At the postmortem examination some interesting facts were revealed. It was found that the right ventricle was transversely opened for about an inch, the ball having penetrated its anterior surface, near the origin of the pulmonary artery. The ball was found loose in the pericardium, where it had fallen during the necropsy. There was a circular lacerated opening in the tricuspid valve, and the ball must have been in the right auricle during the fourteen days in which the man lived. Vite mentions an example of remarkable tenacity of life after reception of a cardiac wound, the subject living four days after a knife-wound penetrating the chest into the pericardial sac and passing through the left ventricle of the heart into the opposite wall. Boone speaks of a gunshot wound in which death was postponed until the thirteenth day. Bullock mentions a case of gunshot wound in which the ball was found lodged in the cavity of the ventricle four days and eighteen hours after infliction of the wound. Carnochan describes a penetrating wound of the heart in a subject in whom life had been protracted eleven days. After death the bullet was found buried and encysted in the heart. Holly reports a case of pistol-shot wound through the right ventricle, septum, and aorta, with the ball in the left ventricle. There was apparent recovery in fourteen days and sudden death on the fifty-fifth day.

Hamilton gives an instance of a shoemaker sixty-three years old who, while carrying a bundle, fell with rupture of the heart and lived several minutes. On postmortem examination an opening in the heart was found large enough to admit a blowpipe. Noble speaks of duration of life for five and a half days after rupture of the heart; and there are instances on record in which life has been prolonged for thirteen hours and for fifty-three hours after a similar injury. Glazebrook reports the case of a colored man of thirty, of powerful physique, who was admitted to the Freedmen's Hospital, Washington, D.C., at 12.30 A.M., on February 5, 1895. Upon examination by the surgeons, an incised wound was discovered one inch above the left nipple, 3 1/4 inches to the left of the median line, the incision being 2 1/4 inches in length and its direction parallel with the 3d rib. The man's general condition was fairly good, and the wound was examined. It was impossible to trace its depth further than the 3d rib, although probing was resorted to; it was therefore considered a simple wound, and dressed accordingly. Twelve hours later symptoms of internal hemorrhage were noticed, and at 8 A.M., February 6th, the man died after surviving his injury thirty-two hours. A necropsy was held three hours after death, and an oblique incision 3/4 inch in length was found through the cartilage-end of the 3d rib. A similar wound was next found in the pericardium, and upon examining the heart there was seen a clean, incised wound 1/2 inch in length, directly into the right ventricle, the endocardial wound being 3/8 inch long. Both the pericardium and left pleura were distended with fresh blood and large clots. Church reports a case of gunshot wound of the heart in a man of sixty-seven who survived three hours. The wound had been made by a pistol bullet (32 caliber), was situated 1 1/4 inches below the mammary line, and slightly to the left of the center of the sternum; through it considerable blood had escaped. The postmortem examination showed that the ball had pierced the sternum just above the xiphoid cartilage, and had entered the pericardium to the right and at the lower part. The sac was filled with blood, both fresh and clotted. There was a ragged wound in the anterior wall 1/2 inch in diameter. The wound of exit was 5/8 inch in diameter. After traversing the heart the ball had penetrated the diaphragm, wounded the omentum in several places, and become lodged under the skin posteriorly between the 9th and 10th ribs. Church adds that the "Index Catalogue of the Surgeon-General's Library" at Washington contains 22 cases of direct injury to the heart, all of which lived longer than his case: 17 lived over three days; eight lived over ten days; two lived over twenty-five days; one died on the fifty-fifth day, and there were three well-authenticated recoveries. Purple tabulates a list of 42 cases of heart-injury which survived from thirty minutes to seventy days.

Fourteen instances of gunshot wounds of the heart have been collected from U.S. Army reports, in all of which death followed very promptly, except in one instance in which the patient survived fifty hours. In another case the patient lived twenty-six hours after reception of the injury, the conical pistol-ball passing through the anterior margin of the right lobe of the lung into the pericardium, through the right auricle, and again entered the right pleural cavity, passing through the posterior margin of the lower lobe of the right lung; at the autopsy it was found in the right pleural cavity. The left lung and cavity were perfectly normal. The right lung was engorged and somewhat compressed by the blood in the pleural cavity. The pericardium was much distended and contained from six to eight ounces of partially coagulated blood. There was a fibrinous clot in the left ventricle.

Nonfatal Cardiac Injuries.--Wounds of the heart are not necessarily fatal. Of 401 cases of cardiac injury collected by Fischer there were as many as 50 recoveries, the diagnosis being confirmed in 33 instances by an autopsy in which there were found distinct signs of the cardiac injury. By a peculiar arrangement of the fibers of the heart, a wound transverse to one layer of fibers is in the direction of another layer, and to a certain extent, therefore, valvular in function; it is probably from this fact that punctured wounds of the heart are often attended with little or no bleeding.

Among the older writers, several instances of nonfatal injuries to the heart are recorded. Before the present century scientists had observed game-animals that had been wounded in the heart in the course of their lives, and after their ultimate death such direct evidence as the presence of a bullet or an arrow in their hearts was found. Rodericus a Veiga tells the story of a deer that was killed in hunting, and in whose heart was fixed a piece of arrow that appeared to have been there some time. Glandorp experimentally produced a nonfatal wound in the heart of a rabbit. Wounds of the heart, not lethal, have been reported by Benivenius, Marcellus Donatus, Schott, Stalpart van der Wiel, and Wolff. Ollenrot reports an additional instance of recovery from heart-injury, but in his case the wound was only superficial.

There is a recent case of a boy of fourteen, who was wounded in the heart by a pen-knife stab. The boy was discharged cured from the Middlesex Hospital, but three months after the reception of the injury he was taken ill and died. A postmortem examination showed that the right ventricle had been penetrated in a slanting direction; the cause of death was apoplexy, produced by the weakening and thinning of the heart's walls, the effect of the wound. Tillaux reports the case of a man of sixty-five, the victim of general paralysis, who passed into his chest a blade 16 cm. long and 2 mm. broad. The wound of puncture was 5 cm. below the nipple and 2 cm. to the outside. The left side of the chest was emphysematous and ecchymosed. The heart-sounds were regular, and the elevation of the skin by the blade coincided with the ventricular systole. The blade was removed on the following day, and the patient gradually improved. Some thirteen months after he had expectoration of blood and pus and soon died. At the necropsy it was seen that the wound had involved both lungs; the posterior wall of the ventricle and the inferior lobe of the right lung were traversed from before backward, and from left to right, but the ventricular cavity was not penetrated. Strange to say, the blade had passed between the vertebral column and the esophagus, and to the right of the aorta, but had wounded neither of these organs.

O'Connor mentions a graduate of a British University who, with suicidal intent, transfixed his heart with a darning-needle. It was extracted by a pair of watchmaker's pliers. In five days the symptoms had all abated, and the would-be suicide was well enough to start for the Continent. Muhlig was consulted by a mason who, ten years before, had received a blow from a stiletto near the left side of the sternum. The cicatrix was plainly visible, but the man said he had been able to perform his daily labors, although at the present time suffering from intense dyspnea and anasarca. A loud bellows-sound could be heard, which the man said had been audible since the time of reception of the injury. This was a double bruit accompanying systole, and entirely obscuring the physical signs. From this time the man speedily failed, and after his death there were cicatricial signs found, particularly on the wall of the left ventricle, together with patency of the interventricular septum, with signs of cicatrization about this rent. At the side of the left ventricle the rent was twice as large and lined with cicutricial tissue.

Stelzner mentions a young student who attempted suicide by thrusting a darning-needle into his heart. He complained of pain and dyspnea; in twenty-four hours his symptoms increased to such an extent that operation was deemed advisable on account of collapse. The 5th rib was resected and the pleural cavity opened. When the pericardial sac was incised, a teaspoonful of turbid fluid oozed out, and the needle was felt in an oblique position in the right ventricle. By pressure of a finger passed under the heart, the eye of the needle was pressed through the anterior wall and fixed on the operator's finger-nail. An attempt to remove by the forceps failed, as the violent movements of the heart drew the needle back into the cavity. About this stage of the operation an unfortunate accident happened--the iodoform tampon, which protected the exposed pleural cavity, was drawn into this cavity during a deep inspiration, and could not be found. Notwithstanding subsequent pneumothorax and extensive pleuritic effusion, the patient made a good recovery at the end of the fourth week and at the time of report it was still uncertain whether the needle remained in the heart or had wandered into the mediastinum. During the discussion which followed the report of this case, Hahn showed a portion of a knitting-needle which had been removed from the heart of a girl during life. The extraction was very slow in order to allow of coagulation along the course of the wound in the heart, and to guard against hemorrhage into the pericardial sac, which is so often the cause of death in punctured wounds of this organ. Hahn remarked that the pulse, which before the removal had been very rapid, sank to 90.

Marks reports the case of a stab-wound penetrating the left 9th intercostal space, the diaphragm, pleura, pericardium, and apex of the heart. It was necessary to enlarge the wound, and, under an anesthetic, after removing one and one-half inches of the 9th and 10th ribs, the wound was thoroughly packed with iodoform gauze and in twenty-one days the patient recovered. Lavender mentions an incised wound of the heart penetrating the right ventricle, from which the patient recovered. Purple gives, an account of a recovery from a wound penetrating both ventricles. The diagnosis was confirmed by a necropsy nine years thereafter. Stoll records a nonfatal injury to the heart.

Mastin reports the case of a man of thirty-two who was shot by a 38-caliber Winchester, from an ambush, at a distance of 110 yards. The ball entered near the chest posteriorly on the left side just below and to the outer angle of the scapula, passed between the 7th and 8th ribs, and made its exit from the intercostal space of the 4th and 5th ribs, 2 1/4 inches from the nipple. A line drawn from the wound of entrance to that of exit would pass exactly through the right ventricle. After receiving the wound the man walked about twenty steps, and then, feeling very weak from profuse hemorrhage from the front of the wound, he sat down. With little or no treatment the wound closed and steady improvement set in; the patient was discharged in three weeks. As the man was still living at last reports, the exact amount of damage done in the track of the bullet is not known, although Mastin's supposition is that the heart was penetrated.

Mellichamp speaks of a gunshot wound of the heart with recovery, and Ford records an instance in which a wound of the heart by a buckshot was followed by recovery. O'Connor reports a case under his observation in which a pistol-ball passed through three of the four cavities of the heart and lodged in the root of the right lung. The patient, a boy of fifteen, died of the effects of cardiac disease three years and two months later. Bell mentions a case in which, six years after the receipt of a gunshot wound of the chest, a ball was found in the right ventricle. Christison speaks of an instance in which a bullet was found in the heart of a soldier in Bermuda, with no apparent signs of an opening to account for its entrance. There is a case on record of a boy of fourteen who was shot in the right shoulder, the bullet entering through the right upper border of the trapezius, two inches from the acromion process. Those who examined him supposed the ball was lodged near the sternal end of the clavicle, four or five inches from where it entered. In about six weeks the boy was at his labors. Five years later he was attacked with severe pneumonia and then first noticed tumultuous action of the heart which continued to increase after his recovery. Afterward the pulsation could be heard ten or 12 feet away. He died of another attack of pneumonia fifteen years later and the heart was found to be two or three times its natural size, soft and flabby, and, on opening the right ventricle, a bullet was discovered embedded in its walls. There was no scar of entrance discernible, though the pericardium was adherent. Biffi of Milan describes the case of a lunatic who died in consequence of gangrene of the tongue from a bite in a paroxysm of mania. At the necropsy a needle, six cm. in length, was found transfixing the heart, with which the relatives of the deceased said he had stabbed himself twenty-two months prior to his death. There is a collection of cases in which bullets have been lodged in the heart from twenty to thirty years.

Balch reports a case in which a leaden bullet remained twenty years in the walls of the heart. Hamilton mentions an instance of gunshot wound of the heart, in which for twenty years a ball was embedded in the wall of the right ventricle, death ultimately being caused by pneumonia. Needles have quite frequently been found in the heart after death; Graves, Leaming, Martin, Neill, Piorry, Ryerson, and others record such cases. Callender mentions recovery of the patient after removal of a needle from the heart.

Garangeot mentions an aged Jesuit of seventy-two, who had in the substance of his heart a bone 4 1/2 inches long and possibly an inch thick. This case is probably one of ossification of the cardiac muscle; in the same connection Battolini says that the heart of Pope Urban VII contained a bone shaped like the Arab T.