Chapter XXII: Part 22

The wound in this instance was through _muscular_, not tendinous parts. The preparation is in the museum at Chatham, No. 63, Class 6.

A French soldier was admitted into the Gensd’armerie Hospital at Brussels, in consequence of a wound from a musket-ball, at the battle of Waterloo, which entered behind between the eighth and ninth ribs, near the spine, and lodged internally. After many severe symptoms and much suffering, he died on the 1st of December, worn out by the discharge, which often amounted to a pint daily, for the free exit of which the external wound had been early enlarged. On examination, the lung was slightly ulcerated on its surface, opposite to where the ball had entered, and a little matter contained in a sac had formed between it and the wall of the chest. That the ball had gone on was proved by the fact of there being an opening in the tendinous part of the diaphragm, through which a portion of the stomach had passed into the chest, from which it was easily withdrawn. The ball could not be found in the abdomen; in all probability, it had passed into the intestine and had been discharged per anum, as has happened in other instances.

James Wilkie, 12th Light Dragoons, aged thirty-four, was suddenly attacked, at four P.M. of the 6th September, 1815, with violent pain in the umbilical and epigastric regions, accompanied with nausea and great irritability of stomach; pulse small, rapid, and regular. Assistant-Surgeon Egan visited him half an hour after the attack, bled him freely, and caused the abdomen to be fomented with hot water; a large blister was applied to the seat of pain, an ounce of castor-oil was given, and emollient and laxative clysters were occasionally administered. At night the symptoms abated, and he slept about three hours. The next morning his countenance exhibited that appearance of haggardness and anxiety which have always been alarming indications; pulse feeble and rapid; the pain severe; at noon he vomited from two to three ounces of black, fetid blood in a fluid state; the pulse became very feeble. At four P.M. the pain increased, he ejected from his stomach from four to six ounces of dark, fluid blood that had less fetor; and at six the same evening he expired in pain.

This man, on the 18th of June, at Waterloo, received a punctured wound from a sword, which entered about an inch below the inferior angle of the scapula on the left side, penetrated the thorax, appeared to have passed through the diaphragm, the point of the weapon coming out on the opposite side of the chest between the first and second false ribs. The wounds were quite healed, and he apparently enjoyed good health, when he arrived from Brussels in August.

_Appearances on dissection._--On opening the abdomen, the whole of the intestines, with the exception of the duodenum, were in a high state of inflammation. On tracing the duodenum upward a very small portion of the stomach was found in its natural situation; while, on opening the thorax, a large spherical tumor was seen in its left cavity, containing two quarts or upwards of black, fluid, fetid blood. This sac was soon seen to be the stomach, which had protruded through the aperture in the diaphragm, by which it was so firmly embraced as to render the communication between the portion of the stomach in the thorax and that in the abdomen impervious to each other. The hernial sac and its contents were supported by the diaphragm. The left lung exhibited a shriveled, contracted appearance, as if its function had been impeded by the pressure of the sac and its contained fluid. The cicatrix and the course of the sword were well marked. The cardiac and pyloric orifices of the stomach were in the natural cavity.

S. Fletcher, 31st Regiment, wounded at Sobraon on the 10th of February, 1846; died at Chatham, February, 1847. On opening the thorax, the greater part of the stomach, and a foot and a half of the transverse arch of the colon, with the omentum attached, were found in the left pleural cavity. There was an opening in the diaphragm with a rounded margin two inches and a half in diameter, two inches to the left of the œsophagus. The stomach, colon, and omentum adhered firmly, at one part, to the pleura covering the diaphragm and lining the ribs to the extent of a few inches, although otherwise loose and free in the cavity. The parts in the aperture of the diaphragm were free from adhesions, and the finger passed easily through the opening from below upward. Two cicatrixes were to be seen on the left side of the chest--one between the eleventh and twelfth ribs, close to the transverse processes of the vertebræ; the other between the eighth and ninth ribs, three inches and a half from the cartilages. The preparation is in the museum at Chatham.

352. These cases confirm the fact that wounds of the diaphragm, whether in the muscular or the tendinous part, never unite, but remain with their edges separated, ready for the transmission between them of any of the loose viscera of the abdomen which may receive an impulse in that direction. That parts of these viscera do pass upward and back again, cannot be doubted; and it is probable that incarceration may take place for a length of time before strangulation occurs from some sudden and distending impulse giving rise to it.

When the solid viscera of the abdomen are injured, as well as the diaphragm against which they are applied in their natural situation, the wound may sometimes be considered a fortunate one; for the liver or spleen may adhere to the opening in the diaphragm and fill up the space between its edges.

A wound of the diaphragm may be suspected from the course of the ball, particularly when it passes across the chest below the true ribs. It is necessarily accompanied by an opening into the cavity of the abdomen, and is by so much the more dangerous. The symptoms will partake of an injury to both, although they are principally referable to that of the chest, and are those of intense inflammation, accompanied by a difficulty of breathing, which in the case of Mr. Drummond was a peculiar sort of jerk; in that of Captain Prevost it was more spasmodic. The risus sardonicus, hiccough, pain on the top of the shoulder, and loss of power of the arm, which were all more or less present, in all probability depended on some larger fibrils of the phrenic nerve being wounded. The treatment should be antiphlogistic, with a free external opening for the discharge of matter. The accession of jaundice shows an injury to the liver; vomiting of blood or its passage per anum indicates a wound of the stomach or intestines.

353. When the patient recovers, the probability of a hernia taking place into the chest through the diaphragm should be explained to him. If any reason should exist for the belief that it had occurred, he should be doubly cautious as to eating and drinking in small quantities only, and remaining in the erect position for some time after each meal; he should carefully avoid a stooping posture and all muscular exertion or straining. If symptoms of strangulation should come on, an opening made into the abdomen would appear to offer the only chance for life. The hernia may perhaps be drawn back into its place in the abdomen; but if firm adhesions have formed between the protruded parts and the edges of the opening in the diaphragm, the case must be treated as one of adherent strangulated rupture in any other part, by a simple division of the stricture in the most convenient situation. The opening should be a straight incision through the wall of the abdomen, large enough to admit the hand, immediately over the part where the diaphragm is supposed to be injured. It should be closed by a continuous suture through the skin. This operation, now for the first time recommended, although apparently formidable, cannot be compared as to danger with the incisions of twelve and fourteen inches long through the wall of the abdomen, which have been in some instances successfully made for the removal of diseased ovaria.

354. _Wounds of the heart_ are for the most part immediately fatal. Many persons have, however, been known to live for hours, nay days, and even weeks, with wounds which could scarcely be otherwise than destructive; and several cases are recorded in which the cicatrixes discovered after death, in persons known to have been wounded in the vicinity of the heart, have shown that even severe wounds of that most important organ are not necessarily fatal. As our knowledge of the nature of the injury inflicted can never be distinct, it follows that every wound should be considered as curable until it is unfortunately proved to be the contrary.

355. _Auscultation_ and _percussion_, and principally auscultation of the whole precordial region, have afforded means of judging of injuries of the heart which were not formerly known. A vertical line, coinciding with the left margin of the sternum, has about one-third of the heart, consisting of the upper portion of the right ventricle, and the whole of the left, on the left. The apex of the heart beats between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple and an inch on its external side; or, if one leg of a compass be fixed at a point midway between the junction of the cartilage of the fifth rib on the left side with the rib and sternum, and a circle of two inches in diameter be drawn around, it will define as nearly as possible the space of the precordial region occupied by the heart while uncovered, except by the pericardium and some loose cellular texture. In the rest of the precordial region it is covered, and separated from the walls of the chest by the intervening lung.

If the chest of the dead subject be transfixed with long needles, it will be found that the center of the first bone of the sternum corresponds with the lower edge of the left subclavian vein and to the arch of the aorta crossing the trachea, the center of the second bone to the upper edge of the appendix of the right ventricle, and the center of the third bone to the right side of the right auricle, the right ventricle being lower down. A needle penetrating the chest at the costal extremity of the fifth rib, close to the upper edge of its cartilage, will touch the septum of the ventricle. The apex of the heart is an inch and a half below this, and inclined to the left side.

The semilunar valves of the pulmonary artery correspond to a spot a little below the center of the third bone of the sternum. The aortic valves are a few lines below and behind the pulmonary. The mitral valves are a little lower, and still more deeply seated. The pulmonary artery, after touching the sternum, inclines to the left, and is found close to the sternum between the second and third ribs. The aorta ascends to the first bone, and crosses it to form the arch.

One-third of the heart, consisting of the upper part of the right ventricle and of the whole of the right auricle, is beneath the sternum; the remainder of the right, with the left ventricle and auricle, are to the left side of that bone.

356. On applying the ear to the precordial region, the patient being in the erect position, two sounds are distinguishable in a healthy heart--one duller and more prolonged, the other clearer and shorter; between these there is scarcely an appreciable interval. The period of repose is sufficiently marked before the first or duller sound returns. Of the time thus occupied, one-half is filled up by the first or dull sound, one-quarter by the second or sharp sound, one-quarter by the pause or period of repose.

Twenty-nine theories have been proposed, each accounting for the sounds of the heart. The theory of Dr. Billing appears to prevail at present, which supposes that the sounds thus heard “are caused by the valves, which, being membranous, each time they resist the reflux of the blood are thrown into a state of sudden tension, which produces sound.”

The impulse of the heart, as far as it can be felt by the touch, depends much on the position in which the body is placed. In the erect position, it is heard between the fifth and sixth ribs. In the recumbent posture, the impulse is almost imperceptible. It is perhaps more observable when the body is turned on the right side, but decidedly more so when it is turned on the left. A clearer sound proceeds from a thin, and a duller sound from a thick heart; a sound of greater extent from a large heart, and a sound of less extent from a small one. A more forcible impulse is given by a thick heart, and one more feeble by a thin one; the impulse is conveyed to a longer distance from a small heart.

From a clearer sound we believe in the probability of an attenuated heart, but we argue its certainty from a clearer sound joined with a weaker impulse. A stronger impulse denotes the probability of a hypertrophied heart, but we argue its certainty from a stronger impulse with a diminished sound.

The terms endocardial and exocardial are used to designate the alterations which take place in the sounds of the heart under disease--endocardial when they occur within the heart, and exocardial when they take place upon its surface. The endocardial murmur of disease, or bellows-sound, takes the place of and is substituted in certain cases for the first or second, or even for both the healthy or normal sounds. The exocardial murmur of disease is heard with the normal sounds, but confusing and overpowering, sometimes overwhelming, them by its rubbing or crumpling noise. The natural sounds exist, although rendered imperceptible by the greater distinctness and nearer approach of the unnatural or unhealthy ones.

The heart apart from the pericardium never moves without a sound; the pericardium apart from the heart never gives out one. Under disease the heart gives out the natural sound, diminished, exaggerated, or modified, or it may be totally altered. The sounds given out by a diseased pericardium must always be new, (there being no old ones,) and are described as rubbing, or to-and-fro sounds. The pleura, when diseased, being a serous structure, like the inner membrane of the pericardium, gives out less marked but somewhat similar sounds (the “_frottement_” of the French) in particular stages of disease.

The alterations in the ordinary sounds constituting the endocardial murmurs of the heart under disease depend principally on the altered state of the endocardium, or membrane lining its cavities; the sounds given off, and called exocardial, on an altered state of the serous membrane of the pericardium, reflected over the outer surface of the heart. The endocardial or bellows-sound, when it accompanies the normal sounds of the heart, may result from any kind of derangement affecting the internal membrane of that organ, particularly rheumatic inflammation, or from any force which may compress its cavities; or it may depend on the altered quality of the blood, from anemia. It should be present after excessive hemorrhages have greatly reduced the powers of the sufferer. When this murmur or sound occurs after injury in the vicinity of the heart, and is accompanied by fever, it indicates inflammation of the lining membrane, although no local pain, no palpitations, no irregular movements of the heart be present.

When a murmur or sound is heard of a different kind, possessing the character of friction, of surfaces moving backward and forward on each other, or to and fro, it is the sign of inflammation of the membrane covering the heart, as well as of that lining the fibrous external tissue of the pericardium. The signs of both external and internal inflammation may be present at the same time, and they frequently are in cases of acute rheumatism.

357. When the heart is supposed to be wounded, even without much loss of blood, there is fainting; palpitation; irregular movement or total cessation of its action; coldness of the extremities; ghastliness of countenance, succeeded by great anxiety; a sense of anguish; an intermission or cessation of pulse, followed, if the patient should survive, by reaction, which renders it very frequent and sometimes increases its impulse; while the anxiety is increased by pain, sometimes intolerable, referred to the part. These symptoms imply a serious injury, although they may not all be present, and many of them differ in intensity. If the patient should survive, the ordinary sounds of the heart will return, with more or less irregularity, accompanied after a few hours by the endocardial murmur, although something like it may perhaps be observed from the first period of injury. The friction or attrition sound, indicating the presence of inflammation of the pericardium, may be absent; it will not be discernible, if a layer of blood be effused into the cavity of that membrane; while the natural sounds of the heart are rendered more indistinct as the heart is separated from the walls of the chest by the effusion which distends the pericardium, and impedes the regular action of the heart, but cannot compress it, as an empyema does the lung. If inflammation take place without an effusion of blood, the friction sound will be heard, and will usually continue even after some effusion of serum and of lymph has occurred, as the quantity of serum secreted is rarely sufficient to prevent the effused and attached portions of lymph from rolling against each other.

The presence of a larger quantity of fluid may be more distinctly known by percussion, if it can be borne in cases of injury, the degree and extent of the dullness being the measure of its existence and accumulation. It may extend over a part or over the whole of the precordial region, reaching as high as the second, or even the first rib, beneath the sternum, and even under the cartilages of the ribs of the right side.

358. That the heart when wounded is capable of recovery by the permanent closure of the wound, in a few rare instances, is indisputable; and it would seem, from a consideration of the different cases which have been recorded, that such recovery takes place in consequence of there being but little blood discharged through the wound, or into the cavity of the pericardium, or into that of the pleura. The absence or the cessation of the hemorrhage by the contraction of the wound, or the formation of a coagulum, is the first step toward a cure, and it was to one or other of these circumstances that most of those who survived the injury for several days or weeks owed their existence for the time, although they usually died from the effects of inflammation, more of the inner lining and outer covering than of the substance of the heart itself.

If the wound be inflicted by a musket or pistol-ball, it cannot be closed, although pressure may be made upon it for a time, so as to suppress the external flow of blood. If this should succeed, it is more than probable that the hemorrhage will continue internally, and that the patient may die after much suffering, principally from oppression, caused by the escape of blood into the cavity of the chest.

If the wound be a stab, the external opening may be accurately closed, and the escape of blood prevented; but as the pressure of the blood in the pericardium is unequal to restrain the action of the heart, blood forced out through the opening fills the cavity of the pleura, and causes suffocation, unless from some accidental circumstance the opening in the heart becomes obstructed, and the bleeding ceases.

If all the circumstances be considered, there can be no doubt of the propriety of closing the wound in the first instance, if the flow of blood be excessive and appear likely to endanger life. It seems to be as little doubtful that the wound should be reopened after a time, if the danger from suffocation be imminent. The relief obtained by the escape of a little blood may be efficacious, while it does not necessarily follow, although it is more than probable it will be so, that its place will be occupied by a further extravasation of blood, which will prove fatal. It is a choice of difficulties, and death from hemorrhage is easier than death from suffocation.

In the case of the Duc de Berri, whose right ventricle was wounded, and who died from loss of blood, Steifensand reprehends Dupuytren for having opened the external wound every two hours, to prevent suffocation; but if death were actually impending from the filling of the cavity of the chest being about to cause suffocation, there was nothing to be done but to give relief at all hazards.

359. When the sufferer has recovered from the imminent danger attendant on the infliction of the injury, and the pericardium is believed to be so full of blood or of serum as to prevent in a great measure the movements of the heart, it has been proposed by Baron Larrey to open the pericardium by the following operation--equally, as he thinks, applicable in an ordinary case of hydrops pericardii:--

“An oblique incision is to be made from over the edge of the ensiform cartilage, to the united extremities of the cartilages of the seventh and eighth ribs. The cellular tissue being divided with some fibers of the rectus and external oblique muscles, there remains only a portion of the peritoneum called its false layer, above the pericardium, which can be seen after the division of all the intervening cellular tissue, projecting between the first and second digitations of the diaphragm. Into this the bistoury is to be entered, with the precaution of doing it with the edge turned upward, and directed a little from right to left, to avoid the peritoneum. The smallest portion possible of the anterior border of the diaphragm is next to be divided, where it is attached to the inner part of the cartilage of the seventh rib. The internal mammary artery is to the outside. The patient should be placed perpendicularly, and supported on his bed, which inclines the anterior part and base of the pericardium to the fore part of the chest.”

Skielderup recommends this operation to be done by first trepanning the sternum a little below the spot where the cartilage of the fifth rib is united to that bone, at which part the periosteum lining it offers considerable resistance, and should not be divided by the trephine. Below this there is a triangular space formed by the separation of the layers of the mediastinum, free from cellular tissue, and tending a little more to the left than to the right. The apex of this triangle is opposite the fifth rib; its base touches the diaphragm. The bone having been removed, the patient is made to lean forward, when the projection of the pericardium will enable the operator to feel that a quantity of fluid is within, and to open it with safety.

360. J. Dierking, a stout, muscular man of the 3d Regiment of German Hussars, was wounded at the battle of Waterloo by a lance, which penetrated the chest between the fifth and sixth ribs, and was then withdrawn. He fell from his horse, lost a good deal of blood by the mouth, and some by the wound, and was carried to Brussels without any particular attention being drawn to the injury. His strength not being restored, while he suffered from palpitations of the heart, and other uneasy sensations in the chest, he was sent to England to be invalided; and in November, 1815, was admitted into the York Hospital, Chelsea, in consequence of an attack of pneumonia, of which he died in two days, without attention being particularly drawn to the cicatrix of the wound.

On examining the body, I found that the lance, having injured the edge of the cartilage of the rib, passed through the inferior lobe of the left lung, the track being marked by a depressed, narrow cicatrix. It then perforated the pericardium under the heart, and sliced a piece of the outer edge of the right ventricle, which, being attached below, turned over and hung down from the heart to the extent of two inches, when in the fresh state, the part of the ventricle from which it had been sliced being puckered and covered by a serous membrane like the heart itself. The lance then penetrated the central tendon of the diaphragm, making an oval opening, easily admitting the finger, the edges being smooth and well defined. It then entered the liver, on the surface of which there was a small, irregular mark or cicatrix. The heart in front was attached to the pericardium by some strong bands, the result of adhesive inflammation, but the general appearance of the serous membrane showed that this had not been either great or extensive. The pericardium was not thickened.

If this man had lived long enough, he might have furnished an instance of hernia of the stomach or of intestine into the pericardium. The preparation is in the military museum at Chatham, Class 1, Div. 1, Sect. 7, No. 156.

_a_, right ventricle;
_b_, left ditto;
_c_, right auricle;
_d_, left ditto;
_e_, aorta;
_f_, pulmonary artery;
_g_, coronary ditto;
_h_, a portion of the cartilages of the ribs seen on the inside;
_i_, a portion of the diaphragm;
_k_, the pericardium.

1, a portion of the pericardium reflected to show abnormal adhesions
to the surface of the heart;
2, aperture of wound through the diaphragm and the pericardium;
3, pendulous slice off the substance of the right ventricle;
4, puckered cicatrix of the wound of the ventricle.]

That the heart, when exposed, is insensible, or nearly so, to the touch, was known to Galen and to Harvey. Galen is said to have removed a part of the sternum and pericardium, and to have laid his finger on the heart. Harvey did the same to the son of Lord Montgomery, who was wounded in the chest. Professor J. K. Jung not only introduced needles into the hearts of animals, but also galvanized them without disadvantage, although Admiral Villeneuve is supposed to have died suddenly from running a long pin into his heart, which scarcely left the mark of its entrance.

That persons may die from the shock of a blow on the heart, need not be doubted, and that they do die when little blood is lost, is admitted. History preserves the fact that Latour d’Auvergne, Captain of the 46th demi-brigade, who had obtained the honorable title of “Premier Grenadier de France,” fell and died immediately after receiving a wound from a lance at Neustadt, in the month of July of the sixth year of the Republic; it struck the left ventricle of the heart near its apex, but did not penetrate its cavity. He was, however, sixty-eight years of age.

361. In wounds of the heart, all extraneous matters should be removed, if possible, and all inflammatory symptoms should be subdued by general bleeding, by leeches, by calomel, antimony, opium, etc. The chest should be examined daily by auscultation. If the cavity of the pleura should fill with blood, it ought to be evacuated to give a chance for life, and if the pericardium should become permanently distended by fluid, it should be evacuated.

_Lacerations and ruptures of the heart_ have frequently taken place from blows or other serious contusions.

Ollivier, who devoted much time to reading and collecting the observations made by different writers on the injuries of the heart, says: “That of forty-nine cases of spontaneous rupture of the heart, thirty-four were of the left ventricle, eight only of the right, two of the left auricle, three of the right, and that in two cases both ventricles were torn in several places; and that these results were in an inverse proportion to those which occurred after blows or contusions; the right ventricle being ruptured in eight out of eleven cases, the left ventricle three times; the auricles being also torn in six of these eleven cases; the ruptures not being confined to one spot, but taking place occasionally in several different parts, or even in the same ventricle.” In eight of these cases he had noticed, the heart was ruptured in several places. That a spontaneous rupture may be cured as well as a wound, seems likely, from a case reported by Rostan, of a woman who died after fourteen years’ suffering with pain about the heart, and was found to have the ventricle ruptured. A cicatrix was observed to the left side of the recent rupture, half an inch in extent in every direction, in which the new matter was evidently different from the natural structure of the heart.

LECTURE XXVI.

WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC.

362. _Wounds of the internal mammary and intercostal arteries_ have so much occupied the attention of theoretical surgeons, and so many inventions have been broached for the suppression of hemorrhage, particularly from the latter, that it becomes consolatory to know that bleeding from these vessels rarely takes place; that the inventions are more numerous than the case requiring them, and that no notice need be taken of them, they being as unnecessary as they are useless. I have never had occasion to see a distinct case of hemorrhage from an internal mammary artery, but if bleeding should take place from a wound in its neighborhood, of a nature to lead to the belief that it came from this vessel, the wound should be enlarged until the part whence the blood flows can be ascertained, when, if it be from that artery, the vessel should be twisted or secured by ligatures, and if these methods should be impracticable, the wound should be closed and the result awaited.

The following method of operating for the application of a ligature on this vessel has been proposed by M. Goyraud. It may be done with ease in the three first intercostal spaces, it offers some difficulties in the fourth, is very difficult in the fifth, and is scarcely to be done lower down. An incision two inches in length is to be made near the side of the sternum from without inward, at an angle of forty-five degrees with the axis of the body. The middle of this incision should be three or four lines distant (a quarter of an inch) from the bone, and in the center of the intercostal space, within which the vessel is to be found. The skin, cellular substance, and the great pectoral muscle having been divided, the aponeurosis of the external intercostal muscle with the muscular fibers of the inner intercostal muscle are to be separated and torn through with a director, until the artery and its two venæ comites are laid bare at the distance of three lines from the edge of the sternum, lying before the fibers of the triangularis sterni muscle, which separates these vessels from the pleura. A bent probe, or other proper instrument, can then be readily passed under the artery. The vessel can only be secured in this way when injured at the upper part of the chest; below this it must bleed into the cavity, unless there be an open wound.

363. The _intercostal artery_, although often injured, rarely gives rise to hemorrhage so as to require a special operation for its suppression; but whenever it does so happen, the wound should be enlarged so as to show the bleeding orifice, which should be secured by one ligature if distinctly open, and by two if the vessel should only be partially divided. The vessel is sometimes so small as to be easily twisted, or its end sufficiently bruised as well as twisted, to arrest the hemorrhage. It lies between the two layers of intercostal muscles, and in the middle of the ribs it runs in a groove in the under part of each.

I have had occasion to twist and bruise the end of an artery bleeding in an intercostal space, and I have tied the vessel under the edge of the rib; but I have not met with any of the great difficulties usually said to be experienced in suppressing a hemorrhage from this artery, when the wound was recent, and the parts were sound; no reliance should be placed on the hypotheses often entertained on this subject.

When the parts are unsound, and the hemorrhage is secondary, greater difficulty is sometimes experienced in arresting it, because the ligature easily cuts its way through the softened parts, and styptics are liable to fall into the cavity of the chest.

The late General Sir G. Walker, G.C.B., after scaling the wall of Badajos, with the fifth division, was wounded by a musket-ball, which struck the cartilages of the lower ribs of the right side, broke the bones, penetrated the chest, and then passed outward. He remained in Badajos under my care during the first three weeks, with many of the other principal officers who were wounded; and overcame the first inflammatory symptoms in a satisfactory manner. After I left him the wound sloughed, some part of the cartilages separated, and one of the intercostal arteries bled, although the bleeding was arrested once by ligature, and afterward, on its return, by different contrivances; each time it reappeared his life was placed in considerable jeopardy from it and the discharge from the cavity of the chest, which was profuse. The bleeding was ultimately arrested by the oil of turpentine, applied on a dossil of lint, and pressed on the bleeding spot by the fingers of assistants until the hemorrhage ceased. He recovered after a very tedious treatment, with a considerable flattening of the chest, and a deep hollow at the lower part of the side, whence portions of the rib, and of the cartilages had been removed.

A young man, aged fifteen, was wounded by small shot in the chest, between the first and second ribs, and near the sternum, at the distance of about forty-eight paces. He ran about six hundred paces, fell, and died thirty-eight hours afterward. On opening the injured cavity of the thorax, it was found to contain twenty-eight ounces of blood, the lung having collapsed to one-fourth its natural size. An opening on its upper part corresponded to the external one in the paries; but the track of the shot could not be traced into its substance for more than two inches and three-quarters; a lacerated spot was, however, perceived at the lower edge of the sixth rib, about two inches from its head, at which part the intercostal artery was found to be torn through; the shot could not be found, and there was no opening in the skin behind.

The discussions which took place on this case led to the statement of an anatomical fact--that when a man is standing erect, a line drawn horizontally from the upper border of the second rib in front would touch the upper edge of the fifth rib behind, and that very little inclination, viz., an inch and a half, was necessary to make the shot wound the intercostal artery of the sixth. Auscultation would have made known the extravasation, and relief might have been given by an incision over the spot where uneasiness was felt; for the loss of blood was not sufficient of itself to destroy life, unless some other injury had been sustained, which was not perceived.

364. _Wounds of the neck_ which are made with swords, or by knives or razors, by persons attempting to destroy themselves, are to be treated on two great principles. The _first_ is, not to place the parts in contact until all hemorrhage has ceased, lest the patient be suffocated. In the mean time, while any oozing continues, a soft sponge should be placed between the edges of the cut. When the larynx or trachea is obstructed by a quantity of blood, it may be sucked out, or drawn up by an exhausting pump, and it may be advisable in some cases to introduce a tube. If the trachea be cut across, a stitch will be necessary to keep the ends in contact. The _second_ is, to keep the divided parts in contact afterward, by position and bandage, but not _by suture_. If the œsophagus be wounded, nourishment should be administered by a gum-elastic tube introduced through the nares into the stomach. It is almost unnecessary to add that the artery, if wounded, should be secured by ligature. A hole in the internal jugular vein may be closed by a thread passed around it when raised by a tenaculum.

Captain Hall, of the 43d Regiment, was wounded by a ball which passed between the upper part of the back of the larynx and the termination of the pharynx, without causing much further inconvenience than the loss of voice. In this instance it must have been the superior laryngeal nerve that was injured, and not the recurrent, yet the voice could only be heard in a whisper, and was not completely recovered for years. If a ball should lodge in the trachea, it must be removed by the operation of laryngotomy or tracheotomy, if the original wound cannot be enlarged; although Birch, says Christopher Wren, hung up a man wounded in this way by the heels, when the ball dropped out through the glottis and mouth. General Sir E. Packenham, who was killed at New Orleans by a ball which went through the common iliac artery, had been twice shot through the neck in earlier life. The first shot, which went through high up from right to left, turned his head a little to the right. The second shot, from left to right, brought it straight. My kind and excellent friend had ever afterward a great respect and regard for the doctors and a strong feeling for the wounded. The recollection of that regard, and the advantages derived from it, have made me sometimes think it might be advantageous for the unfortunate as well as for the doctors if every general could be at least shot once through the neck or the body, before he was raised to the command of an army in the field; for there is nothing like actual experience of suffering to make men feel for their fellow-creatures in distress. A Minister at War would not perhaps be the worse for a little personal experience in this matter.

365. _Wounds of the face_ made by swords or sharp-cutting instruments should be always retained in contact by sutures. When the cut is of small extent, and not deep, the skin only should be included by the thread, and that in the slightest possible manner, and the part supported by adhesive plaster and bandage. When the cheek is divided into the mouth, one, two, or more sutures may require to be inserted more deeply, but the deformity of a broad cicatrix will in general be avoided, by carefully sewing up the whole line, taking the very edge of skin only; and a cut in the bone or bones of the cheek should not prevent the attempt being made to unite the external wound over it.

Incised or even lacerated wounds of the eyelids and brows should be united by suture, as far as can possibly be done in the first instance, by which a subsequent painful operation may be avoided; great care should be taken in doing this; the suture must be inserted through the eyelid, and a leaden thread is often the best, the first being introduced at the very edge of the lid, and two, or as many more afterward as may be necessary. They may remain for three or more days, as circumstances seem to require. If the eye be wounded, any part protruding beyond the sclerotic coat should be cut off with scissors; but the eye, however injured, should not be removed unless the ball be detached in every direction, or destroyed. The treatment should be strictly antiphlogistic, in order to prevent suppuration of the eyeball, which may in general be effected, if too much injury have not been done to it, and if the treatment be sufficiently decided and well continued. These observations apply to the nose and ears, and all parts not actually separated--or, if separated, for a short time only--should be replaced in the manner directed, and every attempt made to procure reunion. If this should fail, surgery may yet be able to yield assistance by replacing the loss by a piece of integument dislodged from the neighboring parts--a proceeding requiring a separate consideration. Injuries from musket-balls are often attended by considerable laceration, particularly when near the eyelids. Whenever this occurs, the parts likely to adhere should be brought together by suture, after any splinters of bone which may present themselves, or can be seen or felt, have been removed from the holes made by the ball. If the bones should be broken, and not splintered, they will frequently reunite under proper management.

366. _Wounds of the eye_ from small shot are remediable when these small bodies lodge in the cornea or sclerotica, whence they may be removed by any sharp-pointed instrument. When a shot or piece of a copper cap is driven through the cornea, into the iris, or lies in the anterior chamber, it should be removed by an incision to the extent of about one-fourth or one-fifth of the cornea, near its junction with the sclerotica, but in these cases a cataract, if not amaurosis, frequently results. When the shot passes through all the coats of the eye, it can neither be seen nor removed with safety; vision will be lost, much pain may be endured, and the eye will frequently be destroyed by suppuration, or by a gradual softening, and ultimate diminution in size. A contused wound from a large shot which only injures the coats of the eye, but does not perforate them, will oftentimes be cured by a proper antiphlogistic treatment, which in all cases should be most strictly enforced, although loss of sight is a frequent consequence after such injuries.

When a ball lodges behind the eye, it usually causes protrusion, inflammation, and suppuration of that organ. If it be not discovered by the usual means, its lodgment may be suspected from the gradual protrusion and inflammation of the eye itself. If it be discovered, it should be removed together with the eye, if such proceeding be necessary for its exposure. If suppuration have commenced in the eye, a deep incision into the organ will arrest, if not prevent, the horrible sufferings about to take place, and allow of the removal of the offending cause. If the eye remain in a state of chronic disease and suffering, a similar incision will give the desired relief. If the chronic state of irritation affect the other eye, the incision and sinking of the ball of the one first affected or injured is urgently demanded, and should not be delayed. If the back part of the eye be left with the muscles attached to it, a stump remains, against which an artificial eye may be fitted, so as sometimes to render the loss of the natural one almost unobservable.

367. I have several times seen both eyes destroyed and sunk by one ball, with little other inconvenience to the patient; one eye sunk, the other amaurotic, and both even amaurotic, almost without a sign of injury, by balls which had passed from side to side through both orbits, but behind the eyes. When the eye becomes amaurotic from a lesion of the first branch of the fifth pair of nerves, the pupil does not become dilated; the iris retains its usual action, although the retina may be insensible and vision destroyed. This was well shown in the case of the late Major-General Sir A. Leith, who was wounded by a sword in the forehead, this nerve being divided. It has so often occurred as to leave no doubt of the fact, and of the error formerly existing on this point.

368. Penetrating wounds implicating the bones of the face are always distressing. When the bones of the nose are carried away, there must always be some deformity remaining, although there is oftentimes but little suffering. When these bones are merely splintered and depressed, great pains should be taken to keep them properly elevated. If the duct of the parotid gland be implicated by an incised wound, care should be taken to divide the cheek into the mouth, if it should not have been already done, and to keep the incised wound open until the external one is closed. If a salivary fistula have formed externally, from inattention or otherwise, it must be treated according to the ordinary methods adopted in such cases. When a wound of the gland itself becomes fistulous, and weeps, which is a rare occurrence, it will be best treated by actual or potential cauterization, if moderate pressure should fail. When these wounds are of some extent, they are often followed by partial paralysis, in consequence of the seventh pair of nerves being injured, when the mouth is drawn somewhat to the other side. When the lachrymal bones or sac are injured by balls or swords, the tears usually continue through life to run over, and give inconvenience, although much good may be done by early attention to the injuries of this part. Wounds injuring the upper jaw are oftentimes followed by much suffering, and by permanent inconvenience.

General Sir Colin Halkett, G.C.B., was wounded on the 18th of June, at Waterloo, when in front of his brigade, which was formed in squares for the reception of the French cavalry, by a pistol-ball, fired by the officer commanding them, which struck him in the neck, and gave him great pain, but without doing much mischief. A second shot shortly afterward wounded him in the thigh, and he was obliged to leave the field toward the close of the day, by a third musket-ball, which struck him on the face, when standing sideways toward the enemy. It entered a little below the outer part of the cheek-bone on the left side, and, taking an oblique direction downward and forward, shattered and destroyed in its course several of the double teeth in the upper jaw, fracturing the palate from its posterior part, forward to the front teeth. The ball then took a direction obliquely upward, destroying the teeth of the opposite side of the upper jaw, which bone it also broke, and lodged under the fleshy part of the cheek. These wounds gave great pain, and until the ball was removed, the left ear was totally insensible to sound and all external impressions, although the general suffered much from distressing noises in his ear. These subsided on the removal of the ball some days afterward.

The treatment of this wound, however, was most painful; the extraction of several pieces of bone was necessary at different times, during the three following years, before the wounds were finally closed. Considerable derangement of health followed, the deafness remains; and the general has ever since been subjected to attacks in the head of an increasing and most distressing nature.

369. Wounds of the lower jaw are perhaps more common, and are certainly more troublesome than those of the upper; they are more difficult of management, and, for the most part, end in greater deformity, unless particular care be taken to prevent it, and then only in very severe cases, by operations which were formerly not in use, but which the intrepidity of the surgeons of the present day have deprived of all their terrors. I mean the methodical division of the soft parts, the sawing off and removal of the broken pieces of bone, and the rounding off of those parts of the jaw which may remain irregular and pointed. M. Baudens has given two good examples of the success of this proceeding during his campaigns in Algeria. In the first case, the ball entered at the middle of the left cheek, and came out by the side of the spinous process of the seventh cervical vertebra. The ascending ramus of the lower jaw was broken into numerous splinters. M. Baudens divided the soft parts down to the bone, entering the straight bistoury four lines, or the third of an inch, below the articulation of the jaw with the temporal bone. He then carried it downward, and a little obliquely forward, so as to terminate it in the fibers of the masseter muscle, about half an inch below the base of the bone. This incision was begun below the seventh pair of nerves, and exposed the parotid gland divided vertically at its middle part. The splinters were removed, a part of the pterygoideus internus muscle was divided, and a projecting point of bone attached to it sawn off. He then separated the attachments of the buccinator, temporal, and pterygoideus externus muscles, divided the ligaments, and removed the coronoid and articulating processes, taking care to avoid the fifth and seventh pairs of nerves. The bleeding from two arteries was suppressed by twisting their ends; and the parts were afterward brought together by sutures, which remained for eight days. A month after the operation the patient ate solid food, and in six weeks was cured. In the second case, the ball entered near the left commissure of the lip, and came out behind on the side of the middle of the neck; three inches of the jaw were splintered, the ends of the bone being sharp and angular. In order to remove the splinters, and to prevent the evils anticipated, M. Baudens divided the lip from the angle downward and outward, below the base of the bone, as far back as the edge of the masseter muscle. He then separated the flaps, and sawed the jaw across, first near the symphysis, and then behind, outside the attachment of the masseter. The facial artery was twisted, four sutures were inserted, and the jaw duly supported. The patient was bled twice, and in six weeks was cured; at the end of that time he could eat solid food. After the healing of such wounds, mechanical means are often necessary to enable the sufferer to eat and to live without causing disgust to his neighbors and his friends.

It is said there are fifteen men in the Hôtel des Invalides, in Paris, wearing silver masks on the lower part of their faces, in consequence of injuries of this kind.

Colonel Carleton was an instance of a ball fracturing the jaw directly through its body, near where the masseter muscle is attached on both sides; the jaw was broken into three pieces, besides splinters; several teeth were knocked out, and the tongue very much hurt. By sawing off the splinters both from within and without, and by cleansing and supporting the parts with great care, he recovered after a length of time, the deformity after such a wound being much less than might be expected.

370. Incised wounds of the tongue do sometimes give rise to hemorrhage somewhat difficult to restrain, particularly if it occur a few days after the receipt of the injury, when the tongue is swollen and painful. It does not so frequently occur after gunshot wounds. As the vessels of one side do not communicate with those of the other, any bleeding which continues after the artery of one side has been properly secured, can only take place from a wound of the artery of the other, which must then also be tied. This should be done by drawing the tongue as far as possible out of the mouth by a flat pair of forceps, which may be easily effected at an early period, when it is not tender and painful. At a later date, and under difficult circumstances, various styptics, such as the mineral acids, nitrate of silver, etc., will be useful. The actual cautery has been recommended, but I have never seen it used in such cases.

371. One of the most curious instances of the lodgment of a foreign body in the face occurred in the person of Captain Fritz, at Ceylon; his gun burst in his hand, and drove the iron breech into the forehead, whence it descended into the nares, and, at the end of a year, part of it made its appearance in the mouth, through the palate. He died eight years afterward, having suffered much inconvenience from the offensive discharge it occasioned. When the iron was removed, it had obviously injured no part of any material importance to life. I have seen balls descend in this way into the throat and soft palate, and have removed them from both places with success, and from the hard palate with equal surprise and advantage to the patient. I have known a ball lodge in the superior maxillary sinus for months, and even for years, before it was removed, or the death of the patient proved the fact.

LECTURE XXVII.

STRUCTURE OF AN INTESTINE, ETC.