CHAPTER XII.

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.

Among the older writers we frequently read of hairs, worms, and snakes

being found in the cavities of the heart. The Ephemerides, Zacutus

Lusitanus, Pare, Swinger, Riverius, and Senac are among the authorities

who mention this circumstance. The deception was possibly due to the

presence of loose and shaggy membrane attached to the endocardial

lining of the heart, or in some cases to echinococci or trichine. A

strange case of foreign body in the heart was reported some time since

in England. The patient had swallowed a thorn of the Prunus spinosa

(Linn.), which had penetrated the esophagus and the pericardium and

entered the heart. A postmortem examination one year afterward

confirmed this, as a contracted cicatrix was plainly visible on the

posterior surface of the heart about an inch above the apex, through

which the thorn had penetrated the right ventricle and lodged in the

tricuspid valve. The supposition was that the thorn had been swallowed

while eating radishes. Buck mentions a case of hydatid cysts in the

wall of the left ventricle, with rupture of the cysts and sudden death.

It is surprising the extent of injury to the pericardium Nature will

tolerate. In his "Comment on the Aphorisms of Hippocrates," Cardanus

says that he witnessed the excision of a portion of the pericardium

with the subsequent cure of the patient. According to Galen, Marulus,

the son of Mimographus, recovered after a similar operation. Galen also

adds, that upon one occasion he removed a portion of carious sternum

and found the pericardium in a putrid state, leaving a portion of the

heart naked. It is said that in the presence of Leucatel and several

theologians, Francois Botta opened the body of a man who died after an

extended illness and found the pericardium putrefied and a great

portion of the heart destroyed, but the remaining portion still

slightly palpitating. In this connection Young mentions a patient of

sixty-five who in January, 1860, injured his right thumb and lost the

last joint by swelling and necrosis. Chloroform was administered to

excise a portion of the necrosed bone and death ensued. Postmortem

examination revealed gangrene of the heart and a remarkable tendency to

gangrene elsewhere (omentum, small intestines, skin, etc.). Recently,

Dalton records a remarkable case of stab-wound of the pericardium with

division of the intercostal artery, upon which he operated. An incision

eight inches long was made over the 4th rib, six inches of the rib were

resected, the bleeding intercostal artery was ligated, the blood was

turned out of the pericardial cavity, this cavity being irrigated with

hot water. The wound in the pericardium, which was two inches long,

was sutured and the external wound was closed. Recovery followed.

Harris gives an instance of a man who was injured by a bar of iron

falling on his shoulder, producing a compound fracture of the ribs as

low as the 7th, and laying the heart and lungs bare without seriously

injuring the pericardium.

Rupture of the heart from contusion of the chest is not always

instantly fatal. According to Ashhurst, Gamgee has collected 28 cases

of rupture of this viscus, including one observed by himself. In nine

of these cases there was no fracture, and either no bruise of the

parietes or a very slight one. The pericardium was intact in at least

half of the cases, and in 22 in which the precise seat of lesion was

noticed the right ventricle was ruptured in eight, the left in three,

the left auricle in seven, the right in four. The longest period during

which any patient survived the injury was fourteen hours.

Among the older writers who note this traumatic injury are Fine, who

mentions concussion rupturing the right ventricle, and Ludwig, who

reports a similar accident. Johnson mentions rupture of the left

ventricle in a paroxysm of epilepsy. There is another species of

rupture of the heart which is not traumatic, in which the rupture

occurs spontaneously, the predisposing cause being fatty degeneration,

dilatation, or some other pathologic process in the cardiac substance.

It is quite possible that the older instances of what was known as

"broken-heart," which is still a by-word, were really cases in which

violent emotion had produced rupture of a degenerated cardiac wall.

Wright gives a case of spontaneous rupture of the heart in which death

did not occur for forty-eight hours. Barth has collected 24 cases of

spontaneous rupture of the heart, and in every instance the seat of

lesion was in the left ventricle. It was noticed that in some of these

cases the rupture did not take place all at once, but by repeated minor

lacerations, death not ensuing in some instances for from two to eleven

days after the first manifestation of serious symptoms. A more recent

analysis is given by Meyer of cases reported since 1870: Meyer collects

25 cases of rupture of the left ventricle seven of the right ventricle,

and four of the right auricle. Within the last year Collings has

reported a case of idiopathic rupture of the heart in a man of

fifty-three, who had always lived a temperate life, and whose only

trouble had been dyspepsia and a weak heart. There was no history of

rheumatism or rheumatic fever. The man's father had died suddenly of

heart disease. After feeling out of sorts for a time, the man

experienced severe pain in the precordium and felt too ill to leave his

bed. He gradually became worse and sick after taking food. Speech

became thick, the mouth was drawn to the right, and the right eye was

partially closed. The left arm became paralyzed, then the right leg.

The tongue deviated to the right on protrusion. The sphincters were

unaffected. The heart sounds were faint and without added sounds. The

man was moved to a water-bed, his body and head being kept horizontal,

and great care being taken to avoid sudden movement. Later, when his

pelvis was raised to allow the introduction of a bed-pan, almost

instantaneous death ensued. Upon postmortem examination prolonged and

careful search failed to reveal any microscopic change in the brain,

its vessels, or the meninges. On opening the pericardium it was found

to be filled with blood-clot, and on washing this away a laceration

about 1 1/2 inches in length was found in the left ventricle; the

aperture was closed by a recent clot. The cavities of the heart were

dilated, the walls thin and in advanced stage of fatty degeneration.

There was no valvular disease. The aorta and its main branches were

atheromatous. Both lungs contained calcifying tubercle; the abdomen was

loaded with fat; the spleen was soft; the kidneys were engorged, but

otherwise healthy.

Stokes gives the case of a man who was severely crushed between the

arms of a water-wheel of great size and the embankment on which the

axle of the wheel was supported; a peculiar factor of the injury being

that his heart was displaced from left to right. At the time of

report, after recovery from the injury, the patient exhibited

remarkable tolerance of great doses of digitalis. When not taking

digitalis, his pulse was 100 to 120, regular, and never intermittent.

Hypertrophy of the Heart.--The heart of a man of ordinary size weighs

nine ounces, and that of a woman eight; in cases of hypertrophy, these

weights may be doubled, although weights above 25 ounces are rare.

According to Osler, Beverly Robinson describes a heart weighing 53

ounces, and Dulles has reported one weighing 48 ounces. Among other

modern records are the following: Fifty and one-half ounces, 57 ounces,

and one weighing four pounds and six ounces. The Ephemerides contains

an incredible account of a heart that weighed 14 pounds. Favell

describes a heart that only weighed 3 1/2 ounces.

Wounds of the aorta are almost invariably fatal, although cases are

recorded by Pelletan, Heil, Legouest, and others, in which patients

survived such wounds for from two months to several years. Green

mentions a case of stab-wound in the suprasternal fossa. The patient

died one month after of another cause, and at the postmortem

examination the aorta was shown to have been opened; the wound in its

walls was covered with a spheric, indurated coagulum. No attempt at

union had been made.

Zillner observed a penetrating wound of the aorta after which the

patient lived sixteen days, finally dying of pericarditis. Zillner

attributed this circumstance to the small size of the wound, atheroma

and degeneration of the aorta and slight retraction of the inner coat,

together with a possible plugging of the pericardial opening. In 1880

Chiari said that while dissecting the body of a man who died of

phthisis, he found a false aneurysm of the ascending aorta with a

transverse rupture of the vessel by the side of it, which had

completely cicatrized. Hill reports the case of a soldier who was

stabbed with a bowie-knife nine inches long and three inches wide. The

blade passed through the diaphragm, cut off a portion of the liver, and

severed the descending aorta at a point about the 7th dorsal vertebra;

the soldier lived over three hours after complete division of this

important vessel. Heil reports the case of a man of thirty-two, a

soldier in the Bavarian army, who, in a quarrel in 1812, received a

stab in the right side. The instrument used was a common table-knife,

which was passed between the 5th and 6th ribs, entering the left lung,

and causing copious hemorrhage. The patient recovered in four months,

but suffered from amaurosis which had commenced at the time of the

stab. Some months afterward he contracted pneumonia and was readmitted

to the hospital, dying in 1813. At the postmortem the cicatrix in the

chest was plainly visible, and in the ascending aorta there was seen a

wound, directly in the track of the knife, which was of irregular

border and was occupied by a firm coagulum of blood. The vessel had

been completely penetrated, as, by laying it open, an internal cicatrix

was found corresponding to the other. Fatal hemorrhage had been avoided

in this case by the formation of coagulum in the wound during the

syncope immediately following the stab, possibly aided by extended

exposure to cold.

Sundry Cases.--Sandifort mentions a curious case of coalescence of the

esophagus and aorta, with ulceration and consequent rupture of the

aorta, the hemorrhage proceeding from the stomach at the moment of

rupture.

Heath had a case of injury to the external iliac artery from external

violence, with subsequent obliteration of the vessel. When the patient

was discharged no pulse could be found in the leg.

Dismukes reports a case in which the patient had received 13 wounds,

completely severing the subclavian artery, and, without any medical or

surgical aid, survived the injury two hours.

Illustrative of the degree of hemorrhage which may follow an injury so

slight as that of falling on a needle we cite an instance, reported by

a French authority, of a child who picked up a needle, and, while

running with it to its mother, stumbled and fell, the needle

penetrating the 4th intercostal space, the broadened end of it

remaining outside of the wound. The mother seized the needle between

her teeth and withdrew it, but the child died, before medical aid could

be summoned, from internal hemorrhage, causing pulmonary pressure and

dyspnea.

Rupture of the esophagus is attributable to many causes. Dryden

mentions vomiting as a cause, and Guersant reports the case of a little

girl of seven, who, during an attack of fever, ruptured her esophagus

by vomiting. In 1837 Heyfelder reported the case of a drunkard, who, in

a convulsion, ruptured his esophagus and died. Williams mentions a case

in which not only the gullet, but also the diaphragm, was ruptured in

vomiting. In this country, Bailey and Fitz have recorded cases of

rupture of the esophagus. Brewer relates a parallel instance of

rupture from vomiting. All the foregoing cases were linear ruptures,

but there is a unique case given by Boerhaave in 1724, in which the

rent was transverse. Ziemssen and Mackenzie have both translated from

the Latin the report of this case which is briefly as follows: The

patient, Baron de Wassenaer, was fifty years of age, and, with the

exception that he had a sense of fulness after taking moderate meals,

he was in perfect health. To relieve this disagreeable feeling he was

in the habit of taking a copious draught of an infusion of "blessed

thistle" and ipecacuanha. One day, about 10.30 in the evening, when he

had taken no supper, but had eaten a rather hearty dinner, he was

bothered by a peculiar sensation in his stomach, and to relieve this he

swallowed about three tumbler-fuls of his usual infusion, but to no

avail. He then tried to excite vomiting by tickling the fauces, when,

in retching, he suddenly felt a violent pain; he diagnosed his own case

by saying that it was "the bursting of something near the pit of the

stomach." He became prostrated and died in eighteen and one-half hours;

at the necropsy it was seen that without any previously existing signs

of disease the esophagus had been completely rent across in a

transverse direction.

Schmidtmuller mentions separation of the esophagus from the stomach;

and Flint reports the history of a boy of seven who died after being

treated for worms and cerebral symptoms. After death the contents of

the stomach were found in the abdominal cavity, and the esophagus was

completely separated from the stomach. Flint believed the separation

was postmortem, and was possibly due to the softening of the stomach by

the action of the gastric acids. In this connection may be mentioned

the case reported by Hanford of a man of twenty-three who had an attack

of hematemesis and melanema two years before death. A postmortem was

made five hours after death, and there was so much destruction of the

stomach by a process resembling digestion that only the pyloric and

cardiac orifices were visible. Hanford suggests that this was an

instance of antemortem digestion of the stomach which physiologists

claim is impossible.

Nearly all cases of rupture of the stomach are due to carcinoma, ulcer,

or some similar condition, although there have been instances of

rupture from pressure and distention. Wunschheim reports the case of a

man of fifty-two who for six months presented symptoms of gastric

derangement, and who finally sustained spontaneous rupture of the

posterior border of the stomach due to overdistention. There was a tear

two inches long, beginning near the cardiac end and running parallel to

the lesser curvature. The margin of the tear showed no evidence of

digestion. There were obstructing esophageal neoplasms about 10 1/3

inches from the teeth, which prevented vomiting. In reviewing the

literature Wunschheim found only six cases of spontaneous rupture of

the stomach. Arton reports the case of a negro of fifty who suffered

from tympanites. He was a hard drinker and had been aspirated several

times, gas heavily laden with odors of the milk of asafetida being

discharged with a violent rush. The man finally died of his malady, and

at postmortem it was found that his stomach had burst, showing a slit

four inches long. The gall bladder contained two quarts of inspissated

bile. Fulton mentions a case of rupture of the esophageal end of a

stomach in a child. The colon was enormously distended and the walls

thickened. When three months old it was necessary to puncture the bowel

for distention. Collins describes spontaneous rupture of the stomach in

a woman of seventy-four, the subject of lateral curvature of the spine,

who had frequent attacks of indigestion and tympanites. On the day of

death there was considerable distention, and a gentle purgative and

antispasmodic were given. Just before death a sudden explosive sound

was heard, followed by collapse. A necropsy showed a rupture two inches

long and two inches from the pyloric end. Lallemand mentions an

instance of the rupture of the coats of the stomach by the act of

vomiting. The patient was a woman who had suffered with indigestion

five or six months, but had been relieved by strict regimen. After

indulging her appetite to a greater extent than usual, she experienced

nausea, and made violent and ineffectual efforts to discharge the

contents of the stomach. While suffering great agony she experienced a

sensation as if something was tearing in the lower part of her belly.

The woman uttered several screams, fell unconscious, and died that

night. Postmortem examination showed that the anterior and middle part

of the stomach were torn obliquely to the extent of five inches. The

tear extended from the smaller toward the greater curvature. The edges

were thin and irregular and presented no marks of disease. The cavity

of the peritoneum was full of half-digested food. The records of St.

Bartholomew's Hospital, London, contain the account of a man of

thirty-four who for two years had been the subject of paroxysmal pain

in the stomach. The pains usually continued for several hours and

subsided with vomiting. At St. Bartholomew's he had an attack of

vomiting after a debauch. On the following day he was seized with

vomiting accompanied by nausea and flatus, and after a sudden attack of

pain at the pit of the stomach which continued for two hours, he died.

A ragged opening at the esophageal orifice, on the anterior surface of

the stomach was found. This tear extended from below the lesser

curvature to its extremity, and was four inches long. There were no

signs of gastric carcinoma or ulcer.

Clarke reports the case of a Hindoo of twenty-two, under treatment for

ague, who, without pain or vomiting, suddenly fell into collapse and

died twenty-three hours later. He also mentions a case of rupture of

the stomach of a woman of uncertain history, who was supposed to have

died of cholera. The examination of the bodies of both cases showed

true rupture of the stomach and not mere perforation. In both cases, at

the time of rupture, the stomach was empty, and the gastric juice had

digested off the capsules of the spleens, thus allowing the escape of

blood into the abdominal cavities. The seats of rupture were on the

anterior walls. In the first case the coats of the stomach were

atrophied and thin. In the second the coats were healthy and not even

softened. There was absence of softening, erosion, or rupture on the

posterior walls.

As illustrative of the amount of paralytic distention that is possible,

Bamberger mentions a case in which 70 pounds of fluid filled the

stomach.

Voluntary Vomiting.--It is an interesting fact that some persons

exhibit the power of contracting the stomach at will and expelling its

contents without nausea. Montegre mentions a distinguished member of

the Faculty of Paris, who, by his own volition and without nausea or

any violent efforts, could vomit the contents of his stomach. In his

translation of "Spallanzani's Experiments on Digestion" Sennebier

reports a similar instance in Geneva, in which the vomiting was brought

about by swallowing air.

In discussing wounds and other injuries of the stomach no chapter would

be complete without a description of the celebrated case of Alexis St.

Martin, whose accident has been the means of contributing so much to

the knowledge of the physiology of digestion. This man was a French

Canadian of good constitution, robust and healthy, and was employed as

a voyageur by the American Fur Company. On June 16, 1822, when about

eighteen years of age, he was accidentally wounded by a discharge from

a musket. The contents of the weapon, consisting of powder and

duck-shot, entered his left side from a distance of not more than a

yard off. The charge was directed obliquely forward and inward,

literally blowing off the integument and muscles for a space about the

size of a man's hand, carrying away the anterior half of the 6th rib,

fracturing the 5th rib, lacerating the lower portion of the lowest lobe

of the left lung, and perforating the diaphragm and the stomach. The

whole mass of the discharge together with fragments of clothing were

driven into the muscles and cavity of the chest. When first seen by Dr.

Beaumont about a half hour after the accident, a portion of the lung,

as large as a turkey's egg was found protruding through the external

wound. The protruding lung was lacerated and burnt. Immediately below

this was another protrusion, which proved to be a portion of the

stomach, lacerated through all its coats. Through an orifice, large

enough to admit a fore-finger, oozed the remnants of the food he had

taken for breakfast. His injuries were dressed; extensive sloughing

commenced, and the wound became considerably enlarged. Portions of the

lung, cartilages, ribs, and of the ensiform process of the sternum came

away. In a year from the time of the accident, the wound, with the

exception of a fistulous aperture of the stomach and side, had

completely cicatrized. This aperture was about 2 1/2 inches in

circumference, and through it food and drink constantly extruded unless

prevented by a tent-compress and bandage. The man had so far recovered

as to be able to walk and do light work, his digestion and appetite

being normal. Some months later a small fold or doubling of the

stomachal coats slightly protruded until the whole aperture was filled,

so as to supersede the necessity of a compress, the protruding coats

acting as a valve when the stomach was filled. This valvular protrusion

was easily depressed by the finger. St. Martin suffered little pain

except from the depression of the skin. He took his food and drink like

any healthy person, and for eleven years remained under Dr. Beaumont's

own care in the Doctor's house as a servant. During this time were

performed the experiments on digestion which are so well known. St.

Martin was at all times willing to lend himself in the interest of

physiologic science. In August, 1879, The Detroit Lancet contains

advices that St. Martin was living at that time at St. Thomas, Joliette

County, Province of Quebec, Canada. At the age of seventy-nine he was

comparatively strong and well, and had always been a hard worker. At

this time the opening in the stomach was nearly an inch in diameter,

and in spite of its persistence his digestion had never failed him.

Spizharny relates a remarkable case of gastric fistula in the loin, and

collects 61 cases of gastric fistula, none of which opened in the loin.

The patient was a girl of eighteen, who had previously had

perityphlitis, followed by abscesses about the navel and lumbar region.

Two fistulae were found in the right loin, and were laid open into one

canal, which, after partial resection of the 12th rib, was dilated and

traced inward and upward, and found to be in connection with the

stomach. Food was frequently found on the dressings, but with the

careful use of tampons a cure was effected.

In the olden times wounds of the stomach were not always fatal. The

celebrated anatomist, Fallopius, successfully treated two cases in

which the stomach was penetrated so that food passed through the wound.

Jacobus Orthaeus tells us that in the city of Fuldana there was a

soldier who received a wound of the stomach, through which food passed

immediately after being swallowed; he adds that two judicious surgeons

stitched the edges of the wound to the integuments, thereby effecting a

cure. There is another old record of a gastric fistula through which

some aliment passed during the period of eleven years.

Archer tells of a man who was stabbed by a negro, the knife entering

the cartilages of the 4th rib on the right side, and penetrating the

stomach to the extent of two inches at a point about two inches below

the xiphoid cartilage. The stomachal contents, consisting of bacon,

cabbage, and cider, were evacuated. Shortly after the reception of the

injury, an old soldier sewed up the wound with an awl, needle, and

wax-thread; Archer did not see the patient until forty-eight hours

afterward, at which time he cleansed and dressed the wound. After a

somewhat protracted illness the patient recovered, notwithstanding the

extent of injury and the primitive mode of treatment.

Travers mentions the case of a woman of fifty-three who, with suicidal

intent, divided her abdominal parietes below the navel with a razor,

wounding the stomach in two places. Through the wound protruded the

greater part of the larger curvature of the stomach; the arch of the

colon and the entire greater omentum were both strangulated. A small

portion of the coats of the stomach, including the wound, was nipped

up, a silk ligature tied about it, and the entrails replaced. Two

months afterward the patient had quite recovered, though the ligature

of the stomach had not been seen in the stool. Clements mentions a

robust German of twenty-two who was stabbed in the abdomen with a dirk,

producing an incised wound of the stomach. The patient recovered and

was returned to duty the following month.

There are many cases on record in which injury of the stomach has been

due to some mistake or accident in the juggling process of

knife-swallowing or sword-swallowing. The records of injuries of this

nature extend back many hundred years, and even in the earlier days the

delicate operation of gastrotomy, sometimes with a successful issue,

was performed upon persons who had swallowed knives. Gross mentions

that in 1502 Florian Mathias of Bradenberg removed a knife nine inches

long from the stomach of a man of thirty-six, followed by a successful

recovery. Glandorp, from whom, possibly, Gross derived his information,

relates this memorable case as being under the direction of Florianus

Matthaesius of Bradenburg. The patient, a native of Prague, had

swallowed a knife eight or nine inches long, which lay pointing at the

superior portion of the stomach. After it had been lodged in this

position for seven weeks and two days gastrotomy was performed, and the

knife extracted; the patient recovered. In 1613 Crollius reports the

case of a Bohemian peasant who had concealed a knife in his mouth,

thinking no one would suspect he possessed the weapon; while he was

excited it slipped into the stomach, from whence it subsequently

penetrated through to the skin; the man recovered. There is another old

case of a man at Prague who swallowed a knife which some few weeks

afterward made its exit from an abdominal abscess. Gooch quotes the

case of a man, belonging to the Court of Paris, who, nine months after

swallowing a knife, voided it at the groin. In the sixteenth century

Laurentius Joubert relates a similar case, the knife having remained in

the body two years. De Diemerbroeck mentions the fact that a knife ten

inches long was extracted by gastrotomy, and placed among the rarities

in the anatomic chamber of the University at Leyden. The operation was

done in 1635 at Koenigsberg, by Schwaben, who for his surgical prowess

was appointed surgeon to the King of Poland. The patient lived eight

years after the operation.

It is said that in 1691, while playing tricks with a knife 6 1/2 inches

long, a country lad of Saxony swallowed it, point first. He came under

the care of Weserern, physician to the Elector of Brandenburgh, who

successfully extracted it, two years and seven months afterward, from

the pit of the lad's stomach. The horn haft of the knife was

considerably digested. In 1720 Hubner of Rastembourg operated on a

woman who had swallowed an open knife. After the incision it was found

that the knife had almost pierced the stomach and had excited a slight

suppuration. After the operation recovery was very prompt.

Bell of Davenport, Iowa, performed gastrotomy on a man, who, while

attempting a feat of legerdemain, allowed a bar of lead, 10 1/8 inches

long, 1 1/2 inches wide, and 9 1/2 ounces in weight, to slip into his

stomach. The bar was removed and the patient recovered. Gussenbauer

gives an account of a juggler who turned his head to bow an

acknowledgment of applause while swallowing a sword; he thus brought

his upper incisors against the sword, which broke off and slipped into

his stomach. To relieve suffocation the sword was pushed further down.

Gastrotomy was performed, and the piece of sword 11 inches long was

extracted; as there was perforation of the stomach before the

operation, the patient died of peritonitis.

An hour after ingestion, Bernays of St. Louis successfully removed a

knife 9 1/2 inches long. By means of an army-bullet forceps the knife

was extracted easily through an incision 5/8 inch long in the walls of

the stomach. Gross speaks of a man of thirty who was in the habit of

giving exhibitions of sword-swallowing in public houses, and who

injured his esophagus to such an extent as to cause abscess and death.

In the Journal of the American Medical Association, March 1, 1896,

there is an extensive list of gastrotomies performed for the removal of

knives and other foreign bodies, from the seventeenth century to the

present time.

The physiologic explanation of sword-swallowing is quite interesting.

We know that when we introduce the finger, a spoon, brush, etc., into

the throat of a patient, we cause extremely disagreeable symptoms.

There is nausea, gagging, and considerable hindrance with the function

of respiration. It therefore seems remarkable that there are people

whose physiologic construction is such that, without apparent

difficulty, they are enabled to swallow a sword many inches long. Many

of the exhibitionists allow the visitors to touch the stomach and

outline the point of the sabre through the skin. The sabre used is

usually very blunt and of rounded edges, or if sharp, a guiding tube of

thin metal is previously swallowed. The explanation of these

exhibitions is as follows: The instrument enters the mouth and pharynx,

then the esophagus, traverses the cardiac end of the stomach, and

enters the latter as far as the antrum of the pylorus, the small

culdesac of the stomach. In their normal state in the adult these

organs are not in a straight line, but are so placed by the passage of

the sword. In the first place the head is thrown back, so that the

mouth is in the direction of the esophagus, the curves of which

disappear or become less as the sword proceeds; the angle that the

esophagus makes with the stomach is obliterated, and finally the

stomach is distended in the vertical diameter and its internal curve

disappears, thus permitting the blade to traverse the greater diameter

of the stomach. According to Guyot-Daubes, these organs, in a straight

line, extend a distance of from 55 to 62 cm., and consequently the

performer is enabled to swallow an instrument of this length. The

length is divided as follows:--

Mouth and pharynx, . . . . . . . . . . . . 10 to 12 cm.

Esophagus, . . . . . . . . . . . . . . . . 25 to 28 cm.

Distended stomach, . . . . . . . . . . . . 20 to 22 cm.

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55 to 62 cm.