350. _Hernia of the lung_, as a consequence of a wound in the chest
which has healed, is a complaint of rare occurrence. It appears to take
place when the intercostal muscles have been much injured and are
deficient, the opening through them being merely covered by the common
integuments which have yielded to the pressure exerted from within. It
has been supposed that it might be mistaken for the thinning of parts
from the formation of matter within, or empyema. The early occurrence
of the abscess after the receipt of the injury forbids the supposition,
while the ear, applied to the protruded part which is most prominent
during EXPIRATION or coughing, perceives not only a crepitation, felt
equally by the touch, but the natural respiratory murmur stronger,
softer, but less vailed and more like the sound given out by a
pulmonary lobule inflated close to the ear, but without enlargement of
the part.
A portion of lung will sometimes protrude during the efforts made by
the sufferer to breathe, particularly in expiration, when the wound
is left open and the lung is sufficiently free to admit of it. When
protruded, it sometimes happens that the efforts of nature are not
sufficient for its retraction, and it remains filling up the opening
into the thorax. A large portion of lung is rarely protruded, except
through an opening which readily admits of its return; but when the
wound is small, the return of a portion of protruded lung, when it
is not positively strangulated, should not be interfered with. The
surface of the lung is but little sensible; touching it causes no
apparent pain, and its adhesion to the edges of the cut pleura is
more advantageous than its separation from it. It should, therefore,
be allowed to remain or be only so far returned, if it can be so
managed, as to rest within the edges of the divided pleura and fill
up the gap made by the incision, over which the integuments should be
accurately drawn and retained. The adhesion of the lung to the pleura
costalis arrests the inflammation, and may prevent its progress to
other parts of the cavity. That the inflammation may extend farther
into the substance of the lung, is possible, but when the sufferers
are otherwise healthy, the chance of evil from pneumonia is less than
from inflammation of the general cavity. Whenever the protruded lung
has been completely returned, more inflammation has followed than where
it has been allowed to remain under the precautions recommended. Three
cases were brought under my notice at Brussels, after the battle of
Waterloo, which were not interfered with, greatly to the advantage of
the patients. It is rare, however, to see a protrusion of the lung
after a gunshot wound.
The protruded lung, when left uncovered and unprotected, soon loses its
natural brilliancy, dies quickly, shrinks, and becomes livid, without
being gangrenous. In such cases the protruded part may be removed, but
it should never be separated at its base from its attachment to the
pleura costalis by which it is surrounded.
351. _Wounds of the diaphragm_ were known to the older surgeons
from the time of Paré; they were aware that these wounds were not
immediately, although generally, mortal. They knew that the viscera
of the abdomen did sometimes pass through such wounds into the cavity
of the chest, but they did not know that a wound of the diaphragm
never closes, except under rare and particular circumstances; that it
remains an opening during the rest of the life of the sufferer, ready
at all times to give rise to a hernia which may become strangulated
and destroy the patient, unless relieved by an operation as yet
unperformed, but to which attention is especially directed--a fact
first pointed out by me early in the war in the Peninsula.
A soldier of the 29th Regiment was wounded at the battle of Talavera,
and died in four days after the receipt of the ball, which went through
the chest into the liver. I found, on examining the body, an opening in
the central part of the diaphragm of an oval shape, the edges smoothing
off as if they were inclined to become round; this opening was nearly
two inches long, evidently ready to allow either the stomach or the
intestines to pass through it on any exertion.
Captain Prevost, aid-de-camp to Sir E. Packenham, was wounded by a
musket-ball, on the 27th September, 1811, on the heights of Saca Parte.
It penetrated the chest from behind, splintering the ninth and tenth
ribs of the left side, and made its exit a little below and to the
right of the xiphoid cartilage. A good deal of blood was lost from
the posterior wound, but he did not spit up any. He was carried to
Alfaiates, and there he threw up a small quantity of bloody matter by
vomiting. The posterior wound was enlarged and continued to discharge
some blood, the intercostal artery being in all probability wounded.
Sixteen ounces of blood were taken from the arm, giving great relief,
and the bowels were opened by the sulphate of magnesia.
Sept. 29th.--Bleeding to eighteen ounces; on the 30th he was bled again
to thirty-two ounces, from which great relief was obtained; he fainted,
however, on making a trifling exertion to relieve his bowels.
Oct. 1st.--Accession of symptoms as yesterday, relieved by bleeding in
a similar manner; bowels open.
3d.--The inflammatory symptoms recurred this morning, and were again
removed by the abstraction of sixteen ounces of blood. Beef-tea.
5th.--Passed a sleepless night, and was evidently suffering from
considerable internal mischief; wandered occasionally; pulse quick,
120, and small; felt very weak and desponding. A little light, red wine
given, with beef-tea and bread; opium night and morning.
6th and 7th.--Much the same; pulse always quick, with much general
irritability.
15th.--The wounds discharged considerably, particularly the posterior
one; has a little cough; pulse continues very quick; spasms of the
diaphragm troubled him for the first time, and caused great pain and
uneasiness; they were relieved by opium in large and repeated doses.
On the 18th the spasmodic affection of the diaphragm and the pain
returned with great violence, so as to threaten his dissolution, which
took place on the 20th.
On examination, I found that the ball had passed through the under part
of the inferior lobe of the left lung, and through the pericardium
under the heart, through the tendinous part of the diaphragm, and
into the liver, before it made its exit. The wound in the lung was
suppurating; the matter and fluid from the cavity of the chest had
a free discharge by the shot-hole; the edges of the wound in the
diaphragm were smooth as if cicatrized, leaving between them an
elliptical opening an inch long. The injury to the liver was through
the substance of the anterior part of its right lobe; the matter having
a free discharge, and generally slightly yellow, as if tinged with bile
in small quantity. The skin did not show a yellowish tinge, neither
were the conjunctivæ discolored.
A soldier of the 23d Regiment was wounded at the same affair, by a
musket-ball, on the right side; it fractured the sixth rib, from three
to four inches from the sternum, and passed out behind, between the
ninth and tenth ribs, near the spine. The rib being fractured, the
splinters were removed after an enlargement of the wound by incision,
when the opening into the cavity of the chest was manifest, air being
discharged freely from it. The shock in the first instance was great;
but after a time reaction took place, and he lost a considerable
quantity of blood in six bleedings during the first sixty hours. The
discharge, at first serous and bloody, gradually became purulent, and
the occurrence of jaundice showed that the diaphragm and liver had in
all probability been injured. Under the administration of calomel,
antimony, and opium, this symptom was gradually disappearing, when I
left him to rejoin the army. He was sent to the rear at the end of ten
weeks nearly well.
On the day preceding the battle of Fuentes d’Onor, in 1811, Sergeant
Barry was wounded in the chest. The ball entered close to the nipple
of the left breast, and passed out at the back, between the eighth and
ninth ribs. The anterior opening of the wound soon healed, but the
posterior one did not do so for a considerable period, when he became
affected by such severe cough, with expectoration, that his medical
attendant deemed it proper to reopen it. The symptoms were relieved,
and portions of his shirt and jacket were discharged. After this
his health improved so rapidly as to enable him soon to rejoin his
corps. The wound in the back repeatedly opened and healed--generally
at intervals of twelve or fourteen months; but for five or six years
it ceased to do so. His appetite was small and delicate; flatulence
was much complained of; and if the stomach at any time happened to be
overloaded, vomiting occurred. He died of mortification of the left
leg, January 4th, 1833.
On examination, the whole of the stomach and the greater part of the
transverse arch of the colon were found in the left cavity of the
chest, having passed through an opening in the diaphragm extending
about three inches in a transverse direction, near the center of the
dorsal attachments of that muscle. The peritoneum lining the diaphragm
was firmly attached to the parts passing through it.
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.
[Illustration:
_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.