SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 1 page

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

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