SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 2 page

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feather was withdrawn the bean followed.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

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