Rachitis or rickets is not a disease of adult life, but of infancy and childhood, and never occurs after the age of p.u.b.erty. It seldom begins before six months or after three years. There are several theories as to its causation, one being that it is due to an abnormal development of acids. There is little doubt that defective nutrition and bad hygienic surroundings are prominent factors in its production. The princ.i.p.al pathologic change is seen in the epiphyseal lines of long bones and beneath the periosteum. Figure 213 shows the appearance during life of a patient with the highest grade of rachitis, and it can be easily understood what a barrier to natural child-birth it would produce. In rachitis epiphyseal swellings are seen at the wrists and ankle-joints, and in superior cases at the ends of the phalanges of the fingers and toes. When the shaft of a long bone is affected, not only deformity, but even fracture may occur. Under these circ.u.mstances the humerus and femur appear to be the bones most likely to break; there is an a.s.sociate deformity of the head, known as "craniotabes," together with pigeon-breast and various spinal curvature. The accompanying ill.u.s.tration is from a drawing of a skeleton in the Warren Museum in Boston. The subject was an Indian, twenty-one years of age, one of the Six Nations. His mode of locomotion was by a large wooden bowl, in which he sat and moved forward by advancing first one side of the bowl and then the other, by means of his hands. The nodules or "advent.i.tious joints" were the result of imperfect ossification, or, in other words, of motion before ossification was completed.

a.n.a.logous to rachitis is achondroplasia, or the so called fetal rickets--a disease in which deformity results from an arrest, absence, or perversion of the normal process of enchondral ossification. It is decidedly an intrauterine affection, and the great majority of fetuses die in utero. Thomson reports three living cases of achondroplasia. The first was a child five months of age, of pale complexion, bright and intelligent, its head measuring 23 inches in length. There was a narrow thorax showing the distinct beads of rickets; the upper and lower limbs were very short, but improved under antirachitic treatment. The child died of pneumonia. The other two cases were in adults, one thirty-nine and the other thirty-six. The men were the same height, 49 inches, and resembled each other in all particulars. They both enjoyed good health, and, though somewhat dwarfed, were of considerable intelligence. Neither had married. Both the upper and; lower limbs showed exaggerations of the normal curves; the hands and feet were broad and short; the gait of both of these little men was waddling, the hunk swaying when they attempted to make any rapid progress.

Osteitis deformans is a hyperplasia of bone described by Paget in 1856.

Paget's patient was a gentleman of forty-six who had always enjoyed good health; without a.s.signable cause he began to be subject to aching pains in the thighs and legs. The bones of the left leg began to increase in size, and a year or two later the left femur; also enlarged considerably. During a period of twenty years these changes were followed by a growth of other bones. The spine became firm and; rigid, the head increased 5 1/4 inches in circ.u.mference. The bones of the face were not affected. When standing, the patient had a peculiar bowed condition of the legs, with marked flexure at the knees. He finally died of osteosarcoma, originating in the left radius, Paget collected eight cases, five of whom died of malignant disease. The postmortem of Paget's case showed extreme thickening in the bones affected, the femur and cranium particularly showing osteoclerosis. Several cases have been recorded in this country; according to Warren, Thieberge a.n.a.lyzed 43 cases; 21 were men, 22 women; the disease appeared usually after forty.

Acromegaly is distinguished from osteitis deformans in that it is limited to hypertrophy of the hands, feet, and face, and it usually begins earlier. In gigantism the so-called "giant growth of bones" is often congenital in character, and is unaccompanied by inflammatory symptoms.

The deformities of the articulations may be congenital but in most cases are acquired. When these are of extreme degree, locomotion is effected in most curious ways. Ankylosis at unnatural angles and even complete reversion of the joints has been noticed. Pare gives a case of reversion, and of crooked hands and feet; and Barlow speaks of a child of two and three-quarter years with kyphosis, but mobility of the lumbar region, which walked on its elbows and knees. The pathology of this deformity is obscure, but there might have been malposition in utero. Wilson presented a similar case before the Clinical Society of London, in 1888. The "Camel-boy," exhibited some years ago throughout the United States, had reversion of the joints, which resembled those of quadrupeds. He walked on all fours, the mode of progression resembling that of a camel.

Figure 216 represents Orloff, "the transparent man," an exhibitionist, showing curious deformity of the long bones and atrophy of the extremities. He derived his name from the remarkable transparency of his deformed members to electric light, due to porosity of the bones and deficiency of the overlying tissues.

Figure 217, taken from Hutchinson's "Archives of Surgery," represents an extreme case of deformity of the knee-joints in a boy of seven, the result of severe osteoarthritis. The knees and elbows were completely ankylosed.

Infantile spinal paralysis is often the cause of distressing deformities, forbidding locomotion in the ordinary manner. In a paper on the surgical and mechanical treatment of such deformities Willard mentions a boy of fourteen, the victim of infantile paralysis, who at the age of eleven had never walked, but dragged his legs along. His legs were greatly twisted, and there was flexion at right angles at the hips and knees. There was equinovarus in the left foot and equinovalgus in the right. By an operation of subcutaneous section at the hips, knees, and feet, with application of plaster-of-Paris and extension, this hopeless cripple walked with crutches in two months, and with an apparatus consisting of elastic straps over the quadriceps femoris, peroneals, and weakened muscles, the valgus-foot being supported beneath the sole. In six months he was walking long distances; in one year he moved speedily on crutches. Willard also mentions another case of a girl of eleven who was totally unable to support the body in the erect position, but could move on all fours, as shown in figure 219.

There was equinovarus in the right foot and valgus in the left. The left hip was greatly distorted, not only in the direction of flexion, but there was also twisting of the femoral neck, simulating dislocation. This patient was also operated on in the same manner as the preceding one.

Relative to anomalous increase or hypertrophy of the bones of the extremities, Fischer shows that an increase in the length of bone may follow slight injuries. He mentions a boy of twelve, who was run over by a wagon and suffered a contusion of the bones of the right leg. In the course of a year this leg became 4 1/2 cm. longer than the other, and the bones were also much thicker than in the other. Fischer also reports several cases of abnormal growth of bone following necrosis. A case of shortening 3 3/4 cm., after a fracture, was reduced to one cm.

by compensatory growth. Elongation of the bone is also mentioned as the result of the inflammation of the joint. Warren also quotes Taylor's case of a lady who fell, injuring, but not fracturing, the thigh.

Gradual enlargement, with an outward curving of the bone, afterward took place.

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 Hilda.n.u.s, Vogel, Rhodius, Pet.i.t, 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 circ.u.mstance 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 quant.i.ty of b.l.o.o.d.y 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 quant.i.ties of b.l.o.o.d.y 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 b.l.o.o.d.y 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 pa.s.sed 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 p.r.o.nounced 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 Hilda.n.u.s 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 succ.u.mbed 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 sh.e.l.l, 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 embarra.s.sment. 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 pa.s.sed 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 pa.s.sed 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 a.s.sistance; 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 const.i.tutional 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 pa.s.sed 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 pa.s.sed 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, pa.s.sing 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 pa.s.sed 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 s.p.a.ces. 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 Hilda.n.u.s, 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, const.i.tuting 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 pa.s.sed 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 G.o.defroy 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 pa.s.senger 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 v.a.g.i.n.a, 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 princ.i.p.al symptoms were hemorrhage from the v.a.g.i.n.a 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 b.l.o.o.d.y 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 pa.s.sed 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 Hilda.n.u.s 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 bra.s.s 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 hoa.r.s.e. 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 gla.s.s, 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 circ.u.mscribed 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 pa.s.sing 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 s.p.a.ce. 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 princ.i.p.al 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.